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TEXAS HEALTH HARRIS METHODIST HOSPITAL SOUTHLAKE
MEDICAL STAFF - BYLAWS AND RULES
Tag No.: A0048
Based on interview and record review, the Governing Body failed to ensure that 1 of 3 healthcare practitioners (Personnel #17) had completed a request for clinical privileges prior to signature of the Governing Board on 11/15/13 in accordance to the Medical Staff Bylaws. Personnel #17 provided care to Patient #1 on January 15, 16, and 17, 2015 which he did not have approved clinical privileges for.
Findings included:
Patient #1 underwent an elective "anterior cervical discectomy and fusion" on 01/15/15 and was admitted as an inpatient for 2 days. Personnel #17 visited and provided care to Patient #1 on January 15, 16, and 17, 2015 which he did not have approved clinical privileges to do.
Review of Personnel #17's credentialed file indicated he did not complete a request of clinical privileges. He was approved by the Governing Body on 11/15/13 without delineation of clinical privileges.
In an interview on 06/15/16 at 10:35 AM, Personnel #3 was informed of the above findings and confirmed Personnel #17 did not complete a request for clinical privileges.
The facility's Bylaws of the Medical Staff approved on 2/18/15 indicated "2.2 ...Granting Privileges ...Each application for appointment and reappointment to the Medical Staff must contain a request for specific clinical privileges desired by the practitioner."
PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION
Tag No.: A0123
Based on interview and record review, the hospital failed to provide a letter of response to 1 of 3 patients (Patient #1) who filed a complaint in 2015, thereby not adhering to their policy.
Findings included:
Patient #1 underwent an elective "anterior cervical discectomy and fusion" on 01/15/15. On 5/29/15 Patient #1 filed a complaint. The hospital did not provide a response letter to Patient #1's complaint.
In an interview on 06/15/16 at 11:00 AM, Personnel #1 was informed of the above findings and confirmed that a written response was not sent to Patient #1.
Patient Grievance and complaint policy dated 2/18/15 page 2 required "C...5. The patient...shall receive written communication from the organization within 7 days of the receipt of grievance..."
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on interview and record review, the facility's registered nurse (RN) did not supervise and evaluate the nursing care for Patient #1, in that the RN did not promptly reassess the patient after administering pain medications twice on 01/16/15, citing 1 of 1 RN (Personnel #6).
Findings included:
Patient #1 underwent an elective "anterior cervical discectomy and fusion" on 01/15/15.
Medication Administration Record (MAR) dated 01/16/15 at 1:29 AM indicated Patient #1 received Tramadol 100 mg for pain. The nurse's notes indicated Patient #1 was reassessed for pain medication effectiveness at 3:46 AM, 2 hours and 17 minutes later.
The MAR dated 01/16/2015 at 3:53 AM indicated Patient #1 received Morphine 2 mg for pain. The nurse's notes indicated Patient #1 was reassessed for pain medication effectiveness at 5:52 AM, 1 hour and 59 minutes later.
In an interview on 6/15/16 at 9:05 AM, Personnel #6 was informed of the above findings and confirmed the findings. Personnel #6 stated that according to their protocol by "Lippincott" Patient #1 should have been reassessed an hour after administering the pain medication.
"Lippincott Procedures-Pain Management" revised 10/02/15 page 3 required " ...reassess the patient's pain level and quality approximately 15 to 30 minutes after parenteral pain medication or approximately 60 minutes after oral pain medication."