Lake Charles Memorial Hospital

“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: 44763 Based on record reviews and interviews, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by: 1.) the hospital failed to have a working system in place to ensure the effective implementation of hospital approved policies/procedures relating to the responsibilities of on-call physicians. This deficient practice was evidenced by failing to consult with the on-call physicians of a potential transfer for 1 (#4) of 20 (#1-#20) sampled patients (see findings tag A-2404); 2.) the hospital failed to maintain a central log on each individual who comes to the hospital seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. This deficient practice was evidenced by failing to document in the Emergency Department (ED) Transfer Request log the reason for denial of a potential transfer in for 2 (#1, #5) of 20 (#1-#20) sampled patients (see findings tag A-2405); and 3.) the hospital failed to accept an appropriate patient transfer for which the hospital had the capacity and capability to provide stabilizing treatment required by the patient’s condition. This deficient practice was evidenced by failure to accept a patient transfer from the transferring hospital emergency department’s physician who had requested services for 3 (#2, #3, #5) of 20 (#1-#20) sampled patients (see findings A-2411).”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to have a working system in place to ensure the effective implementation of hospital approved policies/procedures relating to the responsibilities of on-call physicians. This deficient practice was evidenced by failing to consult with the on-call physicians of a potential transfer for 1 (#4) of 20 (#1-#20) sampled patients. Findings: Review of the hospital’s policy titled “Physician Notification and Escalation Protocol”, last revised 08/2019 with an effective date of 06/2024, revealed in part, “The purpose of this policy is to provide clinical employees and physicians with appropriate direction for the prompt handling of patient care issues. This policy makes available a formal line of communication for staff members who have concerns that a prescribed treatment plan (or the lack thereof) or a medical decision or other medical act might adversely affect the welfare of a patient or that of the hospital.” Review of Patient #4’s emergency department (ED) record from hospital ‘A’ revealed Patient #4 presented to the ED on 12/31/2024 at 7:21 PM. Review of the provider note revealed in part, “Chief Complaint: weakness, vomiting, leg swelling, Patient to ED [room] via wc [wheelchair] with c/o [complaint of] bilateral leg swelling and cramping onset yesterday with accompanying weakness, intermittent SOB [shortness of breath] with exertion and vomiting onset this AM [morning] increasing in intensity to this evening. Patient denies CP [chest pain] in triage.” “Clinical Impression: Final diagnoses: weakness; dyspnea [shortness of breath]; anemia [low number of red blood cells], unspecified type (primary); acute renal failure, unspecified acute renal failure type; cardiogenic shock; history of coronary angioplasty with insertion of stent; history of atrial fibrillation; elevated troponin.” Review of the transfer certificate dated 01/01/2025 revealed Patient #4 was transferred to hospital ‘B’ due to qualified clinical personnel unavailable, services unavailable at hospital ‘A’. Further review of the document revealed “benefits of transfer: specialty services.” Review of Lake Charles Memorial Hospital (LCMH) ED Transfer Request Log revealed in part, Date: 12/31/2024 Time: 10:01 PM Patient #4 Requesting Facility: hospital ‘A’ Requested Services/Reason for Transfer: Diagnosis: Cardiogenic shock Need: Cardiology/GI [gastrointestinal] Reason for Denial: Doctors unavailable x2 / no call back In an interview on 02/04/2025 at 3:48 PM S4UT stated they had two very critical patients in the ED at that time. S4UT stated they also had an inpatient in need of intubation as well. S4UT stated she went to both ED doctors twice. S4UT stated she told the ED doctors a “snip it” about Patient #4. S4UT stated neither ED doctor gave an answer to the transfer request. S4UT stated both ED doctors were too busy and could not come to the phone. In a phone interview on 02/05/2025 at 8:33 AM S4UT stated she told the requesting hospital that she would get a doctor as soon as she could. S4UT stated she asked the requesting hospital to send the paperwork over so she could have the doctor review the paperwork. S4UT stated she did receive the paperwork from the requesting hospital. S4UT stated she left the paperwork on the desk in the doctor’s lounge for the doctors to look at it. S4UT stated she assumed the doctors would look at it when she left the paperwork on the desk. S4UT stated some time went by and the requesting hospital called back. S4UT stated she went back to both doctors and asked if they had time to look at the paperwork. S4UT stated the doctors responded that they were too busy and the acuity was too high in the ED. S4UT stated the requesting hospital told her that hospital ‘B’ was on divert. S4UT stated the requesting hospital told her when hospital ‘B’ would come off of divert in the morning, hospital ‘B’ would have a bed available and able to take Patient #4. S4UT stated she did not contact the on-call doctors. S4UT stated she felt it was not her place to contact the on-call doctors. S4UT stated in this case, she did not have an ED doctor for the on-call doctor to talk to because they were busy. S4UT stated the ED doctor did not have time to speak to any doctor, the doctor from the requesting hospital or the on-call specialty doctor. S4UT stated when the requesting hospital called back, she told them that she was trying to get an ED doctor to look at it. In an interview on 02/05/2025 at 8:52 AM, S1EDD verified the unit tech should have approached the charge nurse and explained the situation. S1EDD further explained the charge nurse should have then gone to the ED physician for direction on what to do. S1EDD verified if the charge nurse could not get a response from the ED physician, the hospital procedure would have been for the charge nurse to escalate the situation to the house supervisor. S1EDD verified if the house supervisor did not get a response, then the house supervisor should have escalated to the administrator on call. S1EDD stated ED staff should have followed the hospital’s escalation policy. In an interview on 02/05/2025 at 9:17 AM S2QD verified the ED staff should have followed the hospital’s escalation policy when the ED physicians were busy. Review of the Staff Manager Report dated 12/31/2024 revealed the hospital had beds available on 12/31/2024. In an interview on 02/05/2025 at 9:48 AM S2QD verified the hospital had beds available on 12/31/2024. Review of the physician on-call schedule revealed S5MD was on-call for Cardiology and S6MD was on-call for GI on 12/31/2024. In an interview on 02/05/2025 at 9:55 AM S2QD verified S5MD was on-call for Cardiology and S6MD was on-call for GI on 12/31/2024. Review of Patient #4’s ED record from hospital ‘B’ revealed Patient #4 arrived on 01/01/2025 at 5:02 a.m. Review of the provider note revealed in part, “Chief Complaint: Patient is an [stated age] male with a PMHx [past medical history] of CAD [coronary artery disease], HLD [hyperlipidemia- high cholesterol], HTN [hypertension- high blood pressure], and stroke presents to the ED via EMS [emergency medical services] as a transfer from hospital ‘A’ for ‘cardiogenic shock’. Per chart review from previous facility, patient initially presented to hospital ‘A’ ED for bilateral leg cramping and swelling with nausea, vomiting, generalized weakness, and dyspnea with exertion. Patient initially hypotensive [low blood pressure]. Labs from the outlying facility remarkable for profound anemia, mild elevation in troponin, elevated BNP [B-type natriuretic peptide], and renal insufficiency. He was typed and crossed for 4 units of blood, he is receiving the 3rd unit at this time. Blood pressure improved. He also received Bumex 1.5 mg [milligrams] and is currently on BiPAP [bilevel positive airway pressure]. Currently he still has mild shortness of breath, generalized weakness, and reports mild chest discomfort but states this is not similar to previous MI [myocardial infarction] in the past. He denies any black or bloody stool, no other signs of bleeding. Denies history of GI bleed. He was admitted here recently for MI s/p [status post] coronary stent placement 2 weeks ago. Patient is prescribed Eliquis, Brilinta, and is compliant with medications. Patient taking Eliquis for paroxysmal a-fib.” Further review of the document revealed in part, “Clinical Impression: Final diagnoses: chest pain; NSTEMI [non-ST elevated myocardial infarction]; gastrointestinal hemorrhage, unspecified gastrointestinal hemorrhage type (primary); current use of long term anticoagulation; acute on chronic congestive heart failure, unspecified heart failure type; acute renal insufficiency.” On 01/01/2025 at 6:31 a.m. Patient #4 was admitted to medical telemetry at hospital ‘B’.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to maintain a central log on each individual who comes to the hospital seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. This deficient practice was evidenced by failing to document in the Emergency Department (ED) Transfer Request log the reason for denial of a potential transfer in for 2 (#1, #5) of 20 (#1-#20) sampled patients. Findings: Review of the hospital’s policy titled “EMTALA Guidelines for Emergency Department Services and Transfer Policy”, last revised and effective 07/2023, revealed in part, “The Emergency Department shall maintain a central log documenting the following information: -Each individual presenting to the ED for assistance; -If the individual refused treatment; -If the individual was refused treatment; and -If the individual was transferred, admitted and treated, stabilized and transferred, or discharged.” Patient #1 Review of Lake Charles Memorial Hospital (LCMH) ED Transfer Request Log revealed in part, Date: 12/07/2024 Time: 11:20 PM Patient #1 Requesting Facility: hospital ‘C’ Requested Services/Reason for Transfer: Pedi Service Available: No Time Denied: 12:00 AM Reason for Denial: blank (no documentation) ER MD: blank (no documentation) In an interview on 02/04/2025 at 1:02 PM S1EDD verified there was no documentation as to why the transfer of Patient #1 was denied. Patient #5 Review of LCMH ED Transfer Request Log revealed in part, Date: 01/26/2025 Patient #5 Requesting Facility: hospital ‘D’ Requested Service/Reason for Transfer: Urology Service Available: No Time Denied: 11:00 AM Reason for Denial: blank (no documentation) ER MD: S12MD In an interview on 02/06/2025 at 4:08 PM S2QD verified there was no rationale documented as to why the transfer of Patient #5 was denied.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to accept an appropriate patient transfer for which the hospital had the capacity and capability to provide stabilizing treatment required by the patient’s condition. This deficient practice was evidenced by failure to accept a patient transfer from the transferring hospital emergency department’s physician who had requested services for 3 (#2, #3, #5) of 20 (#1-#20) sampled patients. Findings: Review of the hospital’s policy titled “Admissions and Transfers”, last revised 05/2015 with an effective date of 06/2023, revealed in part, “It is the policy of Lake Charles Memorial Health System to accept admissions and transfers into the hospital. Patient condition, bed availability, physician acceptance are to be obtained prior to the acceptance of any patient.” Patient #2 Review of Patient #2’s emergency department (ED) record from hospital ‘C’ revealed Patient #2 presented to the ED on 12/12/2024 at 11:00 PM. Review of the provider note revealed in part, “History of Present Illness: Patient via EMS [emergency medical services] from casino where he is staying for work (He is from Beaumont). Pt complaint of SOB [shortness of breath] worsening x 3 days, ‘chest tightness like I can’t get a deep breath.’ He denies specifically chest pain. Pt reports he was out of his medications (carvedilol, omesartan, eliquis, crestor, and spironolactone) for several days and only restarted them on Monday (3 days ago). He reports his legs are considerably more swollen than normal. He reports nausea with recent vomiting. He denies ever being told he had CHF [congestive heart failure]. Has never had an angiogram (or stents). He does admit to a stress test in past. He reports a Hx [history] of a-fib [atrial fibrillation] but it normally goes back into regular rhythm ....he denies knowledge of his a-fib ever being fast.” Further review of the document revealed in part, “Diagnosis: atrial fibrillation with rapid ventricular response; congestive heart failure; elevated troponin; NSTEMI [non-ST segment elevation myocardial infarction].” “Disposition: Transferred.” Review of the nurse’s notes revealed in part, “12:20 AM: MD decision to transfer for cardiology at this time, LCMH [Lake Charles Memorial Hospital] hse [house] sup [supervisor] called for transfer, spoke with [named], hse sup ok to call ER [emergency room].” “12:25 AM: called LCMH ER for doc [doctor] to doc for transfer acceptance for cardiology.” “12:40 AM: [named] doctor to doctor with [named], recommends to call Patient #2’s primary and cardiology services in Beaumont, Texas and transfer Patient #2 there.” Review of the Emergency Room Hospital Transfer form revealed in part, Patient #2 was transferred to hospital ‘E’ on 12/13/2024 for cardiology services. Review of LCMH ED Transfer Request Log revealed in part, Date: 12/13/2024 Time: 12:22 AM Patient #2 Requesting Facility: hospital ‘C’ Requested Services/Reason for Transfer: Cardiology Service Available: No Time Denied: 1:22 AM Reason for Denial: Check with Beaumont hospital first. Around 1:22 AM Patient #2 got accepted to Beaumont. ER MD: S7MD In a phone interview on 02/06/2025 at 9:05 AM S7MD stated the transfer was not denied. He stated these nearby smaller facilities call requesting transfer. S7MD stated we are usually the only hospital they call. S7MD stated they will just call us first. S7MD stated sometimes the requesting hospital does not ask the patient if they have a specialist that they have already seen and are established with. S7MD stated he asked if Patient #2 had a cardiologist. S7MD stated the requesting hospital told him yes, Patient #2’s cardiologist was in Beaumont. S7MD stated he asked the requesting hospital if Patient #2 was stable and asked if they wanted to ask Patient #2 if he wanted to go to Beaumont where his cardiologist was located and potentially go there for continuity of care. S7MD stated this hospital reached back out to the requesting hospital and they responded that Patient #2 was accepted to Beaumont. Review of the physician on-call schedule revealed S8MD was on call for cardiology on 12/12/2024. In an interview on 02/04/2025 at 1:35 PM S1EDD verified S8MD was on call for cardiology on 12/12/2024. Review of the Staff Manager Report dated 12/12/2024 11:00 PM - 12/13/2024 7:00 AM revealed the hospital had inpatient beds available. In an interview on 02/05/2025 at 10:54 AM S9DAS verified the hospital had inpatient beds available on 12/12/2024 11:00 PM - 12/13/2024 7:00 AM. Review of Patient #2’s ED record from hospital ‘E’ revealed Patient #2 arrived on 12/13/2024 at 4:37 AM. Review of the physician documentation revealed in part, “ED Course: Patient #2 is a [stated age] with history of CHF and AFib on Eliquis who presents with chest pain and shortness of breath. Patient presented to an outside facility today due to his chest pain. Patient admitted here as needed medications recently and restarted his medications on Monday. He is compliant with all his medications. He was found have an elevated BNP [B-Type Natriuretic Peptide] at the outside facility. He was also in AFib with RVR [atrial fibrillation with rapid ventricular response]. Patient was given diltiazem and Lasix prior to transfer. RVR improved. Patient had elevated troponin and was transferred here for NSTEMI. He received aspirin. No anticoagulation given. On interview patient states chest pain is improved. On exam, there is 1+ pitting edema bilaterally. Labs with sodium 145 potassium 4.3 Creatinine 1.7. BUN 40. Chest x-ray with left lower lobe infiltrate. EKG [electrocardiogram] with intermittent PVCs [premature ventricular contraction]. Patient has irregular rhythm. Patient is in AFib with 2-1 block. MD [named] contacted for admission. Will consult MD [named] with cardiology.” Further review of the document revealed in part, “Diagnosis: pneumonia, unspecified organism; unspecified atrial fibrillation; chest pain, unspecified; acute congestive heart failure (systolic).” “Hospitalization status: inpatient admission” with a room assigned on 12/13/2024 at 6:43 AM. Patient #3 Review of Patient #3’s ED record from hospital ‘F’ revealed Patient #3 presented to the ED on 12/26/2024 at 4:03 PM. Review of the nurse’s notes revealed in part, “Presenting complaint: Patient states: patient had hernia surgery 3 weeks ago in Houston. Patient states surgical incision started bleeding on Sunday. Patient called surgeon’s office and they told him to just ‘leave it uncovered during the day.’ Today patient’s incision is draining and patient states that his abdomen is ‘hard and hot.’ Transition of care: patient was not received from another setting of care.” Review of the physician documentation revealed a diagnosis of “disruption of external operation (surgical) wound, not elsewhere classified.” Review of the nurse’s notes revealed in part, “6:56 PM: Patient #3 requesting transfer to the Lake Charles area. Patient called friend/family member to discuss transfer and decided on Lake Charles.” “7:03 PM: Phoned LCMH and spoke to [named] supervisor and he gave authorization to speak to ER [emergency room] MD to initiate transfer if accepted.” “7:05 PM: Phoned ER to have ER to ER consultation. ER doctor denied transfer. Patient #3 needs to go to hospital ‘G’ in Houston.” Review of the Patient Transfer Out form revealed in part, “criteria/reason for transfer: for equipment or services not available at this facility. (list): General Surgery (Specialty)” with a “diagnosis: wound recheck, rule out intra-abdominal abscess.” Further review of the document revealed Patient #3 was accepted to hospital ‘I’ on 12/26/2024. Review of LCMH ED Transfer Request log revealed in part, Date: 12/26/2024 Time: 7:07 PM Patient #3 Requesting Facility: hospital ‘F’ Requested Services/Reason for Transfer: General Surgery Service Available: No Time Denied: 7:03 PM Reason for Denial: Recent procedure at hospital ‘G’, needs to go back to hospital ‘G’ for continuity. ER MD: S10MD In an interview on 02/04/2024 at 2:26 PM S2QD verified the documentation for reason of denial was recent procedure at hospital ‘G’, needs to go back to hospital ‘G’ for continuity. In a phone interview on 02/06/2025 at 10:16 AM S10MD stated if he remembered correctly, Patient #3 had a recent hepatobiliary procedure. S10MD stated the procedure was done at hospital ‘G’. S10MD stated the general surgeons here do not have the capability to do those procedures. He stated that was why the transfer of Patient #3 was denied. Review of the physician on-call schedule revealed S11MD was on call for Trauma-General Surgery on 12/26/2024. In an interview on 02/04/2025 at 2:24 PM S1EDD verified S11MD was on call for Trauma-General Surgery on 12/26/2024. Review of the Staff Manager Report dated 12/26/2024 3:00 PM - 11:00 PM revealed the hospital had inpatient beds available. In an interview on 02/04/2025 at 2:46 PM S9DAS verified the hospital had inpatient beds available on 12/26/2024 3:00 PM - 11:00 PM. Review of Patient #3’s ED record from hospital ‘I’ revealed, Patient #3 arrived on 12/27/2024 at 10:51 AM. Review of the emergency department provider note revealed in part, “In brief, [stated age] male with past medical history of hypertension [high blood pressure], hyperlipidemia [high cholesterol], small intestine rupture, inguinal and ventral hernia status post multiple repairs presents emergency department as a transfer from outside hospital for evaluation by general surgery after being found to have a large fluid collection within his superficial abdominal wall and intra-abdominal fluid collection. Initially noticed drainage on Sunday that has progressively worsened.” Further review of the document revealed in part, “Plan: given unknown etiology of patient’s fluid collection he was covered broadly in the event that this is an infection. On repeat lab work patient’s left shift appears to have improved with neutrophil count of 7.10. Patient was consulted to general surgery who evaluated him at bedside and performed a drainage of his large fluid collection with thus far 700 mL [milliliters] of blood output.” “Clinical Impressions: abscess of postoperative wound of abdominal wall, infected hernioplasty mesh, and abdominal fluid collection.” On 12/27/2024 at 5:24 PM Patient #3 was admitted to trauma surgery at hospital “I”. Patient #5 Review of Patient #5’s ED record from hospital ‘D’ revealed Patient #5 presented to the ED on 01/26/2025 at 8:43 AM. Review of the provider note revealed in part, “ED Course: [stated age] female with past medical history of nephrolithiasis [kidney stones] who presents with right-sided flank pain since the morning. Vitals with mild bradycardia [slow heart rate] but otherwise with normal limits. Labs showed urinalysis consistent with UTI [urinary tract infection]. CT [computed tomography]-abdominopelvic showed right renal calculi with moderate right hydroureteronephrosis [dilation of the ureter and kidney], but no obstructing stone noted. Treatment provided with analgesia, antiemetic and IV [intravenous] fluids. Patient will be transferred to hospital ‘H’ for urology services.” Further review of the document revealed in part, “Diagnosis: hydronephrosis [upper urinary tract dilation]; stone in kidney” with a “final impression: nephrolithiasis with UTI.” Review of the nurse’s notes revealed in part, “10:48 AM: While getting patient to sign transfer, family member requested to call Lake Charles due to him living in Sulphur. Spoke with [named] house supervisor, who states they have services. MD [named] speaking with MD who states will not accept Patient #5.” Review of the ED Summary report revealed in part, Patient #5 was transferred to hospital ‘H’ on 01/26/2025 for urology services. Review of LCMH ED Transfer Request Log revealed in part, Date: 01/26/2025 Patient #5 Requesting Facility: hospital ‘D’ Requested Service/Reason for Transfer: Urology Service Available: No Time Denied: 11:00 AM Reason for Denial: blank (no documentation) ER MD: S12MD In a phone interview on 02/06/2025 at 4:58 PM, S12MD stated Patient #5 had hydronephrosis and UTI with no stone, with an unchanged CAT scan and no need for surgical intervention. S12MD stated he consulted with the urology specialist and the specialist agreed. S12MD stated urology would not do anything with Patient #5. S12MD stated there was no need to transfer, no urological intervention would have been done. S12MD stated they were going off an old CAT scan. S12MD stated Patient #5 was not septic. S12MD stated Patient #5 needed antibiotics and to follow up outpatient. Review of the physician on-call schedule revealed S13MD was on call for urology on 01/26/2025. In an interview on 02/04/2025 at 3:35 PM S1EDD verified S13MD was on call for urology on 01/26/2025. Review of the Staff Manager Report dated 01/26/2025 7:00 AM - 3:00 PM revealed the hospital had inpatient beds available. In an interview on 02/04/2025 at 4:07 PM S2QD verified the hospital had inpatient beds available on 01/26/2025 7:00 AM - 3:00 PM. Review of Patient #5’s ED record from hospital ‘H’ revealed, Patient #5 arrived on 01/26/2025 at 1:46 PM. Review of the provider note revealed in part, “[stated age] female presents as transfer from hospital ‘D’ for moderate right hydroureteronephrosis with gross hematuria [blood in urine]. She reports urinary frequency recently but yesterday started with flank pain. Went to an urgent care and was noted to have large amount of blood in her urine. She was started on p.o. [oral] antibiotic and sent home. She presented to the ED today with findings as below. She was then transferred here for urology evaluation. Currently reports pain is starting to creep back up. Reports she just urinated in a sample cup and it was entirely blood. Denies fevers but does report some chills.” Further review of the document revealed in part, “Diagnosis: gross hematuria; right flank pain; hydroureteronephrosis.” “Disposition and Plan: admit.” On 01/26/2025 at 4:04 PM Patient #5 was admitted to inpatient at hospital ‘H’.”

“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: 44763 Based on record reviews and interviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by failing to ensure all staff members were re-educated to prevent future occurrences after a patient arrived to the Emergency Department (ED) with an Order of Protective Custody (OPC), and subsequently placed under a Physician’s Emergency Certificate (PEC) by the ED physician, eloped from the emergency department for 1 of 1 (#1) patient records reviewed for elopement from a total sample of 4. Findings: Review of the hospital’s policy titled “Behavioral Patients- Management and Care in the Emergency Department (ED)” effective date 05/21, revealed in part, “Policy Statement: 1.) Patients presenting to LCMH [Lake Charles Memorial Hospital] ED for acute crisis of mental health or substance use disorders can expect to receive care in a safe, timely, effective, efficient, and patient-centered manner guided by evidenced-based practices.” Review of Patient #1’s emergency department record revealed date and time of arrival was 10/15/2024 at 12:40 p.m. with a chief complaint of OPC. Further review of the record revealed a PEC dated 10/15/2024 and signed by S3MD at 1:50 p.m. Review of the nurse’s note dated 10/15/2024 at 3:33 p.m. by S1EDD revealed attempted to reach patient at phone number given. Spoke with Family Member #1 states as soon as he gets home, she is calling the police to bring him back. Review of the nurse’s note dated 10/15/2024 at 3:52 p.m. by S4RN revealed MD notified at 1:54 p.m.; missing person alert at 1:58 p.m.; Police Department at 2:00 p.m. Review of the nurse’s note dated 10/18/2024 at 12:44 p.m. by S4RN revealed Patient #1 did not come back after 72 hours. In an interview on 11/25/2024 at 4:08 p.m. S2EDM stated the police brought Patient #1 to the ED under an OPC. S2EDM stated Patient #1 was seen by the provider and placed under a PEC. S2EDM stated the charge nurse did not know Patient #1 had a PEC in place. S2EDM stated the charge nurse went to do something, came back to the desk, and then noticed the PEC documentation was left on the charge nurse desk by the provider. S2EDM stated once the charge nurse noticed the document, the charge nurse assumed Patient #1 had been brought to the psychiatric holding unit inside the ED. S2EDM stated the charge nurse went to bring the PEC documentation to the psychiatric holding unit and then realized Patient #1 was not there. S2EDM stated once the charge nurse realized that Patient #1 was not in the psychiatric holding unit, she notified the provider, the house supervisor, the police department, and initiated a missing person code. S2EDM stated when the police officer left Patient #1 and walked out of the ED, the fire alarm went off and those doors were closed. S2EDM stated Patient #1 then meandered through the ED and exited through the waiting room. S2EDM stated Patient #1 was not found and did not return to the emergency department within 72 hours. There was no documentation of all staff members being re-educated to prevent future occurrences. In an interview on 12/02/2024 at 9:01 a.m. S1EDD verified there was no documentation of all staff being educated on the updated policy. S1EDD stated once the updated policy is in place, all staff will be educated. S1EDD stated staff are aware of the updated policy but the policy is still a draft and had not been approved as of this survey. In an interview on 12/02/2024 at 10:35 a.m. S1EDD verified S5MD had not sent out the education to the ED providers.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the nursing staff to accurately document patient observations for 1 of 1 (#3) patient records reviewed for observations out of a total sample of 4. Findings: Review of Patient #3’s emergency department record revealed date and time of arrival was 10/26/2024 at 3:24 p.m. with a chief complaint of Order of Protective Custody (OPC). Further review of the record revealed a Physician’s Emergency Certificate (PEC) dated 10/26/2024 and signed by S7MD at 3:47 p.m. Further review of the record revealed on 10/26/2024 at 3:51 p.m. Patient #3 was placed in a room in the Emergency Behavioral Unit (EBU). On 10/26/2024 at 9:54 p.m. Patient #3 departed the EBU and was transferred to another hospital. Review of Patient #3’s observation sheet dated 10/26/2024 revealed in part, documentation of frequent observations continued until 10:45 p.m. In a phone interview on 12/04/2024 at 9:05 a.m. S6Tech stated she didn’t realize Patient #3 had left. S6Tech stated she had multiple patients. S6Tech stated she didn’t realize Patient #3’s observation sheet was with the other observation sheets that she was filling out. S6Tech stated when she realized, she wrote a line through the documented observations and wrote the word gone. In an interview on 12/04/2024 at 10:13 a.m. S1EDD verified Patient #3 departed from the EBU on 10/26/2024 at 9:54 p.m. S1EDD verified the documentation on the observation sheet continued until 10:45 p.m.”

“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: 50453 Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing 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 is evidenced by failure to ensure the Emergency Department Physicians informed the patient, or a legally responsible person acting on the patient’s behalf, in writing of the risks and benefits of the transfer as evidenced by failure to have documented evidence that 1 (#5) of 20 ED patients (#1-#20) (or their responsible party) transferred were informed of the risks and benefits of transfer (see findings in A-2409).”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure the Emergency Department Physicians informed the patient, or a legally responsible person acting on the patient’s behalf, in writing of the risks and benefits of the transfer as evidenced by failure to have documented evidence that 1 (#5) of 20 ED patients (#1-#20) (or their responsible party) transferred were informed of the risks and benefits of transfer. Findings: A review of hospital policy titled “EMTALA Guidelines for Emergency Department Services and Transfer Policy,” last revised 07/2023, revealed in part: “The Hospital may not transfer patients with an emergency medical condition that has not been stabilized when the Hospital has the capability to treat the patient unless the following apply: A physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected form the provision of appropriate medical treatment at the other medical facility outweigh the increased risks to the patient ... The certification must contain a summary of the risks and benefits upon which it is based. A physician certification for transfer must meet these additional requirements: (1) there must be an express written certification (it cannot be implied from the findings in the patient medical record and the fact that the patient was transferred); (2) the certification must state the reasons for the transfer; and (3) the certification must contain a complete picture of the benefits to be expected from care at the receiving facility and risks associated with the transfer, including the time away from an acute care setting necessary to effect the transfer. Appropriate documentation related to a transfer under this section will be included in the patient’s medical record, including any patient request or physician certification related to a transfer.” A review of hospital policy titled “Standards of Care - Emergency Department” effective date 09/07/2023, revealed in part: “X. Transfers to Other Facilities: A. EMTALA transfers: EMTALA transfer guidelines must be followed when transferring patients with emergency medical conditions to another facility. An appropriate EMTALA transfer must include: a. The patient or person acting on behalf of the patient is informed of the risks and benefits of the transfer; c. A physician signed certification that the benefits of the transfer outweigh the risks; d. Consent of physician and facility acceptance from the receiving hospital. C. The following will be completed on all transfers: d. Transfer form.” A review of Patient #5’s medical record revealed that Patient #5 presented to the Emergency Department for stroke symptoms. Patient #5 received treatment in the ED and was transferred to another facility for higher level of care. Review of Patient #5’s medical record failed to reveal that the Emergency Department Physician informed Patient #5, or a legally responsible person acting on the patient’s behalf, in writing of the risks and benefits of the transfer and request for the transfer. Further review failed to reveal a transfer form in Patient #5’s medical record. In an interview on 11/25/2024 at 3:42 p.m., S4EDD confirmed that there was no documentation by a physician that Patient #5, or a legally responsible person acting on the patient’s behalf, was informed of the risks and benefits of the transfer. S4EDD also confirmed that there was no signed transfer form in Patient #5’s medical record.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by: 1.) Failure of the RN to document routine vital signs for 2 (#1, #2) of 3 (#1, #2, #3) patients reviewed; 2.) Failure of the wound care nurse to assess a patient after consultation according to hospital policy for 2 (#1, #2) of 3 (#1, #2, #3) patients reviewed; and 3.) Failure of the RN to review and validate an initial admission assessment conducted by a LPN for 1 (#1) of 3 (#1, #2, #3) patients reviewed. Findings: 1.) Failure of the RN to document routine vital signs for 2 (#1, #2) of 3 (#1, #2, #3) patients reviewed. Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 03/01/2024 and discharged on 03/12/2024 at 2:30 p.m. Review of the physician order dated 03/01/2024 revealed vital signs- routine, unit specific. Review of Patient #1’s documented vital signs revealed the last set of vital signs were documented on 03/12/2024 at 4:00 a.m. In an interview on 03/13/2024 at 8:37 a.m. S3DMS stated the expectations of routine vital signs on the medical surgical unit are to be documented at 5:00 a.m. or 6:00 a.m., at 2:00 p.m., and at 8:00 p.m. In an interview on 03/13/2024 at 9:49 a.m. S3DMS verified Patient #1 should have had vital signs documented at 2:00 p.m. S3DMS verified vital signs should have been documented prior to discharge. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 11/21/2023 and discharged on 01/11/2024 at 8:15 p.m. Review of the physician order dated 01/03/2024 revealed vital signs per routine. Review of Patient #2’s documented vital signs revealed the last set of vital signs were documented on 01/11/2024 at 5:26 a.m. In an interview on 03/12/2024 at 3:52 p.m. S3DMS verified Patient #2 should have had vital signs documented at least at 2:00 p.m. S3DMS stated staff should be documenting vital signs when a patient arrives (admission) and when a patient leaves (discharge) as well. 2.) Failure of the wound care nurse to assess a patient after consultation according to hospital policy for 2 (#1, #2) of 3 (#1, #2, #3) patients reviewed. Review of the hospital’s policy titled “Consults”, revised 08/2023, revealed in part, all non-urgent physician consults should be completed by the consultant within 24 hours of notification. All patient consults within the ICU should be addressed by the consultant within 12 hours of notification. Further review revealed in part, the following consults may be also be generated by practitioner order or nursing assessment: dietitian; physical, occupational, or speech therapy; pharmacist; diabetes education; long term care; rehab; outpatient therapy; home health; social services; enterostomal therapy (wound care). Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 03/01/2024 on the medical surgical unit. Further review revealed a wound care consult dated 03/02/2024 at 12:00 a.m. The wound care nurse’s initial assessment was documented on 03/05/2024 at 3:16 p.m. In an interview on 03/13/2024 at 8:59 a.m. S2DQ verified the wound care nurse’s initial assessment should have been conducted within 24 hours of consult according to hospital policy. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 11/21/2023 on the ICU unit. Further review revealed a wound care consult dated 11/21/2023 at 7:00 a.m. The wound care nurse’s initial assessment was documented on 11/24/2023 at 10:31 a.m. In an interview on 03/12/2024 at 4:08 p.m. S2DQ verified the wound care nurse’s initial assessment should have been conducted within 12 hours of consult according to hospital policy. 3.) Failure of the RN to review and validate an initial admission assessment conducted by a LPN for 1 (#1) of 3 (#1, #2, #3) patients reviewed. Review of Patient #1’s medical record revealed Patient #1 was admitted on 03/01/2024. Review of the initial admission assessment revealed the assessment was conducted on 03/01/2024 at 11:00 p.m. by S4LPN. Further review revealed no documentation of the assessment being reviewed and validated by a registered nurse. In an interview on 03/13/2024 at 10:02 a.m. S1CNO stated a LPN can conduct an initial admission assessment but a RN must review and validate that assessment within 24 hours. In an interview on 03/13/2024 at 10:14 a.m. S2DQ verified there was no documentation in Patient #1’s medical record that a RN reviewed and validated the initial admission assessment.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflected the patient’s goals and the nursing care expected to meet the patient’s needs. This deficient practice was evidenced by the failure to create individualized care plans based on assessments for 2 (#2, #3) of 3 (#1, #2, #3) patients reviewed for completed and updated care plans. Findings: Review of the hospital’s policy titled “Plan of Care - Nursing”, revised 09/2023, revealed in part, A patient-centered care plan will be developed and initiated on all inpatients, to include age-specific elements as appropriate. A registered nurse will develop and initiate the plan of care. Further review revealed in part, Identify patient problems and determine if they are actual problems (acute and/or chronic) or potential problems. A patient who screens positive for fall risk, skin risk, or suicide risk are examples of patients who have a potential problem related to risks and would need preventive interventions included in the plan of care. Add the problems to the plan of care. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 11/21/2023. Review of the nursing assessment dated 11/22/2023 at 7:00 p.m. revealed in part, large discoloration to sacrum and buttocks with erythema around edges with darker non-blanchable areas. No skin breakdown noted. Area clean/dry and sacral dressings intact. Review of the enterostomal therapy nurse assessment dated 11/24/2023 at 10:31 a.m. revealed in part, Wound Location: Sacrum; Wound Type: Pressure; Wound Type Note: Patient found down at home. Wound present on admit; Pressure Wound Stage Note: Presenting DTI noted. Review of Patient #2’s nursing care plan revealed wound care was initiated on 12/12/2023. In an interview on 03/12/2024 at 1:22 p.m. S2DQ verified wound care should have been initiated within 24 hours of admission to Patient #2’s care plan. S2DQ stated wound care was initiated on 12/12/2023. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 03/11/2024. Review of Patient #3’s initial admission assessment revealed in part, partial amputation to left foot, top half amputated. Redressed foot with saline-soaked gauze, kerlix, and coban; clean, dry, intact. Review of Patient #3’s nursing care plan failed to reveal wound care as a part of the plan of care. In an interview on 03/13/2024 at 10:56 a.m. S2DQ verified Patient #3 was admitted with a wound, the admitting nurse documented the wound, and the nurse did not initiate wound care as part of Patient #3’s plan of care.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 44763 Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. Findings: Observation on 03/11/2024 at 4:01 p.m. - 4:24 p.m. of the medical surgical unit revealed peeling paint on the door frame of the bathroom in patient rooms 706 and 702. In an interview during the observation, S2DQ verified the above stated findings.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 44763 Based on observation and interview, the infection control officer failed to ensure the hospital’s system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by the hospital failing to maintain a sanitary environment. Findings: Observation on 03/11/2024 at 10:09 a.m. - 10:38 a.m. of the ICU unit revealed 2 office style chairs with multiple tears in the seat covers in patient room 317 and 2 office style chairs with multiple tears in the seat covers at the desk in the hallway near patient room 3301. Due to the torn seat covers, all 4 chairs could not be disinfected. In an interview during the observation, S5DICU verified the above stated findings.”