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 713029 (X3) Date Survey Completed 05/14/2025
Name of Provider or Supplier Shreveport Rehabilitation Hospital Llc Street Address, City, State 1451 Fern Circle, Shreveport, 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)
A0286 PATIENT SAFETY
CFR(s): 482.21(a), (c)(2), (e)(3)

(a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure complete a self- report to Louisiana Department of Health within 24 hours of an accusation of possible neglect or abuse. Findings: Review of the form "Self-Reporting Process for Hospitals - Abuse/Neglect," revised 12/01/2024, revealed in part, "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 Louisiana Department of Health (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. It is important to remember that use of the words "abuse," "neglect," or "grievance," are not required to categorize a scenario as a potential abuse/neglect grievance. Additionally, allegations received after the patient's discharge, whether received from the patient, a family member, or another agency or healthcare provider, must be treated in the same manner as indicated above. Please note: In accordance with CMS ยง482.13, an allegation of abuse or neglect must be reported and processed as a grievance, regardless of whether the complainant recants the allegation or expresses satisfaction with resolution. Staff members' assurance that the allegation is unsubstantiated is not relevant to this process (other than to provide supporting evidence as part of the investigation). " Record review of Patient #1's EHR revealed the patient was admitted to the hospital on 03/18/2025 and was discharged to another hospital on 04/01/2025. During an interview on 05/14/2025 S1CNO reported Patient #1's representative called him after Patient #1 was discharged from the hospital. The representative told S1CNO that Patient #1 fell while at the hospital and this resulted in her mother's knee cap having been split in half. The representative stated she was notifying the hospital because she did not want a similar accident to happen to any other patients. During this interview, S1CNO was asked if he completed a self-report after the representative reported this event, and S1CNO verified he did not complete a self-report.