Baton Rouge General Medical Center

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48050 Based on record review and interview the facility failed to ensure consent to treatment was documented according to hospital policy. The deficient practice is evidenced by failure to complete the informed consent for a surgical procedure per hospital policy in 1 (#3) of 3 records reviewed. Findings: Review of the hospital’s policy number RI-245 titled “Informed Consent” last reviewed on 08/2024 revealed in part: “PURPOSE: To establish guidelines for obtaining informed consent from a patient prior to any medical or surgical procedure. DEFINITIONS: Informed consent: The patient or person authorized by law to consent to medical treatment for such patient, is given, in a language or meaning of communication he/she understands, the information, explanations, consequences and options need in order to consent to a procedure or treatment. 2. Emergent situation- A situation written: (1) in competent medical judgement, the proposed surgical or medical treatment or procedures are reasonably necessary; and (2) a person authorized to give consent is not readily available, and any delay in treatment could reasonably be expected to jeopardize the life or health of the person affected or could reasonably result in disfigurement or impair facilities. POLICY: 3. An informed consent is required on: A. Operations or invasive procedures/treatments B. All procedures in which anesthesia is used. 8. Consent for treatment when the patient is unable to consent, and no responsible relative can be located: A. Emergent Situations: if, in the opinion of treating physician, there exists an emergency situation requiring surgical/medical treatment, the physician should note this situation in the medical record and proceed with the surgery/medical treatment.” Review of Patient #3’s medical record revealed Patient #3 was admitted on 08/10/2026 for Chest Pain. Review of Patient #3’s emergency department (ED) medical record revealed Patient #3 presented to the ED on 08/10/2026 at 2:44 AM with chest tightness, so diagnostic testing was performed revealing Patient #3 had a diagnosis of STEMI and was treated with aspirin, cardiology consult, and cath lab activation. The ED medical record did not indicate the treatment plan and/or risk/benefits was discussed with Patient #3. Review of Patient #3’s medical record revealed the Cardiologist’s history & physical revealed Patient #3’s mental status documented as alert and oriented to person, place, time and situation. Cooperative. Memory function normal for age. Normal judgement and insight. Further review of Patient #3’s Cardiologist’s history & physical plan revealed in part: patient was taken emergently for coronary angiography and primary angioplasty on 08/10/2026 at 4:02 AM. There was no documentation in the Cardiologist’s history & physical that the procedure and/or risk/benefits of surgical intervention was discussed with Patient #3 or that informed consent was obtained. In an interview on 08/12/2026 at 9:30 AM, S3RNMIB confirmed the above-mentioned information and also reported S6CLD stated informed consent was not needed for emergency procedures.”

“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: 48050 Based on record review and interview, the hospital failed to ensure the medical record contained documentation as to whether or not the patient had an advanced directive in 3 (#1-#3) of 3 medical records reviewed. Findings: Review of the hospital’s policy number BS-135 titled “Registration Staff’s Guide to Advance Medical Directives” last reviewed 05/2024 revealed in part: “PURPOSE: To define the registration staff procedure for issuing Advance Medical Directives information to patients. POLICY: In the course of registration, all patients must be asked if they have Advance Medical Directives. Patients with Advance Medical Directives will be requested to bring a copy to the hospital to be placed in their Medical Record.” Review of the hospital’s policy number RI-210 titled “Advance Medical Directive” last revised date of 06/2024 revealed in part: “PURPOSE: To determine if patients have, or would like to declare, their intent for care through an Advance Medical Directive (AMD). PROCEDURE: 1. Business services- During the pre-registration/registration process for all patients the Business Services personnel will encourage patients who have AMDs to bring a copy for their medical record. 2. Health Information Management (HIM)- HIM will maintain the AMDs placed in patient’s medical records. 3. Social Services- When information about an AMD is requested, a social worker can be triggered to meet with the patient and provide them with literature and education. 9. If there are ethical concerns about the AMD and or healthcare power of attorney documents, an ethical consult may be considered. If there are concerns about the validity of the AMD and or healthcare power of attorney documents, consult the Legal Department.” Review of the hospital’s education that is provided to staff upon hire and annually revealed education on Informed Consent and Advance Directives. Review of the education on Informed Consent and Advance Directives revealed in part the following: There are two kinds of advance directives: living will and medical power of attorney (POA). A living will is a document that takes effect when a person has a terminal illness and cannot make care choices. It describes a person’s wishes for their care if they cannot communicate them. It lets families and healthcare providers know what they want. A medical POA is a document that gives someone the power to make care choices for the person receiving care. In an interview on 08/12/2026 at 11:15 AM S1DPE confirms the staff education confirms there are two kinds of advance directives: living will and medical power of attorney (POA). S1DPE further confirms hospital staff does not ask about POAs upon admission of patients. Review of Patient #1’s medical record revealed Patient #1 was admitted on 08/08/2026 and Patient #1’s advance directive was not updated since 12/11/2023 which stated patient does not have an advance directive. Review of Patient #2’s medical record revealed Patient #2 was admitted on 06/16/2026 and Patient #2’s advance directive was not updated since 05/30/2019 which stated patient does not have an advance directive. Review of Patient #3’s medical record revealed Patient #3 was admitted on 08/10/2026 and Patient #3’s advance directive was not recorded. In an interview on 08/11/2026 at 3:15 PM, S4DCC confirmed advance directives should be verified/updated for each patient that presents to the hospital for treatment. S3DCC further confirms the above-mentioned findings.”

“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: 48051 Based on observation, record review and interview, the hospital failed to ensure care in a safe setting as evidenced by the failure to observe 1 (#2) of 3 sampled patients as ordered by the physician. Findings: A review of hospital policy titled, “Observation of Patients,” policy number: BHS TX NSG 11, last revised 07/2024 and last reviewed 09/2025, revealed in part: “POLICY: 1. All Psychiatric patients on BHU are observed for location and activity/behavior at least every 15 minutes. This level of observation may be increased to 1:1 observation based on physician/LIP assessment and order in coordination with the RN. 15-Minute Observations 1. At least every 15 minutes a member of the nursing staff (i.e., Mental Health Tech (MHT), Patient Care Associate (PCA), Licensed Practical Nurse (LPN), or Registered Nurse (RN) or other appropriately trained personnel (i.e., Medical Social Worker (MSW), Recreational Therapist (RT), Intern, Unit Secretary or Patient Observation Technician (POT) as designated by the Charge Nurse, shall observe the patient.” Observations of recorded video captured by Camera 414, dated 01/08/2026 revealed recorded video captured from this camera which was mounted in the hallway across from Room “a’s” entry door. This camera angle captured the door and when the door was open, it captured a limited view of the interior of Room “a” - the left side of room including the leg half of the bed. Camera 414 recorded video revealed from approximately 12:30 a.m. to approximately 1:30 a.m. the door of Room “a” remained closed and the motion activated recording of Camera 414 did not sense any activity or movement to record. Observations of recorded video captured by Camera 4th Rear Middle Hall (which was located approximately 10 - 15 feet from this doorway) during the previously mentioned timeframe failed to reveal a staff member approach or open Room “a” door to observe Patient #2. A review of Patient #2’s medical record revealed a provider order as “BHU: OBSERVATION - EVERY 15 MIN,” being submitted on 12/25/2025 at 3:43 a.m. by S8RN as a telephone order from S11MD. A review of a document title, “Baton Rouge General OBSERVATION FLOW SHEET,” dated 01/08/2026 revealed the following observation performances being documented during the previously mentioned and corresponding timeframe (12:30 a.m. to 1:30 a.m.) as follows: 12:30 a.m. L (= Location): 1 (Code correlated to “In Room”), A (= Activities): 19 (Code correlated to lying) and 24 (Code correlated to Eyes Closed (Respirations Noted)), I (= Staff Initials): S9MHT; 12:45 a.m. L: 1, A: 19 and 24, I: S9MHT; 1:00 a.m. L: 1, A: 19 and 24, I: S9MHT: 1:15 a.m. L: 1, A: 19 and 24, I: S9MHT: and 1:30 a.m. L: 1, A: 19 and 24, I: S9MHT. During this timeframe, the corresponding recorded video failed to reveal the performance of these documented observations of Patient #2 being performed. The failure to perform observations per provider order has the potential to negatively impact the patient’s safety. In an interview on 02/09/2026 at 10:20 a.m. S2COO, S3RD and S4DBHS confirmed Patient #2 was not being observed and monitored per provider order and the potential impact to patient safety.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(C) A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort) This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the hospital failed to ensure 1 (#2) of 3 patients had a physician’s order for the use of force (restraint) to be applied to the patient to receive an intramuscular (IM) injection of a psychotropic medication. Findings: A review of hospital policy titled, “Restraint and Seclusion,” policy number: TX-510, effective: 06/87, last reviewed 12/2024 and last revised 09/2025, revealed in part: “PURPOSE: To define guidelines for appropriate therapeutic and safe use of restraint and/or seclusion that supports the patient’s health, welfare, safety, rights, and personal dignity. DEFINITIONS: Physical Restraint: Any manual method, physical or mechanical device, material, equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Generally, if the patient can remove a device intentionally in the same manner they were put on, the device would not be considered a restraint.” Observations of recorded video captured by Camera 414, dated 01/08/2026 from 1:34 a.m. to 1:48 a.m., revealed the recorded video captured from a camera mounted in the hallway across from Room “a’s” entry door. This camera angle captured the entry door and when the door was open, a limited view of the interior of Room “a” - the left side of room including the leg half of the bed. This recorded video revealed nursing staff having to forcibly open the entry door of Room “a” (Patient #2’s assigned room) at approximately 1:34:33 a.m. Once the door was opened, it was determined Patient #2 had pushed Room “a’s” weighted mental health chair next to the entry door of the room. This position of the chair blocked the entry door and inhibited opening when pushed upon from the hallway side of the door. Upon the door being forcibly pushed open by S5RN, recorded video revealed Patient #2 sitting at the foot of her bed facing the doorway and camera angle. S5RN and Patient #2 appeared to be conversing with one another, but the topic of the discussion was not known because the recorded video does not include audio. Further this staff member had been terminated so unavailable for interview. From 1:37 a.m. to 1:46 a.m., the recorded video revealed Patient #2 wandering in and out of her room; opening and closing Room “a’s” door; appeared to be in conversation (with simultaneous arm movement) with someone not viewable on the recorded video; and at times walked away from this camera’s view. A review of recorded video captured during this same time frame from a camera identified as, Camera 4th Rear Middle Hall, and captured the entire length of this hallway, revealed Patient #2 wandering up and down the hallway, appeared to be in conversation (with simultaneous arm movement), although this camera view identified another person was not around the patient. At approximately 1:46:23 a.m., Camera 4th Rear Middle Hall revealed S6RN and S10SG approach Patient #2 in the hallway. The 2 staff members place their hands on the patient and begin to lead or escort her to Room “a.” Camera 415 revealed Patient #2 being returned to Room “a” under the escort of S6RN and S10SG with S7RN and S8RN following. The patient did not resist, however it did appear the patient was being hastily directed by the staff. The patient was positioned sitting at the foot of her bed, facing the entry door and then placed laying on her left side with her feet hanging on the side of the bed. At approximately 1:46:39 a.m. the staff began to physically hold the patient to receive an injection. S10SG was leaned over the foot board with both arms extended and exerting pressure on the right arm and right side of her body, S6RN was standing toward the side of the bed and appeared to be holding her left arm, S7RN was holding her legs, and S8RN was administering the medication injection into the patient’s left hip area. S6RN and S7RN released hold of the patient at approximately 1:47:05 a.m., however S10SG does not release his hold on the patient until approximately 1:47:57 a.m. While S10SG was holding the patient, her head rose at one point, in what appeared to be an attempt to sit up but was unsuccessful because of the physical hold taking place. A review of Patient #2’s medical record revealed a provider order entered on 12/29/2025 for olanzapine (Zyprexa) 10 mg intramuscular injection, twice daily as needed, with an indication for psychiatric disorder and the following comments, “ONLY TO BE GIVEN IM NON REDRIECTABLE PSYCHOSIS INCLUDING AGITATION.” A review of the “Medication Administration History Report,” revealed the administration of Zyprexa 10mg intramuscular (IM) to the left ventrogluteal during the above-mentioned time frame (Documented administration time for 1:59 a.m.). A review of S8RN’s shift note entered on 01/08/2026 at 5:37 a.m. revealed in part, “ ...The pt was compliant with medication although she will only take them after looking at each on and opening them. Pt states she does not trust us. During night rounds, it was observed that she placed a chair in front of the door and refused to let staff enter. Eventually, the door was opened. Afterwards, pt was found entering other patients’ rooms and pacing the hallways while yelling. She was unresponsive to redirection. At 0159, a PRN dose of Zyprexa IM was administered in the left ventrogluteal, the medication was ineffective. The patient continued to enter other patient’s rooms, and when staff attempted to redirect her, she grabbed a staff member’s face and scratched him, also throwing herself to the floor. Psych on-call was contacted, and a one-time dose of 5mg Versed was ordered but not administered. The pt eventually returned to her room. She did not sleep tonight.” Further review of the medical record failed to reveal the administration of the Zyprexa injection had to be accomplished by the patient being held by 3 staff members and failed to reveal a provider order for the use of force to administer the medication. In an interview on 02/10/2026, S2COO, S3RD, S4DBHS, and S5RNNM confirmed the patient was being held for the administration of a medication. However, they did not agree this hold would constitute the patient being restrained or the use of force to administer the medication. S2COO further indicated this technique was used for the safety of the staff while administering the medication.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 48051 Based on observations, record reviews and interviews, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance with patient safety as evidenced by the failure to monitor the performance of patient observations taking place per provider order. Findings: A review of hospital policy titled, “Observation of Patients,” policy number: BHS TX NSG 11, last revised 07/2024 and last reviewed 09/2025, revealed in part: “POLICY: 1. All Psychiatric patients on BHU are observed for location and activity/behavior at least every 15 minutes. This level of observation may be increased to 1:1 observation based on physician/LIP assessment and order in coordination with the RN. 15-Minute Observations 1. At least every 15 minutes a member of the nursing staff (i.e., Mental Health Tech (MHT), Patient Care Associate (PCA), Licensed Practical Nurse (LPN), or Registered Nurse (RN) or other appropriately trained personnel (i.e., Medical Social Worker (MSW), Recreational Therapist (RT), Intern, Unit Secretary or Patient Observation Technician (POT) as designated by the Charge Nurse, shall observe the patient.” A review of the hospitals 2025 and 2026 (year to date) Quality Improvement Activities failed to reveal activities or data related to observation check performance being monitored, tracked and analyzed for the performance of patient observations being performed by the staff member visually observing the patient. Observations of recorded video captured by Camera 414, dated 01/08/2026 revealed recorded video captured from this camera which was mounted in the hallway across from Room “a’s” entry door. This camera angle captured the door and when the door was open, it captured a limited view of the interior of Room “a” - the left side of room including the leg half of the bed. Camera 414 recorded video revealed from approximately 12:30 a.m. to approximately 1:30 a.m. the door of Room “a” remained closed and the motion activated recording of Camera 414 did not sense any activity or movement to record. Observations of recorded video captured by Camera 4th Rear Middle Hall (which was located approximately 10 - 15 feet from this doorway) during the previously mentioned timeframe failed to reveal a staff member approach or open Room “a” door to observe Patient #2. A review of Patient #2’s medical record revealed a provider order as “BHU: OBSERVATION - EVERY 15 MIN,” being submitted on 12/25/2025 at 3:43 a.m. by S8RN as a telephone order from S11MD. A review of a document title, “Baton Rouge General OBSERVATION FLOW SHEET,” dated 01/08/2026 revealed the following observation performances being documented during the previously mentioned and corresponding timeframe (12:30 a.m. to 1:30 a.m.) as follows: 12:30 a.m. L (= Location): 1 (Code correlated to “In Room”), A (= Activities): 19 (Code correlated to lying) and 24 (Code correlated to Eyes Closed (Respirations Noted)), I (= Staff Initials): S9MHT; 12:45 a.m. L: 1, A: 19 and 24, I: S9MHT; 1:00 a.m. L: 1, A: 19 and 24, I: S9MHT: 1:15 a.m. L: 1, A: 19 and 24, I: S9MHT: and 1:30 a.m. L: 1, A: 19 and 24, I: S9MHT. During this timeframe, the corresponding recorded video failed to reveal the performance of these documented observations of Patient #2 being performed. In an interview on 02/10/2026 at 2:20 p.m. S3RD confirmed Quality Improvement Activities did not include activities related to monitoring the visual performance of observation checks being performed.”

“RESPIRATORY CARE PERSONNEL POLICIES CFR(s): 482.57(b)(1) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to maintain documented evidence of training for paramedic personnel assigned to perform specific respiratory care services. This deficient practice was evidenced by failure of the hospital to provide documented evidence of respiratory care service training and competency for 2 (SFF14PAR, SFF16PAR) of 6 (SFF13PAR-SFF18PAR) paramedic personnel records reviewed. Findings: Review of hospital policy number RS 1000, titled “Respiratory Services Ascension,” last revised 11/2025, revealed in part: “PURPOSE: To provide Respiratory Care services to patients at the Ascension campus. POLICY: 2. Delivery of Respiratory Care services occurs via collaboration amongst competently trained physicians, advanced practiced professionals, nursing staff, paramedics, and Respiratory Therapist as needed. 3. Respiratory Care services are primarily handled by nursing staff and paramedics under the direct supervision of physicians with Respiratory Therapist available via telephone consults and/or services provided by an on-call Respiratory Therapist on site as needed. PROCEDURE: 1. Performed by: 3. Paramedics.” Review of hospital policy number HR-100, titled “Competency Validation, Employee,” last revised 04/2023, revealed in part: “PURPOSE: To ensure that all employees in the organization demonstrate competence - application of knowledge, skills and behaviors to carry out job role. POLICY: 1. Verification and documentation of competence is assessed and maintained on each employee. PROCEDURE: 2. Competency Assessment - Orientation: The initial orientation of all employees and volunteers will include job training and information necessary for the individual to safely and competently perform his/her assigned role. Additionally, a probationary period will be utilized to evaluate the new employees’ competency based on the job description and performance expectations. C. Unit Department Orientation is the responsibility of the Department Manager and specific to the departmental/work setting job role responsibilities.” Review of the Job Description and Performance Criteria titled, “Paramedic - Emergency Department,” date written/revised: 09/2025, revealed in part: “JOB PURPOSE AND MISSION: Administers immediate, advanced patient care to sick or injured persons in emergency department environments in accordance with applicable laws, regulations and hospital policies. Performs job duties appropriately for the age population served as defined in the department’s scope of service. Essential Job Functions include, but are not limited to: 1. Administers patient care to patients in the Emergency Department: Treating patients in the emergency department environments in accordance with federal, state, local laws, regulations, and standards and in accordance with Baton Rouge General policies and guidelines. Perform advanced airway management including managing airway/ventilation equipment.” In an interview on 11/24/2025 at 11:29 AM, SFF7DOE confirmed that the paramedics working in the emergency department received respiratory care service education/training titled: 2025 Ascension Emergency Department On-Boarding Drill - Ascension Emergency Department Paramedic Intubation SFF7DOE further confirmed that the above-mentioned paramedic education included, in part, the following learning objectives: -Nebulizer treatments, equipment, policies/protocols; including use with ventilation. -Hamiliton ventilator usage, modes, pre-op checks, programming, CMV (continuous mechanical ventilation), BiPAP/CPAP modes. -Application of in-line suction for endotracheal tubes, sterile suction catheters. -Application of BiPAP/CPAP masks per physician order. -Demonstrate Vapotherm set-up, application, troubleshooting. -Review equipment in red respiratory/yellow difficult intubation boxes, intubation simulation. Review of employee education files for SFF14PAR and SFF16PAR failed to reveal the paramedic respiratory care service education/training titled: 2025 Ascension Emergency Department On-Boarding Drill - Ascension Emergency Department Paramedic Intubation Review of the staffing schedules from 10/28/2025-11/24/2025 revealed in part the following: -SFF14PAR worked 7PM-7AM: 11/19/2025. -SFF16PAR worked 7PM-7AM: 10/30/2025, 11/01/2025, 11/13/2025, and 11/22/2025. Further review of the staffing schedules revealed that SFF14PAR and SFF16PAR were scheduled to work independently. In an interview on 11/25/2025 at 11:49 AM, SFF1EDM and SFF3DR confirmed the above-mentioned findings. SFF1EDM also confirmed that SFF14PAR and SFF16PAR have not completed orientation at the time of the survey and were working independently without a chaperone in the ED.”

“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: 48051 Based on record review and interview, the hospital failed to ensure the patient’s right to receive care in a safe setting. This deficient practice is evidenced by the failure to ensure patient care staff were educated on contraband items that should not be brought to work and are not allowed in the patient care area. Findings: A review of hospital policy, “Security Management: Weapons, Illegal Drugs and Alcohol,” policy number A-140, with an effective date of 10/2005, last revised 08/2014 and last reviewed 03/2024, revealed in part: “Policy Statement: 2. Contraband is defined as anything not specifically listed within this policy that is not permitted in the BRGMC hospital facilities. 4. Weapons, defined as a physical item that is used for fighting or attacking another person or for defending yourself when someone is attacking you, which, for purposes of this policy, includes, but is not limited to, firearms and/or any ammunition, stun guns/Tasers, batons, knives, explosives, pepper spray, MACE/chemical defense spray, nun chucks, brass knuckles, throwing stars/knives, and swords, are not permitted in BRGMC hospital facilities at any time, unless previously authorized by Hospital Administration under the exceptions listed below. 7. Nothing in this policy shall prohibit any employee, volunteer, vendor or contractor from possessing special knives, cutting instruments, tools or other items that could be classified as weapons under this policy, when such items are required for and possessed or used while in the performance of, their duties. RESPONSIBILITIES FOR ENFORCEMENT: 1. Administrators and department heads are responsible for enforcing this policy as it relates to employees, medical staff, and students, with guidance and involvement of Human Resources. Security personnel are responsible for enforcing the policy as it relates to patients and visitors, and are available to enforce the policy with employees as the situation warrants.” A review of the hospital’s safety reporting system log revealed an entry on 08/27/2025, time unavailable, by S5RN (S4PCE confirmed the identity of the writer), “(Staff to Staff/Patient; Disorderly Conduct) [S6BT] and I were performing daily wound care on the patient. Another nurse, [S7RN] came into the room and stood toward the end of the patient’s bed. He took a military/hunting style folding knife out of his pocket. He then opened the knife and asked the patient [Patient #1] if he [Patient #1] had ever cut or stabbed anyone. The patient [Patient #1] appeared startled/scared. [S7RN] then proceeded to walk closer to the top of the bed/patient’s head and started flickering the knife open and closed. The patient [Patient #1] physically shifted his body as best he could away from that side of the bed. I asked him [S7RN] to put the knife away which he did.” In an interview on 11/19/2025 at 11:00 a.m., S8RN confirmed she has witnessed S7RN having a pocketknife on his person and handling the pocketknife at the nurse’s station by continuous opening and closing of the knife. In an interview on 11/19/2025 at 3:13 p.m., S6BT confirmed he was in Patient #1’s room when S7RN entered the room and begin opening and closing a pocketknife. S6BT described the knife as “military grade” and approximately 3 inches in length when closed. S6BT confirmed S7RN used this knife to cut and remove Patient #1’s armband. In an interview on 11/19/2025 at 3:19 p.m., S5RN confirmed she was in Patient #1’s room when S7RN entered the room and begin opening and closing a pocketknife. S5RN described the knife as “a knife that would be used to skin a deer” and further described the knife as “a Spyderco style knife” approximately 3-4 inches in length when closed. In an interview on 11/19/2025 at 2:35 p.m., S1CNO confirmed patient care staff should not be in possession of a pocketknife in the patient care area and this would be considered an item that was not allowed to be used for patient care. S1CNO further confirmed, since the date of the before mention safety event, 08/27/2025, Unit A was the only unit that had received education/in-service review of the hospital’s policies related to items that are prohibited by patient care staff to carry and/or possess on the hospital’s campus or education/in-service review of potential workplace violence scenarios related to disgruntled staff.”

“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 reviews and interviews, the hospital failed to provide documented evidence to indicate an appropriate transfer was provided for 1 (#5) of 20 (#1-#20) patients who presented to the hospital’s emergency department (ED) with an emergency medical condition. The deficient practice is evidenced by failing to ensure the medical record contained a signed physician certification of transfer. Findings: Review of hospital policy number CC-100, titled “Admission/Discharge/Transfer,” last revised 08/2025, revealed in part: “POLICY: Patients will be admitted to, discharged from, or transferred from the Baton Rouge General Medical Center (BRGMC) facilities according to established guidelines and requirements set forth by regulatory agencies. 3. Transfers to Another Healthcare Facility: A. Patients may be transferred to another healthcare facility for the following reasons: a. Appropriate diagnostic or treatment capacity is not available within the BRGMC. b. Patient’s medical condition is stable and the attending physician, patient, or his designee requests transfer. c. Medically unstable patients may be transferred only when appropriate diagnostic or treatment capacity is not available within the BRGMC, and the physician deems the benefits of transfer to outweigh any increased risk to the patient’s life or limb. e. The receiving facility agrees to accept the patient and has diagnostic or treatment capacity required. f. Patient transfer disposition shall be accurately documented in the computer via discharge function. B. Prior to the transfer the patient and/or family will be informed of the reason for the transfer and alternatives if any. C. A copy of pertinent medical records will be sent to the receiving facility/unit for transferred patients, which include physical exam, discharge medications, diet, treatments, and any other follow-up instructions. D. Mode of transportation will be determined by the patient’s physician. E. Report will be called to the receiving facility. F. Patient transfer disposition shall be accurately documented in the computer via discharge function. Procedure: 2. Transfers/Discharges to another healthcare facility: B. If the patient is transferring to the same or higher level of care, complete the External Transfer Record.” Review of Patient #5’s medical record revealed Patient #5 arrived to the Emergency Department on 07/15/2025 for stroke symptoms. Patient #5 presented with aphasia. Workup included blood work, CT imaging, and TNKase (medication to treat the stroke). Patient #5’s symptoms continued to progress, CT was repeated, and Patient #5 was intubated to ensure patent airway during transport. Patient #5 was transferred to another facility for higher level of care. Further review of Patient #5’s medical record failed to reveal documented evidence of a signed physician certification of transfer. In an interview on 09/25/2025 at 1:27 PM, S2EDM confirmed that the signed physician transfer certificate for Patient #5 was not in the medical record. In an interview on 09/29/2025 at 8:45 AM, S6DED confirmed unable to locate the signed physician transfer certificate in Patient #5’s medical record, and believes it may have been sent with patient at the time of transfer.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to meet the requirement for Condition of Participation of Governing Body. This deficient practice was evidenced by the failure to inform the medical staff and governing body of a change in the delivery of respiratory care services in the emergency department and inpatient/observation unit of the offsite location (See Tag A-0049).”

“RESPIRATORY CARE SERVICES CFR(s): 482.57 The hospital must meet the needs of the patients in accordance with acceptable standards of practice. The following requirements apply if the hospital provides respiratory care services. This Condition is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to meet the requirement for Condition of Participation of Respiratory Services as evidenced by: 1) Failure to maintain respiratory care services by eliminating respiratory therapist staff in 2 units of the hospital’s offsite location (See Tag A-1154); and 2) Failure to adopt policies related to nursing staff delivery of respiratory care services (See Tag A-1160).”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the medical staff’s accountability to the governing body for the quality of care provided to patients. This deficient practice was evidenced by the failure to inform the medical staff and governing body of a change in the delivery of respiratory care services in the emergency department and inpatient/observation unit of the offsite location Findings: A review of meeting minutes titled, “ED Clinician Conference Call, Baton Rouge General Medical Center,” from 07/02/2025 at 9:00 AM revealed in part: “5. Ascension Campus REMINDERS Respiratory transition GO Live Tuesday, July 1st; Respiratory will no longer be in the building as of July 1st. Providers are expected to give orders for all vent/Bipap/Cpap settings. This includes recommendations for changes based upon changing assessment or ABG/VBG results. Nurses do not give settings. At this point, we are just trying to make sure we can operate the equipment properly. Ventilator patients will be given top priority for transfer to Bluebonnet. For intubated patients, will be using CMV mode for now. If need help, the intensivist agreed to consult by phone for Ascension patients. ABG’s are the Providers responsibility.” Review of medical executive committee (MEC) meeting minutes from 01/13/2025 and Board of Trustees (GB) meeting minutes from 02/25/2025 and 04/28/2025 failed to reveal any discussion of the change in the method of respiratory services delivery at the offsite location. In an interview on 07/08/2025 at 10:05 AM, S2DER confirmed the offsite location had eliminated respiratory therapist staff. In an interview on 07/14/2025 at 1:37 PM, S11MDED confirmed the offsite location had eliminated respiratory therapist staff. S11MDED further confirmed this change in the method of respiratory services delivery was an ED inter-departmental change and it was not formally brought to the medical executive committee or governing body. S11MDED further confirmed hospital medicine was involved with the approval of the inpatient respiratory services delivery at this offsite location.”

“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: 48051 Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by the failure to document a focal assessment and/or an updated transfer record at the time of the transfer in 1 (#3) of 3 (#1 - #3) patient medical records reviewed. Findings: A review of hospital policy, “Assessment/Reassessment,” Number ED-A2, being effective as of 09/1997, last revised 05/2024 and last reviewed 12/2020, revealed in part: “PURPOSE: To ensure Emergency Department Staff integrate the information from various assessments of the patient to plan patient care based on needs. POLICY: 2. An initial assessment by a registered nurse is completed during triage. Patient reassessment will be performed at a minimum of every 2 hours for patients awaiting medical evaluation. After initiation of the medical exam, patient reassessment will be based on acuity and/or further orders and changes in the patient’s medical condition. PROCEDURE: 2. Reassessment is a process of periodic re-evaluation of the patient’s condition, symptoms, and response to ordered treatment. Reassessment may include some or all of the following: vital signs, a focused physical assessment, pain assessment, general appearance, and/or responses to interventions and treatments. 5. Reassessment will occur based on patient acuity, nursing clinical judgment, and/or physician orders: C. Immediately prior to a patient’s discharge or within 30 minutes, a focused reassessment should be completed and documented. Vital signs will follow the Repeat Vital Sign Policy, ED-R2.” A review of hospital policy, “Assessment/Reassessment,” Number ED-D4, with an effective date unavailable, last revised 05/2024 and last reviewed 12/2021, revealed in part: “POLICY: The Emergency Department utilizes a documented focused assessment, based on patient’s presenting complaint. Documentation of the patient visit will be recorded using the electronic documentation tool determined by the hospital. PROCEDURE: 1. Emergency Department: B. Documentation of patient care shall reflect a focused assessment based on the patient’s presenting complaint. Documentation shall include identifying problems/needs, interventions, and evaluation of care for the duration for the Emergency Department visit.” A review of Patient #3’s medical record revealed the patient arrived to the ED on 05/30/2025 at 10:23 AM with the chief complaint of shortness of breath. Patient #3 was evaluated and diagnosed with Acute Respiratory Failure with Hypoxia and Acute, Chronic Systolic CHF by S6MD. The patient was recommended for admissions, the patient chose to be admitted to Provider B and the request for transfer to Provider B was initiated on 05/30/2025 at 12:45 PM by S7RN. A review of nursing documentation from 05/30/2025 at 5:04 PM by S7RN revealed in part: “Transfer Record; Transfer Assessment: Stable; Transfer Assessment Time: 05/30/2024 17:07; Neurological Status: Alert-oriented to person, place, time, reason” and from 05/30/2025 at 5:47 PM, “Discharge Vital Signs: Discharge Vitals obtained and documented in Patient flowsheets.” Patient #3 remained in the ED on 05/30/2025 to approximately 10:00 PM, the discharge date/time documented on the face sheet. The last documentation in the medical record was on 05/30/2025 at 9:30 PM by S8RN and revealed in part: “Task: bed low/locked, siderails up x 2, call light w/in reach; Patient Updates: pt comfortable, in bed, visitor at bedside, vital signs stable, no complaint; Group Note: still awaiting [Provider C] transport.” Documentation failed to reveal an updated transfer record to include a transfer assessment, departure time, or patient status. In an interview on 07/08/2025 at 8:45 AM, S5RNDR confirmed the above mentioned findings and the patient assessment/status should be updated when the transfer takes place.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the medical record contained all information necessary to monitor the patient’s condition. This deficient practice was evidenced by the failure to obtain and document an active list of home medications prior to disposition in 2 (#2, #3) of 3 (#1 - #3) ED patient medical records reviewed. Findings: A review of hospital policy, “Medication Reconciliation for Emergency Dept. Patients,” Number ED-42, being effective as of 01/2009, last revised 05/2013 and last reviewed 05/2024, revealed in part: “Purpose: To provide a consistent medication reconciliation process for the Emergency Department patients in accordance with Joint Commission patient safety goals. POLICY: A list of patient medications will be obtained at the time of entry into the Emergency Department on all patients and will included as part of the permanent medical record. PROCEDURE: 1. Refer to Policy TX-306.” A review of hospital policy, “Medication Reconciliation,” Number TX-306, being effective as of 01/2006, last revised 02/2021 and last reviewed 03/2024, revealed in part: “POLICY: 1. A complete list of the medications the patient is taking at home is created and documented in the patient’s profile in the Electronic Medical Record. The medication list will include the medication (name, dose, route, frequency [)]. As-needed medications that are routinely and/or recently taken will be included, along with an indication for use if able to obtain from the patient or records. The patient and, as needed, the family are involved in creating this list, supplemented by information from the patient’s care facility (if any) or outpatient pharmacy, as needed. 2. The pharmacy medication history technician (in ED only) or a nurse will complete the medication history. 4. Patients transferred outside the hospital to acute or long-term care facilities will have an up-to-date reconciled medication list communicated from the hospital to the next provider of care. 7. In setting where medication are used minimally, or prescribed for short duration, modified medication reconciliation processes are performed. Obtaining information on the dose, route, and frequency of use is not required. PROCEDURE: OUTPATIENTS: 1. Outpatient settings in which medication are not used, are used minimally, or are prescribed for only a short duration will use a modified medication reconciliation process. These settings will not require obtain information on the dose, route, and frequency. These areas may include but are not limited to the emergency department, clinic/office-based surgery, outpatient radiology, outpatient radiation oncology, ambulatory care and outpatient burn, and hyperbaric wound care setting. 2. The hospital obtains and documents an accurate list of the patient’s current medication and known allergies in order to safely prescribe any setting-specific medications (for example, intravenous contrast media, local anesthesia, antibiotics) and to assess for potential allergic or adverse drug reactions. 4. When patients leave these settings, a list of the original, known and current medications does not need to be provided, unless the patient is assessed to be confused or unable to comprehend adequately. In this case, the patient’s family is provided bother medication lists and the circumstances documented. 5. In these settings, a complete, documented medication reconciliation process is used when: C. The patient is required to be subsequently admitted to an organization from these setting for ongoing care.” A review of hospital policy, “Discharge/Transfer,” Number ED-D2, being effective as of 02/1980, last revised 12/2021 and last reviewed 05/2024, revealed in part: “Purpose: To assist the patient in leaving the Emergency Department and to terminate emergency services/charges to discharge patient. To enhance the continuity of patient care by providing the floor/critical care unit/receiving facility with information needed. PROCEDURE: 2. Transfer to Hospital Bed: H. Transfer to outside facility, see Transfer Policy CC-100.” A review of hospital policy, “Admission/Discharge/Transfer,” Number CC-100, being effective as of 05/1994, last revised 06/2025 and last reviewed 04/2024, revealed in part: “PURPOSE: To provide guidelines for the admission, discharge, and transfer of all patients. POLICY: Patients will be admitted to, discharged from or transferred from the Baton Rouge General Medical Center (BRGMC) facilities according to established guidelines and requirements set forth by regulatory agencies. 3. Transfers to Another Healthcare Facility: C. A copy of pertinent medical records will be sent to the receiving facility/unit for transferred patients, which include physical exam, discharge medications, diet treatments, and any other follow-up instructions. PROCEDURES: 2. Transfers/Discharges to another healthcare facility: C. The physician will complete medication reconciliation upon discharge. D. Send copy of Discharge Report Sheet, face sheet, the physician’s progress notes, the history and physical as well as consultations, pertinent diagnostic reports (recent lab, x-ray, etc), physician orders for the most recent 3 days, and the current electronic Medication Administration Record (EMAR) and nurses’ notes.” Patient #2 A review of Patient #2’s ED medical record revealed an admissions on 07/05/2025 at 9:49 PM. The medications listed below were documented in the record on 05/23/2025 and were not verified on the current visit. -Acetaminophen Tablet, Dose: 650 mg, Route: oral, Frequency: every 6 hours as needed, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -Artificial Tears (polyvinyl alcohol/porvidone) 0.5%-0.6% eye drops, Dose: 2 drops, Route: opthalmic, Frequency: twice daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:01 AM, and indicated unverified; -Complex-Vitamin B12, Dose: 1 tablet, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -Claritin Oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -Entresto, Dose: [empty space], Route: [empty space], Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -Farxiga, Dose: 10 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -Levothyroxine, Dose: 50 mcg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -Nicoderm CQ 21mg/24 hr daily transdermal patch, Dose: 1 patch, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -Vitamin D3 Oral, Dose: Frequency: daily, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -Zofran ODT, Dose: 4 mg, Route: oral, Frequency: every 8 hours, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -albuterol sulfate HFA 90 mcg/actuation aerosol inhaler, Dose: 2 puffs, Route: inhalation, Frequency: every 6 hours, Status: Active, Last Documented by: S9MD on 05/23/2025 9:01 AM, and indicated unverified; -allopurinol 100 mg tablet, Dose: 50 mg, Route: oral, Frequency: one time daily, Status: Active, Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -amiodarone, Dose: 400 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -aspirin, Dose: 81 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -bisacodyl Supp, Dose: 10 mg, Route: rectal, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -carvedilol, Dose: 6.25 mg, Route: oral, Frequency: twice daily, Status: Active, Documented by: S9MD on 05/23/2025 9:01 AM, and indicated unverified; -famotidine, Dose: 40 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -fluticasone 50 mcg/actuation Spray, Dose: 2 sprays, Route: intranasal, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -hydrocodone 5mg-acetaminophen 325 mg tablet, Dose: 1 tablet, Route: oral, Frequency: every 6 hours as needed, Status: Active, Last Documented by: S9MD on 05/23/2025 9:01 AM, and indicated unverified; -iron, Dose: Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -meclizine, Dose: 25 mg, Route: oral, Frequency: 3 times daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -multivitamin, Dose: 1 tablet, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -omega 3 fatty acids-fish oil 300 mg-1000 mg, Dose: 1 capsule, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -pantoprazole Delay Release Tab, Dose: 40 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -potassium chloride ER tab, Dose: 20 mill equivalent, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -sucralfate, Dose: 1 gram, Route: oral, Frequency: 4 times per day, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; -torsemide, Dose: 20 mg, Route: oral, Frequency: 2 times per day, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; and -trelegy, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified. Patient #3 A review of Patient #3’s ED medical record revealed an admission on 05/30/2025 at 10:23 AM. The medications listed below were documented in the record on 03/04/2025 and were not verified on the current visit. -Crestor, Dose: 10 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; -Cymbalta, Dose: 20 mg, Route: oral, Frequency: 2 times per day, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; -Lyrica, Dose: 25 mg, Route: oral, Frequency: 2 times per day, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; -Magnesium Hydroxide Susp, Dose: 15 ml, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; -Nitroglycerin, Dose: 0.4 mg, Route: sublingual, Frequency: every 5 minutes, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; -Protonix Delay Release Tab, Dose: 40 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; -Ranolazine 12 hr Tab, Dose: 500 mg, Route: oral, Frequency: every 12 hours, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; -Synthroid, Dose: 75 mcg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; - albuterol sulfate HFA 90 mcg/actuation aerosol inhaler, Dose: 1 puff, Route: inhalation, Frequency: every 6 hours, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; -aspirin, Dose: 81 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; -clopidogrel, Dose: 75 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; -lidocaine 4% patch, Dose: 2 patch, Route: topical, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; -metoprolol (Tartrate), Dose: 12.5 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; -midodrine oral, Dose: 5 mg, Frequency: 3 times per day, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; and -torsemide oral, Dose: 40 mg, Frequency: 2 times per day, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified. A review of the version of Patient #3’s medical record sent to Provider B upon transfer and titled, “Baton Rouge General Medical Center - ED Patient Transfer Continuity of Care Document,” revealed in part, all of the before mentioned medications as being active, home medications. A review of Patient #2’s and #3’s ED medical record failed to reveal documentation of the patient’s home medication having been reviewed and updated during the timeframe of each patient’s admission to the ED. Further, Patient #3’s home medication list was included as part of the transfer record to Provider B without being reviewed and updated. In an interview on 07/08/2025 at 8:45 AM, S5RNDR confirmed the above mentioned findings.”

“ADEQUATE RESPIRATORY CARE STAFFING CFR(s): 482.57(a)(2) There must be adequate numbers of respiratory therapists, respiratory therapy technicians, and other personnel who meet the qualifications specified by the medical staff, consistent with State law. This Standard is not met as evidenced by: 48051 Based on state regulation review, hospital meeting minute review and interview, the hospital failed to ensure adequate numbers of respiratory therapist consistent with State law. This deficient practice was evidenced by the failure to maintain respiratory care services by eliminating respiratory therapist staff in 2 units of the hospital’s offsite location. Findings: A review of Louisiana Administrative Code, Title 48, Public Health-General, Chapter 93 Hospitals, Subchapter Q. Respiratory Care Services (Mandatory), §9489. Organization and Staffing: B. There shall be adequate numbers of respiratory therapists, respiratory therapy technicians and other personnel who meet the qualifications specified by the medical staff and approved by the governing body, consistent with Louisiana law. A review of meeting minutes titled, “ED Clinician Conference Call, Baton Rouge General Medical Center,” from 07/02/2025 at 9:00 AM revealed in part: “5. Ascension Campus REMINDERS Respiratory transition GO Live Tuesday, July 1st; Respiratory will no longer be in the building as of July 1st. Providers are expected to give orders for all vent/Bipap/Cpap settings. This includes recommendations for changes based upon changing assessment or ABG/VBG results. Nurses do not give settings. At this point, we are just trying to make sure we can operate the equipment properly. Ventilator patients will be given top priority for transfer to Bluebonnet. For intubated patients, will be using CMV mode for now. If need help, the intensivist agreed to consult by phone for Ascension patients. ABG’s are the Providers responsibility.” The offsite campus consisted of 2 acute care units - a 14 bed emergency department and a 10 bed inpatient/observation unit. In an interview on 07/08/2025 at 10:05 AM, S2DER confirmed the offsite location had eliminated respiratory therapist staff. In an interview on 07/14/2025 at 1:37 PM, S11MDED confirmed the offsite location had eliminated respiratory therapist staff.”

“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 48051 Based on interview, the hospital failed to ensure respiratory care services were being delivered in accordance with medical staff directives. This deficient practice was evidenced by the failure to adopt policies related to nursing staff delivery of respiratory care services. Findings: In an interview on 07/14/2025 at 1:25 PM, S5RNDR confirmed the hospital had not updated policies and procedures related to the nursing staff’s delivery of respiratory care services that would be within the scope of nursing practice.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to ensure the medical record contained a current reconciled medication list for 1 (#1) of 20 (#1-#20) patients reviewed for medications on assessment in the emergency department. Findings: Review of the hospital’s policy number ED-M2, titled “Medication Reconciliation for Emergency Department Patients” last revised May 2013 with a last review date of May 2024 revealed in part: “Purpose: To provide a consistent medication reconciliation process for Emergency Department patients in accordance with Joint Commission patient safety goals. Policy: A list of patient medications will be obtained at the time of entry into the Emergency Department on all patients and will be included as a part of the permanent medical record.” Review of Patient #1’s EMS transport report dated 12/02/2024 revealed the following medications listed for Patient #1: Lurasidone, prenatal, Sertraline. Review of Patient #1’s emergency department visit medical record dated 12/02/2024 revealed no home medication reconciliation had been completed upon entry to the emergency department and prior to discharge. On 01/09/2025 at 9:05 AM, S1DOR verified S4RN was currently on FMLA and was not available for interview. S1DOR verified S4RN was the nurse who admitted the patient in the ER and provided the majority of care for the patient. On 01/09/2025 at 10:25 AM, an interview was conducted with S2DES. She stated medication reconciliation would not be reviewed between the nurse and the patient during triage. S2DES stated her expectation of her nursing staff is to complete medication reconciliation with the patient once the patient is brought back to the exam room and the full initial assessments are being completed. On 01/09/2025 at 11:04 AM, an interview was conducted with S5RN who was the nurse who triaged the patient on 12/02/2024 upon her arrival to the emergency department. He confirmed he did not ask her about what medications she was currently prescribed at the time or if she had been compliant with them because medication reconciliation was not a triage task. On 01/09/2024 at 11:13 AM, a telephone interview was conducted with S6RN. S6RN verified he was the nurse who discharged Patient #1 from the emergency department. He stated all of the discharge paperwork had already been completed by the time her arrived for his shift and was just waiting for social services to set up transportation for Patient #1. He confirmed he did not complete a medication reconciliation for Patient #1. On 01/09/2024 at 11:39 AM, a telephone interview was conducted with S3MD. She stated her “pattern of practice was to only write about a patients’ medications when she was making adjustments to them” so if there was nothing written about the medications, she had not made adjustments to them. She confirmed she did not complete a medication reconciliation for Patient #1’s medications.”

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to ensure all patient records included complete documentation of outcomes of hospitalization, complete disposition of care, and complete provisions for follow-up care. This deficient practice was evidenced by failure of the hospital to ensure the treating licensed practitioner completed an accurate and complete discharge summary to include follow-up care for 1 (#1) of 20 (#1 - #20) sampled patient records reviewed for discharge summaries. Findings: A review of Patient #1’s medical record revealed she was brought to the emergency department (ED) by EMS on 12/02/2024 at 2:49 PM after an altercation with her aunt (custodial guardian) for a psychiatric evaluation. Patient #1 was evaluated by S3MD and S9RES at 4:33 PM. Further review revealed social services was the only consult ordered for Patient #1, which was placed by S3MED at 4:33 PM and completed by S7SW at 6:09 PM. A discharge disposition and orders to discharge home were placed by S3MD at 6:38 PM and Patient #1 left the facility at 8:42 PM. Review of S9RES’s “Full ED Note” on 12/02/2024 revealed in part “ED Course Progress Note”: 6:37PM- Social work has seen the patient and spoke to both the patient, her mother, and her aunt regarding the altercation occurred earlier today. At this time, there is no need for PEC as the patient is not suicidal, homicidal, and she has not had any hallucinations. Patient is not a danger to herself or others at this time and will be discharged home. Fetal heart tones were 140 bpm prior to discharge. Diagnosis: Altercation and Aggressive behavior. ED Disposition: Home.” The record failed to reveal provisions for follow-up care. Review of S3MD’s attestation revealed in part “The patient is a 17-year-old Afro-American female who is pregnant and lives with her aunt and cousin. She had a verbal altercation with her aunt and cousin and reportedly threatened harm to her aunt. The patient denies this statement. The patient is under the custody of the aunt secondary to her legal concerns. Patient presents with aggressive behavior at home. Social work consulted and evaluated patient. No indication for PEC or inpatient care. The ED social worker spoke with the outpatient case manager who is very familiar with the patient. Patient safe for ED discharge. Will go home with aunt.” On 01/09/2024 at 11:39 AM, a telephone interview was conducted with S3MD. She stated instructions were provided for Patient #1 to return to the ED if needed.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to include a discharge plan evaluation in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation being discussed with the patient. This deficient practice was evidenced by failure to assist/provide 1 (#1) of 20 (#1 - #20) patients with a discharge plan for follow-up care from the ED. Findings: Review of the hospital’s policy numbered CC-110, titled “Discharge Planning” last revised August 2017 and last reviewed in April 2024 revealed in part: “Purpose: To identify patients admitted to the hospital that are in need of discharge planning, to provide these identified patients with a discharge plan of care and to communicate appropriately to the patients and to agencies that will be providing follow up care. Policy: 1. Preparations for discharge are a continuous, interdisciplinary process that begins on admission and is inclusive of all identified needs. 2. The Discharge Plan will be reviewed and updated on an ongoing basis and based on the patient’s continuing needs. Reassessment of the discharge plan will be ongoing, and updates will be documented in the patient’s medical record.” Review of the hospital’s policy numbered ED-D2, titled “Discharge/Transfer” last revised December 2021 and last reviewed in May 2024 revealed in part: “Purpose: To assist the patient in leaving the Emergency Department and to terminate emergency services/charges to discharged patient. Policy: Upon discharge each patient will receive detailed discharge instructions for continued care and appropriate referral for continued care.” Review of Patient #1’s EMS report revealed in part Patient #1 was found standing outside talking to police following an altercation with her aunt (custodial guardian) where she had become aggressive and threatening her and was non-compliant with her psychiatric medications. Patient #1 was 8-months pregnant. Patient #1 was transported by EMS to hospital for psychiatric evaluation at the request of Patient #1’s aunt and DCFS case worker. Review of Patient #1’s medical record revealed in part Patient #1 arrived in the ED via EMS on 12/02/2024 at 2:49 PM and was triaged as a level 2, emergent acuity, at 2:56 PM for a psychiatric evaluation. Patient #1 was seen by S3MD and S9RES at 4:33 PM. S3MD consulted social services on 12/02/2024 at 4:33 PM and the consult was completed by S7SW at 6:09 PM. S3MD and S9RES placed the disposition order to discharge at 6:38 PM and at 8:42 PM on S8SW was able to obtain transportation, Patient #1 was discharged. Review of Patient #1’s discharge instructions documented by S5RN on 12/02/2024 at 6:57 PM revealed the following: “Final Disposition - Discharged Discharge To - Home Discharge Instructions - Given printed discharge instructions; Education given related to Follow-Up after Discharge; Verbalized Understanding of D/C instructions, medications regimen; Verbalizes understanding of signs and symptoms to return to ED Discharge Instructions Explained To - Patient Patient Left ED - Ambulatory; Valuables with patient; No acute distress noted upon discharge Patient Left ED with Who? - Self” Review of Patient #1’s patient education provided at discharge titled “Medical Clearance for Psychiatric Care - General Information, English” revealed the following special instructions for Patient #1: “You were seen in the emergency department after a verbal altercation. Please return to the emergency department for any new or worsening symptoms, or for any new symptoms you are unable to manage on your own at home.” In fine print at the bottom of the page reads “Follow up with your doctor within 3 days, unless otherwise instructed. The Emergency Room is always available for worsening conditions if you cannot contact your doctor. If you need a doctor, call us.” No other discharge instructions were included related to follow-up for pregnancy and/or OB provider appointment(s) instructions and no instructions regarding psychiatric/mental health and/or community health resources. On 01/09/2025 at 9:05 AM, S1DOR verified S4RN was currently on FMLA and was not availlable forinterview. D1DOR verified S4RN was the admitting nurse for Patient #1 in the emergency department and provided the majority of care for the patient. S4RN was also the nurse who documented in Patient #1’s medical record the discharge instructions were given to her. On 01/09/2024 at 11:13 AM, a telephone interview was conducted with S6RN. S6RN stated he was the nurse who discharged Patient #1 from the emergency department. He stated all of the discharge paperwork had already been completed by the time her arrived for his shift and was just waiting for Social Work to set up transportation for Patient #1. He confirmed he did not complete any additional discharge instructions or education for Patient #1 prior to her discharge from the ED. On 01/09/2024 at 11:39 AM, a telephone interview was conducted with S3MD. She confirmed no discharge education or follow-up instructions were included in Patient #1’s discharge orders regarding pregnancy and/or OB provider appointment(s).”

“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: 48050 Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current, an individualized 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. This deficient practice is evidenced by the failure to update the nursing care plans on 3 (#1, #2, #3) of 3 (#1-#3) sampled patients reviewed for completed and updated nursing care plans. Findings: A review of facility policy number PE-150 titled, “Patient Care, Planning of” revealed in part, under the section Policy 1. The interdisciplinary caregivers work collaboratively to assess patient needs and to develop an individualized plan of care which is implemented, evaluated, revised, and terminated throughout the patient’s hospital stay. The plan of care integrates the information from various assessments of the patient, to identify and assign priorities to the patient’s needs. 5. The Interdisciplinary Plan of Care is reviewed and updated in the electronic medical record every 24 hours by the Registered Nurse (RN) and is based upon assessment needs/resolution. A medical record review on 02/20/2024 at 2:53 p.m. revealed Patient #2 was a moderate to high risk for falls during nursing assessments completed during hospitalizations dated 12/11/2023 and 01/03/204 by RNs. There was no documentation indicating Patient #2’s nursing care plans had initiated or been updated to include this medical diagnosis or treatment interventions. In an interview on 02/20/2024 at 3:00 p.m. S1DR and SI3nformatics confirmed there had been no initiation of fall risk or updates to Patient #2’s nursing care plan. A medical record review on 02/20/2024 at 3:15 p.m. revealed Patient #1’s care plan had not been reviewed or updated on 12/14/2023 and 12/15/2023 by the RN. There was no documentation indicating patient #1’s nursing care plan had been reviewed or updated. In an interview on 02/20/2024 at 3:35 p.m. S1DR and S3Informatics confirmed there had been no updates made by the RN to Patient #1’s nursing care plan. A medical record review on 02/20/2024 at 3:55 p.m. revealed Patient #3’s care plan had not been reviewed or updated on 01/05/2024 and 01/06/2024 by the RN. There was no documentation indicating patient #3’s nursing care plan had been reviewed or updated. In an interview on 02/20/2023 at 4:15 p.m. S1DR and S3Informatics confirmed there had been no updates made by the RN to Patient #3’s nursing care plan.”