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.

PARKLAND HEALTH AND HOSPITAL SYSTEM 5200 HARRY HINES BLVD DALLAS, TX 75235 July 21, 2011
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview, and record review, the hospital did not ensure that the infection control policies were implemented and enforced. Infection control practices were not adhered to by physicians, nursing staff, and other personnel, citing 7 of 14 departments and/or services (Peri-operative Services, GI Lab [Gastrointestinal Laboratory], Cardiac Lab, Ambulatory Surgery Services, Renal Dialysis, Perinatal Services and the Emergency Department [ED]). The following poor infection control practices were observed:

1. Numerous staff wore used masks hanging down from their necks while walking in the hallway or other non-surgical/treatment areas (Physician #C4, #C5, #C6, #C7, #C9, Personnel #C30 and #C37).

2. Numerous staff members did not dispose of their soiled gloves and wash their hands after treating patients and touching patient equipment (Personnel #B12, #C10, #C12, #C31, #C33, #C34, #C36, and #C38).

3. A disposable jacket was hanging in the sterilization area. Personnel food items were sitting in the patient treatment areas.

4. Infectious waste, including used syringes, body fluids, used respiratory equipment and used suction equipment were not disposed of properly in 4 of 4 ED patient rooms/cubicles (Room 3, Cubicle 10, Room 19, and Cubicle 39).

5. One of 1 ED personnel (Personnel #39) was observed not removing his gloves and washing his hands after drawing blood work then touching the surface of equipment thus contaminating the equipment.

6. One of 1 ED bed (SWAT Bed in Main West) was not cleaned with disinfectant between patient use.

7. All ED rooms located in the Main ED contained a yankauer suction tip in an open package that was attached to the suction canister and available for patient use. The open yankauer suction tips are not discarded between each patient after patients are discharged .

8. Two of 2 Environmental Services Technician's (EVS Techs, Personnel #14 and Personnel #37) did not properly transport waste. The waste carts were overfilled with trash bags and not covered during transport through the patient care area of the ED.

Findings Included:

1) On a tour on 07/12/11 at approximately 10:40 AM, 1:35 PM, & 2:10 PM with Personnel #C2, the surveyor observed in the main hallway of the 2nd floor (Surgery Department/ Perioperative Services) the following physicians with used masks hanging down from their necks: Physician #C4, #C5, #C6, #C7, & #C9.

In an interview on 07/12/11 at approximately 2:15 PM, Personnel #C1 was informed of the above findings and was asked what the hospital's PPE (Personal Protective Equipment) protocol was, specifically the wearing of the mask. Personnel #C1 stated that the hospital abides the "Perioperative Standards and Recommended Practices." Personnel #C1 stated that the mask should cover the mouth and nose in a secured manner, the mask should not be worn hanging down from the neck, and the mask should not be worn outside the operating room.

The "Perioperative Standards and Recommended Practices 2011 Edition" printed by the hospital's command center on 07/14/11 required "VI.a. The mask should cover the mouth and nose and be secured in a manner to prevent venting. VI.b.1. Masks should not be worn hanging down from the neck...the filter portion...harbors bacteria collected from the nasopharyngeal airway...VI.c. Surgical masks should be discarded after each procedure."

2) On 07/13/11 at approximately 9:15 AM, the surveyor with Personnel C#2 conducted a tour of the hospital's GI Lab. At 10:25 AM, the surveyor observed Patient #C6 undergoing an EGD procedure (Esophagogastroduodenoscopy) in GI room #1. The surveyor observed Personnel #C10 administering conscious sedation medication at 10:26 AM, 10:28 AM, and at 10:30 AM. Personnel #C10 did not wear gloves when administering the medications. Personnel #C10 did not wash her hands or apply alcohol rub during these direct patient care tasks.

On 07/13/11 at 10:43 AM, the surveyor with Personnel #C2 went to GI room #3 to observe Patient #C9's colonoscopy procedure. At 10:45 AM, the surveyor observed Personnel #C12, without gloves, administered conscious sedation medication to the patient. At 10:50 AM, Personnel #C12, without gloves, administered conscious sedation medication to the patient. At 10:51 AM, Personnel #C12 put on a pair of clean gloves and adjusted the patient's nasal cannula. At 10:53 AM, Personnel #C12 administered "diphenhydramine" as ordered and walked to the computer station and entered data. At approximately 10:54 AM, the physician requested a towel. Personnel #C12 took off her left hand glove and obtained a clean towel from a cabinet with her left hand and handed it over to the physician. Personnel #C12 then put on a clean glove on her left hand. At approximately 10:55 AM, Personnel #C36, the GI technician who assisted Physician #C14 & #C15 took off her soiled gloves. Without washing her hands or applying alcohol rub, she took a small medicine bottle, with a dropper; she then added a few drops to the irrigation water.

Policy # IC 2-00: "Standard Precautions" dated 10/2008 required "Protocol: Standard Precautions are based on principles that all blood, body fluids, secretions...may contain transmissible infectious agents...Standard Precautions are also intended to protect patients by ensuring that healthcare personnel do not carry infectious agents to patients on their hands..."

Policy # IC 2-10: Hand Hygiene" dated 03/2010 required "Categories of opportunities for proper Hand Hygiene: Before patient contact...Before aseptic technique...After patient contact..."

3) On 07/14/11 at approximately 12:35 PM, the surveyor with Personnel #C2 conducted a tour of the hospital's Cardiac Lab. We were joined by the unit manager, Personnel #C29. The three of us observed Patient #C11's cardiac catheterization procedure in Lab A. The surveyor observed Personnel #C30 and Personnel #C37 not properly wearing their masks. The lower portions of their masks were tied loosely which allowed venting. At approximately 1:50 PM, Personnel #C29 was informed of the findings and she stated that the masks should be worn in a secure manner to prevent venting as per hospital policy.

On 07/18/11 at 9:15 AM, the surveyor with Personnel #C2 conducted a tour of the hospital's Cardiac Lab. We were joined by the unit manager, Personnel #C29. The three of us observed Patient #C13's cardiac catheterization procedure in Lab A. At approximately 9:21 AM, the surveyor observed Personnel #C31 with her non-sterile gloves touched the sterile field twice. At approximately 9:25 AM, Personnel #C29 was informed of the findings and she stated that Personnel #C31 should not have touched the sterile field with non-sterile gloves. At 9:30 AM, the physician asked for a sterile catheter. Wearing the same gloves she had worn at the beginning of the procedure, Personnel #C31 obtained a pack of sterile catheter, opened the pack, and handed the opened sterile pack for the physician get the sterile catheter. At 9:33 AM, Personnel #C29 was informed of the findings and was asked how it was supposed to be done. Personnel #C29 replied that Personnel #C31 should have taken off her soiled gloves and performed hand hygiene prior to obtaining the catheter sterile pack.

4) On 07/18/11 at 10:09 AM, the surveyor with Personnel #C2 conducted a tour of the hospital's ambulatory surgery center. We were joined by Personnel #C1 and #C32. At 11:07 AM, the four of us were in the PACU (post-anesthesia care unit). The surveyor observed Personnel #C33 put on a pair of clean gloves and proceeded to perform direct patient care. At 11:10 AM, Personnel #C33 took off her soiled gloves and proceeded to document in the patient's chart. She then pulled the blanket to cover the patient's shoulder. Personnel #C33 did not wash her hands or apply alcohol rub. At approximately 11:15 AM, Personnel #C32 was informed of the findings and he stated that Personnel #C33 should have performed hand hygiene after taking off her gloves.

On 07/18/11 at approximately 11:29 AM, Personnel #C1, #C2, #C32, and the surveyor went to operating room #6 to observe Patient #C16's procedure: open reduction internal fixation on the left ankle. At 11:30 AM, the surveyor observed Personnel #C38 put on a pair of sterile gloves and started to disinfect the patient's left lower extremity in preparation for the surgical procedure. At approximately 11:34 AM, Personnel #C38 took off her soiled gloves and repositioned the patient. She then proceeded to the tourniquet machine to adjust the pressure as ordered by the physician. Personnel #C38 did not wash her hands or apply alcohol rub after taking off her soiled gloves. Personnel #C32 was informed of the findings and stated that Personnel #C38 should have performed hand hygiene after taking off her soiled gloves.

On 07/18/11 at 1:26 PM, Personnel #C1, #C2, #C32, and the surveyor conducted a tour in the ambulatory surgery center's sterile processing area. In the clean area where they packaged the clean instruments for sterilization, the surveyor observed a disposable jacket hung on the upper left corner of a pegboard containing clean instruments hanging in it. Personnel #C20 was asked about the disposable jacket since it was behind her work table. Personnel #C20 immediately removed the disposable jacket and stated it was "clean." Personnel #C32 told the surveyor that the disposable jacket should not have been hung with the cleaned instruments.

At 1:40 PM, Personnel #C1, #C2, #C32, and the surveyor proceeded to go to the decontamination room. The surveyor observed Personnel #C34 come in the room. With a gloved hand, she carried a large deep transparent plastic container that contained dirty instruments and/or equipment. She transferred the dirty instrument and/or equipment to the ultrasound cleaning machine. Wearing the same soiled gloves, she began disinfecting the large deep transparent plastic container and carried the container out of the decontamination room.

At 1:45 PM, Personnel #C32 was informed of the findings. Personnel #C32 was asked how it was supposed to be done. Personnel #C32 explained that prior to cleaning the container; Personnel #C34 should have taken off her soiled gloves and performed hand hygiene.

5) On 07/19/11, during observation of the dialysis unit on the fifth floor at 10:15 AM, the surveyor observed as the Medical Director, Personnel #O4, for the Acute Dialysis Unit consumed a drink from an open Styrofoam cup in the patient treatment area at the nurse's station, while patients in the dialysis unit dialyzed.

In an interview with the supervising nurse and the Director of the dialysis unit (Personnel #O1 and #O2), on 07/19/11 at 2:00 PM, they confirmed that staff members are not allowed to eat or drink in the dialysis unit.

The facility's Acute Dialysis Unit "Infection Prevention Procedures of the Environment" policy RD 06/11 included the following:
"4. Staff members, including physicians, shall not bring food or drinks into the patient care area."

On 07/19/11, during observation of the dialysis unit on the fifth floor at 11:04 AM, the surveyor observed as a nurse assigned to a patient receiving apheresis, use gloved hands to pick up a ball from the floor. The nurse sanitized the ball, and placed the ball on the bedside table. The nurse did not remove the contaminated gloves and sanitize her hands, but instead used the same contaminated gloves to adjust the bloodlines that connected the patient to the apheresis machine.

The facility's STANDARD PRECAUTIONS policy IC 2-00 10/08 includes the following:
"1.B.2.e. Change gloves 1) after handling contaminated items."
The facility's INFECTION CONTROL HAND HYGIENE PROTOCOL IC2-10 03/10 included the following:
"A. Indications for hand antisepsis and hand washing:
b. Before patient contact (before entering the area around the patient that includes the patient's bed, side table, i.v. pole, etc.)
h. After removing gloves.
i. After contact with the patient environment (items around the patient such as the patient's bed, side table, i.v. pole, etc.) if the patient does not have diarrhea or placed in Contact-D isolation."

On 07/19/11 at 11:18 during observation of the dialysis unit on the fifth floor, a nurse was observed entering information into a dialysis machine without gloves, with a patient's blood in the blood lines and while the patient dialyzed.

The facility's Acute Dialysis Unit "Infection Prevention Procedures of the Environment" policy RD 06/11 included the following:

"5. PPE shall be placed in strategic areas in the treatment room. Disposable gloves shall be worn in all procedures involving contact with blood products, veni-puncture and cleaning equipment."

On 7/20/11, during tour and observation of the dialysis unit on the tenth floor, the unit was observed to have a room directly off the patient treatment area, which had a sink with a pHoenix meter station adjacent to it. The room was observed to have various supplies available for patient use: 2 oxygen tanks, 2 dialysis machines, one portable RO, and various Centrisol concentrates. The room also included a microwave, refrigerator, water dispenser, and staff lockers.

(The portable RO machine is water purification system that is connected to the hemodialysis machine and transported to various locations in the acute hospital setting to dialyze the patient when they are not able to be transported to the dialysis unit.)

In an interview with the Unit Director and Equipment Technician (Personnel #O5 and #O2), the equipment technician confirmed that some surfaces of the portable RO machine could not be sanitized after it had been used for patient treatments and was contaminated. They also confirmed that the microwave, refrigerator, and the water dispenser were for staff use.

6) On a tour on 07/12/11 at approximately 1:45 PM with Personnel #B8, the surveyor observed the "turn-over" cleaning of a recently used Delivery Room (OR # 4) located on the 3rd floor (Labor & Delivery Department/ Perinatal Services), where Personnel #B12 cleaned from top to bottom around the OR table and then cleaned the dirty step stool underneath. Personnel #B12 then changed to a clean cloth before cleaning the infant warmer, but did not change her gloves between moving from a "dirty" area to a "cleaner" area.

In an interview on 07/12/11 at approximately 2:15 PM, Personnel #B11 was informed of the above findings, and he agreed that when cleaning medical equipment in the operating rooms that gloves should be changed when moving from a "dirty" area to a "cleaner" area, to prevent contamination of the "cleaner" area.

The facility "Infection Control Protocol/ Standard Precautions" policy IC 2-00, dated 10/08, under B.2(d & e) noted to "remove gloves after contact with...the surrounding environment (including medical equipment) using proper technique," and also to "change gloves after handling contaminated items" and "before touching environmental surfaces after soiling...before touching clean site (moving from "dirty to "clean" sites)."

7) During a tour of the ED at 11:10 A.M. on 07/11/11, accompanied by Personnel #2, the surveyor observed infectious waste, including used syringes, body fluids, and used respiratory equipment that were not disposed of properly in the following patient care areas of the department:

a. Room 3

- The top of the Mayo Stand contained one pair of used gloves, one Endotracheal Tube still inflated, one 10 ml (milliliter) syringe which contained 5 ml of blood, 1 Stylet, 1 used 18 gauge IV catheter and one 5 ml syringe which contained 5 ml of clear fluid.
- The top of the Storage Cart had spots of a brown liquid substance, 1 used yankauer suction tip, 2 soiled 2x2 sponges, a thermometer and a used 20 ml empty syringe.
- The red biohazard container on the floor had blood stained linen on top of it.
- The counter had a 1 ml syringe with an uncapped needle attached to the syringe.

Cubicle 10 - Patient #4 was observed in the bed in cubicle 10. The oxygen flowmeter had a handheld nebulizer containing clear fluid attached with oxygen tubing. The nebulizer and tubing was draped over the flowmeter. The nebulizer was uncovered and did not have a label with patient identifiers. Patient #4 was asked if he had been given a breathing treatment. He stated, "No."

Room 19 - The suction canister on the wall contained approximately 10 ml of clear-pinkish fluid. Suction tubing and a open package containing a yankauer suction tip was attached to suction canister by the suction tubing. The room had been cleaned and indicated ready for use for a new patient.

Cubicle 39 - Patient #5 was observed in the bed in cubicle 39. The air flowmeter had a handheld nebulizer containing clear fluid attached with oxygen tubing. The blue colored wide bore tubing was stuck over the top of the flowmeter with the nebulizer and mouthpiece attached to the oxygen tubing. The nebulizer was uncovered and did not have a label with patient identifiers. Patient #5 was asked if he had been given a breathing treatment. He stated, "No."

During the observation the Charge RN (Personnel #7) and Personnel #2 verified the above findings.

b. RN (Personnel #39) was observed drawing blood for lab work on a patient that was sitting in a chair in the West ED hall. After drawing the blood into the lab tubes, he did not remove the gloves. He carried the lab tubes in his gloved hand over to the computer in the hall. He then proceeded to type on the keyboard off the computer with his contaminated gloves. He then placed stickers on the lab tubes and placed them into a biohazard bag. He then removed his gloves and discarded them in the waste container. He then applied hand sanitizer and took the biohazard bag to the lab. Personnel #2 verified the above findings.

c. The surveyor observed 3 different patients placed in the ED SWAT bed (assessment bed) located in the West ED, Pod 1 at the end of the Nursing Station. The bed was not cleaned between each patient use. The surveyor observed the cleaning process between patients after they were examined by the MD (Personnel #12). RN #9 was observed preparing the bed between patients. RN #9 removed the white paper that partially covered the middle of the bed mattress and did not clean or wipe the bed mattress down with a disinfectant. He then covered the bed with clean white paper between each patient. At that time, RN #9 was asked if it is hospital policy to clean the bed mattress with a disinfectant between each patient prior to placing another patient in the bed. He stated, "Yes." He was asked if he followed hospital policy. He stated, "No." Personnel #2 also verified the above findings.

d. On 07/11/11 at approximately 10:30 AM the surveyor observed the ED rooms located in the Main ED contained a yankauer suction tip in an open package that was attached to the suction canister and available for patient use. The open yankauer suction tips were not discarded between each patient after the patients were discharged from the rooms. At this time the Charge RN (Personnel #7) was asked if it is hospital policy to clean the room between each patient and remove any open supplies and discard them. She stated, "Yes." She was asked if it is hospital policy to keep the open yankauer suction tips attached to the suction canister after each patient had been discharged from the patient room. She stated, "Yes. The suction tips are still covered and in the package. We keep them attached in case of emergency." She was asked if she could verify if the suction tips had not been taken out of the package and tampered with or used between each patient. She stated, "No." She verified each room in the ED had open packages of suction tips attached to the suction canisters.

e. During a tour of the ED at 10:50 A.M. on 07/11/11, the surveyor observed the Environmental Services (EVS) Tech (Personnel #37) transporting waste in an uncovered, overfilled waste cart in the patient care area of the Main ED. The trash bags were stacked approximately 18 inches above the top of the waste cart. Personnel #37 was asked if it is hospital policy to transport waste in the cart when it is overfilled and uncovered. She stated, "Yes. It is in bags."

During a separate tour of the ED at 11:00 AM on 07/12/11, the surveyor observed the EVS Tech (Personnel #14) transporting waste in an uncovered, overfilled waste cart in the patient care area of the Main ED. The trash bags were stacked approximately 24 inches above the top of the waste cart. Personnel #14 was asked if it is hospital policy to transport waste in the cart when it is overfilled and uncovered. She stated, "Yes, it is ok if it is this high (pointed to her upper chest) but no higher than here. (She brought her hand up to the level of her eyes.)"

The Infection Control (IC) Protocol entitled "Standard Precautions" dated 10/08 requires, "Remove gloves after contact with a patient...change gloves...before touching environmental surfaces...Needles and syringes...must be disposed of in rigid, IC approved, puncture-resistant containers at the point of use...All blood specimens are handled as if contaminated by placing in a biohazard labeled bag...Linen: All contaminated linen is placed in a yellow nylon bag at point of use...Patient Care Equipment...must be disinfected or sterilized between patients...Supplies...Supplies which have been in a patient's room...must not be taken back into stock..."

The Infection Prevention (IP) Procedure entitled "Waste Management Procedures" dated 06/11 requires, "Infectious Waste...Needles/Sharps...Liquid Blood/Body Fluids...Waste Disposal Process: Infectious Waste...Needles/Sharps: All used needles and sharps shall be disposed of by placing them in a hospital-approved disposal container...Liquid Blood/Body Fluids...Disposal, in sewer if possible without contaminating self...Disposal suction canisters are discarded in infectious waste, whether full or partially full...Other waste: General/Routine: Waste bagged in clear plastic bags at generation site..."

The Hospital Procedure entitled "Waste Handling" dated 10/01/10 requires, "To establish the proper procedure for waste handling...Tie tops of full waste can liners...Place full waste liners in waste cart, cover cart...Take waste cart to waste holding area...Do not overfill waste can liner with waste..."
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation and interviews with facility personnel, the facility failed to ensure that: A) supplies were safely maintained, in that, expired supplies were available for patient use in 7 of 21 areas, and B) equipment was not safely maintained, in that, there were either expired, or no safety checks of equipment used by, or for patients in 5 of 21 areas surveyed regarding these requirements.

Findings Included:

A) On tours of the facility and selected outpatient clinics on 07/12/11, 07/13/11, 07/14/11 and 07/20/11, the surveyors observed the following expired supplies in patient care areas, available for patient use :

Labor & Delivery, 3 West:
Triage:

1 - Culturette, expired 06/11.
In an interview at 10:30 AM on 07/12/11 with Personnel #B 9, she verified the expired supply in Triage.

Triage Overflow:

7 - surgical blades, expired 2010.
1 - tenderfoot preemie (heel stick device), expired 11/09.
8 - culturettes, expired 11/10.
In an interview at 10:45 AM on 07/12/11 with Personnel #B 8, she verified expired supplies in Triage Overflow.

Neonatal Intensive Care Unit, 3rd Floor:
302 Sub-Station:

1 - 18 gauge needle, expired 05/11.
1 - 20 gauge needle, expired 04/08.
11 - 14 gauge needles, expired 06/11.
In an interview at 2:30 PM on 07/12/11 with Personnel #B 15, she verified expired supplies in the Neonatal Intensive Care Unit.

Homeless Outreach Medical Services (HOMES):
Mobile Clinic # PH010:

5 - 1 cubic centimeter (CC) insulin syringes, expired 03/10 located in a drawer in the nursing station.
1 - skin staple extractor, expired 05/10, found in a cabinet in an exam room.
1 - skin staple extractor, expired 07/10, found in a cabinet in an exam room.

These findings were confirmed in an interview with Personnel #I 1 and #I 7 on 07/13/11 at 10:30 AM.

Homeless Outreach Medical Services (HOMES):
Mobile Clinic # PH014:

71 - blood collection sets, expired 04/11, located in a drawer in the nursing station.
1 - skin staple extractor, expired 05/10, located in a cabinet in an exam room.
These findings were confirmed in an interview with Personnel #I 1 and #I 7 on 07/13/11 at
3:00 PM.

Pediatric Primary Care Clinic:
Outpatient:

9 - packages of 4-0 Monocryl sutures, expired 07/04, located in the supply room.
10 - packages of lubricating jelly, expired 05/11, located in a cabinet in exam room # 3.
2 - sterile cotton tipped applicators, expired 06/11, located in a cabinet in exam room # 6. These findings were confirmed in an interview with Personnel #K 9 and #K 10 on 07/14/11 at 9:30 AM.

Nursing Unit, 7 South:
Inpatient:

9 - neonatal/adult oxygen sensors, expired 12/10, located in a cart in the supply room.
These findings were confirmed in an interview with Personnel #N 10 and #N 14 on
07/20/11 at 2:00 PM.

All of the above expired supplies were found in patient care areas, and were available for patient use.

B) On tours of the facility 07/12/11, 07/14/11 and 07/18/11 the surveyors observed the following equipment used by or for patients, had not been checked for safety, or their safety checks had expired.

Labor & Delivery, 3 West:
Triage:

1 - fetal monitor, expired 06/11.
In an interview at 10:30 AM on 07/12/11 with Personnel #B 9, she verified this expired
equipment check in Triage.

Triage Overflow:

1 - electric patient bed, had no equipment checks.
1 - electric lamp, used for patients, had no equipment checks.
In an interview at 10:45 AM on 07/12/11 with Personnel #B 8, she verified there were
no safety checks on the equipment identified in Triage Overflow.

Labor & Delivery, 3 East:
Room # LDR 8:

1 - electric patient bed, equipment check expired 02/11.
In an interview at 10:45 AM on 07/12/11 with Personnel #B 8, she verified the expired equipment check in Room # LDR 8.

Inpatient Rehabilitation Unit, 8 East:
Physical Therapy Gym:

3 - electric platform exercise mats, had no equipment checks.
In an interview at 3:00 PM on 07/14/11 with Personnel #B 25, and also an interview at approximately 3:00 PM on 07/18/11 with Personnel #B 37, they verified there had been no safety checks performed on the Inpatient electric platform exercise mats.

Simmons Ambulatory Surgery Center:
Medication Area:

1 - Medication refrigerator, equipment check expired 12/10.
In an interview at 11:00 AM on 07/18/11 with Personnel #B 40, he verified the expired
equipment safety check for this medication refrigerator.

The above individual interviews each confirmed that all equipment cited was used in conjunction with direct patient care, and that their safety checks had not been maintained.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation and interview, the hospital failed to ensure that drugs and biologicals were secured and/or locked appropriately to prevent tampering or diversion in 2 of 2 patient care areas (ED Patient Room 2 and ED Patient Room 3) which were readily accessible to unauthorized persons.

Findings Included:

During a tour of the Main ED at 11:00 AM on 07/11/11, the surveyor, accompanied by the ED Charge RN (Personnel #7) and the Intermediate Project Manager (Personnel #2) observed the following unmonitored and unsecured drugs, which were available for use by employees and/or non-employees.

1) ED Patient Room 2, in an unlocked crash cart contained:

- Multiple emergency medications including Epinephrine 1 mg (milligram) 1:10,000 (adrenalin), Atropine Sulfate (anticholinergic agent), and Lidocaine (antiarrhythmic drug).

2) ED Patient Room 3, on top of the counter contained:

- One open 100 ml bottle of Diprivan (Propofol, Hypnotic Agent), one unopened 10 mg bottle of Vecuronium Bromide (muscle relaxant), and one unopened bottle of 10 ml Anectine (muscle paralyzing agent).

During the observations the ED Charge Nurse (Personnel #7) verified the above findings. Personnel #7 immediately removed the medications from Room 3 and notified Pharmacy to secure the medications in the crash cart. She was asked if it is hospital policy to secure drugs and biologicals. She stated, "Yes." She was asked if hospital policy was followed for securing drugs and biologicals. She stated, "No."

The Pharmacy Department Policy entitled "Controlled Substance Storage and Maintenance of Records in the Pharmacy" dated 05/16/11 requires, "All controlled substances shall be stored in a manner consistent with Texas State Board of Pharmacy Regulations and the U.S. Drug Enforcement Administration (DEA) Regulations...controlled substances will be stored in locked cabinets, drawers, in Pyxis Machines...purpose...is to insure the security of controlled substances..."

The Nursing Services Policy entitled "Maintaining & Exchanging Emergency Cart - Main Campus" dated 06/11 requires, "All carts will be kept locked at all times...to ensure integrity and security of emergency drugs and equipment..."
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, review of documentation, and interviews with facility staff, the facility failed to make outdated drugs and biologicals not available for patient use in violation of facility policy as expired medications were found in patient care areas of the facility available for patient use.

Findings Included:

In the Homeless Outreach Medical Services (HOMES) mobile clinic #PH010, the following expired medication was found in a patient care area available for patient use on 7/13/11: poliovirus vaccine, 10 dose vial, expired 6/24/11 located in the medication refrigerator. This finding was confirmed in an interview with facility staff I.1 and I.7 on 7/13/11 at 10:30 AM.

In the Homeless Outreach Medical Services (HOMES) mobile clinic #PH014, the following expired medications were found in patient care areas available for patients use on 7/13/11: [DIAGNOSES REDACTED]/tetanus toxoids for pedi use, 1 dose, 0.5 ml, expired 2/11 located in the medication refrigerator; cephalexin 500 mg, 40 capsules, expired 6/30/11 located in the class D pharmacy box; and 2 bags of 0.9% normal saline for intravenous injection 1000 cc, expired 6/11 located in the crash box. These findings were confirmed in an interview with facility staff I.1 and I.7 on 7/13/11 at 3:00 PM.

The facility policy entitled Pharmacy Services Manual, Inspection of Medication Storage Areas states that "Each inspection shall be a mechanism for assuring the following: "5. That no out-dated medications are present. Out-of-date medications shall be removed from stock and returned to the Bulk Storage Area."
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and interview, the medical records of 19 of 21 patients (Patients #A8, #A9, #A11 through #A14, #A16 through #A24, and #A32 through #A35) treated in the hospital after 12/01/2010, were not complete in that the medical record entries were not dated, timed, and/or signed by the person responsible for providing hospital services to these 19 patients and/or did not contain required documentation.

Findings Included:

The "Patient Discharge Acknowledgment" provider/nurse signatures were not dated and/or timed for the following patients:

Patient #A11 - Nurse signed 04/04/11 and 04/05/11, both of the nurse signatures were not timed.
Patient #A24 - Encounter Date 04/07/11, provider/nurse signature was not dated and timed.
Patient #A35 - Encounter Date 04/06/11, nurse signature was not dated and timed.

The "Patient Discharge Instructions" nurse signatures were not timed for the following patients:

Patient #A8 - "Page 2" nurse signature dated 02/04/11 was not timed.
Patient #A17 - "Page 2" nurse signature dated 01/05/11 was not timed.
Patient #A22 - Nurse signature dated 04/08/11 was not timed.

The "Discharge Report" nurse signatures and/or interpreter signatures were not dated and/or timed for the following patients:

Patient #A8 - Nurse signature dated 02/04/11 was not timed; interpreter signature was not dated and timed.
Patient #A9 - Nurse signature dated 02/15/11 was not timed.
Patient #A32 - Nurse signature dated 05/25/11 was not timed.
Patient #A33 - Nurse signature dated 05/26/11 was not timed.
Patient #A34 - Nurse signature dated 04/04/11 was not timed.

The "Aceptacion de Instrucciones" (Discharge Report) nurse and/or interpreter signature was not timed for the following patients:

Patient #A18 - Interpreter's signature dated 01/25/11 was not timed.
Patient #A21 - Nurse's signature dated 04/08/11 was not timed.

The "Disclosure and Consent for Transfusion of Blood, Blood Components/Derivatives" physician and/or witness signatures were not dated and/or timed for the following patients:

Patient #A9 - patient signed 02/13/11, the physician and witness signatures were not dated and timed.
Patient #A13 - physician signed 05/09/11, the witness signature was not dated and timed.
Patient #A17 - patient signed 12/30/10, the physician and witness signatures were not dated and timed.
Patient: #A21 - physician signed 04/05/11, the witness signature was not dated and timed.

The "Property and Valuables Record" staff signatures were not dated and/or timed for the following patients:

Patient #A13 - admitted [DATE], staff signature was not dated and timed.
Patient #A14 - admitted [DATE], staff signature was not dated and timed.
Patient #A16 - admitted [DATE], staff signature was not dated and timed.
Patient #A17 - admitted [DATE], staff signature was not dated and timed.
Patient #A18 - admitted [DATE], staff signature was not dated and timed.
Patient #A20 - admitted [DATE], staff signature was not dated and timed.
Patient #A21 - admitted [DATE], staff signature was not dated and timed.
Patient #A22 - admitted [DATE], staff signature was not dated and timed.
Patient #A32 - admitted [DATE], staff signature was not dated and timed.

The "Cardiac & Respiratory Arrest Record" signatures were not dated and timed for the following patients:

Patient #13 - 05/08/11 04:41 AM event - physician, recorder, and "med nurse" signatures were not dated and timed.
Patient #20 - 04/30/11 06:05 AM event - physician, recorder, and "med nurse" signatures were not dated and timed.

The "Emergency Services After Visit Summary" nurse signatures were not timed for the following patients:

Patient #A12 - nurse signature dated 03/28/11 was not timed.
Patient #A19 - nurse signature dated 05/03/11 was not timed.

The "Consent to Operation or Other Procedure" physician signatures obtaining consent and/or witness signatures, and/or interpreter signatures were not dated and/or timed for the following patients:

Patient #A11 - Patient signed 04/04/11 at 09:30 AM for "left lower lobe mass, left lung," physician's signature for obtaining consent was not dated and timed; witness signature was not dated and timed.
Patient #A13 - Patient's husband signed 05/09/11 for "femoral or internal jugular...catheter,"
physician's signature obtaining consent was not dated and timed, witness signature was not dated and timed, and interpreter signature was not dated and timed; Patient's husband signed 05/09/11 for "Continuous renal replacement therapy," physician's signature obtaining consent was not dated and timed, witness signature was not dated and timed, and interpreter signature was not dated and timed.
Patient #A14 - Patient signed 06/01/11 09:20 AM for "foot debridement...," physician's signature for obtaining consent was not dated and timed; witness signature was not dated and timed.
Patient #A22 - Daughter signed 03/06/11 04:20 AM for "Ruptured Right middle cerebral artery aneurysm, subarachnoid hemorrhage," the physician's signature for obtaining consent was not dated and timed; the witness signature was not dated and timed; witness signatures (2) dated 03/23/11 were not timed; Daughter signed 03/15/11 03:04 PM for subarachnoid hemorrhage, physician's signature was not dated and timed; witness signature was not dated and timed.
Patient #A34 - Mother signed 03/24/11 02:20 PM for "contracture release...," the physician's signature for obtaining consent was not dated and timed; the witness signature was not dated and timed.

The "Vaccine Consent Form" nurse signature was not timed for the following patient:

Patient #A24 - Nurse signature dated 04/07/11 was not timed.

The "Consent to Operation for Obstetrical Services Vaginal Delivery or Cesarean Section" provider obtaining consent and witness signatures were not dated and timed for the following patient:

Patient #A32 - Patient signed 05/22/11, the provider obtaining consent and witness both did not date and time their signatures.

The "Disclosure and Consent for Procedures" physician signatures obtaining consent and witness signatures were not dated and timed for the following patients:

Patient #A14 - Patient signed 05/17/11, the physician's signature obtaining consent was not dated and timed; the witness signature was not dated and timed.
Patient #A22 - Daughter signed 03/15/11, the physician's signature obtaining consent was not dated and timed; witness signature was not dated and timed.

The "Physician's Order Sheet" physician signature and/or nurse signature was not dated and timed for the following patients:
Patient #A14 - Patient admitted [DATE], orders for "Peripherally Inserted Central Catheter (PICC) Line Placement..." physician's signature was not dated and timed.
Patient #A22 - Patient admitted [DATE], orders for "Peripherally Inserted Central Catheter (PICC) Line Placement..." physician's signature was not dated and timed; nurse's signature was not dated and timed.

The "Nursing Services Pre-Procedure Checklist" nurse signatures were not dated and timed for the following patients:

Patient #A14 - Patient admitted [DATE], the pre-procedure checklist for 05/18/11 and 06/01/11 nurse signatures were not dated and timed.
Patient #A22 - Patient admitted [DATE], nurse's signature was not dated and timed.

The "Operative Suite - Time Out Checklist" signatures were not dated and timed for the following patient:

Patient #A14 - 05/18/11 procedure with time out at 07:45 AM, the surgeon of record, anesthesia provider, and assigned nurse signatures were not dated and timed.

The "Transfer Certification and Consent" physician's signature was not dated and timed for the following patient, and the form was not dated:

Patient #A23 - Benefits of Transfer - Higher level of care, the physician's signature was not dated and timed and form was not dated.

The "Nursing Service Clinical Restraint Flowsheet" nurse signature was not dated and/or timed for the following patients and/or were not complete with start/stop dates:

Patient #A17 - Restraint start 12/30/10 10:00 PM, nurse signature was not dated and timed; Restraint Start 01/01/11 12:00 Midnight, nurse signature was not dated and timed; Restraint time limit 24 hours, was incomplete with no start/stop dates and times, and nurse signature was not dated and timed; Restraint Start 01/04/10 08:00 AM, nurse signature was not dated and timed.

The "Consent for Anesthesia and Sedation" witness signatures were not dated and timed for the following patients:

Patient #A13 - Anesthesia/sedation provider obtaining consent signed 05/11/11, the nurse witness signature was not dated and timed.
Patient #A14 - Anesthesia/sedation provider obtaining consent signed 05/17/11, the witness signature was not dated and timed.
Patient #A17 - Anesthesia/sedation provider obtaining consent signed 01/05/11, the witness signature was not dated and timed.
Patient #A34 - Anesthesia/Sedation provider obtaining consent signed 04/04/11, the witness signature was not dated and timed.

During an interview at approximately 02:00 PM on 07/21/11, the Associate Director Health Information Management (Personnel #A2) was asked if she reviewed the documentation as she obtained her own copy of the documents that were discussed with the surveyor during the medical record review. Personnel #A2 said that she had and agreed with the surveyor's findings.

The "Hospital Health & Hospital System Rules and Regulations" last revised 12/13/10 included that "...every signature must be timed, dated and authenticated."

The "Record of Care" policy (Admin 15-05) revised June 2011 included, "All entries in the medical record will be timed, dated, and authenticated by the author..."
VIOLATION: COMPLIANCE WITH LAWS Tag No: A0020
Based on observation, review of records and interviews, the hospital failed to meet the Emergency Medical Treatment and Labor Act (EMTALA) statute codified at ?1867 of the Social Security Act, (the Act) the accompanying regulations in 42 CFR ?489.24 and the related requirements at 42 CFR 489.20 ( l ), (q), and (r) from 01/01/11 to 07/19/11.

Findings Included:

Hospital policies and procedures were not adopted and enforced to ensure compliance with the EMTALA requirements;

The dedicated Emergency Department (ED) of the hospital did not provide an appropriate medical screening examination (MSE) by a Qualified Medical Professional (QMP) to determine whether or not an emergency medical condition (EMC) existed to all patients who came to the ED requesting an examination;

All patient's who were transferred from the ED to other acute care facilities did not receive stabilizing treatment or an appropriate transfer when the hospital had the capability and capacity to provide the necessary stabilizing treatment; and

Hospital policies and procedures were not adopted and in place to ensure emergency services were available to meet the needs of the individuals with emergency medical conditions after the initial examination to provide treatment necessary to stabilize an individual by providing on-call services of physicians who were current members of the medical staff or had hospital privileges.

Cross refer: Tag A2400
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews, the hospital Governing Body failed to ensure the Medical Staff is accountable to the Governing Body for the quality of care and provision of services provided to patients who presented to the Emergency Department (ED) for emergency care and treatment from 01/01/11 to 07/19/11 in that:

1) Three of 7 patients (Patient #3, Patient #6 and Patient #13) did not receive an MSE (medical screening examination), evaluation or treatment by a qualified member of the medical staff or Qualified Medical Professional (QMP) who was credentialed by the Governing Body to determine if an Emergency Medical Condition (EMC) existed and/or provide stabilization treatment if needed prior to transferring to another health facility.

2) Two of 7 patients (Patient #3 and Patient #13) were evaluated and treated by Resident Physicians (Personnel #83 and Personnel #87) who were not members of the medical staff and not provided privileges by the Governing Body, and were not supervised by a member of the medical staff while providing patient care.

Findings Included:

Review of Medical Records reflected the following findings:

1) Patient #3 presented to Women's ED at 9:46 AM on 07/11/11 with complaints of "severe cramping that travels down legs and nausea." VS (vital signs) were taken and pain was rated at 7 out of 10 on the pain scale (1 being the lowest). There was no documentation of an MSE or complete triage assessment performed in the Women's ED. Patient #3 was transferred to West Assess in the main ED at 10:08 AM to be seen. The Attending Physician was documented as Personnel #88. After arrival to the main ED, the medical record did not reflect any nursing documentation, nursing assessment, or medical screening examination. At 11:38 AM, documentation reflected Resident PGY 3 (Personnel #87) examined the patient for complaints of abdominal pain, severe cramping radiating down the legs, nausea and loose stools. At 11:03 AM, the Resident PGY3 (Personnel #87) ordered labs and "Insert/Maintain IV (intravenous line) Stat (immediately) Continuous." There were no further nursing or physician documentation, assessments, documentation of IV start, or discharge assessment notes. The medical record reflected no documentation of an MSE examination, supervision and/or assessment performed by the ED Attending Physician (Personnel #88).

2) Patient #13 (MDS) dated [DATE] at 10:55 AM with the chief complaint of Eye Pain. The Triage RN (Personnel #82) entered the patient's complaint and did not document any triage assessment, vital signs, pain level, or that the patient was wearing dark sunglasses inside the building due to photophobia (light sensitivity) or having difficulty seeing. RN #82 assigned the patient an Emergency Severity Index (ESI) level 4 and sent her to the UCC (Urgent Care Clinic) unaccompanied by qualified medical personnel. The medical record did not reflect an MSE by a QMP. The patient returned a few minutes later to the main ED due to complaints of severe eye pain (9 out of 10 pain level) unable to see and complaints of nausea. A triage nursing assessment, vital signs, nursing interventions, or MSE was not performed or documented at this time.

At 11:05 AM, the patient was assigned to the west wing of the Main ED. The ED Attending Physician was documented as Personnel #89.

At 11:51 AM, documentation revealed Resident PGY 2 (Personnel #83) examined and treated the patient for bilateral scleral [DIAGNOSES REDACTED]. There was no further nursing or physician documentation, assessment or discharge summary notes. The medical record reflected no documentation of an MSE examination, supervision and/or assessment performed by the ED Attending Physician (Personnel #83).

3) Patient #6, a 3 year old female presented to the Main ED accompanied by her mother on 01/01/11 at 10:30 PM with the chief complaint of fever, nausea, productive cough with yellow phlegm for 2 weeks. Triaminic over the counter medication given at home was ineffective. At 10:52 P.M., the triage RN (Personnel #80) documented the patient was currently febrile at 40.1 degrees Celsius (104.2 degrees Fahrenheit (F), normal temperature 98.6 degrees F). Additional vital signs revealed Pulse 164 (normal range 80-120), Respirations 22 (normal range 20-30), Blood Pressure 80/52 (normal systolic blood pressure range 65-117), and SpO2 (oxygen saturation) of 95% on room air (normal range 100%). At 10:54 P.M., RN #80 documented, "Patient transferred to Hospital C" and at 11:03 P.M. "Patient departed from ED. Follow up with Physician (Personnel #81)." The "Discharge Disposition" reflected, "discharged /transferred to a designated cancer center or children's hospital."

The medical record reflected the Attending ED Physician as Personnel #90. An MSE was not performed by a QMP to determine if an EMC existed. A history and physical assessment was not performed by the ED Physician. There were no ancillary tests ordered, stabilizing treatment provided, physician orders for transfer, a transfer certification and consent form, or an MOT (Memorandum of Transfer) form completed. The RN discharged /transferred the patient to another facility without an appropriate MSE, physician order, stabilizing treatment or appropriate transfer with qualified personnel.

In an interview at 10:00 AM on 07/20/11, the Director of ED (Personnel #17) verified the above medical record findings.

Review of Hospital Personnel Files reflected the following findings:

4) The ED Policy entitled "Triage Guidelines" dated November 2010 required, "All patients requesting care will be entered into the system and given a MSE by a qualified provider in accordance with EMTALA (Emergency Medical Treatment and Labor Act), and Parkland administrative policy...All patients must be screened for medical stability prior to referral for medical screening outside the Main ED..."

The ED Policy entitled "Organizational Plan and Scope of Service" dated June 2011 required, "The ED Role...is to provide optimal emergent care and interventions for patients seeking such care...It is responsible for providing acute emergency care...to all individuals seeking such care...A physician is readily available to examine and treat all patients who present to any area of the ESD (Emergency Services Department)...No patient is denied access to medical treatment...The MSE occurs in the treatment area by a credentialed provider."

The hospital policy entitled "EMTALA" dated June 2011 required, "Any person who comes to Parkland main campus requesting assistance for a potential EMC/emergency services will receive a MSE performed by a QMP to determine if an EMC exists...Persons with EMC's will be treated and their condition stabilized...MSE is the process required to determine, with a reasonable clinical confidence, whether or not an EMC exists...this is evidenced through documentation in the medical record that indicates the patient's medical condition...QMP to perform a MSE at Parkland Health & Hospital System (PHHS) includes: a. doctor of medicine or osteopathy; b. physician's assistant or c. advanced practice providers including nurse practitioner/midwives with Parkland privileges...A patient is stable for transfer if the treating physician attending the patient has determined, within reasonable clinical probability, that the patient is expected to leave the facility and be received at the second facility, with no material deterioration in his/her medical condition...Triage is a sorting process to determine the order in which patients will be provided a MSE by a QMP. Triage is not the equivalent of a MSE and does not determine the presence or absence of an EMC...Transfer means the movement of a living patient to another facility at the direction of any person employed by the clinic or hospital...A MSE is required when an individual: - seeks care in the hospital ESD, - arrives anywhere on the hospital premises and states that he/she has an emergency...the MSE consists of an assessment and any ancillary tests or focused assessment based on the patient's chief complaint necessary to determine the presence or absence of an EMC...is the process a provider must use to reach with reasonable clinical confidence whether an EMC does or does not exist...The MSE must provide evaluation and stabilizing treatment within the scope of the hospital or clinic's abilities...The MSE must be performed by: Physicians and Advanced Practice Providers functioning within the scope of their license who have been credentialed and/or privileged by Parkland's Board of Managers. Non-Physician qualified personnel who perform MSE utilize protocols previously approved by the Medical Staff...The medical record shall reflect the findings of the MSE including any results of any tests performed and analysis including documentation that demonstrates if a EMC does or does not exist (this may include a statement of the patient's general condition upon discharge or transfer)..."

The Administrative Procedure entitled "Graduate Medical Education Supervision" dated December 2010 required, "Attending Physicians are responsible for: the assessment, diagnosis, treatment, and outcomes of all patients...providing the appropriate level of supervision based upon the nature of a patient's condition, complexity of care, and level of competence of the resident's being supervised...Direction of clinical care and supervision of the residents must be documented by the attending physician in the medical record in accordance with the Bylaws and/or Rules and Regulations. In particular, the following events require attending documentation that reflects supervision and ensures comprehensiveness of the record: Patient history and physical examination, and/or patient admission; patient discharge; consultation; surgeries and high risk procedures; and progress notes that cover significant events, complications, patient and family communication, treatments and response to treatment. An attending progress notes is particularly important in the event of transfer of responsibility of care..."

The Texas Occupations Code Section 155.105 entitled "Physician In Training Permit...b. A physician in-training permit does not authorize the performance of a medical act by a permit holder unless act is performed: 1) As part of graduate medical education training program; and 2) under supervision of a physician..."

The Governing Board "Bylaws" dated 06/28/11 required, "The Board is responsible for carrying out its fiduciary and statutory responsibilities in managing, controlling and administering the Hospital District. The Board is ultimately responsible for the quality and safety of care provided by the Hospital District. It is the governing body of the Hospital District responsible for Hospital District Policy...To determine the need for and establish all general policies to be implemented in the operation of the Hospital District...Article X. Medical Staff...The Medical Staff Bylaws shall provide a mechanism for medical staff governance...Non-physician clinical providers are credentialed, privileged, reviewed, recommended, and ultimately approved or denied by the Board pursuant to the Medical Staff process as outlined in the Medical Staff Bylaws...The Medical Staff shall be governed by its own Bylaws...subject to approval by the Board..."

The "Bylaws of the Medical Staff" dated 03/22/11 required, "The Hospital's Medical Staff is responsible for the quality of medical care in the Hospital, and must accept and discharge this responsibility subject to the ultimate authority of the Governing Body; and the cooperation of the Medical Staff, Chief Executive Officer, and Governing Body is necessary to fulfill the Hospital's obligation to its patients...Non-Physician Clinical Provider means an individual who holds an advanced degree in a clinical area, who has been licensed or certified by his or her respective licensing or certifying agencies, and who has received privileges to provide professional clinical services in the hospital. A Non-physician clinical provider must receive the recommendation of and practice under the supervision and/or in collaboration with a sponsoring/supervising physician...Objectives...Assure that all patients admitted to, or treated in, any facility, clinic, department, division, or service of the hospital receive high quality medical care commensurate with the hospital's services and capabilities...Duties of Department and Division Chairs...Shall be responsible for the quality of care in the Department or Division and receive, evaluate, and determine appropriate actions regarding department quality...Be responsible for administrative and professional activities within the Department or Division...improve outcomes, processes and services...Recommend to the MAC (Medical Advisory Committee) policies, procedures and clinical guidelines that guide and support the provision of care, treatment and services for his or her department or division...Cooperate with the Nursing Service and Administration concerning qualifications and competence of licensed and unlicensed personnel, supplies, regulations, clinical guidelines..."

The Medical Staff "Rules and Regulations" dated 12/13/10 required, "Evaluation, Admission, and Discharge of Patients...Each patient's general medical care shall be the responsibility of a Physician Member of the Medical Staff or an Allied Health Professional with privileges necessary to provide the care required...All patient presenting to the ED will be evaluated by medical screen to determine if care can be given in a non-urgent setting. Documentation of the screen will accompany any patient referred to a non-emergent department or clinic...Any person who comes to any hospital facility requesting emergency services will receive a MSE performed by a QMP to determine whether an EMC exists...MSE is the process required to determine, with reasonable clinical confidence, whether or not an EMC exists or a woman is in labor...QMP to perform a MSE at the hospital includes: (1) a doctor of medicine or osteopathy; (2) a physician's assistant; or (3) a nurse practitioner or midwife with hospital privileges..."

5) At 1:30 P.M. on 07/12/11, the Medical Chief of ED Services (Personnel #16) and the Director of ED (Personnel #17) were interviewed.

MD #16 was asked if patient's are medically screened in the ED for EMC's. He stated, "Yes. Every patient who presents for care to the ED gets medical screening." He was asked if the nurses perform medical screening. He stated, "No. The physicians in the ED do the screening." He was asked if the Residents in the ED perform medical screening. He stated, "Yes. They are physicians. The Resident does the initial evaluation and then they discuss and present the case to the Faculty physician." He was asked if the patients that present to the main ED are medically screened before being sent to the UCC. He stated the nurse at triage determines the patient's acuity level using the ESI score. If the patient is assigned to a 4 or 5, the patient can be seen by the physician in the UCC." He was asked to review the hospital ED policy entitled "Triage Guidelines" dated November 2010. He was asked if the policy requires all patients to have an MSE by a QMP for medical stability prior to referral for medical screening outside the Main ED. He stated, "Yes." He was asked if the ED is following the hospital policy for MSE by a QMP. He stated, "No."

He was asked if the nurses or residents are recommended by the Medical Staff and credentialed by the hospital's Governing Body to be a QMP. He stated, "Not that I am aware of." He was asked if the residents are part of the medical staff. He stated, "No. They are physicians but are medical students in their residency and part of the House Staff." He was asked if the hospital governing body credentials and approves privileges for residents or RN's to perform MSEs." He stated, "No." He was asked to review the hospital policy requirements for QMPs performing MSE entitled "EMTALA" dated June 2011 and The Medical Staff Rules and Regulations dated 12/13/10, "Evaluation, Admission, and Discharge of Patients." He was then asked if the hospital policy allows medical residents or RNs to perform MSEs. He stated, "No." He was then asked if the ED is following the hospital policy. He stated, "No."

He was asked if the hospital is capable of medically screening, treating and stabilizing pediatric patients. He stated, "Yes." He was asked if pediatric patients are medically screened and treated in the ED. He stated, "We do not see pediatrics here in the ED. Pediatrics are triaged and transferred to [Hospital C]. If the pedi's are burn patients, they stay here. If they are trauma, we transfer the child to trauma services. We have an agreement with [Hospital C] for pediatrics." He was asked if the physician is responsible for completing a MOT or certification prior to transferring a child to [Hospital C]. He stated, "No. We are not required to by hospital policy and the hospital agreement with [Hospital C]. [Hospital C] is down the hall and a contiguous part of the building. We have an agreement with [Hospital C] to see all of our pedi patients." He was asked if Hospital C is a part of PHHS or if it is a different acute care hospital with a different provider number. He stated [Hospital C] is not a part of PHHS and is a different provider. He was asked to review the hospital policy entitled "EMTALA" dated June 2011 and asked if the policy requires all patients presenting to the ED requesting care will be given a MSE by a QMP to determine if an EMC exists and provide stabilizing treatment prior to transferring to another facility. He stated, "Yes." He was then asked if the hospital policy is following EMTALA rules and regulations in regards to medically screening and providing an appropriate transfer for pediatric patients. He stated, "No."

During this same interview the Director of ED (Personnel #17) was asked if the RNs are providing MSEs prior to referring patients to the UCC. She stated, "No. The RNs are performing a triage. They are using the ESI criteria to make the determination where the patient will be seen by the physician. The physicians do the medical screening." She was asked if the UCC is part of the ED and used as a Fast Track or a separate outpatient clinic. She stated, "It is part of the ED now. It used to be the ACC (Ambulatory Care Clinic) but is now called Urgent Care Clinic." She was asked if the Level 4 and 5 patient's that come from the main ED and the patients that present to the UCC that do not present to the main ED are treated the same. She stated, "Yes. It is a hybrid. They see both patients that present to the ED and walk-ins." She was asked if pediatric patients that present to the ED for medical care are being medically screened by a QMP prior to being transferred to [Hospital C]. She stated, "No. They are being triaged by the RN." She was then asked to review the hospital policies and procedures for QMPs and MSEs. She verified the ED is not following hospital policies and EMTALA requirements in regards to the medical screening and transfer process.

6) In an interview at 9:00 AM on 07/14/11 with the Director of Medical Staff Services (Personnel # 23) she was asked if the House Physicians are part of the Medical Staff. She stated, "No. They are medical residents." She was asked if the residents are credentialed and are provided privileges for clinical care by the Governing Board. She stated, "No." She was asked if the hospital policy and Medical Staff Rules and Regulations allowed a medical resident to be designated as a QMP. She stated, "No." She was asked if it is required by hospital policy and Medical Staff Rules and Regulations that a medical student be supervised by the attending physician or faculty member during clinical care. She stated, "Yes." She was asked to review RY2's (Personnel #10) personnel file and verified the file did not contain an appointment letter from the Governing Body providing privileges to perform MSEs as a QMP.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observation, record review and interviews, the hospital did not ensure all patient's needs for nursing care were met by not providing adequate nurse staffing in the ED for 2 of 2 patients (Patient #3 and Patient #15) from 06/19/11 - 07/11/11 in that patients did not receive appropriate nursing assessments, planning, interventions and/or evaluations. The nurse staffing schedules do not reflect nursing assignments for additional patient beds and chairs located inside the Main ED where patients receive emergency care and treatment.

Findings Included:

During a tour of the main ED at 10:35 AM on 07/11/11, the surveyor, accompanied by Personnel #2, observed and counted a total of 23 patient's waiting in chairs in the West wing halls (POD's [patient care area/unit] 1, 2 & 5) of the ED. Personnel #2 verified the number of patients waiting in the chairs. The surveyor observed patient's being interviewed by staff and physicians, physicians listening to patient's chest's with their stethoscope, lab work drawn, resident physicians giving discharge instructions and IV's being started on patients in the chairs.

At 10:50 AM, the surveyor interviewed Patient #3 that was sitting in one of the chairs in the West Wing. She appeared to be in distress and was leaning over holding her stomach. She was asked by the surveyor if she had been seen by a nurse or a physician. She stated, "No." She was asked how long had she been in the ED. She stated, "I have been here over an hour and have not been seen yet. I went to the Women's emergency room first and was told I was in the wrong place and was sent down here." She was asked why she had come to the ED today. She stated, "My stomach has been hurting real bad that it hurts all the way down my legs. The pain is so much that it makes me sick to my stomach." She was asked what her pain level is on a scale of 0-10 with 10 being the worst pain imaginable. She stated, "Around 7 to 8. If I could just lay down for a minute, it would help."

At 11:05 AM the Charge Nurse (Personnel #7) was asked if the patients in the chairs are assigned a nurse. She stated, "No. These are patients waiting to be examined."
At 11:45 AM the surveyor, accompanied by Personnel #2 toured the East Wing of the Main ED (POD's 3 & 4). The surveyor observed a total of 27 patients waiting in chairs in the halls of the East Wing. Personnel #2 verified the number of patients waiting in the chairs.
Personnel #7 was asked if the patients in the hall chairs of the East Wing are assigned a nurse. She stated, "No." She was asked who is responsible for the patients in the chairs. She stated, "The team lead and the nurses in the PODS."

During a separate tour of the Main ED East Wing at 10:25 AM on 07/12/11, the surveyor accompanied by Personnel #5 observed patients in the hall chairs. The ED RN (Personnel #12) was asked how the PODs are staffed. She stated, "We have 2 RNs and a Team Lead. Myself and the other RNs are assigned to the beds which is 6 beds each and the Team Lead directs the flow of the patients." She was asked which nurse is assigned to the patients in the chairs. She stated, "No one is really assigned to the chairs. The patients in the chairs are waiting to be seen in the SWAT (assessment beds) beds or they are waiting on lab or x-ray." The surveyor asked what SWAT beds are. She stated the SWAT beds are beds the physician uses to examine the patient's in the chairs. The surveyor asked RN #12 who assessed and monitored the patients in the chairs if a nurse is not assigned to them. She stated, "We all keep an eye on them. It is whoever is not busy at the time. The team lead will help with them when we are busy." She was asked to see a copy of the ED Staffing Plan and the Daily Staffing Sheet. She stated, "The charge nurse has them."

2) At 10:40 AM the ED Charge Nurse (Personnel #13) was interviewed. She was asked if she had a copy of the ED Nurse Staffing Plan. She produced a copy of the ED Daily Nurse Staffing Sheet for 07/12/11. She stated, "This is a copy of the staffing plan for the day." The surveyor reviewed the Daily Staffing Sheet and asked if the Daily Staffing Sheet reflected all of the patient assignments for each POD for the day. She stated, "Yes." She was asked if the staffing sheets reflected the assignments for the SWAT beds and chairs. She stated, "No." She then verified the Daily Staffing Sheets did not reflect the patients in the SWAT beds and chairs on the staffing sheets along with a nurse assigned to each patient. She was asked who is responsible for the patient's in the SWAT beds and chairs. She stated, "The POD team is responsible." She was asked if the staffing sheet reflected patient acuity changes and staffing adjustments based on patient acuity changes. She stated, "No."

Review of the ED Daily Nursing Staffing Assignment Sheets reflected the following:

06/19/11 and 07/11/11 did not reflect patient bed assignments. The waiting/assessment chairs, SWAT chairs, or SWAT beds were not listed or accounted for on the daily nurse staffing assignments. The staffing sheets did not reflect adjustment of assignments based on the fluctuating needs of the ED, patient volume or patient acuity as required by the ED Staffing Plan and the Nursing Organizational Plan for ED.

04/01/11 - 06/28/11 did not reflect the patient bed assignments. The waiting/assessment chairs, SWAT chairs, or SWAT beds were not listed or accounted for on the daily nurse staffing assignments. The staffing sheets did not reflect adjustment of assignments based on the fluctuating needs of the ED, patient volume or patient acuity as required by the ED Staffing Plan and the Nursing Organizational Plan for ED.

3) Review of Medical Records reflected:

Patient #3 presented to Women's ED at 9:46 AM on 07/11/11 with complaints of "severe cramping that travels down legs and nausea." VS were taken and pain was rated at 7 out of 10 on the pain scale. She was transferred to "West Assess" in the main ED at 10:08 AM to be seen. After arrival to the main ED, the medical record did not reflect any nursing documentation or nursing assessment. At 11:38 AM, documentation reflected Resident PGY 3 (Personnel #87) examined the patient for complaints of abdominal pain, severe cramping radiating down the legs, nausea and loose stools. At 11:03 AM, the Resident PGY3 (Personnel #87) ordered labs and "Insert/Maintain IV (intravenous line) Stat (immediately) Continuous." There was no documentation the IV was started as ordered. There was no further nursing or physician documentation, assessment or discharge summary notes. The medical record did not reflect an ESI acuity level, complete triage assessment, initial nursing assessment, secondary nursing assessment, nursing interventions for severe pain, physician notification of severe pain, completion of IV order or discharge assessment.

Patient #15 presented to the ED at 12:46 PM on 06/19/11 for complaints of a finger infection, drainage and pain rated 9 out of 10 on the pain scale. At 1:04 PM the patient was assigned to "Pod 6." Initial VS were documented as performed at 1:11 PM with no further repeat VS throughout the stay. At 2:53 PM the patient was assigned to "Main ED." The medical record did not reflect a complete initial triage assessment, triage plan, intervention for complaints of severe pain or ESI acuity level upon admission. At 3:39 PM, the patient was assigned to "Pod 3." An IV was started at 5:42 PM by RN (Personnel #92) without a physician's order. A primary initial nursing assessment was not completed until 10:00 PM. The patient was discharged home at 11:35 PM by the physician. The medical record did not reflect any nursing interventions, physician notification for complaints of severe pain, reassessment of the pain or nursing discharge assessment or discharge vital signs.

4) The ED Policy "Organizational Plan and Scope of Service" dated 06/11 requires, "The ED is broken into specific treatment areas...PODS. Care available to the patient includes initial examination, treatment, intensive medical and nursing management...The triage area is the point of entry. The nursing staff evaluate and define the acuity of a patient's chief complaint...Nurses use established practice guidelines from the Emergency Nursing Association...The Main ED treatment area has 5 PODs of 12 beds each (60 beds), nine critical care rooms...one decontamination room, nine rooms with negative ventilation, one orthopedic room comprised of three beds, and one eye room...Staffing: The ED provides an adequate number of staff...The ESD has a staffing plan which...designates the number and type of staff required...Optimal Standards - Area Staffing Patterns: Optimal staffing for the ED is 22 RN's during peak times from 11 a - 11 p which consists of the following: 1 Charge Nurse, 1 EMS Nurse, 3 Triage Nurses; 1 check-in and 2 triage bay, 5 POD leaders, 10 POD nurses, 2 Critical Care Nurses: 1 West booth and 1 East Critical Care/Trauma, 7 ED Tech/Unit Tech - 2 at triage and 1 in each POD...Optimal POD staffing will consist of three RN's and one ER Tech/Unit Tech. Adjustments will be made as necessary to optimal staffing based on fluctuating needs of the ED, at the discretion of the Charge Nurse on duty. When Optimal POD staffing is affected, the Charge Nurse will notify the ED Service Manager...Assignment...are based upon the skills and qualifications of each staff member..." The ED Staffing Plan did not reflect nurse staffing needs for the patient assessment/waiting chairs or the SWAT beds and chairs.'

The ED handout "Standards of Care" not dated, reflected, "POD System - The policy in this ED is that patients are brought directly to their POD based on a round robin system. Once saturation is established (approximately 20 patients in each POD, the desaturation plan is initiated). Focus begins on dispositions - who has a bed and orders and who can be discharged . Send lower acuity patient to the waiting area (Level 4 and 5 ESI), Reassessment of patients on beds - can they sit in assessment chairs or waiting area?"

The Nursing Policy "Nursing Organizational Plan" dated 06/10 requires, "To outline the mechanism for the provision of nursing care wherever nursing is practiced...In accordance with the State of Texas Nursing Practice Act, the nursing process is the core of all nursing actions in PHHS...The practice of nursing by a RN shall mean assuming responsibility and accountability for nursing activities including assessment, planning, intervention, and evaluation...Nursing care is provided to every patient under the direction of a RN...Scope of Services...Emergency Services...The plan for nursing staff coverage...staffing patterns fluctuate according to the patient acuity, population and specialization of the unit...In areas such as the emergency room ...staffing needs are based on patient volume, acuity and/or area protocols...the Plan is monitored..."

The Nursing Policy "Staffing Plan" dated 06/11 requires, "Nurse staffing requirements are based on the needs of each patient care unit and shift and on evidence relating to patient care needs...To provide an appropriate assessment of the workload based on patient needs on each nursing unit and to provide guidelines to allocate nursing staff...Staffing grids should reflect current minimum standards established by private accreditation organizations, governmental entities, national professional organizations and/or other health care organizations...should be established in accordance with evidence based safe nursing standards and based on Nursing Leaderships assessment of the patient population for each unit...Assignments are based on the staff competency and patient acuity. Additional considerations include...Standards of nursing practice, patient and family needs, infection control, safety, job descriptions, admissions, discharges, transfers, geography...the unit grid will generally be used as an initial determination of numbers and skill mix of staff. The charge nurse may modify the recommended staffing based on patient need or staff considerations...The charge nurse...shall continuously monitor all assignments and take corrective action when indicated..."

The Nursing Policy "Staffing Effectiveness" dated 03/10 requires, "To plan appropriate staffing to ensure the best level of care for our patients and comply with the guidelines of the Hospital Safe Staffing Law...Nurse Staffing Plan - Documents that set minimum staffing levels for each patient care unit and shift. Nurse Staffing Plans are based on: Nursing standards and best practice, Patient characteristics/acuity and number on the unit, Scope of Nursing and health care services provided, Nursing characteristics..."

The "ED Employee Staff Meeting" notes dated "April 2011" reflected, "SWAT Functionality...SWAT Workups: Every module has 2 beds set aside for SWAT workups. The attending physician for the module is responsible for moving patients through the SWAT beds. Patient will spend no more than 30 minutes on a SWAT bed.
SWAT Process:

Patient Flow Scenario 1: POD beds available. Patients go to open beds from triage or EMS/Clinic.

Patient Flow Scenario 2: POD beds are full. Next patient goes to SWAT bed. Nurse notifies attending that patients are on SWAT beds and completes initial assessment. Attending determines if patient is safe to go to waiting room or needs to stay in POD. Disposition of patient in rooms is priority.

Patient Flow Scenario 3: All beds are full including SWAT beds. Next patient to SWAT chair. Registration is OK in SWAT chair. No assessments/treatments! Patients in SWAT chairs = Push patient flow! Communicate with attending to discharge/admit patient on beds.
Nursing Specific Expectations:

POD Lead Expectations: Place patients on beds and hand-off report if applicable to POD nurse...Ensure there is a SWAT bed available and utilize the SWAT bed process - place patient on bed to be evaluated by physician and then the patient moves off bed when exam/tests completed. Assess CP (chest pain) patients as they arrive to the POD and make sure EKG is ordered...Send patients to the waiting room if they are lower acuity or have been seen by a provider...POD Nurse Expectations: Patient in bed to RN assigned/assessed < 10 minutes (it is not an expectation that the POD Lead assess patient prior to placing on beds)...Be prepared to move patients off beds to receive another patient from the chairs in order to expedite the flow of the POD. Disposition to discharge < 30 minutes (discharged patients can be moved to chairs). Constant knowledge of patient care status..."

The hospital "Capacity Management Update" notes by the Vice President and Associate Chief Nursing Officer (VP - CNO, Personnel # 91), not dated, reflected, The Quick Triage Process for Modules 1, 2, 3 and 4. Each module is depicted with a team of 1 Attending Physician, 1 Resident, 3 RN's, 1 Tech, and 1 Registration clerk. Each module is shown to have 12-15 beds. The staffing needs are not addressed for the waiting/assessment chairs or the SWAT beds and chairs in each POD.

5) In an interview at 2:30 PM on 07/19/11 with the VP-CNO (Personnel #91) he was asked to explain the ED Nurse Staffing Plan for the POD system. He stated the ED has a West and an East Wing. Each wing has 2 patient care areas which are broken down into PODS with a total of 4 PODS. Each POD has 12 beds that is staffed by 3 RN's and a Patient Care Tech. One RN is a team leader which directs patient flow and the other 2 RN's are assigned to the beds. Each RN has 6 beds each. The patient's are assigned beds in a "Round Robin" system. In the "Round Robin" System, the first patient is assigned to POD 1, the next patient, POD 2, then POD 3 and POD 4.

He was asked if the POD beds are full, and it is that POD's turn for a patient, does the patient go to another POD? He stated, "No. The patient still goes to the POD in which is it's turn. The patient assignments continue in that fashion, the Round Robin, which motivates the nurses to move the patient's faster. It promotes accountability and team work. If one team does not communicate and work well together, they will have more patients than the other PODS. This system encourages the team to work better and to move the patients out faster."

He was asked what happens if the POD is busy and does not have a bed available. He stated, "Each POD has 3-5 chairs per POD. The patient will be put into a chair to wait for a bed to come available."

He was asked what happens if one POD has a higher acuity level than another POD and if the staffing is adjusted for the higher acuity level. He stated, "No. It is not based on acuity levels. Some PODS will end up having higher acuity levels and more patients than other PODS but it all works out. There are no adjustments. They have their allotted beds and chairs and need to make sure they move the patients."

He was asked if the patients in the chairs are assigned a nurse that is responsible and accountable for monitoring their care. He stated, "No. The chairs are only a waiting room. The patients are not treated in the chairs and are not part of the staffing. The team leaders can monitor the patients while they are in the waiting chairs."

He was asked if the patients in the SWAT beds and chairs are assigned nurses and reflected on the staffing schedule. He stated, "No. The SWAT beds and chairs are used only for the physicians to have a place to examine the patients."

The surveyor explained to the VP-CNO, during the tours of the Main ED, the surveyors observed patients being interviewed, examined, lab work drawn, and IVs being started on patients in the chairs. He stated, "That is not supposed to be happening. The chairs are only supposed to be a waiting area. The patients are supposed to be treated and examined in the SWAT beds then placed back into the chairs." He was asked if the nurse staffing sheets reflected which nurse is responsible for monitoring and assessing the patient after the patient has been examined in the SWAT beds and then have been placed back into the chairs. He stated, "No. It is the POD team's responsibility to monitor the patients in the chairs."
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on observation, interview and record reviews, the hospital failed to ensure the RN supervised and evaluated nursing care for each patient for 7 of 7 patients (Patient #3, Patient #6, Patient #8, Patient #9, Patient #13, Patient #14, and Patient #15) who were seen in the ED from 01/01/11 to 07/19/11. who did not have complete nursing documentation. The nursing notes did not reflect initial assessments, interventions, pain management, medications, treatments, procedures provided, reassessments of interventions, and/or vital signs that are required in order to monitor the patient's condition, communicate necessary patient information to other health care staff involved in the patient's care and ensure appropriate patient care is provided.

Findings Included:

Review of Medical Records reflected the following findings:

1) Patient #3 presented to the ED at 9:46 AM on 07/11/11 with complaints of abdominal pain, severe cramping radiating down the legs, nausea and loose stools. The pain was rated at 7 out of 10 on the pain scale. At 11:03, the Resident (Personnel #83) ordered "Insert/Maintain IV (intravenous line) Stat (immediately) Continuous." There was no documentation the IV was started as ordered. The order was cancelled at 2:42 PM after the patient was discharged . The RN (Personnel #86) documented Patient #3 left at 12:21 PM stating, "Patient states that she does not want to wait any longer and wishes to go home." The medical record did not reflect an ESI (Emergency Severity Index) acuity level, complete triage assessment, initial nursing assessment, secondary nursing assessment, nursing interventions for severe pain, physician notification of severe pain, or discharge assessment.

2) Patient #6 presented to the ED at 10:30 PM on 01/01/11 with complaints of fever, nausea, productive cough with yellow phlegm for 2 weeks presented with an elevated temperature (temp.) 104.2 degrees Fahrenheit (F). The medical record did not reflect an ESI acuity level, initial nursing assessment, pain level, nursing interventions or physician order for medication for elevated temp., or physician notification.

3) Patient #8 presented to the UCC at 8:53 AM on 02/14/11 with complaints of headache and nausea for 1 week after being hit in the head. At 9:48 AM Vital signs reflected a BP (blood pressure) of 159/100 (elevated) and pain scale rated 8 out of 10. The physician documented bruising around the left eye. The medical record did not reflect a complete triage assessment, secondary assessment, nursing interventions for severe pain or elevated BP, physician notification of severe pain or elevated BP, repeat VS or nursing reassessment, or physician order for pain or blood pressure medication.

4) Patient #9 presented to the UCC at 10:19 AM on 03/17/11 with complaints of pain and inflammation in the left breast and axilla (underarm) for 2 weeks. Pain scale rated at 4 out of 10. The medical record did not reflect a complete triage assessment or secondary nursing assessment.

5) Patient #13 presented to the ED at 10:55 AM on 07/19/11 with complaints of bilateral eye pain rated 9 out of 10 on the pain scale, headache, tearing and burning, and blurry vision. The Resident (Personnel # 87) ordered Naproxen 500 mg at 11:50 AM for complaints of pain and was given at 12:00 PM. The medical record did not reflect a complete initial triage assessment, triage vital signs, triage pain level, secondary focused nursing assessment, nursing interventions for complaints of severe pain, notification of physician, or reassessment of pain after pain medication given.

6) Patient #14 presented to the ED at 10:57 AM on 07/19/11 for complaints of severe back pain associated with a fall. The pain was rated 10 out of 10 on the pain scale. The medical record did not reflect an initial triage nursing assessment, secondary nursing assessment, vital signs, pain level, nursing interventions for complaints of severe pain, physician notification, reassessment, repeat vital signs, or discharge assessment.

7) Patient #15 presented to the ED at 12:46 PM on 06/19/11 for complaints of a finger infection, drainage and pain rated 9 out of 10 on the pain scale. Initial VS were performed at 1:11 PM, with no further repeat VS documented throughout the stay. The medical record did not reflect a complete initial triage assessment or ESI acuity level upon admission. An IV was started at 5:42 PM by the RN without a physician's order. A primary initial nursing assessment was not completed until 10:00 PM. The patient was discharged home at 11:35 PM. The medical record did not reflect any nursing interventions or physician notification for complaints of severe pain or reassessment of the pain.

8) The ED Policy entitled "Standards of Documentation" dated 03/10 requires, "The following standards will be followed for documentation on Emergency Services Department (ESD) patients...Initial Triage Documentation to minimally include the following...1. Name of patient. 2. Date of Arrival. 3. Time of Arrival to the ESD. 4. The patient's date of birth. 5. Mode of arrival. 6.Chief complaint. 7. Initial ESI level. 8.General appearance. 9. Subjective and objective assessment that addresses the chief complaint. 10.Initial set of VS. 11. Point of Care Blood Glucose, Urine Pregnancy or Hemocue if needed to determine initial ESI (Emergency Severity Index) Levels. 12. Any interventions initiated at triage, 13. Completed Triage plan...B. Secondary Assessment: 1. Any patient requiring Critical Care Treatment will receive documentation...a. Prehospital and Hx (History), Primary and Secondary Assessment...will be completed during the first assessment. b. Each additional assessment after the initial assessment will be focused on the patient's condition interventions and responses to interventions. c. When assuming care of a critical care patient the on-coming nurse will complete the Primary Assessment and Secondary Assessment...then subsequent documentation will be focused on the patient's condition, interventions and responses to interventions. 2. All other patient's will receive documentation...a. Each patient will have a complete Secondary Assessment...includes the following: 1. Focused chief complaint assessment. 2. Review of medical history. 3. Review of surgical history. 4. Review of allergies. 5. Completion of Regulatory section...b. To indicate that the Secondary Assessment is complete the nurse will select 'Yes' in the '2ndary Assessment Complete'...3. Required minimum documentation after the Initial Triage Assessment will occur based on nursing judgment with consideration of the patient's condition and Initial ESI Level. The documentation provided by the Nurse should reflect: a. Plan of Care. b. Changes in condition. c. Ongoing assessment related to chief complaint. d. Interventions. e. Responses to interventions or procedures. f. Vital signs...7. Upon discharge the following documentation should be completed...Lines, Drains, Airway removals...review of discharge instructions..."

The Administrative Procedure entitled "Assessment - Reassessment" dated 09/10 requires, "To ensure all patients receive the appropriate assessment (including initial/screening and reassessment)...All patients...receiving inpatient, outpatient or emergency services will have an initial assessment and appropriate follow-up assessments based on their individual needs...c. Patient Care Staff. The patient assessment process is collaborative in order to facilitate, identify, and prioritize the patient's needs and determine care...Pain: Onset and duration; location and radiation; quality and severity; factors that exacerbate or relieve..."

The Administrative Procedure entitled "Pain Management" dated 03/08 requires, "To assess and manage acute and chronic pain in a safe and effective manner...Faces Scale (Wong-Baker Pain Scale)- recommended for pediatrics...Pain scale - Pain intensity rating scale used for each patient will be the 0-10 numerical scale where 0 = worst possible pain...Mild pain: 1-3, Moderate pain: 4-6, Severe pain: 7-10...Acceptable pain level - the level of pain (per pain scale) which the patient states they can tolerate without medication or other intervention. Pain Screening - involves using the 0-10 pain scale and documenting a number from 0 - 10. Pain Assessment - Involves assessing location, intensity, quality, duration, aggravating/alleviating factors, effects of pain on activities of daily living (ADL's), and past pain management history...The Documentation of Pain Screening/Assessment and Reassessment is Mandatory: 1. Pain screening/assessment will be documented: On the initial nursing assessment, with routine vital signs...following pain management interventions; to assess relief...when the patient reports pain or appears distress. 2. "No pain" will be documented as "0"...Interventions & Documentation...If the patient's pain score is not at an acceptable level or greater than 4, the nurse should assess and intervene to improve pain control. A reassessment should be carried out in a timely manner. All assessments, reassessments, and interventions must be documented...All medications will be administered according to the physician's orders...The nurse should reassess the patient within a reasonable time of administering pain medications and with each report of new or changed pain...Notify the provider for pain which is greater than the patient's acceptable level post intervention...Reassessment...document intervention and response to intervention...

The Nursing Services Procedure entitled "Vital Signs" dated 12/08 requires, "Vital signs (VS) are an indicator of a patient's general health status and response to treatment...VS are defined as temperature (temp), pulse (HR), respiratory rate (RR), and blood pressure (BP)..."

The Nursing Services Procedure entitled "Nursing Practice Act In The State of Texas" dated 02/01 requires, "Parkland will provide care, treatment and services in accordance with licensure requirements, laws, and rules and regulations set forth by the Texas Board of Nursing...Texas Board of Nursing - Nurse Practice Act..."

The Nursing Services Procedure entitled "Nursing Organizational Plan" dated 02/02 requires, "To outline the mechanism for the provision of nursing care wherever nursing is practiced...Philosophy of Nursing: Central to our philosophy of nursing is the respect for the dignity and worth of the individual. We believe the patient has the right to safe, considerate, respectful care at all times and under all circumstances...We believe the nursing process is the core of all nursing actions. This systematic approach to problem identification, devising and implementing plans for resolution, and evaluating effectiveness of these plans constitutes the process of nursing. Registered Nurses prescribe, delegate, and coordinate the nursing care provided throughout the hospital, and this care is patient-centered and patient-valued. Patient care is personalized by our assistance to those individuals who come to us, sick or well, through activities which contribute to recovery and optimal health...We believe that the quality of nursing care is the responsibility of all nurses and that the monitoring, evaluation and improving of care and services is an integral part of the process of nursing...In accordance with the State of Texas Nursing Practice Act, the nursing process is the core of all nursing actions in Parkland Health & Hospital System (PHHS). The practice of nursing by a RN shall mean assuming responsibility and accountability for nursing activities including assessment, planning, intervention, and evaluation..."

The ED Policy entitled "Organizational Plan and Scope of Service" dated 06/11 requires, "The ED role in the PHHS System is to provide optimal emergent care and interventions for patients seeking such care...The Nursing Process provides the framework for all nursing intervention. Systematic approach to problem identification, planning for problem resolution and evaluation of the effectiveness of intervention to address identified problems constitute the Nursing Process. This process is personalized through patient-specific interventions..."

9) In an interview at 10:00 AM on 07/20/11, the Director of ED (Personnel #17) verified the above medical record findings. She was asked if hospital policies and procedures were followed for documentation of the required nursing processes. She stated, "No."
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the Medical Staff failed to monitor and ensure the Emergency Services Department (ESD) policies and procedures governing the medical care provided in the ESD are current. Three of 3 ED policies and procedures (Organizational Plan and Scope of Service, Triage Guidelines, and EMTALA) do not meet the Medical Staff "Rules and Regulations" and Federal EMTALA requirements to provide to all patients seeking emergency care an appropriate MSE by a QMP to determine if a EMC exists and stabilizing treatment is provided prior to an appropriate transfer to other health care facilities or other departments within the facility. The ED policies and procedures directed personnel to triage pediatric patients with medical complaints to Hospital C, and other adult federally insured patients to federal hospitals (VA hospitals) or nursing homes without either an appropriate MSE or the required Memorandum of Transfer (MOT).

Findings Included:

The ED Policy entitled "Triage Guidelines" dated 11/10 requires, "Triage to [Hospital C]: 1. Medical complaints under [AGE]..."

The ED Policy entitled "Organizational Plan and Scope of Service" dated 06/11 requires, "The Main ED treats patients [AGE] years old and greater requiring emergent and non-emergent evaluation, treatment or procedures..."

The hospital policy entitled "EMTALA" dated 06/11 requires, "[Hospital C] contracts with Parkland to triage, screen and treat children under the age of 14...who are brought to Parkland's ESD...[Hospital C] is contiguous to Parkland's Campus. Retriage children from Parkland's ESD to [Hospital C] will be accompanied by Parkland's staff as appropriate for the chief complaint...Patient Transfers from Parkland...Attachment B, Transfer Decision Matrix...Outgoing from PHHS...MOT: Yes, Except for patients transferred to [Hospital C], Hospital D and other Federal facilities, and nursing homes..."

The Governing Board "Bylaws" dated 06/28/11 requires, "The Board is responsible for carrying out its fiduciary and statutory responsibilities in managing, controlling and administering the Hospital District. The Board is ultimately responsible for the quality and safety of care provided by the Hospital District. It is the governing body of the Hospital District responsible for Hospital District Policy...To determine the need for and establish all general policies to be implemented in the operation of the Hospital District...Article X. Medical Staff...The Medical Staff Bylaws shall provide a mechanism for medical staff governance...The Medical Staff shall be governed by its own Bylaws...subject to approval by the Board..."

The "Bylaws of the Medical Staff" dated 03/22/11 requires, "The Hospital's Medical Staff is responsible for the quality of medical care in the Hospital, and must accept and discharge this responsibility subject to the ultimate authority of the Governing Body; and the cooperation of the Medical Staff, Chief Executive Officer, and Governing Body is necessary to fulfill the Hospital's obligation to its patients...Objectives...Assure that all patients admitted to, or treated in, any facility, clinic, department, division, or service of the hospital receive high quality medical care commensurate with the hospital's services and capabilities...Duties of Department and Division Chairs...Shall be responsible for the quality of care in the Department or Division and receive, evaluate, and determine appropriate actions regarding department quality...Be responsible for administrative and professional activities within the Department or Division...improve outcomes, processes and services...Recommend to the MAC (Medical Advisory Committee) policies, procedures and clinical guidelines that guide and support the provision of care, treatment and services for his or her department or division..."

The Medical Staff "Rules and Regulations" dated 12/13/10 requires, "Evaluation, Admission, and Discharge of Patients...Each patient's general medical care shall be the responsibility of a Physician Member of the Medical Staff or an Allied Health Professional with privileges necessary to provide the care required...All patient presenting to the ED will be evaluated by medical screen to determine if care can be given in a non-urgent setting. Documentation of the screen will accompany any patient referred to a non-emergent department or clinic...Any person who comes to any hospital facility requesting emergency services will receive a MSE performed by a QMP to determine whether an EMC exists...MSE is the process required to determine, with reasonable clinical confidence, whether or not an EMC exists or a woman is in labor...QMP to perform a MSE at the hospital includes: (1) a doctor of medicine or osteopathy; (2) a physician's assistant; or (3) a nurse practitioner or midwife with hospital privileges..."

The "Transfer/Referral Agreement" between Hospital C and Dallas County Hospital District d/b/a Parkland Memorial Hospital (PMH), amended date 10/1994 requires, "3. Standards of Care: The transfer/referral of pediatric patients to and from [Hospital C] and PMH will be accomplished in a medically appropriate manner from physician to physician and hospital to hospital by providing for: a) the use of medically appropriate life support measures which a reasonable and prudent physician in the same or similar locality exercising ordinary care would use to stabilize the patient prior to transfer and to sustain the patient during transfer; and b) the provision of appropriate personnel and equipment which a reasonable and prudent physician in the same or similar locality exercising ordinary care would use for the transfer; and c) the transfer of all necessary records for continuing the care for the patient; and d) the consideration of the availability of appropriate facilities, services, and staff for providing care to the patient. 4. Emergency Medical Conditions. Neither hospital may transfer a patient with an emergency medical condition which has not been stabilized unless: a) the patient or a legally responsible person acting on the patient's behalf, after being informed of the hospital's obligations under this section and of the risk of transfer, in writing, requests a transfer to another hospital; b) a licensed physician has signed a certification, which includes a summary of the risks and benefits, that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient and, in the case of labor, to the unborn child, from effecting the transfer; or c) if a licensed physician is not physically present in the emergency department at the time a patient is transferred, a qualified medical person has signed a certification described in subparagraph (b) above after a licensed physician, in consultation with the person, has made the determination described in subparagraph (b) above and subsequently countersigns the certificate."

At 1:30 PM on 07/12/11, the Medical Chief of ED Services (Personnel #16) was interviewed. He was asked if patients are medically screened in the ED for EMC's. He stated, "Yes. Every patient who presents for care to the ED gets medical screening." He was asked if the nurses perform medical screening. He stated, "No. The physicians in the ED do the screening." He was asked if the Residents in the ED perform medical screening. He stated, "Yes. They are physicians. The Resident does the initial evaluation and then they discuss and present the case to the Faculty physician." He was asked if the patient's that present to the main ED are medically screened before being sent to the UCC. He stated the nurse at triage determines the patient's acuity level using the ESI score. If the patient is assigned to a 4 or 5, the patient can be seen by the physician in the UCC." He was asked to review the hospital ED policy entitled "Triage Guidelines" dated 11/10. He was asked if the policy requires all patients to have an MSE by a QMP for medical stability prior to referral for medical screening outside the Main ED. He stated, "Yes." He was asked if the ED is following the hospital policy for MSE by a QMP. He stated, "No."

Personnel #16 was asked if the nurses or residents are recommended by the Medical Staff and credentialed by the hospital's Governing Body to be a QMP. He stated, "Not that I am aware of." He was asked if the residents are part of the medical staff. He stated, "No. They are physicians but are medical students in their residency and part of the House Staff." He was asked if the hospital governing body credentials and approves privileges for residents or RN's to perform MSE's". He stated, "No." He was asked to review the hospital policy requirements for QMP's performing MSE entitled "EMTALA" dated 06/11 and The Medical Staff Rules and Regulations dated 12/13/10, "Evaluation, Admission, and Discharge of Patients." He was then asked if the hospital policy allows medical residents or RN's to perform MSE's. He stated, "No." He was then asked if the ED is following the hospital policy. He stated, "No."

Personnel #16 was asked if the hospital is capable of medically screening, treating and stabilizing pediatric patients. He stated, "Yes." He was asked if pediatric patients are medically screened and treated in the ED. He stated, "We do not see pediatrics here in the ED. Pediatrics are triaged and transferred to [Hospital C]. If the pedi's are burn patients, they stay here. If they are trauma, we transfer the child to trauma services. We have an agreement with [Hospital C] for pediatrics." He was asked if the physician is responsible for completing a MOT or certification prior to transferring a child to [Hospital C]. He stated, "No. We are not required to by hospital policy and the hospital agreement with [Hospital C]. [Hospital C] is down the hall and a contiguous part of the building. We have an agreement with [Hospital C] to see all of our pedi patients." He was asked if Hospital C is a part of PHHS or if it is a different acute care hospital with a different provider number. He stated Hospital C is not a part of PHHS and is a different provider. He was asked to review the hospital policy entitled "EMTALA" dated 06/11 and asked if the policy requires all patients presenting to the ED requesting care will be given a MSE by a QMP to determine if an EMC exists and provide stabilizing treatment prior to transferring to another facility. He stated, "Yes." He was then asked if the hospital policy is following EMTALA rules and regulations in regards to medically screening and providing an appropriate transfer for pediatric patients. He stated, "No."
VIOLATION: RESPIRATORY CARE SERVICES POLICIES Tag No: A1160
Based on observation, record review, and interview, the hospital failed to ensure the Respiratory Care Department policies and procedures were followed for infection control and prevention practices in that used respiratory equipment was not stored properly, labeled with patient identifiers or disposed of properly in 2 of 2 ED patient cubicles (Cubicle 10 and Cubicle 19) where patient's were present.

Findings Included:

During a tour of the ED at 11:10 AM on 07/11/11, accompanied by Personnel #2, the surveyor observed used respiratory equipment that was not stored properly, labeled with patient identifiers or disposed of properly in the following patient ED rooms/cubicles:

Cubicle 10 - Patient # 4 was observed in the bed in cubicle 10. The oxygen flowmeter had a handheld nebulizer containing clear fluid attached with oxygen tubing. The nebulizer and tubing was draped over the flowmeter. The nebulizer was uncovered and did not have a label with patient identifiers. Patient #4 was asked if he had been given a breathing treatment. He stated, "No."

Cubicle 39 - Patient #5 was observed in the bed in cubicle 39. The air flowmeter had a handheld nebulizer containing clear fluid attached with oxygen tubing. The blue colored wide bore tubing was stuck over the top of the flowmeter with the nebulizer and mouthpiece attached to the oxygen tubing. The nebulizer was uncovered and did not have a label with patient identifiers. Patient #5 was asked if had been given a breathing treatment. He stated, "No."

During the observations the Charge RN (Personnel #7) and Personnel #2 verified the above findings.

The Respiratory Care Department Policy entitled "Processing and Sterilization of Respiratory Equipment" dated 06/11 requires, "Small volume medication nebulizers...Hand-held...Discard after patient use...Discontinuing equipment. Strip disposable supplies from equipment and discard in the appropriate bag/container in area. Place permanent equipment in clear plastic bag...label with a sticker indicating "Soiled" and return to department..."

The Respiratory Care Department Policy entitled "Disposable Equipment Changes" dated 06/11 requires, "To reduce the risk from nosocomial infections...RCP's (Respiratory Care Practitioners) will follow Standard Precautions for infection control...All disposable tubing and equipment will be put in regular bags when removed...label all equipment appropriately with patient identifiers. Label equipment with date and initials..."

In an interview at 1:30 PM on 07/14/11 with the Director of Respiratory Care (Personnel #28), he was asked if the Respiratory Care Department had any infection control policies. He stated, "No. We go by the Hospital Infection Control policies." He was asked if it is the hospital Infection Control policy or Respiratory Care Department policy to discard disposable handheld nebulizers after patient use in the ED. He stated, "Yes." He was asked if it is department policy to label and store hand-held nebulizers in plastic bags at the bedside. He stated, "Yes."
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on observation, review of records and interviews, the hospital failed to comply with 489.24 in that:

1) All patients presenting to the Emergency Department (ED) from 01/01/11 to 07/19/11 were not provided an appropriate medical screening examination (MSE) by a Qualified Medical Professional (QMP) to determine whether or not an emergency medical condition (EMC) existed.
The patients were medically screened by Registered Nurse's (RN's) or Medical Residents who were not determined qualified by hospital bylaws or the medical staff rules and regulations.

Cross refer: Tag A2406

2) Hospital policies and procedures were not adopted and enforced to ensure compliance with Emergency Medical Treatment and Labor Act (EMTALA) requirements are met in order to provide for all patients presenting to the ED for emergency care an appropriate medical screening examination by a QMP to determine whether or not an emergency medical condition exists, provide stabilizing treatment and ensure appropriate transfers.

The hospital EMTALA policy does not meet EMTALA compliance requirements in that it directs medical staff and hospital personnel to refer children under the age of 14 who present to the ED for emergency medical treatment to be triaged, medically screened and treated at a different acute care facility that is not part of the Parkland Health System.

Cross refer: Tag A2406


3) All patient's who were transferred from the ED from 01/01/11 to 07/19/11 to other acute care facilities did not receive stabilizing treatment or an appropriate transfer when the hospital had the capability and capacity to provide the necessary stabilizing treatment.

Pediatric patients were transferred to another facility without an examination by a physician or upon the order of a physician. Patients were transferred without the parent or guardian being informed of the risks and benefits of transfer or obtaining written informed consent.

Cross refer: Tag A2409

4) Hospital policies and procedures were not adopted and in place to ensure emergency services are available to meet the needs of the individuals with emergency medical conditions after the initial examination to provide treatment necessary to stabilize an individual by providing on-call services of physicians who are current members of the medical staff or have hospital privileges from 06/01/11 - 06/30/11;

The hospital did not maintain the required on-call list of specialty physicians and their alternates who are current members of the medical staff or who have hospital privileges including their accurate contact information for 8 of 8 listed specialties;

The on-call schedule reflected Medical Residents, who are not members of the medical staff and do not have hospital privileges were on call for 5 of 8 specialties;

The on-call list did not contain the required individual physician names who were on call for 3 of 8 specialties but rather listed a group name; and

The hospital did not have policies and procedures that: (a) defined the responsibilities of the on-call physician to respond, examine and treat patients with emergency medical conditions, (b) defined the availability of on-call physician requirements for responding to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control, (c) defined if the hospital allows physicians to perform elective surgery or other procedures during the times they are on call, and (d) if the hospital allows physicians to be on-call simultaneously at two or more facilities.

Cross refer: Tag A2404
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation, record review and interview, the hospital did not post signage in the Emergency Department (ED) that was prominent and conspicuous and likely to be noticed by all individuals entering the ED as well as waiting for examination and treatment which specified the rights of individuals with respect to examination and treatment of emergency medical conditions and women in labor as required by the Emergency Medical Treatment and Labor Act (EMTALA).

Findings Included:

During a tour of the ED at 10:15 AM on 07/11/11, the surveyor entered the ED from the outside of the main ED entrance. The surveyor did not observe any EMTALA signage outside the main entrance of the ED.

Upon entry into the facility, the surveyor observed a posting entitled "Parkland and You" on the wall to the right of the entrance. The sign contained numerous postings. The postings at the top of the signage, reading left to right included: "Duty To Report Abuse and Neglect", "Notice Concerning Complaints About Physicians", and Important Numbers for Patient Rights." The EMTALA portion of the signage was located at the bottom left hand corner of the sign which was not prominent or conspicuous and was detracted from by the other postings included on the same signage. The EMTALA notice in English and Spanish was in small font and not clearly visible from a distance of 20 feet.

The surveyor then entered the main ED waiting room where patient registration is performed. The surveyor did not observe any EMTALA signage upon entry to the main ED waiting room. The surveyor toured the main waiting room and found one EMTALA sign posted on the back side of a supporting pole which was visible only to one row of chairs in the back of the waiting room.

The surveyor then toured the triage waiting room. Upon entry, the surveyor observed a posting entitled "Parkland and You" on the back wall of triage. The sign contained numerous postings. The postings at the top of the signage, reading left to right included: "Duty To Report Abuse and Neglect", "Notice Concerning Complaints About Physicians", and Important Numbers for Patient Rights." The EMTALA portion of the signage was located at the bottom left hand corner of the sign which was not prominent or conspicuous and was detracted from by the other postings included on the same signage. The EMTALA notice in English and Spanish was in small font and not clearly visible from a distance of 20 feet.

The surveyor then toured the 3 patient triage rooms. The surveyor did not observe any of the required EMTALA signage posted in the triage rooms.

The surveyor then toured the ambulance entrance. The surveyor did not observe any of the required EMTALA signage posted inside or outside of the ambulance entrance.

The surveyor then toured the West and East wings of the main ED where patient care and treatment is provided. The surveyor did not observe any of the required EMTALA signage posted in the halls or patient treatment rooms of either the West or East wings.

The Administrative Policy, entitled "EMTALA" dated 03/07 requires, "What EMTALA Signage is Required: Each department that provides emergency services shall post a sign (English and Spanish) in a place or places likely to be noticed by all individuals entering the department..."

In an interview at 11:05 AM on 07/11/11, the ED Nurse Supervisor (Personnel #7) confirmed the above findings.



Based on observation and interviews, on 08/29/11 it was determined this element is now present and abated.
The surveyors observed appropriate EMTALA signage present inside and outside the main ED.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on observation, record review and interview, the hospital:

1. Did not maintain an adequate on-call list of specialty physicians and their alternates who are current members of the medical staff or who have hospital privileges with telephone numbers or accurate contact information for 8 of 8 (Apheresis Consult, Burn Consult, Cardiovascular Thoracic Surgery, Drug and Alcohol Emergency Services Department (ESD) Consult, Drug and Alcohol Patient Consult, Emergency General Surgery Consult, Gynecology (GYN) Consult, and Obstetrics (OB) Consult) medical specialties provided by the hospital from 06/01/11 - 06/30/11.

2. The on-call list did not contain the individual physician names who were on call in 3 of 8 specialties (Apheresis Consult, Drug and Alcohol ESD Consult, and Drug and Alcohol Patient Consult) from 06/01/11 - 06/30/11.

3. The on-call schedule reflected Medical Residents who were on call for hospital specialty services that are not current members of the medical staff and do not have hospital privileges as required by the hospital Medical Staff in 5 of 8 (Burn Consult, Cardiovascular Thoracic Surgery Consult, Emergency General Surgery Consult, GYN Consult, and OB Consult) specialties from 06/01/11 - 06/30/11 to provide stabilizing treatment in the event an individual presented with an emergency medical condition.

4. The hospital did not have the required written policies and procedures to ensure emergency services are available to meet the needs of the individuals with emergency medical conditions by failing to: (a) define the responsibilities of the on-call physician to respond, examine and treat patients with emergency medical conditions, (b) defining the availability of on-call physician requirements for responding to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control, (c) defining if the hospital allows physicians to perform elective surgery or other procedures during the times they are on call, and (d) if the hospital allows physicians to be on-call simultaneously at two or more facilities.

Based on observation, record reviews and interviews, on 08/29/11 it was determined this element is now present and abated.
The surveyors observed the testing of the on-call system. The physician response time was within 3 minutes by telephone.


Findings Included:

During a tour of the ED at 10:30 AM on 07/12/11, the surveyor interviewed the ED Nurse (Personnel #12). She was asked if she knew where the physician on-call schedule for emergency consultations was located. She stated, "Yes, it is online." She was then asked to show the surveyor the on-call schedule. ED Nurse #12 pulled up the on-call schedule on the computer. She was then asked to show the surveyor who was on-call for Burn Consultations for this date. ED Nurse #12 showed the surveyor the on-call list for Burn Consult for 07/12/11. The on-call list did not contain the required contact information for the on-call consult but rather a pager icon beside each name or an alternate on-call physician who is a member of the medical staff with hospital privileges.

Review of the on-call "Burn Consult" for 07/12/11 reflected:
1) Priority 1: Resident 1st year (RY1, Personnel #42) 6:00 A.M. - 6:00 PM.
3) Priority 1: RY1 (Personnel #43) 6:00 PM - 6:00 AM.
4) Priority 2: Resident 3rd year (RY3, Personnel #44) 7:00 A.M. - 7:00 A.M.
5) Priority 3: fell ow 6th year (FY6, Personnel #45) 7:00 A.M. - 7:00 A.M.
6) Priority 4: Faculty MD (Personnel #46) 7:00 A.M. - 7:00 A.M.

The ED Nurse (Personnel #12) was asked what Priority 1, 2, 3 and 4 means. She stated, "Priority 1 is the first physician we call, then as we need to, we go to number 2, 3 then 4 to contact the physician on call. If Resident 1 needs help then the next priority level is called." She was asked if they contacted the MD first. She stated, "No. We contact the Priority 1 Resident first." She was then asked how she contacted the on-call physician. She stated, "It is all done online. We click on the pager icon next to their name and it pulls up another screen and we type in the request and the system contacts them." She was then asked to demonstrate the process. The ED Nurse #12 demonstrated by clicking on the pager icon located next to RY1 #42. She was then asked if she knew the contact information of RY1 #42 or if it was posted anywhere where she had access. She stated, "No. We do not have their phone numbers or pager numbers." She was then asked if the paging system or computer was down, how would she get in touch with the on-call physician. She stated, "We would have to call the operator and they will page them. We do not have their cell phone or pager number. It is all on computer."

The surveyor then requested a printed copy of the "On-Call Log" with physician contact information for further review for the dates of 06/01/11 - 06/30/11. The surveyor reviewed a sample of 8 different specialties (Apheresis Consult, Burn Consult, Cardiovascular Thoracic Surgery, Drug and Alcohol Emergency Services Department (ESD) Consult, Drug and Alcohol Patient Consult, Emergency General Surgery Consult, Gynecology (GYN) Consult, and Obstetrics (OB) Consult) specialties from 06/01/11 - 06/30/11 who were on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition.

The "On-Call Log" reflected the following findings:

1) Apheresis Consult: 06/01/11 - 06/30/11

8:00 AM - 5:00 PM On-Call Group: Apheresis Day Consult, Title: Rotation Pager with pager ID
5:00 PM - 8:00 AM On-Call Group: Apheresis Afterhour Consult, Title: Rotation Pager with pager ID
The On-Call Log did not include the individual physician's name, alternate on-call physician, or contact information.

2) Burn Consult:

RY1 (Personnel #48) who is not a member of the medical staff was on call as Priority 1 on 06/01/11, 06/04/11, 06/07/11, 06/10/11, 06/13/11, 06/16/11, 06/19/11, 06/22/11, 06/26/11, and 06/28/11 from 7:00 AM - 7:00 AM.

RY1 (Personnel #49) who is not a member of the medical staff was on call as Priority 1 on 06/02/11, 06/05/11, 06/08/11, 06/11/11, 06/14/11, 06/17/11, 06/20/11, 06/23/11, 06/25/11, and 06/30/11 from 7:00 AM - 7:00 AM.

RY1 (Personnel #51) who is not a member of the medical staff was on call as Priority 1 on 06/03/11, 06/06/11, 06/09/11, 06/12/11, 06/15/11, 06/18/11, 06/21/11, 06/24/11, 06/27/11, and 06/29/11 from 7:00 AM - 7:00 AM.

RY1 (Personnel #52) who is not a member of the medical staff was on call as Priority 1 on 06/26/11 from 7:00 AM - 7:00 AM.

RY2 (Personnel # 47) who is not a member of the medical staff was on call as Priority 2 on 06/01/11, 06/02/11, 06/04/11, 06/06/11, 06/07/11, 06/08/11, 06/09/11, 06/10/11, 06/11/11, 06/12/11, 06/13/11, 06/14/11, 06/15/11, 06/16/11, 06/17/11, 06/20/11, 06/21/11, 06/22/11, 06/23/11, 06/24/11, 06/25/11, 06/26/11, 06/27/11, 06/28/11, 06/29/11, and 06/30/11 from 7:00 AM - 7:00 AM.

RY4 (Personnel # 50) who is not a member of the medical staff was on call as Priority 2 on 06/03/11, 06/05/11, 06/18/11, and 06/19/11 from 7:00 AM - 7:00 AM.

MD (Personnel #46) who is a faculty member and a member of the medical staff was on call as Priority 3 on 06/01/11, 06/02/11, 06/06/11, 06/07/11, 06/08/11, 06/09/11, 06/10/11, 06/11/11, 06/12/11, 06/13/11, 06/14/11, 06/15/11, 06/16/11, 06/17/11, 06/18/11, 06/19/11, 06/20/11, 06/21/11, 06/22/11, 06/23/11, 06/24/11, 06/25/11, 06/26/11, 06/27/11, 06/28/11, 06/29/11, and 06/30/11 from 7:00 AM - 7:00 AM and 06/05/11 from 7:00 PM - 7:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates or personal contact information.

MD (Personnel #30) who is a faculty member and a member of the medical staff was on call as Priority 3 on 06/03/11 from 7:00 AM - 7:00 AM and 06/05/11 from 7:00 AM - 7:00 PM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates or personal contact information.

3) Cardiovascular Thoracic Surgery Consult:

RY1 (Personnel #53) who is not a member of the medical staff was on call as Priority 1 on 06/01/11, 06/03/11, 06/04/11, 06/05/11, 06/07/11, 06/09/11, 06/13/11, 06/15/11, 06/17/11, 06/18/11, 06/19/11, 06/21/11, 06/24/11, 06/27/11, and 06/29/11 from 8:00 AM - 8:00 AM.

RY1 (Personnel #54) who is not a member of the medical staff was on call as Priority 1 on 06/02/11, 06/06/11, 06/08/11, 06/10/11, 06/11/11, 06/12/11, 06/14/11, 06/16/11, 06/20/11, 06/22/11, 06/24/11, 06/25/11, 06/26/11, 06/28/11, and 06/30/11 from 8:00 AM - 8:00 AM.

RY1 (Personnel #55) who is not a member of the medical staff was on call as Priority 1 on 06/03/11, 06/04/11, and 06/05/11 from 8:00 AM - 8:00 AM.

RY4 (Personnel # 56) who is not a member of the medical staff was on call as Priority 2 on 06/01/11, 06/02/11, 06/03/11, 06/06/11, 06/07/11, 06/08/11, 06/09/11, 06/10/11, 06/11/11, 06/12/11, 06/13/11, 06/14/11, 06/15/11, 06/16/11, 06/17/11, 06/20/11, 06/21/11, 06/22/11, and 06/23/11 from 8:00 AM - 8:00 AM.

FY6 (Personnel #57) who is not a member of the medical staff was on call as Priority 2 on 06/04/11, 06/05/11, 06/24/11, 06/25/11, and 06/26/11 from 8:00 AM - 8:00 AM.

FY6 (Personnel #58) who is not a member of the medical staff was on call as Priority 2 on 06/18/11, 06/19/11, 06/27/11, 06/28/11, 06/29/11 and 06/30/11 from 8:00 AM - 8:00 AM.

MD (Personnel #59) who is a faculty member and a member of the medical staff was on call as Priority 3 on 06/01/11, 06/21/11, 06/24/11, 06/25/11, and 06/26/11 from 8:00 AM - 8:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates or personal contact information.

MD (Personnel #60) who is a faculty member and a member of the medical staff was on call as Priority 3 on 06/02/11, 06/03/11, 06/04/11, 06/05/11, 06/09/11, 06/16/11, 06/17/11, 06/18/11, 06/19/11, 06/23/11 and 06/30/11 from 8:00 AM - 8:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates or personal contact information.

MD (Personnel #61) who is a faculty member and a member of the medical staff was on call as Priority 3 on 06/06/11, 06/13/11, and 06/29/11 from 8:00 AM - 8:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates or personal contact information.

MD (Personnel #62) who is a faculty member and a member of the medical staff was on call as Priority 3 on 06/07/11, 06/10/11, 06/11/11, 06/12/11, 06/15/11, 06/22/11, and 06/27/11 from 8:00 AM - 8:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates or personal contact information.

MD (Personnel #63) who is a faculty member and a member of the medical staff was on call as Priority 3 on 06/08/11 and 06/14/11 from 8:00 AM - 8:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates or personal contact information.

MD (Personnel #64) who is a faculty member and a member of the medical staff was on call as Priority 3 on 06/20/11 from 8:00 AM - 8:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for this date or personal contact information.

MD (Personnel #65) who is a faculty member and a member of the medical staff was on call as Priority 3 on 06/28/11 from 8:00 AM - 8:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for this date or personal contact information.

4) Drug and Alcohol ESD Consult: 06/01/11 - 06/30/11:

6:00 AM - 6:00 PM. On-Call Group: Drug and Alcohol Rotation Pager, Title: Rotation Pager with pager ID
6:00 PM - 6:00 AM. On-Call Group: Apheresis After hour Consult, Title: Rotation Pager with pager ID
The On-Call Log did not include the individual physician's name, alternate on-call, or contact information.

5) Drug and Alcohol Patient Consult: 06/01/11 - 06/30/11:

6:00 AM - 6:00 PM. On-Call Group: Drug and Alcohol Rotation Pager, Title: Rotation Pager with pager ID
6:00 PM - 6:00 AM. On-Call Group: Apheresis After hour Consult, Title: Rotation Pager with pager ID
The On-Call Log did not include the individual physician's name, alternate on-call, or contact information.

6) Emergency General Surgery Consult:

RY1 (Personnel #69) who is not a member of the medical staff was on call as Priority 1 on 06/28/11 from 7:00 AM - 7:00 AM.

RY2 (Personnel #66) who is not a member of the medical staff was on call as Priority 1 on 06/02/11, 06/05/11, 06/08/11, 06/11/11, 06/14/11, 06/17/11, 06/20/11, 06/23/11, 06/26/11, and 06/29/11 from 7:00 AM - 7:00 AM.

RY2 (Personnel #67) who is not a member of the medical staff was on call as Priority 1 on 06/03/11, 06/06/11, 06/09/11, 06/12/11, 06/15/11, 06/18/11, 06/21/11, 06/24/11, 06/27/11, and 06/30/11 from 7:00 AM - 7:00 AM.

RY2 (Personnel #68) who is not a member of the medical staff was on call as Priority 1 on 06/26/11 from 7:00 AM - 7:00 AM.

MD (Personnel #70) who is a faculty member and a member of the medical staff was on call as Priority 2 on 06/01/11 and 06/17/11 from 7:00 AM - 7:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates.

MD (Personnel #71) who is a faculty member and a member of the medical staff was on call as Priority 2 on 06/02/11, 06/08/11, 06/14/11, and 06/29/11 from 7:00 AM - 7:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates.

MD (Personnel #72) who is a faculty member and a member of the medical staff was on call as Priority 2 on 06/03/11, 06/15/11, 06/18/11, 06/27/11 and 06/30/11 from 7:00 AM - 7:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates.

MD (Personnel #73) who is a faculty member and a member of the medical staff was on call as Priority 2 on 06/04/11, 06/13/11, 06/20/11, and 06/22/11 from 7:00 AM - 7:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates.

MD (Personnel #74) who is a faculty member and a member of the medical staff was on call as Priority 2 on 06/05/11, 06/11/11, 06/17/11, and 06/23/11 from 7:00 AM - 7:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates.

MD (Personnel #75) who is a faculty member and a member of the medical staff was on call as Priority 2 on 06/06/11 and 06/25/11 from 7:00 AM - 7:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates.

MD (Personnel #76) who is a faculty member and a member of the medical staff was on call as Priority 2 on 06/07/11, 06/10/11, and 06/12/11 from 7:00 AM - 7:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates.

MD (Personnel #77) who is a faculty member and a member of the medical staff was on call as Priority 2 on 06/09/11 from 7:00 AM - 7:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for this date.

MD (Personnel #30) who is a faculty member and a member of the medical staff was on call as Priority 2 on 06/19/11 from 7:00 AM - 7:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for this date.

MD (Personnel #78) who is a faculty member and a member of the medical staff was on call as Priority 2 on 06/21/11, 06/24/11, and 06/28/11 from 7:00 AM - 7:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for these dates.

MD (Personnel #79) who is a faculty member and a member of the medical staff was on call as Priority 2 on 06/26/11 from 7:00 AM - 7:00 AM. The schedule did not reflect an alternate on-call physician that is a member of the medical staff for this date.

7. GYN Consult: From 06/01/11 - 06/30/11 reflected RY2 and RY3 Residents on-call with no faculty members, members of the medical staff or alternates scheduled as on-call.

8. OB Consult: From 06/01/11 - 06/30/11 reflected RY3 and RY4 Residents on-call with no faculty members, members of the medical staff or alternates scheduled as on-call.

The Administrative Policy 6-46 entitled, "On-Call Coverage Schedules" dated 06/11 reflected, "To establish standards and procedures to support compliance with federal and state regulations related to the availability, maintenance, and archival of on-call schedules...Each schedule must include the physician responsible for providing the primary on-call coverage as well as the backup coverage/escalation, up to and including the faculty physician responsible for that service...required to provide coverage every day of the calendar year, including after-hours, weekends and holidays..."

The hospital policy entitled "EMTALA" dated 06/11 requires, "If needed to complete the medical screening and stabilizing treatment, on-call physicians are available in a timely manner that will not delay the patient's needed treatment. If a physician does not respond in a timely manner, the Chief of Service/Department will be notified to obtain coverage and the situation shall be reported to the Medical Advisory Committee...Who May Perform The Medical Screening: The medical screening exam must be performed by: Physicians and Advanced Practice Providers functioning within the scope of their license who have been credentialed and/or privileged by Parkland's Board of Managers..."

The Medical Staff "Rules and Regulations" dated 12/13/10 requires, "Section 1. Evaluation, Admission, and Discharge of Patients. 1.2 An appropriately licensed member of the Medical Staff shall be responsible for the diagnosis and treatment of each patient within the area of his/her privileges...1.5 Any person who comes to any hospital facility requesting emergency services will receive a medical screening performed by a qualified provider...medical screening examination is the process required to determine, with reasonable clinical confidence, whether or not an emergency medical condition exists...Qualified Provider to perform a medical screen at the hospital includes: (1) a doctor of medicine or osteopathy; (2) a physician assistant; or (3) a nurse practitioner or midwife with hospital privileges...1.7 Other direct medical care of patients shall be provided by House Staff or by other specified professional personnel under the appropriate degree of supervision by a Medical Staff member with clinical privileges...2.7 Consultations. The purpose of a consultation is to provide prompt and expert specialty evaluation and clinical management advice that benefits the patient and meets the expectation of both the patient and requesting physician...The Physician Member is ultimately responsible for the quality and content of the consultation...Indications for consultation shall include...when a patient requires care which is outside the scope of privileges granted the attending physician...Section 4. Supervision of House Staff, Medical Students, Physician Assistants, Advanced Practice Nurses, and Clinical Pharmacists. 4.1 House Staff. a. House Staff are physicians or dentists in post graduate training who are pursuing clinical training at the hospital. House Staff may provide clinical care...shall be supervised by a Physician Member...House Staff are not part of the Medical Staff..."

The "Bylaws of the Medical Staff" dated 03/22/11 requires, "Medical Staff membership is limited to Physicians, Dentists, Oral and Maxillofacial Surgeons and Podiatrists...Practitioners are eligible for membership only if they...f. Respond to, examine, and treat patients with emergency medical conditions when scheduled for "on-call" coverage...D. Responsibilities of Membership...12. Each member shall participate in emergency and consultation services as appropriate in all aspects of clinical coverage and/or consultation as appropriate...Article V. Categories of the Medical Staff...Section C. Consulting Staff. The consulting staff shall consist of physicians, dentists, oral and maxillofacial surgeons and podiatrists...may participate in teaching activities for medical students, residents...Article VI. House Staff...May provide clinical care and write orders and notes in the medical record...shall be supervised by a member of the Medical Staff...House Staff is not part of the Medical Staff..."

The Governing Body "Bylaws" dated 06/28/11 did not address the on-call requirements of the Medical Staff.

The Administrative policy for On-Call Coverage, the hospital policy for EMTALA, the Medical Staff Bylaws, Rules and Regulations or the Governing Body Bylaws did not address if the on-call physician has the option of sending a representative to appear at the hospital and provide further assessment or stabilizing treatment to an individual or if a resident physician is qualified to assume on-call coverage or appear at the hospital for the on-call physician.

In an interview at 1:30 PM on 07/12/11, the Director of ED (Personnel #17) and the Chief of ED Services (Personnel # 16) was asked how the ED personnel and ED physicians made the determination of which consulting physician to call first on the on-call schedule. The Chief of ED Services stated, "All on-call Priority 1 is called first." The Director of ED and Chief of ED Services was asked if the ED has an on-call policy for consultations. They both stated, "No."

In an interview at 9:30 AM on 07/13/11, the Director of Call Center Operations (Personnel #21) was asked if the Call Center is responsible for the On-Call Schedule. She stated, "Yes." She was then asked if the On-Call Schedule contains the current contact information for the physicians on-call for each shift scheduled. She stated, "No. We do not publish their contact information. All the on-call physicians have pagers and we do not publish the numbers because the pagers change frequently. All orders for consults go into the EPIC (computer) system and the system will page the current physician on-call." She was then asked how the hospital personnel would contact the physician on-call in the event of a computer failure. She stated, "Our computer system is backed up. If the personnel needs to get in touch with the physician, and is unable to use the computer, they can call the operator at the call center and the operator will contact the physician."

In an interview at 9:00 AM on 07/14/11, the Director of Medical Staff Services (Personnel #23) was asked if it is hospital policy to allow Residents to be scheduled on-call for specialty consultation services. She stated, "The Residents are physicians and physicians are allowed to take call under our policy." She was then asked if the Residents are members of the Medical Staff and credentialed with clinical privileges by the hospital Governing Body. She stated, "No." She was asked to review the Medical Staff Rules and Regulations, Bylaws and Governing Body Bylaws. She was then asked if the Medical Staff Rules and Regulations, Bylaws and Governing Body Bylaws addressed on-call requirements or coverage. She stated, "No. The rules and regulations or bylaws do not speak to on-call requirements or coverage." She was asked to review the hospital policies for "Call Coverage Schedules" and "EMTALA" and asked if the policies addressed on-call requirements or coverage. She stated, "No." She was asked if the hospital had any other policies or documents that addressed the hospital's responsibilities in regard to physician on-call policies and coverage requirements. She stated, "No."
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interviews and record reviews, the hospital's Governing Board failed to:

1) Ensure all patients presenting to the Emergency Department (ED) from 01/01/11 to 07/19/11 received an appropriate medical screening examination to determine whether or not an emergency medical condition existed, stabilizing treatment was provided and appropriate transfers were initiated if needed. The Registered Nurse's (RN's) and Medical Residents who performed the medical screening examinations (MSE's) in the ED were not appointed through the hospital's credentialing process as Qualified Medical Professional (QMP). The RN's and Medical Residents performing MSE's were not recommended by the Medical Staff, nor appointed by the Governing Board to provide MSE as QMP.

2) Adopt and enforce a hospital policy to ensure EMTALA requirements are met in order to provide for all patients presenting to the ED for emergency care an appropriate medical screening examination by a QMP to determine whether or not an emergency medical condition exists, provide stabilizing treatment and appropriate transfers. The hospital EMTALA policy does not meet EMTALA compliance requirements in that it directs medical staff and hospital personnel to refer children under the age of 14 who present to the ED for emergency medical treatment to be triaged, medically screened and treated at a different acute care facility that is not part of the Parkland Health System.

It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk of their emergency health condition not being stabilized thus potentially causing them to worsen or possibly die.

Findings Included:

During a tour of Main ED at 10:50 A.M. on 07/11/11, the surveyor observed Patient # 3 sitting in a chair in the hall inside the West Wing. She appeared to be in distress and was leaning over holding her stomach. She was asked by the surveyor if she had been seen by a nurse or a physician. She stated, "No." She was asked how long had she been in the ED. She stated, "I have been here over an hour and have not been seen yet. I went to the Women's emergency room first and was told I was in the wrong place and was sent down here." She was asked why she had come to the ED today. She stated , "My stomach has been hurting real bad that it hurts all the way down my legs. The pain is so much that it makes me sick to my stomach." She was asked what her pain level is on a scale of 0-10 with 10 being the worst pain imaginable. She stated, "Around 7 to 8. If I could just lay down for a minute, it would help."

During a separate tour of the hospital at 10:55 A.M. on 07/19/11, the surveyor observed Patient #13 in the hallway leading away from the Main ED. Patient #13 was observed following closely behind her companion, walking slowly, with her hand on her partner's shoulder, being led down the hallway. She was observed wearing sunglasses inside the building and to be having difficulty walking and following the companion. The surveyor observed a printed hospital map in the companion's hand. The surveyor overheard Patient #13 tell her companion that she was not sure she could make it to the clinic because she could not see and was in so much pain. The surveyor asked Patient #13 and the companion if they needed any assistance. The companion told the surveyor they had just come from the ED and was trying to make it to the UCC (Urgent Care Clinic). The surveyor asked Personnel #5, who was accompanying the surveyor to the ED to find a wheelchair to assist Patient #13.
She was asked why she had presented to the ED. Patient #13 stated she had slept in her contacts and they scratched her eyes a few days ago and the pain is getting worse. She stated she could not see, her eyes were watering and the pain was really bad. The surveyor asked if the Triage RN that checked her in asked what pain level she is experiencing. She stated, "No." The surveyor explained the 0-10 pain level scale (0 being no pain and 10 being the worst imaginable pain) to the patient and asked her pain level. She stated she was a 9 out of 10. She was then asked if the Triage Nurse took her vital signs or assessed her. She stated, "No. She just took my information and told us to go to the UCC and gave us the map." The surveyor asked to see the map. The copy of the map contained a floor plan of the ground floor and first floor of the hospital with written directions in English and Spanish to the UCC on first floor. The UCC was shown to be located on the first floor at the opposite end of the hospital.

At this time, Patient #14 stopped in the hall across from the surveyor. The surveyor observed the patient leaning against the wall, bent over with a grimace on her face. A copy of the same map was observed to be in her hands. Patient #14 stated, "I am so lost. I don't know where to go. Can you help me? They sent me from the emergency room to go to another clinic but I don't know how to get there. I am hurting so bad I don't even know if I can walk that far." Personnel #5 stated she would go get someone else to help assist Patient #14. The surveyor interviewed Patient #14 and inquired if she had been seen or checked into the main ED. The patient stated, "Yes. The nurse checked me in and gave me this map and told me to go to the clinic." She was asked why she presented to the ED today. She stated her lower back was hurting so bad she could barely walk. She was asked if the nurse took her vital signs or assessed her. She stated, "No." She was asked if the triage nurse asked her what her pain level is. She stated, "No." The surveyor explained the 0-10 pain level scale (0 being no pain and 10 being the worst imaginable pain)to the patient and asked her what her pain level is. She stated she was a 10 out of 10.

While waiting for assistance, Patient #13 was leaning against the wall and stated she was getting nauseated and did not feel well. Personnel #5 stated she would remain with Patient #14 while the surveyor and Patient #13's companion assisted Patient #13 back to the main ED. The Director of ED (Personnel #17) was at the triage desk. The surveyor asked Personnel #17 to assist Patient #13.

Review of Medical Records reflected the following findings:

Patient # 3 presented to Women's ED at 9:46 A.M. on 07/11/11 with complaints of "severe cramping that travels down legs and nausea." VS were taken and pain was rated at 7 out of 10 on the pain scale. She was transferred to West Assess in the main ED at 10:08 A.M. to be seen. After arrival to the main ED, the medical record did not reflect any nursing documentation or nursing assessment. At 11:38 A.M., documentation reflected Resident PGY 3 (Personnel # 87) examined the patient for complaints of abdominal pain, severe cramping radiating down the legs, nausea and loose stools. At 11:03 A.M., the Resident PGY3 (Personnel # 87) ordered labs and "Insert/Maintain IV (intravenous line) Stat (immediately) Continuous." There was no documentation the IV was started as ordered. There was no further nursing or physician documentation, assessment or discharge summary notes. The medical record reflected there was no MSE examination performed by the ED Medical Staff member or QMP. The medical record did not reflect an ESI acuity level, complete triage assessment, initial nursing assessment, secondary nursing assessment, nursing interventions for severe pain, physician notification of severe pain, completion of IV order or discharge assessment.

Patient # 13 (MDS) dated [DATE] at 10:55 A.M. with the chief complaint of Eye Pain. The Triage RN (Personnel # 82) entered the patient's complaint and did not document any triage assessment, vital signs, pain level or that the patient was wearing dark sunglasses inside the building due to photophobia (light sensitivity) or having difficulty seeing. RN #82 assigned the patient an ESI level 4 and sent to the UCC unaccompanied by qualified medical personnel. The medical record did not reflect a MSE by a QMP. The patient returned a few minutes later to the main ED due to complaints of severe eye pain (9 out of 10 pain level) unable to see and nauseated. A triage nursing assessment, vital signs, nursing interventions or MSE was not performed or documented at this time. The ESI level was not elevated to a 3 as required by ED policies and procedures.
At 11:05 A.M., the patient was assigned to the west wing of the Main ED.
At 11:21 A.M., VS were performed by RN (Personnel # 9). The VS were noted to be within normal range and the Pain Severity was rated at a level 9. The ED Notes reflected, "Patient with reports of bilateral eye pain since Sunday...reports she slept with her contacts in and the next morning has increase pain...now has tearing and burning...reports blurry vision. At 11:23 A.M. Patient #13 was assigned an ESI level 3 by the RN # 9. The medical record showed the RN did not perform a focused nursing assessment or any nursing interventions for complaints of severe pain at this time. At 11:51 A.M., documentation revealed Resident PGY 2 (Personnel # 83) examined and treated the patient for bilateral scleral [DIAGNOSES REDACTED]. There was no further nursing or physician documentation, assessment or discharge summary notes. The medical record reflected there was no MSE examination performed by an ED Medical Staff member or QMP.
A triage nursing assessment or medical screening examination was not performed in the Main ED by a QMP to determine if an EMC existed prior to sending the patient to the UCC.
The triage nurse failed to identify and assess the correct ESI level as a 3 per policy requiring the patient be seen in the Main ED when severe pain is present.

Patient # 14, a [AGE] year old female presented to the Main ED at 10:57 A.M. on 07/19/11 for complaints of severe back pain. Her past medical history was available to the triage nurse from previous visits to the ED in the electronic medical record which showed multiple comorbidities including Hepatitis C, Crack Cocaine Use, IV Drug User, Homelessness, Habitual Alcohol Use, Bipolar Disorder, Schizophrenia, HIV (Human Immunodeficiency Virus) Infection and HSV (Herpes Simplex Virus) Infection. The Triage RN (Personnel # 82) entered the patient's complaint and did not document any triage nursing assessment, vital signs, pain level or history of multiple comorbidities. RN #82 assigned the patient an ESI level 4 and the ED destination as ACC (Ambulatory Care Clinic).
The medical record did not reflect Patient #14 was sent to the UCC or if the patient was accompanied by qualified medical personnel.
The physician (Personnel # 85) in the UCC documented, "Problem has been gradually worsening...associated with fall...pain severity of 10/10..."
A triage nursing assessment or medical screening examination was not performed in the Main ED by a QMP to determine if an EMC as required prior to sending the patient to the UCC.
The triage nurse failed to identify and assess the correct ESI level as a 3 per policy requiring the patient be seen in the Main ED when severe pain and multiple comorbidities are present.

Patient #6, a 3 year old female presented to the Main ED accompanied by her mother on 01/01/11 at 10:30 P.M. with the chief complaint of fever, nausea, productive cough with yellow phlegm for 2 weeks. Triaminic over the counter medication given at home was ineffective for control. At 10:52 P.M., the triage RN (Personnel #80) documented the patient was currently febrile at 40.1 degrees Celsius (104.2 degrees Fahrenheit (F), normal temperature 98.6 degrees F). Additional vital signs revealed Pulse 164 (normal range 80-120), Respirations 22 (normal range 20-30), Blood Pressure 80/52 (normal systolic blood pressure range 65-117), and SpO2 (oxygen saturation) of 95% on room air (normal range 100%). At 10:54 P.M., RN #80 documented, "Patient transferred to Hospital [C]" and at 11:03 P.M. "Patient departed from ED. Follow up with Physician (Personnel #81)." The "Discharge Disposition" reflected, "discharged /transferred to a designated cancer center or children's hospital."
The medical record reflected a medical screening examination was not performed by a QMP to determine if an EMC existed, an assessment or history and physical performed by an ED Physician, ancillary tests, stabilizing treatment provided, physician orders for transfer, a transfer certification and consent form or an MOT form. The nurse failed to document the required ESI Acuity level, nursing interventions, or QMP notification. The nurse also failed to perform a nursing assessment or address the complaints of nausea or productive cough. The RN discharged /transferred the patient to another facility without an appropriate MSE, physician order, stabilizing treatment or appropriate transfer with qualified personnel.

In an interview at 10:00 A.M. on 07/20/11, the Director of ED (Personnel #17) verified the above medical record findings.

Review of Hospital Personnel Files reflected the following findings:

The personnel files for RN # 8, RN # 9, and RN # 15 who provides triage and medical screening in the ED did not contain a recommendation from the Medical Staff or an appointment letter from the Governing Board designating her as a QMP to provide MSE's in the ED.

The personnel file for Medical Resident Year 2 (Personnel # 10) who provides medical screening in the ED did not contain a recommendation from the Medical Staff or an appointment letter from the Governing Board designating him as a QMP to provide MSE's in the ED.

The ED Policy titled "Triage Guidelines" dated 11/10 requires, "To establish consistent guidelines for the triage of patients that present to the Emergency Services Department (ESD) for care...To ensure that all patients are triaged to the appropriate area to provide them with optimal care...All patients requesting care will be entered into the system and given a MSE by a qualified provider in accordance with EMTALA, and Parkland administrative policy...All patients must be screened for medical stability prior to referral for medical screening outside the Main ED. Any patients meeting ESI Level 1 or 2 criteria should be seen and stabilized in the main ED prior to referral...Triage to Hospital C: 1.Medical complaints under [AGE]. 2. Trauma under [AGE]. 3. Patient's and guardian's have the right to choose the facility of their choice. If the patient/guardian requests treatment at Parkland, regardless of the triage criteria, patients have the right to be seen in the facility of their choice. The patient will be registered and granted access to care at Parkland. 4. Voluntary children presenting with a guardian requesting care for a psychiatric complaint...Triage to UCC: 1.Patients being sent to the UCC clinic will meet the level 4 or 5 ESI criteria. 2. Special attention should be paid to patients with co-morbitdi/ities like diabetes or hypertension to ensure that these patients are not an ESI level 3 as indicated by blood pressure findings or blood sugar levels. 3. Patients with abdominal pain will not be sent to the UCC, as the necessary work-up for this complaint would preclude an ESI level of 4 or 5..."

The ED Policy titled "Triage Acuity Levels" dated 06/11 requires, "To provide an accurate system by which patients are triaged and assigned a level of care...In order to provide guidelines for assigning each patient that presents at triage an acuity level, the ESD uses the established ESI acuity system...Level One...patients require immediate life saving interventions... Level Two...patients have a condition that may require immediate interventions...to help determine whether the patient meets level 2 criteria are: is this a high risk situation, is the patient confused, lethargic, or disoriented, and is the patient in severe pain or distress?...Any patient meeting level 3 ESI score with abnormal vital signs (VS) should be considered for uptriage to level 2 acuity...ESI level 3, 4, and 5 are decided by assessing both acuity and predicting resource needs...Level 3...patients may require many different resources...consider uptriage to ESI 2 if any VS criterion is exceeded...Level Four...patients are stable but may require one resource...Level Five...patients are stable with no resources required for their care...ESI Algorithm: If patient has abnormal vitals such as: Heart Rate (HR) >100, Respiratory Rate (RR) >20, SaO2 (oxygen saturation) < 92% and Temp. (temperature) <34 or >39...Reference: Gilboy N, Tanabe P, Travers D, Rosenau AM, Eitel DR. Emergency Severity Index, Version 4: Implementation Handbook. AHRQ Publication No. 05-0046-2. Rockville, MD: Agency for Healthcare Research and Quality. May 2005."

The hospital's copy of the "Emergency Severity Index, Version 4: Implementation Handbook" provided to the surveyor reflected, "Chapter 3. Introduction to the Emergency Severity Index...Decision Point D: The Patient's Vital Signs. Before assigning a patient to ESI level 3, the nurse needs to look at the patient's vital signs and decide whether they are outside the accepted parameters for age...If the vital signs are outside accepted parameters, the triage nurse should consider upgrading the triage level to ESI level 2...Danger Zone Vital Signs: Age 3-8 years, HR > 140, RR > 30, SaO2 < 92%...Chapter 6. The Role of Vital Signs in ESI Triage...D. Danger Zone Vital Signs: Consider uptriage to ESI 2 if any vital sign criterion is exceeded. Pediatric Fever Considerations...3 months to 3 years of age: Consider assigning ESI 3 if: temp. > 39.0 C (102.2 F)...The range of vital signs may provide supporting data for potential indicators of serious illness. If any of the danger zone vital signs are exceeded, it is recommended that the triage nurse consider up-triaging the patient from level 3 to level 2..."

The ED Policy titled "Standards of Documentation" dated 03/10 requires, "The following standards will be followed for documentation on emergency services department patients...Initial Triage Documentation to minimally include the following...1.Name of patient. 2. Date of Arrival. 3. Time of arrival to the ESD. 4. The patient's date of birth. 5. Mode of arrival. 6. Chief complaint. 7. Initial ESI level. 8. General appearance. 9. Subjective and objective assessment that addresses the chief complaint. 10.Initial set of VS. 12. Any interventions initiated at triage, 13. Completed Triage plan..."

The ED Policy titled Notification of Physician" dated 06/11 requires, "It is the nurse's responsibility to recognize and interpret the significance of any change in a patient's condition and...to notify a physician for any of the following...Temp. greater than 39.0 degrees Celsius..."

The ED Policy titled "Organizational Plan and Scope of Service" dated 06/11 requires, "The ED Role...is to provide optimal emergent care and interventions for patients seeking such care...It is responsible for providing acute emergency care...to all individuals seeking such care...The Nursing Process provides the framework for all nursing intervention. Systematic approach to problem identification, planning for problem resolution and evaluation of the effectiveness of intervention to address identified problems constitute the nursing process. The process is personalized through patient-specific interventions...A Registered Nurse (RN) triage system is utilized. This process ensures appropriate evaluation and expedient entrance into the system. Treatment is timely and appropriate, based on the nature and severity of the patient's chief complaint...A physician is readily available to examine and treat all patients who present to any area of the ESD (Emergency Services Department)...No patient is denied access to medical treatment...The triage area serves as the point of entry. The nursing staff evaluate and define the acuity of a patient's chief complaint and determine the appropriate area for treatment...Nurses use established practice guidelines from the Emergency Nursing Association ESI to define acuity and set triage disposition. The MSE occurs in the treatment area by a credentialed provider...The Main ED treats patients [AGE] years old and greater requiring emergent and non-emergent evaluation, treatment or procedures..."

The hospital policy titled "EMTALA" dated 06/11 requires, "Any person who comes to Parkland main campus requesting assistance for a potential EMC/emergency services will receive a MSE performed by a QMP to determine if an EMC exists...Persons with EMC's will be treated and their condition stabilized...Emergency Services Department (ESD) - triages patients (per written criteria and severity of chief complaint) to the most appropriate area within the ESD for MSE or based on medical condition/age based criteria or to another department for the MSE...UCC - an ambulatory medical-surgical urgent care department...Hospital C contracts with Parkland to triage, screen and treat children under the age of 14...who are brought to Parkland's ESD...Hospital C is contiguous to Parkland's Campus. Retriage children from Parkland's ESD to Hospital C will be accompanied by Parkland's staff as appropriate for the chief complaint...MSE is the process required to determine, with a reasonable clinical confidence, whether or not an EMC exists...this is evidenced through documentation in the medical record that indicates the patient's medical condition...QMP to perform a MSE at Parkland Health & Hospital System (PHHS) includes: a. doctor of medicine or osteopathy; b. physician's assistant or c. advanced practice providers including nurse practitioner/midwives with Parkland privileges...A patient is stable for transfer if the treating physician attending the patient has determined, within reasonable clinical probability, that the patient is expected to leave the facility and be received at the second facility, with no material deterioration in his/her medical condition...Triage is a sorting process to determine the order in which patients will be provided a MSE by a QMP. Triage is not the equivalent of a MSE and does not determine the presence or absence of an EMC...Transfer means the movement of a living patient to another facility at the direction of any person employed by the clinic or hospital...A MSE is required when an individual: - seeks care in the hospital ESD, - arrives anywhere on the hospital premises and states that he/she has an emergency...the MSE consists of an assessment and any ancillary tests or focused assessment based on the patient's chief complaint necessary to determine the presence or absence of an EMC...is the process a provider must use to reach with reasonable clinical confidence whether an EMC does or does not exist...The MSE must provide evaluation and stabilizing treatment within the scope of the hospital or clinic's abilities...The MSE must be performed by: Physicians and Advanced Practice Providers functioning within the scope of their license who have been credentialed and/or privileged by Parkland's Board of Managers. Non-Physician qualified personnel who perform MSE utilize protocols previously approved by the Medical Staff...The medical record shall reflect the findings of the MSE including any results of any tests performed and analysis including documentation that demonstrates if a EMC does or does not exist (this may include a statement of the patient's general condition upon discharge or transfer)...Patient Transfers from Parkland...A transfer for the purpose of completing formal transfer forms is defined as patient movement from the campus of one acute care facility to the campus of another acute care facility...All transfers from Parkland to another facility require completion of the transfer packet (see attachment B) which includes: MOT, Transfer Certification and Consent, Transfer Checklist...Copies of all pertinent medical records, tests, orders, forms, certifications, and radiology studies should be sent with the patient...Attachment B, Transfer Decision Matrix...Outgoing from PHHS...MOT: Yes, Except for patient transferred to Hospital "C", Hospital "D" and other Federal facilities, and nursing homes...Admission Eligibility: The transfer of a patient may not be predicated upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition or economic status...Consent: Yes...Role of Physician: Determine PHHS clinical capability and patient's stability for transfer, Complete transfer certification and consent form and MOT form, Contact the transfer hotline, arrange for duplication of patient's medical record which shall include: medical history and physical exam; provisional diagnosis; recorded observation of physical assessment of patient's condition at the time of transfer and treatment provided; results of all diagnostic test...reason for transfer; and any other pertinent information...Role of RN: Complete patient transfer checklist..."

The Administrative Procedure titled "Graduate Medical Education Supervision" dated 12/10 requires, "Attending Physicians are responsible for: the assessment, diagnosis, treatment, and outcomes of all patients...providing the appropriate level of supervision based upon the nature of a patient's condition, complexity of care, and level of competence of the resident's being supervised...Direction of clinical care and supervision of the residents must be documented by the attending physician in the medical record in accordance with the Bylaws and/or Rules and Regulations. In particular, the following events require attending documentation that reflects supervision and ensures comprehensiveness of the record: Patient history and physical examination, and/or patient admission; patient discharge; consultation; surgeries and high risk procedures; and progress notes that cover significant events, complications, patient and family communication, treatments and response to treatment. An attending progress notes is particularly important in the event of transfer of responsibility of care..."

The Governing Board "Bylaws" dated 06/28/11 requires, "The Board is responsible for carrying out its fiduciary and statutory responsibilities in managing, controlling and administering the Hospital District. The Board is ultimately responsible for the quality and safety of care provided by the Hospital District. It is the governing body of the Hospital District responsible for Hospital District Policy...To determine the need for and establish all general policies to be implemented in the operation of the Hospital District...Article X. Medical Staff...The Medical Staff Bylaws shall provide a mechanism for medical staff governance...Non-physician clinical providers are credentialed, privileged, reviewed, recommended, and ultimately approved or denied by the Board pursuant to the Medical Staff process as outlined in the Medical Staff Bylaws...The Medical Staff shall be governed by its own Bylaws...subject to approval by the Board..."

The "Bylaws of the Medical Staff" dated 03/22/11 requires, "The Hospital's Medical Staff is responsible for the quality of medical care in the Hospital, and must accept and discharge this responsibility subject to the ultimate authority of the Governing Body; and the cooperation of the Medical Staff, Chief Executive Officer, and Governing Body is necessary to fulfill the Hospital's obligation to its patients...Non-Physician Clinical Provider means an individual who holds an advanced degree in a clinical area, who has been licensed or certified by his or her respective licensing or certifying agencies, and who has received privileges to provide professional clinical services in the hospital. A Non-physician clinical provider must receive the recommendation of and practice under the supervision and/or in collaboration with a sponsoring/supervising physician...Objectives...Assure that all patients admitted to, or treated in, any facility, clinic, department, division, or service of the hospital receive high quality medical care commensurate with the hospital's services and capabilities...Duties of Department and Division Chairs...Shall be responsible for the quality of care in the Department or Division and receive, evaluate, and determine appropriate actions regarding department quality...Be responsible for administrative and professional activities within the Department or Division...improve outcomes, processes and services...Recommend to the MAC (Medical Advisory Committee) policies, procedures and clinical guidelines that guide and support the provision of care, treatment and services for his or her department or division...Cooperate with the Nursing Service and Administration concerning qualifications and competence of licensed and unlicensed personnel, supplies, regulations, clinical guidelines..."

The Medical Staff "Rules and Regulations" dated 12/13/10 requires, "Evaluation, Admission, and Discharge of Patients...Each patient's general medical care shall be the responsibility of a Physician Member of the Medical Staff or an Allied Health Professional with privileges necessary to provide the care required...All patient presenting to the ED will be evaluated by medical screen to determine if care can be given in a non-urgent setting. Documentation of the screen will accompany any patient referred to a non-emergent department or clinic...Any person who comes to any hospital facility requesting emergency services will receive a MSE performed by a QMP to determine whether an EMC exists...MSE is the process required to determine, with reasonable clinical confidence, whether or not an EMC exists or a woman is in labor...QMP to perform a MSE at the hospital includes: (1) a doctor of medicine or osteopathy; (2) a physician's assistant; or (3) a nurse practitioner or midwife with hospital privileges..."

The "Transfer/Referral Agreement" between Hospital C and Dallas County Hospital District d/b/a Parkland Memorial Hospital (PMH), amended date 10/1994 requires, "3. Standards of Care: The transfer/referral of pediatric patients to and from Hospital C and PMH will be accomplished in a medically appropriate manner from physician to physician and hospital to hospital by providing for: a) the use of medically appropriate life support measures which a reasonable and prudent physician in the same or similar locality exercising ordinary care would use to stabilize the patient prior to transfer and to sustain the patient during transfer; and b) the provision of appropriate personnel and equipment which a reasonable and prudent physician in the same or similar locality exercising ordinary care would use for the transfer; and c) the transfer of all necessary records for continuing the care for the patient; and d) the consideration of the availability of appropriate facilities, services, and staff for providing care to the patient. 4. Emergency Medical Conditions. Neither hospital may transfer a patient with an emergency medical condition which has not been stabilized unless: a) the patient or a legally responsible person acting on the patient's behalf, after being informed of the hospital's obligations under this section and of the risk of transfer, in writing, requests a transfer to another hospital; b) a licenesed physician has signed a certification, which includes a summary of the risks and benefits, that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient and, in the case of labor, to the unborn child, from effecting the transfer; or c) if a licensed physician is not physically present in the emergency department at the time a patient is transferred, a qualified medical person has signed a certification described in subparagraph (b) above after a licensed physician, in consultation with the person, has made the determination described in subparagraph (b) above and subsequently countersigns the certificate."

In an interview at 9:20 A.M. on 07/12/11, RN (Personnel # 8) in the ED was asked if she performs triage in the ED. She stated, "Yes." She was asked to explain the triage process. She stated, "We have criteria that we use which is a 5 level process. We decide if the patient where the patient is seen. If the patient is a level 1,2 or 3 we see them here in the main ED. If they are less acute and are a 4 or 5 we send them to urgent care. If a woman is in labor we take them to 3rd floor L&D (labor and delivery), if they are pregnant and not in labor and have
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews, the hospital's Governing Board failed to enforce the hospital transfer policy to ensure all patient's who were transferred from the Emergency Department (ED) from 01/01/11 to 07/19/11 to other acute care facilities were appropriately transferred. One of 1 patient (Patient #6) was transferred to another facility and did not receive an appropriate medical screening examination and physical examination by a physician or Qualified Medical Professional (QMP) to determine whether or not an emergency medical condition existed prior to the transfer. The medical record did not contain a request in writing for the transfer or that the mother of the patient was informed of the risks and benefits of the transfer. The medical record also did not contain a copy of a signed certification by a physician that contained a summary of the risks and benefits of the transfer, a Memorandum of Transfer (MOT), documentation the receiving facility had available space and qualified personnel for the treatment of the patient or agreement from the facility to accept the transfer. The medical record did not contain evidence that a copy of the medical record was sent with the patient or was transported with qualified personnel and/or equipment when the patient transferred to another facility.

Based on record reviews and interviews, on 08/31/11 it was determined this element is now present and abated.



Findings Included:

Review of Patient #6's medical record, the 3 year old female presented to the Main ED accompanied by her mother on 01/01/11 at 10:30 PM with the chief complaint of fever, nausea, productive cough with yellow phlegm for 2 weeks. Triaminic over the counter medication given at home was ineffective for control. At 10:52 PM, the triage RN (Personnel #80) documented the patient was currently febrile at 40.1 degrees Celsius (104.2 degrees Fahrenheit (F), normal temperature 98.6 degrees F). Additional vital signs revealed Pulse 164 (normal range 80-120), Respirations 22 (normal range 20-30), Blood Pressure 80/52 (normal systolic blood pressure range 65-117), and SpO2 (oxygen saturation) of 95% on room air (normal range 100%). At 10:54 PM, RN #80 documented, "Patient transferred to [Hospital C]" and at 11:03 PM "Patient departed from ED. Follow up with Physician (Personnel #81)." The "Discharge Disposition" reflected, "discharged /transferred to a designated cancer center or children's hospital."

The medical record reflected a medical screening examination was not performed by a QMP to determine if an EMC existed, an assessment or history and physical performed by an ED Physician, ancillary tests, stabilizing treatment provided, physician orders for transfer, a transfer certification and consent form or an MOT form. The nurse failed to document the required ESI Acuity level, nursing interventions, or QMP notification. The nurse also failed to perform a nursing assessment or address the complaints of nausea or productive cough. The RN discharged /transferred the patient to another facility without an appropriate MSE, stabilizing treatment or appropriate transfer with qualified personnel.

The ED Policy entitled "Triage Guidelines" dated 11/10 requires, "All patients requesting care will be entered into the system and given a MSE by a qualified provider in accordance with EMTALA, and Parkland administrative policy..."

The hospital's copy of the "Emergency Severity Index, Version 4: Implementation Handbook" provided to the surveyor reflected, "Chapter 3. Introduction to the Emergency Severity Index...Decision Point D: The Patient's Vital Signs. Before assigning a patient to ESI level 3, the nurse needs to look at the patient's vital signs and decide whether they are outside the accepted parameters for age...If the vital signs are outside accepted parameters, the triage nurse should consider upgrading the triage level to ESI level 2...Danger Zone Vital Signs: Age 3-8 years, HR > 140, RR > 30, SaO2 < 92%...Chapter 6. The Role of Vital Signs in ESI Triage...D. Danger Zone Vital Signs: Consider uptriage to ESI 2 if any vital sign criterion is exceeded. Pediatric Fever Considerations...3 months to 3 years of age: Consider assigning ESI 3 if: temp. > 39.0 C (102.2 F)...The range of vital signs may provide supporting data for potential indicators of serious illness. If any of the danger zone vital signs are exceeded, it is recommended that the triage nurse consider up-triaging the patient from level 3 to level 2..."

The ED Policy entitled "Organizational Plan and Scope of Service" dated 06/11 requires, "A Registered Nurse (RN) triage system is utilized. This process ensures appropriate evaluation and expedient entrance into the system. Treatment is timely and appropriate, based on the nature and severity of the patient's chief complaint...The triage area serves as the point of entry. The nursing staff evaluate and define the acuity of a patient's chief complaint and determine the appropriate area for treatment...Nurses use established practice guidelines from the Emergency Nursing Association ESI to define acuity and set triage disposition. The MSE occurs in the treatment area by a credentialed provider...The Main ED treats patients [AGE] years old and greater requiring emergent and non-emergent evaluation, treatment or procedures..."

The hospital policy entitled "EMTALA" dated 06/11 requires, "Any person who comes to Parkland main campus requesting assistance for a potential EMC/emergency services will receive a MSE performed by a QMP to determine if an EMC exists...Persons with EMC's will be treated and their condition stabilized..."[Hospital C] contracts with Parkland to triage, screen and treat children under the age of 14...who are brought to Parkland's ESD...[Hospital C] is contiguous to Parkland's Campus. Retriage children from Parkland's ESD to [Hospital C] will be accompanied by Parkland's staff as appropriate for the chief complaint...MSE is the process required to determine, with a reasonable clinical confidence, whether or not an EMC exists...this is evidenced through documentation in the medical record that indicates the patient's medical condition...QMP to perform a MSE at Parkland Health & Hospital System (PHHS) includes: a. doctor of medicine or osteopathy; b. physician's assistant or c. advanced practice providers including nurse practitioner/midwives with Parkland privileges...A patient is stable for transfer if the treating physician attending the patient has determined, within reasonable clinical probability, that the patient is expected to leave the facility and be received at the second facility, with no material deterioration in his/her medical condition...Triage is a sorting process to determine the order in which patients will be provided a MSE by a QMP. Triage is not the equivalent of a MSE and does not determine the presence or absence of an EMC...Transfer means the movement of a living patient to another facility at the direction of any person employed by the clinic or hospital...A MSE is required when an individual: - seeks care in the hospital ESD, - arrives anywhere on the hospital premises and states that he/she has an emergency...the MSE consists of an assessment and any ancillary tests or focused assessment based on the patient's chief complaint necessary to determine the presence or absence of an EMC...is the process a provider must use to reach with reasonable clinical confidence whether an EMC does or does not exist...The MSE must provide evaluation and stabilizing treatment within the scope of the hospital or clinic's abilities...The MSE must be performed by: Physicians and Advanced Practice Providers functioning within the scope of their license who have been credentialed and/or privileged by Parkland's Board of Managers. Non-Physician qualified personnel who perform MSE utilize protocols previously approved by the Medical Staff...The medical record shall reflect the findings of the MSE including any results of any tests performed and analysis including documentation that demonstrates if a EMC does or does not exist (this may include a statement of the patient's general condition upon discharge or transfer)...Patient Transfers from Parkland...A transfer for the purpose of completing formal transfer forms is defined as patient movement from the campus of one acute care facility to the campus of another acute care facility...All transfers from Parkland to another facility require completion of the transfer packet (see attachment B) which includes: Memorandum of Transfer (MOT), Transfer Certification and Consent, Transfer Checklist...Copies of all pertinent medical records, tests, orders, forms, certifications, and radiology studies should be sent with the patient...Attachment B, Transfer Decision Matrix...Outgoing from PHHS...MOT: Yes, Except for patient transferred to [Hospital C], Hospital D and other Federal facilities, and nursing homes...Admission Eligibility: The transfer of a patient may not be predicated upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition or economic status...Consent: Yes...Role of Physician: Determine PHHS clinical capability and patient's stability for transfer, Complete transfer certification and consent form and MOT form, Contact the transfer hotline, arrange for duplication of patient's medical record which shall include: medical history and physical exam; provisional diagnosis; recorded observation of physical assessment of patient's condition at the time of transfer and treatment provided; results of all diagnostic test...reason for transfer; and any other pertinent information...Role of RN: Complete patient transfer checklist..."

The Governing Board "Bylaws" dated 06/28/11 requires, "The Board is responsible for carrying out its fiduciary and statutory responsibilities in managing, controlling and administering the Hospital District. The Board is ultimately responsible for the quality and safety of care provided by the Hospital District. It is the governing body of the Hospital District responsible for Hospital District Policy...To determine the need for and establish all general policies to be implemented in the operation of the Hospital District...Article X. Medical Staff...The Medical Staff Bylaws shall provide a mechanism for medical staff governance...Non-physician clinical providers are credentialed, privileged, reviewed, recommended, and ultimately approved or denied by the Board pursuant to the Medical Staff process as outlined in the Medical Staff Bylaws...The Medical Staff shall be governed by its own Bylaws...subject to approval by the Board..."

The "Bylaws of the Medical Staff" dated 03/22/11 requires, "The Hospital's Medical Staff is responsible for the quality of medical care in the Hospital, and must accept and discharge this responsibility subject to the ultimate authority of the Governing Body; and the cooperation of the Medical Staff, Chief Executive Officer, and Governing Body is necessary to fulfill the Hospital's obligation to its patients...Non-Physician Clinical Provider means an individual who holds an advanced degree in a clinical area, who has been licensed or certified by his or her respective licensing or certifying agencies, and who has received privileges to provide professional clinical services in the hospital. A Non-physician clinical provider must receive the recommendation of and practice under the supervision and/or in collaboration with a sponsoring/supervising physician...Objectives...Assure that all patients admitted to, or treated in, any facility, clinic, department, division, or service of the hospital receive high quality medical care commensurate with the hospital's services and capabilities...Duties of Department and Division Chairs...Shall be responsible for the quality of care in the Department or Division and receive, evaluate, and determine appropriate actions regarding department quality...Be responsible for administrative and professional activities within the Department or Division...improve outcomes, processes and services...Recommend to the MAC (Medical Advisory Committee) policies, procedures and clinical guidelines that guide and support the provision of care, treatment and services for his or her department or division...Cooperate with the Nursing Service and Administration concerning qualifications and competence of licensed and unlicensed personnel, supplies, regulations, clinical guidelines..."

The Medical Staff "Rules and Regulations" dated 12/13/10 requires, "Evaluation, Admission, and Discharge of Patients...Each patient's general medical care shall be the responsibility of a Physician Member of the Medical Staff or an Allied Health Professional with privileges necessary to provide the care required...All patient presenting to the ED will be evaluated by medical screen to determine if care can be given in a non-urgent setting. Documentation of the screen will accompany any patient referred to a non-emergent department or clinic...Any person who comes to any hospital facility requesting emergency services will receive a MSE performed by a QMP to determine whether an EMC exists...MSE is the process required to determine, with reasonable clinical confidence, whether or not an EMC exists or a woman is in labor...QMP to perform a MSE at the hospital includes: (1) a doctor of medicine or osteopathy; (2) a physician's assistant; or (3) a nurse practitioner or midwife with hospital privileges..."

The "Transfer/Referral Agreement" between [Hospital C] and Dallas County Hospital District d/b/a Parkland Memorial Hospital (PMH), amended date 10/1994 requires, "3. Standards of Care: The transfer/referral of pediatric patients to and from [Hospital C] and PMH will be accomplished in a medically appropriate manner from physician to physician and hospital to hospital by providing for: a) the use of medically appropriate life support measures which a reasonable and prudent physician in the same or similar locality exercising ordinary care would use to stabilize the patient prior to transfer and to sustain the patient during transfer; and b) the provision of appropriate personnel and equipment which a reasonable and prudent physician in the same or similar locality exercising ordinary care would use for the transfer; and c) the transfer of all necessary records for continuing the care for the patient; and d) the consideration of the availability of appropriate facilities, services, and staff for providing care to the patient. 4. Emergency Medical Conditions. Neither hospital may transfer a patient with an emergency medical condition which has not been stabilized unless: a) the patient or a legally responsible person acting on the patient's behalf, after being informed of the hospital's obligations under this section and of the risk of transfer, in writing, requests a transfer to another hospital; b) a licensed physician has signed a certification, which includes a summary of the risks and benefits, that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient and, in the case of labor, to the unborn child, from effecting the transfer; or c) if a licensed physician is not physically present in the emergency department at the time a patient is transferred, a qualified medical person has signed a certification described in subparagraph (b) above after a licensed physician, in consultation with the person, has made the determination described in subparagraph (b) above and subsequently countersigns the certificate."

In an interview at 9:20 AM on 07/12/11, RN (Personnel # 8) in the ED was asked if she performs triage in the ED. She stated, "Yes." She was asked to explain the triage process. She stated, "We have criteria that we use which is a 5 level process. We decide if the patient where the patient is seen. If the patient is a level 1,2 or 3 we see them here in the main ED. If they are less acute and are a 4 or 5 we send them to urgent care. If a woman is in labor we take them to 3rd floor L&D (labor and delivery), if they are pregnant and not in labor and have a general medical complaint such as spotting, cramping, nausea and vomiting, we send them to the Women's ED." She was asked who performs the medical screening before sending the patient to L&D. She stated, "We do, the nurses."
She was then asked about triaging pediatric patients. She stated, "We do not do pediatrics here. We triage and medically screen them and then have one of our techs take them over to [Hospital C]." She was asked if a physician medically screens the pediatric patient before sending them to [Hospital C] She stated, "No. We do at triage."

In an interview at 9:50 AM on 07/12/11, RN (Personnel #9) in the ED was interviewed. He was asked if he ever performs triage in the ED. He stated, "Yes." He was asked how the decision is made in triage where the patient is seen. He stated, "We use the ESI levels. The triage check in nurse can make a decision based on EDI levels, such as a 4 or 5, a non-urgent is sent to the UCC." He was asked who medically screens the patient before sending them to the UCC. He stated, "The nurses do. The nurses triage and medically screen using the ESI criteria and make the decision where the patient goes."

At 1:30 PM on 07/12/11, the Medical Chief of ED Services (Personnel #16) and the Director of ED (Personnel #17) was interviewed. MD #16 was asked if patients are medically screened in the ED for EMC's. He stated, "Yes. Every patient who presents for care to the ED gets medical screening." He was asked if the nurses perform medical screening. He stated, "No. The physicians in the ED do the screening." He was asked to review the hospital ED policy entitled "Triage Guidelines" dated 11/10. He was asked if the policy requires all patients to have an MSE by a QMP for medical stability prior to referral for medical screening outside the Main ED. He stated, "Yes." He was asked if the ED is following the hospital policy for MSE by a QMP. He stated, "No."

He was asked if the nurses or residents are recommended by the Medical Staff and credentialed by the hospital's Governing Body to be a QMP. He stated, "Not that I am aware of." He was asked if the residents are part of the medical staff. He stated, "No. They are physicians but are medical students in their residency and part of the House Staff." He was asked if the hospital governing body credentials and approves privileges for residents or RN's to perform MSE's". He stated, "No." He was asked to review the hospital policy requirements for QMP's performing MSE entitled "EMTALA" dated 06/11 and The Medical Staff Rules and Regulations dated 12/13/10, "Evaluation, Admission, and Discharge of Patients." He was then asked if the hospital policy allows medical residents or RN's to perform MSE's. He stated, "No." He was then asked if the ED is following the hospital policy. He stated, "No."

He was asked if the hospital is capable of medically screening, treating and stabilizing pediatric patients. He stated, "Yes." He was asked if pediatric patients are medically screened and treated in the ED. He stated, "We do not see pediatrics here in the ED. Pediatrics are triaged and transferred to [Hospital C]. If the pedi's are burn patients, they stay here. If they are trauma, we transfer the child to trauma services. We have an agreement with [Hospital C] for pediatrics." He was asked if the physician is responsible for completing a MOT or certification prior to transferring a child to [Hospital C]. He stated, "No. We are not required to by hospital policy and the hospital agreement with [Hospital C]. [Hospital C] is down the hall and a contiguous part of the building. We have an agreement with [Hospital C] to see all of our pedi patients." He was asked if [Hospital C] is a part of PHHS or if it is a different acute care hospital with a different provider number. He stated [Hospital C] is not a part of PHHS and is a different provider. He was asked to review the hospital policy entitled "EMTALA" dated 06/11 and asked if the policy requires all patients presenting to the ED requesting care will be given a MSE by a QMP to determine if an EMC exists and provide stabilizing treatment prior to transferring to another facility. He stated, "Yes." He was then asked if the hospital policy is following EMTALA rules and regulations in regards to medically screening and providing an appropriate transfer for pediatric patients. He stated, "No."

The Director of ED (Personnel # 17) was asked if the RN's are providing MSE's prior to referring patient's to the UCC. She stated, "No. The RN's are performing a triage. They are using the ESI criteria to make the determination where the patient will be seen by the physician. The physician's do the medical screening." She was asked if pediatric patients that present to the ED for medical care are being medically screened by a QMP prior to being transferred to [Hospital C]. She stated, "No. They are being triaged by the RN." She was then asked to review the hospital policies and procedures for QMP's and MSE's. She verified the ED is not following hospital policies and EMTALA requirements in regards to the medical screening and transfer process.

In an interview at 10:00 AM on 07/20/11, the Director of ED (Personnel #17) was asked to review the medical record of Patient #6. She was asked if Patient was transferred to [Hospital C]. She stated, "Yes." She was asked if Patient #6 received an appropriate medical screening examination and physical examination by a physician or QMP to determine whether or not an emergency medical condition existed prior to the transfer. She stated, "No."

She was asked if the medical record contained a request in writing for the transfer or if the mother of the patient was informed of the risks and benefits of the transfer. She stated, "No."
She was asked if the medical record had a copy of the MOT with a signed certification by a physician with a summary of the risks and benefits of the transfer, documentation the receiving facility had available space and qualified personnel for the treatment of the patient or agreement from the facility to accept the transfer. She stated, "No."

She was asked if there is evidence a copy of the medical record was sent with the patient or was transported with qualified personnel and/or equipment when the patient transferred to another facility. She stated, "No."

She was asked if an appropriate patient transfer was initiated for Patient #6. She stated, "No."
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, interviews and record reviews, the hospital's Governing Board failed to ensure hospital policy was implemented to ensure requirements were met in order to provide appropriate Medical Screening Examination (MSE) by a Qualified Medical Professional (QMP) for patients presenting to the Emergency Department (ED).

Findings Included:

Patients presenting to the ED did not receive an appropriate medical screening examination to determine whether or not an emergency medical condition existed, stabilizing treatment was provided and appropriate transfers were initiated if needed. The Registered Nurse's (RN's) and Medical Residents who performed the MSE's in the ED were not appointed through the hospital's credentialing process, nor appointed by the Governing Board as QMP's.

Cross Refer: Tag A2406
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, interview, and record review, the hospital did not ensure that the infection control policies were implemented and enforced. Infection control practices were not adhered to by physicians, nursing staff, and other personnel, for 7 of 14 departments and/or services (Peri-operative Services, GI Lab [Gastrointestinal Laboratory], Cardiac Lab, Ambulatory Surgery Services, Renal Dialysis, Perinatal Services and the Emergency Department [ED]).

It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk of severe infection and possibly subsequent death.

Findings Included:

1. Numerous staff wore used masks hanging down from their necks while walking in the hallway or other non-surgical/treatment areas.

2. Numerous staff members did not dispose of their soiled gloves and wash their hands after treating patients and touching patient equipment.

3. A disposable jacket was hanging in the sterilization area. Personnel food items were sitting in the patient treatment areas.

4. Infectious waste, including used syringes, body fluids, used respiratory equipment and used suction equipment were not disposed of properly in patient rooms/cubicles.

5. Personnel did not remove their gloves and wash their hands after drawing blood work then touching the surface of equipment thus contaminating the equipment.

6. ED bed was not cleaned with disinfectant between patient use.

7. All ED rooms located in the Main ED contained a yankauer suction tip in an open package that was attached to the suction canister and available for patient use. The open yankauer suction tips are not discarded between each patient after patients are discharged .

8. Environmental Services Technician's did not properly transport waste. The waste carts were overfilled with trash bags and not covered during transport through the patient care area of the ED.

Cross Refer: Tag A0749
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record reviews, the hospital failed to ensure nursing services were provided for 6 of 7 patients (Patient #3, Patient #6, Patient #8, Patient #13, Patient #14, and Patient #15) who were seen in the ED (Emergency Department) from 01/01/11 to 07/19/11 for complaints of severe pain. The medical records did not reflect a plan of care for pain management that included documentation of a complete assessment and evaluation, plan, interventions, patient response to interventions, reassessment of interventions, ongoing monitoring and/or education.

Findings Included:

Review of Medical Records reflected the following findings:

1) Patient #3 presented to the ED at 9:46 AM on 07/11/11 with complaints of abdominal pain, severe cramping radiating down the legs, nausea and loose stools. The pain was rated at 7 out of 10 on the pain scale. The patient was not given any pain medication or treatment for pain during this visit. The medical record did not reflect a complete triage assessment, initial nursing assessment, secondary nursing assessment, nursing interventions for severe pain, physician notification of severe pain, or discharge assessment.

2) Patient #6 presented to the ED at 10:30 PM on 01/01/11 with complaints of fever, nausea, productive cough with yellow phlegm for 2 weeks presented with an elevated temperature (temp.) 104.2 degrees Fahrenheit (F). The medical record did not reflect a complete initial nursing assessment, pediatric pain assessment or level, physician notification, nursing interventions or physician order for medication for elevated temperature.

3) Patient #8 presented to the UCC at 8:53 AM on 02/14/11 with complaints of headache and nausea for 1 week after being hit in the head. Vital signs reflected a BP (blood pressure) of 159/100 (elevated) and pain scale rated 8 out of 10. The physician documented bruising around the left eye. The patient was not given any pain medication or treatment during the visit. The medical record did not reflect a complete triage assessment, secondary assessment, nursing interventions for severe pain or elevated BP, physician notification of severe pain or elevated BP, repeat VS or nursing reassessment.

4) Patient #13 presented to the ED at 10:55 AM on 07/19/11 with complaints of bilateral eye pain rated 9 out of 10 on the pain scale, headache, tearing and burning, and blurry vision. The Resident (Personnel #87) ordered Naproxen 500 mg at 11:50 AM for complaints of pain and was given at 12:00 PM. The medical record did not reflect a complete initial triage assessment, triage vital signs, triage pain level, secondary focused nursing assessment, nursing interventions for complaints of severe pain, notification of physician, or reassessment of pain after pain medication given.

5) Patient #14 presented to the ED at 10:57 AM on 07/19/11 for complaints of severe back pain associated with a fall. The pain was rated 10 out of 10 on the pain scale. The medical record did not reflect an initial triage nursing assessment, secondary nursing assessment, vital signs, pain level, nursing interventions for complaints of severe pain, physician notification, reassessment, repeat vital signs, discharge assessment, or pain medication or treatment provided during the visit.

6) Patient #15 presented to the ED at 12:46 PM on 06/19/11 for complaints of a finger infection, drainage and pain rated 9 out of 10 on the pain scale. Initial VS were performed at 1:11 PM, with no further repeat VS documented throughout the stay The medical record did not reflect a complete initial triage assessment. A primary initial nursing assessment was not completed until 10:00 PM. The patient was discharged home at 11:35 PM without any treatment for complaints of pain medication. The medical record did not reflect any nursing interventions or physician notification for complaints of severe pain or reassessment of the pain.

7) The hospital "Patient Rights and Responsibilities" dated 06/28/11 requires, "As a patient, you have the right to: 1) participate in the development and implementation of your plan of care. 2) Information necessary to make informed decisions regarding your care, treatment and services. 3) Request, accept or refuse treatment....7) Receive considerate and respectful care in a safe setting...12) Reasonable response to request and needs for treatment or service..."

The hospital "Patient Information Packet" dated 03/24/08 given to patients reflects, "Understanding Your Pain...Pain relief is part of the plan for your health care. At Parkland, we promise to work hard to offer safe and helpful treatment when you have pain. Whether your pain is caused by disease, injury, surgery or a medical procedure, it is important that most pain can be controlled. We can work together to lessen your pain and help you get well faster. When you feel pain please tell your doctor or nurse about it. You are the one who can best tell us about your pain..."

The ED Policy entitled "Standards of Documentation" dated 03/10 requires, "The following standards will be followed for documentation on Emergency Services Department (ESD) patients...Initial Triage Documentation to minimally include the following...6. Chief complaint...8. General appearance. 9. Subjective and objective assessment that addresses the chief complaint. 10. Initial set of VS...12. Any interventions initiated at triage, 13. Completed Triage plan...a. Each patient will have a complete Secondary Assessment...The documentation provided by the Nurse should reflect: a. Plan of Care. b. Changes in condition. c. Ongoing assessment related to chief complaint. d. Interventions. e. Responses to interventions or procedures. f. Vital signs...7. Upon discharge the following documentation should be completed...Lines, Drains, Airway removals...review of discharge instructions..."

The Administrative Procedure entitled "Assessment - Reassessment" dated 09/10 requires, "To ensure all patients receive the appropriate assessment (including initial/screening and reassessment)...All patients...receiving inpatient, outpatient or emergency services will have an initial assessment and appropriate follow-up assessments based on their individual needs...c. Patient Care Staff. The patient assessment process is collaborative in order to facilitate, identify, and prioritize the patient's needs and determine care...Pain: Onset and duration; location and radiation; quality and severity; factors that exacerbate or relieve..."

The Administrative Procedure entitled "Pain Management" dated 03/08 requires, "To assess and manage acute and chronic pain in a safe and effective manner...Faces Scale (Wong-Baker Pain Scale)- recommended for pediatrics...Pain scale - Pain intensity rating scale used for each patient will be the 0-10 numerical scale where 0 = worst possible pain...Mild pain: 1-3, Moderate pain: 4-6, Severe pain: 7-10...Acceptable pain level - the level of pain (per pain scale) which the patient states they can tolerate without medication or other intervention. Pain Screening - involves using the 0-10 pain scale and documenting a number from 0 - 10. Pain Assessment - Involves assessing location, intensity, quality, duration, aggravating/alleviating factors, effects of pain on activities of daily living (ADL's), and past pain management history...The Documentation of Pain Screening/Assessment and Reassessment is Mandatory: 1. Pain screening/assessment will be documented: On the initial nursing assessment...following pain management interventions; to assess relief...when the patient reports pain or appears in distress. 2. "No pain" will be documented as "0"...Interventions & Documentation...If the patient's pain score is not at an acceptable level or greater than 4, the nurse should assess and intervene to improve pain control. A reassessment should be carried out in a timely manner. All assessments, reassessments, and interventions must be documented...All medications will be administered according to the physician's orders...The nurse should reassess the patient within a reasonable time of administering pain medications and with each report of new or changed pain...Notify the provider for pain which is greater than the patient's acceptable level post intervention...Reassessment...document intervention and response to intervention...

The Nursing Services Procedure entitled "Nursing Practice Act In The State of Texas" dated 02/01 requires, "Parkland will provide care, treatment and services in accordance with licensure requirements, laws, and rules and regulations set forth by the Texas Board of Nursing...Texas Board of Nursing - Nurse Practice Act..."

The Nursing Services Procedure entitled "Nursing Organizational Plan" dated 02/02 requires, "To outline the mechanism for the provision of nursing care wherever nursing is practiced...Philosophy of Nursing: Central to our philosophy of nursing is the respect for the dignity and worth of the individual. We believe the patient has the right to safe, considerate, respectful care at all times and under all circumstances...We believe the nursing process is the core of all nursing actions. This systematic approach to problem identification, devising and implementing plans for resolution, and evaluating effectiveness of these plans constitutes the process of nursing. Registered Nurses prescribe, delegate, and coordinate the nursing care provided throughout the hospital, and this care is patient-centered and patient-valued. Patient care is personalized by our assistance to those individuals who come to us, sick or well, through activities which contribute to recovery and optimal health...We believe that the quality of nursing care is the responsibility of all nurses and that the monitoring, evaluation and improving of care and services is an integral part of the process of nursing...In accordance with the State of Texas Nursing Practice Act, the nursing process is the core of all nursing actions in Parkland Health & Hospital System (PHHS). The practice of nursing by a RN shall mean assuming responsibility and accountability for nursing activities including assessment, planning, intervention, and evaluation..."

The ED Policy entitled "Organizational Plan and Scope of Service" dated 06/11 requires, "The ED role in the PHHS System is to provide optimal emergent care and interventions for patients seeking such care...The Nursing Process provides the framework for all nursing intervention. Systematic approach to problem identification, planning for problem resolution and evaluation of the effectiveness of intervention to address identified problems constitute the Nursing Process. This process is personalized through patient-specific interventions..."

8) In an interview at 10:00 A.M. on 07/20/11, the Director of ED (Personnel #17) verified the above medical record findings. She was asked if hospital policies and procedures were followed for documentation of the required nursing processes. She stated, "No."