Ochsner St Anne General Hospital

“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: 14442 Based on observation, record review, and interview, the CAH failed to ensure the governing body assumed responsibility for policies to provide health care in a safe environment. This deficient practice was evidenced by failing to ensure hospital weapon detection system policies and security personnel competencies were updated after an incident of a patient (#1) bringing a weapon into the hospital. Findings: Review of Patient #1’s medical record revealed, in part: “Psychiatry. Nursing Addendum. When skin assessment completed patient had a gun wrapped in towels, in his sock on his ankle.” In an interview on 08/04/2025 at 11:26 AM, S1Director of Quality confirmed Patient #1 was found with a gun in the hospital behavioral health unit. S1Director of Quality confirmed Patient #1 entered the hospital through the ED, passed through the ED EVOLV Weapon Detection System and the system did not alert that the patient had a weapon. On 08/04/2025 at 1:51 PM, an observation of the ED EVOLV Weapon Detection System was conducted with S1Director of Quality and S2Security Manager. Observation revealed the EVOLV Weapon Detection System located near a walk-in/ambulatory entrance door and sliding entrance doors for ambulance personnel. In an interview at this time, S2Security Manager indicated for the EVOLV Weapon Detection System to function properly both the walk-in/ambulatory entrance door and sliding entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System. S2Security Manager indicated that if a door was not completely closed, the EVOLV Weapon Detection System may not alert security personnel of the presence of a weapon. Review of the hospital “EVOLV Express Weapon Detection System” policy and procedure with an approval date 03/17/2025 revealed, in part: “I. Purpose. This operational standard provides guidelines on the effective operation of the Evolv Express Weapon Detection System and the identification and safe securing of any potential weapons threats entering an Ochsner facility. IV. Procedure. All individuals entering an Ochsner facility where Evolv Express Weapon Detection Systems are deployed are required to pass through and be scanned for weapons or dangerous instrumentalities except patients in active labor or patients with a medical emergency in route to the Emergency Department. Further review of the section “IV. Procedure” revealed no procedure stating that ED entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System. Review of the hospital “EVOLV Weapon Detection System Checklist and Competency Acknowledgment” form for hospital security personnel assigned a security EVOLV post of duty or temporary assignment for EVOLV revealed the checklist and competency form did not address that ED entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System. In an interview on 08/05/2025 at 9:17 AM, S1Director of Quality confirmed that ED entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System for the system to function properly. In an interview on 08/05/2025 at 11:17 AM, S1Director of Quality confirmed hospital “EVOLV Express Weapon Detection System” policy and procedure and hospital “EVOLV Weapon Detection System Checklist and Competency Acknowledgment” form for hospital security personnel had not been updated to include ED entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (5) Address outcome indicators related to improved health outcomes and the prevention and reduction of medical errors, adverse events, CAH acquired conditions, and transitions of care, including readmissions. This Standard is not met as evidenced by: 14442 Based on observation, record review, and interview, the CAH failed to ensure the Quality Assessment Performance Improvement program addressed prevention of adverse events. This deficient practice was evidenced by failing to include monitoring of an identified issue with the weapon detection system after an incident of a patient (#1) bringing a weapon into the hospital. Findings: Review of Patient #1’s medical record revealed, in part: “Psychiatry. Nursing Addendum. When skin assessment completed patient had a gun wrapped in towels, in his sock on his ankle.” In an interview on 08/04/2025 at 11:26 AM, S1Director of Quality confirmed Patient #1 was found with a gun in the hospital behavioral health unit. S1Director of Quality confirmed Patient #1 entered the hospital through the ED, passed through the ED EVOLV Weapon Detection System and the system did not alert that the patient had a weapon. On 08/04/2025 at 1:51 PM, an observation of the ED EVOLV Weapon Detection System was conducted with S1Director of Quality and S2Security Manager. Observation revealed the EVOLV Weapon Detection System located near a walk-in/ambulatory entrance door and sliding entrance doors for ambulance personnel. In an interview at this time, S2Security Manager indicated for the EVOLV Weapon Detection System to function properly both the walk-in/ambulatory entrance door and sliding entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System. S2Security Manager indicated that if a door was not completely closed, the EVOLV Weapon Detection System may not alert security personnel of the presence of a weapon. In an interview on 08/05/2025 at 9:17 AM, S1Director of Quality confirmed that ED entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System for the system to function properly. Review of the hospital quality assurance and performance improvement records revealed no documented evidence the hospital monitored the ED EVOLV Weapon Detection System to ensure that ED entrance doors were completely closed prior to individuals walking through the EVOLV Weapon Detection System. In an interview on 08/05/2025 at 12:51 PM, S1Director of Quality confirmed there was no documented evidence the hospital monitored that ED entrance doors were completely closed prior to individuals walking through the EVOLV Weapon Detection System in the quality program.”

“CONSTRUCTION CFR(s): The CAH is constructed, arranged, and maintained to ensure access to and safety of patients, and provides adequate space for the provision of services. This Standard is not met as evidenced by: 14442 Based on observation, record review, and interview, the CAH failed to ensure the physical environment was maintained for the safety of patients. This deficient practice was evidenced by failing to ensure the ED consult room used for patient care had a call bell system for patients’ to contact hospital staff. This deficient practice had the potential to impact ED patients’ placed in the ED consult room. Findings: Observation of the emergency department on 06/12/2025 at 8:37 AM revealed the ED consult room did not have a call bell system for patients’ to contact hospital staff. Review of Patient #1’s medical record revealed, in part, Patient #1 arrived in the ED on 05/12/2025 at 4:07 PM with a chief complaint of hand injury. At 4:17 PM, Patient #1 had a pain assessment pain rating of 8 on a scale of 0-10 (0-no pain, 10-worst possible pain). At 5:19 PM, Patient #1 transferred to ED consult room. At 5:27 PM, Patient #1 had an IM injection of Ketorolac 30 mg (used for treatment of moderate to severe pain). At 5:42, Patient #1 “was yelling for a nurse. RN walked in on patient sitting in the chair. Patient stated that they fell out of the chair onto the floor and hit their left hip. Patient diaphoretic upon assessment.” Further review of Patient #1’s medical record revealed, in part: “Post Fall Summary: Safety Interventions at time of fall: Instructed to call staff for mobility.” In an interview on 06/12/2025 at 8:41 AM, S2ED Manager confirmed the ED consult room did not have a call bell system and Patient #1 could not call staff. S2ED Manager confirmed the hospital ED consult room used routinely or daily for patient care, such as, medication administration, venipuncture for laboratory work, IV cannulation, and discharge instructions.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 14442 Based on record review, observation, and interview, the CAH failed to ensure emergency department nursing services were provided to meet the needs of the patient. This deficient practice was evidenced by failing to ensure nursing staff monitored a patient that experienced a potential adverse medication reaction after an IM injection for 1 (#1) of 3 (#1-#3) sampled patients. Findings: Review of the hospital “Quick Sheet” for Intramuscular (IM) injections revealed, in part: “IM injections have been associated with adverse effects and pain, and this route of medication injection should be used as a last resort. 34. Stay with the patient for several minutes and observe for any allergic reactions. Dyspnea, wheezing, and circulatory collapse are signs of severe anaphylactic reaction. 36. Watch the patient for adverse and allergic reactions to the medication. If a reaction occurs, follow the organization’s practice for emergency response. Report rash, seizures, and difficulty breathing.” Review of Patient #1’s medical record revealed, in part, Patient #1 arrived in the ED on 05/12/2025 at 4:07 PM with a chief complaint of hand injury. At 4:17 PM, Patient #1 had a pain assessment pain rating of 8 on a scale of 0-10 (0-no pain, 10-worst possible pain). At 5:19 PM, Patient #1 transferred to ED consult room. At 5:27 PM, Patient #1 had an IM injection of Ketorolac 30 mg (used for treatment of moderate to severe pain). At 5:33 PM, Patient #1’s vital signs were: BP: 127/65; Pulse: 88. At 5:40 PM, Patient #1’s vital signs were: BP: 111/60; Pulse: 59! (Pulse decreased by 29 beats per minute from previous reading). At 5:42, Patient #1 “was yelling for a nurse. RN walked in on patient sitting in the chair. Patient stated that they fell out of the chair onto the floor and hit their left hip. Patient diaphoretic upon assessment.” Observation of the emergency department on 06/12/2025 at 8:37 AM revealed the ED consult room did not have a call bell system for patients’ to contact hospital staff. In an interview on 06/12/2025 at 8:41 AM, S2ED Manager confirmed the ED consult room did not have a call bell system and Patient #1 could not call staff. In an interview on 06/12/2025 at 10:20 AM, S2ED Manager confirmed that it was nursing judgment for how long to monitor a patient after an IM injection and observe for adverse and allergic reactions to the medication.”

“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: 14442 Based on record review and interview, the CAH failed to ensure the emergency department registered nurse evaluated the nursing care for each patient. This deficient practice was evidenced by failing to ensure a registered nurse completed fall risk assessments for 2 (#1, #3) of 3 (#1-#3) sampled patients. Findings: Review of hospital policy “Emergency Department Assessment Standards” with an Approval Date: 10/27/2023 revealed, in part: “I. The purpose of this policy is to establish assessment guidelines for patients presenting to the Emergency Department (ED). III. All patients presenting to the ED will be appropriately assessed. IV. Policy Implementation. B. General Assessment: 1. The following will be reviewed and documented by the RN and/or paramedic on the medical record, if applicable: e. Fall risk.” 1. Review of Patient #1’s medical record revealed, in part, Patient #1 arrived in the ED on 05/12/2025 at 4:07 PM with a chief complaint of hand injury. At 5:19 PM, Patient #1 transferred to ED consult room. At 5:27 PM, Patient #1 had an IM injection of Ketorolac 30 mg (used for treatment of moderate to severe pain). At 5:42, Patient #1 “was yelling for a nurse. RN walked in on patient sitting in the chair. Patient stated that they fell out of the chair onto the floor and hit their left hip. Patient diaphoretic upon assessment.” Further review of Patient #1’s medical record revealed no evidence fall risk assessment completed prior to Patient #1 stating that they fell. In an interview on 06/12/2025 at 10:22 AM, S2ED Manager confirmed Patient #1 did not have a fall risk assessment completed prior the patient stating that they fell. 2. Review of Patient #3’s medical record revealed, in part, Patient #3 arrived in the ED on 06/07/2025 at 12:22 PM with a chief complaint of back pain. At 1:22 PM, Patient #3 had IM injections of Ketorolac 60 mg and Orphenadrine 60 mg (muscle relaxant). At 1:38 PM, Patient #3 discharged from the hospital. Further review of Patient #3’s medical record revealed no evidence fall risk assessment completed. In an interview on 06/12/2025 at 10:56 AM, S2ED Manager confirmed Patient #3 did not have a fall risk assessment completed.”

“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: 44495 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 1) failure of the hospital to ensure an appropriate medical screening examination was provided to each patient presenting to the emergency department to determine whether or not an emergency medical condition existed in 1 (#15) of 20 (#1- #20) reviewed medical records of patients presenting for evaluation (See findings under tag A-2406); and 2) failure of the hospital to ensure a transferred patient was certified as stable and the transfer was to a facility with the capability to meet the medical needs of the patient in 1 (#20) of 7(#1-#5, #19, #20) reviewed patient transfer records from a total of 20 reviewed records (See findings under tag A-2409).”

“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: 44495 Based on record review and interview, the emergency department failed to ensure each patient received an appropriate screening medical examination. The deficient practice is evidenced by failure of the emergency department staff to address nausea and vomiting 1 (#15) of 20 (Patients #1-#20) reviewed records of patients who presented to the emergency department with compaints of shortness or breath and weakness. Findings: Review of the emergency department record for Patient #15 revealed the patient presented on 11/11/2024 at 12:15 p.m. with complaints of “shortness of breath, weakness, swelling to his ankles since last night, denies chest pain.” The patient was triaged at 12:19 PM and assigned an Emergency Severity Indes (ESI) of 3. Triage vital signs included temperature 98.2 degrees Fahrenheit, blood pressure (!)187/111 millimeters of mercury (mmHg), pulse 91 beats per minute (bpm), respirations 22/ minute, and SPO2 97 %. Review of the “History of Present Illness” for Patient #15 revealed in part, “ a past medical history of hypertension, diabetes presents to ER today with complaints of shortness of breath, bilateral leg swelling. Calf tenderness to the left calf. Patient denies chest pain at this time. Patient also reports he has weakness as well as nausea. Patient reports he cannot keep his medicine down this morning due to nausea. Blood pressure in triage 187/111. Patient reports 2 months ago he was evaluated by [name removed] cardiology for similar physical feelings. Patient reports he was compliant with all prescription medications at this time.” Further review of Patient #15’s history failed to reveal a reconciliation or list of routine home medications. Review of the “Physical Examination” was significant for left calf tenderness. The workup included EKG, radiology and blood studies. The EKG, chest x-ray, CTA of chest (non-coronary), and ultrasound of the left thigh and calf were all normal. Significant abnormal findings from the studies included the following results: Carbon Dioxide (CO2)- 19 milliequivalents per liter (mEq/L) [normal 20-29 mEq] Total Protein- 8.5 grams per deciliter (g/dL) [normal 6.0- 8.5 g/dL] Alkaline Phosphatase- 39 international units per liter (IU/L) [normal 48- 121 IU/L] Aspartate Aminotransferase (AST)- 64 units per liter (U/L) [normal less than or equal to 40 IU/L] Hemoglobin 13.5 grams per liter (g/L) [indicated to be low] Hematocrit 37.5% [indicated to be low] D dimer 2.04 milligrams per liter (mg/ L) [normal range <0.50] Anion Gap- 19 milliequivalents per liter (mEq/ L) [normal range 8-12 mEq/L] Review of the medical record revealed no acknowledgement or further assessment of the elevated anion gap and slightly low CO2 despite the presentation of nausea in a known diabetic. Further review of the record failed to reveal an oral challenege of liquids to assess Patient #15’s nausea and inability to tolerate oral intake including daily medications. Review of the orders and medication administration revealed Patient #15 was only administered the contrast for the imaging study. Review of the emergency provider’s note at the time of discharge revealed, “Patient stable at time of discharge in no acute distress. No life threatening illnesses were found during ER visit today. Patient was instructed to follow-up with PCP or other recommended specialist within the next 48- 72 hours. Patient was instructed to return to ER immediately for any worsening symptoms or concerning symptoms. All discharge instructions discussed with patient, and patient agrees to comply with discharge instructions given today.” Review of the discharge instructions for Patient #15 revealed at the blood pressure documented at the time of discharge was 176/ 104mm/Hg. Further review of the discharge instructions failed to reveal a list of the home medications for Patient #15 and failed to reveal instructions for taking the home medications if the nausea persisted. In interview on 12/09/2024 at 1:10 PM, S3EDM verified all of the blood pressure readings for Patient #15 while in the emergency department were elevated and the patient had stated that he was unable to keep his medications down. S3EDM verified the physician did not document the home medications for Patient #15. S3EDM verified the physician did not assess the patient’s complaint of nausea, did nothing to ensure the patient would be able to tolerate his medications after returning home.”

“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: 44495 Based on record review and interview, the hospital failed to ensure a patient with an emergency medical condition was properly transferred as required by the Emergency Medical Treatment and Labor Act (EMTALA). The deficient practice is evidenced by failure of the hospital to ensure a transferred patient was certified as stable and the transfer was to a facility with the capability to meet the medical needs of the patient in 1 (#20) of 7(#1-#5, #19, #20) reviewed patient transfer records from a total of 20 reviewed records. Findings: Review of Policy Number OHS.ED.001, “Admission, Discharge and Transfer Guidelines for the Emergency Department,” approved 09/14/2023, revealed in part: “IV.B. Transfer: 1.Patients requesting or in need or transfer to another facility will be deemed stable by the attending physician or designee before transfer can be approved. a. In situations where the patient is not stable, the benefits of the transfer must outweigh the risks. 2.The transferring physician will document the reason for transfer, accepting physician, method of transfer and care required during transfer.” Review of Policy Number OHS.PTCARE.005, “Emergency Department Transfer of Patients to Another Hospital or Physician,” last revised July 2012, revealed in part: “III. Policy Statements A.When and evaluation determines that a patient has an emergency the hospital will provide appropriate services within its capabilities until the patient is stabilized (as defined below) or the labor treated baby delivered, the patient is admitted to the hospital or the patient is discharged following completion of all medically- indicated treatment. B. Medically Necessary patient transfers for patients who have and emergency medical condition prior to the patient being stabilized or who is in labor, will not occur until the physician certification (as defined below) is completed and the transfer is an appropriate transfer (as defined below) unless the patient ( or his appropriate representative) requests the transfer to be effected.” Further review revealed in part: “D. Indications for Transfer of Stabilized Patient (assumes patient consents to transfer): 1. Patient Care: a. The patient will receive at the receiving facility the benefit of a more appropriate facility, medical personnel and/or services than are available at Ochsner. b. The transferring Ochsner facility lacks the capability to care for the patient (the facilities, equipment, and/or medical staff/personnel).” [and] “IV.E. The hospital will not transfer a patient with an emergency medical condition which has not been stabilized or a patient who is in labor unless: 1. The patient or a legally responsible person on the patient’s behalf requests that the transfer be effected. The request must be in writing, the patient must be advised of the hospital’s obligation to provide emergency medical treatment, and the transfer is an “appropriate transfer” to another medical facility. 2. A physician/ APC has certified in writing (Physician Certification) that, based upon the reasonable risks and benefits to the patient and the information then available, the medical risks and benefits reasonably expected from the provision of appropriate medical treatment at the other facility (receiving hospital) outweigh the increased risks to the patient’s or unborn baby’s medical condition from effecting the transfer.; and the transfer is an “appropriate transfer” to that other medical facility. F. An appropriate transfer is one in which: 1. The receiving facility has available space and qualified personnel for the treatment of the patient and has accepted the patient, and a physician or other responsible person has agreed to accept the patient prior to transfer and to provide appropriate treatment on arrival of the patient. The sending physician/APC will arrange this aspect of the transfer as a direct physician to physician contact and will exchange clinical information.” [and] “G. Duties of the Transferring Physician/ APC 1. Prior to transfer, the transferring physician/ APC will secure a receiving physician and hospital that is appropriate for the medical needs of the patient and will accept the responsibility for the patient’s medical treatment and hospital care on arrival of the patient. Transferring APC will document transfer acceptance by the receiving physician and hospital.” [and] “G.5. Prior to patient transfer, the physician / APC who authorizes the transfer will have personally examined and evaluated the patient to determine the patient’s medical needs and to assure that the proper transfer procedures are used. “ Review of the emergency department record for Patient #20 revealed the patient presented on 06/12/2024 at 7:20 PM with complaints of “increased blood pressure and heart rate, falling more frequently with restless leg syndrome. Recent med [medication] changes. Abilify was stopped. Started on Zyprexa.” Review of the “History of Present Illness,” S4MD documented in part, “. . . presents with continued medication issues. Patient suffers from bipolar disorder was recently started on Abilify 2 weeks ago per family. Significant side-effects afer the Abilify which was recently stopped due to side-effects. Patient was shaking, falling, agitated and not sleeping per the family at bedside this p.m. Patient was prescribed Klonipin; has not helped the side effects from the medications. Family was requesting inpatient behavioral health evaluation and further treatment as well.” Review of the vital signs for Patient #20 at the time of presentation revealed: Blood Pressure- (!)139/99 milimiters of mercury (mm/Hg) Pulse- (!)123 beats / minute Respirations- 20 respirations/ minute Temperature- 97.8 degrees Fahrenheit SpO2- 97% Review of the abnormal laboratory studies revealed in part: Creatinine Phosphokinase (CPK) - 822 units/ liter (U/L) [normal range 20-200U/L] Potassium- 3.3 millimoles per liter (mmol/L) [normal range 3.5 to 5.2 mmol/L] Ketones, UA- 3+ [normal is negative] The electrocardiogram was interpreted by the ED physician. The physician documented: EKG Readings: (Independently Interpreted) No STEMI Normal Sinus Rhythm No ectopy Normal conduction; Normal ST segments Normal T wave Normal Axis Heart Rate in 100’s Vital signs were repeated on 06/12/2024 at 9:24 PM and revealed: Blood Pressure- (!) 137/93 mm/Hg Pulse- 104 beats / minute Respirations- 20 respirations/ minute SpO2- 96% On 06/12/2024 at 9:33 PM under “ED Management and Risks of Complication, Morbidity, and Mortality” S4MD documented, “Patient was not doing well since medication changes by Psychiatry. Will admit to inpatient psychiatry for further treatment and evaluation. Medically cleared for psychiatry placement.” Further review of the medical record revealed on 06/12/2024 at 9:40 PM, S4MD entered an order for a” Physician’s Emergency Certificate” (PEC). Review of the PEC revealed under mental condition the physician documented, “patient is not psychotic, patient is not violent, and patient has been entirely cooperative in the ER today. Agitated, not sleeping, several medication changes by Psychiatry in the last couple of weeks.” He then checked off the boxes for dangerous to self, unwilling, and gravely disabled. Patient #20 remained in the emergency department waiting for psychiatry placement from 06/12/2024 at 10:28 PM until 06/14/2024 at 5:42 PM The results of the EKG performed on 06/12/2024 at 8:12 PM were finalized by S7MD on 06/13/2024 at 12:14 PM The final results included: Sinus tachycardia Possible left atrial enlargement Nonspecific ST abnormality Borderline Abnormal ECG When compared with ECG of 04/16/1997 at 3:15 PM, T wave inversion now evident in inferior leads T wave amplitude has decreased in Anterior-lateral leads Review of the vital signs for Patient #20’s pulse remained above 100 beats/ minute beginning at 9:31 AM on 06/13/2024. Review of the vital signs for 06/13/2024 at 5:30 PM revealed: Blood Pressure- (!)164/108 mm/Hg Pulse- (!)131 beats/ minute Respirations- 18 respirations/ minute SpO2- 97% On 06/13/2024 at 5:43 PM, S5MD documented, “Patient was transitioned to me at 6:00 AM, awaiting BHU[Behavioral Health Unit] placement. In the afternoon at 2:15 PM patient was noted to be tachycardic and diaphoretic. Repeat blood work was obtained and resulted as normal. Patient is afebrile. Patient had recent discontinuation of Abilify in the last 3 days which may be contributing to withdrawal symptoms. I gave the patient Ativan as well as normal saline [intravenous hydration] and symptoms did not improve. Patient had been transitioned to olanzapine 3 days ago but has not been given it since he was admitted to the emergency room, so his normal dose of olanzapine was given. We will continue workup and monitor until patient’s symptoms improve.” Further review of the record failed to reveal documentation by a physician in the last 12 hours before Patient #20 was transferred to Hospital B. Review of the RN note from 06/13/2024 at 5:44 PM revealed, “Notified S5MD that received call from BHU [Behavioral Health Unit] stating S8MD wanted patient to be admitted to the 3rd floor to get fluids [intravenous hydration] throughout the night along with benzo [benzodiazepines] then BHU will be willing to take patient in a.m.” Review of the “Medication Administration Record” for Patient #20 on 06/13/2024 revealed nursing staff administered lorazepam 1milligram at 2:51 PM, olanzapine 10 milligrams at 4:45 PM, clonidine 0.3 milligrams administered at 5:49 PM., and clordiazepoxide HCl 50 mg administered at 6:48 PM. Review of the ordered laboratory studies for 06/13/2024 revealed an abnormal CPK level of 684 U/L [normal range 20-200U/L] reported at 7:14 PM, and an abnormal D dimer level of 12.90 mg/L [normal range <0.50] reported at 7:23 PM. Computed tomography angiogram (CTA) of the chest (non-cardiac) was also performed on 06/13/2024 and the result was reported at 9:01 PM and revealed in part, “No pulmonary embolism to the segmental level.” On 06/13/2024 at 9:53 PM, new transfer orders were entered for transfer to “medical/psych due to labile vital signs.” On 06/14/2024 at 5:42 AM, Patient #20 was transferred to Hospital B which was not a medical/psychiatric facility as ordered. Review of the medical record for Patient #20 revealed S6MD ordered the D dimer, CPK, and CTA, but there was no documented acknowledgement of the test results, no differential diagnosis, and no assessment and plan. There was no “Physician Certification” documenting Patient #20 had been stabilized such that within reasonable medial probability, no deterioration of the patient’s condition was likely to result from the transfer. There was no documentation that S6MD called the receiving psychiatrist to discuss Patient #20’s normal CTA and abnormal creatinine phosphokinase, D dimer, and EKG. There was no documentation to explain why Patient #20 was transferred to a lower level of care when a bed on the behavioral unit at the current hospital was to be available on the same day and was designated for Patient #20’s admission. Review of the medical records from Hospital C revealed emergency transport services transferred the patient from Ochsner St. Anne General Hospital to Hospital B and then to Hospital C. It was noted that Hospital B refused Patient #20 because of a possible seizure in route and sent the patient to the nearest emergency department for evaluation. While at Hospital C, consideration was given to having Patient #20 return to the behavioral unit at Ochsner St. Anne General Hospital when the patient again had an unresponsive episode, coded several times, was intubated and transferred to a critical care unit at Hospital D. At Hospital D it was determined that Patient #20 had a large pulmonary embolism and right lower extremity deep vein thrombosis. In interview on 12/09/2024 during the chart review between 1:00 PM and 1:10 PM, S3EDM verified she was familiar with the patient and the events that occurred after Patient #20’s presentation to the emergency department. S3EDM verified there was no documentation by a physician after 06/13/2024 at 5:43 PM. S3EDM verified after the normal CTA result was released, there were no other studies ordered or repeated in an attempt to determine the significance of the elevated D dimer, creatinine phosphokinase, and changes in the EKG. S3EDM verified the record did not have “Physician Certification” prior to transfer as required by hospital policy. S3EDM verified arrangements had been made to have Patient #20 admitted to the onsite psychiatric unit on the same day Patient #20 was transferred to another psychiatric hospital with no onsite acute care services. S3EDM verified the orders were for transfer to a facility that could provide both medical and psychiatric care. In interview on 12/12/2024 at 12:00 PM, the Director of Nursing at Hospital B verified the facility did not accept psychiatric patients with complex medical diagnoses and the facility only provided psychiatric services.”

“NOTICE OF RIGHTS CFR(s): A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under state law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible This Standard is not met as evidenced by: 14442 Based on record reviews and interview, the hospital failed to inform each patient of the patient’s rights. This deficient practice was evidenced by failing to ensure patients presenting to the emergency department with a chief complaint psychiatric evaluation were offered a copy of the Mental Health Patient Rights for 2 (#1, #2) of 3 (#1, #2, #3) sampled patients. Findings: Review of the hospital policy Title: Care of the Psychiatric Patient in the Emergency Department, Effective Date 03/03/2023 revealed, in part: I. Purpose. This policy provides guidance for the patient presenting with a psychiatric complaint in the Emergency Department, patients documented on a Psychiatric Hold, patients assessed at risk for suicide, homicide, and/or patients gravely disabled and patients requiring psychiatric observation. III. Policy Statement. 5. Every patient that presents to the Emergency Department will receive a medical screening exam by the Emergency Department provider. If it is determined by the ED provider that the patient is in need of inpatient psychiatric care and the patient is deemed a harm to self, others or gravely disabled, a Psychiatric Hold will be executed by the ED provider. e. All PEC/Psychiatric Hold patients will be offered a copy of the Mental Health Patient Rights, as per State law, and will be asked to sign an Acknowledgment that they have received these. Note: If Patient is unable or unwilling to sign the Mental Health Patient Rights form, medical personnel will document the reason in the patient’s medical record. 1. Review of Patient #1’s medical record revealed the patient presented to the emergency department on 03/23/2024 with a chief complaint psychiatric evaluation and was a PEC/Psychiatric Hold patient. Further review of Patient #1’s medical record revealed no evidence the patient received or offered a copy of the Mental Health Patient Rights. 2. Review of Patient #2’s medical record revealed the patient presented to the emergency department 02/20/2024 with chief complaint psychiatric evaluation and was a PEC/Psychiatric Hold patient. Further review of Patient #1’s medical record revealed no evidence the patient received or offered a copy of the Mental Health Patient Rights. In an interview on 03/26/2024 at 11:13 a.m., S3Quality Director confirmed there was no evidence Patient #1 and Patient #2 offered a copy of the Mental Health Patient Rights.”