The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

THE HOSPITALS OF PROVIDENCE MEMORIAL CAMPUS 2001 N OREGON ST EL PASO, TX 79902 May 9, 2017
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to provide emergency services in a safe setting when

a.) A high risk patient was left unmonitored in the facility's waiting room for 2 hours and did not receive treatment for a fever for almost 5 hours. (Patient #5)

b.) An Emergency cardiac defibrillator was missing from a crash cart and the facility was not aware and an opened unusable defibrillator pad was available for use.

Findings Include:

a.) Review Patient #5's Medical Records reflected a [AGE] year old female with a history of [DIAGNOSES REDACTED] presented to the facility's emergency room on [DATE] at 3:36 p.m. with a complaint of fever.

Time Line for Patient #5's ED visit on 02/22/17:
Arrived at the facility's ED at 3:36 p.m. with a fever of 101.6 (Axillary)
Triaged at 3:42 p.m. and placed back out in waiting room
Patient #5 was seen by Physician at 5:32 p.m.
Patient #5 was seen by Nurse at 5:52 p.m.
Patient #5 was given Tylenol for fever at 8:22 p.m.

Review of Patient #5's initial triage note dated 02/22/2017 at 15:42 reflected the Triage nurse assigned Patient #5 an ER (ED) ESI (Emergency Severity Level) 2. Patient #5's Triage Vitals reflected Temperature F 101.6 , Temperature Method Axillary (under the arm, can result in a lower than actual temperature), Heart Rate 132, (tachycardia) Respiratory Rate 20, Blood Pressure 127/77, Sp02/Pulse Oximetry 93% Oxygen saturation on 3 liters of oxygen vial Nasal Cannula.

Review of records reflected Patient #5 was placed back out in the patient waiting room.

Review of Physician's note "Time seen: Date & time 02/22/2017 17:32:00 (5:32 p.m.) reflected "... The patient presents with fever. The onset was at 04:00 (p.m.). The course/duration of symptoms is constant. Associated symptoms: cough and yellow sputum production, hypoxia, chest discomfort per mother, sweats. Temperature is 103 Fahrenheit. Prior episodes: occasional. Therapy today: non-steroidal anti-inflammatory. Per mother, pt [sic] started with a 103 F fever today at 04:00. Pt was given Albuterol nebulizer treatments at home and had 1 L of nasal suctioning but mother denies any improvement. Pt sees...Pulmonologist on a regular basis and was notified prior to ED arrival...."

Review of Patient #5's physician's orders reflected at 7:50 p.m. Acetaminophen 1000 grams by mouth was ordered.

Review of the Patient #5's Medication Administration Record reflected Acetaminophen 1000 grams was administered at 8:22 p.m.

Review of Patient #5's Lab results on 02/22/2017 at 18:25 (6:25 p.m.) reflected
PH ...p02 43.8 mmHg Critical
Base Excess02 Sat Mea 79.1 % LOW


Patient #5's vital signs, on 02/22/2017 at 18:14 (6:00 p.m.), reflected Heart rate 121 (tachycardia), Respirations 33 BPM (breaths per minute, tachypnea) 89% O2 Saturation on 3 liter of oxygen via nasal cannula. The blood pressure and temperature were not recorded.

Review of Patient #5's ER Nurse's notes dated 2/22/17 did not reflect the ongoing monitoring and reassessment of the patient while out in the waiting room and only one set while in the emergency room .

INTERVIEWS

During an interview on the morning of 5/9/17 in the facility's ED Triage area, Staff #28, Triage Nurse stated, "...If a patient is an ESI of 2, they will be reassessed every 30 minutes....I can see all patients in the waiting room from the triage window....an ESI of 3 would need to be assessed every 4 hours...."

During an interview in the afternoon of 5/9/17 in the facility's conference room Staff #2, Director Quality confirmed Patient #5 was triaged at an ESI level 2 and stated, "...I don't know why she wasn't brought back ..."

FACILITY POLICIES:

Review of the facility provided document TRIAGE ASSESSMENT (dated 8/15) reflected
"PURPOSE: To provide guidelines for accurately assessing triage patients presenting to the Emergency Department ....
III. POLICY:
All Individuals who come to the hospital and request examination or treatment will be promptly assessed by a qualified nurse to determine the appropriate order in which the individual will receive a medical screening examination based upon the acuity of the Individual's presenting complaint....
IV.PROCEDURE...
1. Individuals who report to the Emergency Department will receive a medical screening examination based upon the acuity of the individual's presenting complaints.
2. Patients will be triaged utilizing the Emergency Severity Index as outlined below:...
The patient has/is or in:
1) High risk situation
2) Confused
3) Lethargic
4) Disoriented
5) Severe pain (_> 7/0-10 scale) in the context of organ/tissue loss
6) Severe distress (emotional, psychological)
Level 2 ...
...b. Patients categorized ESI level 2 are escorted to the treatment area whenever possible and assigned to a primary nurse upon completion of triage. In the event that the patient cannot be immediately escorted to the treatment area, the patient will be reassessed every 30 minutes.
...e. Reassessment includes a repeat of vital signs, excluding temperature unless indicated....
2) All monitoring and interventions will be documented on the ED record and patient care notes..."


Review of the facility provided document PATIENT RIGHTS AND RESPONSIBILITIES (dated 8/15) reflected,
"I. SCOPE: This policy applies to all patients (inpatient and outpatient) who receive services at Providence Memorial Hospital.
II. PURPOSE:
... have been established with the expectation that observation of these rights and responsibilities will contribute to patient care...
III. POLICY:
It is the policy of Providence Memorial Hospital to respect the patient's rights to treatment and service subject to the hospital's capability, mission, and applicable regulations Conditions of Participation 42 CFR 482.13. See also State Operations Manual, Appendix A, ...
15. The right to the hospital's reasonable response to your requests and needs for treatment or service, within the hospital's capacity, its stated mission, and applicable law and regulation.
16. The right to an environment that preserves dignity and contributes to a positive self-image and considerate and respectful care which will include consideration of the psycho-social, spiritual, and cultural variables that influence the perceptions of illness.
17. The patient has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse...."

b.) On observation made during a tour on the morning of 5/8/17 of the facility's 4 west medical inpatient unit revealed a crash cart on the unit with an opened package of cardiac defibrillator pads that was available for use.

During an interview on the morning of 5/9/17 on the facility's 4 west medical inpatient unit Staff #2, Director Quality confirmed the finding and stated, "...they have to be used when they are opened...."

On observation made during a tour of the facility's emergency room on the morning of 5/9/17 revealed the cardiac defibrillator was missing from the emergency crash cart by Room 20.

During an interview in the afternoon of 5/9/17 in the facility's emergency room Staff #27, Pediatric emergency room (ED) Director stated, "...it's been out of service for 3 days...."

During an interview in the afternoon of 5/9/17 in the facility's emergency room Staff #1, Interim CNO stated, "...It should have been removed from service and replaced by a working one...."
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on record review and interview the facility's Governing Body failed to ensure the proper oversight of the dialysis contracted service when the Dialysis service did not provide required monthly reports to the hospital (Two positive water cultures in February were not reported until April of 2017) and the contracted Dialysis Service was not reviewed annually.

Findings Include:

Review of the facility provided document Culture Reports reflected "...In February 2017, 1 RO water was positive and above acceptable limits, and positive again when it was retested 5 days later....These positive cultures were discovered by Infection Control when the results were requested on 4/13/17 ...."

During an interview on the morning of 5/9/17 in the facility conference room Staff #4, Director of Infection Prevention stated, "I was not informed of the two positive cultures until I requested the reports....I wasn't used to seeing any positive cultures..."

During an interview on the morning of 5/9/17 in the facility conference room Staff #6, Director ICU stated, "...I have been over the dialysis unit for over 2 years...we were meeting monthly...we went over the QAPI and data...I usually get the reports by the middle of the month ...when they had two positive cultures they did not contact me...I didn't know about the cultures ...they did not send me the culture results ...they didn't call me..." When asked if
the facility was holding the Joint Dialysis Oversight Committee meetings as the contract required
Staff#6 stated, "...We haven't discussed having the meetings, I didn't know about them...I never saw the contract...."

During an interview on the afternoon of 5/8/17 in the facility conference room Staff #25, Risk Manager stated, "...I didn't notice I wasn't getting the reports...they have a new Bio Medical Person...he didn't notice he had positive either...they have had changes in Bio Med...I received January and March in April...."

Review of the facility provided document Devita Contract reflected "Documentation requirements are set forth on Exhitit A-2....Provider shall also provide all required routine testing reports and log books required to demonstrate compliance with licensure, certification and accreditation standards and Hospital policy...Provider shall deliver to Hospital those reports...on a monthly basis not later than the end of each month for the month prior...j. Joint Dialysis Oversight Committee. Provider and each Hospital shall establish a Joint Dialysis Oversignt Committee which shall be responsible for the operational and clinical components of the Agreement...""

Review of the facility provided document Exhibit A-2 "Required Reports and Documentation Key Performance Indicators shall be reported on a monthly basis...Provider shall provide the following information to Customer and Hospitals on a monthly basis, not later than the end of each month for the prior month....A.1.2. Acute Clinical Outcome Indicators...."

Review of the Governing Body meeting minutes for 2016 thru 2017 did not reflect an annual review of the contracted dialysis services.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to provide adequate nursing oversight when a patient developed a rash and excoriation to the buttocks. (Patient #4)

Findings Include:

Review of Patient #4's medical records reflected an [AGE] year old female was admitted on [DATE] for nausea. Patient #4's Braden Score (used to determine risk of Pressure Sores) was scored at a 12.

During an interview on the morning of 5/9/17 in the facility conference room Staff#21, Nursing Director of 4 West stated, "...A score of 12 is considered high risk for pressure sores...." Staff #21 confirmed the documentation findings.

Review of Patient #4's skin assessment dated
1/31/17, on admission, reflected no skin breakdown
2/6/18 at 9:00 a.m. reflected "...excoriation to buttock..."
2/6/18 at 9:30 p.m. reflected "...Rash, redness..."

The facility's wound care nurse was consulted on 2/6/17 due to the excoriation to Patient #4's buttocks. Treatment orders were written for a barrier cream.

Review of the facility provided policy SKIN INTEGRITY (dated 8/15) reflected,
"...PURPOSE To provide guidelines for assessment and reassessment of patients at risk for tissue breakdown or with existing tissue breakdown.
POLICY
Guidelines are established to:
-Identify patients at risk for developing tissue integrity issues and / or a pressure ulcer
-Institute pressure redistribution interventions appropriate to level of risk
-Ensure comprehensive assessment, documentation and accurate description of pressure ulcers
-Ensure uniform terminology for documentation
-Provide tissue load management for at risk patients...."
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview and record review the facility failed to provide patient care in a sanitary environment to prevent the spread of infectious diseases when a Patient Care Technician (PCT) entered two different isolation rooms wearing the same isolation gown.

Findings Include:

An observation on the morning of 5/8/17 during a tour of the facility's 4 West unit revealed Staff #7 , PCT exit patient room 4202 wearing a yellow personal protection gown; an isolation cart was sitting next to the doorway and a Contact Isolation Sign was on the door . Staff #7 walked across the hall into a non-patient room. Staff #7 was then observed walking across the hallway wearing the same yellow gown and entering Patient Room 4203; an isolation cart was sitting next to the doorway and a Contact Isolation Sign was on the door. Staff #7 did not change her contaminated gown between patients.

During an interview on the morning of 5/8/17 on the facility's 4 West inpatient unit Staff #7 when asked why she had crossed the hall and gone into another patient's room wearing the same gown stated, "...I had to throw out some linen ...I thought because it was a yellow gown it would be okay....I shouldn't have ...."

Review of the facility provided document Isolation: Transmission Based and Standard Precautions (dated 5/15) reflected
..."PURPOSE: To establish standard definitions and procedures for daily Infection control practices and isolation practices. Transmission based isolation practices are designed to prevent the transmission of significant pathogens/diseases from infected or colonized patients to other patients, hospital visitors, and healthcare workers (HCW)....
STANDARD: Isolation techniques are used to break the chain of transmission from an infected host to a susceptible person. It is the goal of this policy to isolate the Infectious organism, not the patient. ...
8. Gowns/Aprons are worn when soiling of clothing with body substances is reasonably expected and are available in the patient's room and in departments utilizing contact precautions.
a. Gowns are to be disposed at the site of use.
b. Gowns are not to be worn out of the patient's room or area where care is being provided.
c. Hands are to be washed at the site of care.
d. The procedure to remove a contaminated gown
1. Unfasten neck and waistband.
2. Remove gown turning it inside out.
3. Discard gown in appropriate trash receptacle at point of service (in the patient room)...."

During an interview on the morning of 5/8/17 on the facility's 4 West inpatient unit,
Staff # 21 Director of 4 West confirmed the finding.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to provide emergency services in a safe manner when

a.) A high risk patient was left unmonitored in the facility's waiting room for 2 hours and did not receive treatment for a fever for almost 5 hours. (Patient #5)

b.) An Emergency cardiac defibrillator was missing from a crash cart and the facility was not aware and an opened unusable defibrillator pad was available for use.

Findings Include:

b.) On observation made during a tour on the morning of 5/8/17 of the facility's 4 west medical inpatient unit revealed a crash cart on the unit with an opened package of cardiac defibrillator pads that was available for use.

During an interview on the morning of 5/9/17 on the facility's 4 west medical inpatient unit Staff #2, Director Quality confirmed the finding and stated, "...they have to be used when they are opened...."

On observation made during a tour of the facility's emergency room on the morning of 5/9/17 revealed the cardiac defibrillator was missing from the emergency crash cart by Room 20.

During an interview in the afternoon of 5/9/17 in the facility's emergency room Staff #27, Pediatric emergency room (ED) Director stated, "...it's been out of service for 3 days...."

During an interview in the afternoon of 5/9/17 in the facility's emergency room Staff #1, Interim CNO stated, "...It should have been removed from service and replaced by a working one...."


a.) Review Patient #5's Medical Records reflected a [AGE] year old female with a history of [DIAGNOSES REDACTED] presented to the facility's emergency room on [DATE] at 3:36 p.m. with a complaint of fever.

Time Line for Patient #5's ED visit on 02/22/17:
Arrived at the facility's ED at 3:36 p.m. with a fever of 101.6 (Axillary)
Triaged at 3:42 p.m. and placed back out in waiting room
Patient #5 was seen by Physician at 5:32 p.m.
Patient #5 was seen by Nurse at 5:52 p.m.
Patient #5 was given Tylenol for fever at 8:22 p.m.

Review of Patient #5's initial triage note dated 02/22/2017 at 15:42 reflected the Triage nurse assigned Patient #5 an ER (ED) ESI (Emergency Severity Level) 2. Patient #5's Triage Vitals reflected Temperature F 101.6 , Temperature Method Axillary (under the arm, can result in a lower than actual temperature), Heart Rate 132, (tachycardia) Respiratory Rate 20, Blood Pressure 127/77, Sp02/Pulse Oximetry 93% Oxygen saturation on 3 liters of oxygen vial Nasal Cannula.

Review of records reflected Patient #5 was placed back out in the patient waiting room.

Review of Physician's note "Time seen: Date & time 02/22/2017 17:32:00 (5:32 p.m.) reflected "... The patient presents with fever. The onset was at 04:00 (p.m.). The course/duration of symptoms is constant. Associated symptoms: cough and yellow sputum production, hypoxia, chest discomfort per mother, sweats. Temperature is 103 Fahrenheit. Prior episodes: occasional. Therapy today: non-steroidal anti-inflammatory. Per mother, pt [sic] started with a 103 F fever today at 04:00. Pt was given Albuterol nebulizer treatments at home and had 1 L of nasal suctioning but mother denies any improvement. Pt sees ...Pulmonologist on a regular basis and was notified prior to ED arrival...."

Review of Patient #5's physician's orders reflected at 7:50 p.m. Acetaminophen 1000 grams by mouth was ordered.

Review of the Patient #5's Medication Administration Record reflected Acetaminophen 1000 grams was administered at 8:22 p.m.

Review of Patient #5's Lab results on 02/22/2017 at 18:25 (6:25 p.m.) reflected
PH ...p02 43.8 mmHg Critical
Base Excess02 Sat Mea 79.1 % LOW


Patient #5's vital signs, on 02/22/2017 at 18:14 (6:00 p.m.), reflected Heart rate 121 (tachycardia), Respirations 33 BPM (breaths per minute, tachypnea) 89% O2 Saturation on 3 liter of oxygen via nasal cannula. The blood pressure and temperature were not recorded.

Review of Patient #5's ER Nurse's notes dated 2/22/17 did not reflect the ongoing monitoring and reassessment of the patient while out in the waiting room and only one set while in the emergency room .

INTERVIEWS

During an interview on the morning of 5/9/17 in the facility's ED Triage area, Staff #28, Triage Nurse stated, "...If a patient is an ESI of 2, they will be reassessed every 30 minutes....I can see all patients in the waiting room from the triage window....an ESI of 3 would need to be assessed every 4 hours...."

During an interview in the afternoon of 5/9/17 in the facility's conference room Staff #2, Director Quality confirmed Patient #5 was triaged at an ESI level 2 and stated, "...I don't know why she wasn't brought back..."

FACILITY POLICIES:

Review of the facility provided document TRIAGE ASSESSMENT (dated 8/15) reflected
"PURPOSE: To provide guidelines for accurately assessing triage patients presenting to the Emergency Department....
III. POLICY:
All Individuals who come to the hospital and request examination or treatment will be promptly assessed by a qualified nurse to determine the appropriate order in which the individual will receive a medical screening examination based upon the acuity of the Individual's presenting complaint....
IV.PROCEDURE...
1. Individuals who report to the Emergency Department will receive a medical screening examination based upon the acuity of the individual's presenting complaints.
2. Patients will be triaged utilizing the Emergency Severity Index as outlined below:...
The patient has/is or in:
1) High risk situation
2) Confused
3) Lethargic
4) Disoriented
5) Severe pain (_> 7/0-10 scale) in the context of organ/tissue loss
6) Severe distress (emotional, psychological)
Level 2 ...
...b. Patients categorized ESI level 2 are escorted to the treatment area whenever possible and assigned to a primary nurse upon completion of triage. In the event that the patient cannot be immediately escorted to the treatment area, the patient will be reassessed every 30 minutes.
...e. Reassessment includes a repeat of vital signs, excluding temperature unless indicated....
2) All monitoring and interventions will be documented on the ED record and patient care notes..."


Review of the facility provided document PATIENT RIGHTS AND RESPONSIBILITIES (dated 8/15) reflected,
"I. SCOPE: This policy applies to all patients (inpatient and outpatient) who receive services at Providence Memorial Hospital.
II. PURPOSE:
...have been established with the expectation that observation of these rights and responsibilities will contribute to patient care...
III. POLICY:
It is the policy of Providence Memorial Hospital to respect the patient's rights to treatment and service subject to the hospital's capability, mission, and applicable regulations Conditions of Participation 42 CFR 482.13. See also State Operations Manual, Appendix A, ...
15. The right to the hospital's reasonable response to your requests and needs for treatment or service, within the hospital's capacity, its stated mission, and applicable law and regulation.
16. The right to an environment that preserves dignity and contributes to a positive self-image and considerate and respectful care which will include consideration of the psycho-social, spiritual, and cultural variables that influence the perceptions of illness.
17. The patient has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse...."