Our Lady of the Lake Regional Medical Center

“PATIENT RIGHTS: GRIEVANCE PROCEDURES CFR(s): 482.13(a)(2)(i) [At a minimum:] The hospital must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the hospital. This Standard is not met as evidenced by: 48050 Based on record reviews and interviews, the hospital failed to ensure its grievance procedure was implemented according to hospital policy as evidenced by failure to have documented evidence of the investigation of 1 (#1) of 3 (#1-#3) sampled patients’ medical records reviewed. Findings: Review of the hospital’s policy #1083 titled “Patient Rights, Responsibilities, Complaints, and Grievance Process” last revision effective date 02/18/2025 revealed in part: PURPOSE: To support our patient’s rights and responsibilities and define a process for prompt resolution of patient grievances and complaints. POLICY STATEMENT: Patients shall receive care, treatment and services with compassion and respect that fosters dignity, autonomy, positive self-regard, civil rights and the involvement of the patient, or when appropriate, the patient’s representative in care. DEFINITIONS: An expression of dissatisfaction by the patient, or the patient’s representative, related to a relatively minor issue that can be immediately and effectively identified and addressed on a nursing unit or in the department where it occurred by the staff present. A patient grievance is a formal or informal written or verbal expression of dissatisfaction that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the concern is not resolved at the time reported by staff present), abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation, or a Medicare beneficiary billing issue. Receiving a Patient Complaint: 1. All expressed concerns regarding care or treatment are entered into the approved complaint tracking software program. 2. If someone other than the patient or the patient representative expresses a concern about care or treatment, contact the patient. Investigation of Grievances: 3. The investigation can include but is not limited to speaking with the patient or the patient’s representative, discussing the concern with staff involved, reviewing the medical record, reviewing any appropriate policies and procedures, reviewing any medical or clinical process, performing a physical and/or psychosocial assessment of the patient. 4. Based on the findings of the investigation, appropriate actions to resolve the patient or patient’s representative’s concerns. 8. The investigation should be completed within an average of seven working days from receiving the grievance. If the investigation cannot be completed within seven working days, the hospital may send a written acknowledgement of the concern to the patient or patient’s representative. Review of the hospital’s Grievance Log dated December 2025 to February 2026 did not reveal complaint/grievance for Patient #1. Review of the Patient Assignment Sheet for the Neurology Unit revealed S6RN and S10CNA were assigned to Patient #1 on 12/04/2025. In an interview on 03/02/2026 at 1:30 PM, S10CNA confirmed she administered a soap and water bed bath to Patient #1 while he was in restraints due to being soiled. S10CNA further confirmed that Patient #1 had no complaints during the bath or the shift she worked on 12/04/2025. S10CNA reports it was not until the next day 12/05/2025 that she learned that Patient #1 accused her of throwing hot water on him during the bath, so S10CNA was told not to go back in Patient #1’s hospital room. S10CNA then stated “that lasted a couple of days and then everything was fine and I was allowed back in Patient #1’s room”. In an interview on 03/02/2025 at 2:00 PM, S5DN confirmed Patient #1’s significant other reported on 12/04/2025 while S10CNA was giving Patient #1 a bed bath that Patient #1 reported that S10CNA threw hot water on him burning his skin and scaring him. S5DN reported that she had a discussion with S10CNA regarding the complaint and it was decided S10CNA would not care for Patient #1 anymore. S5DN reported that further patient rounding on Patient #1 didn’t result in any further complaints, so S5DN thought the issue was resolved. S5DN confirmed that Patient #1’s significant other’s complaint was not recorded nor did she speak to Patient #1 due to his limited cognition related to recent CVA.”

“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: 48050 Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. The deficient practice is evidenced by failure of the Registered Nurse to document restraint documentation every 2 hours per hospital policy on 2 (#1, #2) of 2 (#1, #2) patients who had nonviolent restraints ordered. Findings: Review of the hospital’s policy #5165 titled “Restraint and/or Seclusion and Safe Patient Behavior Management” last revision effective date 12/23/2025 revealed in part: PURPOSE: 5. To provide guidelines for the care of patients whose behaviors require the use of restraint or seclusion while ensuring: a. maximum safety, security, and emotional wellbeing of the patient. B. Patient Rights, dignity and wellbeing are supported and maintained. C. Restraint and/or seclusion is discontinued as soon as possible. D. Alternative measures have been utilized as the preferred intervention. E. The use of restraint or seclusion is limited to emergencies in which there is an imminent risk of physically harming self or others, including staff. PROCEDURE: 4. Is performed in a setting in which the patient must be assessed, monitored and reevaluated. RESTRAINT PROCEDURE FOR MANAGEMENT OF THE NON-VIOLENT PATIENT INTERFERING WITH MEDICAL/SURGICAL TREATMENT: 5. Monitoring and Documentation: Monitoring is accomplished by observation, interaction with the patient, or related direct examination of the patient by qualified staff. Documentation of patient observation, range of motion, and neurovascular checks will occur every 3-hour intervals. 6. Discontinuation: Restraint is discontinued when the patient is no longer: a. interrupting medical/surgical care b. interrupting treatment c. interfering with medical devices, tubes, and dressings d. at risk of harming self/others due to medical condition. Review of Patient #1’s medical record revealed Patient #1 was admitted on 11/27/2025 for Acute CVA. Further review of Patient #1’s medical record revealed provider orders for nonviolent restraints for the following dates/times: 11/27/2025 11:51 AM to 11/28/2025 at 11:29 AM, 11/30/2025 4:20 AM to 12/03/2025 at 11:59 PM, and 12/04/2025 4:33 AM to 12/04/2025 at 2:19 PM. Review of Patient #1’s nursing notes regarding restraint Q2H monitoring documentation revealed on 12/04/2025 at 9:00 AM every 2 hour nursing restraint monitoring documentation stopped even though Patient #1’s nonviolent restraints were not discontinued until 2:19 PM. Review of Patient #2’s medical record revealed Patient #2 was admitted on 11/27/2025 for Left Frontal Intraparenchymal Hemorrhage of Brain. Further review of Patient #2’s medical record revealed a provider order for nonviolent restraints for 12/03/2025 at 5:19 AM to 12/04/2025 4:36 PM. Review of Patient #2’s nursing notes regarding restraint 2H monitoring documentation revealed on 12/04/2025 at 11:00 AM every 2 hour nursing restraint documentation stopped even though Patient #1’s nonviolent restraints were not discontinued until 4:36 PM. In an interview on 03/02/2026 at 3:00 PM, S3RNI confirmed the above mentioned information. In an interview on 03/02/2025 at 3:15 PM, S2SDIC confirmed that nursing restraint Q2H monitoring documentation should include the following: visual check, skin assessment, edema assessment, capillary refill, distal pulse, sensation, movement, range of motion, fluids, food/meal, elimination and restraint type.”

“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: 47397 Based on record review and interview the hospital failed to ensure care in a safe setting as evidenced by: 1) failure to provide required monitoring of Patient #1’s vital signs following a fall and prior to the patient being discovered with abdominal compartment syndrome, requiring emergent surgery, and subsequently being pronounced deceased in the operating room; and 2) failure to notify a provider of a change in Patient #1’s physical assessment following a fall and prior to the patient being discovered with abdominal compartment syndrome, requiring emergent surgery, and subsequently being pronounced deceased in the operating room. Findings: Review of hospital policy #OrgClin/031 titled “Patient Assessment / Reassessment” last reviewed on 09/01/2025, revealed in part: “Purpose: To provide guidelines for an interdisciplinary, collaborative approach in assessing, reassessing, planning and providing care to meet each patient’s individualized needs for treatment. Policy: 6. Ongoing reassessment is done through out the course of the patient’s stay with changes to the plan of care as appropriate. Reassessment will be performed in the following situations or as deemed appropriate by the Registered Nurse, in part: a. related to the patient’s course of treatment. c. When a new significant change occurs in patient’s condition.” Review of hospital policy #NN-001 TITLED “Nursing Standards for Patient Care Services”, created 11/22/2025, revealed in part: “Definitions: 1. Nursing-Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of individuals. Standards of practice: 1. Assessment, 4. Planning, 5. Implementation, 6. Evaluation.” Review of hospital document titled “Patient Rights and Responsibilities”, revised 01/2019, revealed in part: “As a patient you have the right to: Security and Safety: Get care in a safe setting that preserves dignity.” 1) Failure to provide required monitoring of Patient #1’s vital signs following a fall and prior to the patient being discovered with abdominal compartment syndrome, requiring emergent surgery, and subsequently being pronounced deceased in the operating room. Review of Patient #1’s medical record revealed an admit date of 12/07/2026 with a history of cerebral palsy, Lennox-Gastaut Syndrome, nonverbal autism and principle problem of seizure disorder. Patient presented to the emergency department with seizures was admitted to the ICU and required intubation on 12/08/2025 due to continued seizures on 12/08/2025. Patients AEDs were adjusted and he was extubated on 12/09/2025. He subsequently developed hypotension and sedation on 12/10/2025 was started on midodrine. He developed hypoglycemia and hypothermia on 12/12/2025, found to have sick euthyroid. His blood pressure, appetite, glycemic control and baseline mental status began to improve and patient was transferred out of the ICU and moved to PCU on 12/13/2025. On 12/14/2025 at 7:35 AM patient was found on the floor in a crawling position beside the bed. Review of Patient #1’s vital signs flow sheet located in the electronic medical record navigated by S3RN in the presence of S2RN, S4RN and S1COM revealed the following in part: 12/14/2025 at 12:05 PM: BP-84/36, Pulse-91, Respirations-23, Sp02-93. Notation: “MD Aware at 12/14/2025 at 12:05 PM”. 12/14/2025 at 12:09 PM: BP-84/34, Pulse-90, Respirations-21, Sp02-98. Notation: “MD Aware at 12/14/2025 at 12:09 PM”. 12/14/2025 at 12:50 PM: BP-112/79, Pulse-108, Respirations-20, Sp02-98. 12/14/2025 at 3:51 PM: Temperature-97.6 12/14/2025 at 4:00 PM: No vital signs taken. 12/14/2025 at 4:20 PM: Pulse-83, Respirations-22, Sp02-99. (No BP taken). 12/14/2025 at 8:46 PM (4 hours and 26 minutes since last vital signs): Blood Pressure-133/98, Respirations-32. No Sp02, or pulse taken. 12/14/2025 at 9:30 PM (44 minutes since last vital signs): Blood Pressure-not taken, Pulse-125, Respirations-22 and Sp02-77. 12/14/2026 at 9:38 PM Physician order for transfer back to ICU. Review of medical record revealed that on the evening of 12/14/2025 at approximately 9:00 PM, Patient #1 was found to be hypoxic and on evaluation was found to have severe abdominal distension. He was emergently intubated and KUB demonstrated diffuse bowel gas. STAT surgery consult was obtained and decision was made to emergently take patient to OR for decompressive laparotomy for abdominal compartment syndrome. The patient suffered cardiac arrest during surgery and was unable to be resuscitated. TOD was called by attending surgeon at 1:03 AM on 12/15/2025. During an interview on 01/21/2026 at 1:28 PM, S2RN stated vital sign measurements should be recorded at least every 4 hours in the PCU. S2RN, S3RN and S4RN confirmed Patient #1’s vital signs were not monitored as required. 2) failure to notify a provider of a change in Patient #1’s physical assessment following a fall and prior to the patient being discovered with abdominal compartment syndrome, requiring emergent surgery, and subsequently being pronounced deceased in the operating room. Review of Patient #1’s Provider Progress Notes dated 12/13/2025 at 9:14 AM revealed the following in part: Physical Exam, in part: abdominal: Abdomen is flat. Bowel sounds are normal. Abdomen is soft. No abdominal tenderness. No guarding. Review of Patient #1’s Provider Progress Notes dated 12/14/2025 at 6:51 AM (approximately 20 minutes prior to nursing assessment at 7:10 AM) all systems negative except for previous day’s dis-impaction. Review of Patient #1’s nursing assessment flow chart located in the electronic medical record navigated by S3RN in the presence of S2RN, S4RN and S1COM revealed the following in part: 12/12/2025-12/13/2025 at 12:00 AM - 9:14 PM in ICU: Abdomen flat and soft for each assessment. 12/13/2025 at 4:43 PM a bowel movement was documented at 4:43 PM. 12/14/2025 in PCU: 4:08 AM: Abdomen flat and soft abd. 7:10 AM (approximately 20 minutes after provider assessment at 6:51 AM): Abdomen rounded, distended, taut, non-tender. 7:35 AM: Patient’s bed alarm noted to be going off. Upon arrival to patient’s room by RNs and nursing assistants patient was found on the floor in a crawling position beside the bed. Physician was notified with no new orders. 12:00 PM: Abdomen rounded, distended, taut non-tender. No indication provider was notified of abdominal distention. 4:00 PM: Abdomen rounded, distended, taut. No indication provider was notified of abdominal distention. 8:45 PM: Abdomen rigid and round with constipation, had a bowel movement. 8:58 PM: Provider Notification: Patient #1 with a pulse of 140s -160s, Spo2 in the 70s, and a rigid abdomen. 9:00 PM: Physician at bedside, Patient #1 was in respiratory distress with a rigid abdomen. A stat consult to general surgery was made. 9:30 PM: Patient #1 intubated. 9:48 PM: surgeon recommended emergent decompression. 11:00 PM: Patient #1 with rigid abdomen and hypotension, physician at ICU bedside. Was emergently taken to OR for decompressive laparotomy for abdominal compartment syndrome. 12/15/2025 at 1:03 AM: Patient #1 deceased. During an interview, S2RN, S3RN, and S4RN verified the above findings. S2RN indicated the nurses might not have notified the provider of Patient #1’s distended abdomen due to this symptom could be expected with recent history of constipation and prior bowel movements.”

“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: 47397 Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by failure to implement orders for seizure precautions in 3 (#1, #3, and #5) of 5 patient records reviewed. Findings: Review of hospital policy# NNA-051 titled “ Implementation of Physician Orders”, created on 10/07/2025, revealed in part: “Purpose: to establish the standard implementation of physician orders in an efficient manner to facilitate and expedite safe patient care. Procedure: 5. During each shift, it is the responsibility of the patient’s nurse to a. Review the medical record for accuracy of electronic or written orders received.” Patient #1 Review of Patient #1’s medical record revealed an admit date of 12/07/2025 with a history including cerebral palsy, Lennox-Gastaut Syndrome, nonverbal autism and principle problem of seizure disorder. Review of physician orders dated 12/13/2025 at 1:48 PM revealed seizure precautions, continuous until specified. Review of Patient #1’s nursing assessment flow chart located in the electronic medical record navigated by S3RN in the presence of S2RN, S4RN and S1COM, failed to reveal the seizure precautions were implemented. Patient #3 Review of medical record revealed an admission date of 12/11/2025 with diagnoses including seizures, nonverbal autism, abdominal distention second to Ogilvie syndrome, cerebral palsy, and functional quadriplegia. Review of physician orders dated 12/12/2025 at 2:46 AM revealed seizure precautions, continuous until specified. Review of Patient #3’s nursing assessment flow chart located in the electronic medical record navigated by S3RN in the presence of S2RN, S4RN and S1COM, failed to reveal the seizure precautions were implemented. Patient #5 Review of medical record revealed an admission date of 01/19/2026 with diagnoses that tincluded profound encephalopathy and suspected uro-sepsis in this patient with paraplegia. Review of physician orders dated 01/19/2026 at 3:19 PM revealed seizure precautions, continuous until specified. On 01/21/2026 at 1:50 PM a review of Patient #5’s nursing assessment flow chart located in the electronic medical record navigated by S3RN in the presence of S2RN, and S4RN failed to reveal the seizure precautions were implemented. During an interview on 01/21/2026 at 2:06 PM, S2RN, S3RN, and S4RN confirmed the above findings. S2RN stated that the hospital did not have a policy or a procedure that speaks to seizure precautions. Seizure precautions were provider driven and often included but was not limited to suction at the bedside and wrapping the bedrails.”

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure medications were controlled and distributed in accordance with applicable standards of practice. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed for appropriateness of the dose, frequency, possible medication interactions, and other contraindications in 1 (Patient #1) of 1 patient records review for pharmacy dose review. Findings: Review of hospital policy #: NMA-024 titled “Medication Administration”, reviewed 04/07/2025, revealed in part: “Policy: A. Medications must be verified by pharmacy prior to their administration by use of the Medication Administration Record and or original Physician’s Orders.” Review of Patient #1’s medical record revealed an admit date of 12/07/2025 with a history including cerebral palsy, Lennox-Gastaut Syndrome, nonverbal autism and principle problem of seizure disorder. Patient was a 22-year-old male with recurrent seizures secondary to lack of medications at home for approximately 3 weeks due to insurance issues. The AEDs he was taking at home included lamotrigine, 100 mg twice a day. On 12/08/2025, patient required intubation secondary to status epilepticus. EEG performed showed tonic-clonic seizure 12/08/2025. His AED’s were adjusted and patient was extubated on 12/09/2025. He developed hypotension and sedation on 12/10/2025 and his AEDs were further weaned. He improved on 12/12/2025 and was moved out of the ICU on 12/13/2025. Review of medication orders dated 12/07/2025 at 12:15 PM revealed the provider ordered lamotrigine, 100 mg twice a day. Although the ordered dose matched the patient’s home regimen, the patient had not taken lamotrigine for approximately three weeks. Per standard titration guidelines, lamotrigine should be restarted at a low dose after an interruption longer than five days to reduce the risk of serious dermatologic and neurological reactions. Review of Patient #1’s MAR revealed lamotrigine 100 mg was administered on 12/07/2025 at 1:40 PM. Continued review failed to reveal the order was reviewed by a pharmacist for appropriateness of the dose, frequency, possible medication interactions, and other contraindications. Review of Patient #1’s physician orders dated 12/07/2025 at 2:57 PM revealed another provider discontinued the lamotrigine 100 mg twice a day and ordered lamotrigine 25 mg twice a day. During an interview on 01/21/2026 at 12:00 PM, S2RN and S3RN confirmed Patient #1 received the 100 mg dose of lamotrigine on 12/07/2026 but were not aware of the standard titration guidelines of lamotrigine. They were not sure if pharmacy reviewed the order before the medication was administered but speculated the medication could not show up on the MAR unless reviewed by pharmacy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(iv) [there must be documentation in the patient’s medical record of the following: ] The patient’s condition or symptom(s) that warranted the use of the restraint or seclusion. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure there was documentation in the medical record of the patient’s condition that warranted the use of 4-point soft restraints for 1 (#1) of 3 patients medical records reviewed. Findings: Review of the hospital’s policy titled “Restraint and/or Seclusion and Safe Patient Behavior Management” last reviewed 06/23/2025 revealed in part: “Philosophy: Whenever restraint must be used, the least restrictive device is utilized. Policy: The patient has the right to be free from restraint or seclusion that is not deemed clinically appropriate and justified. The decision to use restraint or seclusion is not driven by setting or diagnosis, but by a comprehensive individual assessment which concluded that for this patient, at this time, the use of less intrusive measures poses a great risk than the risk of using restraint or seclusion.” Review of Patient #1’s medical record revealed Patient #1 was admitted on 11/01/2025 with an admit diagnosis of circulatory shock. Further review of the medical record revealed an order dated/timed on 11/05/2025 at 4:00 AM for bilateral 4-point soft wrist and ankle restraints. The 4-point soft restraints were discontinued on 11/05/2025 at 11:30 AM. Further review of Patient #1’s medical record revealed Patient #1 was pronounced dead on 11/05/2025 at 1:23 PM. Review of Patient #1’s nursing notes dated 11/05/2025 at 4:12 AM by S3RN revealed a clinical justification for the use of 4-point soft restraints for pulling lines; pulling tubes; removal of equipment; and removal of dressing. Further review of Patient #1’s nursing notes dated 11/05/2025 at 4:14 PM revealed another note documented by S3RN stating Patient #1 was restless with a Richmond Agitation Sedation Scale of +1, but responded and obeyed commands. In an interview on 12/09/2025 at 2:30 PM with S3RN, he verified the only clinical justification documented for the 4-point soft restraints were the following: pulling lines; pulling tubes; removal of equipment; and removal of dressing. S3RN further verified no documentation for clinical justification for the bilateral soft ankle restraints.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure patients were treated in a manner that maintained dignity. The deficient practice is evidenced by failing to remove indwelling tubes and lines postmortem in 1 (#1) of 3 (#1-#3) patients’ medical records reviewed. Findings: Review of the hospital’s policy titled, “Death of a Patient/Autopsy” revealed in part: POLICY: Deceased patients and their families are treated with respect, dignity, and compassion at all times. PROCEDURES: 4. Documentation: The nurse should complete an expiration note in the electronic medical record, indicating the date and time of death, the physician pronouncing the patient deceased, disposition of valuables, and post-death arrangements. Additional documentation will be necessary if the patient’s death is deemed a coroner’s case. 8. Preparation of the Body: a. After the family has left the hospital, the body is prepared and transported on the morgue cart to the morgue. The body is cleansed, all personal valuables are removed, insure that an ID bracelet is placed on the patient, and all indwelling tubes are removed. A paper isolation gown/hospital gown is placed on the body, then the body is placed in a plastic zippered body bag and tags to be placed on great toe, the zipper on the outside of the bag, and on any valuables. Review of Patient #1’s medical record revealed Patient was admitted to MICU on 06/19/2025 and expired on 06/20/2025 at 11:32 AM. Further review of Patient #1’s expiration note revealed in part the following information: Time of Death: On 06/20/2025 at 11:32 AM Pronounced by S11MD Notifications: Coroner; OPO; Funeral Home Date/Time of Coroner Notification: 06/20/2025 at 12:58 PM Not suitable for donation Body released by Coroner: Yes Lines, Drains, Airways: Yes Body Cleaned? Yes Body Preparation: placed in gown, body tagged, body bagged Review of the Patient Care Service Record of Death for Patient #1 revealed The Coroner’s office returned phone call regarding Patient #1’s death at 4:05 PM on 06/20/2025 and released the body. Review of the morgue log Patient #1 was picked up from MICU on 06/20/2025 and transferred to the morgue at 6:00 PM. Further review of the morgue log revealed Patient #1 left the facility by the funeral home at 6:50 PM. On 08/12/2025 at 1:20 AM S1VPPCS verified the above mentioned information, and Patient #1’s indwelling tubes and lines were not removed per hospital policy.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 48051 Based on record review and interview, the governing body failed to ensure that a contractor of services furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This deficient practice was evidenced by the failure to complete pre-employment criminal background checks by an approved Louisiana State Police Authorized Agency, pursuant Louisiana Revised Statues (La. R.S.) and Hospital State Regulations on 8 (S1APOA - S8APOA) of 8 (S1APOA - S8APOA) personnel files reviewed. Findings: Pursuant to La. R.S. 40:1203.1-5, Licensed health care providers shall request that a criminal history and security check be conducted on the non-licensed person, prior to any employer making an offer to employ or to contract with a non-licensed person or any licensed ambulance personnel to provide nursing care, health-related services, medic services, or supportive assistance to any individual. Pursuant to La. R.S. 40:2179 and 2179.1, “Non-licensed person” means any person who provides for compensation nursing care or other health-related services directly related to patient care to residents in or patients of a nursing facility, intermediate care facility for people with developmental disabilities, adult residential care facility or provider, pediatric day healthcare facility, adult day healthcare center, psychiatric residential treatment facility, end stage renal disease facility, behavioral health services provider, home health agency, hospice agency, provider of ambulance services, hospital, adult brain injury facility, crisis receiving center, pain management clinic, outpatient abortion facility, rural health clinic, ambulatory surgical center, therapeutic group home, forensic supervised transitional residential and aftercare facility, case management provider, or home- and community-based service provider and who is not a licensed health provider. “Non-licensed person” also means any person who provides such services to individuals in their own homes as an employee or contract provider of a home health agency, hospice, or home- and community-based service provider. Pursuant to La. R.S. 15:575, The Louisiana Office of State Police, Bureau of Criminal Identification and Information (Bureau), is the State’s designated repository for criminal history information pursuant to the laws cited in La. R.S. 15:575 et seq. Any criminal event that is documented by the submission of fingerprints to the State is stored in the Louisiana Computerized Criminal History (LACCH) database. The Bureau may only release criminal history information stored in LACCH for noncriminal justice purposes when authorized by law. The Bureau is authorized to release criminal history information stored in LACCH to those employers and Authorized Agencies defined in La. R.S. 40:1203.1 as required by La. R.S. 40:1203.2. Pursuant to La. R.S. 40:1203.7, Authorized Agencies must be domiciled in the state of Louisiana and must be certified by the La. Secretary of State’s office. Authorized Agents must also be certified by the Bureau. Companies that perform background check services that are not domiciled in Louisiana nor certified through the Secretary of State’s office and the Bureau are not authorized to request or receive criminal history information stored in LACCH. A personnel file review of S1APOA - S2APOA revealed pre-employment criminal background checks completed for each of the before mentioned personnel by Company A. A review of the list of approved Louisiana State Police Authorized Agencies did not reveal Company A. In an interview on 04/09/2025 at 3:40 PM, S2VP confirmed the above mentioned findings and confirmed the facility should be using an approved state police authorized agency.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 50453 Based on record review and interviews, the hospital failed to ensure the patient rights were protected. This deficient practice is evidenced by failing to comply with the documented directives of the patient and informing the representative of an injury discovered while admitted to the hospital. Findings: Review of hospital policy titled “Patient Rights, Responsibilities, Complaints, and Grievance Process,” last reviewed: 02/01/2024, revealed in part: “POLICY: Patients shall receive care, treatment and services with compassion and respect that fosters dignity, autonomy, positive self-regard, civil rights and the involvement of the patient, or when appropriate, the patient’s representative in care. The patient, or when appropriate the patient’s representative are informed of patient’s rights in advance of furnishing or discontinuing patient care whenever possible.” Review of hospital organizational policy titled “Advance Directives,” last approved: 05/07/2018, revealed in part: “PURPOSE: To acknowledge and respect the patient’s right and responsibility to determine his or her own level of health care, and honor and abide by a person’s decision to have life-sustaining procedures withheld or withdrawn in instances where such persons are diagnosed as having a terminal and irreversible condition. In furtherance of this purpose, this policy is implemented to educate patients and their caregivers on the availability of various forms of Advanced Directives and to facilitate the execution of these documents for patients and/or their families wishing to do so. POLICY: In compliance with Louisiana and federal law, and the Ethical and Religious Directives for Catholic Healthcare Services, FMOLHS will provide patients with information regarding Advance Directives and resources for assistance in formulating Advance Directives upon request, promote the use of Advance Directives during a patient’s hospitalization, emergency care, residential care in nursing facilities or outpatient care and treatment, document patient Advance Directives in the patient’s medical record, and honor the patient’s Advance Directive.” Review of Patient #1’s medical record revealed that Patient #1 was admitted 10/14/2024 after a fall that resulted in a left femur fracture requiring surgery. Patient #1 also arrived with a previously diagnosed closed left calcaneal fracture from an injury at home. Patient #1’s medical record revealed that Patient #1 had an active Medical Power of Attorney on file, listing her sister as POA. Further review revealed Patient #1 had the following medical diagnoses: ESRD with dialysis, Hypertension, Type 2 Diabetes, Schizophrenia, CHF, Vitamin D Deficiency, Hypercalcemia, Hyperparathyroidism, and Hypermagnesemia. On 10/21/2024 Patient #1 was placed on a PEC for being gravely disabled. On 10/22/2024 Patient #1 was deemed medically appropriate to discharge to the inpatient psychiatric unit, and was admitted to the inpatient psychiatric unit on 10/23/2024. Review of Patient #1’s nursing documentation revealed an assessment on 11/05/2024 at 7:30 AM documenting that Patient #1 had swelling noted to her left hand. On 11/05/2024 at 11:42 AM a provider notification note was entered for evaluation of left hand pain. Further review of Patient #1’s medical record failed to reveal documentation that Patient #1’s legal representative was notified of the injury. Review of Patient #1’s provider notes revealed an orthopedic consult note on 11/05/2024 at 7:48 PM which revealed an x-ray was obtained of the left hand. Patient #1’s x-ray of the left hand revealed a fracture to the 4th metacarpal. The orthopedic provider documented due to patient significant past medical history, we will treat this non-operatively. Further review of Patient #1’s provider notes failed to reveal documentation that Patient #1’s legal representative was notified of the injury. In an interview on 12/17/2024 at 2:52 PM, S2DOQ and S3INF confirmed that there was no documentation in Patient #1’s medical record that their representative was informed of the injury that was discovered on 11/05/2024 while admitted to the hospital.”

“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: 50453 Based on record review and interviews, the hospital failed to track all adverse patient events. This deficient practice is evidenced by failure of the hospital staff to complete an incident report after a patient injury while admitted to the hospital. Findings: A review of hospital policy titled “Safety Event (Incident or Variance) Reporting,” last reviewed: 11/13/2024, revealed in part: “Purpose: The purpose of this policy is to establish a systematic and consistent approach for reporting safety events that occur within Our Lady of the Lake Health. The aim is to ensure all safety events are reported, analyzed, and addressed in a timely manner to prevent recurrence and improve patient safety. Definitions: B. Safety event (variance or incident) - any occurrence, which deviates from policy or procedure of the hospital, interrupts orderly routine care, or exposes the hospital to risk. a. Near Miss Safety Event - refers to an event that could have resulted in harm to a patient but did not. b. Actual Safety Event - a safety event which reaches a patient and may result in no harm, temporary harm, severe harm, or death. Refers to an event which impacts the patient in such a way that the patient may require additional treatment or monitoring, prolonged hospitalization, or where the patient has experienced serious physical or emotional harm or death. Patient Safety Event: Reporting Process: 4. Safety event reports are reviewed by quality outcomes analyst or other designated personnel and assigned to an appropriate department for investigation and analysis. Appropriate supervisory and management personnel are notified of the event through the safety event reporting system. 5. Investigation of the safety event is completed and documented by the appropriate leader, appointed delegate or subject matter expert within time frames as set forth by the safety event management workflow.” Review of Patient #1’s medical record revealed a diagnosis of ESRD with dialysis, Hypertension, Type 2 Diabetes, Schizophrenia, CHF, Vitamin D Deficiency, Hypercalcemia, Hyperparathyroidism, Hypermagnesemia, and a left calcaneal fracture. Patient #1 was admitted to the inpatient psychiatric unit on 10/23/2024 after inpatient treatment for a left femur fracture. Review of Patient #1’s nursing documentation revealed on 11/05/2024 at 7:30 AM an assessment documented that Patient #1 had swelling noted to her left hand. The provider was notified and an x-ray was ordered of the left hand. Further review of Patient #1’s medical record failed to reveal nursing documentation of what led to the injury. Review of Patient #1’s provider notes revealed an orthopedic consult note on 11/05/2024 at 7:48 PM. The x-ray results of the left hand revealed a fracture to the left 4th metacarpal. The Orthopedic consult note also revealed they were consulted after Patient #1 was trying to adjust herself in bed last night when she felt a hand pain and then this morning the nurse noticed it was swollen and painful. Review of the list of incident reports provided failed to reveal an incident report involving Patient #1. In interview on 12/17/2024 at 1:30 PM, S7SDNM confirmed there was not an incident report completed for Patient #1 on 11/05/2024 following the injury. In an interview on 12/17/2024 at 2:40 PM, S3INF confirmed there were no nursing notes documented about the incident in Patient #1’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: 50453 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 (#1) of 3 (#1-#3) patient records reviewed. Findings: A review of hospital policy titled “Special Precautions,” last reviewed 06/27/2024, revealed in part: “PURPOSE: To ensure that a decision-making process is used which includes, ongoing assessment of patient need for special precaution monitoring, goal setting within the plan of care, use of alternative strategies, documentation of continued need for special precautions by the nurse every 4 hours and by the psychiatrist daily, reassessment, monitoring and discontinuation of special precautions.” Review of the Behavioral Patient Observation Record for Patient #1 revealed the registered nurse failed to review and sign the following observation records every 4 hours within the timeframes below: 11/01/2024 between 12:00 PM - 7:30 PM 11/02/2024 between 12:00 AM - 6:45 AM and 11:00 AM - 7:00 PM 11/03/2024 between 7:30 AM - 7:30 PM 11/04/2024 between 7:00 AM - 6:45 PM 11/08/2024 between 2:30 PM - 7:30 PM 11/09/2024 between 12:00 PM - 7:15 PM 11/10/2024 between 12:00 AM - 7:00 AM 11/11/2024 between 2:15 PM - 7:15 PM 11/17/2024 between 11:00 AM - 7:00 PM In an interview on 12/17/2024 at 2:37 PM, S3INF and S4DIP confirmed the findings mentioned above.”

“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 medical 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 1 (#15) of 20 (#1-#14, #16-#20) being transferred to another facility when the transferring hospital had the capability and capacity to provide services. (see findings tag 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 medical record review and interviews, the hospital failed to provide documented evidence to indicate an appropriate transfer was provided for 1 (#15) of 20 patients who presented to the hospital ED with an emergency medical condition. This failed practice was evidenced by Patient #15 being transferred to another facility when the transferring hospital had the capability and capacity to provide services. Findings: Review of hospital policy, “Treatment and Transfer of Individuals Requesting/In Need of Emergency Medical Services,” last reviewed 04/19/2024, revealed in part: Patient Request: When a patient (patient representative) requests a transfer, the request must be documented. The transfer may then occur if the ... legal representative: (a.) makes a request for transfer to another medical facility ... (b) acknowledges his or her request and understanding of the risks and benefits of the transfer ... Physician Certification: Physicians who request to transfer a patient (non-patient request) from the Emergency Department to another healthcare facility will have the request reviewed by the House Manager and the Emergency Physician who requested the consult. If their review is in conflict with the physicians request to transfer, the Chief Medical Officer and the Administrator on Call review may preclude the actual transfer ... and other specialties/subspecialties not available at OLOLRMC are reviewed and approved by the attending physician. If medical treatment has been provided within available capabilities and it is determined to be in the best interest of the patient to transfer to another facility: * Patient condition will be stabilized to the point that within reasonable medical probability, no material deterioration will occur during or as the result of transfer. Review of Patient #15 medical record revealed that the patient was a 3 year old with a history of short gut syndrome. Further review revealed the following nursing documentation: Patient #15 arrived on 05/27/2024 at 7:14 a.m. with a chief complaint of a vascular access problem. Bedside glucose was 62 at 7:25 a.m. Dextrose 10% IV Bolus and Dextrose 10 IV infusion initiated by 8:18 a.m. 10:09 a.m. Surgery at bedside. 10:24 a.m. Nurses Note: Per surgery resident, “family has chosen to have their care done at Hospital “B,” they can do the central line care there as well, we are no longer taking care of him.” Surg at bedside. Provider notified. 11:23 a.m. Nurse free text note: Surgery refusing to repair central line after “popping” the line, S4EDMD at bedside explaining to father transfer to Hospital “B.” 12:29 p.m. - Patient left Our Lady of the Lake Regional Medical Center Children’s Hospital. Review of the documentation by the ED provider revealed the following ED Course: 7:44 a.m. - On examination patient is awake and crying. Vital signs are stable. Afebrile. Heart is regular rate and rhythm. Lungs are clear. G-tube placed into anterior abdomen. Central line placement to the left side chest wall- no surrounding skin changes. Ostomy bag in place- no leakage present. Differential diagnosis consist of but not limited to hypoglycemia, dehydration, electrolyte abnormality, central line malfunction. 8:26 a.m. - Half of tPA placed in line- unable to flush. Will try again 8:49 a.m. - CBC does not show a leukocytosis. Hemoglobin is 15.4 higher than his baseline, could be from hemoconcentration/dehydration. CMP does not show any signs of acute kidney injury. Patients LFTs are slightly elevated-these are higher than his baseline. CO2 is 18- patient is receiving continuous fluids. On arrival patient’s blood glucose was 62- patient received a D10 bolus and a D10 normal sodium drip. 9:02 a.m. - Able to insert remainder of tPA into the line. 9:32 a.m. - Unable to flush central line. 9:52 a.m. - Patient has had his central line replaced multiple times at our facility. General Surgery consulted. 10:48 a.m. - General surgery at bedside- resident attempted to flush the line and it popped. General surgery resident informed the nurse that father wants to go to Hospital “B” for their care and they will not replace the line here. After speaking to the father- he states he never said he wanted to go to Hospital “B.” States patient always has his central line replaced here along with receiving majority of his care at our facility. 11:21 a.m. - General surgery states that they will not replace patient’s central line and that patient needs to be transferred to Hospital “B” where patient has received care in the past. Patient was hypoglycemic from not receiving his TPN overnight- currently on a D10 drip. 11:27 a.m. - Will call Hospital “B” to initiate transfer. 11:37 a.m. - Accepted at Hospital “B.” Diagnosis: 1. Problem with vascular access 2. Clotted dialysis access, initial encounter (HCC) 3. Hypoglycemia. Disposition and Plan: Transfer to another facility. Review of Patient #15’s Plan of Care - Encounter Notes by S12GSMD (General Surgery) at 05/27/2024 10:42 a.m. revealed the following: Patient is a Ochsner short bowel multidisciplinary patient and has all care coordinated through GI and surgery in New Orleans. Patient does not require emergent intervention presently. Should be transferred to his primary care givers and primary surgeon who performed his recent intestinal surgery. Signed by S12GSMD at 10:45 a.m. on 05/27/2024. Review of Patient #15’s Transfer Record revealed the reason for transfer was service or qualified clinical personnel unavailable. Further review revealed the following: Patient condition: Patient is stable. Benefits of transfer: Clinical personnel of receiving facility are capable of providing the level of care needed; Hospital resources available at receiving facility. Further record review revealed that during the 4 hours following the Dextrose bolus and the initiation of the Dextrose infusion, the blood glucose of the patient was not rechecked prior to departure from facility to ensure patient was stable for transfer. Initial documented bedside Blood Glucose of patient was 62 at 7:25 a.m. on 05/27/2024. In an interview on 06/12/2024 at 1:54 p.m. with S4EDMD stated surgeon S12GSMD had capability of replacing and/or inserting central line at Our Lady of the Lake Regional Medical Center Children’s Hospital. In a phone interview on 06/12/2024 at 2:26 with S11EDRES revealed in part: She spoke with Surgeon who told the nurse the patient’s father wants to go to Hospital “B.” S11EDRES states, “I thought this was strange and when I spoke to the dad about it, he said that wasn’t true.” S11EDRES called surgeon back and said to send him Hospital “B” because that is where his specialist are and he should go there to get it done.” S11EDRES stated patient was not stable because the patient was hypoglycemic and had to be put on a D10 drip to get blood glucose up. In a phone interview on 06/12/2024 at 3:40 p.m. with S12GSMD revealed the following statements in part: “I did not see the patient. I was called about the patient and spoke to the ED provider/resident.” S12GSMD stated the surgery resident saw the patient. S12GSMD stated he didn’t remember which surgery resident saw the patient. S12GSMD stated that over the past month, they have had conversations regarding this patient with GI due to the patient being a “complex patient.” “We decided that since this patient is so complex” and most of his procedures have been done with Hospital “B.” “It is in the best interest for this patient to receive care at Hospital “B.” S12GSMD stated, “If he had an emergency and was not stable, then we will care for him. He didn’t have an issue that kept him from being transferred to Hospital “B.” I’m not going to do simple minor things anymore for him, because he is more complex and his care has been shifted to Hospital “B.” “Just about everyone in our group has done a procedure on him at some point, and every time we operate there is something else.” “If he comes in for something that is not emergent, he will be transferred to Hospital “B” where his team is.” In an interview on 06/12/2024 at 1:28 p.m. S2VPPCS verified that on 05/24/2024 Our Lady of the Lake Regional Medical Center Children’s Hospital was not at capacity and had the capability to care for patient #15. S2VPPCS also verified at this time that S12GSMD is credentialed for central line placement at Our Lady of the Lake Regional Medical Center Children’s Hospital.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure patient complaints were recognized as grievances. This deficient practice was evidenced by failing to correctly identify patient grievances for 1 (#2) of 1 (#2) patients reviewed for complaints/grievances from a total patient sample of 4. Findings: Review of the hospital policy titled, Patient Rights, Responsibilities. Complaints, and Grievance Process, revealed in part, “Grievance” is a formal or informal written or verbal expression of dissatisfaction that is made to the hospital by a patient or the patient’s representative, regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issue related to the hospital’s compliance with CMS Hospital Condition of Participation, or Medicare beneficiary billing issues. Review of hospital document titled “Weekly Grievances” revealed inclusion of grievances dated 09/07/2023-12/18/2023. Further review failed to reveal Patient #2 was included on the “Affected Person” list of the Grievance document. In an interview on 12/27/2023 at 8:20 a.m., Patient #2 stated he submitted two verbal complaints over a month ago. One was with the billing department and the other with the hospital grievance department. Patient #2 reported he expected contact from the hospital regarding the grievances he submitted and was surprised he had not had a representative from the hospital contact him regarding his concerns. Patient #2 reported he received a new hospital invoice showing the hospital reversed the charges originally invoiced to him for the second surgery required to remove the surgical needle that was found after his first surgery was completed. In an interview on 12/19/2023 at 11:15 a.m., S7RM stated that the hospital did not initiate the grievance process because the incident disclosure was located in Patient #2’s chart.”

“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: 47397 Based on record review and interview, the hospital failed to ensure each patient received care in a secure setting. This deficient practice is evidenced by: 1) failure to ensure that contracted non-licensed security personnel had completed criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for all non-licensed personnel; 2) failure to ensure the LDH- Louisiana Adverse Action List Search website was reviewed before hire and every six months for all non-licensed contracted security personnel; 3) failure to ensure staff and patients were protected from infectious disease as evidenced by failure to assure all contracted security personnel files had documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II. Findings: 1) Failure to ensure that contracted security personnel completed criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for all non-licensed contracted security personnel. Review of S4SEC’s human resource file revealed a hire date of 09/2023. Further review failed to reveal evidence of a completedcriminal background check . 2) Failure to ensure the LDH- Louisiana Adverse Action List Search website was reviewed before hire and every six months for all non-licensed contracted security personnel. Review of S4SEC’s human resource file failed to reveal evidence that the Adverse Action List Search website was reviewed before hire. 3) Failure to ensure all contracted security personnel files had documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II. Review of S4SEC’s human resource file failed to reveal evidence that S4SEC was screened for Tuberculosis and was provided annual educational information explaining the health concerns, signs, symptoms, and risks of Tuberculosis. In an interview on 12/19/2023 at 2:35 p.m., S6RM verified the hospital did not have documented evidence of completed criminal background checks and reviews of Adverse Action List Search website for any of the contracted security personnel. S6RM confirmed the hospital did not have documented evidence that each contracted security personnel was screened for Tuberculosis and was provided annual educational information explaining the health concerns, signs, symptoms, and risks of Tuberculosis.”