Christus Shreveport-Bossier Health System

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40957 Based on record review and interview, the hospital failed to ensure one to one observation level on a PEC patient for 2 (#1, #4) of 4 (#1, #2, #3, #4) sampled patients. Findings: Review of the hospital policy, “PEC/CEC- Provisional Psychiatric Care.” created on 09/2008 and the latest reviewed on 05/2024 revealed the following: “Objective/s: To ensure that every individual in need of care and treatment related to psychology and/or psychiatric disorders receives care in prompt, safe, and calm environment. To provide guidelines for appropriate treatment and placement of patients admitted by a Physician’s Emergency Certificate (PEC)/Coroner’s Emergency Certificate (CEC) while promoting patient safety. Process or Procedures: F. All PEC/CEC patients are placed on one to one (1:1) observation with a de-escalation-trained, CSBHS associate.” Review of the “Sitter Education Checklist for 1:1 Monitoring of Patients,” revealed in part: “Observe the patient at ALL TIMES if you need a break notify the nurse. Maintain visual observance of the patient at all times. This includes the use of restroom facilities. Never leave the patient. Observe the patient at all times including him/her in the bathroom. Notify the patient’s nurse if you require a break.” Patient #1 Record review of Patient #1’s medical record revealed the following, in part: Patient #1 presented to the emergency department (ED) on 06/17/2025 at 4:59 PM with a chief complaint of suicide attempt. Patient arrived to ED from home with complaint of suicide attempt. EMS reported patient states she took 50 HCTZ. Patient states she was going to but washed them down the sink. EMS also reports multiple lacerations to left arm from self-inflicted razor cuts. Patient AAO x 3 and denies any SI or HI but just states she is depressed. Patient states she has a family history of bipolar. No complaints of chest pain or SOB. Respirations even and unlabored. NAD noted. The patient was evaluated by a physician and placed under a Physician’s Emergency Certificate (PEC). Review of Patient #1’s PEC dated 06/17/2025, exam time 5:10 PM, signed 5:20 PM by MD reveled, in part, “Patient #1 PEC exam included mental illness or substance abuse, possible suicide attempt with HCTZ, currently depressed, dangerous to self, multiple superficial lacerations to left forearm.” Further review of the record revealed Patient #1 eloped from the hospital after having been left unattended in the restroom. Review of the hospital’s self-report to Louisiana Department of Health revealed, in part: Surveillance/Video- Patient #1 was escorted to the bathroom by S1RN, Patient #1 exited, spoke to S1RN and asked for a medication. S1RN left the Patient in the bathroom and went to ask for the order at 06:54:11 PM. S1RN returned to Line-of Sight Monitoring at 07:00:04 PM. At 07:02:15 PM, S1RN checks the bathroom and realizes Patient #1 has fled. S1RN notifies all parties and a search ensues. Video Surveillance identifies the patient exiting through the vending area, walking across the ER lobby, exiting through the main ER Entrance then running across the street. Last image was of Patient #1 across the street. Investigation results- We were not able to provide a 1:1 sitter and monitoring for this PEC patient at that time of the elopement secondary to current census and staffing. Nursing Services was preparing to send a sitter from our request. They had not yet arrived when the elopement occurred. Review of the hospital’s House Supervisor’s Daily Duties (updated 06/26/2025) revealed, in part, “If a patient is placed on a PEC or CEC, immediately review staffing in all departments including nurse externs and shift resources to provide 1:1 observation. Instruct nursing staff to remain with patient until a sitter arrives ...” Review of the hospital’s occurrence report for this incident revealed the following, in part: Date of event 06/17/2025 at 7:05 PM. PEC patient (Patient #1) eloped. Interview on 07/22/2025 at 11:35 AM, S2QM reported, the facility’s PEC/CEC policies state that all PEC/CEC patients are placed on 1:1 observation with a de-escalation-trained associate. S2QM reported that a sitter never arrived prior to Patient #1’s elopement. S2QM also reported the staff did not maintain 1:1 observations per the facility’s policy. Patient #4 Record review of Patient #4’s medical record revealed the following, in part: Patient #4 was admitted to the ER on 07/23/2025 at 4:36 AM with a chief complaint of severe paranoia. Patient reports he was supposed to go to a Behavioral Health facility yesterday but he could not get a ride. Patient reports he feels like people are following him and trying to get him. Patient reports he did use meth and alcohol today. Patient denies SI/HI. Patient #4 was evaluated by the physician and placed under a Physician’s Emergency Certificate (PEC) at 5:00 AM on 07/23/2025. The physician documented, “flight of ideas. He repeats the statement over and over, he has suicidal ideations without plan, lots of social issues. Recent separation. Using Meth and alcohol. Not sleeping. Paranoid. Patient #4 is currently suicidal. “ Observation in the emergency department on 07/23/2025 at 10:05 AM, accompanied by S3ERCD, revealed Patient #4 was in his room lying on stretcher. The assigned sitter for 1:1 observation was not present, an empty chair was at the door to the room. S3ERCD was with surveyor and also reported the sitter was not present. S2ERCD asked the two nurses (S4RN and S5RN) where the sitter was and they both said they did not know. S3ERCD asked the two nurses if the sitter notified them and they both said “NO.” Interview on 07/23/2025 at 10:10 AM, S3ERCD verified there was not a sitter present for 1:1 observation for Patient #4 and the emergency department staff were not following the hospital policy for patients under a PEC.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 40957 Based on record review and interview, the hospital failed to recognize deficiencies related to patient safety. The deficient practice is evidenced by failure to recognize neglect after the elopement of a patient from the emergency department. Findings: Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed “Department” shall mean the Department of Health and Hospitals. “Unit” means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, “Abuse” is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. “Neglect” is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer’s well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer’s physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report. Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to the Louisiana Department of Health (LDH). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence. Review of the document, “Self Reporting Process for Hospitals- Abuse/Neglect,” revised 12/01/21, revealed in part, “ 11. Facility Investigation (Administrative Review) and Final Investigative Report The Final Investigative Report should be submitted to HSS as soon as it is concluded, but within five working days of submitting the initial report. The hospital may submit additional information (such as completion of staff education, etc.) after the Final Investigative Report has been submitted. An addendum of this nature should clearly identify the hospital, the five-digit ID number HSS assigned to the event, the date of the incident, and must include enough information to link the document to the appropriate incident/event. Final reports and attached documents should be submitted via email, whenever possible, and should be encrypted as they will contain Protected Health Information (PHI). The final report should provide evidence that the facility conducted a thorough investigation and took measures to prevent future incidents. Issues with hospital systems, policies and procedures, regular practices that contributed to the event should be scrutinized and identified in the report. Specific actions taken in regard to systems and personnel involved should be documented (e.g., education, disciplinary actions, policy revisions, etc.). The final report must indicate whether the allegations were substantiated or not (it is acceptable to state that allegations were unable to be substantiated due to lack of evidence). Review of the “Sitter Education Checklist for 1:1 Monitoring of Patients,” revealed in part: Observe the patient at ALL TIMES if you need a break notify the nurse. Maintain visual observance of the patient at all times. This includes the use of restroom facilities. Never leave the patient. Observe the patient at all times including him/her in the bathroom. Notify the patient’s nurse if you require a break. Review of the hospital’s House Supervisor’s Daily Duties (updated 06/26/2025) revealed, in part, “If a patient is placed on a PEC or CEC, immediately review staffing in all departments including nurse externs and shift resources to provide 1:1 observation. Instruct nursing staff to remain with patient until a sitter arrives ...” Patient #1 Record review of Patient #1’s medical record revealed the following, in part: Patient #1 presented to the emergency department (ED) on 06/17/2025 at 4:59 PM with a chief complaint of suicide attempt. Patient arrived to ED from home with complaint of suicide attempt. EMS reported patient states she took 50 HCTZ. Patient states she was going to, but washed them down the sink. EMS also reports multiple lacerations to left arm from self-inflicted razor cuts. Patient AAO x 3 and denies any SI or HI but just states she is depressed. Patient states she has a family history of bipolar. No complaints of chest pain or SOB. Respirations even and unlabored. NAD noted. The patient was evaluated by a physician and placed under a Physician’s Emergency Certificate (PEC). Review of Patient #1’s PEC dated 06/17/2025, exam time 5:10 PM, signed 5:20 PM by MD reveled, in part, “Patient #1 PEC exam included mental illness or substance abuse, possible suicide attempt with HCTZ, currently depressed, dangerous to self, multiple superficial lacerations to left forearm.” Further review of the record revealed Patient #1 eloped from the hospital after having been left unattended in the restroom. Review of the hospital’s self-report to Louisiana Department of Health revealed, in part: Surveillance/Video- Patient #1 was escorted to the bathroom by S1RN, Patient #1 exited, spoke to S1RN and asked for a medication. S1RN left the Patient in the bathroom and went to ask for the order at 06:54:11 PM. S1RN returned to Line-of Sight Monitoring at 07:00:04 PM. At 07:02:15 PM, S1RN checks the bathroom and realizes Patient #1 has fled. S1RN notifies all parties and a search ensues. Video Surveillance identifies the patient exiting through the vending area, walking across the ER lobby, exiting through the main ER Entrance then running across the street. Last image was of Patient #1 across the street. Investigation results- (Was the allegation substantiated, unsubstantiated, or unable to substantiate due to lack of evidence?) We were not able to provide a 1:1 sitter and monitoring for this PEC patient at that time of the elopement secondary to current census and staffing. Nursing Services was preparing to send a sitter from our request. They had not yet arrived when the elopement occurred. Interview on 07/22/2025 at 11:35 AM, S2QM reported, the facility’s PEC/CEC policies state that all PEC/CEC patients are placed on 1:1 observation with a de-escalation-trained associate. S2QM reported that a sitter never arrived prior to Patient #1 elopement. S2QM also reported the staff did not maintain 1:1 observations per the facility’s policy.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 20310 Based on record review, the hospital failed to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice was evidenced by the physician failing to evaluate for presence of a PE (pulmonary embolism) for 1 (#1) of 1 patients (#1) who presented to the emergency department with chest pain with persistent tachycardia [increase heartrate] and mild hypoxia [decrease oxygen to tissue] . (See findings at A-2406).”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 20310 Based on record review, the hospital failed to ensure a medical screening examination (MSE) was provided to each patient presenting to the Emergency Department (ED) to determine whether or not an emergency medical condition existed. This deficient practice was evidenced by the physician failing to evaluate for presence of a pulmonary embolism (PE) for 1 (#1) of 1 patients (#1) who presented to the emergency department with chest pain with persistent tachycardia [increase heart rate] and mild hypoxia [decrease oxygen to tissue]. Findings: Review of the medical record for Patient #1 revealed an 80-year-old female with history of hypertension [elevated blood pressure], hyperlipidemia [high cholesterol], gastroesophageal reflux (GERD), and tobacco abuse presented to the Emergency Department on 10/08/24 at 1:03 p.m. for evaluation of sternal chest pain and epigastric[upper center of abdomen] pain which the patient rated as severe at 9/10 that had been ongoing for 4 hours. Review of the MSE revealed there was no evaluation for pulmonary embolism [blood clot in the lung] . Patient #1 demonstrated tachycardia on multiple evaluations (including a heart rate of 105 at discharge) and borderline hypoxia (92%). There was no d-dimer [blood test used to help diagnosis blood clots] or computed tomography (CT) angiography performed. In summary, the MSE was inappropriate as PE [blood clot in the lung] was not evaluated for in the setting of chest pain with persistent tachycardia and mild hypoxia. Review of the policy, “Emergency Medical Treatment and Active Labor Act,” created 01/2023 and revised/ reviewed 03/2023 and 06/202424, revealed in part: “IV. DEFINITIONS: A. EMTALA [Emergency Medical Treatment and Active Labor Act] requires that a hospital provide a MSE [medical screening examination] within the capability and capacity of its emergency department including ancillary services routinely available to the emergency department. Capabilities of a hospital refers to the physical space, equipment, supplies, and specialized services of the hospital (e.g., surgery, psychiatry, obstetrics, intensive care, pediatrics, trauma care). Capabilities of the staff refers to the level of care that the personnel of the hospital can provide within the training and scope of their professional licenses. This includes coverage available through the hospital’s on-call roster. Capacity to render care is not reflected simply by the number of persons occupying a specialized unit, the number of staff on duty, or the amount of equipment on the hospital’s premises. Capacity includes whatever a hospital customarily does to accommodate patients in excess of its occupancy limits. If a hospital has customarily accommodated patients in excess of its occupancy limits by whatever means (e.g., moving patients to other units, calling in additional staff, borrowing equipment from other facilities) it has, in fact, demonstrated the ability to provide services to patients in excess of its occupancy limits.” and “E. Emergency Medical Condition (EMC) is defined as: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part;” and “K. Medical Screening Examination (MSE) is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition (EMC) or not. A MSE is not an isolated event. It is an ongoing process that begins, but typically does not end, with triage. “ and “V. PROCESS OR PROCEDURES: A. If an individual “comes to the emergency department” as defined in Paragraph C under Definitions, the Hospital must: 1. Provide an appropriate MSE [medical screening examination] within the capability of the Hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether an EMC [emergency medical condition] exists. The examination must be conducted by a physician or a QMP [qualified medical professional].””