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.

METHODIST DALLAS MEDICAL CENTER 1441 NORTH BECKLEY AVENUE DALLAS, TX 75203 Feb. 7, 2012
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on review of records and interview with staff, the facility failed to ensure that 1 of 1 patient whose record was reviewed was informed of his or her health status, including participation in the plan of care. Patient #1's spouse (next of kin) was not aware of a pressure ulcer that developed during the patient's stay at the facility.

Findings were:

Review of Patient #1's medical record revealed that the patient had an altered mental status and a diagnosis of dementia. The patient did receive a copy of the patient rights information supplied to each patient at the time of admission. Included in the packet is a pamphlet entitled, Speak Up ...Know Your Rights. The brochure states that "knowing your rights and role can help you make better decisions about your care." The first patient right listed in the pamphlet is "You have the right to be informed about the care you will receive."

An in-person interview was conducted with the Manager of Guest Services, Staff #5, on 2/6/12 at 2:10 pm in a facility conference room. According to Staff #5, Patient #1's spouse called and filed a grievance with the hospital about not being informed of the patient's skin ulcer, and didn't recall seeing any treatment. Staff #5 stated that a review of the grievance was performed, and the main finding of the internal investigation was that Patient #1's rights were violated, as the staff didn't communicate with the patient's spouse about the status and treatment of the pressure ulcer. Staff #5 also found during the investigation of the grievance that during care of the wound to the buttock area, the family was asked to leave the room, and no one communicated with them about the ulcer.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and interviews with staff, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for 1 of 1 patient whose record was reviewed. Patient #1 developed a pressure ulcer during an inpatient stay, and the staff did not address the ulcer per facility policy.

Findings were:

An in-person interview was conducted at 2:30 pm on 2/6/12 with Staff #6, the Clinical Nurse Supervisor of MICU/CCU. Staff #6 explained that Patient #1 came to the hospital in cardiogenic shock (a state in which the heart has been damaged so much that it is unable to supply enough blood to the organs of the body). The patient was admitted to the unit from the cardiac catheterization lab on a balloon pump (mechanical device that increases oxygen perfusion to the heart muscle while at the same time increases cardiac output). Patient #1 also came to the unit with a temporary pacemaker in his groin area, and with the balloon pump, ventilator, and pacemaker, it was difficult to turn except by log roll. Staff #6 stated that the patient stayed on the unit for 19 days. According to the Clinical Nurse Supervisor, Patient #1 received blue protective ointment over the skin in order to protect the skin from breakdown, and was repositioned every 2 hours. Because of tube feedings, the patient started having diarrhea, and a flexi-seal was placed. (This device is a temporary containment device, indicated for bedridden or immobilized incontinent patients with liquid or semi-liquid stool). According to Staff #6, on 10/24/11, because of the fecal incontinence, the ointment was changed to zinc oxide. Staff #6 assessed Patient #1's skin on 11/3/11 for the first time. By this time it was darker in color, so they switched to Xeniderm ointment, which required a physician order. November 3, 2011 was a Thursday; Staff #6 stated that the weekend nurse left a note requesting reevaluation of the patient's skin, because it had gotten worse, becoming darker and sloughing. A wound care physician was consulted on 11/7/11, 4 days after the worsening of the pressure ulcer was noted. The physician identified the ulcer as stage II (out of Stages I-IV). The physician ordered MIST therapy-which is a device used to help improve circulation. The patient was then transferred the next day to a long term acute care hospital for further treatment.

Review of the medical record of Patient #1 revealed that at the time of admission 10/20/11, the nursing assessment reported that skin was intact. The nursing notes state "no wounds." On 10/22/11, nursing notes also state "no wounds." On 10/23/11, nursing notes identify "multiple bruises with blanchable redness to bilateral buttocks/coccyx area." The nurses have documented turning the patient every 2 hours and applying protective cream to the patient's back. Nursing staff performs the Braden Scale evaluation of patients, which is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers. A score of 15-16 = low risk, 13-14 = moderate risk, 12 or less = high risk. Nursing notes for the day of admission indicate Patient #1's score as 14, moderate risk. The facility policy which is printed in the electronic medical record states "A Braden score of 18 or less will trigger a notification to Wound care." On 10/21/11, the day after the patient was admitted , the Braden score was 14; by 10/26/11, the score was 11, considered high risk. Nursing staff also evaluates for skin breakdown if the patient has a urinary catheter. Patient #1 had a catheter each day during the stay to protect against skin breakdown due to incontinence. Each evaluation throughout the stay indicated that there was no skin breakdown on the patient's back. On 11/7/11, Patient #1's 18th day on the unit, a wound care physician was consulted and a stage II pressure ulcer was diagnosed . Patient #1 was discharged on [DATE] to a long term acute care hospital.

In an in-person interview conducted the afternoon of 2/6/12, the facility CNO stated that there is usually a nurse who is trained in wound care and oversees the care of patient wounds for the hospital. According to the CNO, this nurse would evaluate the patient with a low Braden Scale score. At the time of Patient #1 ' s stay, the wound-care nurse position was vacant. The CNO acknowledged the above findings during the interview.