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 Aug. 4, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interviews and record reviews, the hospital did not protect and promote each patient's rights in that it did not adequately address each patient care complaint or grievance, respect the patient's basic right to respect, dignity, and comfort by providing personal privacy during procedures and examinations, provide a safe environment where care and treatment are provided and prevent personal health information from being disclosed.


Findings Included:

1) Patient care complaints were not adequately addressed in 9 of 9 grievances received from a patient's and/or families (Patients #1, #29, #30, #31, #32, #33, #34, #35 and #36) for 5 of 5 months (January 2011 - May 2011) in that the hospital failed to provide written notice of its decision, steps taken on behalf of the patient to investigate the grievance, results of the investigation and date of completion to regarding patient care complaints.
Cross refer: A0123


2) Patients in 12 of 12 patient hall beds (Beds 218, 219, 220, 221, 222, 223, 224, 225, 230, 231, 232, and 233) located in the main ED on 06/29/11 were not provided privacy from people that were not involved in their care while being interviewed, assessed, examined and treated.
Cross refer: A0143

3) 1 of 1 Patient (Patient #34) was not provided privacy on 03/03/11 by the RN while performing a history and assessment.
Cross refer: A0143

4) 1 of 1 Patient (Patient #1) personal medical information was disclosed on 05/13/11 to an outside third party organization without prior consent of the patient.
Cross refer: A0143

5) The hospital did not provide a sanitary environment to avoid sources and transmission of infections and communicable diseases in that multiple staff did not dispose of their soiled gloves and wash their hands after treating patients and touching patient equipment.
Cross refer: A0144

6) The hospital did not provide basic infection control supplies and equipment including hand sanitizer, linen hampers, trash cans and biohazard disposal boxes close to or in proximity of the patient hall beds for the staff to use.
Cross refer: A0144

7) The ED patient hall beds did not have nurse call lights for patient's to notify the nursing staff in the event of an emergency.
Cross refer: A0144
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on review of records and interview, the hospital failed to provide written notice of its decision, steps taken on behalf of the patient to investigate the grievance, results of the investigation and date of completion to 9 of 9 grievances received from a patient's and/or families (Patients #1, #29, #30, #31, #32, #33, #34, #35 and #36) for 5 of 5 months (January 2011 - May 2011) regarding patient care complaints.

Findings include:

The "Complaint/Grievance Log " dated "January 2011- May 2011" reflected the following patient care complaints:

04/19/11 - Patient #1's husband complained that his wife had delivered their child by herself without any assistance from a physician or nurse in her room and her call light for help had been ignored.

01/24/11- Patient #29's family complained of the room being filthy, her sister smelled, an IV that was causing her arm to swell, her blood pressure (BP) was not monitored and due to the lack of monitoring by the staff, her sister had a stroke and is now in ICU (Intensive Care Unit).

06/02/11 - Patient #30 complained about the care provided in the ED. Stated she had come to the ED with multiple complaints (blue diarrhea, elevated blood sugar, rash around the neck, pain in right lower abdomen, and edema in legs). The ED physician only addressed the pelvic pain and was rude to her stating "I don't know what your problem is." The physician prescribed medication she is allergic to.

01/11/11 - Patient #31 complained about the hospital not giving her medications that she is taking at home and not providing adequate care.

03/28/11 - Patient #32 complained that during her MRI, the placement of dye did not go through the vein causing her arm to swell. She stated she was crying and calling out for help to no avail and her arm is swollen and disfigured. When she was discharged , she was told to put a hot compress on it and she would be all right. She was upset that no one seemed concerned.

02/23/11 - Patient #33's daughter complained that patient was found on floor at home and believes patient was a victim of sexual assault. She was concerned why patient was not transferred to another hospital for possible rape treatment and concerned about possible delay with obtaining rape kit and lack of treatment of injuries

03/03/11 - Patient #34 complained she presented to the ED with complaints of deep back pain and was treated for abdominal pain. States she received discharge information on abdominal pain and informed the staff it was back and not abdominal pain. States she does not know why her information was not listed correctly and questioned the treatment provided. Stated she continued to have back pain and had to return back to the ED to see a different physician. She also complained about being placed in the hallway corridor and was not provided privacy during an interview with a nurse regarding her private health information.

04/22/11 - Patient #35 complained the nurse was very rude to her and her mother when taking her vital signs. States she came in with a lot of abdominal pain and the RN told her to "shut up and stop being a drama queen" and was told if she had drank the medication another hospital had given her she would not be in this kind of pain. She stated when her mother attempted to provide the nurse with paperwork from the other facility the nurse ignored her and when her mother attempted again the nurse snatched the paperwork from her.

01/07/11 - Patient #36's daughter complained her mother was administered Morphine (narcotic pain medication) in the hospital and discharged with a prescription of Hydrocodone (narcotic pain medication) when her chart showed she is allergic to both Morphine and Hydrocodone. When she notified the physician, he appeared annoyed.

The Hospital Policy, "Complaints/Comments/Grievances" dated 04/30/09 required, "To provide mechanisms for receiving and responding to concerns...A patient grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patients care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation...related to rights and limitations provided by 42 Code of Federal Regulations...The following types of concerns should be communicated...They include but are not limited to...Significant or unresolved concerns (also called Grievances)...concerns crossing multiple department lines or processes...allegations of harm...should be responded to in writing and substantively address the areas of concern...If a review and reply cannot be completed within 7 calendar days of receipt...acknowledgement of receipt and a reasonable timeframe to respond to the issues should be communicated to the complainant...complaints about physicians should be forwarded to Medical Staff Services... "

The "Methodist Bylaws", 05/26/09 requires, "The activities, property and affairs of the Corporation shall be managed by its Board of Directors...The System Quality Review Committee...a standing committee of the Board of Directors....shall...regularly review reports from the medical staff and hospital administration regarding the quality of medical services provided...analyze quality initiatives at each System Institution to assure processes are in place to facilitate the implementation of system-wide best practices...monitor progress with quality initiatives...provide, on behalf of the Board, general governance oversight for the quality of service in the respective System Institutions...assure processes are in place at each System Institution to perform the following functions: report regularly to the System Quality Review Committee on the quality of services provided; assist the System Quality Review Committee in implementing system-wide quality improvement initiatives; review processes and methods used by the medical staff and hospital staff to monitor and improve the quality of service in the respective System Institutions; advise the System Quality Review Committee as to whether monitoring and follow-up programs and activities are effective and whether identified deficiencies in the safety, reliability, effectiveness, and acceptability of hospital and medical care are being addressed...Corporate Medical Board...shall...evaluate and monitor quality monitoring and improvement activities and systems for monitoring and evaluating the quality of patient care and improving patient care in the System Institutions..."


At 2:00 P.M. on 07/05/11, the Patient Representative Manager (Personnel #41) was interviewed. She was asked if she is responsible for the Complaint and Grievance process. She stated, "Yes, I am the Manager for Patient Representatives." She was asked if the hospital provided written notice of its decision, steps taken, results of the investigation and date of completion on the grievance's that were received from the patients or family of Patients #1, #29, #30, #31, #32, #33, #34, #35 and #36. She stated,"No." She was asked if the hospital followed the required grievance process. She stated, "No."
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation, interviews and record review, the hospital failed to provide, protect and promote patient privacy for:

1) Patients in 12 of 12 patient hall beds (Beds 218, 219, 220, 221, 222, 223, 224, 225, 230, 231, 232, and 233) located in the main ED on 06/29/11 were not provided privacy from people that were not involved in their care while being interviewed, assessed, examined and treated.

2) 1 of 1 Patient (Patient #34) was not provided privacy on 03/03/11 by the RN while performing a history and assessment.

2) 1 of 1 Patient (Patient #1) personal medical information was disclosed on 05/13/11 to an outside third party organization without prior consent of the patient.

Findings Included:

During a tour of the ED on 06/29/11 at 2:00 P.M., the surveyor accompanied by the CNO (Personnel #1) and the ED Nurse Manager (Personnel #2) observed the main hall was crowded with patients in hall beds with their family members present. The patients in the hall beds were not protected by curtains. The surveyor observed bed numbers posted above the beds in the halls.

The areas and hall adjacent to the Main Nursing Station contained patients in hall beds # 222, 223, 224, 225, 230, 231, 232, and 233. Patients in beds # 232 and 233 were directly stationed on the wall beside glass doors which opened directly to the outside ambulance entrance.

The hall located by Zone 2 of the Main ED contained patient beds # 218, 219, 220, and 221.

The surveyor, CNO and ED Nurse Manager observed multiple personnel interviewing, assessing and examining the patient's in the hall beds. The personnel were also observed starting IV's (intravenous lines), drawing blood for lab work and giving medications without providing any patient privacy while other people not involved in their care were present.

Review of Patient #34's complaint of care to the hosptial dated 03/03/11 reflected, "Patient #34 states during the first visit she was placed in the hallway corridor. States when the RN began asking her medical history she asked the RN to lower her voice as she did not want the gentleman in the next gurney listening to her personal information. States the RN then began to have an attitude. States the RN brought her a gown and told her to put it on. She questioned how and why she was going to put a gown on in the hallway....States when the RN returned she tried to start over and apologize for their rough start; but the nurse just became more agitated and informed the patient she is the one with the attitude...Spoke with RN #55, the patient's initial nurse. RN #55 said when she asked the patient when her last menstrual period was, the patient responded, will you keep your voice down...only other patient in hallway was the gentleman across the hall and she did not know whether or not he could hear what she was saying...said she lowered her voice and continued the assessment..."

Review of patient complaint TX 87 received by Texas Department of State Health Services (TDSHS) reflected the following emails between Patient #1 and Organization #1 on 05/13/11:
1) At 7:13 A.M. an email from Patient #1 to Organization #1 reflected, "Could you remind me of when meetings are and also how you reached out to me?"
2) At 9:20 A.M. an email from Organization #1 to Patient #1 reflected, "Your name and address came to me from Methodist Hospital..."
3) At 9:41 A.M. an email from Organization #1 to Patient #1 reflected, "It was from Personnel #40 (Patient Representative). She sends us all the losses at Methodist so we can send the parents our information..."

Review of Patient #1's medical record reflected:
1)The "Authorization to Release Information" dated 04/18/11, not timed, did not reflect consent for release of personal information to the third party Organization #1.
2)The "Referral Screens" dated 04/18/11, not timed, did not reflect a referral to the third party Organization #1.
3) The "Doctor's Orders" dated 04/19/11 timed at 4:30 P.M. did not reflect discharge orders for a referral to the third party Organization #1 for grief counseling.
4)The "Discharge Instructions" dated 04/19/11 timed at 6:30 P.M. did not identify any other services were required after discharge home. There was no discharge instructions or teaching documented for referral to grief counseling and no written request to release or disclose patient information to the third party Organization #1 for referral for grief counseling.

The hospital did not have a contract or agreement with the third party Organization #1 to provide continuation of or referral of services for patients or to ensure the agent will not use or disclose the health care information for any other purpose or take appropriate steps to protect the health care information.

The hospital policy "Patient's Rights and Responsibilities" dated 04/30/11 requires, "MHS honors your rights as a patient...As a member of the partnership between you and your healthcare team we respect your right to...Considerate and respectful care. You can expect quality treatment within the scope of our mission, with concern for your personal privacy and dignity...Confidentiality and access to your medical records. You may expect all communications and clinical records pertaining to your care to be treated as confidential and that you should be able to access information contained in your records within a reasonable time frame...Reasonable continuity of care, and to be informed by physicians and other caregivers of available and realistic patient care options when hospital care is no longer appropriate..."

The hospital policy "Control of Patient Information (Including Confidentiality of Medical Records)" dated 01/30/08 requires, "Patient confidentiality should be protected in accordance with law...These guidelines apply to requests for records and to inquires concerning patients. "Medical Information" is defined as information in any form that identifies a patient and relates to the history, diagnosis, treatment or prognosis of a patient...Releases of information without patient consent should normally be accomplished pursuant to a written request...Medical information may generally be released to third parties upon presentation of a valid patient authorization...A properly completed and signed authorization to release patient information...should be retained in the medical record with notation of information released, the date of release and the name of the person releasing the information..."

At 5:00 P.M. on 07/05/11 the CNO (Personnel #1) was interviewed. The CNO confirmed the above findings and verified the hospital is not following policies and procedures for providing and promoting patient privacy.She was asked if the hospital provides patient information to the third party Organization #1 of families who have neonatal deaths. She stated, "Yes. It is part of our continuation of care." She was asked if the hospital has a contract with the Organization #1 to provide continuing care services for patients. She stated, "No." She was asked if the hospital has any agreement or contract to provide private health information to Organization #1. She stated, "No." She was asked if Patient #1's medical record reflected permission to release her private information to Organization #1. She stated, "No."

At 1:00 P.M. on 08/04/11 MD #9 the Attending Physician was interviewed. He was asked if he referred Patient #1 to Organization #1. He stated, "Yes. It is our Standard of Care to refer all fetal demise mothers for grief support. It is a continuation of care we provide. "He was asked if he wrote an order for a referral to Organization #1. He stated, "No."
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation, record review and interview, the hospital did not post the required EMTALA (Emergency Medical Treatment and Labor Act) signage in the Emergency Department (ED) and Labor and Delivery (L&D) Unit where patient's present for Emergency Medical Conditions (EMC) that was prominent and conspicuous and likely to be noticed by all individuals entering the ED or L&D which specified the rights of individuals with respect to examination and treatment of emergency medical conditions and women in labor.

Findings included:

On 06/29/11 at 2:00 P.M., a tour of the ED was conducted with the CNO (Personnel #1) and the ED Nurse Manager (Personnel #2). Upon entry to the ED from the outside entrance into the main waiting room, the surveyor did not observe the required EMTALA signage posting in either English or Spanish. A tour of the main waiting room revealed one small EMTALA sign posted beside the registration area which was not visible from the waiting room. The EMTALA sign was obscured by numerous other postings. The EMTALA sign was not prominent and conspicuous in that it was not clearly visible from a distance of 20 feet. The required Patient Complaint signage was not posted in the main ED.

Continuation of the tour of the ED revealed there was no EMTALA signage posted in the patient triage rooms, patient treatment areas or the ambulance entrances.

After the tour of the Main ED, at 3:30 P.M., the surveyor accompanied by the CNO (Personnel #1) and ED Nurse Manager (Personnel #2) left the Main ED and toured the L&D Unit. The surveyor did not observe any of the required EMTALA postings at the entrance of the L&D area. There was one small sign posted inside of the L&D area on the opposite wall of the registration clerk ' s desk which was not clearly visible from 20 feet distance. There was no EMTALA signage posted in the patient triage area or treatment rooms.

On 06/30/11 at 11:00 A.M., during a separate tour of the facility accompanied by Personnel #5, Vice President (VP) of Administration, the surveyor did not observe any of the required EMTALA signage posted in the Front Lobby Entrance, Main Admitting Entrance, or Outpatient Registration areas.

The hospital policies and procedures did not address the required EMTALA Signage postings.

In an interview at 3:30 P.M. on 06/29/11, the CNO (Personnel #1) confirmed the above findings.

In an interview at 11:00 A.M. on 06/30/11, the VP of Administration (Personnel #5) confirmed the above findings.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on observation, record review and interview, the hospital failed to:

1. Maintain an adequate on-call list of individually named OB/GYN physicians and their alternates who are current members of the medical staff or who have hospital privileges with accurate contact information for 6 of 6 months from 01/01/11 - 06/30/11 who were available to provide stabilizing treatment to individuals presenting with emergency medical conditions.

2. Maintain a written on-call list of physicians and their alternates who were on call for Anesthesia Services for 6 of 6 months from 1/01/11 - 06/30/11 that are available to provide treatment to individuals presenting with emergency medical conditions.

Findings included:

During a tour of the L&D Department at 3:30 P.M. on 06/29/11, the surveyor was accompanied by the CNO (Personnel #1) and ED Nurse Manager (Personnel #2). The surveyor asked the L&D Charge Nurse (Personnel #33) where the physician on-call schedule is posted. She handed the surveyor a clipboard with a calendars for January 2011 - June 2011. The calendars did not contain the full names of the physicians with their contact information or alternate physician's on-call. She was asked if she had a copy of the on-call schedule for anesthesiology. She stated, "No. Anesthesia will come in and write their name on the dry erase board when they are on call." She was asked if L&D is provided an Anesthesia schedule with the physicians on-call and the physician that is the alternative for back-up call. She stated, "No."

Review of the On-Call Schedules reflected:

Labor and Delivery On-Call Schedule:

The L&D On-Call Attending Physician Schedule dated "January 2011 - June 2011" did not reflect the full name of the on-call physician's with their contact information or any on-call alternate physician's in the event the on-call physician cannot respond.

The On-Call schedules for Faculty dated "January 2011 - June 2011" did not reflect the full name of the on-call physician's with their contact information or any on-call alternate physician's in the event the on-call physician cannot respond.

Labor and Delivery Anesthesiology On-Call Schedule:
The L&D Department did not have any written copies of on-call schedules for Anesthesiology from 01/01/11 through 06/30/11. A Dry Erase Board posted in the department is utilized for the one person on-call for anesthesia for the day. The Dry Erase Board did not contain an alternate anesthesia on-call person with the contact number.

The Obstetrics/Gynecology Department Medical Staff Committee Meeting Minutes:
The 05/04/11 Committee Notes reflects, "Stand by deliveries requires staff on call must be present at delivery...MD #7 reminded members of the department who participate in attending staff call, that they (the attending staff supervisor) are responsible for the case and well be held accountable...Residency Report...MD # 54 reemphasized the importance of attending staff call physician's responsibilities as stated by MD # 7..."

The "Medical Staff Policy Manual" dated 05/24/11 requires, "Medical staff appointment is set forth in the bylaws...shall...provide continuous care and supervision of his patient...Emergency Services...ED Call and Coverage...The Medical Staff Executive Committee (MEC)...shall determine the clinical departments and other services for which an ED call list will be required... to ensure for the provision of adequate on call coverage to meet the needs of patients coming to the system's hospital's emergency department and to provide coverage for the services offered in the system hospital...provide for use...a current list of practitioners within the department who are on call for ED patients who do not request a specific member of the medical staff...each department shall provide such list to the Medical Staff office in a timely, regular an consistent manner...Each practitioner having Active 1 status...shall be required to take emergency department call when assigned...acknowledges the responsibility and expectation of every medical staff member to participate in fulfilling the requirements for providing emergency department call and providing emergency care to patients coming to a system hospital...It is the policy of MHS hospitals to comply with the EMTALA...requires that any patient who presents at the ED must receive an appropriate MSE to determine if that patient has an EMC. If so and except as authorized under EMTALA, the patient's condition must be stabilized...The provisions of EMTALA apply not only to the hospital but also to the practitioners who provide on-call coverage...the obligations of on-call practitioners...the on-call practitioner must come to the ED when requested by the ED physician, another physician, a nurse...the on-call practitioner shall be physically present in the ED to assist in providing an appropriate MSE, as well as in the ongoing stabilization and treatment of an ED patient...EMC means: a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy...with respect to pregnant woman who is having contractions: there is inadequate time to effect a safe transfer to another hospital before delivery, or the transfer may pose a threat to the health or safety of the woman or the unborn child...Stabilize mean: with respect to EMC, to provide such medical treatment of the condition as may be necessary to assure within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or, with respect to an EMC involving a pregnant woman, that the woman has delivered (including the placenta)..."

The hospital policy "Patient Transfers" dated 04/30/09 requires, "The Board of Directors...having consulted with the Medical Staff, adopt this policy to comply with state and federal laws...Patient Evaluation. All individuals presenting at the ED shall receive an appropriate MSE to determine whether they have an EMC...Each patient who presents to the ED must be evaluated by: a physician who is present in the hospital at the time the patient presents or is presented, or by a physician on call..."

The hospital policy "Response to Medical Emergencies Occurring on Hospital Premises (Code MERT)" dated 12/30/10 requires, "Methodist Dallas Medical Center (MDMC)...will provide a MSE on any person who is not a patient, while on hospital property for any reason, needs emergency medical assistance, to determine whether that person has an EMC...EMC means a medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably result in: placing the health of the individual, or with respect to a pregnant woman, the health of the woman or unborn child, in serious jeopardy...MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency exists... "

The "Plan for Provision of Patient Care" dated FY 2011, requires, "Methods Used to Assess and Meet Patient Care Needs: Patients are assessed by the medical staff in accordance with the medical staff Rules and Regulations...ED...Any individual...who presents...for examination or treatment, will be provided an appropriate MSE by an emergency physician or primary care physician...Women's and Children's Services...patients presenting with actual or potential problems related to pregnancy...can be accessed via Emergency Services, through the outpatient services, through transport, as a direct admit or as a drop-in patient...patients are assessed by the medical staff in accordance with the medical staff Rules and Regulations..."

In an interview at 3:30 P.M. on 06/29/11, the CNO (Personnel #1) confirmed the above findings and verified the hospital policies and procedures were not followed for on-call physicians.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on observation, interviews and record reviews, the hospital's Governing Board failed to:

1) Ensure all patients presenting to the Emergency Department (ED) and L&D (Labor and Delivery) from 01/01/11 to 06/29/11 received an appropriate medical screening examination (MSE) to determine whether or not an emergency medical condition (EMC) existed, stabilizing treatment was provided and appropriate transfers were initiated if needed. Patient #2 presented to the ED for a potential EMC did not receive an appropriate MSE to determine if stabilizing treatment was needed prior to transferring the patient to L&D without appropriate qualified medical personnel.

The Registered Nurses (RNs) and Medical Residents who performed the MSE in the ED and L&D were not appointed by the Governing Body as Qualified Medical Practitioners (QMP) to provide MSE.

2) Adopt and enforce a hospital policy to ensure EMTALA requirements are met in order to provide for all individuals presenting to the ED and L&D for examination of a medical condition an appropriate MSE by a QMP to determine whether or not an EMC exists, provide stabilizing treatment and/or effect an appropriate transfer.

It is determined this deficient practice creates an Immediate Jeopardy situation and places the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.

Findings Included:

During a tour of the facility at 3:30 P.M. on 06/29/11, the surveyor accompanied by the CNO (Personnel #1) and the ED Nurse Manager (Personnel #2) observed the ED Volunteer (Personnel #53) escorting a pregnant patient (Patient #2) and her husband down the hall. The pregnant patient was holding her stomach and appeared to be in distress. The Volunteer (Personnel #53) stopped at the end of the hall and gave directions to Patient #2 and her husband to the L&D Unit. The Volunteer (Personnel #53) then left Patient #2 and her husband alone to find the L&D area unaccompanied. The CNO (Personnel #1) and the ED Nurse Manager (Personnel #2) verified the escort is a volunteer and not a qualified medical person.

The surveyor, CNO (Personnel #1) and the ED Nurse Manager (Personnel #2) then followed Patient #2 and her husband down the hall to the elevator. The CNO intervened at this point and asked the patient if she needed help. Patient #2 stated she is having contractions and is going to the L&D area. The CNO, ED Manager and the surveyor accompanied Patient #2 in the elevator to the 3rd floor where the L&D is located. The CNO asked the registration clerk to open the door to allow the patient in. The CNO handed the patient off to the L&D Nurses and gave them report. Patient #2 was then placed at the Registration desk inside the L&D area. The surveyor observed the Registration Clerk taking Patient #2's personal information including asking her for a copy of her Identification and Insurance or Medicaid paperwork prior to a medical screening examination (MSE) being performed to determine if an emergency medical condition (EMC) existed.

The surveyor asked Patient #2 if she was checked into the ED and examined first before being sent to L&D. She stated, "No. The person at the desk told the Volunteer to take me to the Labor and Delivery area."

RN #4 escorted Patient #2 to the patient care area to be assessed. RN #4 was asked if she does the medical screening for the L&D patients. She stated, "Yes. The nurses do it if the patient's have a private physician. They will ask us to check the patient and call them back with what the exam looked like. We let them know and if everything is ok then we discharge them home. If the patient is without a physician, we call the resident to examine them and they are listed under MD #54. He is the attending over the resident program."

The surveyor then interviewed the L&D Charge Nurse (RN #33). She was asked if the resident or physician performs the medical screening for patient's that present to the L&D. She stated, "No. The RN's do the medical screening." She was asked what the responsibilities of the Triage Nurse are. She stated, "The triage nurse gets the patient's to sign the consents, fills out the doctor's order sheet, performs maternal vital signs (VS), monitors the fetal heart rate (HR), uterine contractions, pain and medical history." She was asked if the attending physician comes in to see the patient when he is notified one of his or her patient's have presented to L&D. She stated, "No. Not all the time. They have privileges to see the fetal strip on a computer." She was asked if the residents perform care on the patients. She stated, "Yes, with help of the attending."

Review of the ED or OB/GYN Nursing Staff files did not contain letters of recommendation from the Medical Staff or letters of appointment from the Governing Board determining any nurses as QMP's to perform MSE's to determine if an EMC exists for patient's that present to the hospital for emergencies.

The ED or OB/GYN Nursing Staff files did not contain specific QMP competencies or evaluations to perform MSE's for EMC's.

The Obstetrics/Gynecology Department Medical Staff Committee Meeting Minutes dated 05/04/11 reflects, "Documentation and communication between attending OB/GYN and resident...Attending and Residents need to document when the attending is present for the procedure and when the attending leaves the procedure...Stand by deliveries requires staff on call must be present at delivery...MD #7 reminded members of the department who participate in attending staff call, that they (the attending staff supervisor) are responsible for the case and well be held accountable...Residency Report...MD #54 reemphasized the importance of attending staff call physician's responsibilities as stated by MD #7..."

The Governing Body Bylaws: Reviewed and amended 02/22/11 requires, "The activities, property and affairs of the corporation shall be managed by its Board of Directors...Medical Staff Organization...Hospital Medical Staff...shall...administer its affairs in accordance with the corporate bylaws and policies, including the corporate medical staff bylaws, policies, and rules, and with that System Institution's policies and program requirements...shall approve all appointments...Corporate Medical Board...make recommendations to the Board of Directors on...applications for appointment...privileges...evaluate and monitor quality monitoring and improvement activities and systems for monitoring and evaluating the quality of patient care and improving patient care in the system institutions..." The Governing Body Rules and Regulations did not address the requirements for QMP's to perform MSE's for EMC's.

Medical Staff Bylaws and Rules and Regulations: Dated 05/24/11 requires "The Medical Staff is responsible for the quality of medical care in the system hospitals...Medical Staff shall be interpreted to mean all duly licensed Physicians, Dentists and Podiatrists holding unlimited licenses who are granted medical staff appointment...House Staff shall mean those physicians who are graduates of a medical school...and are pursuing additional training in a system hospital's medical education program...Clinical Privileges shall be interpreted to mean having the right to render specific diagnostic, therapeutic, medical, dental or surgical services in a system hospital...Appointment to the Medical Staff or the granting of temporary privileges shall be extended only to those professionally competent Physicians, Dentists, and Podiatrists who meet the qualifications, standards and requirements set forth in these bylaws and policies...each practitioner shall have only such clinical privileges as have been granted by the Board of Directors as recommended by the Medical Staff in accordance with these bylaws ..."

The "Medical Staff Policy Manual" dated 05/24/11 requires, "Medical staff appointment is set forth in the bylaws...shall...provide continuous care and supervision of his patient; to abide by the Bylaws, the Policies, the MHS bylaws and all other established standards, policies, and rules of the Medical Staff...and, to participate in fulfilling the requirements for providing emergency care...Degree of Care/Management of Patient by House Staff...The medical record should reflect the involvement of the teaching practitioner in the management of a patient treated by a House Staff Member...House Staff shall not be considered Medical Staff members nor shall the term House Staff be considered a category of Medical Staff membership...Medical Records...There shall be evidence in the medical record that the teaching physician has been involved in the management of a patient treated by a member of the House Staff...Progress Notes...Pertinent progress notes should be recorded at the time of observation, sufficient to permit continuity of care...each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders...An appropriate medical record shall be kept for every patient receiving emergency medical care and shall be incorporated in the patient's hospital record...Each patient's medical record shall be signed by the physician in attendance that is responsible for its clinical accuracy...Emergency Services...the obligations of on-call practitioners...the on-call practitioner must come to the ED when requested by the ED physician, another physician, a nurse...the on-call practitioner shall be physically present in the ED to assist in providing an appropriate MSE, as well as in the ongoing stabilization and treatment of an ED patient...EMC means: a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy...with respect to pregnant woman who is having contractions: there is inadequate time to effect a safe transfer to another hospital before delivery, or the transfer may pose a threat to the health or safety of the woman or the unborn child...Stabilize mean: with respect to EMC, to provide such medical treatment of the condition as may be necessary to assure within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual...with respect to an EMC involving a pregnant woman, that the woman has delivered (including the placenta)...Transfer means: the movement (including discharge) of an... "The Medical Staff Bylaws, Rules and Regulations did not address the requirements for QMP's to perform MSE's for EMC's.

The hospital policy "Patient Transfers" dated 04/30/09 requires, "The Board of Directors...having consulted with the Medical Staff, adopt this policy to comply with state and federal laws...Patient Evaluation. All individuals presenting at the ED shall receive an appropriate MSE to determine whether they have an EMC...Each patient who presents to the ED must be evaluated by: a physician who is present in the hospital at the time the patient presents or is presented, or by a physician on call is: physically able to reach the patient within 30 minutes...accessible by direct, telephone...within 30 minutes, with a RN or PA or other qualified medical personnel as established by the hospital's governing body at the MHS hospital under orders to assess and report the patient's condition to the physician...The MSE should not be delayed in order to inquire about the patient's method of payment or insurance... "

The hospital policy "Response to Medical Emergencies Occurring on Hospital Premises (Code MERT)" dated 12/30/10 requires, "Methodist Dallas Medical Center (MDMC)...will provide a MSE on any person who is not a patient, while on hospital property for any reason, needs emergency medical assistance, to determine whether that person has an EMC...EMC means a medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably result in: placing the health of the individual, or with respect to a pregnant woman, the health of the woman or unborn child, in serious jeopardy...MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency exists..."

The hospital policy "Guidelines for Obstetrical (OB) Patients Presenting to the ED" dated 08/30/10 requires "Any OB patient greater than, or suspected to be greater than 20 weeks gestation, presenting to the ED (either ambulatory, by wheelchair, or ambulance) with any of the following, should be transported to L&D as soon as possible, after they are deemed to be stable enough for transport: Symptoms suggestive of labor, rupture of membranes, complications related to the pregnancy, injuries that could endanger the unborn infant...If indicated during the stabilization process, the ED staff may contact L&D for assessment and monitoring of the fetal status..."

The "Plan for Provision of Patient Care" dated FY 2011, requires, "ED...Any individual...who present...for examination or treatment, will be provided an appropriate MSE by an emergency physician or primary care physician...The ED triages all patients using RN's experienced in emergency care. Patients are triaged according to a 5-level tier system which ensures patients are assessed and prioritized to acuity...Women's and Children's Services...patients presenting with actual or potential problems related to pregnancy...can be accessed via Emergency Services, through the outpatient services, through transport, as a direct admit or as a drop-in patient...patients are assessed by the medical staff in accordance with the medical staff Rules and Regulations and by nursing...in accordance with the established reference guideline...Volunteer Services ...provide non-clinical patient services that do not require a license or certificate..."

The hospital policy "Supervision of Residents in Obstetrics and Gynecology" dated February, 2008 requires "L&D...Supervising physicians are required to personally assess all patients admitted to L&D and the antepartum unit...Supervising physicians are required to directly supervise...and must be immediately available for supervision of normal spontaneous vaginal deliveries...Summary...A qualified faculty or attending physician is assigned to supervise all resident activities at all times on all services. There is a supervising physician in the hospital 24 hours per day, seven days per week. The supervising physician should directly or indirectly supervise the residents patient care activities depending upon the type of care and PGY level of the resident."

At 4:00 P.M. on 06/29/11 the surveyor interviewed Personnel #2, the ED Nurse Manager. She was asked if the nurses perform MSE's in the ED. She stated, "No. The nurses perform triage and the physician's do the medical screening." She was asked if the nurses make the determination when the patient's are taken back to the main ED or Fast Track to see a physician. She stated, "Yes. We use the 5 level triage system. We make the determination based on the triage system who is seen first by the physician." She was asked if the Paramedic checking in the patient's performs triage. She stated, "The paramedic does a quick check based on their complaint and makes the determination which patient needs to see the nurse first." She was asked if it is the ED policy to send patient's to L&D without medical screening. She stated, "We send all of our patient's that are greater than 20 weeks pregnant to L&D for screening unless they are trauma patients." She was asked if it is the hospital policy to send pregnant patient's to L&D with a volunteer. She stated, "Yes, if the other personnel are busy."

At 5:00 P.M. on 06/29/11 the surveyor interviewed the CNO (Personnel #1). She verified it is not the hospital policy to send a patient unescorted to the L&D without a qualified medical person. She was asked if the hospital Governing Body has approved and appointed the ED and L&D RN's as QMP's to perform MSE's. She stated, "No." She verified the hospital is not following the required policies and procedures for providing appropriate MSE's with QMP's in the ED and L&D.

At 8:45 A.M. on 06/30/11 the surveyor interviewed Personnel #19, Director of Medical Staff Services. She was asked if the Residents are part of the medical staff and credentialed with privileges. She stated, "No." She verified the hospital policies and procedures and the Medical Staff Rules, Regulations and Bylaws do not allow residents to practice without direct supervision.

At 9:30 A.M. on 06/30/11 the surveyor interviewed MD #7, Assistant Vice President of the Graduate Medical Education Program. He was asked if he is responsible for the Resident's that practice within the hospital. He stated, "Yes." He was asked what area's the Resident's practice within the hospital. He stated, "We have four core programs, OB, Gynecology (GYN), L&D and OR (operating room). The residents answer consultations in the OB/GYN for emergency or unassigned patient consultations. Our clinic is the Golden Cross Clinic across the street and where our residents practice. Our fell owship is located here in the hospital." He was asked if the residents are paid by the hospital to take call. He stated, "They receive a stipend/salary. They are in training and not independent practitioners and practice under an attending physician. They are employees of Methodist Health System and have a contract." He was asked if the hospital or program has policies and procedures for the residents. He stated, "They practice and are subject to the hospital policies and procedures. "He was asked if the residents are part of the medical staff. He stated, "No they are not privileged providers. The work under different levels of supervision which varies to what year they are in. They all have temporary permits to work as residents or students in training."
VIOLATION: DELAY IN EXAMINATION OR TREATMENT Tag No: A2408
Based on observation, interviews and record reviews, the hospital's Governing Board failed to ensure an appropriate MSE for a potential EMC was not delayed for all patients presenting to the L&D (Labor and Delivery) from 01/01/11 to 06/29/11 for 1 of 1 patients (Patient #2) in order to inquire about the patient's method of payment or insurance before determining if stabilizing treatment was required.

It is determined this deficient practice creates an Immediate Jeopardy situation and places the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.

Findings Included:

During a tour of the facility at 3:30 P.M. on 06/29/11, the surveyor accompanied by the CNO (Personnel #1) and the ED Nurse Manager (Personnel #2) observed the ED Volunteer (Personnel #53) escorting a pregnant patient (Patient #2) and her husband down the hall. The pregnant patient was holding her stomach and appeared to be in distress. The Volunteer (Personnel #53) stopped at the end of the hall and gave directions to Patient #2 and her husband to the L&D Unit. The Volunteer (Personnel #53) then left Patient #2 and her husband alone to find the L&D area unaccompanied. The CNO (Personnel #1) and the ED Nurse Manager (Personnel #2) verified the escort is a volunteer and not a qualified medical person.

The surveyor, CNO (Personnel #1) and the ED Nurse Manager (Personnel #2) then followed Patient #2 and her husband down the hall to the elevator. The CNO intervened at this point and asked the patient if she needed help. Patient #2 stated she is having contractions and is going to the L&D area. The CNO, ED Manager and the surveyor accompanied Patient #2 in the elevator to the 3rd floor where the L&D is located. The CNO asked the registration clerk to open the door to allow the patient in. The CNO handed the patient off to the L&D Nurses and gave them report. Patient #2 was then placed at the Registration desk inside the L&D area. The surveyor observed the Registration Clerk taking Patient #2's personal information including asking her for a copy of her Identification and Insurance or Medicaid paperwork prior to a medical screening examination (MSE) being performed to determine if an emergency medical condition (EMC) existed.

The surveyor asked Patient #2 if she was checked into the ED and examined first before being sent to L&D. She stated, "No. The person at the desk told the Volunteer to take me to the Labor and Delivery area."

RN #4 escorted Patient #2 to the patient care area to be assessed. RN #4 was asked if she does the medical screening for the L&D patients. She stated, "Yes. The nurses do it if the patient's have a private physician. They will ask us to check the patient and call them back with what the exam looked like. We let them know and if everything is ok then we discharge them home. If the patient is without a physician, we call the resident to examine them and they are listed under MD #54. He is the attending over the resident program."

The surveyor then interviewed the L&D Charge Nurse (RN #33). She was asked if the resident or physician performs the medical screening for patient's that present to the L&D. She stated, "No. The RN's do the medical screening." She was asked what the responsibilities of the Triage Nurse are. She stated, "The triage nurse gets the patient's to sign the consents, fills out the doctor's order sheet, performs maternal vital signs (VS), monitors the fetal heart rate (HR), uterine contractions, pain and medical history." She was asked if the attending physician comes in to see the patient when he is notified one of his or her patient's have presented to L&D. She stated, "No. Not all the time. They have privileges to see the fetal strip on a computer." She was asked if the residents perform care on the patients. She stated, "Yes, with help of the attending."

At 4:00 P.M. on 06/29/11 the surveyor interviewed Personnel #2, the ED Nurse Manager. She was asked if the nurses perform MSE's in the ED. She stated, "No. The nurses perform triage and the physician's do the medical screening." She was asked if the nurses make the determination when the patient's are taken back to the main ED or Fast Track to see a physician. She stated, "Yes. We use the 5 level triage system. We make the determination based on the triage system who is seen first by the physician." She was asked if the Paramedic checking in the patient's performs triage. She stated, "The paramedic does a quick check based on their complaint and makes the determination which patient needs to see the nurse first." She was asked if it is the ED policy to send patient's to L&D without medical screening. She stated, "We send all of our patient's that are greater than 20 weeks pregnant to L&D for screening unless they are trauma patients." She was asked if it is the hospital policy to send pregnant patient's to L&D with a volunteer. She stated, "Yes, if the other personnel are busy."

At 5:00 P.M. on 06/29/11 the surveyor interviewed the CNO (Personnel #1). She verified the hospital policies and procedures were not followed in regards to inquiring about the patient's method of payment or insurance prior to providing MSE's.
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), and the implementing regulations at 42 CFR ?489.24 and the related requirements at 42 CFR 489.20 ( l ), (q), and (r) from 01/01/11 to 06/29/11.

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 individuals who came to the ED requesting an examination for a medical condition;

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.

Cross refer: Tag A2400
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview and review of records, the hospital failed to have an effective governing body which failed to ensure patient care was provided in a safe and effective manner and comply with state and federal rules.

Findings included:


1) The hospital did not protect and promote each patient's rights in that it did not adequately address each patient care complaint or grievance, respect the patient's basic right to respect, dignity, and comfort by providing personal privacy during procedures and examinations, provide a safe environment where care and treatment are provided, prevent personal health information from being disclosed and ensure properly executed informed consents for procedures and treatments.
Cross refer: A0115 and A0466

2) The hospital failed to ensure that each patient who presented for treatment to the hospital had appropriate medical screening examination or treated by a qualifed medical person or member of the medical staff.
Cross refer: A0353

3) All drugs were not administered upon an order by an authorized practitioner.
Cross refer: A0406

4) The hospital failed to adequately maintain a medical record for every individual that presented to the hospital for inpatient and outpatient treatment.
Cross refer: A0431

5) The medical staff failed to monitor and ensure that the ED (Emergency Department) policies and procedures governing the medical care provided in the ED were enforced.
Cross refer: A1104

6) The Governing Body failed to ensure that the hospital was in compliance with 489.24 with EMTALA (Emergency Medical Treatment and Labor Act) in that all patients who presented to the ED were not provided an appropriate MSE (medical screening examination) by a QMP (qualified medical personnel) to determine whether or not an EMC (emergency medical condition) existed.
Cross refer: A2400

The Governing Body Bylaws: Reviewed and amended 02/22/11 requires, "The activities, property and affairs of the corporation shall be managed by its Board of Directors...Medical Staff Organization...Hospital Medical Staff...shall...administer its affairs in accordance with the corporate bylaws and policies, including the corporate medical staff bylaws, policies, and rules, and with that System Institution's policies and program requirements...shall approve all appointments...Corporate Medical Board...make recommendations to the Board of Directors on...applications for appointment...privileges...evaluate and monitor quality monitoring and improvement activities and systems for monitoring and evaluating the quality of patient care and improving patient care in the system institutions..."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview and record review, the hospital failed to promote patient rights by providing care in a safe setting by failing to:

1) Provide a sanitary environment to avoid sources and transmission of infections and communicable diseases in that multiple staff did not dispose of their soiled gloves and wash their hands after treating patients and touching patient equipment.

2) Provide basic infection control supplies and equipment including hand sanitizer, linen hampers, trash cans and biohazard disposal boxes close to or in proximity of the patient hall beds for the staff to use.

3) The ED patient hall beds did not have nurse call lights for patient's to notify the nursing staff in the event of an emergency.

Findings Included:

During a tour of the ED on 06/29/11 at 2:00 P.M., the surveyor accompanied by the CNO (Personnel #1) and the ED Nurse Manager (Personnel #2) observed multiple personnel interviewing, assessing and examining the patient's in the hall beds. The personnel were also observed starting IV's (intravenous lines), drawing blood for lab work and giving medications on multiple patients in the main ED hall.

The ED patient hall beds did not have patient call lights, linen hampers, trash cans, biohazard disposal boxes or hand sanitizer posted beside each bed. The hall did not have any hand washing facilties. The surveyor observed multiple personnel wearing gloves and did not remove the gloves and wash their hands after drawing blood or providing patient care prior to touching other equipment.

The hospital "Plan for the Provision of Patient Care" dated FY 2011 requires, "The Board of Directors...has ultimate responsibility for operations...carries out this responsibility through goal-focused allocation of resources, performance improvement, risk management, patient safety...Infection Prevention and Control...to identify, assess, and reduce the risks of acquiring and/or transmitting infections among patient, employees, physicians...is crucial in minimizing morbidity, mortality and the economic burden associated with healthcare associated infections...surveillance and monitoring...prevent and/or reduce the risk of infections...participate in monitoring of the Environment of Care for infection risks...methods are used to decrease or eliminate exposures..."

The hospital policy "Patient's Rights and Responsibilities" dated 04/30/11 requires, "MHD honors your rights as a patient...to provide a safe setting..."

At 5:00 P.M. on 07/05/11 the CNO (Personnel #1) was interviewed. The CNO confirmed the above findings and verified the hospital is not following policies and procedures for providing and promoting safe patient care.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on observation, interviews and record reviews, the hospital did not enforce the Medical Staff Bylaws by failing to ensure 4 of 5 patients (Patient #1, #2, #4, and #5) who presented for treatment in L&D (Labor and Delivery) from 01/01/11 - 06/29/11 received treatment or MSE's from a physician who is approved by the Governing Body for clinical privileges.
The Medical Residents and RN's who provided MSE's and patient treatment were not directly supervised by a faculty physician or appointed by the Governing Board to provide MSE's as a QMP to determine if an EMC existed.

Findings Included:

Review of the following patient medical records reflected:

Patient #1's medical record dated 04/18/11 reflected the patient was admitted for induction of labor for fetal demise. On 04/19/11 at 3:07 A.M. delivered the baby without the attending physician (MD #9) present.
The Nursing "Maternal Review of Systems" dated 04/19/11 timed at 3:07 A.M. reflected "Patient called out stating baby is out...Unit Secretary asked to page MD #9..."
The "Delivery Summary" dated 04/19/11 timed at 3:08 A.M. reflected, "Delivery Doctor/other: MD #6/Resident #13, Assist: MD #9..."
The Nursing "Maternal Review of Systems" dated 04/19/11 timed at 3:10 A.M. reflected "Resident #13 called and asked to assist...until MD #9 arrives..."
The Nursing "Maternal Review of Systems" dated 04/19/11 timed at 3:14 A.M. reflected "Resident #13 at bedside."
The Nursing "Maternal Review of Systems" dated 04/19/11 timed at 3:21 A.M. reflected "MD #9 called and notified that patient has delivered. MD states he is on his way. Resident #13 remains at bedside for anticipated delivery of placenta."
The Nursing "Maternal Review of Systems" dated 04/19/11 timed at 3:43 A.M. reflected, "Morphine Sulfate 6 mg was given SIVP (slow intravenous push)...analgesic medication ordered by Resident #13 and administered to provide relief of pain from imminent placenta delivery." The medical record did not reflect a written order from MD #9 or Resident #13 for Morphine.
The Nursing "Maternal Review of Systems" dated 04/19/11 timed at 3:46 A.M. reflected "MD #9 in room...Resident #13 remains at bedside to assist in delivery of placenta..."
The "Operative Report" dated 04/19/11 timed at 4:22 A.M. reflected, "Name of Procedure: Induction of Labor. 2. Spontaneous vaginal delivery. 3. Delivery of placenta by extraction. Surgeon: MD #9, Assistant: Resident #13...I was called by nursing to be notified of spontaneous vaginal delivery, which they noted too tight nuchal cord delivery at time of delivery of a male fetus with no signs of life. Resident #13 reports placing a cord clamp and then having cord avulsion with minimal amount of tension on the cord. On my arrival, the patient was not hemorrhaging..."

Patient #2's medical record dated 06/29/11 reflected the patient was admitted to the L&D Unit (Labor and Delivery) for observation of "leaking/mucus plug."
The "Doctor's Notes" timed at 4:00 P.M. reflected an examination that was not signed by any provider.
The nursing "OB Triage" notes timed at 4:35 P.M. reflected, "Exam by: MD #58" and at 6:20 P.M. reflected, "Exam by: Resident #36."
The medical record did not contain a medical H&P, assessment or discharge summary documented by a physician who is a member of the medical staff.

Patient #4's medical record dated 05/14/11 reflected the patient was admitted to the L&D Unit for observation of "Spotting."
The nursing "OB Triage" notes timed at 5:13 A.M. reflected, "Exam by: Resident #56."
The medical record did not contain a medical H&P, assessment, progress notes or discharge summary documented by a physician who is a member of the medical staff.

Patient #5's medical record dated 06/05/11 reflected the patient was admitted to the L&D Unit for observation
The nursing "OB Triage" notes timed at 6:36 A.M. reflected, "Exam by: Resident #57."
The medical record did not contain a medical H&P, assessment, progress notes or discharge summary documented by a physician who is a member of the medical staff.

The Governing Body Bylaws: Reviewed and amended 02/22/11 requires, "The activities, property and affairs of the corporation shall be managed by its Board of Directors...Medical Staff Organization...Hospital Medical Staff...shall...administer its affairs in accordance with the corporate bylaws and policies, including the corporate medical staff bylaws, policies, and rules, and with that System Institution's policies and program requirements...shall approve all appointments...Corporate Medical Board...make recommendations to the Board of Directors on...applications for appointment...privileges...evaluate and monitor quality monitoring and improvement activities and systems for monitoring and evaluating the quality of patient care and improving patient care in the system institutions..." The Governing Body Rules and Regulations did not address the requirements for QMP's to perform MSE's for EMC's.

Medical Staff Bylaws and Rules and Regulations: Dated 05/24/11 requires "The Medical Staff is responsible for the quality of medical care in the system hospitals...Medical Staff shall be interpreted to mean all duly licensed Physicians, Dentists and Podiatrists holding unlimited licenses who are granted medical staff appointment...House Staff shall mean those physicians who are graduates of a medical school...and are pursuing additional training in a system hospital's medical education program...Clinical Privileges shall be interpreted to mean having the right to render specific diagnostic, therapeutic, medical, dental or surgical services in a system hospital...Appointment to the Medical Staff or the granting of temporary privileges shall be extended only to those professionally competent Physicians, Dentists, and Podiatrists who meet the qualifications, standards and requirements set forth in these bylaws and policies...each practitioner shall have only such clinical privileges as have been granted by the Board of Directors as recommended by the Medical Staff in accordance with these bylaws ..."

The "Medical Staff Policy Manual" dated 05/24/11 requires, "Medical staff appointment is set forth in the bylaws...shall...provide continuous care and supervision of his patient; to abide by the Bylaws, the Policies, the MHS bylaws and all other established standards, policies, and rules of the Medical Staff...and, to participate in fulfilling the requirements for providing emergency care...Degree of Care/Management of Patient by House Staff...The medical record should reflect the involvement of the teaching practitioner in the management of a patient treated by a House Staff Member...House Staff shall not be considered Medical Staff members nor shall the term House Staff be considered a category of Medical Staff membership...Medical Records...There shall be evidence in the medical record that the teaching physician has been involved in the management of a patient treated by a member of the House Staff...Progress Notes...Pertinent progress notes should be recorded at the time of observation, sufficient to permit continuity of care...each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders...An appropriate medical record shall be kept for every patient receiving emergency medical care and shall be incorporated in the patient's hospital record...Each patient's medical record shall be signed by the physician in attendance that is responsible for its clinical accuracy...Emergency Services...the obligations of on-call practitioners...the on-call practitioner must come to the ED when requested by the ED physician, another physician, a nurse...the on-call practitioner shall be physically present in the ED to assist in providing an appropriate MSE, as well as in the ongoing stabilization and treatment of an ED patient...EMC means: a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy...with respect to pregnant woman who is having contractions: there is inadequate time to effect a safe transfer to another hospital before delivery, or the transfer may pose a threat to the health or safety of the woman or the unborn child...Stabilize mean: with respect to EMC, to provide such medical treatment of the condition as may be necessary to assure within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual...with respect to an EMC involving a pregnant woman, that the woman has delivered (including the placenta)...Transfer means: the movement (including discharge) of an... "The Medical Staff Bylaws, Rules and Regulations did not address the requirements for QMP's to perform MSE's for EMC's.

The hospital policy "Supervision of Residents in Obstetrics and Gynecology" dated February, 2008 requires "L&D...Supervising physicians are required to personally assess all patients admitted to L&D and the antepartum unit...Supervising physicians are required to directly supervise...and must be immediately available for supervision of normal spontaneous vaginal deliveries...Summary...A qualified faculty or attending physician is assigned to supervise all resident activities at all times on all services. There is a supervising physician in the hospital 24 hours per day, seven days per week. The supervising physician should directly or indirectly supervise the residents patient care activities depending upon the type of care and PGY level of the resident."

The hospital policy "Specific Duties for Residents" , not dated, requires "PGY 1. The first year resident should know how to manage a normal labor and delivery...recognize both acute and chronic conditions...L&D coverage...with supervision at the end of the year..."

The "Resident Physician Agreement" for Resident #13 dated 06/24/10 requires "This Resident Physician Agreement is entered into by and between Methodist Hospitals of Dallas...and Resident #13...to participate in MHS Obstetrics/Gynecology GME (graduate medical education) Training Program during the 2010-2011 training year...principal purpose of this agreement is to provide an educational experience for resident, rather than to provide employment for the resident or service to MHS or its medical staff...Performance of Duties. Resident shall participate in safe, effective, and compassionate patient care, under supervision, and commensurate with his/her level of advancement and responsibility..."
Resident #13's file did not contain a letter of recommendation from the Medical Staff or letter of appointment from the Governing Board determining any residents as Qualified Medical Personnel (QMP) to perform Medical Screening Examinations (MSE's) to determine if an Emergency Medical Condition (EMC) exists for patient's that present to the hospital for emergencies.

The Obstetrics/Gynecology Department Medical Staff Committee Meeting Minutes dated 05/04/11 reflects, "Documentation and communication between attending OB/GYN and resident...Attending and Residents need to document when the attending is present for the procedure and when the attending leaves the procedure...Stand by deliveries requires staff on call must be present at delivery...MD #7 reminded members of the department who participate in attending staff call, that they (the attending staff supervisor) are responsible for the case and well be held accountable...Residency Report...MD #54 reemphasized the importance of attending staff call physician's responsibilities as stated by MD #7..."

At 8:45 A.M. on 06/30/11 the surveyor interviewed Personnel #19, Director of Medical Staff Services. She was asked if the Residents are part of the medical staff and credentialed with privileges. She stated, "No." She verified the hospital policies and procedures and the Medical Staff Rules, Regulations and Bylaws do not allow residents to practice without direct supervision.

At 9:30 A.M. on 06/30/11 the surveyor interviewed MD #7, Assistant Vice President of the Graduate Medical Education Program. He was asked if he is responsible for the Resident's that practice within the hospital. He stated, "Yes." He was asked what area's the Resident's practice within the hospital. He stated, "We have four core programs, OB, Gynecology (GYN), L&D and OR (operating room). The residents answer consultations in the OB/GYN for emergency or unassigned patient consultations. Our clinic is the Golden Cross Clinic across the street and where our residents practice. Our fell owship is located here in the hospital." He was asked if the residents are paid by the hospital to take call. He stated, "They receive a stipend/salary. They are in training and not independent practitioners and practice under an attending physician. They are employees of Methodist Health System and have a contract." He was asked if the hospital or program has policies and procedures for the residents. He stated, "They practice and are subject to the hospital policies and procedures. "He was asked if the residents are part of the medical staff. He stated, "No they are not privileged providers. The work under different levels of supervision which varies to what year they are in. They all have temporary permits to work as residents or students in training."

At 5:00 P.M. on 07/05/11 the CNO (Personnel #1) was interviewed. She verified the above findings and verified the RN's and Medical Residents are not appointed by the Governing Body as QMP's to provide MSE's.
VIOLATION: WRITTEN MEDICAL ODERS FOR DRUGS Tag No: A0406
Based on observation, interviews and record reviews, the hospital failed to enforce its policy to ensure drugs were administered upon an order of an authorized physician for 1 of 1 patients (Patient #1) on 04/19/11. The nurse administered a narcotic medication upon a verbal order from a medical resident. The medical resident's order was not written and authenticated by the patients attending physician.

Findings Included:

Review of Patient #1's medical record reflected the nursing "Maternal Review of Systems" dated 04/19/11 timed at 3:43 A.M. by RN #14, "Morphine Sulfate 6 mg was given SIVP (slow intravenous push)...analgesic medication ordered by Resident #13 and administered to provide relief of pain from imminent placenta delivery." The medical record did not reflect a written or verbal order from MD #9 or Resident #13 for Morphine.

Medical Staff Bylaws and Rules and Regulations: Dated 05/24/11 requires "The Medical Staff is responsible for the quality of medical care in the system hospitals...Medical Staff shall be interpreted to mean all duly licensed Physicians, Dentists and Podiatrists holding unlimited licenses who are granted medical staff appointment...House Staff shall mean those physicians who are graduates of a medical school...and are pursuing additional training in a system hospital's medical education program...Clinical Privileges shall be interpreted to mean having the right to render specific diagnostic, therapeutic, medical, dental or surgical services in a system hospital...Appointment to the Medical Staff or the granting of temporary privileges shall be extended only to those professionally competent Physicians, Dentists, and Podiatrists who meet the qualifications, standards and requirements set forth in these bylaws and policies...each practitioner shall have only such clinical privileges as have been granted by the Board of Directors as recommended by the Medical Staff in accordance with these bylaws ..."

The "Medical Staff Policy Manual" dated 05/24/11 requires, "Degree of Care/Management of Patient by House Staff...The medical record should reflect the involvement of the teaching practitioner in the management of a patient treated by a House Staff Member...House Staff shall not be considered Medical Staff members nor shall the term House Staff be considered a category of Medical Staff membership...Pertinent progress notes should be recorded at the time of observation, sufficient to permit continuity of care ...each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders...Authentication of Routine Order. A medical staff member's routine orders...shall be reproduced in detail on the order sheet of the patient's record, dated, timed, and signed by the staff member...Medical Records...There shall be evidence in the medical record that the teaching physician has been involved in the management of a patient treated by a member of the House Staff...Each patient's medical record shall be signed by the physician in attendance that is responsible for its clinical accuracy...All orders for treatment shall be in writing...and signed by the person to whom dictated with the name of the Medical Staff member...the ordering or attending practitioner, or any physician with like privileges participating in the patient's care shall authenticate the orders based upon Federal and State law..."

The hospital policy "Medical Record Documentation" dated 06/30/11 requires " To ensure a complete legal medical record ...Documentation completed by non-medical staff members must be countersigned by the responsible physician for the following: All dictated reports, ED record, Orders (PA, CRNA, and midwife only), Progress notes...All orders, including verbal orders, must be dated, timed, and signed by the ordering practitioner or another practitioner involved in the care of the patient...All verbal orders must be signed, dated, and timed within 48 hours...Nursing documentation, including but not limited to nursing assessment, medication reconciliation...interventions are required ...Is not limited to but may include other components for inclusion or monitoring as deemed necessary..."

The hospital policy "Job Description - Staff Nurse" not dated requires "The RN...follows hospital's policies and procedures...follows scope of practice and legal consequences...Implementing clinical and technical aspects of care and physician's orders in compliance with standards of practices and standards of care...Provides a therapeutic environment through safe, accurate, and timely medication and IV administration ...verifying or rectifying patient medication record...completing documentation on correct forms...Medication Administration Record (MAR)...Completing consistently all parts of the documentation system...Knowledgeable about hospital policies, procedures, and nursing care standards and utilizes these when providing nursing care... "

The hospital policy "Medication Handling and Administration" dated 02/28/11 requires "Verbal or telephone orders should be clarified by the person taking the order..." The policy did not address Medical Resident's giving verbal medication orders or the RN taking verbal medication orders from a Resident.

The hospital policy "Supervision of Residents in Obstetrics and Gynecology" dated February, 2008 requires "L&D...Supervising physicians are required to personally assess all patients admitted to L&D and the antepartum unit...Supervising physicians are required to directly supervise...and must be immediately available for supervision of normal spontaneous vaginal deliveries...Summary...A qualified faculty or attending physician is assigned to supervise all resident activities at all times on all services. There is a supervising physician in the hospital 24 hours per day, seven days per week. The supervising physician should directly or indirectly supervise the residents patient care activities depending upon the type of care and PGY level of the resident."

At 8:45 A.M. on 06/30/11 the surveyor interviewed Personnel #19, Director of Medical Staff Services. She was asked if the Residents are part of the medical staff and credentialed with privileges. She stated, "No." She verified the hospital policies and procedures and the Medical Staff Rules, Regulations and Bylaws do not allow residents to practice without direct supervision.

At 9:30 A.M. on 06/30/11 the surveyor interviewed MD #7, Assistant Vice President of the Graduate Medical Education Program. He was asked if the hospital or program has policies and procedures for the residents. He stated, "They practice and are subject to the hospital policies and procedures." He was asked if the residents are part of the medical staff. He stated, "No they are not privileged providers. The work under different levels of supervision which varies to what year they are in. They all have temporary permits to work as residents or students in training."

At 1:30 P.M. on 07/01/11 Resident #13 was interviewed. He was asked to the review the medical record of Patient #1. He was asked if he documented anything in the medical record regarding his practice or findings on Patient #1. He stated, "No." He was asked if he wrote an order for Morphine Sulfate to be given to Patient #1. He stated, "No."

At 2:45 P.M. on 07/05/11 RN #14 was interviewed via telephone. She was asked if she was Patient #1's primary nurse. She stated "Yes." She was asked if Resident #13 was present during the delivery. She stated, "No. He was called and present after the delivery and helped deliver the placenta." She was asked if she received a verbal order from Resident #13 to give 6 mg of Morphine IV to Patient #1. She stated, "Yes."

At 5:00 P.M. on 07/05/11 the CNO (Personnel #1) was interviewed. She was asked to review the medical record of Patient #1. She was asked if the medical record contained a physician order for Morphine Sulfate. She stated, " No. It does not. " She then verified Patient #1 received 6 mg of Morphine IV upon a verbal order from a Medical Resident without a physician order. She was asked if the hospital's policies and procedures were followed for nursing accepting medication orders from someone other than credentialed medical staff. She stated, "No."
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on observation, interviews and record reviews the hospital failed to adequately maintain a medical record for every individual that presented to the hospital for inpatient and outpatient treatment.

Findings Included:

1) All medical record entries were either not complete, dated, timed or authenticated by the provider.
Cross refer: A0450, A0454 and A0457

2) All medical records did not contain a medical history and physical examination completed for each patient.
Cross refer: A0458

3) All informed consents for procedures and treatments were not properly executed.
Cross refer: A0466
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on review of records and interview, the medical records of 5 of 5 Patients (Patient # 1, #2, #3, #4 and #5 ) treated in the hospital from 04/18/11 to 06/29/11 were not complete in that each medical record entry was not dated, timed, signed and/or contained the required documentation by the person responsible for providing hospital services for these patients.

Findings Included:

The "Authorization To Release Information, Financial Agreements and Patient Rights" witness signatures were not dated and/or timed for the following patients:
Patient #1 - Witness signature dated 04/18/11 was not timed.
Patient #2 - Witness signature dated 06/29/11 was not timed.
Patient #3 - Witness signature dated 05/04/11 was not timed.
Patient #5 - Witness signature dated 06/05/11 was not timed.

The "Request for Restriction of Information" witness and/or nursing supervisor signatures were not dated, timed and/or completed for the following patients:

Patient #1 - The witness signature dated 06/29/11 was not timed and the signature of the nursing supervisor was incomplete.

Patient #2 - The witness signature dated 06/29/11 was not timed and the signature of the nursing supervisor was incomplete.

Patient #3 - The witness signature dated 05/04/11 was not timed and the signature of the nursing supervisor was incomplete.

Patient #4 - The witness signature dated 05/14/11 was not timed and the signature of the nursing supervisor was incomplete.

Patient #5 - The witness signature dated 06/05/11 was not timed and the signature of the nursing supervisor was incomplete.

The "Consent to Inpatient and/or Outpatient Admission and Treatment" provider/nurse signatures were not dated and/or timed for the following patients:
Patient #4 - The witness signature dated 05/14/11 was not timed.

The "Doctors Orders" physician, provider and/or nurse signatures were not dated and/or timed for the following patients:

Patient #1 - The "MDMC Labor and Delivery Initial Orders" dated 04/18/11 nursing telephone order did not contain a time and the physician signature did not contain a time. The "Referral Order Screens" did not contain a nurse signature time. The "Thrombosis Risk Assessment and Venous Thromboembolism (VTE) Prophylaxis" physician order sheet, not dated, did not contain a physician signature. The "Inpatient Pneumoccoccal/Influenza Immunization Orders" sheet nurse signature did not contain a date or time.

Patient #2 - The "Doctor Order" sheet dated 06/29/11 contained 3 separate entries (3:40 P.M., 4:30 P.M. and 6:30 P.M.) which were not individually dated. The 3:40 entry contained two orders that was not signed by a physician or nurse. The 4:30 physician signature was dated or timed. The 6:30 entry to discharge home was signed by Resident #36 but not validated or co-signed by a member of the medical staff.

Patient #3 - The "Doctor Order" sheet dated 05/04/11 contained 2 separate entries (2:45 P.M. and 4:10 P.M.) which were not individually dated. The 2:45 P.M. physician signature for authentication of a telephone order (TO) was not dated or timed.

Patient #4 - The "Doctor Order" sheet dated 05/14/11 contained 2 separate entries (5:10 A.M. and 5:20 A.M.) which were signed and not timed or dated by Resident #56. The residents signatures were not validated or co-signed by a member of the medical staff.

Patient #5 - The "Doctor Order" sheet dated 06/05/11 contained 2 separate entries (6:00 A.M. and 6:50 A.M.) which were signed by Resident #57 was incomplete in that the signatures were not validated or co-signed by a member of the medical staff.

The "Doctors Notes" physician, provider and/or nurse signatures were not dated and/or timed for the following patients:

Patient #2 - The entry timed at 4:00 P.M. did not contain a physician attending signature.

Patient #3 - Was incomplete in that it did not not contain any physician notes. The attending physician signed the incomplete notes with a principal diagnosis with no date or time.

Patient #4 - Was incomplete in that it did not contain any physician notes. The attending physician signed the incomplete notes with a principal diagnosis with no date or time.

Patient #5 - Was incomplete in that it did not contain any physician notes or an attending physician signature.

The "Progress Record" provider and/or nurse signatures were not dated and/or timed:
Patient #1 -
The nurse signature dated 04/19/11 was not timed.
The RN Bereavement Coordinator dated 04/19/11 was not timed.

The "Notification to Physician of Pressure Ulcer Progress Record" were incomplete in that the physician signature was missing.
Patient #1 - The notification for 04/18/11 and 04/19/11 was missing the physician signature.

The "Shift Totals for Intake and Output" did not contain a date or signature for each entry.
Patient #1 - The entries for 8:00 A.M., 12:00 P.M., 4:00 P.M. and 7:00 P.M. were not signed and dated.

The "Birth Certificate Data Sheet" nurse signatures were not timed:
Patient #1 - The nurse signature dated 04/19/11 was not timed.

The "Home and Discharge Medication List" nurse signatures were not timed:
Patient #1 - The nurse signature dated 04/19/11 was not timed.

The "Discharge Instructions" nurse and patient signatures were not dated and/or timed:
Patient #2 - The nurse and patient signature dated 06/29/11 was not timed.
Patient #3 - The nurse and patient signature dated 05/04/11 was not timed.
Patient #4 - The nurse and patient signature dated 05/14/11 was not timed.
Patient #5 - The nurse and patient signature dated 06/05/11 was not timed.

The "Disclosure and Consent for Medical, Surgical and Diagnostic Procedures" for Anesthesia was incomplete and/or signatures were not dated or timed.
Patient #1 - The request for treatment by the physician contained the department "ACD" (Anesthesia Care Department) instead of an individual physician's name. The physician signature was not dated or timed.

The "Disclosure and Consent for Medical, Surgical and Diagnostic Procedures" for Vaginal Delivery was incomplete and/or signatures were not dated or timed.
Patient #1 - The consent was incomplete in that the planned and completed procedure was Induction of Labor for Intrauterine Fetal Demise with Cytotec. The physician signature was not dated or timed.

The hospital policy "Medical Record Documentation" dated 06/30/11 requires "To ensure a complete legal medical record...All patient medical record entries must be legible, complete, dated, timed and signed in written or electronic form by the person responsible for providing or evaluating the service provided...Documentation completed by non-medical staff members must be countersigned by the responsible physician for the following: All dictated reports, ED record, Orders (PA, CRNA, and midwife only), Progress notes...ED documentation will be authenticated by the responsible physician including but not limited to ED Record and physician orders. An appropriate medical record shall be kept for every patient receiving emergency medical care...A properly executed informed consent form for the operation/procedure must be in the patient's chart before surgery...All orders, including verbal orders, must be dated, timed, and signed by the ordering practitioner or another practitioner involved in the care of the patient...All verbal orders must be signed, dated, and timed within 48 hours...Nursing documentation, including but not limited to nursing assessment, medication reconciliation ..interventions are required...Is not limited to but may include other components for inclusion or monitoring as deemed necessary..."

At 5:00 P.M. on 07/05/11 the CNO (Personnel #1) was interviewed. She confirmed the hospital policies and procedures were not followed for the correct completion, dating and timing of the medical records.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on review of records and interview, the medical records of 5 of 5 Patients (Patient # 1, #2, #3, #4 and #5 ) treated in the hospital from 04/18/11 to 06/29/11 were not complete in that each physician order was not dated, timed, signed and/or authenticated by the ordering practitioner responsible for providing hospital services for these patients.

Findings included:

The "Doctors Orders" physician, provider and/or nurse signatures were not dated and/or timed for the following patients:

Patient #1 - The "MDMC Labor and Delivery Initial Orders" dated 04/18/11 nursing telephone order did not contain a time and the physician signature did not contain a time. The "Referral Order Screens" did not contain a nurse signature time. The "Thrombosis Risk Assessment and Venous Thromboembolism (VTE) Prophylaxis" physician order sheet, not dated, did not contain a physician signature. The "Inpatient Pneumoccoccal/Influenza Immunization Orders" sheet nurse signature did not contain a date or time.

Patient #2 - The "Doctor Order" sheet dated 06/29/11 contained 3 separate entries (3:40 P.M., 4:30 P.M. and 6:30 P.M.) which were not individually dated. The 3:40 entry contained two orders that was not signed by a physician or nurse. The 4:30 physician signature was dated or timed. The 6:30 entry to discharge home was signed by Resident #36 but not validated or co-signed by a member of the medical staff.

Patient #3 - The "Doctor Order" sheet dated 05/04/11 contained 2 separate entries (2:45 P.M. and 4:10 P.M.) which were not individually dated. The 2:45 P.M. physician signature for authentication of a telephone order (TO) was not dated or timed.

Patient #4 - The "Doctor Order" sheet dated 05/14/11 contained 2 separate entries (5:10 A.M. and 5:20 A.M.) which were signed and not timed or dated by Resident #56. The residents signatures were not validated or co-signed by a member of the medical staff.

Patient #5 - The "Doctor Order" sheet dated 06/05/11 contained 2 separate entries (6:00 A.M. and 6:50 A.M.) which were signed by Resident #57 was incomplete in that the signatures were not validated or co-signed by a member of the medical staff.


The hospital policy "Medical Record Documentation" dated 06/30/11 requires "To ensure a complete legal medical record...All patient medical record entries must be legible, complete, dated, timed and signed in written or electronic form by the person responsible for providing or evaluating the service provided...Documentation completed by non-medical staff members must be countersigned by the responsible physician for the following: All dictated reports, ED record, Orders (PA, CRNA, and midwife only), Progress notes...ED documentation will be authenticated by the responsible physician including but not limited to ED Record and physician orders. An appropriate medical record shall be kept for every patient receiving emergency medical care...A properly executed informed consent form for the operation/procedure must be in the patient's chart before surgery...All orders, including verbal orders, must be dated, timed, and signed by the ordering practitioner or another practitioner involved in the care of the patient...All verbal orders must be signed, dated, and timed within 48 hours...Nursing documentation, including but not limited to nursing assessment, medication reconciliation ..interventions are required...Is not limited to but may include other components for inclusion or monitoring as deemed necessary..."

At 5:00 P.M. on 07/05/11 the CNO (Personnel #1) was interviewed. She confirmed the hospital policies and procedures were not followed for the correct completion, dating and timing of the medical records.
VIOLATION: VERBAL ORDERS AUTHENTICATED BASED ON LAW Tag No: A0457
Based on review of records and interview, the medical records of 5 of 5 Patients (Patient # 1, #2, #3, #4 and #5 ) treated in the hospital from 04/18/11 to 06/29/11 were not complete in that each physician verbal and/or telephone order was not authenticated within 48 hours by the ordering practitioner responsible for providing hospital services for these patients.

Findings Included:

Patient #1 -
The "Doctor Orders" sheet dated 04/19/11 timed at 4:54 A.M. contained a telephone order from MD #9 for "Discontinue Acetaminophen (pain and fever reducer), Ancef (antibiotic) 2 gram IV (intravenous) x 1 dose only." It was electronically signed by MD #9 on 05/18/11 at 12:14 P.M.

The "Doctor Orders" sheet dated 04/19/11 timed at 3:30 P.M. contained a telephone order from MD #9 for "Patient is allowed to do whatever form of testing - genetic testing/autopsy - that she wants." It was electronically signed by MD #9 on 05/18/11 at 12:14 P.M.

The "Doctor Orders" sheet dated 04/19/11 timed at 4:10 P.M. contained a telephone order from MD #9 for "Rh Immune Globin studies stat (blood test for antibodies, immediately)." It was electronically signed by MD #9 on 05/18/11 at 12:14 P.M.

The "Doctor Orders" sheet dated 04/19/11 timed at 4:30 P.M. contained an order written by PA #16 for "Discharge to home, Follow-up with MD #9." It was electronically signed by MD #9 on 05/18/11 at 12:14 P.M.

The "Doctor Orders" sheet dated 04/19/11 timed at 4:45 P.M. contained a telephone order from MD #9 for "Rhogam x 1 dose now (medication to treat blood Rh incompatibility)." It was electronically signed by MD #9 on 05/18/11 at 12:14 P.M.

Patient #2 -
The "Doctor Order" sheet dated 06/29/11 timed at 6:30 P.M. contained an order by Resident #36 for "OK to discharge home." The order was not signed or validated by a member of the medical staff.

Patient #3 -
The "Doctor Order" sheet dated 05/04/11 timed at 2:45 P.M. contained a telephone order from MD #43 for "Admit for observation of rule out labor, Electronic fetal monitoring, Recheck cx (cervix) in one hour. If < 5 cm (centimeters), D/C (discharge) home with labor warnings." The order was not dated and timed for validation by the MD within 48 hours.

Patient #4 -
The "Doctor Order" sheet dated 05/14/11 timed at 5:10 A.M. contained an order by Resident #56 for "Admit for observation of spotting." The order was not signed or validated by a member of the medical staff.

The "Doctor Order" sheet dated 05/14/11 timed at 5:20 A.M. contained an order by Resident #56 for "D/C home with labor precautions." The order was not signed or validated by a member of the medical staff.

Patient #5 -
The "Doctor Order" sheet dated 06/05/11 timed at 6:00 A.M. contained an incomplete order by Resident #57 for "Admit for observation of ___ (left blank)." The order was not signed or validated by a member of the medical staff.

The "Doctor Order" sheet dated 06/15/11 timed at 6:50 A.M. contained an incomplete order by Resident #57 for "D/C home." The order was not signed or validated by a member of the medical staff.

The hospital policy "Medical Record Documentation" dated 06/30/11 requires "To ensure a complete legal medical record...All patient medical record entries must be legible, complete, dated, timed and signed in written or electronic form by the person responsible for providing or evaluating the service provided...Documentation completed by non-medical staff members must be countersigned by the responsible physician for the following: All dictated reports, ED record, Orders (PA, CRNA, and midwife only), Progress notes...ED documentation will be authenticated by the responsible physician including but not limited to ED Record and physician orders. An appropriate medical record shall be kept for every patient receiving emergency medical care...A properly executed informed consent form for the operation/procedure must be in the patient's chart before surgery...All orders, including verbal orders, must be dated, timed, and signed by the ordering practitioner or another practitioner involved in the care of the patient...All verbal orders must be signed, dated, and timed within 48 hours...Nursing documentation, including but not limited to nursing assessment, medication reconciliation ..interventions are required...Is not limited to but may include other components for inclusion or monitoring as deemed necessary..."

At 5:00 P.M. on 07/05/11 the CNO (Personnel #1) was interviewed. She confirmed the hospital policies and procedures were not followed for the validation of orders by the admitting physician or member of the medical staff.
VIOLATION: CONTENT OF RECORD Tag No: A0458
Based on review of records and interview, the medical records of 4 of 5 Patients (Patient #2, #3, #4 and #5 ) treated in the hospital from 04/18/11 to 06/29/11 did not contain documented evidence that a medical history and physical examination (H&P) was completed for each patient seen or treated in the hospital by a physician who is a member of the medical staff.

Findings Included:

Patient #2's medical record dated 06/29/11 reflected the patient was admitted to the L&D Unit (Labor and Delivery) for observation of "leaking/mucus plug."
The "Doctor's Notes" timed at 4:00 P.M. reflected an examination that was not signed.
The nursing "OB Triage" notes timed at 4:35 P.M. reflected, "Exam by: MD #58" and at 6:20 P.M. reflected, "Exam by: Resident #36."
The medical record did not contain a medical H&P, assessment or discharge summary documented by a physician who is a member of the medical staff.

Patient #3's medical record dated 05/04/11 reflected the patient was admitted to the L&D Unit for observation of "R/O (rule out) labor."
The nursing "OB Triage" notes timed at 3:49 P.M. reflected, "Exam by: MD #43."
The medical record did not contain a medical H&P, assessment, progress notes or discharge summary documented by a physician who is a member of the medical staff.

Patient #4's medical record dated 05/14/11 reflected the patient was admitted to the L&D Unit for observation of "Spotting."
The nursing "OB Triage" notes timed at 5:13 A.M. reflected, "Exam by: Resident #56."
The medical record did not contain a medical H&P, assessment, progress notes or discharge summary documented by a physician who is a member of the medical staff.

Patient #5's medical record dated 06/05/11 reflected the patient was admitted to the L&D Unit for observation
The nursing "OB Triage" notes timed at 6:36 A.M. reflected, "Exam by: Resident #57."
The medical record did not contain a medical H&P, assessment, progress notes or discharge summary documented by a physician who is a member of the medical staff.

The hospital policy "Medical Record Documentation" dated 06/30/11 requires "To ensure a complete legal medical record...All patient medical record entries must be legible, complete, dated, timed and signed in written or electronic form by the person responsible for providing or evaluating the service provided...Documentation completed by non-medical staff members must be countersigned by the responsible physician for the following: All dictated reports, ED record, Orders (PA, CRNA, and midwife only), Progress notes...documentation will be authenticated by the responsible physician including but not limited to ED Record and physician orders. An appropriate medical record shall be kept for every patient...All orders, including verbal orders, must be dated, timed, and signed by the ordering practitioner or another practitioner involved in the care of the patient..."
The Obstetrics/Gynecology Department Medical Staff Committee Meeting Minutes dated 05/04/11 reflects, "Documentation and communication between attending OB/GYN and resident...Attending and Residents need to document when the attending is present for the procedure and when the attending leaves the procedure...Stand by deliveries requires staff on call must be present at delivery...MD #7 reminded members of the department who participate in attending staff call, that they (the attending staff supervisor) are responsible for the case and well be held accountable...Residency Report...MD #54 reemphasized the importance of attending staff call physician's responsibilities as stated by MD #7..."

Medical Staff Bylaws and Rules and Regulations: Dated 05/24/11 requires "The Medical Staff is responsible for the quality of medical care in the system hospitals...Medical Staff shall be interpreted to mean all duly licensed Physicians, Dentists and Podiatrists holding unlimited licenses who are granted medical staff appointment...House Staff shall mean those physicians who are graduates of a medical school...and are pursuing additional training in a system hospital's medical education program...Clinical Privileges shall be interpreted to mean having the right to render specific diagnostic, therapeutic, medical, dental or surgical services in a system hospital...Appointment to the Medical Staff or the granting of temporary privileges shall be extended only to those professionally competent Physicians, Dentists, and Podiatrists who meet the qualifications, standards and requirements set forth in these bylaws and policies...each practitioner shall have only such clinical privileges as have been granted by the Board of Directors as recommended by the Medical Staff in accordance with these bylaws ..."

The "Medical Staff Policy Manual" dated 05/24/11 requires, "Medical staff appointment is set forth in the bylaws...shall...provide continuous care and supervision of his patient; to abide by the Bylaws, the Policies, the MHS bylaws and all other established standards, policies, and rules of the Medical Staff...and, to participate in fulfilling the requirements for providing emergency care...Degree of Care/Management of Patient by House Staff...The medical record should reflect the involvement of the teaching practitioner in the management of a patient treated by a House Staff Member...House Staff shall not be considered Medical Staff members nor shall the term House Staff be considered a category of Medical Staff membership...Medical Records...There shall be evidence in the medical record that the teaching physician has been involved in the management of a patient treated by a member of the House Staff...Progress Notes...Pertinent progress notes should be recorded at the time of observation, sufficient to permit continuity of care...each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders...An appropriate medical record shall be kept for every patient receiving emergency medical care and shall be incorporated in the patient's hospital record...Each patient's medical record shall be signed by the physician in attendance that is responsible for its clinical accuracy..."

The hospital policy "Supervision of Residents in Obstetrics and Gynecology" dated February, 2008 requires "L&D...Supervising physicians are required to personally assess all patients admitted to L&D and the antepartum unit...Supervising physicians are required to directly supervise...and must be immediately available for supervision of normal spontaneous vaginal deliveries...Summary...A qualified faculty or attending physician is assigned to supervise all resident activities at all times on all services. There is a supervising physician in the hospital 24 hours per day, seven days per week. The supervising physician should directly or indirectly supervise the residents patient care activities depending upon the type of care and PGY level of the resident."

At 5:00 P.M. on 07/05/11 the CNO (Personnel #1) was interviewed. She confirmed the medical records did not contain the required medical history and physical examination documentation performed by a member of the hospital's medical staff.
VIOLATION: CONTENT OF RECORD - INFORMED CONSENT Tag No: A0466
Based on interview and record review, the hospital failed to ensure properly executed informed consents for 1 of 1 patient (Patient #1) who underwent a medical procedure on 04/19/11. The consents for medical procedures did not contain the name of the provider and/or correct intended procedure. The consents were not dated or timed by the physician and witnessed by the RN without the physician being present.

Findings Included:

Review of Patient #1's medical record dated 04/18/11 reflected Patient #1 was admitted for induction of labor for fetal demise under the care of MD #9.

The "Disclosure and Consent" dated 04/18/11 timed at 4:16 P.M. reflected a voluntary consent for "Dr. ACD (Anesthesia Care Department)" to perform "spinal or epidural anesthesia" and was witnessed by RN #10. MD #9 signed the consent without dating or timing the consent form. The medical record reflected MD #9 was not present in the hospital at the time the Disclosure and Consent was obtained by the nurse.

The "Disclosure and Consent" dated 04/18/11 timed at 4:20 P.M. reflected a consent for MD #9 to perform a planned procedure for "vaginal delivery, possible episiotomy, possible use of forceps or use of Vacuum and possible Cesarean Section." The form was witnessed by RN #10. The physician, MD #9 signed the consent form without dating or timing the consent. The consent did not reflect the intended procedure of Induction of Labor with Cytotec. The medical record reflected MD #9 was not present in the hospital at the time the Disclosure and Consent was obtained by the nurse.

The hospital policy "Medical Record Documentation" dated 06/30/11 requires "To ensure a complete legal medical record...All patient medical record entries must be legible, complete, dated, timed and signed in written or electronic form by the person responsible for providing or evaluating the service provided...A properly executed informed consent form for the operation/procedure must be in the patient's chart before surgery..."

The hospital policy "Patient's Rights and Responsibilities" dated 04/30/11 requires, "Information about treatment. You are encouraged to discuss your condition, diagnosis, treatments and prognosis with your physician and other caregivers...Know the identity of your physicians and other caregivers, as well as when those involved are students, residents, or trainees...Informed Consent. You have the right to receive from your physician information needed to make decisions regarding your care, including treatment options and the risks and benefits of those choices..."

The hospital "Disclosure and Consent for Medical, Surgical and Diagnostic Procedures Including Consent for Blood Transfusions" dated 08/30/10 requires "All planned procedures and anticipated procedures should be listed on the consent form...The physician, and if applicable anesthesiologist/anesthetist, is responsible for obtaining the patient consent. The physician, and if applicable anesthesiologist/anesthetist should sign the consent form prior to the procedure certifying that the patient...has been provided information on the risk and hazards, benefits and alternatives to treatment, and had questions answered within the physicians area of expertise and has given consent...The nurse's role is limited to obtaining, at the physician's request, the patient's signature on the appropriate consent form and/or witnessing the execution of a consent form. Any questions concerning the diagnosis, the nature and purpose of treatment, the risks and consequences, the reasonably feasible alternatives, and the prognosis if no treatment is given, should be directed to the physician...should indicate both date and time of signature..."

At 5:00 P.M. on 07/05/11 the CNO (Personnel #1) was interviewed. She was asked to review the medical record of Patient #1. She was then asked to review the Disclosure and Consent for Spinal and Epidural Anesthesia and asked who Dr. ACD is. She stated, "It means the Anesthesia Care Department." She was then asked to review the Disclosure and Consent for MD #9 to perform a Vaginal Delivery and asked if the consent form was properly executed and signed or included the intended procedure for Induction of Labor with Cytotec. She stated, "No." She was asked if nursing and the medical staff followed hospital policies and procedures for the correct completion of disclosure and consents for medical procedures performed. She stated, "No."
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on observation, interviews and record reviews, the hospital's Governing Board failed to ensure the emergency needs of the patients presenting to the hospital were met in that:

1) All patients presenting to the Emergency Department (ED) and L&D (Labor and Delivery) from 01/01/11 to 06/29/11 received an appropriate medical screening examination (MSE) to determine whether or not an emergency medical condition (EMC) existed, stabilizing treatment was provided and appropriate transfers were effected if needed. Patient #2, presented to the ED for a potential EMC, did not receive an appropriate MSE to determine if stabilizing treatment was needed prior to transferring the patient to L&D without appropriate qualified medical personnel. The Registered Nurses (RNs) and Medical Residents who performed the MSE in the ED and L&D were not appointed by the Governing Body as Qualified Medical Practitioners (QMP) to provide MSE.
Cross refer: A2406

2) Adopt and enforce a hospital policy to ensure EMTALA requirements are met in order to provide for all individuals presenting to the ED and L&D for examination of a medical condition an appropriate MSE by a QMP to determine whether or not an EMC exists, provide stabilizing treatment and/or effect an appropriate transfer.
Cross refer: A2406

3) Failed to ensure an appropriate MSE for a potential EMC was not delayed for all patients presenting to the L&D (Labor and Delivery) from 01/01/11 to 06/29/11 for 1 of 1 patients (Patient #2) in order to inquire about the patient's method of payment or insurance before determining if stabilizing treatment was required.
Cross refer: A2408


It is determined this deficient practice creates an Immediate Jeopardy situation and places the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to monitor and ensure the ED policies and procedures governing the medical care provided in the ED are enforced in that 1 of 1 Patient's (Patient #2) presenting to the ED on 06/29/11 with an emergency complaint did not receive an appropriate MSE by a QMP to determine if an EMC existed prior to transferring the patient to the L&D unit with a volunteer who is an unlicensed staff member that is not qualified to monitor or emergently treat the patient in the event the patient should deteriorate during transport.

Findings included:

Patient #2 (MDS) dated [DATE] at approximately 3:30 P.M. with complaints of labor after losing her mucus plug, cramps and having contractions. The medical record did not reflect a MSE by a QMP to determine if an EMC existed prior to sending the patient, accompanied by a hospital volunteer to the L&D unit.

During a tour of the facility at 3:30 P.M. on 06/29/11, the surveyor accompanied by the CNO (Personnel #1) and the ED Nurse Manager (Personnel #2) observed the ED Volunteer (Personnel #53) escorting a pregnant patient (Patient #2) and her husband down the hall. The pregnant patient was holding her stomach and appeared to be in distress. The Volunteer (Personnel #53) stopped at the end of the hall and gave directions to Patient #2 and her husband to the L&D Unit. The Volunteer (Personnel #53) then left Patient #2 and her husband alone to find the L&D area unaccompanied. The CNO (Personnel #1) and the ED Nurse Manager (Personnel #2) verified the escort is a volunteer and not a qualified medical person.

The surveyor, CNO (Personnel #1) and the ED Nurse Manager (Personnel #2) then followed Patient #2 and her husband down the hall to the elevator. The CNO intervened at this point and asked the patient if she needed help. Patient #2 stated she is having contractions and is going to the L&D area. The CNO, ED Manager and the surveyor accompanied Patient #2 in the elevator to the 3rd floor where the L&D is located. The CNO asked the registration clerk to open the door to allow the patient in. The CNO handed the patient off to the L&D Nurses and gave them report. Patient #2 was then placed at the Registration desk inside the L&D area. The surveyor observed the Registration Clerk taking Patient #2's personal information including asking her for a copy of her Identification and Insurance or Medicaid paperwork prior to a medical screening examination (MSE) being performed to determine if an emergency medical condition (EMC) existed.

The surveyor asked Patient #2 if she was checked into the ED and examined first before being sent to L&D. She stated, "No. The person at the desk told the Volunteer to take me to the Labor and Delivery area."

The hospital policy "Patient Transfers" dated 04/30/09 requires, "The Board of Directors...having consulted with the Medical Staff, adopt this policy to comply with state and federal laws...Patient Evaluation. All individuals presenting at the ED shall receive an appropriate MSE to determine whether they have an EMC...Each patient who presents to the ED must be evaluated by: a physician who is present in the hospital at the time the patient presents or is presented, or by a physician on call is: physically able to reach the patient within 30 minutes...accessible by direct, telephone...within 30 minutes, with a RN or PA or other qualified medical personnel as established by the hospital's governing body at the MHS hospital under orders to assess and report the patient's condition to the physician...The MSE should not be delayed in order to inquire about the patient's method of payment or insurance... "

The hospital policy "Response to Medical Emergencies Occurring on Hospital Premises (Code MERT)" dated 12/30/10 requires, "Methodist Dallas Medical Center (MDMC)...will provide a MSE on any person who is not a patient, while on hospital property for any reason, needs emergency medical assistance, to determine whether that person has an EMC...EMC means a medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably result in: placing the health of the individual, or with respect to a pregnant woman, the health of the woman or unborn child, in serious jeopardy...MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency exists..."

The hospital policy "Guidelines for Obstetrical (OB) Patients Presenting to the ED" dated 08/30/10 requires "Any OB patient greater than, or suspected to be greater than 20 weeks gestation, presenting to the ED (either ambulatory, by wheelchair, or ambulance) with any of the following, should be transported to L&D as soon as possible, after they are deemed to be stable enough for transport: Symptoms suggestive of labor, rupture of membranes, complications related to the pregnancy, injuries that could endanger the unborn infant...If indicated during the stabilization process, the ED staff may contact L&D for assessment and monitoring of the fetal status..."

The "Plan for Provision of Patient Care" dated FY 2011, requires, "ED...Any individual...who present...for examination or treatment, will be provided an appropriate MSE by an emergency physician or primary care physician...The ED triages all patients using RN's experienced in emergency care. Patients are triaged according to a 5-level tier system which ensures patients are assessed and prioritized to acuity...Women's and Children's Services...patients presenting with actual or potential problems related to pregnancy...can be accessed via Emergency Services, through the outpatient services, through transport, as a direct admit or as a drop-in patient...patients are assessed by the medical staff in accordance with the medical staff Rules and Regulations and by nursing...in accordance with the established reference guideline...Volunteer Services ...provide non-clinical patient services that do not require a license or certificate..."

At 4:00 P.M. on 06/29/11 the surveyor interviewed Personnel #2, the ED Nurse Manager. She was asked if the nurses perform MSE's in the ED. She stated, "No. The nurses perform triage and the physician's do the medical screening." She was asked if the nurses make the determination when the patient's are taken back to the main ED or Fast Track to see a physician. She stated, "Yes. We use the 5 level triage system. We make the determination based on the triage system who is seen first by the physician." She was asked if the Paramedic checking in the patient's performs triage. She stated, "The paramedic does a quick check based on their complaint and makes the determination which patient needs to see the nurse first." She was asked if it is the ED policy to send patient's to L&D without a medical screening. She stated, "We send all of our patient's that are greater than 20 weeks pregnant to L&D for screening unless they are trauma patients." She was asked if it is the hospital policy to send pregnant patient's to L&D with a volunteer. She stated, "Yes, if the other personnel are busy."

At 5:00 P.M. on 06/29/11 the surveyor interviewed the CNO (Personnel #1). She verified the hospital is not following the required policies and procedures for providing appropriate MSE's with QMP's in the ED and L&D. She was asked if the hospital volunteer is qualified to treat emergent medical conditions. She stated, "No."
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on observation, record reviews and interviews, the hospital failed to comply with 489.24 in that:

1) All patients presenting to the ED from 01/01/11 to 06/29/11 were not provided an appropriate MSE by a QMP to determine whether or not an EMC existed. The medical screening examination of the patients were performed by 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 were not adopted or enforced to ensure compliance with EMTALA requirements.

Cross Refer: Tag A2406

3) Hospital policies and procedures were not adopted and in place to ensure emergency services are available to meet the needs of individuals with EMC's after the initial examination.

Cross Refer: Tag A2404