Acadia St Landry

“RECORDS SYSTEM CFR(s): For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; This Standard is not met as evidenced by: 48050 50453 Based on record reviews and interviews, the hospital failed to include a discharge summary in the medical record within 30 days of discharge according to hospital policy for 2 (#2, #6) of 20 patient records reviewed. Findings: Review of hospital policy titled “Discharge Summary,” last reviewed 05/2026, revealed in part: “PURPOSE: To ensure proper completion of a discharge summary. PROCEDURE: The medical record must contain information/documentation regarding medial history assessment, health status and health care needs of the patient. The discharge summary is required for Acute care, Swing Bed and Inpatient psych. The discharge summary shall discuss the outcome of the stay, disposition of the patient, and provisions for follow-up. The MD or other qualified practitioner with admitting privileges is responsible for completion of the discharge summary. Discharge summary must be completed within 30 days of discharge.” Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 03/26/2026 and discharged/expired on 03/28/2026. Further review of Patient #2’s medical record failed to reveal a discharge summary. In an interview on 07/14/2026 at 2:40 PM, S4RN confirmed Patient #2’s medical record did not contain a discharge summary. Patient #6 Review of Patient #6’s medical record revealed Patient #6 was admitted on 02/05/2026 at 4:25 PM and discharged/transferred on 02/05/2026 at 7:30 PM. Further review of Patient #6’s medical record failed to reveal a discharge summary. In an interview on 07/15/2026 at 9:56 AM, S4RN confirmed Patient #2’s medical record did not contain a discharge summary.”

“RECORDS SYSTEM CFR(s): Reports of physical examinations, diagnostic and laboratory test results, including clinical laboratory services, and consultative findings; This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure that each patient had a completed history and physical within 24 hours of admission for 2 (#3, #4) of 9 patients (#3, #4, #5, #6, #9, #10, #11, #19, #20) reviewed for history and physicals. Findings: Review of the CAH’s Medical By-Laws revealed in part: A complete history and physical examination shall in all cases be recorded within twenty-four (24) hours after admission of the patient. Review of Patient #3’s medical record revealed an admit date of 04/03/2026. Further review of the record revealed no documented history and physical. An interview on 07/14/2026 at 2:48 PM, S4RN confirmed there was no documented evidence that a history and physical exam had been completed for Patient #3. Review of Patient #4’s medical record revealed an admit date of 04/19/2026 at 1:00 PM. Further review of the record revealed history and physical completed on 04/21/2026 at 8:28 AM by the nurse practitioner. An interview on 07/14/2026 at 3:47 PM, S4RN confirmed Patient #4’s history and physical examination was completed greater than 24 hours from admission.”

“RECORDS SYSTEM CFR(s): All orders of doctors of medicine or osteopathy or other practitioners, reports of treatments and medications, nursing notes and documentation of complications, and other pertinent information necessary to monitor the patient’s progress, such as temperature graphics, progress notes describing the patient’s response to treatment; and This Standard is not met as evidenced by: 50453 Based on record reviews and interviews, the hospital failed to ensure the medical record contained an order for discharge per medical staff bylaws for 5 (#12-#15, #17) of 20 patient records reviewed. Findings: Review of the hospital’s Medical Staff Bylaws revealed in part: “Rules and Regulations: 17. Patients shall be discharged only on written order of the attending physician. At the time of discharge, the attending physician shall see that the record is complete, state his/her final diagnosis and sign the record.” Patient #12 Review of Patient #12’s medical record revealed Patient #12 arrived to the emergency department on 07/08/2026 and transferred for psychiatric services on 07/09/2026. Further review of Patient #12’s medical record failed to reveal a discharge order for transfer by the physician. Patient #13 Review of Patient #13’s medical record revealed Patient #13 arrived to the emergency department on 07/10/2026 and transferred for psychiatric services on 07/10/2026. Further review of Patient #13’s medical record failed to reveal a discharge order for transfer by the physician. Patient #14 Review of Patient #14’s medical record revealed Patient #14 arrived to the emergency department on 07/11/2026 and transferred for psychiatric services on 07/11/2026. Further review of Patient #14’s medical record failed to reveal a discharge order for transfer by the physician. Patient #15 Review of Patient #15’s medical record revealed Patient #15 arrived to the emergency department on 07/10/2026 and transferred for psychiatric services on 07/11/2026. Further review of Patient #15’s medical record failed to reveal a discharge order for transfer by the physician. Patient #17 Review of Patient #17’s medical record revealed Patient #17 arrived to the emergency department on 06/16/2026 and transferred for psychiatric services on 06/16/2026. Further review of Patient #17’s medical record failed to reveal a discharge order for transfer by the physician. In an interview on 07/14/2026 at 3:00 PM, S4RN confirmed the above-mentioned findings.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): Ensure that the CAH works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues, reviewing death records to improve identification of potential donors, and maintaining potential donors while necessary testing and placement of potential donated organs, tissues, and eyes takes place. §485.643(f) For purpose of these standards, the term “organ” means a human kidney, liver, heart, lung, pancreas, or intestines (or multivisceral organs). This Standard is not met as evidenced by: 47123 Based on record review and interview, the hospital failed to provide evidence of training regarding donation issues and how to work with organ procurement, tissue bank and eye bank. Findings: Review of the facilities trainings and personnel files provided failed to reveal evidence of training regarding donation issues, and how to work with organ procurement, tissue bank and eye bank. In an interview on 07/15/2026 at 12:00 PM, S1DON confirmed the above findings.”

“ADMISSION, TRANSFER, & DISCHARGE RIGHTS CFR(s): Admission, Transfer and Discharge Rights (§483.5 definition of transfer & discharge, §483.15(c)(1), (c)(2), (c)(3), (c)(4), (c)(5), (c)(7), (c)(8), and (c)(9) of this chapter). “ §483.5 definition of transfer & discharge: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. “ §483.15(c)(1) Transfer and discharge-(1) Facility requirements- (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A) The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Non-payment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to §431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to §431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. “ §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident’s medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident’s medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident’s physician when transfer or discharge is necessary under paragraph (c)(1)(A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident (B) Resident representative information including contact information. (C) Advance Directive information. (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals, (F) All other necessary information, including a copy of the resident’s discharge summary, consistent with §483.21(c)(2), as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. “ §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident’s representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident’s medical record in accordance with paragraph (c)(2) of this section; and (iii)Include in the notice the items described in paragraph (c)(5) of this section. “ §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii)Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident’s health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident’s urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. “ §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident’s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. “ §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. “ §483.15(c)(8) Notice in advance of facility closure. In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at §483.70(l). “ §483.15(c)(9) Room changes in a composite distinct part. Room changes in a facility that is a composite distinct part (as defined in §483.5) are subject to the requirements of §483.10(e)(7) and must be limited to moves within the particular building in which the resident resides, unless the resident voluntarily agrees to move to another of the composite distinct part’s locations. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure each patient or patient representative consented to transfer. This deficient practice is evidenced by failure to obtain a signed consent for transfer for 2 (#4, #5) of 2 transferred patients reviewed from a total sample of 9. Findings: Review of the CAH’s policy titled, Patient Rights for Acute/Swing Bed, revealed in part: PURPOSE: To ensure the patient, their families, or their designee, are aware of their patient rights. PATIENT RIGHTS FOR ACUTE/SWING BED ADMISSIONS: 8. Every patient or his or her representative (as allowed by state law) has the right to make informed decisions regarding his or her care; 9. The patient’s rights include being informed of his/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. Review of the CAH’s policy titled, Patient Transfer and Discharge, revealed in part: PURPOSE: To ensure that a patient requiring or requesting a transfer for further medical care and follow-up is transferred appropriately. PROCEDURE: The patient’s clinical record will accurately document the reason for transfer/discharge by the attending physician. Review of Patient #4’s medical record revealed Patient #4 was admitted on 04/19/2026 for weakness and discharged on 04/24/2026. Patient #4’s medical record revealed in the discharge summary Patient #4 would be transferred to Hospital B. Further review of Patient #4’s medical record did not reveal a transfer consent. Review of Patient #5’s medical record revealed Patient #5 was admitted on 04/27/2026 for cellulitis and discharged on 04/30/2026. Patient #5’s medical record revealed in the discharge summary Patient #5 would be transferred to Hospital C. Further review of Patient #5’s medical record did not reveal a transfer consent. In an interview on 07/14/2026 at 4:20 PM, S4RN confirmed that Patient #4 and Patient #5 did not sign a transfer consent. S4RN further confirmed that the facility discharges patients although the provisions for transfer have been arranged.”

“EXERCISE OF RIGHTS CFR(s): This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure each patient or patient representative was informed of his or her patient rights. This deficient practice is evidenced by failure to initial he/she received the information on patient rights for 2 (#3, #4) of 9 medical records reviewed. Findings: Review of Patient #3’s medical record revealed Patient #3 was admitted on 04/03/2026 at 1:21 PM for Cellulitis. Further review failed to reveal documented evidence that the patient or their representative were notified of their rights or that consent for treatment was obtained. An interview on 07/14/2026 at 2:49 PM S4RN verified the above mentioned information. Review of Patient #4’s medical record revealed Patient #4 was admitted on 04/19/2026 at 1:00 PM for weakness. Further review failed to reveal documented evidence that the patient or their representative were notified of their rights or that consent for treatment was obtained. An interview on 07/14/2026 at 3:21 PM S4RN verified the above mentioned information.”

“EXERCISE OF RIGHTS CFR(s): 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, 489.102, and 489.104 of this chapter. This Standard is not met as evidenced by: 48050 Based on interviews and record reviews the hospital failed to ensure Advance Directives were properly documented in the patients’ medical records upon admission. This failed practice was evidenced by inaccurate Advance Directive documentation in 4 (#3, #4, #5 #20) of 9 (#3, #4, #5, #6, #9, #10, #11, #19, #20) patient medical records reviewed for Advance Directives. Findings: Review of the CAH’s policy titled, “Advance Directives”, revealed in part: PURPOSE: To provide an atmosphere of respect and caring and to ensure that each patient’s ability and right to participate in the medical and mental health decision making is maximized. PROCEDURE: An inquiry will be made by authorized staff members as to whether or not the patient has completed an advance directive. A request of the patient or patient representative to provide a copy of the advance directive for medical record entry will be made. As part of the admission process the patient or patient representative will be provided with access to information outlining the individual’s rights for make decisions concerning medical care. Authorized personnel will document in the medical record whether the patient has completed an advance directive or that information concerning advance directives has been given to the patient/patient representative. Review of the CAH’s policy titled, “Patient Rights for Acute/Swing Bed”, revealed in part: PURPOSE: To ensure the patient, their families, or their designee, are aware of their patient rights. PATIENT RIGHTS FOR ACUTE/SWING BED ADMISSIONS: 8. Every patient or his or her representative (as allowed by state law) has the right to make informed decisions regarding his or her care; 9. The patient’s rights include being informed of his/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. 12. The right to formulate advance directives and have hospital staff and practitioners who provide care in the hospital comply with these directives. Review of Patient #3’s medical record revealed Patient #3 did not receive information on advance directives or questioned if he/she had an advance directive. Review of Patient #4’s medical record revealed the advance directive form was incomplete and no documentation in the medical record whether Patient #4 did or did not have an advance directive. Review of Patient #6’s medical record revealed Patient #6 did not receive information on advance directives or questioned if he/she had an advance directive. Review of Patient #20’s medical record revealed Patient #20 did not receive information on advance directives or questioned if he/she had an advance directive. In an interview on 07/15/2026 at 11:30 AM S4RN verified the above mentioned information.”

“PRIVACY AND SAFETY CFR(s): The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48050 Based on record review and interview, the CAH failed to ensure patients received care in a safe setting. This deficient practice was evidenced by failure to transfer a patient with an emergent medical condition to the nearest emergency department. Findings: Review of Patient #6 revealed Patient #6 was admitted on 02/05/2026 at 4:25 PM for Cellulitis. Review of Patient #6’s nursing notes dated 02/05/2026 at 5:01 PM revealed Patient #6 started experiencing chest pain and MD notified. Further review of Patient #6’s nursing notes dated 02/05/2026 at 6:40 PM nurse documented Patient #6’s chest pain continues and MD ordered patient to be discharged to a higher level of care for a cardiac work up. On 02/05/2026 at 7:12 PM nurse documents Patient #6 was discharged to ER at Hospital C. In an interview on 07/15/2026 at 9:56 AM S4RN confirmed swing bed patients who need a higher level of care do not go to the CAH’s emergency department, but are discharged to another facility’s emergency department. In an interview on 07/15/2026 at 12:15 PM S1DON confirmed the CAH’s emergency department can provide a higher level of care for a cardiac work up.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 50453 Based on record review and interview, the provider failed to comply with applicable Federal, State, and local emergency preparedness requirements by failing to review and revise their Emergency Preparedness Plan (EPP) at least every two years. Findings: Review of the facilities Emergency Preparedness Policy and Procedure Manual revealed the EPP was last reviewed and revised 05/2022. In an interview on 07/14/2026 at 3:55 PM, S3CPO confirmed the above-mentioned findings. S3CPO confirmed the EPP had not been reviewed every 2 years.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 35367 Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas within a supervised sprinklered facility are required to be constructed to resist the passage of smoke and provide a door that self closes and self-latches properly. The deficiency has the potential to affect twelve of twelve patients. Findings: During the facility tour on July 15, 2026 between the hours of 9:15 a.m. to 12:00 p.m. the boiler room interior access door did not self latch when fully closed, had a two step release via a dead bolt, the interior wall had multiple penetrations (was not smoke tight) and door had a kick stand. The interview with the administrator revealed the facility was not aware that the boiler room was not fully smoke tight due to several penetrations and the interior access door was required to have a one release motion and self latch when fully closed.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 35367 Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. The deficiency has the potential to affect twelve of twelve patients. Findings: During the facility tour on July 15, 2026 between the hours of 9:15 a.m. to 12:00 p.m. the fire alarm was yellow tagged by a licensed fire alarm company due to the CT room pull station not being operable. The interview with Administrator revealed the facility was not aware that the fire alarm system had been yellow tagged by the licensed fire alarm company.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 35367 Based on visual observation the facility failed to assure that the sprinkler system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 25. The sprinkler system gives a sense of security to offer an advance warning in fire and/or smoke emergency. The deficiency has the potential to affect twelve of twelve patients. Findings: During the facility tour on July 15, 2026 between the hours of 9:15 a.m. to 12:00 p.m. the sprinkler system as yellow tagged by a licensed sprinkler company due to ten corroded sprinkler sidewalls in the kitchen being in need of replacement. Additionally, a cooler and freezer located within six inches of hospital main building under a overhang which extends more than ten feet lacked pendant dry sprinkler protection. The interview with the Administrator revealed the facility was unaware the sprinkler system had been yellow tagged by a licensed sprinkler company and was the cooler/ freezer was lacking dry pendant sprinkler protection.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 35367 Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficiency has the potential to affect twelve of twelve patients. Findings: During the facility tour on July 15, 2026 between the hours of 9:15 a.m. to 12:00 p.m. the fourth quarter of the year 2025 documented fire drills were lacking and the 2026 first quarter, 2026 second quarter and the 2025 third quarter documented fire drills were lacking the night shift 7:00 p.m. to 7:00 a.m. The interview with the Administrator revealed the facility recognized the deficiency and is in the process of ensuring the fire drill policy will be properly executed for each shift of each quarter.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 35367 Based on record review the facility failed to provide annual fire door testing documentation. Written annual records demonstrate all fire doors are properly being maintained to ensure protection for life and property. The deficiency has the potential to affect twelve of twelve patients. Findings: During the facility tour on July 15, 2026 between the hours of 9:15 a.m. to 12:00 p.m. it was observed the annual documented fire door inspection was lacking. The interview with the Administrator revealed the facility was not aware annual fire door inspections were required to be conducted annually.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 35367 Based on review of the documentation, the facility failed to provide records of a annual inspection from a qualified medical gas specialist. The proper maintenance and inspection of all medical gas equipment is essential to ensure compliance with NFPA 99 and to provide a safe environment for all patients, staff and the general public. The deficiency has the potential to affect twelve of twelve patients. Findings: During the facility tour on July 15, 2026 between the hours of 9:15 a.m. to 12:00 p.m. the documented medical gas inspection was lacking for review at time of survey. The interview with the Administrator revealed the facility had a paid invoice from a qualified medical gas inspection company, but the facility was unable to retrieve and furnish the annual medical gas inspection to LSC Specialist at time of survey for review.”

“NEUROLOGICAL EXAMINATION CFR(s): 485.647(a)(1) [ ...the services furnished by the distinct part unit must comply with ...the additional requirements of §412.27 of Part 412 of this chapter for excluded psychiatric units. Excluded psychiatric units: Additional requirements (§412.27): “(c)(1) Development of assessment/diagnostic data. Medical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the inpatient is treated in the unit.] (v) When indicated, a complete neurological examination must be recorded at the time of the admission physical examination.” This Standard is not met as evidenced by: 48050 Based on a record review and staff interview, the Critical Access Hospital failed to ensure documentation of a History and Physical examination which included a descriptive neurological examination indicating what tests were performed to assess neurological functioning for 3 (#1-#3) of 3 sampled patients. The absence of this information limits the clinician’s ability to accurately diagnose the patient’s condition and to provide a measure of baseline function, thereby potentially adversely affecting care. Findings: Review of the hospital’s policy PC-403 titled, “History and Physical Assessment”, revealed in part: A complete admission history and physical examination, to include an examination of cranial nerves, shall be recorded within 24 hours of admission. Review of Patient #1’s history and physical completed on 05/15/2025 failed to reveal a detailed cranial nerves assessment and only included cranial nerves II-XI grossly intact. Review of Patient #2’s history and physical completed on 05/19/2025 failed to reveal a detailed cranial nerves assessment and only included cranial nerves II-XI grossly intact. Review of Patient #3’s history and physical completed on 05/14/2025 failed to reveal a detailed cranial nerves assessment and only included cranial nerves II-XI grossly intact. In an interview on 06/03/2025 at 3:15 PM, S3PM confirmed Patients #1, #2, and #3’s history and physical did not contain a detailed cranial nerves assessment but merely listed cranial nerves 2-11 intact.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 48050 Based on record review and interview the governing body failed to ensure policies were administered to ensure quality healthcare. The deficient practice was evidenced by failure to ensure contract staff working in the hospital’s behavioral unit were oriented to the hospital policies/procedures for 7 (S7RN, S8RN, S9LPN, S10MHT, S11MHT, S12MHT, S13MHT) of 7 (S7RN, S8RN, S9LPN, S10MHT, S11MHT, S12MHT, S13MHT) sampled contracted staff personnel records reviewed. Findings: Review of personnel records revealed orientation documentation only contained education to the behavioral health unit. Further review failed to reveal that contract staff received education on the hospital policies/procedures that were not specific to the behavioral health unit. In an interview on 06/03/2025 at 4:00 PM, S4CPO verified the above information mentioned.”

“NURSING SERVICES CFR(s): A registered nurse or, where permitted by State law, a physician assistant, must supervise and evaluate the nursing care for each patient, including patients at a SNF level of care in a swing-bed CAH. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by failure of the Registered Nurse to document on admission a body/contraband search, and skin assessment for 1 (#3) of 3 (#1-#3) patient medical records reviewed. Findings: Review of hospital policy number NU 613, titled “Sharps/Contraband Search and Inventory,” effective date 08/28/2024, revealed in part: “POLCY: Patient belongings will be searched upon admission and as clinically appropriate or ordered. This search will be initiated immediately. II. PURPOSE: To provide a safe environment for staff and patients.” Review of hospital policy number NU 403, titled “Body Search,” effective date 08/28/2024, revealed in part: “PERSONAL SEARCH GUIDELINES: C. A visual body search shall be conducted on all new patients immediately upon admission to the unit. The patient should remain under staff visual supervision until a body search is completed. II. PROCEDURE: F. Document this procedure in the medical record.” A review of Patient #3’s medical record revealed Patient #3 was admitted on 05/14/2025 at 6:50 PM for Schizophrenia with substance abuse. Further review did not reveal documentation of contraband or body search assessments. A review of the hospital’s incident reports revealed in part on 05/15/2025 at 4:01 PM Patient #3 was found sitting on the patio slumped over, drooling from the mouth and not verbally able to respond. Medical care rendered immediately. Staff searched Patient #3’s room and found a small clear plastic bag or plastic wrap that was tied with small bead like substance. When Patient #3 was questioned, he admitted to smoking “MOJO/SPICE”. In an interview on 06/03/2025 at 11:09 AM, S1RNPM confirmed that there was no documentation in the medical record by the nurse that a contraband or body search assessment had been performed on Patient #3. In an interview on 06/02/2025 at 1:30 PM, S2DSS confirmed incident regarding Patient #3 was not reported to LDH-HSS as possible neglect nor was an investigation documented.”

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. 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 a current, and 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 care plan of 2 (#2, #3) of 3 (#1-#3) patient reviewed for completed and updated care plans. Findings: A review of the hospital policy number PM 002A last reviewed 08/28/2024 titled, “Treatment Plan,” revealed in part: POLICY: Each patient will have a written, individualized; interdisciplinary treatment plan based on assessments of their clinical needs and strengths. III. PROCEDURE: B. 2. Problems requiring immediate attention are added to the problem list by the treatment team as needed and/or applicable. J. the treatment plan is adapted throughout the patient’s admission. A review of the hospital policy number NU 432B last reviewed 08/28/2025 titled, “Precautions: Fall, Seizure, Withdrawal, Elopement, Suicide/Self Harm, Homicidal/Aggression, and Sexual,” revealed in part: I. POLICY: It is the policy of the hospital to ensure the safety and well-being of patients by placing them on precautions such as fall, seizure, elopement, suicide, homicide/ aggression withdrawal/seizure, and sexual. Upon admission, all patients will have staff present during their initial shower/bath. III. PROCEDURE: A. Falls: 1. When a patient gives evidence of fall risk due to previous history, clinical or medical presentation, high-risk scores on the Falls Risk Assessment, or fall experienced during hospital stay, the patient may be placed on fall precautions by the Physician. A review of Patient #2’s medical record revealed Patient #2 was admitted on 04/15/2025 with Delusional Disorder, Amphetamine/Opioid use disorder. Further review of Patient #2’s Fall Risk Assessment scored a 35 which puts Patient #2 at risk for falls. Review of Patient #2’s Master Treatment Plan did not reveal fall precautions as per hospital policy or address patient’s diagnosis of substance abuse. In an interview on 06/03/2025 at 10:15 AM, S1RNPM verified above mentioned findings.”

“PRIVACY AND SAFETY CFR(s): The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48050 Based on observation, record review, and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by failure of the staff to monitor 1(#1) of 3 (#1-#3) patients according to the physician’s orders including special precautions and documented the care provided in real time according to accepted standards and hospital policy. Findings: Review of hospital policy number NU432B, titled “Precautions: Fall, Seizure, Withdrawal, Elopement, Suicide/Self Harm, Homicidal/Aggression, and Sexual,” revision date 07/2021, revealed in part: I. POLICY: it is the policy to ensure safety and well-being of patients by placing them on precautions such as fall, seizure, elopement, suicide, homicide/aggression, withdrawal/seizure, and sexual. G. 1. If at any time during the patient’s stay, a patient is classified as requiring sexual precautions, the attending physician will be notified, and the patient may be placed on a higher level of observation. 2. Notification of MHT, Nursing personnel, and staff regarding observation level and precautions. Review of Patient #1’s medical record revealed Patient #1 was placed on sexual precautions on 05/20/2025 at 2:36 PM after an incident with a male peer. Further review of Patient #1’s medical record revealed mental health observation forms dated 05/20/2025 through 05/23/2025 did not have sexual precautions indicated. In an interview on 06/02/2025 at 3:30 PM, S1RNPM verified Patient #1 was placed on sexual precautions on 05/20/2025. S1RNPM verified RNs routinely place the precautions ordered by the provider on the MHT’s observation forms and further verified Patient #1’s MHT observation forms dated 05/20/2025 to 05/23/2025 did not indicate sexual precautions.”

“PRIVACY AND SAFETY CFR(s): The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure patients were kept free of all forms of abuse or harassment. This deficient practice is evidenced by the hospital failing to report potential allegations of abuse/neglect related to 1 (#3) of 3(#1-#3) patients reviewed to LDH-HSS (Louisiana Department of Health - Health Standards Section) within 24 hours of the awareness of this potential allegation. Findings: Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed “Department” shall mean the Department of Health and Hospitals. “Unit” means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, “Abuse” is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. “Neglect” is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer’s well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer’s physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report. Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Department of Health and Hospitals (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence. A review of incident logs from 01/2025 to 5/2025 revealed Patient #3 became unresponsive after smoking unknown substance on 05/15/2025 resulting in transfer to the ED. A review of the hospital’s self-reports to LDH-HSS did not reveal the possible neglect being self-reported. In an interview on 06/03/2025 at 10:10 AM S2DSS confirmed the above mentioned findings.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure all patients who presented to the hospital’s emergency department (ED) were provided on-going stabilizing treatment for an emergency medical condition. The deficient practice is evidenced by failure of the emergency department to provide stabilizing treatment and appropriate monitoring for one patient (F6) who were evaluated and placed under a Physician’s Emergency Certificate (PEC) after an emergency medical condition was confirmed. Findings: Review of the hospital policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA)” last reviewed 02/23/2023 revealed in part: DEFINITIONS: Hospital Property: The entire main hospital campus including the parking lot, sidewalk, and driveway or hospital departments, including any building owned by the hospital that is within 250 yards of the hospital. Emergency Medical Condition: A medical condition with sufficient severity (including severe pain, psychiatric disturbances, symptoms of substance abuse, pregnancy/active labor) such that the absence of immediate medical attention could place the individual’s health at risk. Upon completion of the MSE: Provide any necessary stabilizing treatment for an emergency medical condition (EMC) or patient in labor within the hospital’s capability and capacity. Emergency Medical Conditions include: Psychiatric disturbances, including severe depression, insomnia, suicide ideation or attempt, dissociative state, and inability to comprehend danger or care for self. Patient #F6 Review of Patient #F6’s medical record revealed Patient #F6 was brought to the emergency department (ED) on 10/28/2024 at 7:43 p.m. by family for possible overdose. The patient was unresponsive and the family reported the patient took heroin. The chief complaint listed for Patient #F6 was “unresponsive” and the patient was assigned a triage level 1- RESUSCITATION. Patient #F6 was immediately evaluated by ED MD who documented the patient was unresponsive and apneic. ED Nurse inserted IV heplock and administered Narcan IV push. After Narcan was administered, the patient woke up and was aggressive/combative. Security was called to assist. ED MD completed the Physician Emergency Certificate at 8:20 p.m. due to Patient #F6 being a danger to self and unwilling. At 8:34 p.m. ED nurse administered Benadryl and Haldol IM due to Patient #F6 being uncooperative, threatening, and abusive to ED staff. Patient #F6 then eloped from the ED at 9:05 p.m. Family brought Patient #F6 back to the ED on 10/28/2024 at 9:53 p.m. Review of the Event log for 10/28/2024 revealed the following documentation, in part, of the event: Description: Patient was a very uncooperative PEC patient who arrived unresponsive with apparent overdose. After Narcan admin [administered] patient became very aggressive and threatening so security [named] and Town A PD [police department] called for assistance. Security was at bedside when patient ran out of the hospital eloping from the ED. Closing Remarks: . . . . Security at bedside, patient eloped out of ED with security chasing after him with no success to stop him. Patient brought back into ED after some time and treatment was continued, as well as PEC . . . In an interview on 11/14/2024 at 3:30 p.m. S1DON revealed that the emergency department staff were not trained in de-escalation techniques, and training was not provided after the elopements. S1DON also verified the emergency department does not have a safe room for psychiatric patients, only a curtained ED bay across from the nursing station. S1DON verified the doors to the emergency department are not locked, entry and departure from the area is not restricted, and no changes were made to provide a secure setting for psychiatric patients after the elopements. S1DON also verified staff should have called a code white when Patient #F5 stated he was leaving the ED. S1DON also stated once the patient reaches the outside of the hospital, the hospital staff will not go outside even if the patient is still on hospital property, but will call the police department.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 44763 Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice was evidenced by failing to provide an appropriate medical screening exam for 1 (#2) of 20 (#1 - #20) patients who presented to the emergency department. (See findings tag A-2406).”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure all patients who presented to emergency department (ED) had an appropriate medical screening exam. This deficient practice was evidenced by failing to provide an appropriate medical screening exam for 1 (#2) of 20 (#1 - #20) patients who presented to the emergency department. Findings: Review of the hospital’s policy titled “Emergency Department: Medical Screening Exam” reviewed 05/2017, revealed in part, any individual who comes on hospital property requesting examination or treatment is entitled to and shall be provided an appropriate medical screening examination by a physician to determine whether or not an emergency medical condition exists. The medical screening examination shall be the same medical screening examination that the hospital would perform on any individual coming to the hospital’s emergency department with those signs and symptoms regardless of the individual’s ability to pay for medical care. Review of Patient #2’s medical record revealed Patient #2 presented to the emergency department on 07/25/2024 at 10:45 a.m. Review of the ED summary report revealed in part, Patient #2’s chief complaint was hallucinations and was given a triage level 5 - Non Urgent. Triage note revealed in part, 10:50 a.m. Patient #2 ripped blood pressure cuff off and took off on foot beating ER doors and ran outside where she met officers who took her into custody. Further review revealed a nursing note dated 07/25/2024 at 11:11 a.m. Patient #2 was brought to the ED by local police department with c/o hallucinations. Patient #2 was escorted to bed ER3 by police officers. While obtaining vital signs, S6CP stated he and officer had to return to road as only two officers were working. As soon as police left the ED, Patient #2 became belligerent, yelling and attempted to get out of the bed by climbing over bed rails. Patient #2 was prevented from climbing over rail to prevent injury; Patient #2 then exited bed at foot of bed and began to walk out of the ED in aggressive manner. As Patient #2 was walking out, Patient #2 began yelling and striking at floor scale, striking the ED doors to the exit of ED. ED door was opened and Patient #2 exited the ED into parking lot. Review of Patient #2’s medical record failed to reveal a medical screening examination performed by a physician. Review of the Police Department Offense Report presented by S1Adm revealed in part, on the above date I, S6CP responded to Barousse St to assist S7PO on a call of a female running down the road with no clothes on. Upon my arrival S7PO had located the female and convinced her to go into her residence and put clothing on. As I was talking with S7PO and the female who overdose herself to S7PO as Patient #2 I could see she was seriously under the influence of some type of narcotics. I asked Patient #2 what she was on and she advised Xanax and jiggers. Patient #2 advised she had taken 7 Xanax and 2 1/5 jiggers which is street terms for ecstasy. Patient #2 had sweat pouring from her and her eyes were huge and it was obvious that she was having a severe medical issues and mental issues. We requested an ambulance which we tried waiting for which was taking quite a while as usual here in town. It appeared that Patient #2 reactions and the drugs were getting worse and I was in fear for her medical well-being and advised S7PO that we could no longer wait for an ambulance we would transport before she went onto severe medical conditions. I radioed the dispatcher and advised to cancel the ambulance that we were transporting to the hospital. Upon arrival at the hospital we walked Patient #2 in and I informed the ER nurse S4LPN what the situation was and how we found her naked and also what I observed and that she was heavily under the influence of some type of drugs. I also stated to him that she appears to be in medical distress from the narcotics taken. We walked her to station three where 2 nurses began to get her vitals and start to exam her. I asked S4LPN if we could go because S7PO was the only unit on the road and he responded yes. Myself and S7PO walked out the hospital and stopped outside the ER door to speak with one of the maintenance guys. While speaking with the maintenance guy, the ER doors come flying open and Patient #2 comes out the ER and lets herself fall down to the concrete. Right behind her is the ER doctor screaming and hollering at us and says S6CP you can take her to jail. I advised him I was not taking her to jail that she needs medical and mental treatment and did nothing to go to jail for. He then advised me that he was not treating her and that she was not coming back in his hospital and hollering at me. I asked him if he was refusing medical treatment and he advised she is not coming back in the hospital. He then advised she was cutting up so I asked him why did someone not come get us we were at the back door which has cameras and they can see we were there. The ER doctor continued to scream and insist we take her to jail, I advised him that in her medical condition I was not taking her to jail and the ER doctor screamed I am medically clearing her right now for jail. I advised him I was not taking her to jail, she needs medical help and he refused again and closed the ER door on us. We tried calling an ambulance to transport her to another hospital but was refused as we were stated that they could not pick her up on hospital property without hospital request. At that time for her safety and her getting more and more needing what I appeared to be medical treatment and with the ER doctor refusing medical treatment I made the decision where we would transport her to the Police Department and have an ambulance pick her up there. Upon arrival at the Police Department, ambulance personnel transported Patient #2 to another hospital for medical treatment. In a phone interview on 08/14/2024 at 12:45 p.m. S3RN stated shortly after the police left, Patient #2 ripped off the blood pressure cuff and scooted down to the foot of the bed. She stated Patient #2 stormed to the ED doors. She stated Patient #2 started banging on the ED doors and S5MD went to meet Patient #2. She stated she heard S5MD say “get her out of here, I don’t want her in my ER”. She stated she didn’t see the police officers but that’s who she assumed S5MD was talking to. In a phone interview on 08/14/2024 at 1:09 p.m. S5MD stated he was at the desk observing when Patient #2 came in. He stated Patient #2 was a little agitated when the police walked Patient #2 to the ED bed. S5MD stated Patient #2 was cooperative at this point. He stated the staff began taking vital signs. S5MD stated he overheard bits and pieces that Patient #2 was upset about a death in her family. He stated S6CP had left when the triage nurse was taking their report. He stated Patient #2 never stated she wanted to harm herself or anyone else. S5MD stated when the triage nurse walked away to get something, Patient #2 became belligerent, trying to get out the stretcher. He stated he was concerned for her safety. He stated Patient #2 got out the bed before he could get to her. S5MD stated as Patient #2 ran down the hall she was yelling saying she didn’t want to be here. He stated Patient #2 threatened the staff’s safety in general. S5MD stated Patient #2 was yelling, “If yall try to stop me, I will hurt yall”. He stated within 30-40 seconds from S6CP leaving is when Patient #2 became belligerent. S5MD stated Patient #2’s presentation was of stimulant intoxication rather than psychosis. S5MD stated he had not examined Patient #2 but determined that from what he had observed. He stated Patient #2 picked up the floor scale and attempted to throw it but couldn’t. He stated Patient #2 then ran into the ED doors. S5MD stated he pressed the button to open the ED doors because those doors cost $700 to repair if broken. S5MD stated when the doors opened Patient #2 walked in the waiting area, turned right, and pressed the button and the ED entrance door opened. S5MD stated he followed Patient #2 into the parking lot. He then stated he stood in the ED door entrance. S5MD stated S6CP was standing on the grass near the entrance and Patient #2 sat down in front of him. He stated he addressed S6CP, not in an angry or disrespectful but was forceful with S6CP. S5MD stated he told S6CP that Patient #2 is threatening him and his staff, destroying the ER, and he couldn’t have her here in this condition. S5MD stated he told S6CP that he would be happy to medically clear her. S5MD stated they needed some help from the police to secure Patient #2 to be able to give medication to calm Patient #2 down. S5MD stated triage was initiated, he had observed Patient #2 calmly answering questions when S6CP was present. He stated as soon as S6CP left, Patient #2 became violent and wanted to leave. S5MD stated in the state Patient #2 was in, there was no way to evaluate the patient until they could get her to calm down and that was not the case. In an interview on 08/15/2024 at 8:48 a.m. S1Adm stated it did not appear that a medical screening exam was performed by the physician for Patient #2. S1Adm verified there was no physician documentation included in the medical record for Patient #2. He verified the only documentation from the physician was on the Alternate Discharge Status Form where the physician signed acknowledging Patient #2 eloped from the ED. In an interview on 08/15/2024 at 2:10 p.m. while reviewing the hospital’s policy titled “Emergency Department: Medical Screening Exam”, S1Adm stated once a patient reaches the outside of the hospital, the hospital staff will not go outside. He stated at that point the hospital staff calls the police department for the patient. He stated the police would bring the patient back inside the emergency department. In a phone interview on 08/19/2024 at 10:07 a.m. S2DON stated hospital “a” has 10 psychiatric beds. He stated on 07/25/2024 the psychiatric unit had 6 patients. He verified there was a bed available in the psychiatric unit on 07/25/2024. Review of Patient #2’s medical record from hospital “b” revealed in part, Patient #2 was brought in by ambulance on 07/25/2024 at 12:04 p.m. with a chief complaint of psychiatric evaluation and was given a triage level 2- Emergent high risk. Review of the ED notes by provider revealed in part, 30-year-old black female to the emergency department via EMS for evaluation of bizarre behavior. Patient #2 was found outside running around naked yelling. Patient #2 appears to be acutely psychotic and is agitated yelling at staff. She is having flight of ideas and is very pressured speech. Unable to get history of previous psychiatric illness. Is able to state she has no physical complaints. No chest pain or shortness of breath. Patient #2 required chemical sedation. Further review of Patient #2’s medical record from hospital “b” revealed in part, Patient #2 was placed on PEC on 07/25/2024 at 12:28 p.m. Patient #2 was transferred to hospital “c” on 07/25/2024 at 5:44 p.m. with a diagnosis of bizarre behavior; psychosis, unspecified psychosis type.”