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The facility failed to ensure that the medical staff operated under the current bylaws, rules and regulations. The facility failed to ensure that patients were seen by an approved, teaching attending physician within 24 hours of being seen by a teaching resident and failed to ensure that documentation by the teaching resident had co-signatures/attestations within 24 hours (Patient ID #1).

Findings Included:

Record Review of electronic health record for Patient ID #1 performed with Nurse Informaticist Staff ID #62 on 9/4/24 at 1:30 pm. She confirmed that Patient ID #1 had a plastic surgery consult ordered and had been seen by Plastic Surgery Resident physician staff ID # 67 on 1/28/24 at 8:15 pm. Patient ID #1 had been seen by plastic surgery resident staff ID # 68 on 1/29/24 at 07:58 am. She confirmed the medical record reflected an attestation/co-signature for both notes which was signed on 2/13/24 at 10:15 am by Attending Physician Staff ID #66.

Record Review of facility "General Rules of the Medical Staff", last approved 9/23/2019, stated "Supervision of Residents. D. A note and signature by the attending physician, with whom the resident is working or who is supervising the resident, is required every 24 hours and/or a daily basis ..."

Record Review of facility policy "Graduate Medical Education (GME) Resident
Supervision Policy and Guidelines", last revised 10/9/2020 stated "Supervision in the setting of graduate medical education provides safe and effective care to patients; ensures each resident's development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishes a foundation for continued professional growth. ... Documentation of supervision is required by the ACGME and the Hospital Medical Staff By-Laws. The Medical Staff By-Laws require that documentation of the supervision of the resident must occur on a daily basis in the patient's medical record."

Telephone Interview 9/6/2024 at 10:55 am with Graduate Medical Education Coordinator Staff ID #74. She confirmed that plastic surgery resident physician staff ID #67 was a qualified and approved plastic surgery resident from 7/1/2021 through 06/30/2024. She confirmed that the "Graduate Medical Education (GME) Resident Supervision Policy and Guidelines", last revised 10/9/2020, were the guidelines which are set forth by the facility for supervision of medical residents.

Telephone Interview 9/6/2024 at 10:30 am with Director of Medical Staff Administration Staff ID #75 was conducted. She reviewed medical staff rules and regulations and document titled "General Rules of the Medical Staff." She confirmed that medical staff rules required that patients who were seen by teaching residents and fellows, would need to have consult or progress notes signed every 24 hours or on a daily basis. She confirmed that a note performed by a resident physician on 1/28/2024 and 1/29/2024 and signed by an attending physician on 2/13/2024 would not meet this requirement.

Based on interview and record review, the facility failed to fully uphold the patients' right to informed decision-making regarding their care and treatment. Three (3) of 3 sampled patient records failed to contain current anesthesia consents as required by 25 TAC §604.5(1). (Patient IDs # 1, 14, and 15).


Findings included:

Review of the Texas Medical Disclosure Panel showed the following:
Effective Dec. 26, 2023, the TMDP repealed and replaced certain portions of the Texas Administrative Code (TAC), as listed below ...
adopted new 25 TAC Chapter 604, concerning Disclosure Forms


Medical record review for patient (ID#1) for procedure date of service 1/30/2024, 2/2/2024 and 2/5/2025 showed anesthesia consent not as required in 25 TAC §604.5(1).

Medical record for patient (ID#14) for procedure date of service 9/4/2024 showed anesthesia consent not as required in 25 TAC §604.5(1).

Medical record for patient (ID#15) for procedure date of service 9/4/2024
showed anesthesia consent not as required in 25 TAC §604.5(1).

The above findings were verified by Quality staff ID# 51 on 9/4/2024 at 2:25 PM. She stated that corporate has the ability to change forms that are utilized at the facility, it cannot be done at the local level.

Based on interviews and record review, the facility failed to ensure patient's discharge plans were re-evaluated and updated to reflect occurrences/care provided at the facility. Therefore, the patient failed to receive:
1) comprehensive specialty follow-up instructions
2) wound care/post-operative dressing instructions and
3) failed to include home health services provider and contact information for IV antibiotic infusion therapy (Patient ID #1).

Findings included:

Record review of electronic health record for Patient ID #1 performed with Nurse Informaticist Staff ID #62 on 9/4/24 at 1:30 pm. The medical record for Patient ID #1 "Discharge Summary", dated 2/9/2024, and provided by RN Staff ID #70 on Date of Service 2/9/2024 stated "Follow up with Physician ID # 69 (primary care)." Nurse Informaticist Staff ID #62 confirmed she was unable to locate the plastic surgeon's name (Physician ID # 65) who had operated on the patient, his clinic information, contact information or when to make a follow-up appointment in the instructions. She confirmed there were no wound care instructions in the discharge instructions. She was unable to locate the name of the post-acute home health agency and contact information for the home health provider for which home antibiotic infusion therapy had been arranged in the discharge summary/instructions, which had been provided to the patient at discharge.

Record review of facility policy "Discharge of Patients Policy and Procedure", approved 10/23/23, stated "Procedure: ... d. Provide patient and family/caregiver(s) with the discharge instruction sheet on prescribed treatments, medications, diet, activity level, and scheduled follow-up appointments, if any."

Record review of facility policy "Discharge/Transition of Care Planning Department", Policy #CM02, last revised 08/31/2021, stated "General Guidelines 1. Discharge planning is completed and documented in a timely manner to ensure the continuity of patient care by developing an adequate post-hospital care plan which considers the medical, social, emotional and financial needs of the patient and family .... 3. A written, comprehensive individualized discharge plan consistent with medical discharge orders and identified patient needs will be provided to each patient and/or family/representative at the time of discharge ... 8. Members of the healthcare team will provide and document in-hospital education/training to the patient or patient's representative relative to the discharge plan, self-care, arrangements post-discharge."

Interview 9/4/2024 at 12:15 pm with Nursing Director Staff ID #58. She stated it was the provider and nurse's responsibility to ensure comprehensive discharge instructions were completed in the electronic medical record and provided to the patient in writing prior to discharge home.

Based on interview and record review, the facility failed to assess its discharge planning process, by failing to re-assess and analyze a patient who was re-admitted within 30 days of a previous admission, to ensure that the plans were responsive to the patient post-discharge needs (Patient ID #1).

Findings Included:
Record Review of electronic health record for Patient ID #1 performed with Nurse Informaticist Staff ID #62 on 9/4/24 at 1:30 pm. She confirmed that that Patient ID #1 had been admitted to the facility from 01/28/2024 until discharge 02/09/2024. She confirmed the patient re-presented to the ED on 2/16/2024 and was re-admitted to the facility. The patient was discharged 02/20/2024. The plastic surgery consult completed on 2/16/2024 at 1:41 pm by Physician ID # 68 stated "patient did not get antibiotics for 4 days." Informaticist Staff ID #62 confirmed she could not locate a case management assessment or re-assessment which assessed for prior discharge barriers and etiologies for non-compliance with home antibiotic infusions.

Record Review of facility policy "Discharge/Transition of Care Planning Department", Policy #CM02, last revised 08/31/2021, stated "8. Members of the healthcare team will provide and document in-hospital education/training to the patient or patient's representative relative to the discharge plan, self-care, arrangements post-discharge. 9. Monitoring and Evaluation of the Discharge Planning Process are reported to the Utilization Management Committee and include, but are not limited to the following metrices: a. Readmission rates. B. Utilization and referrals to transition partners including tele-monitoring. C. Patient satisfaction comments, complaints, or grievances received related to the Discharge planning process ..."

Interview 9/6/24 at 12:25 pm with Case Manager Staff ID #73 performed with record review. She was unable to locate case management re-admission assessment in Patient ID #1 medical record from 2/16/24 - 2/20/24 hospitalization/re-admission, which assessed patient's etiology for non-compliance with home health IV antibiotic regimen.