Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 713026 (X3) Date Survey Completed 04/09/2026
Name of Provider or Supplier Bogalusa Rehabilitation Hospital Street Address, City, State 621 Columbia Street, Bogalusa, LA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0144 PATIENT RIGHTS: CARE IN SAFE SETTING
CFR(s): 482.13(c)(2)

The patient has the right to receive care in a safe setting.


This STANDARD is not met as evidenced by:
Based on record review, observation, and interview, the hospital failed to ensure that patients received care in a safe setting. This deficient practice was evidenced by: 1) Failure to ensure the basic life support guidelines were followed during an emergent condition of 1 (#6) of 1 rapid response event reviewed; 2) Failure to ensure the nurse call system was functioning via call buttons located on the side rails of the patient's beds in Rooms "a"- "k"; 3) Failure to ensure documentation of quality controls performed on glucometers used in the hospital; 4) Failure to ensure the driver of the hospital's van that transports patients had a chauffer's license and followed hospital policy; 5) Failure to ensure the hospital's van was in safe operating condition for patient transportation; and 6) Failure to appropriately label the patient's electronic medical record with the appropriate code status in 3 (#8, #16, #17) of 30 medical records reviewed. Findings: 1) Failure to ensure the basic life support guidelines were followed during an emergent condition of 1 (Patient #6) of 1 rapid response event reviewed Review of the hospital's policy # EM-29 titled, "Code Blue," effective date 06/2025 revealed in part: Policy: 1. Code Blue Team: the code blue team is available on a 24-hour basis and should be activated for any emergency (cardiac or respiratory) requiring resuscitation. All staff members are required to maintain BLS certification. 3. Code Blue Carts: Code Blue carts are to be kept in designated on each nursing unit. Post Code Blue Event, the code blue cart is to be promptly checked, exchanged, and supplies restocked by staff from the unit where the cart was used. References: BLS Provider Manual- American Heart Association. BLS guideline recommended administering 100% oxygen (10-12 LPM) during cardiopulmonary resuscitation (CPR) as soon as it becomes available. Use a bag-mask device with a reservoir to maximize oxygen delivery. Patient #6 Review of Patient #6's medical record revealed Patient #6 was admitted on 10/07/2025 for Circulatory Disorder and was a full code. Further review of medical record revealed Patient #6 became unresponsive while in the bathroom on 10/09/2025 and CPR was initiated. Review of the Patient #6's rapid response event form dated 10/09/2025 from 8:00 PM to 8:31 PM revealed Patient #6 became unresponsive in the bathroom and was transferred to bed where it was noted that Patient #6's pupils were fixated and agonal respiratory. CPR was started by staff, AED applied, oxygen increased to 10 liters via nasal cannula, and 911 called. Further review revealed MD and EMS arrived and Patient #6 was pronounced at 8:31 PM. In an interview on 04/08/2026 at 8:55 AM with S1NSM verified the above information. In an interview on 04/08/2026 at 10:35 AM S14RN verified a non-rebreather mask used to deliver 100% oxygen during an emergent situation is stored in the emergency cart at the nurses' station. 2) Failure to ensure the nurse call system was functioning via call buttons located on the side rails of the patient's beds in Rooms "a"- "k" Observations made during a walk-though on 04/06/2026 from 10:20 AM to 12:12 PM revealed nurse call buttons were located on the each side rails of the patient beds in Rooms "a" - "k." Each bed's side rails contained a nurse call button located on its interior sides (mattress sides). The nurse call button was a red button with a picture of a bell. When each of the call button was depressed, it did not activate the nurse call system at the nurses' station, illuminate the call light above the entry door or activate an audible sound that would be indicative of a patient calling for assistance. This had the potential to place undue distress and/or harm on a patient and/or a family member attempting to call staff for assistance. In an interview on 04/06/2026 at 11:00 AM S1NSM verified the above-mentioned information. 3) Failure to ensure documentation of quality controls performed on glucometers used in the hospital Observations during a walk-through of the facility and its corresponding medication room on 04/06/2026 from 10:15 a.m. to 12:10 p.m. revealed the current glucometers being used by the hospital as the EvenCare PROVIEW Meter #1 serial number (SN) #M12Y00187369, Ref: MPH4540 RLI8EMQ and EvenCare PROVIEW Meter #2 SN# unavailable (a number was not on back of meter), Ref: MPH4540 V1RE22EMQ. A request was initiated during the observations of the medication room with S14RN for the most recent documentation of quality controls being performed on each glucometer. A request was also initiated for the owner's manual related to the EvenCare PROVIEW Glucose Meter. A review of the Medline's, online user's guide titled, "EVENCARE ProView BLOOD GLUCOSE MONITORING SYSTEM USER'S GUIDE" revealed, in part: "You should perform a control solution test when: o Using the meter for the first time. o Using a new package of EVENCARE ProView Blood Glucose Test Strips. o At least once per week to verify that the meter and test strips are working properly together. o If the test strip bottle is left open. o The meter is dropped. o You suspect the meter and test strips are not working properly together. o A patient's test results do not agree with how they feel. o A patient's readings appear to be abnormally high or low. o Test strips have been exposed to a condition outside the specified storage conditions. o Practicing your testing technique." In an interview on 04/06/2026, during the observations of the medication room, S14RN confirmed the hospital did not have any documentation of quality controls being performed on these 2 glucose meters. S14RN confirmed she has performed quality control testing on the 2 glucose meters; however she has never documented this information. 4) Failure to ensure the driver of the hospital's van that transports patients has a chauffer's license and followed hospital transport policy. Requests were initiated for a policy related to transportation/transportation of patients on 04/07/2026 at 1:35 p.m. with S3CPO; a second request on 04/08/2026 at 8:30 a.m. with S3CPO and S25Consult; and a third request on 04/09/2026 at 2:30 p.m. with S3CPO and S25Consult. A policy or policies related to transportation/transportation of patients were not presented to the survey team. Review of the requirements for a Class "D" Chauffer's license and Class "E" Personal license in Louisiana revealed: (d) Class "D" Chauffeur's License. Permits the operation of all vehicles included in Class "E" plus any single motor vehicle used in commerce to transport passengers or property if the motor vehicle has a gross vehicle weight rating of ten thousand one or more pounds but less than twenty-six thousand one pounds, or any combination of vehicles used in commerce to transport passengers or property if the motor vehicle has a combined gross vehicle weight rating of ten thousand one or more pounds but less than twenty-six thousand one pounds inclusive of a towed unit with a gross vehicle weight rating of more than ten thousand pounds; or any vehicle designed or utilized for the transportation of passengers for hire or fee; and not utilized in the transportation of materials found to be hazardous under the provisions of the Hazardous Materials Transportation Act which requires the vehicle to bear a placard under the provision of Hazardous Materials Regulations, 49 CFR Part 172, Subpart F. The provisions of this Subparagraph shall not apply to taxi cab drivers. Taxi cab drivers shall only comply with the requirements for a Class "E" driver's license. (e) Class "E" Driver's License - "Personal Vehicle". Permits the operation of any single motor vehicle under ten thousand one pounds gross vehicle weight rating or any such vehicle towing a vehicle not in excess of ten thousand pounds gross vehicle weight rating; any personal use of recreational vehicle or combination of vehicles; or any vehicle which is not within the definition of Group "A", "B", "C", or "D" and not utilized in the transportation of materials found to be hazardous under the provision of the Hazardous Materials Transportation Act which requires the vehicle to bear a placard under provisions of the Hazardous Materials Regulations (49 CFR Part 172, Subpart F). This class of vehicles does not include the operation of motorcycles and motor scooters except as an endorsement to the basic license. In an interview on 04/07/2026 at 1:30 PM S3CPO verified S26RSW is the driver for the hospital who transports patients. On 04/09/2026 at 2:15 PM an observation was made of S26RSW driving the hospital van to transport a discharged patient home. Observations included S26RSW working the lift alone to place the patient in the van. In interview on 04/09/2026 at 3:39 PM, S3CPO verified S26RSW had a Class "E"- personal vehicle driver's license and the hospital had no documentation a driving record was requested from the state before allowing her to drive the van. 5) Failure to ensure the hospital's van was in safe operating condition for patient transportation On 04/07/2026 from 1:30 PM to 1:45 a tour of the hospital van revealed the van's VIN # was IFDEE3FS8CDB24530. Further observation revealed the following: no inspection sticker, no license plate, and no first aid kit. In an interview on 04/07/2026 1:45 PM S3CPO verified the hospital van has insurance. S3CPO presented the following insurance card with the following information: Progressive Paloverde Insurance Company Policy # 02248404 Effective Date: 12/16/2025 Expiration Date: 06/16/2026 Make/Model: Ford Transit T-350 H Year: 2016 Vehicle Identification #: 1FDES8PM3GKB26144 Name of Insured: Bogalusa Rehabilitation Hospital, LLC A request was made for the correct insurance card for the hospital van with the VIN# IFDEE3FS8CDB24530 from S3CPO on 04/07/2026 at 1:50 PM, 04/08/2026 at 8:40 AM, and 04/09/2026 2:30 PM. As of exit conference on 04/09/2026 at 6:30 PM, S3CPO had not provided an insurance card for the hospital van (VIN# IFDEE3FS8CDB24530) being used to transport patients. 6) Failure to appropriately label the patient's electronic medical record with the appropriate code status in 3 (#8, #16, #17) of 30 medical records reviewed. A review of medical records revealed: --Patient #8's medical record revealed an admission on 03/13/2026. The electronic medical record (EMR) face sheet had a category labeled as "Code Status" and the corresponding response as "FULL CODE." This status also appeared in the demographic ribbon across the top of the EMR when this patient was selected. A review of the document titled, "Physician Admission Orders," revealed an order for "Code Status" and the corresponding response as "DNR." A review of document titled, "LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) revealed Box A. "CARDIOPULMONARY RESUSCITATION (CPR): PERSON IS UNRESONSIVE, PULSELESS, AND IS NOT BREATHING," and the option checked as, "DNR/Do Not Attempt Resuscitation (Allow Natural Death)." The LaPOST form was not completed in its entirety, however the form was signed by the patient and S22MD on 03/13/2026; --Patient #16's medical record revealed an admission on 01/26/2026. The electronic medical record (EMR) face sheet had a category labeled as "Code Status" and the corresponding response was not assigned (blank). This blank status appeared in the demographic ribbon across the top of the EMR when this patient was selected. A review of the document titled, "Physician Admission Orders," dated 01/26/2026, revealed an order for "Code Status" and the corresponding response as "Full code"; --Patient #17's medical record revealed an admission on 01/16/2026. The electronic medical record (EMR) face sheet had a category labeled as "Code Status" and the corresponding response was not assigned (blank). This blank status appeared in the demographic ribbon across the top of the EMR when this patient was selected. A review of the document titled, "Physician Admission Orders," dated 01/16/2026, revealed an order for "Code Status" and the corresponding response as "Full"; The clarification of the patient's code status in an emergency situation could place each of these patients safety at risk due to the withholding of emergency care related to the wrong code status being identified or emergency care being performed on a patient that had made the choice to waive emergency resuscitation care. In an interview on 04/09/2026 at 11:00 a.m. S25Consult confirmed the above-mentioned findings.