By Malcolm Butler
A follow-up inspection by state and federal health regulators found Northern Louisiana Medical Center corrected some previously cited deficiencies but resulted in an Immediate Jeopardy determination during a revisit intended to assess the hospital’s corrective actions following a June inspection.
The Louisiana Department of Health, acting on behalf of the Centers for Medicare & Medicaid Services (CMS), completed the 36-page revisit survey July 8 to evaluate corrective actions taken after a June inspection cited numerous deficiencies. While regulators found improvements in several areas, they concluded the hospital remained out of compliance with Medicare’s Patient Rights Condition of Participation.
Asked about the Immediate Jeopardy determination, the remaining Patient Rights deficiency, the hospital’s regulatory timeline and efforts to restore public confidence, Northern Louisiana Medical Center declined to answer specific questions, citing the ongoing regulatory process and issuing a written statement.
“The follow-up survey reflects meaningful progress, and we have already submitted our response to the remaining items identified during the revisit process,” NLMC Chief Executive Officer Monica Adams wrote. “That progress is a direct reflection of the extraordinary work of our physicians, nurses, department leaders and employees, who have embraced change while continuing to provide exceptional care to our patients.”
According to the survey, regulators issued an Immediate Jeopardy determination at 12:30 p.m. July 7 after finding the hospital’s cardiac catheterization laboratory lacked a functioning backup battery system in the event of a power outage. CMS defines Immediate Jeopardy as a situation in which a provider’s noncompliance “has caused, or is likely to cause, serious injury, harm, impairment, or death” to a patient.
The survey states the cath lab’s backup battery had reportedly been inoperable since February after a power outage revealed the system was no longer functioning. Although a service report documented the problem, surveyors found repairs had not been completed by the time of the July inspection.
Staff told inspectors that if another power failure occurred during a heart catheterization procedure, physicians would have to stop the procedure and transfer the patient because the backup battery displayed “0 minutes” of reserve power. The survey also noted that switching the laboratory to generator power required a manual transfer by maintenance personnel, who were not routinely on-site during nights and weekends.
The Immediate Jeopardy determination was removed less than three hours later after the hospital placed its cardiology and cardiac catheterization services on diversion while implementing corrective measures. However, surveyors wrote there was “not enough evidence to determine sustainability of compliance,” leaving the Patient Rights condition-level deficiency unresolved.
Surveyors also reviewed the medical record of a patient whose heart catheterization procedure was interrupted by the power failure and backup battery malfunction, requiring transfer to another hospital to complete the procedure.
The revisit survey also identified significant documentation deficiencies surrounding the July 4 death of another patient following a code blue. Surveyors found an eight-minute period during the resuscitation in which no interventions were documented and said staff could not explain a six-minute delay before CPR because “there was no documentation.” Records also showed six doses of epinephrine and one dose of sodium bicarbonate were removed during the code, while the code sheet documented only five doses of epinephrine and no bicarbonate. An intraosseous line documented on the code sheet was absent from the physician’s death note, and staff questioned whether a documented dose of dextrose had actually been administered.
The survey does not conclude the documentation deficiencies caused the patient’s death. Instead, surveyors cited the inconsistent and incomplete records as one of the findings supporting the hospital’s continued noncompliance with the Medicare Patient Rights Condition of Participation.
Beyond those findings, surveyors cited additional deficiencies involving infection control, overdue preventive maintenance on medical equipment, nonfunctioning nurse call systems and 232 delinquent medical records more than 30 days old. Inspectors also found the hospital’s quality improvement program failed to track the reasons for 86 surgeries canceled during June and another 13 canceled during the first week of July. The report further described an incident in which a scheduled surgery was postponed after a patient had already been anesthetized because holes were discovered in sterile implant packaging while all of the hospital’s autoclaves were reportedly out of service.
The revisit did identify progress in several areas. Previous condition-level deficiencies involving the Governing Body and Nursing Services were reduced to standard-level deficiencies. However, regulators determined the Patient Rights Condition of Participation remained out of compliance, meaning the hospital had not yet demonstrated sustained compliance with federal requirements.
Adams wrote the hospital remains engaged with the Louisiana Department of Health throughout the ongoing regulatory process.
“While the regulatory process is still ongoing, we remain fully engaged with the Louisiana Department of Health and are committed to achieving full compliance,” Adams wrote. “Because this process remains active, we are not commenting on any specific timelines or ongoing discussions with LDH. We continue working closely with regulators and remain focused on completing every required corrective action.”
Adams also emphasized her confidence in the hospital’s employees and its future.
“I continue to believe that trust is earned through transparency, accountability, and consistent action,” Adams wrote. “We understand that trust isn’t rebuilt overnight. It is earned by listening, improving, and demonstrating through our actions — day after day — that we are committed to moving Northern Louisiana Medical Center forward.”
She added that Northern Louisiana Medical Center “remains fully operational” and said the hospital “will continue to take immediate action whenever opportunities to strengthen patient safety are identified.”
The Lincoln Parish Journal also submitted questions to the Louisiana Department of Health regarding the hospital’s current regulatory status, the remaining Patient Rights Condition of Participation deficiency, the Immediate Jeopardy determination, the hospital’s regulatory timeline and the next steps in the state’s oversight process. As of publication, the department had not responded.
Hospitals that remain out of compliance with Medicare’s Conditions of Participation can ultimately face termination from the Medicare program if deficiencies are not corrected, although providers are given opportunities to submit corrective action plans and demonstrate compliance before any final enforcement action is taken.
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