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.

CHRISTUS MOTHER FRANCES HOSPITAL 800 EAST DAWSON TYLER, TX 75701 Oct. 7, 2015
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the facility failed to ensure patient discharge information which included personal information was given to the correct patient. The facility failed to ensure Emergency department patients received their discharge instructions. This deficient practice was found in 2 of 2 patients (Patient #s' 3 and 12).

This deficient practice had the likelihood to cause harm in all patients.

Findings include:


Review of clinical records revealed the following:

Patient #3 was a [AGE] year old female who (MDS) dated [DATE] at 11:18 a.m. with a chief complaint of shortness of breath.

At 3:08 p.m. there was documentation that the discharge instructions were reviewed and the patient verbalized understanding

Patient #3's discharge records revealed three prescription orders written on discharge. A blood pressure agent, a corticosteroid Predisone and antihistamine Bendryl. According to the discharge sheet the following was listed "I have received my discharge instructions and have been given the opportunity to ask questions concerning my condition, treatment and medications, if applicable". There was a place for the patient's signature, nurse's signature date and time at the bottom of the sheet. The areas were left blank.



Patient #12 was a [AGE] year old female who (MDS) dated [DATE] at 12:52 p.m. According to the record Patient #12 had a past history of diabetes insipidus, migraine headache, seizures, stroke, and hypertension.

Patient #12's discharge information dated 04/22/2015 at 3:03 p.m. revealed documentation of Patient #3's signature on the discharge information.

At 4:29 p.m. Patient #12 was documented as being discharged from the ED.

During a confidential interview it was revealed that Patient #3 received Patient #12's discharge information. Patient #3 was not given her own discharge information at all on 04/22/2015.

Staff #13 confirmed she handled incidents like this and there was no documentation of the incident that occurred on 04/22/2015. The only one she knew of occurred in August 2015.

Staff #4 confirmed the discharge information in the charts. Staff #4 reported she could not find a discharge sheet with Patient #3 signing in her record. She reported the discharge sheets were suppose to be signed by the patient at discharge and are scanned into the computer. Staff #4 revealed she was only aware of one incident that occurred in August 2015. Staff #4 reported after that they started the nurses to copying the discharge information off at the nurses station.

Staff #5 confirmed staff had been in-serviced on HIPPA in August 2015. Only 38 out of a total of 88 ED employees had completed the training given in August 2015.

During an observation of a discharge on 10/07/2015 at 10:20 a.m., Staff #12 removed discharge papers from a nurses station for a patient. The discharge papers was on the nurses lined up with other discharge papers. With the paperwork being placed on the desk all together there was still the opportunity to select the wrong paperwork.

Review of facility patient rights information provided at admission revealed the following:

As a patient, you can expect the following standards

Respect for your privacy regarding visitors, examinations, and medical discussions.

Confidentiality of communication and records pertaining to your care.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on observation, interview, and record review, the facility failed to:

A. ensure patients presenting with respiratory complications, elevated blood pressure,and severe pain received thorough assessments and timely interventions. They failed to ensure patients received complete assessments on discharge. This deficient practice was found in 5 of 5 patients (#s'3, 6, 7, 9 and 12).


B. ensure the Emergency department was kept clean and sanitary.


Refer to tag A1101 for additional information.
VIOLATION: ORGANIZATION AND DIRECTION Tag No: A1101
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to:

A. ensure patients presenting with respiratory complications, elevated blood pressure,and severe pain received thorough assessments and timely interventions. They failed to ensure patients received complete assessments on discharge. This deficient practice was found in 5 of 5 patients (#s'3, 6, 7, 9 and 12).


B. ensure the Emergency department was kept clean and sanitary.


This deficient practice had the likelihood to cause harm in all patients.


Findings include:



Review of the clinical record of Patient #7 revealed, she was a 50 year old, female, who (MDS) dated [DATE], at 8:40 a.m., with an abscess to the left side of her head.


Review of a triage assessment at 9:17 a.m. revealed, Patient #7 had a pain level of 7 (0 meaning no pain and 10 meaning severe pain) and the location of the pain was her head.


Review of the physician assessment at 9:54 a.m. revealed, Patient #7 had a golf ball sized nodule to the left temple.


At 10:06 a.m., an incision and drainage was done and at this time a local anesthetic was given of lidocaine 1 percent with epinephrine.


At 10:15 a.m., discharge orders were written.


During an observation on 10/07/2015, at 10:20 a.m., Patient # 7 was noted to have an undressed incision to the left side of her head.


At 10:51 a.m., Patient #7 was discharged to home.


There was no other documentation of an assessment of the patient's pain level prior to discharge. There was no documentation of anything given for pain until the incision and drainage was performed and a local anesthetic was used.




Review of the clinical record on Patient #9 revealed, he was a 20 year old, male, who (MDS) dated [DATE] at 7:05 a.m., with a chief complaint of headache.


At 7:14 a.m., Patient #9 was described as having a pain level of 10.


Patient #9 was given an antihistamine Benadryl and anti-ulcer agent Reglan, and a a CT Scan of the head was done, during the visit.


At 8:40 a.m., there was documentation that the headache had improved. There was no documentation of what the pain level was at this time.


At 9:00 a.m., Patient #9 was discharged home from the hospital.


There was no documentation of administration of pain medication nor another assessment of the pain level prior to leaving the hospital.




Review of the clinical record of Patient #6 revealed, she was a 89 year old, female, who (MDS) dated [DATE], at 5:16 p.m., with a chief complaint of shortness of breath.


A triage assessment was performed at 5:21 p.m. on Patient #6 and there was no documentation of her breath sounds.


At 5:22 p.m., Patient #6 was documented as having a pain level of 6.


At 5:41 p.m., Patient #6's BNP ( B-Type Natriuretic Peptide) was elevated at 1490. The reference range for the BNP was <300. The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable.


At 7:15 p.m.,, an x-ray impression revealed when compared to prior study of 04/15/2015, there was worsening infiltrate in the right upper lobe .....


At 7:42 p.m., was the first documentation of a physician's assessment (over 2 hours after presenting). The physician documented Patient #6 was positive for cough, shortness of breath, no respiratory distress, exhibited no tenderness, and had minimal basal wheezing.


At 8:02 p.m., was the first nursing documentation of a complete respiratory assessment which included breath sounds (over 2.5 hours after presenting).


There was no documentation of another pain assessment since the initial assessment. There was no documentation of any medication being given to Patient #6 during her stay to address the pain or respiratory complications. There was no follow-up on the elevated BNP laboratory result.


At 8:41 p.m., there was documentation Patient #6 was given the diagnosis of community acquired pneumonia.


At 8:50 p.m., discharge orders were written for the antibiotic Zithromax and respiratory inhaler Albuterol.


At 9:20 p.m., Patient #6 left the ED and was discharged home.






Review of the clinical record of Patient #3 revealed she was a 57 year old, female, who (MDS) dated [DATE], at 11:18 a.m., with a chief complaint of shortness of breath.


At 11:18 a.m., the nursing triage was started and there was no documentation of an assessment of Patient #3 breath sounds.


At 11:21 a.m., the physician documented Patient #3 had pain in her ears and jaw. There was documentation of her wheezing and had rhonchi. Patient #3 was hyperventilating, very anxious and had a normal oxygen saturation.


At 11:33 a.m., staff described the pain level as being 9 and the pain location was the jaw,ear, head and back.


At 11:43 a.m., Patient #6 was given nebulizer treatments and at 11:48 a.m. she was given prednisone.

At 11:44 a.m., was the first documentation of a complete respiratory assessment by nursing. There was no documentation of an assessment of the breath sounds prior to the medication so a comparison could be made.


Review of chest x-ray results at 12:17 p.m., revealed Patient #3 lungs were hyperexpanded which could result from COPD or reactive airway disease.


There was no documentation of an assessment of Patient #3's respiratory status nor pain level prior to discharge.


Staff #4 confirmed the assessment information in the charts



Review of the clinical chart on Patient #12 revealed she as a 24 year old, female, who (MDS) dated [DATE], at 12:52 p.m. According to the record, Patient #12 had a past history of diabetes insipidus, migraine headache, seizures, stroke, and hypertension.


At 1:20 p.m., the triage assessment revealed Patient #12 had a pain level of 10 (head) and a blood pressure of 138/102.


At 1:55 p.m., the physician documented that Patient #12 was having severe pain and the diagnosis given was a headache.


At 2:39 p.m., (over an hour later), Patient #12 was given Phenergan, Benadryl, Toradol and Decadron.


At 2:45 p.m., the pain level was still at a 10.


At 3:10 p.m., the blood pressure was still elevated at 137/109, at 3:40 p.m., blood pressure was 132/111 and at 4:10 p.m., the blood pressure was 138/95.


At 4:29 p.m., Patient #12 was documented as being discharged from the ED.


There was no documentation that the pain was relieved or if the blood pressure came down.


At 4:57 p.m., according to triage notes Patient #12 was witnessed seizing in waiting room. Patient was just discharged from ED after being treated for migraine headache. There was documentation that staff were unable to assess pain level at this time.


At 4:48 p.m., the physician documented Patient #12 said she had "shooting pain" coming down the right side of her face. States she fell and hit the right side of her head yesterday. She was unsure if she had a seizure then.


At 5:01 p.m., the blood pressure was still elevated at 139/98.


At 5:10 p.m., Patient #12 was put on seizure precautions.


At 5:27 p.m., a Cat Scan of the head was performed.


At 6:25 p.m., Patient #12 had another seizure and at 6:26 p.m. Ativan was administered.


At 8:00 p.m., the pain medication Dilaudid was administered and the pain level was still at a 10 (after 8 hours of the last documented pain level assessment).


At 8:38 p.m., Patient #12 had a pain level of 6 and she was discharged at 8:45 p.m..


Staff #4 confirmed the assessment information in the records.




During an observation of the Emergency Department (ED) on 10/07/2015 after 9:00 a.m. the following was found:


Quick Registration area

The top of the EKG machine was covered with tape. The tape was noted to be soiled with a build-up of dirt.


Patient basins were stored directly on the floor underneath a table.


The top of a treatment cart was rusted. There was no way the cart could be sanitized.


A portable heater was stored in a corner in the room and had a build-up of dust.


A cardboard box full of midstream urine collectors were stored directly on the floor.


An airway cart was in the hallway and it had soiled tape on the top. The cart had a build-up of dust. The floor tile in the area was chipped and missing areas. The baseboards had a build-up for dust and dirt.


Rapid Assess Center

An open shelf where the Pyxis (medication storage equipment) was located, contained a caddy of IV supplies, respiratory supplies. The bottom shelf had no splash guard to protect supplies stored on the bottom shelf. Underneath the shelf was a yellow and black floor pad which was heavily soiled with dirt. IV tourniquets were draped over one arm of the shelf. They were exposed to anyone passing by in the hallway.


Linen was stored in the hallway on a cart that had a mesh covering. The linen was not protected from dust or spills.


Exam Room #2 on the same unit had patient monitor equipment which had soiled cords attached to them. A ceiling vent over the bed was soiled with a brown build-up.


Staff #4 confirmed the observations.





Review of a facility policy named "Triage of Emergency Patients" dated 11/2014 revealed the following:


3.7 Patients will be taken to treatment rooms expeditiously, for triage, unless treatment rooms are unavailable, patients will be triaged and placed in the waiting room until a bed is available.


3.8 Patients waiting on rooms will be reassessed according to need but at least every 2 hours.


3.9 Initiate treatments and interventions immediately, per ECC (Emergency Care Center) guidelines.


3.10 Documentation of assessment data and triage activity for patients will be done in the Electronic Health Record (EHR).


3.12 The full patient assessment will be completed upon arrival to the treatment room and documented in the EHR.


Review of the policy named "Reassessment of Emergency Department Patient " dated 01/2015 revealed the following:


POLICY:


1. Accurate, appropriate initial and ongoing assessment is required for all patients in the emergency care center to identify the patient's initial clinical status, identify patient's needs and determine response to interventions and improvement or deterioration in patient status.


PROCEDURE:


5. Prior to discharge, an Emergency Care Patient should have any abnormal vital signs reassessed to assure that the patient is ready for discharge. Continued abnormal vital signs should be communicated to the physician and documented in the record.