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Based on record review and interview, it was determined that this facility is not compliance with 42 C.F.R. § 482.11 (a)(1) because it is not "primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons," as required by Social Security Act 1861(e )(1). The facility operates as surgical center that primarily provides services to outpatients and limits inpatient admissions to post surgical patients, as necessary.


Findings were:


An interview with the Chief Nursing Officer and Director of Quality/Risk Management revealed that all inpatients are post-surgical cases, and cases that are admitted to the hospital with post-operative complications.


The Director of Inpatient Services stated in an interview on 3/17/15, at 10:35 a.m., that they currently had 4 patients on the inpatient floor. She stated that there were 20 beds on the floor and all were private rooms. She stated that they anticipated 8 admissions for observation from the surgical cases for that day, and staffing would be herself, 1 other RN, and 2 CNAs. She stated they usually averaged 2-3 patients but at times would have up to 8 patients.


Observation on 3/17/15, showed that there were 8 surgical cases being performed and were anticipated to be admitted to the floor for overnight observation.


The Director of Surgical Services stated in an interview on 3/17/15, at 11:00 a.m., that there are 10 pre-op beds, 10 PACU beds, 6 OR suites, and 3 Endoscopy rooms. She stated that most of their surgical cases are outpatient cases, and all endoscopy cases are outpatient cases.


In an interview on 3/17/15, at 5:00 p.m., the Chief Nursing Officer stated that "we do not have many patients, no ICU," and "the majority of patients are outpatients, not admitted to the floor. Average census is 2-3 patients per day and sometimes they have no patients on weekends. Some surgery cases are done on Saturdays but none on Sundays."


The hospital's length of stay for inpatients is short, with an average length of stay being 2.2 days, as indicated in a facility document, Facility Report (inpatient/outpatient services).

On 3/17/15, review of the facility's Patient Volume Statistics from January 2014 to January 2015, obtained from the Chief Nursing Officer and Quality/Risk Manager revealed that there were only 855 patients admitted to the hospital and 7056 outpatients. This hospital is primarily engaged in providing services to outpatients (89%) and the only inpatients are post-surgical patients. The facility has a low inpatient census and occupancy rate for a "general acute care" hospital in a large city.

The facility is certified for 40 inpatient beds, but only an average census of 2-3. The inpatient lengths of stay and occupancy rates are far below average for acute care hospitals in urban Texas counties.


On 3/17/15, review of the facility's Patient Volume Statistics from January, 2014 to January, 2015 obtained from the Chief Nursing Officer and Quality/Risk Manager revealed that there were no admissions to the hospital from the emergency room. All patients treated in the emergency department that need admissions to inpatient for medical reasons were transferred to other facilities.


The Emergency Room Director said that the hospital transfers 15-20 cases per month to other hospitals for higher level of care that are cardiac, pediatric, or respiratory issues. He also said that the hospital is on permanent ambulance diversion, meaning there are no emergency ambulances that present to the hospital. By contrast, a majority of acute care hospitals in Texas admit inpatients to the facility from the emergency room.


In an interview on 3/17/15, at 3:20 p.m., the Quality/Risk Manager said that the hospital is "not a regular hospital, it is only a surgical hospital and most patients are outpatient or 23 hour observation patients."


During a tour of the facility emergency department on 3/17/15, at 10:30 a.m., the emergency call lights in the rooms were tested by the surveyor. The system had a visual light outside the room but no audible alarm was initialed with the activation of the button. In an interview with the emergency room nurse, at the time of occurrence, he stated he had never used the code blue button and he thought when it was activated it sent a direct alert to the operator to announce the code blue. The button was activated and the hospital operator stated she did not receive an alarm message to activate the code blue situation. He confirmed there was not an audible alarm when the emergency call system was activated to alert other staff of the emergency situation occurring in the treatment room. This emergency call system failure places the health and safety of individuals that required immediate assistance in emergency situation in immediate jeopardy.


In an interview on 3/17/15, at 1:30 p.m., the House Supervisor/Emergency Department Director, and sole ER nurse for the day. He said that the ER nurse on the day shift from Monday to Friday also served as the House Supervisor. He stated that as the House Supervisor, he makes rounds 4-5 times per day, handles complaints, arranges patient transfers, etc. He stated he also covered the emergency room as the only RN on duty. During periods that the ER nurse is away from the emergency department performing his House Supervisor responsibilities, the patient care needs of patients are the main responsibility of an unlicensed staff. The unlicensed staff is not qualified to access or provide medications required by patients, treatments needed, and/or provide emergency intervention in the event that patients' condition deteriorates.


In an interview on 3/17/15, at 5:00 p.m., the Chief Nursing Officer stated that the House Supervisor (AOD) on Monday, Tuesday, Wednesday and Thursday is also the ER nurse on the days they are the House Supervisor.


The facility is staffed in a manner that demonstrates that its primary focus is on outpatients and surgical patients, not inpatients. The combination of the above factors demonstrates that the facility fails to meet that statutory requirement of a hospital to be primarily engaged in providing inpatient services as required under section 1861(e)(1) of the Act.

Based on record review and interview, it was determined that the Governing Body of this facility failed to ensure that this facility meets the requirements of 42 C.F.R. § 482.11 (a)(1). This facility is not primarily engaged in providing inpatient services as required by Social Security Act 1861(e )(1). The facility operates as surgical center that primarily provides services to outpatients and limits inpatient admissions to post surgical patients, as necessary.

Findings were:


An interview with the Chief Nursing Officer and Director of Quality/Risk Management revealed that all inpatients are post-surgical cases, and cases that are admitted to the hospital with post-operative complications.


The Director of Inpatient Services stated in an interview on 3/17/15, at 10:35 a.m., that they currently had 4 patients on the inpatient floor. She stated that there were 20 beds on the floor and all were private rooms. She stated that they anticipated 8 admissions for observation from the surgical cases for that day, and staffing would be herself, 1 other RN, and 2 CNAs. She stated they usually averaged 2-3 patients but at times would have up to 8 patients.


Observation on 3/17/15, showed that there were 8 surgical cases being performed and were anticipated to be admitted to the floor for overnight observation.


The Director of Surgical Services stated in an interview on 3/17/15, at 11:00 a.m., that there are 10 pre-op beds, 10 PACU beds, 6 OR suites, and 3 Endoscopy rooms. She stated that most of their surgical cases are outpatient cases, and all endoscopy cases are outpatient cases.


In an interview on 3/17/15, at 5:00 p.m., the Chief Nursing Officer stated that "we do not have many patients, no ICU," and "the majority of patients are outpatients, not admitted to the floor. Average census is 2-3 patients per day and sometimes they have no patients on weekends. Some surgery cases are done on Saturdays but none on Sundays."


The hospital's length of stay for inpatients is short, with an average length of stay being 2.2 days, as indicated in a facility document, Facility Report (inpatient/outpatient services).

On 3/17/15, review of the facility's Patient Volume Statistics from January 2014 to January 2015, obtained from the Chief Nursing Officer and Quality/Risk Manager revealed that there were only 855 patients admitted to the hospital and 7056 outpatients. This hospital is primarily engaged in providing services to outpatients (89%) and the only inpatients are post-surgical patients. The facility has a low inpatient census and occupancy rate for a "general acute care" hospital in a large city.

The facility is certified for 40 inpatient beds, but only an average census of 2-3. The inpatient lengths of stay and occupancy rates are far below average for acute care hospitals in urban Texas counties.


On 3/17/15, review of the facility's Patient Volume Statistics from January, 2014 to January, 2015 obtained from the Chief Nursing Officer and Quality/Risk Manager revealed that there were no admissions to the hospital from the emergency room. All patients treated in the emergency department that need admissions to inpatient for medical reasons were transferred to other facilities.


The Emergency Room Director said that the hospital transfers 15-20 cases per month to other hospitals for higher level of care that are cardiac, pediatric, or respiratory issues. He also said that the hospital is on permanent ambulance diversion, meaning there are no emergency ambulances that present to the hospital. By contrast, a majority of acute care hospitals in Texas admit inpatients to the facility from the emergency room.


In an interview on 3/17/15, at 3:20 p.m., the Quality/Risk Manager said that the hospital is "not a regular hospital, it is only a surgical hospital and most patients are outpatient or 23 hour observation patients."


During a tour of the facility emergency department on 3/17/15, at 10:30 a.m., the emergency call lights in the rooms were tested by the surveyor. The system had a visual light outside the room but no audible alarm was initialed with the activation of the button. In an interview with the emergency room nurse, at the time of occurrence, he stated he had never used the code blue button and he thought when it was activated it sent a direct alert to the operator to announce the code blue. The button was activated and the hospital operator stated she did not receive an alarm message to activate the code blue situation. He confirmed there was not an audible alarm when the emergency call system was activated to alert other staff of the emergency situation occurring in the treatment room. This emergency call system failure places the health and safety of individuals that required immediate assistance in emergency situation in immediate jeopardy.


In an interview on 3/17/15, at 1:30 p.m., the House Supervisor/Emergency Department Director, and sole ER nurse for the day. He said that the ER nurse on the day shift from Monday to Friday also served as the House Supervisor. He stated that as the House Supervisor, he makes rounds 4-5 times per day, handles complaints, arranges patient transfers, etc. He stated he also covered the emergency room as the only RN on duty. During periods that the ER nurse is away from the emergency department performing his House Supervisor responsibilities, the patient care needs of patients are the main responsibility of an unlicensed staff. The unlicensed staff is not qualified to access or provide medications required by patients, treatments needed, and/or provide emergency intervention in the event that patients' condition deteriorates.


In an interview on 3/17/15, at 5:00 p.m., the Chief Nursing Officer stated that the House Supervisor (AOD) on Monday, Tuesday, Wednesday and Thursday is also the ER nurse on the days they are the House Supervisor.


The facility is staffed in a manner that demonstrates that its primary focus is on outpatients and surgical patients, not inpatients. The combination of the above factors demonstrates that the facility fails to meet that statutory requirement of a hospital to be primarily engaged in providing inpatient services as required under section 1861(e)(1) of the Act.

Based on observation and policy review, the chief executive officer (CEO) failed to ensure that the facility staff followed governing body approved policies and procedures related to staffing in he Emergency Department.

Findings were:

During the entrance conference at the facility on 3/17/15, the emergency room nurse identified themselves as the house supervisor. He further stated that he also had the responsibility as director of the emergency department and was the staff nurse in the emergency room for that day.

Facility policy titled "Emergency Room Staffing; revision date Jan 2015" states, in part, "Establish criteria for minimum staffing of the Emergency Department on a 24 hour basis. Emergency department will staff licensed personnel 24 hours a day: One Registered Nurse who is ACLS certified and Emergency Department experienced per shift; Appropriate personnel to meet quality patient care-Emergency Department Technician as patient load requires; One Emergency Department physician."

Facility policy titled "Emergency Room Triage; revision Jan 2015" states in part, "The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department......"

Facility job description titled "Registered Nurse, Department: Emergency Room" states in part, " Provides professional nursing care within the Emergency Department; coordinates care planning with other disciplines. Provides direct and indirect patient care in the emergency room setting."

Facility job description titled "House Supervisor, Department: Nursing Administration" states in part, "The House Supervisor is responsible for promoting and maintaining quality patient care through effective management of the activities of the total patient care services during his/her assigned shift. Duties and Responsibilities: Makes rounds on all patient care units to ascertain condition of patients, ensures staffing needs are met, provides direct care if required. Assists staff in delivery of care if needed. Keeps the Nurse Executive, his/her representative and/or the Administrator informed regarding circumstances or situations which have or may have serious impact/or potential life threatening. Participates in patient care meetings and inservice education. Participates and leads various committees such as Code Blue, Rapid Response, performs chart audits as assigned. Responsible for scheduling add-on procedures for OR, Endo, etc. including staff MDs."


In an interview with the House Supervisor on 3/17/15, at 1:30 p.m., he stated "The ER nurse is the House Supervisor." When asked what he did as House Supervisor he stated he makes rounds 4-5 times per day, handles complaints by patients or visitors, makes patient transfers to other facilities, and just oversees the hospital. He said the House Supervisor on night shift is not the emergency room nurse. There is an emergency room (ER) nurse and a House Supervisor on night shift and on weekends. He stated he carries a phone with him and the ER calls him if a patient presents to the ER.

In an interview with the Chief Nursing Officer on 3/17/15, at 5:00 p.m., in an office on the first floor of the facility she stated the AOD (Administrator on Duty) is the House Supervisor. She stated this is Staff #2 on Monday, Tuesday, Wednesday. He is also the ER nurse. On Thursday and Friday it is Staff #8 who also works the ER. She stated this decision was made in December by the CEO and herself to maximize their resources. She stated the AOD is not a dual role at night or on weekends.

Based on observation and staff interview the facility failed to ensure that the registered nurse assigned to the emergency department was not assigned additional nursing responsibilities outside of the emergency department;. Additionally, the facility failed to follow their own policies for nurse staffing.

Findings were:

The only registered nurse (Staff #2, House Supervisor/ER Nurse Director) assigned to work in the emergency department was simultaneously assigned additional nursing responsibilities that could require his attention in other areas of the hospital away from the emergency department. These other responsibilities could take Staff #2's physical presence out of the emergency department multiple times throughout the day. Cross reference A0392

Based on observation and staff interview, the facility failed to ensure that the registered nurse (Staff #2) assigned to the emergency department was not assigned additional nursing responsibilities that could require his attention in other areas of the hospital away from the emergency department.

Findings were:

During the entrance conference at the facility on 3/17/15, the emergency room nurse identified themselves as the house supervisor. He further stated that he also had the responsibility as director of the emergency department and was the staff nurse in the emergency room for that day.

Facility policy titled "Emergency Room Staffing; revision date Jan 2015" states in part, "Establish criteria for minimum staffing of the Emergency Department on a 24 hour basis. Emergency department will staff licensed personnel 24 hours a day: One Registered Nurse who is ACLS certified and Emergency Department experienced per shift; Appropriate personnel to meet quality patient care-Emergency Department Technician as patient load requires; One Emergency Department physician."

Facility policy titled "Emergency Room Triage; revision Jan 2015" states in part, "The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department......"

Facility job description titled "Registered Nurse, Department: Emergency Room" states in part, "Provides professional nursing care within the Emergency Department; coordinates care planning with other disciplines. Provides direct and indirect patient care in the emergency room setting."

Facility job description titled "House Supervisor, Department: Nursing Administration" states in part, "The House Supervisor is responsible for promoting and maintaining quality patient care through effective management of the activities of the total patient care services during his/her assigned shift. Duties and Responsibilities: Makes rounds on all patient care units to ascertain condition of patients, ensures staffing needs are met, provides direct care if required. Assists staff in delivery of care if needed. Keeps the Nurse Executive, his/her representative and/or the Administrator informed regarding circumstances or situations which have or may have serious impact/or potential life threatening. Participates in patient care meetings and inservice education. Participates and leads various committees such as Code Blue, Rapid Response, performs chart audits as assigned. Responsible for scheduling add-on procedures for OR, Endo, etc. including staff MDs."


In an interview with the House Supervisor on 3/17/15, at 1:30 p.m., he stated "The ER nurse is the House Supervisor." When asked what he did as House Supervisor, he stated that he makes rounds 4-5 times per day, handles complaints by patients or visitors, makes patient transfers to other facilities, and just oversees the hospital. He said that the House Supervisor on night shift is not the emergency room nurse. There is an emergency room (ER) nurse and a House Supervisor on night shift and on weekends. He stated he carries a phone with him and the ER calls him if a patient presents to the ER.

In an interview with the Chief Nursing Officer on 3/17/15, at 5:00 p.m., in an office on the first floor of the facility she stated the AOD (Administrator on Duty) is the House Supervisor. She stated this is Staff #2 on Monday, Tuesday, Wednesday. He is also the ER nurse. On Thursday and Friday it is Staff #8 who also works the ER. She stated this decision was made in December by the CEO and herself to maximize their resources. She stated the AOD is not a dual role at night or on weekends.

Based on observation and staff interview, the facility failed to ensure that the emergency call system in the emergency department had functional visual and audible alarms in each emergency treatment room. 2 of 2 emergency treatment rooms had no audible alarm when the emergency call button and the Code Blue button was activated in the rooms.

Findings were:

During a tour of the facility emergency department on 3/17/15, at 10:30 a.m., the emergency call lights in the rooms were tested by the surveyor. The system had a visual light outside the room but no audible alarm was initialed with the activation of the button.

In an interview with the emergency room nurse, at the time of occurrence, he stated he had never used the code blue button and he thought when it was activated it sent a direct alert to the operator to announce the code blue. The button was activated and the hospital operator stated she did not receive an alarm message to activate the code blue situation. He confirmed there was not an audible alarm when the emergency call system was activated to alert other staff of the emergency situation occurring in the treatment room.

Failure to have an active functional system to alert other personnel of emergency situations can delay care to patients affecting their safety and well-being.

Based on observation and staff interview, the facility failed to ensure that the registered nurse assigned to the emergency department was not assigned additional nursing responsibilities outside of the emergency department. These other duties could take his physical presence out of the emergency department multiple times throughout the day.

Findings were:

During the entrance conference at the facility on 3/17/15, the emergency room nurse identified himself as the house supervisor. He further stated that he also had the responsibility as director of the emergency department and was the staff nurse in the emergency room for that day.

Facility policy titled "Emergency Room Staffing; revision date Jan 2015" states in part, "Establish criteria for minimum staffing of the Emergency Department on a 24 hour basis. Emergency department will staff licensed personnel 24 hours a day: One Registered Nurse who is ACLS certified and Emergency Department experienced per shift; Appropriate personnel to meet quality patient care-Emergency Department Technician as patient load requires; One Emergency Department physician."

Facility policy titled "Emergency Room Triage; revision Jan 2015" states,in part, "The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department......"

Facility job description titled "Registered Nurse, Department: Emergency Room" states in part, "Provides professional nursing care within the Emergency Department; coordinates care planning with other disciplines. Provides direct and indirect patient care in the emergency room setting."

Facility job description titled "House Supervisor, Department: Nursing Administration" states in part, "The House Supervisor is responsible for promoting and maintaining quality patient care through effective management of the activities of the total patient care services during his/her assigned shift. Duties and Responsibilities: Makes rounds on all patient care units to ascertain condition of patients, ensures staffing needs are met, provides direct care if required. Assists staff in delivery of care if needed. Keeps the Nurse Executive, his/her representative and/or the Administrator informed regarding circumstances or situations which have or may have serious impact/or potential life threatening. Participates in patient care meetings and inservice education. Participates and leads various committees such as Code Blue, Rapid Response, performs chart audits as assigned. Responsible for scheduling add-on procedures for OR, Endo, etc. including staff MDs."


In an interview with the House Supervisor on 3/17/15, at 1:30 p.m., he stated "The ER nurse is the House Supervisor." When asked what he did as House Supervisor, he stated that he makes rounds 4-5 times per day, handles complaints by patients or visitors, makes patient transfers to other facilities, and just oversees the hospital. He said that the House Supervisor on night shift is not the emergency room nurse. There is an emergency room (ER) nurse and a House Supervisor on night shift and on weekends. He stated that he carries a phone with him and the ER calls him if a patient presents to the ER.

In an interview with the Chief Nursing Officer on 3/17/15, at 5:00 p.m., in an office on the first floor of the facility she stated the AOD (Administrator on Duty) is the House Supervisor. She stated this is Staff #2 on Monday, Tuesday, Wednesday. He is also the ER nurse. On Thursday and Friday it is Staff #8 who also works the ER. She stated this decision was made in December by the CEO and herself to maximize their resources. She stated the AOD is not a dual role at night or on weekends.