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Based on record review and interview, the hospital's governing body failed to ensure the operation of the grievance process, in that, 1 of 3 grievances (Patient #11) was not reviewed by the governing body and a timely letter sent to the complainant.

Findings Included


The 2/24/14 documented grievance for Patient #11 did not have a complainant letter until 4/02/14.

The 11/18/13 through 11/20/14 "Somervell Hospital District Board" (Governing Body) meeting minutes were reviewed. There is no evidence in the minutes the complaints or grievances are investigated or reported.

During a telephone interview on 12/16/14 ending at 4:24 PM, Personnel #6 was asked about the incidents not being reported through the Governing Body. Personnel #6 acknowledged they were not being reported through Governing Body and stated, "We knew that it was a need and I hadn't gotten to it fast enough." Personnel #6 was asked if the letter was sent timely. Personnel #6 stated, "No."

The January 2014 "Complaint/Grievance Resolution - Patient/Family" policy required, "Grievance...receive immediate priority and must be investigated...timely resolution with the intent that on average all grievances will be resolved during a 7 business day timeframe...a letter will be sent to the patient...Quality Managements' analysis...reported to the Medical Executive...Governing Board...twice a year..."

Based on record review and interview, the Hospital's Quality Assessment and Performance Improvement program failed to measure, analyze and track adverse patients' events, in that, the 1/08/14 through 11/12/14 Quality Meeting Minutes did not document the reporting of incidents to the Quality Committee.


Findings Included


There was no incident report for the 11/28/13, 10/10/14 and 10/13/14 unsuccessful code blues.


The 1/08/14 through 11/12/14 Department Director and Quality Management" minutes were reviewed. The 1/27/14 through 11/04/14 "Board Quality Committee" Minutes were reviewed. There was no evidence in the minutes that incidents are tracked, trended or analyzed for improvement opportunities except for falls.


During a telephone interview on 12/16/14 ending at 4:24 PM, Personnel #6 was asked about the incidents not being reported through Quality. Personnel #6 acknowledged they were not being reported through Quality and stated, "We knew that it was a need and I hadn't gotten to it fast enough."

The March 2006 "Incident / Event Reporting Policy" required, "...Incident Report Form be completed...turned into the department supervisor...Quality/Risk Manager who then reviews the incident and refers the incident to the appropriate department, committee, or to the medical staff within 48 hours for further action and resolution..."

The March 2013 "Incident Reporting Protocol" required, "...all incidents...patient, personnel, or visitor...Unsuccessful Code Blue...All sections of the incident report must be completed...Risk Management to supply the...Committee with a quarterly summary of patient incidents..."

Based on record review and interview, the facility failed to have a registered nurse supervise and evaluate the nursing care, in that,

A) 1 of 3 coded patients (Patient #1) did not have an initial admit assessment;

B) 2 of 3 coded patients (Patient #2 and #3) had at least one missing shift assessment by their nurse;

C) 3 of 3 coded patients (Patient # 1, #2, and #3) had abnormal vital signs (Blood Pressure - B/P, Heart Rate - HR, Respiratory Rate - RR, Oxygen Saturation - SaO2) without documented physician notification of the patient's issue;

D) 1 of 3 coded patients (Patient #3) was administered Dopamine and had no blood pressure and heart rate documented by the staff for over 12 hours; and

E) 1 of 3 coded patients (Patient #3) had no nursing documentation and/or code blue record of what occurred during the code, and no documentation from the physician who directed the code.


Findings Included

The Electronic Medical Records were navigated by Personnel #17 in her office on 12/12/14 from 9:00 AM through 1:00 PM. Personnel #17 was able to show the surveyor all records requested except the following items that she confirmed were not completed or missing:

A) Patient #1's record was missing an initial admit assessment on 11/27/13.

B) Patient #2's record was missing the 10/10/14 AM Shift assessment.
Patient #3's record was missing the 10/10/14 AM Shift assessment.

C) Patient #1's record reflected, "11/28/13 12:00 AM HR 122 RR 35 SaO2 90%, 3:29 AM HR 130 RR 36 SaO2 90%, 4:00 AM HR 134 RR 35 SaO2 86%, 4:32 AM HR 130, SaO2 87%." Patient #1's record did not document any physician notification of the patient's abnormal vital signs. (Blood Pressure - B/P, Heart Rate - HR, Respiratory Rate - RR, and Oxygen Saturation - SaO2.)

Patient #2's record reflected, "10/11/14 12:00 AM B/P 98/53 SaO2 90%, 9:13 AM B/P 80/46 HR 96, 10/12/14 4:00 AM B/P 97/55 HR 95." Patient #2's record did not document any physician notification of the patient's abnormal vital signs.

Patient #3's record reflected, "10/09/14 4:44 AM B/P 81/57, 5:15 AM B/P 80/55 HR 110." Patient #3's record did not document any physician notification of the patient's abnormal vital signs.

D) Patient #3's record documented she was administered Dopamine. There was no blood pressure and heart rate documented on 10/09/14 by the staff from 8:00 AM through 8:37 PM. The vitals signs were recorded for 10/09/14 8:00 AM and 8:37 PM.

E) Patient #3's record reflected a code blue on 10/10/14 and she passed. There is no nursing documentation and/or code blue record of what occurred during the code, and no documentation from the physician who directed the code.

The hospital did not have policies for the Administration of Intravenous Dopamine, Vital Signs - abnormal versus reportable, and Physician Notifications.

The February 2014 "Scope of Practice and Delivery of Care Methodology for Medical Surgical Nursing Unit" required, "All admissions to the Medical Surgical Unit are reviewed for appropriateness...patient experience a worsening of his/her condition (ie, a medical or surgical emergency, life threatening event), the patient will be transferred to a more intensive level of care, designed to provide the level of service necessary to address the patient's condition..."

The "Admission Assessment, Shift Assessment & Reassessment" policy required, "Admission Assessment Time Frames...Assessment...initial 30 minutes...completion 12 hours...shift assessment 12 hours...Any change in the patient's conditions hall (sp - shall) require an immediate reassessment with changes in the plan of care reflecting the change in conditions...Registered nurse: collects and analyzes data about the patient, determines the need for additional data, the patient's healthcare and or treatment needs and the care of the patient."