Ochsner LSU Health Shreveport

“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: 17450 Based on observation, record review and interview, the hospital failed to ensure patients received care in a safe setting. This was evidenced by the hospital failing to reevaluate patients in the ED waiting room who had prolonged wait times for 5 of 5 patients with ED wait times between 9 and 23 hours (Patients #1, 2, 3, 4, 5). Findings: Review of the hospital policy titled, ED Assessment Standards and Triage Guidelines (approval date 07/13/2026), revealed in part that patients will be reevaluated at appropriate intervals. In the event of prolonged wait times, the triage nurse and/or paramedic will document a reevaluation at a minimum of every two hours. Further review of this policy revealed that patients would receive reassessments based on the patient’s acuity, condition, history of complaint, or as directed by the physician, minimally every four hours. Patient #1 Review of the medical record revealed the patient presented to the ED on 07/21/2026 at 1:33 PM with complaints of a fall, head pain and vomiting up blood. The patient was triaged and received a MSE on 07/21/2026 at 1:58 PM with vital signs obtained. The ED notes revealed the patient had lab specimens collected on 07/21/2026 at 2:39 PM and an IV was started at 5:58 PM. The patient remained in the ED waiting room at this time. Further review of ED notes dated 07/22/2026 at 1:26 AM revealed the relatives of patient demanded to remove patient’s IV and leave AMA. The relatives were upset for waiting for available bed. Talked to relative and explained the situation. Relatives still insisted to leave against medical advice. The note further stated on 07/22/2026 at 0153, patient disposition was set to “eloped”. The patient remained in the ED waiting room for 12 hours and 20 minutes prior to leaving AMA. There was no documented evidence of any reevaluations or reassessments of the patient since triage. On 08/25/2026 at 10:25 AM, S1ED Director reviewed the patient’s medical record and confirmed the patient was not reevaluated or reassessed since the triage time. Further interview at that time with S1ED Director revealed that patients should be reassessed by a nurse every four hours during long wait times in the ED waiting room. The hospital policy titled, ED Department Assessment Standards and Triage Guidelines (approval date 07/13/2026) was reviewed with S1ED Director and she stated that this policy was incorrect regarding reevaluations in the ED waiting room every two hours. S1ED Director stated it should be every four hour reevaluations. When asked what the reevaluation/reassessment should include, S1ED Director stated the policy was not clear on this. Patient #2 Review of the medical record revealed the patient presented to the ED on 06/08/2026 at 3:10 PM with complaints of chest pain. The patient was triaged and received a MSE on 06/08/2026 at 4:39 PM with vital signs obtained. Labs and an EKG was ordered at this time. On 06/08/2026 at 5:24 PM, labs were collected and the patient remained in the ED waiting room. Further review of the ED notes revealed on 06/09/2026 at 1:25 AM, the patient did not answer when name was called in the ED waiting room and patient disposition was set as “eloped”. There was no documented evidence in the medical record that the patient was reevaluated or reassessed since the triage time (10 hours and 18 minutes earlier). On 08/25/2026 at 12:45 PM, interview with S1ED Director confirmed there was no documented evidence that the patient was reevaluated or reassessed since the triage time. Patient #3 On 08/24/2026 at 2:30 PM, observation revealed the patient was sitting in the ED waiting room wrapped up in a blanket. At that time, review of the ED electronic log revealed the patient had been waiting in the ED waiting room since 08/23/2026 at 2:34 PM (23 hours and 24 minutes). Review of the medical record revealed the patient presented to the ED on 08/23/2026 at 2:34 PM with complaints of extremity weakness. The patient was triaged and received a MSE on 08/23/2026 at 3:56 PM with vital signs obtained. The ED notes dated 08/24/2026 at 3:28 AM revealed medications were administered to the patient while in the ED waiting room. The notes revealed vital signs were obtained on the patient on 08/24/2026 at 8:28 AM and at 2:05 PM. There were no further reevaluations or reassessments documented during this patient’s 23 hour ED waiting room stay. On 08/24/2026 at 2:20 PM, interview with S1ED Director confirmed that there was no documented evidence that the patient received reevaluations or reassessments every four hours. Patient #4 On 08/24/2026 at 2:00 PM, review of the ED electronic log revealed that the patient had been in the ED waiting room for 18 hours and 38 minutes. Review of the medical record revealed the patient presented to the ED on 08/23/2026 at 7:41 PM with complaints of painful urination and flank pain. The patient was triaged and received a MSE on 08/23/2026 at 7:58 PM with vital signs obtained. Further review of the ED record revealed vital signs were obtained on 08/24/2026 at 8:15 AM and 2:06 PM. There was no other documented evidence of reevaluations or reassessments of the patient during the patient’s 18 hour wait. On 08/24/2026 at 2:30 PM, S1ED Director confirmed that the patient was not reevaluated or reassessed every four hours during the patient’s prolonged waiting time in the ED waiting room. Patient #5 On 08/24/2026 at 2:20 PM, review of the ED electronic log revealed that the patient had been in the ED waiting room for 8 hours and 48 minutes. Review of the medical record revealed the patient presented to the ED on 08/24/2026 at 5:33 AM with complaints of right leg pain. The patient was triaged and received a MSE on 08/24/2026 at 5:43 PM with vital signs obtained. Further review of the ED record revealed vital signs were obtained again on 08/24/2026 at 2:06 PM. There was no other documented evidence of reevaluations or reassessments of the patient during the patient’s 8 hour wait. On 08/24/2026 at 2:40 PM, S1ED Director confirmed that the patient was not reevaluated or reassessed every four hours during the patient’s prolonged waiting time in the ED waiting room.”

“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: 17450 Based on record review and interview, the hospital failed to implement opportunities for improvement and initiate changes by failing to ensure that patient grievances regarding prolonged wait times in the ED were addressed and monitored for 2 of 2 patients with grievances involving extended wait times in the ED (Patients #1, #2). Findings: Patient #1 Review of a grievance letter filed by the family of Patient #1, dated 07/29/2026, revealed that the patient waited in the ED for nearly 12 hours without being placed in a treatment room without anybody checked on the patient and the patient began vomiting in the waiting room. The grievance further complained of a lack of communication with the ED staff. Review of the documented investigation of the grievance revealed that it was identified that there was no reassessments of the patient during the extended waiting time in the ED. The investigation further stated that the ED Manager spoke with the nurse involved in the patient’s care regarding lack of documented reassessments or repeat vital signs as required, stating this standard was not met for this patient. The manager coached the nurse regarding the importance of documenting patient reassessments and that the night supervisor was also reminded of the importance of reassessing patients experiencing extended wait times in the ED lobby. On 08/25/2026 at 10:25 AM, interview with S1ED Director confirmed that she was involved in this investigation with Patient #1. When asked if there was any documented evidence of the nurse involved or any other nursing staff was reeducated on patient reassessments after this incident, S1ED Director stated no. S1ED Director further stated that there was no QA/PI process put in place to address the lack of reassessments for patients who had prolonged ED wait times. Patient #2 Review of a grievance letter filed by Patient #2 dated 06/10/26 revealed the patient expressed concern regarding the length of the wait in the ED and the lack of information regarding when she could be evaluated. The patient stated she reported when she inquired about the wait time, she was advised that it would be likely a while longer before she could be seen. The grievance letter further stated that the patient left the ED due to the prolonged wait time and uncertainty regarding her care. Review of the documented investigation of the grievance revealed that the ED manager reviewed operations for the ED on the date in question and found that the department was holding 35 admitted patients on that morning. The ED manager acknowledged that patients should be reassessed every four hours, even during periods of high ED volume. The investigation further stated that the department continues to identify opportunities to improve patient flow, communication and timeliness of care. Review of the patient’s ED medical record revealed the patient presented to the ED on 06/08/2026 at 3:10 PM. Further review of the ED notes revealed on 06/09/2026 at 1:25 AM, the patient did not answer when name was called in the ED waiting room and patient disposition was set as “eloped”. There was no documented evidence in the medical record that the patient was reevaluated or reassessed since the triage time (10 hours and 18 minutes earlier). On 08/25/2026 at 1:00 PM, interview with S1ED Director confirmed that after receiving the grievance from Patient #2, there was no QA/PI process put in place to address the lack of reassessments for patients who had prolonged ED wait times. S1ED Director further stated that she was aware of this issue and knew the ED staff needed to improve on their reevaluations/reassessments of patients with long wait times.”