Lafayette Regional Health Center

“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: 50321 Based on interview, record review and policy review the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#23) of 23 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). Findings included: Review of the hospitals document titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) - Medical Screening Exam (MSE) and Stabilization Policy,” dated 07/18/24, showed: - A MSE was the process required to reach, within reasonable clinical confidence, the point at which it could be determined whether the individual had an EMC. - The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital. - A MSE was required when an individual came to the hospital and requested examination or treatment for a medical condition, including when the individual requested medication to resolve or provide stabilizing treatment for a medical condition. Review of the hospital’s undated document titled, “Lafayette Regional Health Center Medical Staff Rules and Regulations,” showed: - The attending practitioner shall be responsible for the preparation of a complete and legible age-specific medical record for each patient. - The record shall include physical examination findings. - The history and physical examination shall include all pertinent findings resulting from an assessment of all body systems. Please refer to 2406 for further details.”

“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: 50321 Based on interview, record review and policy review the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#23) of 23 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). Findings included: Review of the hospitals document titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) MSE and Stabilization Policy,” dated 07/18/24, showed: - A MSE was the process required to reach, within reasonable clinical confidence, the point at which it could be determined whether the individual had an EMC. - The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital. - A MSE was required when an individual came to the hospital and requested examination or treatment for a medical condition, including when the individual requested medication to resolve or provide stabilizing treatment for a medical condition. Review of the hospital’s undated document titled, “Lafayette Regional Health Center Medical Staff Rules and Regulations,” showed: - The attending practitioner was responsible for the preparation of a complete and legible age-specific medical record, for each patient. - The record shall include physical examination findings. - The history and physical examination shall include all pertinent findings resulting from an assessment of all body systems. Review of Patient #23’s medical record, dated 03/28/25, showed: - On 03/28/25 at 6:36 PM, she was a 69-year-old female who presented to the ED with a chief complaint of shaking, dizziness, nausea, and vomiting related to Trazadone (a medication used to treat depression) withdrawal. She had run out of Trazadone two days prior. - Provider documentation showed the only portion of the physical examination recorded was a review of vital signs (VS, measurements of the body’s most basic functions) and “shakiness, sweats, malaise (body weakness or discomfort).” - At 7:50 PM, she was discharged with a prescription for three Trazadone tablets. During a telephone interview on 06/30/25 at 9:45 AM, Staff N, ED Medical Director, stated that the physical examination documented for Patient #23 was not to his personal preference or expectations, he would have documented more. However, he would not state that Staff L, ED Physician’s, documentation did not meet the requirements of the hospital for the physical exam completed for Patient #23.”

“ORGANIZATIONAL STRUCTURE CFR(s): Organizational Structure This Condition is not met as evidenced by: 41474 Based on interview, record review and policy review, the hospital’s Governing Body failed to ensure that: - The Chief Executive Officer (CEO) effectively managed the hospital in order to meet applicable regulatory requirements. - A thorough investigation was completed to accurately determine whether abuse had occurred for one patient (#12) of one patient who alleged abuse. - Ensure there was a policy and procedure in place that identified the process for staff to patient abuse allegations. These failed practices had the potential to adversely affect the quality of care and safety of all patients in the hospital and resulted in non-compliance with 42 CFR 485.627 Condition of Participation: Organizational Structure. Please refer to C-0962.”

“PATIENTS RIGHTS CFR(s): A CAH must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41474 Based on interview, record review and policy review, the hospital failed to provide care in a safe setting when they failed to complete a thorough investigation to accurately determine whether abuse had occurred and immediately remove the staff member from patient care after allegations of abuse were reported for one discharged patient (#12) of one allegation of abuse reviewed. These failed practices placed all patients admitted to the hospital at increased risk for their safety and resulted in noncompliance with 42 CFR 485.614 Condition of Participation: Patient’s Rights. Please refer to C-2523”

“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: 41474 Based on interview, record review and policy review, the hospital’s Governing Body failed to ensure that: - The Chief Executive Officer (CEO) effectively managed the hospital in order to meet applicable regulatory requirements. - A thorough investigation was completed to accurately determine whether abuse had occurred for one patient (#12) of one patient who alleged abuse. - Ensure there was a policy and procedure in place that identified the process for staff to patient abuse allegations. These failed practices had the potential to adversely affect the quality of care and safety of all patients in the hospital. Findings included: Review of the hospital’s document titled, “Medical Staff Rules and Regulations,” dated 06/27/23, showed each patient shall be under the medical care and treatment of a responsible practitioner. The practitioner shall also be responsible for the prompt completeness and accuracy of the medical record, for the special instructions necessary to insure the protection of patients from those who are a source of danger from any cause whatsoever, and to assure protection of patients from self-harm. Review of the hospital’s document titled, “Medical Staff Bylaws,” dated 08/26/19, showed the purposes and responsibilities of the Medical Staff were: - To provide a formal organizational structure through which the Medical Staff carries out its responsibilities and governs the professional activities of its members and other practitioners and to provide mechanisms for accountability of the Medial Staff to the Board of Trustees. - To provide patients with the quality of care that is commensurate with acceptable standards and available community resources. - To provide education that will assist in maintaining patient care standards and encourage continuous advancement in professional knowledge and skills. Review of the hospital’s complaint investigation, dated 03/11/24 at 11:15 PM, showed the following: - The investigation consisted of an electronic mailed (e-mail) message sent from Staff F, Medical Surgical Director and Intensive Care Units (ICU, a unit where critically ill patients are cared for), to herself. - Staff L, Charge Nurse, received a phone call from staff at Facility B stating there was a complaint that one of the nurses caring for Patient #12 had smacked her hand and yelled at her. The nurse’s name badge was turned so Facility B staff did not know her name. - Staff F spoke with staff from Facility B present with Patient #12 and then called the Director for Facility B. She also spoke with Staff D, Registered Nurse (RN), who was caring for Patient #12. Review of Patient #12’s medical record dated 03/11/24 through 03/13/24, showed the following: - She was a 61-year-old female who presented to the Emergency Department (ED), from the outpatient gastroenterology (GI, branch of medicine concerned with the structure and diseases of the stomach and intestines) clinic, with a chief complaint of abdominal pain, vomiting, and diarrhea. - Past medical history included profound intellectual disabilities, down syndrome (a condition in which a person has an extra chromosome causing development and intellectual delays), high cholesterol, abdominal hernia (when part of the intestine bulges through the opening of abdominal muscles near the bellybutton), diverticulitis (an infection or inflammation of small pouches that form on the wall of the colon), unspecified mood disorder (when a person’s general emotional state or mood is distorted or inconsistent with their circumstances and interferes with their ability to function) and anxiety (a feeling of fear or worry experienced intermittently). - Staff D, RN, documented nursing care for the patient on 03/11/24, 03/12/24 and 03/13/24. - Patient #12 was discharged on 03/13/24 to her home, with her caregiver. During an interview on 04/02/24 at 10:15 AM, Staff A, Administrative Director, stated that there was no abuse and neglect policy pertaining to staff to patient allegations. During an interview on 04/02/24 at 9:30 AM, Staff F, Director of the Medical Surgical Unit, stated that Staff L, Charge Nurse, told her a staff member from Facility B called and reported a nurse had slapped the patient on the hand while in the ED. She spoke with Staff D, RN, about the incident, who was upset and taken off guard by the complaint. Staff D, RN, reported to her that she never slapped the patient but did have to move her hand away from her intravenous (IV, in the vein) catheter and loudly told her not to touch the IV. Staff F then spoke with Facility B staff in the room with Patient #12. Staff F stated that she reported to Facility B she had spoken with the nurse involved. The investigation consisted of interviewing Staff D and speaking with the Director of Nursing from Facility B. There was no documentation of the conversation with Staff D and the only documentation of the complaint investigation was an email she sent to herself. Since she was able to speak with Staff D and the Director of Nursing for Facility B, she felt the complaint had been resolved. During an interview on 04/08/24 at 10:00 AM, Staff S, CEO, stated that he was responsible for the day-to-day conduct, but ultimately the board was responsible for the hospital. He did not know there was not an abuse and neglect policy for staff to patient allegations. He reviewed the complaint for Patient #12 and the only investigation he received was the email. The complaint warranted an investigation.”

“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: 41474 Based on interview, record review, and policy review, the hospital failed to provide care in a safe setting when they failed to complete a thorough investigation to accurately determine whether abuse had occurred and immediately remove the staff member from patient care after allegations of abuse were reported for one discharged patient (#12) of one allegation of abuse reviewed. These failed practices placed all patients admitted to the hospital at increased risk for their safety. Findings included: Review of the hospital’s policy titled, “Rights and Responsibilities of Patients,” dated 09/19/23, showed patients have the right to the following: - To be free from abuse or harassment; - To receive ethical, high-quality, safe and professional care without discrimination; and - To an impartial review of alleged violations of patient rights. Review of the hospital’s policy titled, “Resolution of Patient Concerns/Complaint/Grievances,” dated 09/19/23, showed complaints that endanger the patient (abuse and neglect) should be reviewed immediately given the seriousness of the allegations and the potential for harm to the patient. Review of the hospital’s complaint investigation, dated 03/11/24 at 11:15 PM, showed the following: - The investigation consisted of an electronic mailed (e-mail) message sent from Staff F, Medical Surgical Director and Intensive Care Units (ICU, a unit where critically ill patients are cared for), to herself. - Staff L, Charge Nurse, received a phone call from staff at Facility B stating there was a complaint that one of the nurses caring for Patient #12 had smacked her hand and yelled at her. The nurse had her name badge turned so Facility B did not know her name. - Staff F spoke with staff from Facility B and then called the Director for Facility B. She also spoke with Staff D, Registered Nurse (RN), caring for Patient #12. Review of the hospital’s document titled, “Personnel File,” dated 12/10/18 through 04/01/24, showed Staff D, RN, had no documented disciplinary action since her employment. There were no indications of inappropriate behavior toward patients or complaints against her. Review of Patient #12’s medical record dated 03/11/24 through 03/13/24, showed the following: - She was a 61-year-old female who presented to the Emergency Department (ED), from the outpatient gastroenterology (GI, branch of medicine concerned with the structure and diseases of the stomach and intestines) clinic, with a chief complaint of abdominal pain, vomiting, and diarrhea. - Past medical history included profound intellectual disabilities, down syndrome (a condition in which a person has an extra chromosome causing development and intellectual delays), high cholesterol, abdominal hernia (when part of the intestine bulges through the opening of abdominal muscles near the bellybutton), diverticulitis (an infection or inflammation of small pouches that form on the wall of the colon), unspecified mood disorder (when a person’s general emotional state or mood is distorted or inconsistent with their circumstances and interferes with their ability to function) and anxiety (a feeling of fear or worry experienced intermittently). - Physician documentation showed Patient #12 was admitted to the medical surgical unit for intravenous (IV, in the vein) fluid replacement and antibiotics (medications that destroy or slow down the growth of bacteria). - Staff D, RN, documented nursing care for the patient on 03/11/24, 03/12/24 and 03/13/24. - Patient #12 was discharged on 03/13/24 to her home, with her caregiver. During an interview on 04/02/24 at 10:15 AM, Staff A, Administrative Director, stated that there was no abuse and neglect policy pertaining to staff to patient allegations. During an interview on 04/02/24 at 1:10 PM, Staff L, Charge Nurse, stated that Facility B called her and reported a nurse had slapped Patient #12. She never had a complaint like that before, so she reported it to Staff F, Director of Medical Surgical and ICU. A staff member from Facility B went to the nursing station and spoke with Staff L, but they didn’t say anything about the slap or not wanting Staff D, RN, to care for Patient #12. During an interview on 04/02/24 at 9:30 AM, Staff F, Director of Medical Surgical and ICU, stated that Staff L, Charge Nurse, told her a staff member from Facility B called and reported a nurse had slapped Patient #12 on the hand. She spoke with Staff D, RN, about the incident, who was upset and taken off guard by the complaint. Staff D, RN, reported to her that she never slapped the patient but did have to move her hand away from her IV and loudly told her not to touch the IV. Staff F then spoke with Facility B staff in the room with Patient #12. She could tell the staff member was upset, but it was not the same staff member that had witnessed the alleged slap in the ED. Staff F stated that she reported to Facility B she had spoken with the nurse involved. Staff D, RN, did have an issue with controlling her emotions and tone of voice and not just her actions. The investigation consisted of interviewing Staff D and speaking with the Director of Nursing from Facility B. There was no documentation of either conversation and the only documentation of the complaint investigation was an email she sent to herself. Staff D continued to provide care for Patient #12 throughout her hospitalization and had other patients under her care. Staff from Facility B were fine with Staff D providing care for Patient #12. If complaints were resolved right away, they were not elevated to the level of a grievance. Since she was able to speak with Staff D and the Director of Nursing for Facility B, she felt the complaint had been resolved. A staff member slapping a patient would be considered an abuse allegation. Staff F felt she handled the situation appropriately. She was not worried about Staff D taking care of Patient #12 or any other patients. During an interview on 04/02/24 at 11:15 AM, Staff M, Chief Nursing Officer (CNO), stated that she felt Staff F, Director of Medical Surgical and ICU, addressed the complainant’s issues. Slapping allegations would be abuse if it happened. Staff D, RN, only pushed the patient’s hand away and said “no no no” to her. She believed Staff D, she had no history of slapping and was very good with patients. She would definitely have taken it seriously if she felt it had happened. During an interview on 04/03/24 at 8:25 AM, Staff D, RN, stated that Patient #12 was a non-verbal patient who was in the ED waiting to be taken to the medical surgical unit for admission. ED staff reported problems getting an IV in the patient. She began disconnecting IV lines and monitoring devices, and Patient #12 attempted to remove her IV. She grabbed Patient #12’s hand, pushed it away from the IV and told her “no, no, no.” Staff D stated that she was not upset she had to continue caring for Patient #12 after the complaint, but she was very uncomfortable because of the staff from Facility B’s behavior toward her.”