44975 Complaint # TX00399635 was Substantiated with deficiencies cited. Based on interview and record review, one of ten patients (Patient #1) did not receive care in a safe settiing in that the bed alarm was not appropriately minitored if it was on at all times. Findings included: Patient #1 was diagnosed with Dementia and was assessed as High Risk for Falls. The hospital was unable to provide and monitor that high fall risk precautions were implemented and observed at all times while providing care to the patient. The practice was not consistent with the Medical City Arlington Policy #: PCS 080. Title: Fall Prevention: Effective Date: 06/28/2016 Date Revised: 02/2019. Purpose: To describe a systematic approach to reduce patient falls and/or if the patient does fall, prevent injury from the fall. IV. Procedure: IV. Implementation of High Fall Risk Precautions in addition to above will include: High Fall Risk Precautions will be implemented for all patients identified as high fall risk, will be based on individualized nursing assessment, and will include all the following: o Keeping bed/chair alarms on at all times unless patient is alert and oriented and refuses. If patient refuses, risks of refusal must be explained to the patient and documented in the medical record When the fall incident happened, it was noted that the bed alarm was off, and Patient #1 was getting out of bed by himself without the staff knowing. Patient #1 had a ground level fall resulting to laceration on his head. After the incident, a post fall analysis was done by the hospital's Fall Team with the following additional findings: o Was patient's room close to the nursing station? NO o Was patient in a camera room? NO o Call light was easily accessible, but Patient #1 had dementia and was confused and cannot remember how to call. The hospital needs to provide an action plan to ensure that interventions for high fall risk patients are implemented at all times thereby preventing occurrence of further falls related to the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29934 Based on review of documentation and interviews of facility staff, the facility failed to inform the patient of the patient's rights in advance of furnishing care as 2 of 10 inpatient medical records reviewed did not contain admission forms signed by the patient which include receipt of the Patient Bill of Rights which resulted in an incomplete record and the patient being uninformed regarding his patient rights. The findings were: Electronic medical records were reviewed on 10/23/18 with the assistance of the VP Quality, staff #1. The record of patient #1 and 4 did not contain signed admission forms which included receipt of the Patient Bill of Rights. The record of patient #1 admitted on [DATE] and patient #4 admitted on [DATE] did not contain a Conditions of Admission form. The record of patient #1 did contain a Patient Choice Letter - Used for patients selecting SNF services signed by patient #1's sister who was patient #1's power of attorney. The record of patient #4 did contain surgical and anesthesia consent forms signed by the patient's mother on 8/29/18 who was patient #4's power of attorney. The facility policy entitled Procedure for Registration Forms and Signatures #PARA.PP.PTAC.038 dated 5/15 reflected in part The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance .Reasonable attempts will be made for follow up on signatures not obtained during the registration process .Standard forms required at time of Pre-Registration or Registration .2. The Conditions of Admission is obtained for all other types of Registrations (Emergency, Observation, Surgery, Inpatient and Newborn) .3. Authorization for Release of Information. 4. Patient Bill of Rights .Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign. In an interview with the Director of Patient Access, staff #3 on the morning of 10/23/18, staff #3 acknowledged that the electronic medical records of patients #1 and 4 did not contain signed Conditions of Admission forms which included receipt of the Patient Bill of Rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29934 Based on review of documentation and interviews with facility staff, the facility failed to inform a Medicare inpatient of a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization as there was no signed Important Message from Medicare form in the medical record of patient #1. The findings were: Electronic medical records were reviewed on 10/23/18 with the assistance of the VP Quality, staff #1. The medical record of patient #1, a Medicare patient admitted on [DATE] did not contain an Important Message from Medicare form. The record of patient #1 did contain a Patient Choice Letter - Used for patients selecting SNF services signed by patient #1's sister who was patient #1's power of attorney. The facility policy entitled Procedure for Registration Forms and Signatures #PARA.PP.PTAC.038 dated 5/15 reflected in part The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance .Reasonable attempts will be made for follow up on signatures not obtained during the registration process .Additional forms are required in the following situations: Important Message from Medicare .if the patient is a Medicare or Managed Medicare Inpatient, it is required that the Important Message from Medicare be issued within two days of the inpatient admission .In addition, the patient's or patient's representative's signature is required .Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign. In an interview with the Director of Patient Access, staff #3 on the morning of 10/23/18, staff #3 acknowledged that the electronic medical record of patient #1 did not contain a signed Important Message from Medicare form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29934 Based on review of documentation and interviews with facility staff, the facility failed to determine upon admission if 2 of 10 inpatients reviewed had formulated advanced directives as the admission forms documenting the advanced directive statements were not completed by patient #1 and 4 upon admission which resulted in an incomplete record and the facility being unaware if patient #1 and #4 had an advanced directive. The findings were: Electronic medical records were reviewed on 10/23/18 with the assistance of the VP Quality, staff #1. The record of patient #1 and 4 did not contain signed admission forms which included the advanced directive statements. The record of patient #1 admitted on [DATE] and patient #4 admitted on [DATE] did not contain a Conditions of Admission form which included the advanced directive statements. The record of patient #1 did contain a Patient Choice Letter - Used for patients selecting SNF services signed by patient #1's sister who was patient #1's power of attorney. The record of patient #4 did contain surgical and anesthesia consent forms signed by the patient's mother on 8/29/18 who was patient #4's power of attorney. The facility policy entitled Procedure for Registration Forms and Signatures #PARA.PP.PTAC.038 dated 5/15 reflected in part The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance .Reasonable attempts will be made for follow up on signatures not obtained during the registration process .Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign .The Advanced Directives statements are contained within the Parallon standard COA (Conditions of Admission) and COS (Consent for Outpatient Services) forms .Only one of three applicable PSDA (Patient Self Determination Act) statements is initialed or marked by the patient or legally authorized/legally empowered representative. In an interview with the Director of Patient Access, staff #3 on the morning of 10/23/18, staff #3 acknowledged that the electronic medical record of patient #1 and 4 did not contain signed admission forms which included the advanced directive statements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29934 Based on review of documentation and interviews of facility staff, the facility failed to inform the patient of Privacy Practices and obtain Authorization for Release of Information as 2 of 10 inpatient medical records reviewed did not contain admission forms signed by the patient which include the Authorization for Release of Information form and the Notice of Privacy Practices form which resulted in an incomplete record and the patient being uninformed of confidentiality rights. The findings were: Electronic medical records were reviewed on 10/23/18 with the assistance of the VP Quality, staff #1. The record of patient #1 and 4 did not contain signed admission forms which included Authorization for Release of Information and the Notice of Privacy Practices. The record of patient #1 admitted on [DATE] and patient #4 admitted on [DATE] did not contain a Conditions of Admission or Authorization for Release of Information form. The record of patient #1 did contain a Patient Choice Letter - Used for patients selecting SNF services signed by patient #1's sister who was patient #1's power of attorney. The record of patient #4 did contain surgical and anesthesia consent forms signed by the patient's mother on 8/29/18 who was patient #4's power of attorney. The facility policy entitled Procedure for Registration Forms and Signatures #PARA.PP.PTAC.038 dated 5/15 reflected in part The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance .Reasonable attempts will be made for follow up on signatures not obtained during the registration process .Standard forms required at time of Pre-Registration or Registration .2. The Conditions of Admission is obtained for all other types of Registrations (Emergency, Observation, Surgery, Inpatient and Newborn) .3. Authorization for Release of Information. 4. Patient Bill of Rights .Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign .Procedure: Responsible Party, Patient Access. Action, Notice of Privacy Practices. The patient or legally authorized/legally empowered representative or family member initials this section to acknowledge receipt of the Notice of Privacy Practices. In an interview with the Director of Patient Access, staff #3 on the morning of 10/23/18, staff #3 acknowledged that the electronic medical records of patients #1 and 4 did not contain signed Conditions of Admission forms which included Authorization for Release of Information and the Notice of Privacy Practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20015 Based on record review and interview, the hospital failed to identify early in the hospitalization a patient who was likely to suffer adverse health consequences without adequate discharge planning, in that, 1 of 1 patient (Patient #10) did not receive discharge planning during the early part of her hospitalization that could cause the patient to suffer adverse health consequences. Findings: Patient #10 was admitted to the hospital on 7/16/2015. Review of the medical record documents indicated the first date of discharge planning by the Case Management Department to be 8/5/2015. Patient #1 was discharged on [DATE] without any rehabilitative services or referral to outside sources. The medical record documents on 7/31/2015 Occupational Therapy recommended that the patient needed rehabilitation. On 8/4/2015, Occupational Therapy recommended patient needed inpatient rehabilitation. An interview with Staff #7 on 1/28/2016 at approximately 1:30 PM, confimed that the patient did not have a note made by the Case Management department until 8/5/2015 during the hospitalization of 7/16/2015 - 8/7/2015.

20015 Based on chart review, policy review and interview, the hospital failed to complete a discharge evaluation in a timely basis, in that, 1 of 1 patient (Patient #10) did not have a discharge evaluation during her hospitalization of 7/16/2015 - 8/7/2015. Findings: Review of the medical record of Patient #10 did not document a discharge evaluation. There were notes from physicians that the patient was not safe to return to her home and notes from Occupational Therapy that the patient needed to go to inpatient rehabilitation. Review of the policy titled Discharge Planning: Reviewed 4/8/2014 stated: It is the policy at Medical Center of Arlington that based upon the patient admission assessment, the registered nurse initiates discharge planning on admission, writes an ongoing discharge plan, makes referrals to the case manager/social worker and coordinates discharge planning with the patient, case manager, and family throughout hospitalization . Prior to discharge, any post-discharge continuing nursing care needs are assessed and noted in the medical record. Appropriate referrals are made as needed to facilitate a patient's post-discharge continuing nursing care needs. An interview with Staff #7 on 1/28/2016 confirmed that there was not a discharge evaluation completed on Patient #10 during her hospitalization . No nursing referrals were made to the case manager/social worker.

27128 Based on interview and record review, Hospital A (Medical Center of Arlington) failed to enforce its policy to ensure compliance with 489.24 (j) (1) and 489.24 (d) (1) (i)stabilizing treatment. The ED (emergency department) physician on-call schedule did not accurately reflect the urologist who was on call for 4 of 4 schedules on 01/17/16, 01/18/16, 01/19/16 and 01/21/16. Patient #1 was seen in the ED on 1/18/16 for right testicular pain and Patient #1 wasn't stabilized before being transferred to Hospital B. He was not seen by a urologist on-call. Cross refer to A2404 and A2407

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27128 Based on interviews and record reviews the hospital failed to ensure the hospital's ED on-call schedule accurately indicated which physician was on call for urology on 4 of 4 on-call schedules that were reviewed (01/17/16, 01/18/16, 01/19/16, and 01/21/16). Patient #1 was seen in the ED (Emergency Department) on 01/18/16 for right testicular pain. Findings included: Patient #1's medical record face sheet at Hospital A indicated that he was [AGE] years old and seen in the ED on 1/18/16 for right testicular pain. The ED Physician's notes dated 1/18/16 at 4:45 PM included that he had improved with mild relief and was transferred to Hospital B in stable condition for pediatric care. A review of the ED physician on-call schedule for the dates of 01/17/16, 01/18/16, 01/19/16, and 01/21/16 revealed the name of the physician for urology coverage was documented with only the physician's last name and first name initial along with his office telephone number. During an interview on 01/21/16 at 12:30 PM with Personnel #8 she said there were 2 urologists (father and son) who were partners that took call for the ED department. They had the same first and last name but their middle names were different. The surveyor asked which urologist was on call on 01/18/16. She said she thought it was Physician #15 because his name was documented in Patient #1's medical record. The surveyor asked how staff knew which physician to call for urology because the on-call sheet dated 01/18/16 listed only the last name with a first initial. She said a call would be placed to the physician's office. The urologists decided between themselves which one would be on call. The physician taking call would respond to the ED's phone call. Personnel #8 confirmed the ED physician on-call schedules for the dates of 01/17/16, 01/19/16, and 01/21/16 reflected the same information. During a telephone interview on 01/21/16 at 3:00 PM with Physician #11 he was asked by the surveyor who was the consulting urologist for Patient #1 on 01/18/16. Physician #11 thought he was speaking to Physician #15. When he was informed it was Physician #12 he said they both sound a lot alike on the phone. During a telephone interview on 01/21/16 at 3:30 PM with Physician #12 he indicated that he was the consulting physician for Patient #1 on 01/18/16. The hospital's EMTALA- Texas Provision of ON-CALL COVERAGE POLICY with a revision date of 7/2013 indicated on page 2, .The facility's governing board must assure that the medical staff is responsible for developing an on-call rotation schedule that includes the name and direct pager or telephone number of each physician who is required to fulfill on-call duties. Physician group names are not acceptable for identifying the on-call physician. Individual physician names with accurate contact information, including a telephone number where the physician can be reached are to be put on the on-call list .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27128 Based on interview and record review Hospital A failed to provide stabilizing treatment to: 1 of 1 (Patient #1) patient. Patient #1 presented to the hospital's ED on 01/18/16 for right testicular discomfort. Patient #1 was diagnosed with right testicular torsion. Patient #1 was not seen by the urologist on-call before he was transferred and his medical condition was not stabilized. The patient was transferred to Hospital B where he was treated and discharged . Findings included: A review of Patient #1's Hospital A medical record revealed: On 01/18/16 at 3:23 PM Patient #1 arrived at the hospital's ED via a car accompanied by his mother for right testicular discomfort per the patient's face sheet. ED Nurse's Notes dated 01/18/16: At 3:23 PM Patient #1 arrived in the ED, was registered, and then had a nursing Rapid Initial Assessment at 3:30 PM. Patient #1 indicated he had right testicular pain and swelling that began on 01/16/16 at 8:00 AM. Patient #1's right testicle did not appear to be reddened. Patient #1 was 5 ft. 8 inches tall and weighed 226 lbs. His temperature was 99.8 F. (normal 97.8-99.0 F.), blood pressure was 132/69 (normal 120/80), pulse was 110 (normal 60-100) and his respirations were 17 (normal 12-20). At 4:42 PM Patient #1 received a detailed nursing assessment. Patient #1 indicated his right testicular pain began 2 days ago and it had been a constant aching pain. On a pain scale of 0-10 with 0 being no pain and 10 being extreme pain Patient #1 indicated his pain level was at a 3. At 5:17 PM EMS (Emergency Medical Service) arrived to transfer Patient #1 to Hospital B's ED. ED Physician Notes dated 01/18/16. Physician #11: At 3:23 PM: Patient #1 complained of right moderate scrotal pain. The onset of scrotal pain and swelling was spontaneous and began 2 days ago. Patient #1's pain was exacerbated by movement and unrelieved by Tylenol. He denied dysuria. Patient #1 generally appeared well and was smiling. Patient #1's right testicle was tender, red, with no cremasteric reflex noted. An attempt was made to detorse the right scrotum using the open book technique. The attempt was unsuccessful due to the hardening of the right testicle. At 3:30 PM: A portable ultrasound of the right testicle was conducted and indicated a right testicular torsion At 3:58 PM: Physician #15 (as indicated in the medical record) was consulted by phone. Physician #15 indicated he would come and see the patient. He agreed with Physician #11's evaluation and plan. Physician #15 would take patient to the operating room the next day. At 4:45 PM: Patient #1 had improved with mild relief. Patient #1 was stable for transfer. .Pt was diagnosed with torsion during my initial clinical examination. I immediately called the US [ultrasound] tech to come into the room to confirm diagnosis. No blood flow was noted on US. I attempted to detorse the testicle using the open-book method. The scrotum appears to be hardened. There is significant thickening of the scrotum wall on US. I suspected that the right testicle may no longer be viable. [Physician #15], the oncall urologist was called. After discussing case, he instructed me to admit pt to hospitalist service for orchiectomy. He is not able to perform this procedure immediately since he is in the OR with other cases. I contacted our hospitalist service, they informed me that pediatric pts can not be admitted to our hospital even though pt was > 100 kg. Discussed case with [Physician #15] again, he instructed me to transfer pt to [Hospital B]. Discussed case with [Hospital B's] Urology service. They did not feel that it was in the best interest of pt to be transferred to [Hospital B] given that we have a urology service here in our hospital. I gave contact information for both urologist [Hospital A's Physician #12 and #15] so they can discuss case and figure out the best way to take pt to OR as soon as possible. [Hospital B's] urologist called me back and was willing to accept pt. Discussed case with mom and transferred pt to [Hospital B] . Transfer request call: 1645 Call returned at: 1645. Spoke with attending physician and transfer was accepted. Transfer reason: pediatric care. Patient was stable for transfer. ED Disposition: Patient #1 was transferred to [Hospital B]. Patient #1's blood chemistry results dated 01/18/16 were normal (at Hospital A). Patient #1's right scrotal ultrasound findings (at Hospital A) dated 01/18/16 indicated the patient's right testis had a diffusely abnormal echotexture and parenchymal hypo-echogenicity. There was no blood flow detected and there was marked scrotal wall thickening. The left testis was normal. Impression: Rt. Testicular torsion. Review of the ED medical record for Patient #1 at Hospital B dated 01/18/16 reflected: History of Present Illness: Patient #1 presented to the ED on 01/18/16. Patient #1's vital signs were taken at 6:02 PM. A history and physical was done at 6:16 PM. Patient #1 was a [AGE] year-old male with a history of autism who presented with onset of right testicular pain on 01/16/16. Patient #1 tried taking some pain medicine at home without resolution of pain. The patient reportedly noticed some swelling on 01/17/16 but didn't inform his mother. The patient's mother noticed Patient #1 was walking funny today and looked and noticed significant swelling. Patient #1 continued to have significant pain. The patient was taken to Hospital A where he was evaluated and was transferred for a concern of testicular torsion to Hospital B. The outside hospital (Hospital A) evaluation, laboratory evaluation and ultrasound of Patient #1's testicles were reviewed by Hospital B. Physician #18 with urology at Hospital B was consulted immediately and evaluated Patient #1 in the ED. The plan was to take Patient #1 to the operating room for exploration of the right testicle. Hospital B Discharge: 01/18/16 at 6:24 PM. Diagnosis: Torsion of the right testicle. Disposition: Patient #1 was discharged from the ED to surgery for exploration of his right testicle. During a telephone interview with Physician #18 at Hospital B on 01/21/16 at 9:27 AM he said no one knows the time of salvageability of a testicle from the time of the testicular torsion until the time of the incision of the scrotum. Studies that have been completed indicate salvageability can range from 4-12 hours after the onset of the testicular torsion. Considerations have to be made on whether the testicular torsion had been constant or intermittent and the degree of the torsion. Nobody really had the answer. That's why it's an emergency. After the patient's arrival to Hospital B's ED, Patient #1 was immediately taken to surgery. The patient's right testicle was torsed and Physician #18 was unable to salvage the testicle. During an interview on 01/21/16 at 12:30 PM with Personnel #8 at Hospital A she said Physician #15 offered to come and see Patient #1 when he was finished with his procedure and indicated he would take Patient #1 to surgery. She thought Physician #15 was doing a procedure in surgery but wasn't certain. There were 2 urologists that were available for ED consults. They were father and son partners, Physician #15 and Physician #12. Their first and last names were the same, but their middle name was different. When the surveyor asked which urologist was on call at Hospital A on 01/18/16 ED Personnel #8 said she thought it was Physician #15 because his name was documented in Patient #1's medical record. No patients were admitted to Hospital A who were younger than 18. The ED accepted all ages. If a pediatric patient needed an admission to a hospital they were transferred to a hospital that provided pediatric services. During an interview on 01/21/16 at 1:00 PM with Personnel #2 at Hospital A, she said the hospital did not accept the admissions of patients who were under the age of 18. Nurses were not prepared with competencies to take care of pediatric patients. The physician hospitalist's malpractice insurance didn't cover treatment of pediatric patients. During an interview with Personnel #4 of Hospital A on 01/21/16 at 2:30 PM he said the hospital did not admit pediatric patients. The malpractice insurance didn't cover any patient under the age of 18. Patient #1 was not admitted because he was 12-years-old. The hospital did not have the capability to provide treatment and care for pediatric patients except in the ED. The pediatricians who were on staff, were for the women's center only. During a telephone interview on 01/21/16 at 3:00 PM with Physician #11 (Hospital A) he was asked by the surveyor who was the consulting urologist for Patient #1. He said he thought it was Physician #15. When he was informed it was Physician #12 he said they sound a lot alike on the phone. He said Patient #1 was diagnosed with testicular torsion soon after his admission to the ED. Patient #1 indicated his pain had been constant for 2 days. Two sonograms of the patient's testicles indicated there was a right testicular torsion and there was no blood flow to Patient #1's right testicle. Physician #11 said he attempted to detorse the testicle but was unable to in that the testicle was hardened. He called Physician #12 who told him he was doing a procedure and couldn't come right away but would come and see the patient when he was finished. Physician #12 said to admit Patient #1 and he would do his surgery in the morning. Physician #11 spoke to Physician #14 regarding Patient #1's admission and Physician #14 said the hospital could not admit patients under the age of 18. Physician #11 then called Physician #12 and informed him the patient could not be admitted due to his age. Physician #12 instructed Physician #11 to transfer Patient #1 to Hospital B. The situation was discussed with Patient #1's mother and she requested that Patient #1 be transferred to Hospital B. A call was placed to the transfer center to have Patient #1 transferred to Hospital B. Physician #11 received a phone call from Hospital B's urologist Physician #18. He told Physician #11 that the transfer was inappropriate because Hospital A provided urology services. Physician #11 informed Physician #18 about all avenues. Physician #18 was given both of Hospital A's urologist's phone numbers and was told they could discuss the case and decide what was best for the patient. Physician #18 said if the patient was transferred to him and there was no blood flow to the testicle he was going to report Physician #11. Physician #18 called Physician #11 after speaking with Physician #12 and said he would accept Patient #1's transfer. During an interview with Physician #13 at Hospital A on 01/21/16 at 3:15 PM he said Physician #18 from Hospital B called him on the afternoon of 01/18/16 to discuss Patient #1's case. Physician #13 said at first he thought he was a physician on staff at Hospital A. Physician #13 was asked if he was comfortable with providing anesthesia for Patient #1 after he was given some facts about the case. Physician #13 said he had not seen the patient but he probably would be comfortable with providing anesthesia to Patient #1. He couldn't speak for any of the staff who would be caring for Patient #1 in that they don't provide pediatric services at the hospital. Personnel #4 was called and he confirmed Hospital A did not admit pediatric patients. During a telephone interview on 01/21/16 at 3:30 PM with Physician #12 at Hospital A he said he was on call for the ED on 01/18/16, and not Physician #15. When he received a call from the ED on 01/18/16 regarding Patient #1 he was in the hospital's ICU (intensive care unit) inserting a suprapubic catheter and irrigating it. Physician #11 explained the details of Patient #1's case. Physician 12's intentions were to finish up with the procedure and see Patient #1. Physician #12 said he intended to admit the patient and perform surgery on him that evening. Physician #12 said the patient had experienced constant testicular pain for almost 3 days and the testicle was way beyond saving at that point. He planned to take him to surgery to explore the right testicle and to save the left testicle in that many times the other testicle will also torse. Physician #12 was at the hospital and would have done the surgery right then and there. The surveyor asked how many hours had to pass from the onset of a testicular torsion to the point that the testicle was no longer salvageable. Physician #12 said it varied from 6-10 hours. Two of Patient #1's right testicle sonograms indicated there was no blood flow. Physician #12 said he instructed Physician #11 to admit the patient to Hospital A for surgery. He received another call from Physician #11 informing him that Patient #1 couldn't be admitted to Hospital A in that he was 12-years-old and the hospitalist said their malpractice insurance wouldn't cover the care of anyone under 18-years-old. Physician #12 instructed him to transfer the patient. Physician #12 received a phone call from Hospital B's urologist Physician #18 who informed him that he should take Patient #1 to surgery instead of transferring the patient. Physician #12 informed Physician #18 that he wouldn't put the hospital at risk for a non-acute emergency. He explained to Physician #18 the situation several times. Physician #12 said he didn't perform procedures on pediatric patients at Hospital A. He always had to perform those surgeries elsewhere. During a phone interview with Physician #14 at Hospital A on 01/25/16 at 10:15 AM he confirmed he told Physician #11 that Patient #1 couldn't be admitted to Hospital A in that the hospitalists didn't have privileges to treat patients under 18-years-old. Physician #14 along with the other physician hospitalists belonged to a group that provided hospitalist coverage to the hospital. Their malpractice insurance didn't allow them to admit anyone under 18-years-old or cross-cover anyone under 18-years-old. During a phone interview with Hospital B's ED Physician #19 on 02/01/16 at 11:15 AM he said Patient #1 presented to the ED on 01/18/16 with right testicular pain. Physician #19 examined Patient #1 and reviewed his medical record from the Hospital A. Physician #18 was notified of the patient's arrival to the ED. Physician #18 quickly arrived to the ED and Patient #1 was taken to surgery. Physician #19 said the transfer seemed appropriate.

25373 Based on record review and interview, the hospital did not accurately document 1 of 1 patient's (Patient #1) Operative Report. The report reflected Physician #7 assisted Physician #6 in Patient #1's surgical procedure on 2/5/13. Personnel #8 was the one who assisted Physician #6. Findings included: Patient #1 underwent a surgical procedure, open reduction internal fixation of the right hip . on 2/5/13. The Operative Report electronically signed on 2/7/13 indicated Assistant: Physician #7 assisted Physician #6 with Patient #1's surgical procedure. This was not accurate. Personnel #8 was the individual who assisted Physician #6. In an interview on 12/15/14 between 9:50 AM and 10:00 AM, Personnel #3 and Personnel #5 were asked if Physician #7 assisted Physician #6. Personnel #3 replied Physician #7 had been inactive since 2010. Personnel #3 stated the Operative Report was inaccurate. Personnel #8 was the individual who assisted Physician #6.

25122 Based on record review, and interview, the hospital's nursing service did not ensure that drugs had been administered as ordered by the physician, and in accordance of accepted standards of practice, in that, 1 of 1 patient (Patient #19) did not receive pain medication after being ordered on 11/30/12 by the physician (Personnel #18) for Patient #19's abdominal pain. Findings included: The medical record showed that Patient #19 was admitted through the Emergency Department (ED) at 8:30 PM on 11/29/12, with a chief complaint of abdominal pain, inflamed colon, continues to get worse. Patient #19 had a history of Lap Band procedure in August 2010, and she had not had a bowel movement in 10 days. Her course of care in the ED included Labs, X-rays, EKG (electrocardiogram), all essentially normal. Patient #19 also had an Acute Abdomen Series which noted findings of a lap band is in position .there is increased gas within the colon perhaps from aerophagia .there is no small bowel dilatation to suggest intestinal obstruction .there is no mass or visceromegaly. She also received a CT (computerized tomography) of the Abdomen and Pelvis with Contrast, with findings of small amount of free intraperitoneal fluid .this could be related to the abnormal small bowel for infectious or inflammatory fluid . IV (intravenous) fluids given (Normal Saline) .Zofran (prevents nausea & vomiting) given, 4 mg (milligrams) IV, and Protonix (suppresses gastric secretions) given 40 mg. IV. The ED Physician (Personnel #14) documented that the patient complains of moderate abdominal pain, and ordered to Admit to Medicine Service .Diagnosis: Abdominal pain, Constipation, Nausea, and partial SBO (Small Bowel Obstruction). ED Nurses Notes documented that patient reports pain level as 5/10 (with 10 being the greatest pain). Patient #19 had no orders for pain medication while in the ED, and none were ordered when admitted to the hospital. At 5:02 AM on 11/30/12, Patient #19 was admitted as an inpatient to the Heart & Vascular Care (HVC) Unit, with orders for IV fluids, IV antibiotics, and NPO (nothing by mouth). Her nursing pain assessment by the registered nurse (Personnel #12), at 8:00 AM was verbalized as a 7, with an aching in her abdomen. The nursing intervention at that time was to re-position the patient, as no pain medication was ordered. Personnel #12 documented the following: 11:35 AM: spoke with Internal Medicine Physician (Personnel #16) .explained patient is having severe abdominal pain . 15:20 PM: Gastroenterologist Physician (Personnel #18) on floor . Physician's Orders (Personnel #18), at 15:50 PM for pain medication, Dilaudid. At 15:53 PM, the Medication Administration Record documented that the Pharmacy had put the order entry into the system for Dilaudid 1 mg IV every 6 hours, as needed for pain. However, this pain medication was not charted as ever given to the patient. Patient #19 left the hospital AMA (Against Medical Advice), at 17:20 PM, and had not received pain medication that had been ordered 1 and 1/2 hours earlier. In a telephone interview at 10:35 AM on 4/24/13 with the registered nurse (Personnel #12), she was asked why Patient #19 did not get pain medication, and she stated that she had reported that the patient was in pain, but the primary physician (Personnel #16) wanted to get consults from the gastroenterologist (Personal #18), about giving pain medication as it can cause constipation, which was already a major issue with the patient. When asked if she had given Patient #19 IV pain medication, after it had been ordered by the gastroenterologist at 15:20 PM, she said no. The hospital's Pain Management policy, last revised 8/03/11, noted that Pain/Pain management is assessed and documented in all patients .managed in a timely uniform manner .

29937 Based on review of documentation, and an interview with the director of 1 East, it was determined, the facility failed to follow their own policy; patient #2 and his wife were not given discharge instructions for care of the abdominal incision. Findings were: Review of facility policy # PC8017, Discharge Planning, II, stated It is the policy at MCA, based upon patient admission requirements and assessments, the registered nurse initiates discharge planning on admission, writes an ongoing discharge plan, makes referrals to the case manager/social worker and coordinates discharge planning with the patient case manager, and family throughout the hospitalization . Prior to discharge, any post-discharge continuing nursing care needs are assessed and noted in the medical record. Review of the patient clinical discharge education 11/11/11 revealed there was no documentation instructing the patient #2 and his wife on the care of the incision. In an in-person interview with director of 1 East on the afternoon of 03/13/12, it was confirmed the facility failed to provide discharge instructions to patient #2 and his wife, for care of the abdominal incision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29937 Based on documentation, and an interviews with the facility staff, it was determined that the facility failed to complete an occurrence report on patient # 1, for leaving the facility against medical advice. Findings were: Review of the medical record of patient #1, revealed that patient #1 was admitted to the facility on [DATE] and left against medical advice on 01/18/12. Review of progress note 01/18/12 per the Nurse Practitioner stated,Patient called her daughter and left against medical advice because she felt that I was accusatory, rude, and refused an explanation for the rationale, for her treatment modality. Review of Policy # PCSO40, Against Medical Advice/Elopement, Leaving, without Treatment, revised 05/11. AMA/ELOPEMENT 7. An occurrence report is completed on all AMA's/elopements and sent to the Department Director. In a telephonic interview conducted with the Family Nurse Practitioner on 03/13/12 at 2:20 pm at the facility, it was confirmed that an occurrence report had not been completed for patient #1, who was admitted to the facility on [DATE] and left against medical advice on 01/18/12. In an interview with the [NAME] President of Quality on the afternoon of 03/13/12 at the facility, it was confirmed that an occurrence report had not been completed for patient #1 who was admitted to the facility on [DATE] and left against medical advice on 01/18/12.

29937 Based on review of facility documentation, policies, and an interview with the Quality Improvement Coordinator, it was determined, the nursing staff failed to change the dressing of patient # 2 each shift, as ordered by the physician. Findings were: Review of the medical record patient #2, revealed an exploratory laparotomy was performed on 11/04/11 with findings of ischemic right colon and a right colectomy was performed. The physician ordered 11/07/11 stated Can change abdominal dressing q (every) shift with dry gauze. Review of the clinical documentation record 11/10/11 and 11/11/11 revealed the dressing was not changed each shift, as ordered by the physician. Review of facility policy, Diagnostic and Therapeutic Orders of Medical Staff: Acknowledgement, Coordination and Implementation # PCSO24, stated, registered nurses will coordinate the implementation of the physician's orders. Physicians' orders for patient care are processed in a timely manner to ensure that each patients needs are assessed and met. Based on each patient's presenting needs, orders are prioritized and implemented. In an interview with the Quality Improvement Coordinator on the afternoon of 03/13/12, clinical records 11/10/11 and 11/11/11 were offered to the surveyor, revealing the dressing had been changed on 11/10/11 and 11/11/11. No other documentation was offered to the surveyor indicating that the dressing had been changed each shift as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21021 Based on review of records and interview with staff, the facility failed to ensure that an appropriate medical screening examination (MSE) to determine whether or not an emergency medical condition exists occurred for 1 of 20 patients whose records were reviewed. Patient #1 was discharged in an unstable condition following the MSE. Findings were: Facility policy #PCS084, entitled, ASSESSMENT/REASSESSMENT OF PATIENTS, states under Section 6(2) that All triage assessments should be analyzed by a Registered Nurse to determine the triage acuity level according to the [NAME] (Emergency Nurses Association) Emergency Severity Index triage system, Levels I-V. Level I is the most severe, and is for patients who require immediate life-saving intervention. Level II is considered Emergent, a high risk situation. Beginning with Level III, the policy indicates that any patient assigned this level would require 2 or more resources. In an interview conducted the afternoon of 9/12/11, the ED Director stated that a resource is defined as an intervention, such as IV, lab work, etc. There are no recommended number of resources assigned to the highest levels, I and II. Patient #1 was given a Level II, Emergent, status when she was admitted to the MCA ED on 8/20/2011, yet no resources were provided to the patient. Review of the medical record for Patient #1 revealed that the patient presented to MCA ED on 8/20/11 at 5:20 pm complaining of Chest and Headache. Complaints also included blurry vision and facial numbness. The patient's blood pressure reading was 210/115 (normal is below 140/90). The patient delivered a baby 4 days prior by C-Section at a different hospital, and had been diagnosed with high blood pressure during the pregnancy. The patient was discharged from the hospital where her delivery took place that same day, 8/20/2011. According to nursing triage notes, Patient #1 reported not feeling well and reported headache pain as a 6 on a scale of 1-10. No other treatments or tests were ordered by the physician, Staff # 4. The physician clinical report stated that Patient #1 also complained of facial numbness and blurred vision. The patient reported to the physician that the results of an MRI at the hospital where she delivered her baby did not make any sense when explained to her. There was no documentation by the physician that the results of the MRI were obtained from the other hospital. At 7:20 pm, the patient was cleared for discharge to home. According to nursing notes, at the time the patient was discharged , the family asked to speak with the physician. The physician did speak with the family at that time, however, there were no physician progress notes regarding the conversation documented in the medical record. Nursing notes indicate that the condition of the patient at discharge was unchanged. Patient #1's blood pressure was 192/111 at the time of discharge. The patient's pain level remained 6/10. These findings in the medical record were confirmed by the facility CNO's review of the record on 9/12/2011. A telephonic interview was conducted with the treating physician, Staff #4, at noon on 9/13/2011 in a conference room in the presence of hospital administrative staff. The physician recalled the conversation with the family, and confirmed that the conversation was not documented in the patient's medical record. The physician stated that the prescription for high blood pressure medications given to the patient at the time of discharge from the other hospital had not been filled yet and the physician thought the patient should give those a chance to work. The physician assumed the other hospital knew what they were doing when they discharged Patient #1 and they wouldn't have let her go if there was anything wrong on the MRI. Review of other ED patient records revealed that four patients were recently seen in the ED for complaints of high blood pressure (readings lower than Patient #1). One patient was pregnant. These 4 patients all had resources provided to them such as lab work; 1 patient had a CT of the head due to headache and visual changes. Patient #1 was not provided any ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists, such as the other 4 patients were provided. Review of Patient #1's medical record from another acute care hospital indicated that Patient #1 still felt ill after discharge to home from MCA ED on 8/20/11, left the facility and came to their hospital ED; the patient was then admitted for a 4 day stay for stabilization and treatment of high blood pressure, facial numbness, and visual changes.