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)
A0457 CONTENT OF RECORD: STANDING ORDERS
CFR(s): 482.24(c)(3)

(3) Hospitals may use pre-printed and electronic standing orders, order sets, and protocols for patient orders only if the hospital: (i) Establishes that such orders and protocols have been reviewed and approved by the medical staff and the hospital's nursing and pharmacy leadership; (ii) Demonstrates that such orders and protocols are consistent with nationally recognized and evidence-based guidelines; (iii) Ensures that the periodic and regular review of such orders and protocols is conducted by the medical staff and the hospital's nursing and pharmacy leadership to determine the continuing usefulness and safety of the orders and protocols; and (iv) Ensures that such orders and protocols are dated, timed, and authenticated promptly in the patient's medical record by the ordering practitioner or another practitioner responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure standing order protocols related to venous thromboembolism prophylaxis (VTE) were reviewed and approved by the medical staff, and the hospital's nursing and pharmacy leadership. Findings: A request was initiated on 04/08/2026 at 4:25 p.m. with S25Consult for a policy/procedure, protocol and its corresponding approval related to the hospital's VTE Prophylaxis Protocol. A review of medical records revealed the following: --Patient #2's medical record revealed the document, "Physician Admission Orders" dated 03/24/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #3's medical record revealed the document, "Physician Admission Orders" dated 02/06/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #4's medical record revealed the document, "Physician Admission Orders" dated 03/10/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #5's medical record revealed the document, "Physician Admission Orders" dated 02/24/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #6's medical record revealed the document, "Physician Admission Orders" dated 10/07/2025. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #7's medical record revealed the document, "Physician Admission Orders" dated 12/31/2025. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #8's medical record revealed the document, "Physician Admission Orders" dated 03/13/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #9's medical record revealed the document, "Physician Admission Orders" dated 08/04/2025. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #10's medical record revealed the document, "Physician Admission Orders" dated 03/03/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #11's medical record revealed the document, "Physician Admission Orders" dated 02/27/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #12's medical record revealed the document, "Physician Admission Orders" dated 02/26/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #13's medical record revealed the document, "Physician Admission Orders" dated 02/19/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #14's medical record revealed the document, "Physician Admission Orders" dated 02/11/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #15's medical record revealed the document, "Physician Admission Orders" dated 02/04/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #16's medical record revealed the document, "Physician Admission Orders" dated 01/26/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #17's medical record revealed the document, "Physician Admission Orders" dated 01/16/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #18's medical record revealed the document, "Physician Admission Orders" dated 01/15/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #22's medical record revealed the document, "Physician Admission Orders" dated 11/11/2025. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; and --Patient #23's medical record revealed the document, "Physician Admission Orders" dated 11/07/2025. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use. In an interview on 04/09/2026 at 9:00 a.m., S25Consult confirmed the above-mentioned findings and the hospital did not have a policy/procedure or protocol related to this physician order for VTE Prophylaxis Protocol.