Ochsner Medical Center - Baton Rouge

“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: 48051 Based on policy review, record review and interview, 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. Findings: A review of hospital policy, “Scope of Social Services,” Number: OHS.CASEM.OS.004, with an effective date of 10/19/2022, revealed in part: V. Procedure: Services Available: Post Hospital/Emergency Department (Discharge) Planning: b. If unable to return to home environment, help patient and family to address response to life change and prepare for an alternate plan such as boarding home, nursing home, or other facility. c. Educating of and assisting to obtain any appropriate services for which the patient may be eligible. d. Assure patient/caregiver understanding and involvement in discharge plan and arrangement of post discharge services. Crisis Intervention: b. Assess the situation as to the resources and action needed to resolve the immediate crisis. c. Implement the most reasonable plan to resolve the crisis. This may require the assistance of community agencies. Information and Referral: a. Give agency names, numbers and eligibility criteria to the patients, families and staff for accessing services. b. Directly contact a resource on behalf of an individual for the purpose of obtaining a service. A medical record review of Patient #1 revealed in part the patient arriving to the emergency department (ED) on 09/13/2024 at 12:22 a.m. via EMS (emergency medical services). EMS report revealed in part, Patient #1 was found naked, sitting in the driveway of an unknown residence, with strange inexplicable behaviors and slow response. EMS report indicated law enforcement was told by Patient #1 that he had ingested something. The patient was held in the ED for approximately 9 hours where he was examined, lab work obtained, medically monitored and observed by a sitter at bedside. This facility was able to located contact information for Patient #1 from prior medical records. The medical records reflected a prior psychiatric history with the patient’s last known group home and case worker telephone number. Attempts to contact each were unsuccessful. Note entry at 6:21 a.m. revealed S7RN sending message to SW (social worker) and CN (charge nurse). Note entry at 7:36 a.m. revealed S6MD initiating a consult to social work (case management). Note entry at 8:33 am by S6MD revealed ED disposition to discharge and at 8:36 a.m. S6MD printed the After Visit Summary (AVS). The medical record did not reveal any documentation of case management (CM) involvement until 8:51 a.m., when S11CM was assigned. Note entry for 9:47 a.m. revealed in part, Patient #1 had been provided an AVS, it was reviewed with verbalization of understanding and the patient was discharged via cab (Lyft). CM note entry at 9:47 a.m. revealed in part S10CM spoke with the patient’s group home and case worker, the patient was unable to return due to sexually aggressive and violent behavior. The case worker was going to follow up with APS (possibly Adult Protective Services) on this day to inform the patient was not appropriate for group home setting as he could not manage medications, continues to leave the group house and the patient was violent. The case worker further indicated she would follow up with this facility’s CM once she made contact with APS and it was determined where the patient should be discharged. CM updated the ED charge nurse with this information and was notified the patient had been discharged. A review of Provider Note entered and signed on 09/14/2024 at 6:20 pm by S6MD and dated for 09/13/2024 at 8:36 am revealed, “Patient re-evaluated, no complaints, urine normal, he is at his baseline mental status, has history of TBI and extensive psych history, he does not appear gravely disabled, no SI (suicidal ideations) or HI (homicidal ideations), nothing to suggest PEC (physicians emergency certificate), he currently resided in group home, group home contacted without any answer, social work consulted to assist with group home placement and discharge.” S6MD’s Discharge Diagnosis: Chronic mental disability; Substance abuse; Housing issue. S6MD’s Clinical impression: Awaiting action for housing (this information was typed in bold print); Chronic mental illness; Lives in group home. A review of the facility’s log for Lyft (cab) services revealed in part, an entry for Patient #1 on 09/13/2024, without a time indicated, with the destination address of 153 N. 17th Street, Baton Rouge. This address matches the complainants address and is the location Patient #1 was found stumbling on the side walk and confused according to complaint narrative. This complaint narrative revealed in part, the patient was speaking incoherently with eyes wide open as if he was still very medicated and he had no recollection of how he got to the hospital. On 09/30/2024 at 1:40 p.m. an on-site attempt by this surveyor to obtain a medical record from this facility was unsuccessful as there was no history of Patient #1’s name and date of birth ever being seen at this clinic. Review of the AVS did not reveal any information related to after care instruction - housing, follow up for mental disabilities, substance abuse or the above mentioned address listed as Lyft’s destination for Patient #1. In an interview on 09/25/2024 at 2:10 p.m. S10CM confirmed the above mentioned CM notes, the patient was discharged without information related to follow up resources to potentially assist in his current condition and the patient was transported to a facility that was mentioned as a possible destination, however it had not been confirmed the patient should be sent there and it was not listed as a resource on Patient #1’s AVS.”

“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: 48051 Based on record review and interview the hospital failed to measure, analyze, and track all patient adverse events in the quality assessment and improvement program. This deficient practice is evidenced by failure of the facility to measure, analyze, and track all incidents involving bedbugs in multiple patient care areas and staff lounge areas of the hospital. Findings: A record review of or area); 07/24/2023 - Emergency Department (no documented room or area); 08/29/2023 - 4th floor (no documented room ordocumentation completed by Company #C and provided by S4EOC revealed Company #C had been on-site and treated for bed bugs on 10 different occasions during the prior 4 months. This documentation revealed the pest treatments being performed in the following areas: 07/21/2023 - 4th floor (no documented room area); 09/11/2023 - Serenity Room (staff lounge); 09/26/2023 - Serenity Room (staff lounge); 10/12/2023 - Serenity Room (staff lounge); 10/19/2023 - 4th floor (no documented room or area); 11/20/2023 - 4th floor (no documented room or area); 12/02/2023 - 4th floor (no documented room or area) and Emergency Department #G; and 12/05/2023 - 4th floor-Room #E, Emergency Department-#G, and 2nd floor Rooms #A and #B. In an interview on 12/12/2023 at 8:30 a.m. S3DPI confirmed the Performance Improvement Team had not formally measured, analyzed, and/or tracked patient adverse events related to the bed bug incidents and treatments.”