Based on observation, interview and record review, the facility failed to provide care in a safe environment when the facility did not ensure maintenance repairs were initiated and completed, this failure places patients at risk of injuries. Finds include: Observations on the morning of 1/31/22, during a tour of the facility's emergency room , revealed a metal door jamb railing had come loose, the staff had placed gauze bandages and tape to protect patients and staff from being cut by the railing. Review of the facility provided incident reported, dated 10/13/21, reflected ROOMS 10-16 DOOR ENTRANCE PAINT CHIPS AND METAL TRIM LOOSE. Assigned to HCA Engineering Central. During an interview, on the afternoon of 1/31/22 in the administrative conference room, Staff #2, ER Director confirmed the findings in the ER and stated, If we have something that needs to be urgently repaired, we will call facilities ...We keep a book of maintenance requests. Part of the problem is there are two different requests on the report, paint chips and loose trim. They probably repaired the painting and someone else would repair the trim, it was missed. Observations on the morning of 1/31/22, during a tour of the facility's 4th floor inpatient unit, Room 431 had a large piece of hard plastic on the door which was cracked and exposing sharp edges. The nursing station, Pod C, had missing laminate, and there was fabric string stuck on the edge, indicating there was a sharp edge. During an interview on the afternoon of 1/31/22, when asked to see the 4th floor work orders, Staff #1, Quality, stated, We don't have work orders.
Based on record review and interview it was determined the facility failed to ensure care in a safe setting. Finding included: A History and Physical completed by a birthing center in Austin was sent with Patient #1 during an emergency transfer to St. David's North Austin Medical Center. This History and Physical documented the patient's allergies as chlorahexidine: Hives (moderate to server) and chloropracaine. A review of Patient #1's medical record revealed a transcription error in the Intraoperative Record and Labor and Obstetric Anesthesia record at St. David's North Austin Medical Center. Patient #1's allergy was recorded as Duraprep instead of chloraprep (chlorahexidine) in error. The Intraoperative Record indicates chloraprep, the patients known allergy was used as the surgical skin prep prior to initiation of the patient's cesarean section surgery. Due to this transcription error, Patient #1 had an allergic reaction. The above finding were confirmed in an interview with the Assistant Chief Nursing Officer, Staff #3.
Based on interview, and document review, the hospital failed to ensure a safe setting for patients in that a patient with a Peace Officer Emergency Commitment (POEC) was permitted to elope out of the hospital Adult Emergency Department. Findings included: Review of patient #1's Adult Emergency Department medical record revealed documentation by registered nurses, Licensed Master Social Workers (LMSWs), and security officers that provided care to patient #1 during his stay in the ED revealed no documentation that patient #1 had been placed in a purple gown as per hospital policy for elopement precautions. Review of the triage RN staff #11 notes stated 06/23/17 at 1734 Risk for elopement? Y Review of ED RN, Staff #7 nurse notes stated 6/24/17 at 1345 - Unable to find the patient. Security has no answer why patient eloped Security #5 at bedside. Let the pt. go he thought pt. was discharged . Amended by RN staff #7 on 06/24/17 at 1408 Charge nurse and security supervisor is aware and they are unable to find the patient. Social worker called police and bystander out in the parking lot who saw the pt. called 911. Review of the Adult ED Licensed Master Social Worker (LMSW), Staff #14 documentation dated 6/24/17 at 0017 stated that at 23:45 an APD Peace Officer, Staff #13, placed patient on POEC in order to keep patient hospitalized for decompensation for his own safety. POEC # 1354. Review of a hospital document titled Suicide /Violent Patient Initial Safe Environment Checklist For Patients Identified as Imminent or High Risk for Suicide and/or Violence stated in part 1. Place patient in purple gown .... #14. Assign staff to monitor patient per the physician order. Utilize the Patient Monitoring Form as indicated. The ED RN, staff #7 signed and dated the form on 6/24/17 at 0800. Review of a facility document titled Psychiatric Checklist stated in part: Initial Tasks: ___Inform Social Worker of patient's arrival, ___Equipment removed from room -cables, monitors, and call lights, remove cart if in room 1-4, ___Red/Purple gown, red/purple socks The Patient Monitoring form dated 6/23/17 stated in part Line of Sight Level 2 revealed initialed 15 minute monitoring of patient that started at 1728 through 2345. The Patient Monitoring form dated 6/24/17 stated in part Line of Sight Level 2 revealed initialed 15 minute monitoring of patient that started at 0000 through 1245. The 1245 time slot was initialed by Security Officer, staff #5 with a Behavioral Assessment Code as discharged . Review of the hospital incident report of Patient #1's elopement on 6/24/17 revealed it was created on 6/24/17 at 7:50 pm by the Security Supervisor, staff #12 and contained details of the event's leading up to the patient's elopement. There was also a written report of the elopement incident created by ED RN, staff #7 on 6/24/17. An interview was conducted the morning of 7/18/17 in a conference room with the, Chief Nursing Officer, Staff #2. Staff #2 was asked by the surveyor if she was on duty the day of Patient #1's elopement. Staff #2 stated that she was not on duty on the day of the incident and that she was notified on Saturday 6/24/17 by a text message and email from the ED Director, Staff #3. Staff #2 stated The triage nurse saw the patient sitting with the security guard. The security guard went to the bathroom and when he returned the patient was gone. He called the patient's mother. Immediately they started looking over the whole campus for the kid. Staff #2 stated the administrative staff created an immediate Serious Event Analysis (SEA) regarding the patient's elopement. Staff #2 stated the security guard involved was placed on immediate disciplinary action that included suspension and a repeat competency training. There is a plan to roll out training to all of the security guards and ED staff. There will be repeat training of the ED nursing staff to a revised Code Exit policy that includes the procedure on when a patient leaves.
Based on interview, and document review, the hospital failed to ensure the nursing care for a patient that had an Emergency Detention order was assessed and evaluated on an ongoing basis while in the Adult Emergency Department. Findings included: Review of Patient #1's Adult Emergency Department medical record revealed documentation by the Adult ED registered nurses provided care to Patient #1 during his stay in the ED revealed no documentation that Patient #1 had been placed in a purple gown as per hospital policy for elopement precautions. Review of the triage RN Staff #11 notes stated 06/23/17 at 1734 Risk for elopement? Y An interview was conducted with ED RN, Staff #7, at approximately 11:00 am on 7/18/17 in a hospital conference room. When Staff #7 was asked what her ED schedule was on 7/24/17 she stated she worked 7:00am - 7:00 pm. Staff #7 stated that when she first comes on duty if her psychiatric patients are asleep she lets them sleep. She stated that she was told in report that Patient #1 was on a Protective Order of Emergency Custody (POEC) and that she had gotten a purple gown for him to change into but he was asleep when she first checked him so she let him sleep until around 9:00 am and then she did a head to toe assessment. She stated she did vitals around 9:15 am and ordered breakfast and that Patient #1 ate breakfast around 10:30 am. Staff #7 stated that Patient #1 was walking a lot with the security officer, Staff #5 in the ED hallway within the locked doors. Staff #7 stated she was giving report when the charge nurse, Staff #8 told her Patient #1 had eloped around 1:15 pm - 1:20 pm. An interview was conducted with Security Officer, Staff #5 at approximately 2:55 pm in a facility conference room. When the surveyor asked Staff #5 to explain what happened regarding the elopement incident of Patient #1 on 6/24/17, Staff #5 stated he received Patient #1 wearing a regular gown not a purple gown and that there was no nurse available for approximately 35 minutes. Staff #5 stated the security officer told him in the verbal report that Patient #1 was on a bed watch and could not leave. Staff #5 stated that a purple hospital gown means the patient is on a bed watch and can't leave. A phone interview was conducted with the Licensed Master Social Worker (LMSW), Staff #9 on 7/19/17 at approximately 8:50 am in a facility conference room. Staff #9 stated that Patient #1 was placed on an Emergency Detention the night before and that the night staff put the Emergency Detention on the chart and notified the nurse desk clerk so it could be changed on the census. She stated when they checked the chart on 6/24/17 the Emergency Detention was on the chart. Staff #9 stated that typically when the ED has a patient on elopement precautions, the mental health clients are placed in a purple gown. She stated that Patient #1 was in a regular gown when she came to work the morning of 6/24/17. Review of facility policy titled Elopement Prevention stated in part PROCEDURE: 1. Patients will be assessed for elopement risk in the ED and when admitted . All admitted patients will also be assessed with each nursing shift assessment. 2. Immediate notifications regarding patients who are identified as being an elopement risk will be made by the charge nurse to the director/manager over the area the patient is admitted (during business hours), the house supervisor, and security. 3. Elopement risk patients will be placed in a purple patient gown. This elopement risk identifier will remain on the patient throughout their stay or until the patient is no longer deemed an elopement risk. 4. Elopement precautions will be initiated immediately to elopement risk patients.
Based on interview and record review the facility failed to maintain a central log on each individual who comes to the emergency department, when a patient presenting to the facility's Pediatric emergency department seeking treatment was not recorded, preventing the tracking of the hospital care provided. (Patient #1) Findings include: During a telephone interview on 7/13/17 at 10:00 a.m., the EMS Supervisor stated, ...the ambulance arrived at North Austin Medical Center at 1:45 a.m. and cleared at 2:21 a.m .... Review of the facility provided EMTALA Log reflected Patient #1 was logged into the Adult ER on 5/14/17 at 2:08 a.m. The initial arrival time to the Pediatric ER was not documented. During an interview on the morning of 7/11/17 in the administrative conference room, when asked why there was no record of Patient #1 on the Pediatric ER log, Staff #15, Director of Adult ER stated, ...she wasn't logged into the Pediatric ER; she was logged in when she arrived at Adult ER... Review of the Facility provided EMTALA-Definitions and General Requirements Policy (Dated 10/15/2016) Central Log is a log that a hospital is required to maintain on each individual who comes to the emergency department seeking assistance that documents whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged . The purpose of the Central Log is to track the care provided to each individual where EMTALA is triggered. The Central Log includes, directly or by reference, logs from other areas of the hospital that may be considered DEDs (Dedicated Emergency Department), such as labor and delivery where an individual might present for emergency services or receive an MSE (Medical Screening Exam) instead of the traditional emergency department; as well as individuals who seek care for an EMC (Emergency Medical Condition) in other areas located on the hospital property other than a DED....
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to determine whether or not an emergency medical condition existed when an examining physician(s) or other qualified medical personnel of the hospital did not provide a medical screening examination (MSE) to a patient arriving by ambulance to the facility's Pediatric emergency room , the ambulance was sent to the Adult ER across the campus. (Patient #1) Findings include: Review of Patient #1's Adult Emergency Physician's note reflected, ...Initial Greet Date/Time 05/14/17 0216 (2:16 a.m.) Presentation Chief Complaint Breathing problem...18 y/o female h/o of ADENYLOSUCCINATE LYASE DEFICIENCY, central hypoventilatio[DIAGNOSES REDACTED], epilepsy, [DIAGNOSES REDACTED], presents with hypoxia. Mother states she [sic] normally on CPAP at night and presents with episodes of hypoxia. Pt required increased duration of ventilation via Bag valve mask per mother this evening. Pt had 3 episodes of desaturation to 60% on pulse ox requiring bagging via BVM. Mother denies any fevers, + rhinnorhea, no productive cough. No vomiting, diarrhea, no wheezing, no hemoptysis....Reports: Seizure disorder, Stroke/TIA. Additional Medical History hypothyroid, epilepsy - requiring extensive medication, [DIAGNOSES REDACTED], SIADH, sleep apnea with hypoventilation, ADENYLOSUCCINATE LYASE DEFICIENCY, FUNGAL VENTRICULITIS, CYCLICAL VOMITING SYNDROME Additional Surgical History Neurosurgical ablation procedure to left sided scar on 1/22/16 by team at Texas Children's. VNS. G-TUBE. Review of the Patient #1's EMS Patient Care Report dated 5/14/17 reflected, ...Called for a female with difficulty breathing and decreased oxygen saturation. AOS TF a female pt lying in bed. 1. Is alert to her normal state per family. They informed crew that for the last several hours pt. has had to have ventilation assist by BVM multiple times to maintain oxygen saturation. Pt saturation would drop to the 60s without ventilation support. Family did tell crew that pt. relies on Non- Invasive Ventilation while she sleeps but can be on room air when awake. As pt became more awake and awake. Saturation improved and pt. was able to maintain saturation of 96-100% on NRM. Crew observed pt. for several minutes to insure that pt. was going to maintain Saturation prior to moving to Unit. Pt. secured to Stretcher and moved to ambulance. While loading pt. into ambulance, she had a brief full body seizure that was stopped by VNS. Pt. did not have a postictal period after and returned to normal baseline rapidly. Pt. placed on 4 lead ekg which showed Sinus Tach. ETC02 WNL, Crew did note that pt CO was slightly elevated at 11-12. CO reading did come down WNL continued oxygen therapy. During transport pt experienced 5 more seizures that were quickly stopped by VNS. Further assessment unremarkable. Transported without incident. Upon arrival at NAMC care to RN with report Bed 6... During a telephone interview on 7/13/17 at 10:00 a.m. Staff#16, EMS Supervisor stated, ...the ambulance arrived at North Austin Medical Center on 5/14/17 at 1:45 a.m. and cleared at 2:21 a.m.... During a telephone interview on 7/13/17 at 12:00 p.m. Staff #17, Emergency Services Crew member that transported Patient #1 to NAMC, stated, ...We encoded directly to the Pediatric emergency room ... the staff met us at the door and instructed us to go to the Adult ER, we didn't take her off the ambulance ...we stayed at the Pediatric ER bay for a while, the mother was trying to contact her physician; she was trying to get her daughter admitted into the Pediatric ER, she didn't want her in the Adult ER ...the mother was deciding if she should go somewhere else...the patient seized nine times during the transport and had an acute condition...It made sense for her to go to the Pedi ER. When asked why the EMS report did not include being sent to the Adult ER after presenting to the Pediatric ER, Staff #17 stated, ...we didn't think anything was wrong with it, they didn't refuse care...We were focused on providing care to the patient... During an interview on the afternoon of 7/11/17, in the administrative conference room, Staff #2, Chief Medical Officer confirmed the Pediatric Physician did not conduct a medical screen in the ambulance while it was in the Pediatric ER bay. During an interview on the morning of 7/11/17 in the administrative conference room Staff #1, Chief Nursing Officer stated, ...The patient had turned [AGE] years old two weeks before....The staff tried to call the ambulance to direct them to the Adult ER, they couldn't contact them...We didn't think to report it...We were not turning them away.... Review of the facility provided policy EMTALA - Texas Medical Screening Examination and Stabilization (Revision date 07/05/2017) reflected, ... An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and: 1. the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or 2. a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition. Internal Distribution Such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition (EMC). Further, if a prudent layperson observer would believe that the individual is experiencing an EMC, then an appropriate MSE, within the capabilities of the hospital's DED.... ii. The individual arrives as a transfer from another hospital or health care facility. Upon arrival of a transfer, a physician or qualified medical person (QMP) must perform an appropriate MSE. The physician or QMP shall provide any additional screening and treatment required to stabilize the EMC. The MSE of the individual must be documented. This type of screening cannot be performed by the triage nurse. If an EMC is determined to exist and the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under EMTALA ceases.... iii. Transporting to other hospital property: The facility may direct individuals to other hospital-based facilities that are on hospital property and operated under the hospital's provider number. However, the hospital should not move an individual to a hospital-based facility located off-campus, such as a rural health clinic or physician office, for an MSE or other emergency services. Individuals should only be moved to the hospital-based on-campus facility when the following conditions are met: o all persons with the same medical condition are moved to this location regardless of their ability to pay for treatment, o there is a bona fide medical reason to move the individual, and o QMP accompany the individual ... iii. Transporting to other hospital property: The facility may direct individuals to other hospital-based facilities that are on hospital property and operated under the hospital's provider number .... Individuals should only be moved to the hospital-based on-campus facility when the following conditions are met: o all persons with the same medical condition are moved to this location regardless of their ability to pay for treatment, o there is a bona fide medical reason to move the individual, and o QMP accompany the individual... 5. No Delay in Medical Screening or Examination ... c. EMS. A hospital has an obligation to see the individual once the individual presents to the DED whether by EMS or otherwise. A hospital that delays the MSE or stabilizing treatment of any individual who arrives via transfer from another facility, by not allowing EMS to leave the individual, could be in violation EMTALA and the Hospital CoP for Emergency Services. Even if the hospital cannot immediately complete an appropriate MSE, the hospital must assess the individual's condition upon arrival of the EMS service to ensure that the individual is appropriately prioritized based on his or her presenting signs and symptoms to be seen for completion of the MSE....
Based on a review of documentation, the governing body failed to be responsible for services furnished in the hospital. Findings were: A review of facility policy and procedure titled Interpreters and Adaptive Aids states, in part, 'Hearing Impaired: 1) Sign-Language Interpreter-Staff will contact Communication by Hand at (512) 467-1917 when an interpreter is needed. Review of the clinical record of patient #1 revealed that the patient was deaf but no interpreter was contacted. The following documentation indicated that interpretive services were needed: ? The Emergency Medical Services Patient Care Report states, pot is also deaf and a significant amount of anxiety is related to her inability to communicate with personnel onscene. ? The Physician's emergency room Report states, Evaluation limited bypt is deaf..History limited by a language barrier. ? The Nursing Progress Notes state, The initial plan of care for this patient includes an assessment with eforts to address the patient's anxiety; The above was confirmed in an interview with the Chief Nursing Officer and the Director of Quality on the afternoon of 5-24-12 in the Administrative conference room.
Based on a review of the clinical record, the hospital failed to inform the patient of her patient rights. Findings were: During a review of the clinical record for patient #1, it was revealed that the patient was deaf. Further review of the clinical record revealed no effort on the part of the facility to obtain an American Sign Language Interpreter so that the patient could be informed of her rights in her primary language. The above was confirmed in an interview with the Chief Nursing Officer and the Director of Quality on the afternoon of 5-24-12 in the administrative conference room.
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