CMS-Medical-City-Plano - HCAvsAmerica

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to provide an appropriate Medical Screening Examination (MSE) to patient #1 who presented in the emergency department (ED) via ambulance on June 01, 2021, citing one of twenty one patients.

Findings included:

On 06/01-02/2021 Patient #1's medical screening exam was in process. The patient was seen upon arrival to the hospital's ED, however there was a delay in completion of the medical screening exam because the patient was able to elope several times during the visit. On the last elopement, the patient was arrested and taken into custody by the police and taken to jail. At the time the patient was taken into custody, the patient's physical exam and workup were unremarkable, however the patient was not fully stabilized and had not been medically cleared.

Patient #1's Medical Record

06/01/2021 at 2237. Room 06.

Patient Patient #1 was an ...Approximately [AGE]-year-old female who presents to the ER via EMS [with a local Police Department] for altered mental status. PD was called out by an apartment complex after patient was found in a maintenance room acting odd. PD states patient has not communicated with them. Patient was noted to have a large bag of handwritten notes, which appear to have delusional messages. Unknown if patient has any psychiatric history or medical history. Patient not speaking here in the ER ...

Patient #1's past medical history, surgical history, family history, smoking history, and social history was unable to be obtained due to Patient #1 being nonverbal.

Physical Exam

Patient #1 was awake, alert, and in no acute distress. Her head appeared to be atraumatic. Her pupils were equal, round, and reactive to light. Her conjunctiva was clear. Her membranes were moist. Her abdomen was soft and non-tender. She had no gross abnormality. Her skin was warm/dry and without rashes. Her neck was atraumatic and supple. Her chest was atraumatic with normal breath sounds. No respiratory distress. Her heart rate was normal with a regular rhythm. She had no motor deficits, no sensory deficits, and her cranial nerves II-XII were intact. The patient refused to answer questions.

Laboratory Tests

06/01/21 at 2255. Chemistry, Hematology, Toxicology, and Urine tests.

Her toxicology test results were negative except for Alcohol, Quantitative was <3 (0-80 mg/dl). Hematology was normal. Chemistry had some elements that were slightly outside of normal but with no concerns. Urine was normal except for a trace of protein.

Radiography

Physician's Order: CT Head with no contrast

to be read by Radiologist and reviewed by ED physician. The order was not carried out due to the patient's elopement and arrest.

Re-Evaluation

06/02/21. ... [AGE]-year-old female who presented to the ER for altered mental status. On arrival to the ER patient awake, alert, not speaking and uncooperative. Patient came with large bag full of handwritten notes, with obvious delusional messages. Patient with normal vital signs. Labs are unremarkable. UDS is negative. Patient eloped from her ER room, PD was notified ... Condition Stable ... Primary Impression: Altered mental status ... Disposition Decision time 0136. Patient eloped from her ER room.

ED Nurse's Notes.

06/01/21-2235 PM. Arrival Date/Time

2235 PM. Triage was started.

Subjective Assessment. 06/01/21. 2235. ...Brought in by EMS from apartment building after management called after finding her in their riser room. Patient refuses to answer questions or speak aloud. EMS reports patient refused to comply with vital signs en route and frequently tried to escape. Patient found with soiled belongings and notes written in crayon describing herself as a Christ figure and an 'Elite' ...

Objective Assessment. ...Patient awake, nonverbal, airway patent & midline, RR even & unlabored, skin warm, dry, color WNL for race, cap refill 2> seconds ... belongings soiled and moist ...

Suicide screening. Unable to assess.

Finger stick blood glucose prior to arrival: 140's

BMI calculated: 20.4

Chief Complaint: Behavioral Health Related

Expected outcome of chief complaint: Stabilized/maintained

Patient is Homeless.

Violence/Aggression Screening

BROSET screening completed. BROSET risk type: Small.

Right peripheral IV line inserted 06/01/21 at 2235.

IV line removed by patient 06/02/21 at 0100.

Vital Signs. 06/01/21. 2331. B/P-128/74, Pulse-92, Respiration rate-22. Oxygen level on room air-98%.

ED Nurse's Notes

06/01/21. 2306. ... PT not answering any questions, obeying commands, or opening eyes. PT brought in by EMS with a local PD, unknown how long PT has been like this. Per a local PD, PT has been seen on security cameras at this hotel she was brought in from for the past 2 days ...

06/02/21. 0009. ...Pt was out of ED lobby without clothes. PPD provides sheet for patient to cover self. This RN assists patient by ambulation with assistance back to ED room 6. Patient has a smirk on face and appears to be feeling happy; however, patient does not respond to questions but does move her head ...

06/02/21. 0101. ...PT wondering halls after dressing self, displaying hand written signs stating she is 'Hearing impaired and vision impaired and that it is late and she needs to go' PT redirected back to room 6 and informed that she needs to finish being checked out and evaluated before being able to leave. Pt still not verbally answering questions ...

06/02/21. 0140. PT got out of bed and walked out of department. a local PD notified and followed PT out of department ... Patient left at 0145.

Hospital's Incident Report by the Security Department

Reporting Officer #6

Defendant: Patient #1

06/02/21 at 3:51 AM. Author: Officer #8

Officer #8 was coming inside from a helicopter, and ran into a patient leaving. Patient #1 was trying to leave while under the influence. She came from the ER in nothing but a sheet. Officer #8 tried to take the patient back to her room. The patient at first refused, then Officer #8 called local PD Officer #9 to help. Officer #9 came and grabbed the patient, both security officer and a local PD officer waited for staff. While waiting Patient #1 began to urinate on the floor. Environmental Services was called to come clean it up. Officer #8 and staff got the patient back in the room.

After the patient got in the room, the patient tried to leave again 4 more times. Officer #8 asked if the patient was on a legal hold. The patient was not on an OPC (order of protective custody). Officer #8 made the judgment call to staff that if the patient leaves again a local PD would come to arrest them for PI (Public intoxication). Officer #8 saw the patient leave and had local PD Officer #9 call for a patrol car. Local PD Officer #6 who arrested the patient, arrived. The patient was subsequently arrested.

Police Department Incident/Arrest Report.

Offense Location/Date: 3901 W 15th St, Plano, Collin County, Texas, on the 2nd day of June, 2021 at 0109 hours.

On Tuesday, June 2, 2021 at approximately 0109 hours PD Officer #6 was operating a clearly marked Police Tahoe. He responded to the hospital located at 3901 W 15th St, Plano, Collin County, Texas in reference to local Police Officer #9 requesting for an additional officer/officers at the location in reference to Patient #1 who had been admitted to the location attempting to leave. Local Police Officer #10 and Police Officer #11 also responded to the location to assist.

PD Officer #6 had earlier dealt with the Patient #1 under incident #21- 0 which he had responded to local apartments in reference to a possible homeless subject sleeping in the fire room at approximately 2150 hours on 06/01/2021. The officer made contact with the unknown female subject who was sleeping on the floor of the fire room. He attempted multiple call outs to her however she was unresponsive to his verbal commands and questions. He observed her eyelids to be constantly fluttering during this time.

Due to the totality of the circumstances, a local FD (fire department) transported Patient #1 to the hospital where she was placed into the care custody and control of the staff at the location to be medically evaluated..

PD Officer #6 arrived to assist PD Officer #9 at 0116 hours in the parking lot area to the west of the hospital. PD Officer #6 was advised by PD Officer #9 that Patient #1 had attempted to leave the hospital about five times including once with only shoes on before she was brought back. A small empty bottle was discovered among her property and Patient #1 had also urinated on the ground while at the hospital. PD Officer #6 stated he observed Patient #1 displaying the same signs as he had dealt with her earlier. At that time, PD Officer #6 detained Patient #1 with cuff wrist restraints (double-locked to prevent tightening) for Public Intoxication.

PD Officer #11 searched Patient #1's property before her arrest and located a Texas Class C driver's license (DL) with Patient #1's name and date of birth 12/09/1980. He was able to match the picture on the DL to that of Patient #1 at hand. A check of Patient #1 through dispatch by PD Officer #9 also yielded an outstanding warrant for her arrest.

Fire-Rescue Patient Care Record

Incident #21-

Date: 06/01/2021.

Patient First Name: Patient

Patient Last Name: Patient

Age: 35 years (estimated)

Primary impression: Mental disorder

Complaint: No complaints/will not talk to EMS.

Signs & Symptoms: No Patient Complaint-No Complaints or injury/illness noted

Narrative

...Medic 12 and Engine 5 AOSTF an approximately [AGE] year old female patient with a cc of a possible mental disorder. a local PD requested EMS to the location to asses Pt. PD stated to EMS that according to the apartment complex personnel the Pt has been living in the fire riser room in one of the buildings for approximately three days. Pt was found standing next to fire riser room non verbally with a GCS of 11, with a local PD next to Pt. Pt's v/s, assessment, and treatment is as noted in report. Pt had no trauma noted by EMS, Pt was nonverbal to EMS and refused to let EMS assess BP. Pt was ambulatory to EMS stretcher, Pt was secured to ambulance stretcher, and moved to the back of unit, with assistance from Engine 5 crew members, without incident... Patient #1 was transported to the hospital without incident. At the hospital patient care and report were transferred over to the emergency department staff RN without incident. Patient #1 refused to sign the report.

Interviews

During an interview on 09/28/21 at 2:15 PM with RN (registered nurse)-ED Director #7 she said when patients present with behaviors that could result in harm to the patient or others they utilized an off-duty local Police officer, hospital security, and/or paramedics who are used as sitters.

During a telephone interview on 09/30/21 at 1:01 PM with RN #4 he said Patient #1 was brought in by the paramedics who said she had not been cooperative and was nonverbal. She had been found in a riser room at an apartment complex where she appeared to have been staying. She had a large bag with her. Staff asked if they could look inside the bag and she shook her head yes. There were a lot of handwritten notes inside. The notes indicated she was Christ or something like that. They did not empty the bag and did not find any personal identification. She attempted to leave several times. Mostly going to the secretary and handing her handwritten notes. One note said she couldn't see or hear well. When she was spoken to it appeared she was giving direct eye contact and was understanding what was being said. When she was spoken to she appeared to hear. She had an MSE and labs were drawn. A CT of her head had been ordered but it was thought she left before it could be completed. RN #4 thought she had a sitter that night but couldn't remember for sure. The police didn't talk to him before arresting the patient. Her vital signs were stable and her level of consciousness seemed normal.

During a telephone interview on 09/30/21 at 2:10 PM with Physician #3 she said Patient #1 was entered into the system as a Jane Doe because the patient was nonverbal and they didn't know her name or date of birth. She was calm and cooperative and restraints were not warranted even though she attempted to elope several times. She had a big sack of psychotic notes. Physician #1 attempted to take a medical history but the patient wouldn't answer her questions. She assessed the patient physically and ordered lab work, CT of the head, and an IV. Patient #1's vital signs were stable and her lab work wasn't concerning. She had some alcohol detected in her blood. She left before the CT of her head was done. She was medically stable when she left. Physician #3 planned to call Behavioral Health to fast track her to a behavioral health facility after she had her CT and was medically cleared. The police did not talk to Physician #3 before arresting the patient.

During a telephone interview on 09/30/21 at 4:30 PM with RN #5 she said the patient was brought in by the police and EMS due to concerns about her, and they wanted her to be evaluated. Patient #1 was nonverbal. She attempted to leave several times. She would bring notes to the secretary telling her she wanted to leave. She said she had hearing and vision problems. Her notes were perfectly written. When she attempted to leave and staff would talk to her she would have this little smile, almost a smirk on her face. She would remove her monitor and her IV and leave her room. The patient had no problems navigating through the halls of the ED. RN #5 alerted security about the patient being an elopement risk. Before Patient #1 left for the last time she dressed herself completely and left. The police arrested her outside of the building. The police did not talk with RN #5 before they arrested Patient #1.

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Based on record review and interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient in accordance with the patient's needs, in that,

There was no documented patient response/nursing re-assessment after pain medication administration for 1 of 9 patients (Patient #1) reviewed;

There was no verification of patient allergies documented prior to pain medication administration for 1 of 9 patients (Patient #1) reviewed; AND

There was no documented patient response/nursing re-assessment after Narcan administrations for 3 of 9 patients (Patient #1, #2, and #3) reviewed.

Findings were

Patient #1 received pain medication and Narcan on 5/26/2018. Family was present. Patient #1's allergies were documented 4/18/2018, and not re-verified prior to the 5/26/2018 medication administration.

Patient #2 received Narcan on 4/28/2021.

Patient #3 received Narcan on 4/24/2021.

There was no documented patient response/nursing re-assessment after any of the administrations of the above medications.

During an interview and record review on 4/28/2021 at 1:05 PM, Personnel #4 navigated the electronic records and confirmed the above findings.

During an interview on 4/28/2021 ending at 2:39 PM, Personnel #3 stated, PRN medication follow-up is expected for all medications. Personnel #3 pointed out re-assessment is required in the policy.

During an interview on 4/28/2021 at 3:10 PM, Personnel #1 stated, I followed up with the Director of the ER about re-assessment after Narcan administration. Narcan is considered an intervention - re-assessment would be expected to be documented.

The facility's Assessment/Re-Assessment policy required, individualized care/treatment/services...Reassessment - Further data collection and analysis, the scope of which is determined by the patient's diagnosis, the treatment setting, the patient's desire for treatment, and the patient's response to treatment...administration of pain control medications and during/after procedures to determine effectiveness...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, and record reviews, the hospital failed to ensure its medical staff by laws/rules/regulations/policies on medication reconciliation were followed in 1 on 1 (patient #1) in that:

The facility failed to administer a physician recommended medication to patient #1 for 7 days.

The facility physicians documented in their progress notes Patient #1 was on gabapentin medication for peripheral neuropathy though no medication administration records showed its administration.

Findings included:

Patient # 1 was an [AGE]-year-old African American female with past medical history including hypertension, diabetes, CVA, chronic kidney disease and a history of peripheral neuropathy. Patient #1 was admitted to the facility on [DATE] at 1920 with a chief complaint of generalized weakness and left flank pain.

Admission History and Physical record dated 07/17/2019 reviewed on 01/06/2020 at 10:45 a.m. revealed patient #1 was on home medication gabapentin 300 mg by mouth twice daily among other medications. Physician #1 in her assessment recommended continuation of her home medication (gabapentin) due to the patient's history of peripheral neuropathy.

Physician progress note signed and dated 07/18/19 by physician #2 indicated (on assessment and plan) that history of peripheral neuropathy, on gabapentin. Progressive physician notes from 19th to 24th indicated patient #1 still complains of significant bilateral heel pain on gabapentin. This was despite the patient not being on any gabapentin medication.

Medication records reviewed did not indicate patient # 1 was on any gabapentin from 07/17/19 up to 07/24/19.

Physician order reviewed indicated patient #1 was put on Gabapentin 300mg by mouth three times daily on 07/25/19.

Interview with Personnel # 1 on 01/06/2020 at 12:30 p.m. confirmed physician recommendation to continue gabapentin was not followed. Subsequent physician assessment and plan revealed patient was thought to be on the medication up to 07/25/19 when an order was written. Personnel #1 reported nurses are to check on H&P and should notify the physician for any discrepancies .... Pharmacists are not involved in medication reconciliation. The patient or patient family notifies the nurse the medications the patient was taking at home. The physician decides what medication to continue or discontinue.

Review of hospital policy ref #716-049, entitled: Medication Reconciliation stated in its definition: Medication reconciliation is an interdisciplinary process of identifying the most accurate and complete list of medications a patient is taking and using this list to provide correct medications for the patient. Reconciliation involves comparing the patient's current list of medications against the physician's admission, transfer, and/or discharge orders. The policy stated All admitted patients should have all medications reconciled within 24 hours. Each patient's home medications ...are documented.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the facility failed to ensure nursing service had adequate number of licensed registered nurses and other staff personnel for each department or nursing unit that was immediately available to provide patient care when needed in that:

The facility failed to provide timely MRI head /brain examination as ordered.

This failure placed the patient at an increased risk of harm/potential by not getting prompt diagnosis and treatment/care.

Findings included:

Patient #1 is a [AGE]-year-old female who presented to the Emergency Department via an EMS transfer for a possible middle cerebral artery occlusion on 03/06/19 at 08:19 a.m. Patient had a MRI (Magnetic resonance Imaging) of head/brain ordered by the physician at 11:16 a.m. The MRI exam was done the following day on 03/07/19 at 01:38 a.m. This was more than 14 hours after the exam had been ordered.

Physician order record reviewed on 09/10/19 at 09:45 a.m. indicated MRI exam was ordered at 11:16 a.m.

Records reviewed indicated MRI pre-procedure history questionnaire was completed on 03/06/19 at 0844.

Interview with the Staff # 2 and Staff # 3 on 09/10/19 revealed the MRI screening form was never faxed to the radiology department but was handed to the Technician. Staff #2 reported MRI technician called the nurse at NSICU on 03/06/19 at 3:30 p.m. and requested patient to be brought in for the examination. Staff #2 said the nurse reported was not ready until 1700. Staff #2 reported MRI technician called again at 1700 and the nurse was not available.

Nurses entry notes reviewed on 09/10/19 indicated the nurse called MRI technician on 03/06/19 at 1938 and requested to know if the patient was on the list to be scanned by the MRI technician. The MRI technician stated No I don't see this patient on my list. I don't know about the screening form ....it will be another two hours. Nurses notes indicate the nurse called again MRI technician at 2129 and was told It will be a while longer and I have not checked for the form, but I will after I am done with this patient.

Interview with Staff # 3 on 09/11/19 at 11:25 a.m. she reported they realized MRI technicians were able to view the worklist from the MRI scanner. She said, we will educate all staff on this feature. Staff # 3 said an app will be added to the current computer where we can track our eMAR's on. She said, through this investigation today we have found several tools that will improve our communication in the department and nursing floors. She said the facility had no current Radiology Staffing Plan that reflect the actual hospital image. Staff # 3 said it was in progress of being revised.

Interview with the Staff # 4 on 09/11/19 at 1:45 p.m. revealed she was the Director NSICU. She stated the nurses in NSICU om 03/06/19 were caught up in a situation there was a patient that required intubation and others who were 'crashing.

Review of facility policy titled Prioritization of Imaging Services Exams with an effective date 06/2019 stated Radiology will perform all routine orders within eight hours of the origination of the request or order as appropriate/necessary, unless designated for a specific time.

Review of facility NSICU Scope and Staffing Plan revised 12/24/2018 stated Patients waiting to be admitted or transferred to unit ...when staff is unable to meet demand/acuity - Manager and director will be notified. Call in PT and FT staff for extra shifts, utilize SRT, offer bonus as appropriate, utilize contract labor, unit educator in staffing. NM/ANM/CN/House Supervisor to notify director and NM of staffing shortage and patient holding.

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Based on observations, interviews, and records review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. The facility failed to:

A.) Ensure facility staff followed nationally accepted standards of infection control measures by not walking on the hallway with soiled gloves. Failure to ensure soiled gloves were removed and hands sanitized or washed with soap and water.

B.) Ensure Environmental Services/Housekeeping staff wore gloves when removing soiled linen and donning gloves when cleaning patient room after dismissal.

C.) Ensure clean linen were properly stored and covered to prevent cross-contamination.

D.) Ensure the floor in the medication room was properly mopped, medication cart and pixes were properly cleaned and kept free from dirt.

E.) Ensure trash was contained and emptied promptly.

These failures placed the patients at increased risk to their health by transmission of infections and contracting communicable diseases.

Findings included:

During a tour of the hospital 5th floor on 08/29/19 at 10:25 a.m. in the company of Nurse Supervisor Personnel #1, a staff member Personnel #2 was observed walking on the hallway with gloves on after coming from a patient room. Personnel # 2 thereafter removed gloves mid hallway and sanitized hands. This was confirmed by Personnel #1 who reported staff members were supposed to remove their dirty gloves and either wash hands or sanitize them using the hand sanitizers. She said, he's not supposed to walk the hallway with gloves on.

Interview with Personnel # 2 on 08/29/19 at 10:30 a.m. revealed he was student volunteer in the facility. He stated he removed gloves and sanitized on his way to the whirlpool room. He said he was aware not to walk with gloves on the hallway but forgot to remove them.

Observation of the 5th Floor clean linen storage room on 08/29/19 at 10:45 a.m. revealed uncovered clean linen on top of a laundry cart. Cleaning rags were observed on the floor in the housekeeping janitors room. Trash was overflowing and had not been emptied in the unit. A cover matt was placed on the floor at the Nurse station. The floor in the medication room was dusty and had dirty brown-black markings. The medication cart was covered with dirt. These observations were confirmed by Personnel #1.

Observation on 6th floor on 08/29/19 revealed patient's refrigerator had undated opened milk. Dirty gloves thrown on the floor in the soiled utility room. Medication pixes top were covered with dust. Trash bins were overflowing and had not been emptied. These observations were confirmed by Nurse Manager Personnel #3.

Housekeeping Personnel # 4 was observed on 08/29/19 at 11:45 a.m. removing soiled linen from room 601 with no gloves on. She was observed mopping the floor and cleaning the room without gloves. Her linen cart was overflowing with dirty linen. A dining knife and a bottle of patient shampoo was observed in her cleaning water solution in her cleaning cart. These observations were confirmed by Personnel #3 and Personnel # 5.

Interview with Personnel # 4 on 08/29/19 at 11:55 a.m. through a Spanish interpreter (Personnel # 5) revealed she knew she was supposed to wear gloves but decided not to do so. She reported she was a contracted employee and said she was not sure whether she had been trained on infection control and transmission. Personnel #5 (Environmental services manager) reported he did not know whether she had been trained on infection control. He said, she is supposed to be trained before working here but not sure since she is contracted.

Review of the Hospital policy titled Environmental Services Infection Prevention with an effective date 05/17 revealed in part... gloves should be removed when leaving each patient room and hand hygiene should be performed.

Review of the Hospital policy titled Hand Hygiene with an effective date 03/19 stated in part... Gloves should be used for hand contaminating activities.

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Based on record review and interview, the facility failed to ensure it's QAPI (Quality Assessment and Performance Improvement) program investigation and review of a 11/26/18 patient grievance identified opportunities of improvement, in that,

the investigation did not identify:

1) Missing medical record documentation for Patient #1 including:

missing pre and post procedure orders, post sedation assessment, immediate post-op note, post operative nursing care, and care plan update for a behavioral issue.

2) Missing incident report for Patient #1's behavioral issue.

Findings included

The 11/26/18 Patient #1 complaint record reflected, meeting with staff...case discussed...all nursing care was found appropriate...

Patient #1's record did not contain complete pre-procedure orders. The faxed-in, pre-procedure order sheets did not contain time, date, and physician signature.

The nurse did not document a nurse call to verify orders and secure a telephone order prior to Patient #1's care.

Pre-operative care provided by the nurse without an order included laboratory work, intravenous (IV) catheter insertion, pre-operative IV medications.

Patient #1 had moderate sedation administered by a registered nurse during their procedure without a post sedation physician assessment documented.

Patient #1 had no immediate post-operative note by the physician available to post-op caregivers.

There was no nurse documentation for Patient #1's unexpected events including the behavioral issues of the patient pre and post procedure, the sheath removal, precautions taken for risk of bleeding with the patient being resistant to medical care and direction post sheath removal.

Patient #1 was discharged after their procedure without a discharge order from the physician.

Patient #1's Cardiac Cath Report reflected, extreme precaution in managing her groin site due to prior history of pseudo-aneurysm. The patient threatened to leave the hospital right after the Cath today and she therefore had to be sedated for groin management to reduce the risk of major bleeding and death...

There was no documented incident report for Patient #1's unexpected events/behavior that occurred.

During an interview and record review on 1/23/19 ending at 12:02 PM, Personnel #3 discussed multiple behavior issues of the patient prior to and post procedure including hitting the husband, and staff members which utilized multiple staff to contain. Personnel #3 discussed conversation with Personnel #6 during the complaint investigation. Personnel #3 was asked about pre and post operative orders. Personnel #3 reviewed the orders and stated, I should have called to verify orders. Personnel #3 was informed there was no updated care plan for the behavioral issues. Personnel #3 stated, No. Personnel #3 was asked if an incident report was completed. Personnel #3 stated, No.

The December 2018 Interventional Care Center policy required, establish an approved scoring guideline/discharge criteria for patients receiving outpatient anesthesia and conscious sedation, in order to assess the patient's readiness for discharge...the physician will order the discharge...the patient must have a total score of 18 before discharge...discharge criteria score...Modified Post-Anesthesia Recover (PAR) Score for Ambulatory Patients...

Show Text of Violation

Based on record review and interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient, in that,

A)

3 of 11 patients (Patient #1, #6, and #11) did not have pre-procedure (Cardiac Cath) orders prior to being cared for by the nurses;

B)

3 of 11 patients (Patient #1, #7, and #10) did not have post-procedure orders including discharge after the procedure was completed; and

C)

4 of 11 (Patient #1, #3, #5, and #7) patients did not have post-op nurse documentation to reflect their post op care and outcomes.

Findings included

A)

Patient #1's, #6's, and #11's record did not contain complete pre-procedure orders. The faxed-in, pre-procedure order sheets did not contain time, date, and physician signature.

The nurse did not document a nurse call to verify orders and secure a telephone order prior to care. Pre-operative care provided by the nurse without an order included laboratory work, intravenous (IV) catheter insertion, pre-operative IV medications.

During a telephone interview and record review on 1/25/19 from 7:30 AM to 9:56 AM, Personnel #2 reviewed the records and confirmed the findings.

B)

Patient #1, #7, and #10 were discharged after their procedure without a discharge order from the physician. There was no Modified Post-Anesthesia Recover (PAR) Score for Ambulatory Patients documented post operatively to determine readiness for discharge.

During a telephone interview and record review on 1/25/19 from 7:30 AM to 9:56 AM, Personnel #2 reviewed the records and confirmed the findings.

The December 2018 Interventional Care Center policy required, establish an approved scoring guideline/discharge criteria for patients receiving outpatient anesthesia and conscious sedation, in order to assess the patient's readiness for discharge...the physician will order the discharge...the patient must have a total score of 18 before discharge...discharge criteria score...Modified Post-Anesthesia Recover (PAR) Score for Ambulatory Patients...

The 8/26/15 Medical Staff Rules and Regulations required, routine orders...dated, timed, and signed by the practitioner...

C)

There was no nurse documentation for Patient #1's unexpected events including the behavioral issues of the patient pre and post procedure, the sheath removal, subsequent hematoma size, precautions taken for risk of bleeding with the patient being resistant to medical care and instructions post sheath removal.

Patient #1's Cardiac Cath Report reflected, extreme precaution in managing her groin site due to prior history of pseudo-aneurysm. The patient threatened to leave the hospital right after the Cath today and she therefore had to be sedated for groin management to reduce the risk of major bleeding and death...

During an interview and record review, Personnel #3 discussed multiple behavior issues of the patient prior to and post procedure which utilized multiple staff to contain. Personnel #3 was informed there was no documentation that reflected the verbal account of what occurred. Personnel #3 stated, No. I didn't document it. I didn't want that to follow her around in her medical record.

Patient #3, #5, and #7 record did not reflect post-op nurse documentation including post-procedure vital signs, level of consciousness, oxygen saturations, dressing/site, pain, and activity/ambulation status.

During a telephone interview and record review on 1/25/19 from 7:30 AM to 9:56 AM, Personnel #2 reviewed the records and confirmed the findings.

Show Text of Violation

Based on record review and interview, the facility failed to ensure adequate provisions for immediate postoperative care, in that,

A)

7 of 11 post-op patients (Patient #1, #4, #5, #6, #8, #9, and #10) did not have available to post-op caregivers an immediate post-operative note by the physician; and

B)

3 of 11 post-op patients (Patient #1, #7, and #10) did not have Post-procedure orders including discharge after the procedure was completed.

Findings included

A)

Patient #1, #4, #5, #6, #8, #9, and #10 all had procedures with no immediate post-operative note by the physician available to post-op caregivers.

During a telephone interview and record review on 1/25/19 from 7:30 AM to 9:56 AM, Personnel #2 reviewed the records and confirmed the findings.

The 8/26/15 Medical Staff Rules and Regulations required, Operative reports...procedures...must be dictated or electronically documented immediately following the procedure. If the report is dictated, a timed operative progress note shall be completed to provide all caregivers information about the procedure until the transcribed report is placed in the record...physicians who fail to complete operative reports in a timely manner will have admitting privileges suspended...

B)

Patient #1, #7, and #10 were discharged after their procedure without a discharge order from the physician.

During a telephone interview and record review on 1/25/19 from 7:30 AM to 9:56 AM, Personnel #2 reviewed the records and confirmed the findings.

The December 2018 Interventional Care Center policy required, establish an approved scoring guideline/discharge criteria for patients receiving outpatient anesthesia and conscious sedation, in order to assess the patient's readiness for discharge...the physician will order the discharge...the patient must have a total score of 18 before discharge...discharge criteria score...Modified Post-Anesthesia Recover (PAR) Score for Ambulatory Patients...

The 8/26/15 Medical Staff Rules and Regulations required, routine orders...dated, timed, and signed by the practitioner...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure the patient right 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 for 1 of 2 discharged patients (Patient #1), in that, Patient #1's family member requested an impartial review of alleged violations of patient rights pertaining to the discharge plan and the facility did not grant/fulfill the request.

Findings included

Patient #1's record reflected:

~ hospitalized [DATE] through 10/26/17 for a life altering traumatic brain injury due to a motorcycle accident.

~ Provided 24/7 - 1:1 sitter care in the hospital after 10/20/17 due to confusion and agitation.

~ 10/23/17 Psychology Consult...judgement, decision making, memory has been affected...denied AH/VH/SI/HI (auditory/visual hallucinations; Suicidal/homicidal ideation) titrate depakote...based on tolerability.

~ 10/25/17 Psychotic and easily agitated...confused speech...impulsive...delusional...injuries: Bilateral frontal/temporal/cerebellar...Active Problems: Deconditioning...psychosis...Unfunded...Plan to discharge home with family, continue family training...family currently refusing to take patient home home...establishing charity bedside commode, wheelchair - family to purchase rolling walker...may need to make patient stable enough for discharge to shelter...

The Case Manager documentation for Patient #1 reflected:

~ 10/25/17 Patient adamantly refused to go to rehab only wants to go home.

~ Rehab willing...charity rehab...then denied as pt still had a sister.

~ PT (Physical Therapy) recommended inpatient rehab, day neuro rehab, or 24/7 supervision. ~ SW explained ready for discharge...per their inquiry about putting pt out the front door if they don't pick him up, SW explained that we might arrange pt to go to the Bridge Shelter.

~ 10/24/17 weight bearing left arm...ambulating with rolling walker...mother reported that pt can't afford adult day care... ~ 10/20/17 demonstrates flight of ideas with delusional thinking...mother, father, sis in law described that because of pt's delusional flight of ideas, that pt is not safe to be home alone and that (family) work and that there is not other family to care for pt while they are at work...

~ 10/18/17 SW talked with therapy and patient should be able to go home now.

~ 10/16/17 SW met with family...medically stable and is ready for discharge...Family concerned about his safety...no one home during the day to watch him...

The hospital's 10/25/17 email from Patient #1's sister reflected, file a complaint...my brother...patient rights...has a right to an impartial review of alleged violations of patient rights...We request a review...they are putting my brother and family at risk by forcing a discharge, we were threatened...they would drop him off at a homeless shelter. I do not believe he can be cared for at home...

During an interview on 11/28/18 at 9:18 AM, Personnel #1 was asked for the impartial review for the 10/25/17 emailed request. Personnel #1 stated, It (request for review) was not identified at the time. Personnel #1 was asked the process to complete the impartial review. Personnel #1 stated, We don't have a policy for that.

The facility's undated, Patient Rights handout required, Protective Services...impartial review...of alleged violations of patient rights...

The facility's 10/01/14 Patient Rights policy required, treat all patients with respect and dignity...ensure that there is no harassment, discrimination...discharge of patients...payment source or ability...provide each patient with a written statement of patient rights at registration and AGAIN AT THE TIME any patient or patients representative has questions regarding their rights...

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Based on record review and interview, the Medical Staff failed to ensure the quality of the medical care, in that,

A) 3 of 3 consults (Patient #4/Gynecological Oncology - GYN/ONC & Surgical Oncology - ONC and Patient #6/ Pain Management) did not occur for the patients; and

B) the transfer/admission In Good Faith did not receive the required service. Patient #4 was accepted by the hospital designee for Oncology for Uterine and Cervical Mass and did not receive the service during the hospitalization .

Findings included

Patient #4:

The medical record for Patient #4 reflected, 4/10/18...Memorandum of Transfer - Medical Condition: Diagnosis: Uterine and Cervical Mass...Reason for transfer...Medically Indicated...Obtain level of care/service NA (not available)...Service: Oncology (ONC)...

The 4/15/18 Discharge Summary reflected, Large cervical mass with bladder invasion ...the patient was transferred here for a surgical evaluation; however, speaking with both Gynecology-Oncology as well as a Surgical Oncology given the patient's unfunded status, it was felt that she would best be served by being at (another county's Hospital)...she was advised to go directly to the emergency room at (Another county's Hospital) for admission and further work-up...

Both hospital face sheets reflect Patient #4 lives in Grayson county, not Dallas county.

During an interview on 8/28/18 ending at 4:49 PM, Personnel #2 was asked if the hospital was aware of the multiple notes on Patient #4 about the GYN/ONC and Surgical ONC consults and no consults being completed. Personnel #2 stated, No. Personnel #2 was informed the patient was accepted via the MOT for Oncology for uterine and cervical mass. Personnel #2 was asked if that was provided. Personnel #2 stated, No. Personnel #2 was asked if the hospital had that service. Personnel #2 stated, Yes, but they do not take call. A Doctor can choose whether they want to see a patient.

During an interview on 8/29/18 at 11:20 AM, Personnel #11 was asked about Patient #4's consult for GYN/ONC not being done. Personnel #11 was asked if there were issues with services completing consults at the hospital. Personnel #11 stated, It depends. Personnel #11 was asked if the hospital had GYN/ONC and Surgical ONC services. Personnel #11 stated, Yes. Personnel #11 was asked if there were issues getting those services to see patients. Personnel #11 stated, Usually, the issue is time. Personnel #11 was asked if money or payment was an issue. Personnel #11 stated, I can't say.

During a telephone interview on 8/29/18 at 12:22 PM, Personnel #23 was asked about Patient #4's case. Personnel #23 stated, the note said Per (Attending) gyn onc has been consulted and will not see pt. If I remember right, she was supposed to be a direct admit and (Attending) spoke to them (GYN/ONC) and they said they wouldn't see the patient. Personnel #23 was asked about consults not being done with GYN/ONC. Personnel #23 stated, It is often the case with GYN/ONC service. Meaning, they are not on-call and we have no binding agreement for the hospital line (service). Per my experience, they have not seen patients for a variety of reasons. Personnel #23 was asked reasons up to and including payment. Personnel #23 stated, Yes.

During a telephone interview on 8/29/18 at 2:20 PM, Personnel #13 was asked about Patient #4's case. Personnel #13 stated she spoke with Personnel #24, GYN/ONC and Personnel #25, Surgical ONC by phone. They asked the funding status...told them she was unfunded and they chose not to take the patient...spoke to Personnel #9 (Chief Medical Officer) because I was not getting a normal response to consult requests for caring for my patient. Personnel #9 said no physician can be forced to take the patient.

Patient #6:

The medical record for Patient #6 reflected, 9/14/17...22:30 Consulting Physician: (Personnel #21) Reason for Consult: Chronic Pain...9/15/17...2:24 (AM)...(H&P addition) the patient is asking for pain medication to increase the dose...Discussed with family that (Personnel #21) will be there to discuss other issues...

There was no Chronic Pain Consultation Note.

During an interview on 8/29/18 at 11:10 AM, Personnel #1 was asked for Patient #6's consultation note for Personnel #21. Personnel #1 stated, There is no note.

The 3/29/17 MCP Medical Staff Rules and Regulations required, Admission...the management of each patient's general medical condition...A physician for each service/speciality shall be oncall and immediately available...attending physician shall be responsible for coordination the treatment of the patient...the attending physician shall be responsible for consulting the appropriate specialists to evaluate and assist in the patient's care...regardless of the patient's social status or ability to pay...consultations shall be obtained and completed within 24 hours or sooner...any qualified practitioner can be called for consultation...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, review of documentation, and interviews with facility staff, the facility failed to maintain facilities, supplies and equipment to ensure an acceptable level of safety as 5 argon cylinders and 5 nitrous oxide cylinders in 2 of 4 storage areas were observed to be unsecured in violation of facility policy. Also, during a tour of the Surgery Department the facility also failed to properly dispose of approximately 52 expired supplies which were available for patient use.

The findings were:

The facility policy entitled Cylinder and Waste Gas Management Plan dated 12/11 reflected in part 5. Cylinders (empty or full) should be stored upright and chained or otherwise secured to a support system to prevent falling over. Free-standing cylinders are not allowed in any location.

I. During a tour of the facility on 8/20/12 in the company of staff #11, 12 and 13 at 3:30 pm 5 compressed argon size F gas cylinders were observed in the Main Tank Farm storage room to be unsecured in any manner. In an interview conducted 8/20/12 at 3:30 pm, Staff #13 confirmed the 5 argon cylinders were unsecured and stated that they should have been secured.

II. During a tour of the facility on 8/21/12 in the company of staff #8 at 9:40 am, 5 nitrous oxide size E gas cylinders were observed in the Cath Lab storeroom lying on a table unsecured in any manner. In an interview conducted 8/21/12 at 9:40 am, staff #8 confirmed that the 5 nitrous oxide cylinders were unsecured.

Facility policy entitled, [DIAGNOSES REDACTED] stated, 8. A [DIAGNOSES REDACTED] supply/treatment cart will be maintained in L&D and OR, where succinylcholine (anectine) and/or general anesthesia are most often administered. The MH cart will be locked at all times. The following checks will be completed by anesthesia or nursing and documented in the MH log book: Monthly inventory check (exchange all products that are missing, non-functional, expired or will expire within 60 days).

III. During a tour of the Surgery Department on 8/21/2012 at approximately 1:15pm, revealed the following expired supplies in the operating rooms and the [DIAGNOSES REDACTED] emergency cart:

1. One Barrel Bur Hollow 12-Flute 5.5 mm disposable arthroscopy blade expired 9/2010.

2. Three Tegaderm 10cm x 12cm expired 10/2010.

3. Three Green top laboratory tubes expired 12/2010.

4. One Barrel Bur Hollow 12-Flute 5.5mm disposable arthroscopy blade expired 1/2011.

5. Three Tiger top laboratory tubes expired 1/2011.

6. One Arthro Wand CoVac 70 Wand 3.0mm expired 1/2011.

7. One Multi-Lumen Central Venous Catheter Kit expired 2/2011.

8. One IntraVenous Catheter 24 gauge expired 2/2011.

9. One IntraVenous Catheter 24 gauge expired 3/2011.

10. Pressure Monitoring Kit w/ Truwave disposable Pressure Transducer expired 5/2011.

11. Four Red top laboratory tubes expired 5/2011.

12. IntraVenous Catheter 24 gauge expired 6/2011.

13. Three Pink top laboratory tubes expired 6/2011.

14. Seven Purple top laboratory tubes expired 8/2011.

15. One Arterial Blood Gas (ABG) Sampler expired 1/2012.

16. Six Aspirator ABG expired 1/2012.

17. Three Radial Artery Catheterization Set expired 1/2012.

18. One Barrel Bur Hollow 6-Flute 5.5mm disposable arthroscopy blade expired 1/2012.

19. Five ABG Sampler expired 3/2012.

20. One Aggressive Plus 5.5mm disposable arthroscopy blade expired 3/2012.

21. Two Compound Benzoin Tincture expired 6/2012.

22. One Resector 3.5 disposable arthroscopy blade expired 7/2012.

The expired supplies were confirmed during the tour of the Surgery Department in the company of staff members #57, #58, #59, and #63 the afternoon of 8/21/2012.

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Based on review of documentation, observation, and interviews with staff, the facility failed to identify areas of unsanitary conditions which could lead to infection control issues in 3 areas observed, the Emergency Department (ED), Women's Services, and the Surgery Department. Visible dust, debris, torn mattress covers, and reddish-brown substances which appeared to be blood were found in patient care areas and on equipment available for patient use.

Findings were:

A tour of the Emergency Department (ED) was conducted the afternoon of 8/20/12 in the company of staff #53 and staff #54. In the triage room, treatment room #16, and treatment #17, visible dust was noted on high horizontal surfaces. For example, in the triage room, 2 overhead examination light fixtures had visible dust that fell from the surface when touched. In treatment rooms #16 and #17, visible dust was also noted on equipment. In the ED triage room, there were 2 of 3 mattress covers that had small 1-inch tears in the coverings and small +-inch diameter holes in the covers. These surfaces could not be cleaned and could become infection control problems.

A tour of the Women ' s Services Department was conducted 8/20/2012 at 1:40 PM in the company of staff #1, the Women ' s Services Director. In Labor and Delivery (L&D) room 1, The arm handle on the side of the bed had smears of a reddish brown substance which appeared to be blood. There was black/brown hair in the radiant warmer. In L&D room 9, a brownish substance which appeared to be blood was found at the end of the bed. Black/brown hair was found in the radiant warmer. In L&D room 11, the placenta bin also had smears of what appeared to be blood. The unit also contains L&D operating rooms. In LDOR 1, there was a reddish brown substance which appeared to be blood on the frame of the OR table and a footprint plate was left in the radiant warmer. Underneath the OR table was also spots of what appeared to be blood. In the LDOR housekeeping room, a rusty disc, broken hose, and a blue latex glove were inside the drain. The isolette in the LDOR had visible dust on the outside coverings. These findings were acknowledged by staff #1 during the tour.

A tour of the Surgical Department was conducted on 8/21/12 at 1:15 PM in the company of the hospital COO, staff #57 and associate COO, staff #58. The surgical bed had a 2-inch tear in the mattress covering which was covered by clear tape. This surface could not be cleaned and could become an infection control problem. Visible dust was noted on high horizontal surfaces in the post anesthesia care unit. These findings were acknowledged by staff #57 and staff #58 during the tour of the department.

According to facility policy 810-404, entitled CLEANING OF THE SURGICAL DEPARTMENT, surgery suites, to include both OR and L&D are to be cleaned on a daily basis. Policy 810-407, entitled ROUTINE DISCHARGE CLEANING OF PATIENT ROOMS, states that all patient rooms will be cleaned when a patient has been discharged or transferred. In the PROCEDURE portion, step 2 outlines the requirements for dusting high surfaces, including the over-bed light.

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Based on a review of documentation and interview the facility failed to correctly identify a restraint as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

Findings were:

Facility policy & procedure titled Patient Restraint Appendix D: Definitions stated, in part, A. Physical restraint: Any Manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body to include immobilization or reduction of the ability of a patient to move his or her arms, legs, or head freely is considered a physical restraint ....Under this definition, many commonly used facility devices and practices could meet this definition of restraint (e.g., tucking in sheets very tightly, use of side rails, to prevent patient from voluntarily getting out of bed, holding a patient to prevent movement ...E. Physical Holds: ...Holding a patient in a manner that restricts the patient's movements against the patient's will is considered restraint.

Review of facility paperwork revealed a written statement by staff member # 6 regarding and describing an incident between him and Patient #1 stated, in part, Patient threw cell phone on ground and came at me. Patient ' s significant other tried to stop her and she got around him and grabbed her boots that were in the chair and threw them at me. They hit me in the face and I saw stars. I then grabbed patient and threw her to the bed so she would not come after me. Patient kicked and scratched, got away, and came after me again. I grabbed patient from behind, around her neck and took her to the ground. Security showed up and grabbed her.

A facility Incident Report completed by staff member # 9 on 2/9/11 stated, in part, On Wednesday, February 9th, 2011 at approximately 1145 I, (staff member # 9) responded to a radio call for security to ER room 7 stat. Upon arrival I observed ER Tech (staff member # 6) holding Patient (#1) in a restraint position with her arms plat to the floor. I took control of the situation, with a continued restraint on the Patient: (referring to patient #1 by name) because she was still being combative.

In an interview on 5/15/12, staff member # 6 described the events of 2/9/11 involving patient # 1 as follows, She picked her boots up and slammed them into my face. She shattered my glasses which cut my nose and my cheek. That staggered me back a little. She turned to grab something, her purse bag on the bed. I pushed him (the boyfriend) out of the way. I grabbed her wrestled her to the ground. She was kneeling on ground holding onto the bed. She reached for her purse 2nd time. I grabbed her hand and grabbed her from behind with a choke hold around her neck back down off the side of the bed to the floor. She wanted to get up and get her purse. The boyfriend pushed me off of her. She jumped up and went for the purse again. I stopped her again and we wrestled. I wrestled her back ground on the floor away from the bed and the purse. At that time security showed up. He grabbed one end and I had the other end of her. When he (Security) grabbed her I let go.

On 5/14/12, the medical chart for Patient # 1 was reviewed and no physician order or any documentation was present for the above described physical restraint.

In an interview with staff member # 4 on 5/16/12 she acknowledged she did not obtain any physician orders for a restraint involving Patient # 1.

This inappropriate use of restraint was confirmed in an interview with Chief Nursing Officer on 5/15/12.

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Based on review of documentation and interviews, the facility failed to utilize restraint in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient according to hospital policy.

Findings were:

Facility policy & procedure titled Patient Restraint stated, in part,

5. Order for Restraint

a. An order for restraint must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of the restraint. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release ...

d. When a LIP/physician is not available to issue a restraint order, an RN with demonstrated competency may initiate restraint use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the application or immediately (within minutes) after the restraint is applied ...

5B. Order for Restraint with Violent or Self Destructive Behavior

a. Physician orders for restraint must be time limited, must specify clinical justification for the restraint/seclusion, the date and time ordered, duration of restraint/seclusion uses, the type of restraint, and behavior-based criteria for release ...

A written statement dated (2/9/11 at 1351) and an interview (on 5/15/12) with staff member # 6 indicate that on 2/9/11 he physically restrained Patient # 1 2- 3 times before staff member # 9 arrived to assist.

A written statement by staff member # 9 on 2/9/11 indicates he observed the restraint and assisted staff member # 6 in physically restraining patient #1 upon his arrival to Room # 7.

On 5/14/12, the medical chart for Patient # 1 was reviewed and no physician order or any documentation was present for the above described physical restraint.

In an interview with staff member # 4 on 5/16/12 she acknowledged she did not obtain any physician orders for a restraint involving Patient # 1.

This use of restraint without an order from a physician or other licensed independent practitioner was confirmed in an interview with Chief Nursing Officer on 5/15/12.

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Based on review of documentation and interviews, the facility failed to ensure the condition of a patient who is restrained is monitored by a physician, other licensed independent practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy.

Findings were:

Facility policy & procedure titled Patient Restraint stated, in part,

7. Monitoring the Patients in Restraints

a. Patients are assessed by an RN immediately after restraints are applied to assure safe application of the restraint ...

9. Face-to-face assessment by a Physician or LIP:

a. A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint/seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ...

Facility policy & procedure titled Patient Restraint Appendix A: Training Requirements stated, in part, A. Direct Care Staff Staff will demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion. Training will be provided to all staff designated as having direct patient care responsibilities (the facility to list), including contract or agency personnel. In addition, if hospital security guards or other non-healthcare staff (the facility to list) assist direct care, or other non-healthcare staff (the facility to list) assist direct care staff, when requested in the application of restraint or seclusion, the security guards, or other non-healthcare staff (as defined by the facility) are also expected to be trained and able to demonstrate competency in the safe application of restraint and seclusion. Training will occur:

1. Before performing restraint application, implementation of seclusion,

monitoring, assessment and providing care of patient in restrain or seclusion,

2. As part of orientation, and ....

On 5/14/12, the medical chart for Patient # 1 was reviewed there was no documentation of the two physical restraints staff member # 6 implemented with the patient. There was also no documented monitoring of the patient while restrained in the medical chart.

A review of personnel records revealed that staff member #6 was up to date on his restraint training. Staff member # 9 who participated in restraining patient # 1 was not current in his training and had not received any restraint training at the time of the incident. Staff member # 1 confirmed staff member # 9's lack of restraint training in the date of the incident, in an interview on 5/14/12

This lack of proper monitoring of the patient and lack of up to date training for staff involved in the restraint was confirmed in an interview on 5/15/12 with the Chief Nursing Officer.

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Based on review of documentation and interviews, the facility failed to ensure the patient's right to safe implementation of restraint or seclusion by trained staff.

Findings were:

Facility policy & procedure titled Patient Restraint Appendix A: Training Requirements stated, in part, A. Direct Care Staff Staff will demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion. Training will be provided to all staff designated as having direct patient care responsibilities (the facility to list), including contract or agency personnel. In addition, if hospital security guards or other non-healthcare staff (the facility to list) assist direct care, or other non-healthcare staff (the facility to list) assist direct care staff, when requested in the application of restraint or seclusion, the security guards, or other non-healthcare staff (as defined by the facility) are also expected to be trained and able to demonstrate competency in the safe application of restraint and seclusion. Training will occur:

1. Before performing restraint application, implementation of seclusion,

monitoring, assessment and providing care of patient in restrain or seclusion,

2. As part of orientation, and ....

Staff member # 6 utilized improper restraint technique on the patient described in a written statement as I grabbed patient from behind, around her neck and took her to the ground and in interview as grabbed her from behind with a choke hold.

Staff member # 9 who was involved in the restraint had not received training in restraint technique at the time of the incident. Staff member # 1 confirmed staff member # 9's lack of restraint training, on the date of the incident, in an interview on 5/14/12

This lack of ensuring the patient's right to safe implementation of restraint or seclusion by trained staff was confirmed in an interview on 5/15/12 with the Chief Nursing Officer.

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Based on record reviews and interviews, Hospital B did not meet the requirements of 489.24(j)(1) to ensure the availability of on-call trauma specialty physicians on it's medical staff to meet the needs of the hospital's patients, in that, the hospital could not provide a neurosurgical evaluation for 1 (Patient # 1) of 3 patients, who had an emergency medical condition during the month of December 2011.

Findings Included:

Review of the medical record for Patient # 1, revealed he had been transferred from Hospital A to Hospital B on 12/27/11, to be evaluated and treated by a neurosurgeon for identified spinal fractures received in a fall down 2 flights of stairs, 2 days prior. An evaluation by Hospital B's Emergency Department (ED) physician (Personnel # 12), at 9:28 PM described specific neck and back pain, and a sensory deficit present (numbness and tingling to the left arm and slightly weaker grip in left hand).

The ED physician documented the following sequence of events related to obtaining a neurosurgery consult the evening of 12/27/11:

9:50 PM: Discussed with Personnel # 9 (backup neurosurgeon on-call), neurosurgery declining to see patient.

10:00 PM: Trauma surgeon (Personnel # 13), is in the ED to evaluate patient.

11:01 PM: Discussed with Personnel # 9 (backup neurosurgeon), still declines to see patient.

11:40 PM: Trauma surgeon is currently trying to coordinate with neurosurgery to have patient evaluated.

01:45 AM: It does not appear that we will be able to obtain a spine/neuro surgery consult. Trauma surgeon has been attempting to coordinate care of Patient #1 for the last few hours and has agreed to coordinate transfer to Hospital C if necessary.

The Trauma surgeon noted: plan was to have neurosurgery consultation on the patient ...upon consultation with the neurosurgeon, the neurosurgeon on-call refused to see the consult ...I referred this to the chief of surgery, who had asked if I would consult the neurosurgeon on-call for spine, Personnel #9 ...I called his partner, Personnel #10....subsequently, Personnel #9 called back and reported that neither he or Personnel #10 would see the patient in the emergency room and they were not going to see him in the future ...

Hospital B's ED Physician Call Schedule for Neurosurgery for the Month of December 2011, included the following on-call physicians:

12/27/11: Primary on-call physician, Personnel #10; Backup physician, Personnel #9.

12/28/11: Primary on-call physician, Personnel #10; Backup physician, Personnel #9.

Professional Services Agreement:

The written contract between Hospital B and the neurosurgeon (Personnel #10) included the following requirements to be fulfilled by the contractor (Personnel #10):

- Contractor will provide Emergency Department call coverage in accordance with Facility's Bylaws, Rules and Regulations and Policies and Procedures and in accordance with the call schedule maintained by the Facility.

- Contractor must provide timely and complete coverage services 24 hours per day, 7 days per week as assigned by ED call schedule as set forth by Medical Staff Bylaws and Rules and Regulations.

- Contractor must respond to Facility Emergency Department in accordance with Trauma Team Activation Guidelines ...

- Contractor must be dedicated to the facility when on call. Contractor will have posted backup coverage in the event dedicated call surgeon is engaged in patient care and unavailable...

- Contractor will accept patient transfers requiring neurosurgical services within physician capabilities from all facilities which have been approved by Facility...

- Contractor will personally evaluate all ED patients requiring neurosurgical consultation...

Hospital B's Medical Staff By-Laws, which also included a section of Medical Staff Rules & Regulations, last revised 09/04/08, required that physicians: when on call to the Emergency department for the respective department/specialty, members of the staff shall accept responsibility for emergency service care of their own patients as well as those patients determined to be unassigned to any physician ...the on-call physician must respond to the Emergency Department within 30 minutes of being paged; and arrive at the hospital within one hour if the clinical situation warrants the presence of the on-call physician as determined by the Emergency Department physician.

The Physician Re-credentialing File of both Personnel #9 and Personnel #10's revealed each of these neurosurgeons signed a statement that they agreed to abide by the Medical Staff Bylaws, Rules & Regulations and Policies & Procedures of (Hospital B), if reappointed to the Medical Staff.

In an interview at 3:45 PM on 02/27/12 with the Director of Medical Staff Services(Personnel #8), she stated that Hospital B had addressed this lack of response from the neurosurgeon (Personnel #9), by following the Medical Staff By-Laws, and it's process as documented in the Medical Executive Committee (MEC) minutes on 01/18/12. Personnel #8 verified that the lack of response from Personnel #10,was being addressed according to his contract with the facility, and the issue had been referred to administration for contractual enforcement.

In a telephone interview at 4:00 PM on 02/28/12 with the Chief of Medical Staff (Personnel #11), he confirmed that Hospital B had proceeded according to the Medical Staff By-Laws, and that he had been personally involved in this process.

Hospital B's Trauma Patient Evaluation, Admission, transfer in the Emergency Department policy, last revised 09/2011, noted: Trauma patients with a High Risk of serious injury who, during or after evaluation by the ED, have been determined to require hospitalization and immediate surgical evaluation will receive a surgical evaluation in the Emergency Department (ED) by the appropriate surgical service prior to admission to the hospital...physicians, Admitting and/or Consulting, shall arrive within 30 minutes of notification as requested by the ED physician ...the ED physician will determine if a patient is considered to be at High Risk for serious injury ...and may use this list as part of their evaluation in determining if a patient is at high risk...and, includes...Falls over 10 feet.

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Based on record review and interviews, the facility (Hospital B), under 489.24(d)(1),

failed to provide the necessary stabilizing medical treatment that was needed for 1 of 1 patient (Patient # 1), and which was within their capacity as a Trauma Center, in that, the 2 neurosurgeons on-call refused to come to the hospital when called.

Findings Included:

Review of the medical record for Patient # 1, revealed he had been transferred from Hospital A to Hospital B on 12/27/11, to be evaluated and treated by a neurosurgeon for identified spinal fractures received in a fall down 2 flights of stairs, 2 days prior. An evaluation by Hospital B's Emergency Department (ED) physician (Personnel # 12), at 9:28 PM described specific neck and back pain, and a sensory deficit present (numbness and tingling to the left arm and slightly weaker grip in left hand).

Hospital B's ED Physician Call Schedule for Neurosurgery for the Month of December 2011, included the following on-call physicians:

12/27/11: Primary on-call physician, Personnel #10; Backup physician, Personnel #9.

12/28/11: Primary on-call physician, Personnel #10; Backup physician, Personnel #9.

The Trauma surgeon noted: plan was to have neurosurgery consultation on the patient ...upon consultation with the neurosurgeon, the neurosurgeon on-call refused to see the consult ...I referred this to the chief of surgery, who had asked if I would consult the neurosurgeon on-call for spine, Personnel #9 ...I called his partner, Personnel #10....subsequently, Personnel #9 called back and reported that neither he or Personnel #10 would see the patient in the emergency room and they were not going to see him in the future ...

The ED physician documented the following in the medical record, regarding the lack of response from the 2 neurosurgeons on-call the early morning of 12/28/11:

01:45 AM: It does not appear that we will be able to obtain a spine/neuro surgery consult. Trauma surgeon has been attempting to coordinate care of Patient #1 for the last few hours and has agreed to coordinate transfer to Hospital C if necessary.

In a telephone interview at 4:00 PM on 02/28/12 with the Chief of Medical Staff (Personnel #11), he confirmed that Hospital B had not been able to provide the medical treatment necessary to stabilize Patient # 1, and which was within the hospital's capacity, as neither of the 2 on-call neurosurgeons had responded when called.

Evaluation, Admission, transfer in the Emergency Department policy, last revised 09/2011, noted: Trauma patients with a High Risk of serious injury who, during or after evaluation by the ED, have been determined to require hospitalization and immediate surgical evaluation will receive a surgical evaluation in the Emergency Department (ED) by the appropriate surgical service prior to admission to the hospital...physicians, Admitting and/or Consulting, shall arrive within 30 minutes of notification as requested by the ED physician ...the ED physician will determine if a patient is considered to be at High Risk for serious injury ...and may use this list as part of their evaluation in determining if a patient is at high risk...and, includes...Falls over 10 feet.

Show Text of Violation

Based on interviews and record review, the facility did not follow their grievance process, in that, they did not meet their policy's specified time frames for this grievance, where: 1) the grievance will be reviewed and an investigation initiated within seven days of receipt of grievance, and 2) a written response of the hospital's decision will be sent as soon as possible (but no later than 30 days) ...if the investigation takes longer than 30 days to resolve, the patient (or complainant) will be kept informed either verbally or in writing, with an anticipated date of completion, for 1 of 1 patients (Patient # 1).

Findings included:

The complainant reported that he/she had initially voiced his/her grievance regarding Patient #1 at the neurosurgeon's (Personnel #12's) office, while being informed of the autopsy report, regarding the death of Patient # 1, four days after a scheduled surgery on 09/21/10. The complainant said he/she spoke to the Vice President (VP) of Risk Management (Personnel #2), who told him/her they would hold a Root Cause Analysis meeting, and about 2 weeks later, he/she received a call from the VP's office, advising him/her that this meeting was being scheduled to find out what went wrong. The complainant said that when he/she asked when he/she would hear back with the results, he/she was told the week of December 6, 2010, but never heard from them again (by the time he/she submitted the complaint to the department on 01/10/11).

Policy & Procedure:

The facility's Patient Grievance & Complaint Resolution Process policy, last revised 06/09 which was in use at the time of this incident, noted the following under Procedure:

B. Upon receipt of a patient grievance, the person receiving the information will document the grievance and forward it to the Director of Guest Services.

C. The Director of Guest Services will work with the Department Director to coordinate a response to the person filing the grievance within 7 days, by letter or verbally with the following information:

? Acknowledgement of the receipt of the grievance.

? Grievance will be reviewed and an investigation initiated within seven days of receipt of grievance.

? A written response of the hospital's decision will be sent as soon as possible (but no later than 30 days) to the patient and will include name of contact person, steps taken to investigate, the results of the grievance process, and the date of completion. If the investigation takes longer than

30 days to resolve due to complexity, the patient will be kept informed either

verbally or in writing, with an anticipated date of completion.

E. Quality of care issues...may be managed through the Medical Staff Peer Review

Committee, Nursing Peer Review Committee, and/or the Performance Improvement/Patient Safety Committee

H. Any grievance...that may require intense analysis for clinical quality of care

Issues...will be referred via the Director of Quality Services to the Event Analysis Team for review.

J. At the conclusion of the investigation, a written response will be provided to the

patient or his/her legal representative to include:

? The results of the grievance process.

? Steps included on behalf of the patient to investigate.

? Name of contact person.

? Date of completion.

K. All grievances/complaints are forwarded to Guest Services for tracking. In

addition, the appropriate Administrative officer will review all patient grievances

for appropriateness of response and ultimate resolution.

Interviews:

In an interview at 10:30 AM on 04/28/11 with the Vice President of Health Care Improvement/Risk Management (Personnel #2), she was asked if she had met with the complainant at neurosurgeon's office on 11/12/10, and she said yes. She stated that the PA (Personnel #13) had called to tell her that the complainant was in their office and very upset over the autopsy report, and had asked if Personnel #13 could come and meet with him/her personally. Personnel #2 said that she had done this, and tried to defuse the situation. She verified that she had said they would do a Root Cause Analysis to look into the situation, and that her office had called the complainant later to let him/her know that this meeting was scheduled. She did not remember if the complainant had been told that he/she would hear results by the week of December 6, 2010, as alleged by the complainant.

In an interview at 3:55 PM on 04/26/11 with the Risk Analyst (Personnel # 4), she was asked if the hospital had documented a formal grievance had been received from the complainant, regarding the death of Patient #1, and she said no. Personnel # 4 was asked when she first became aware of this grievance, and she said that it was through a telephone call she received from the VP of Risk Management (Personnel #2), on 11/12/10 regarding the complainant's concerns, which she had documented in her personal notes. When asked for documentation of her first interaction with the complainant, she provided a letter she had sent to him/her, dated 11/29/10 which said: ...thank you for your patience as our team has conducted an analysis of the concerns related to [Patient #1's] recent hospitalization . Specifically, we have focused on the care, treatment and services provided to [Patient #1]. As part of our review, your grievance will be routed through the appropriate Medical Staff process...unfortunately, all proceedings are privileged and confidential, and therefore, I will not be able to disclose the outcome with you..., and gave the name and contact telephone number of the Risk Analyst. Personnel #4 verified this response letter was sent 17 days after the initial notification of this grievance on 11/12/10, and was not within the 7 day time frame required by their grievance policy.

When Personnel # 4 was asked for documentation of any further interactions with the complainant, she said she sent a second letter on March 11, 2011, when the hospital's investigation was completed, which read:

...thank you for your patience as our team concluded the review process related to [Patient #1's] recent hospitalization . We recently received the results of the external Medical Peer Review. Although all proceedings are privileged and confidential, I can assure you a fair and unbiased review was conducted.

Personnel # 4 confirmed there was no documented interaction with the complainant between the dates of these 2 letters, dated 11/29/10 and 03/11/11. She also confirmed that the facility had no record of providing the complainant a response by December 6, 2010 specifically regarding the outcome of the Root Cause Analysis, allegedly promised to the complainant.

When asked why there was so much time between the 1st and 2nd letters to the complainant, the Risk Analyst said the facility had been waiting for the Medical Staff external Peer Review results. She verified the facility had not kept the complainant informed of the complex investigation process during this 3 and 1/2 month period, either verbally or in writing, with an anticipated date of completion, as required by their grievance policy.

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Medical City Plano

44 CMS Violations since 2011-04-28

Non Immediate Jeopardy Violations

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_78100cfcd9ff3ccea18f60bb74dfb8e2','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_568222da05ac3c7dab9ef256282fef2e','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: POST-OPERATIVE CARE(A-0957) toolTips('.tooltip_post_id_custom_0e8eded1cfbff0007b246e4f29c9a132','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>\-º482\.51\(b\)\(4\) \- There must be adequate provisions for immediate post\-operative care\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_47f80ead33758d3715b51d34eb00e814','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144) toolTips('.tooltip_post_id_custom_75490e72dbec3b7613f240c1fbf29a4b','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>The patient has the right to receive care in a safe setting\.');

Violation Name: PATIENT RIGHTS(A-0115) toolTips('.tooltip_post_id_custom_23b3aee6a0c30b18c980a9c6b10fb665','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A hospital must protect and promote each patients rights\.');

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144) toolTips('.tooltip_post_id_custom_d11f0a8280c47a8ea2c6b0ac1bb26990','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>The patient has the right to receive care in a safe setting\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: POST-OPERATIVE CARE(A-0957)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

Violation Name: PATIENT RIGHTS(A-0115)

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)