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.

RENAISSANCE HOSPITAL GROVES 5500 39TH ST GROVES, TX Jan. 10, 2012
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on observation, records review, and interviews, the CNO (Chief Nursing Officer) of the facility failed to ensure that nursing services was organized in order to have lines of authority that delegate responsibility within the department.

Review of the record titled "Organizational Chart" reveals Nursing Supervisors, Emergency Department, Medical ICU/Cardiovascular ICU/ Cardiac Cath Lab, Surgery/PACU/ Endoscopy/ Pre-OP Holding, and Medical Surgical Telemetry /Outpatient Day Surgery all report to the CNO.

Interview with staff #9 on 01/03/2012 at 3:00 PM confirmed there was no Director of the Surgical Department. When questioned if surgery schedules or issues come up, who do you report to and she answered "the CNO".

The CEO, staff #1 informed the surveyors on 01/10/2012 at 12:05 PM that staff #2 has limited operating room experience and will rely on the nursing agency contract company. At the time of investigation the nursing agency contract company had not been established.

In further interviews with facility staff #3 and # 4 on 01/03/2012 at approximately 4:00 PM, the surveyors were informed that there is no Directors for the emergency room , Medical ICU/Cardiovascular ICU/Cardiac Cath Lab, and Medical Surgical Telemetry /Outpatient Day Surgery. Staff #3 and #4 reported that the schedules and department issues are reported to the CNO and the decisions are made the by the CNO.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on records review, observations, and interviews, the facility failed to provide adequate staffing and/or follow the facility policy for the (1) Surgical Department, (2) Cath Lab (Cardiac Catheterization Lab), and (3) Medical Surgical Telemetry Station.
These deficient practices posed an immediate jeopardy to the health and safety of patients due to unqualified and inadequate staff to provide care for them.
(1.) A review of the accepted standards of practice for perioperative staffing, Association of Perioperative Registered Nurses (AORN), requires a minimum staffing as follows: 1 RN in the preoperative area, and 1 RN per patient per OR in the role of the circulating nurse. The postoperative area will have two licensed nurses, one of whom is a RN competent in post anesthesia nursing and must be present whenever a patient is receiving post anesthesia care.
Review of the accepted standards of practice, American Society of Perianesthesia Nurses (ASPAN), requires staffing as follows: two registered nurses, one of whom is an RN competent in Postanesthesia Nursing, are in the same room/unit where the patient is receiving post anesthesia care."
On 01/04/2012 at approximately 10:10 AM, staff #4 confirmed that there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department.

During a tour of the preoperative area on 01/04/2012 at approximately 10:15 AM with staff #3, three patients were observed awaiting their surgical procedures with no licensed personnel present to care for them.

On 01/04/2012 at approximately 10:15 AM, staff #3 confirmed there were three patients in the pre-operative area awaiting surgery and observed no licensed surgical staff present to care for them. Staff #3 also confirmed there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department. Staff #5 was working in the actual operating room with the patient. Staff #6 was the only Registered Nurse in the Perianesthesia area with the patients.

Review of the on call surgery schedule dated January 2012 reveals staff #9 (scrub tech), staff # 5 (RN Circulator), staff # 10 (LVN, scrub tech), and staff #11(scrub tech, Certified Scrub Tech) were on call for the surgery department. Staff #10 and staff #5 are on call every day for 31 straight days and staff #10 for 29 straight days. These employees are the only full time staff members for the surgical department.

Review of policy titled "Staffing the Operating Room Department" Policies and Procedures IVI-B Revised July 2011 revealed;
"Policy: C. There is a complete crew on call during non-staffed hours. A complete crew is a R.N. Circulator, Scrub Nurse/Tech, and a PACU (post-anesthesia care unit) nurse. The Circulator and PACU personnel are all ACLS (Advanced Cardiac Life Support) certified."
Review of the on call surgery schedule for January 2012 revealed no PACU nurse on call as per "Staffing the Operating Room Department" policy.

(2.) The surveyors observed on 01/04/2012 at approximately 10:00 AM on the Medical Surgical floor (Station 2) that a patient had been admitted for a Heart Catheterization and ready for the procedure.

Interview with staff #3 on 01/04/2012 at approximately 10:00 AM, confirmed that there were no facility staff available for the procedure.

(3.) On 1/4/2012 at approximately 9:00 AM, surveyor observed on medical surgical floor (station 2) that there was no staff monitoring the telemetry machine. The surveyors observed three patients that were on telemetry monitoring. At approximately 9:30 AM, the surveyors observed staff #8 sitting in front of the telemetry monitor.

An interview with staff #8 on 1/4/2012 at approximately 10:00 AM confirmed that she had no experience monitoring telemetry patients. As such, she was not able to recognize abnormal telemetry patterns, particularly the critical ones. The surveyor questioned staff #8 if this is in your job description or in her assignment for the day and she answered "no."

An interview with staff #4 on 1/4/2012 at approximately 9:45 AM confirmed staff #8 is not a telemetry monitor (a person qualified by training to monitor cardiac patients and able to identify potentially fatal cardiac arrhythmia's).


On 01/04/2012 at approximately 10:30 AM the Chief Nursing Officer (CNO) staff #2 was interviewed. The CNO was also acting as the House Supervisor due to shortage of staff. The CNO confirmed there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department, no staff available for the Cath Lab, and telemetry patients were not being monitored. The CNO confirmed that she was aware of the shortage in staffing.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records review and interviews, this facility failed to provide pharmaceutical service that met need of the patients. 4 of 4 patients (#1, 2, 3, and 4) did not receive medications as ordered by the physician because this facility failed to maintain adequate pharmaceutical supplies or provide pharmaceutical supplies in accordance with its policies.

Findings include:

Review of Pharmacy Policy #08.03, "Formulary: Non-Formulary Drugs (Prescribing/Ordering & Procuring)" revealed the following: "If a practitioner orders drugs that are not in the formulary, the pharmacy will attempt to obtain them after consultation with the prescriber. If the drugs are unobtainable or their procurement will be delayed, the pharmacy shall notify the practitioner and nursing service. "

Review of Pharmacy Policy #13.03, "Administration of Drugs/Patient ' s Personal Drugs," revealed the following: "Unless administration of a patient's personal drugs is authorized by the responsible prescribing practitioner, these drugs shall be sent home with the family or others. If the drugs must be retained in the facility, they shall be packaged, sealed, labeled with the patient ' s name, and stored."

Review of Pharmacy Policy #24.05, "Administration of Drugs: General," revealed the following: "Drugs shall be prepared and administered in accordance with the orders of the prescriber or practitioner responsible for the resident ' s care and accepted standards of practice."

Review of patient #1's chart revealed the following:
-The patient was admitted on [DATE] at 1:18 AM
-Advair 100/50 inhaler twice a day was ordered on [DATE]
-The medication administration record (MAR) for 1/2/12 shows the 9:00 AM dose was not available and #18 was notified. There is no order to discontinue the medication or to substitute with another medication. The 9:00 PM dose was circled (meaning not administered)
-The MAR for 1/3/12 indicates that neither the 9:00 AM nor the 9:00 PM dose was administered. The 9:00 AM dose notes, "not available"
-The MAR for 1/4/12 indicates that neither the 9:00 AM nor the 9:00 PM dose was administered. The 9:00 AM dose notes, "not available"
-The MAR for 1/5/12 indicates that 9:00 AM was not administered, with a note "unavailable."
-On 1/5/12 at 12:00 noon, an MD order reads, "Change Advair to Flovent 44 mcg one puff BID"
-There is no evidence that a pharmacist informed the physician that the medication was unavailable in the facility.

During an interview on 1/9/12 at 4:30 PM in the conference room, the Chief of Staff reviewed the chart for patient #1 and agreed that the patient did not receive the ordered medication for three days. He also reported that this was a process that needed to be corrected.

Review of patient #2's chart revealed the following:
-The patient was admitted on [DATE] at 3:37 PM
-Flovent 2 puffs inhaler twice a day was ordered on [DATE] at 6:15 PM
-The MAR for 1/4/12 has a dose of Flovent for 9:00 PM, but there is no documentation that it was administered (it is neither initialed as given, nor circled as held)

During an interview on 1/9/12 at 4:30 PM in the conference room, the Chief of Staff reviewed the chart for patient #2 and agreed that there was no documentation that the patient received the 9:00 PM dose of the ordered medication.

Review of patient #3 ' s chart revealed the following:
-The patient was admitted on [DATE] at 5:52 PM
-Trilipix 134 mg by mouth daily was ordered on [DATE] at 11:07 PM
-The MAR for 12/29/11 indicates that the medication was not administered, with a note, "not available"
-The MAR for 12/30/11 indicates that the medication was not administered
-The MAR for 12/31/11 indicates that the medication was not administered, with a note, "not available"
-The MAR for 1/1/12 indicates that the medication was not administered
-The MAR for 1/2/12 indicates that the medication was not administered
-The MAR for 1/3/12 indicates that the medication was not administered
-The MAR for 1/4/12 indicates that the medication was not administered
-The patient was discharged on [DATE]
-There was no documentation that the physician was notified that the drug was not available and was not being administered
-No substitute medication was ordered and there was no order to discontinue the medication

Review of the facility ' s document titled, "Renaissance Hospital Groves-Pharmacy Department Hospital Drug Formulary," approved by the Medical Executive Committee in 2011, revealed that Trilipix is not on the formulary.

There is no evidence that a pharmacist informed the physician that the medication was not on the formulary and unavailable in the facility.

During an interview on 1/9/12 at 4:30 PM in the conference room, the Chief of Staff reviewed the chart for patient #3 and agreed that the patient did not receive the ordered medication while in the facility. He also reported no substitute drug was ordered or administered. He reported that this was a process that needs to be corrected.

Review of patient #4's chart revealed the following related to the medication Viibryd:
-The patient was admitted on [DATE] at 6:22 PM
-Viibryd 40 mg ? tablet by mouth daily was ordered on [DATE]
-The MAR for 1/4/12 was blank for this medication
-The MAR for 1/5/12 indicated the medication was not administered, with a note, "pt wants to eat 1st"
-The MAR for 1/6/12 indicated the medication was not administered, with a note, "took own med"
-There was no order for the patient to take medications brought from home
- There is no evidence that a pharmacist informed the physician that the medication was not on the formulary and unavailable in the facility.

Review of patient #4's chart revealed the following related to the medications Combivent, Xopenex, and Symbicort:
-Combivent 2 puffs twice a day was ordered on [DATE]
-Xopenex 2 puffs twice a day was ordered on [DATE]
-Symbicort 2 puffs twice a day was ordered on [DATE]
-The MAR for 1/4/12 at 9:00 AM noted, "pt took own." The 9:00 PM dose was initialed as administered
-The MAR for 1/5/12 at 9:00 AM noted, "pt took own." The 9:00 PM dose was initialed as administered
-The MAR for 1/6/12 at 9:00 AM was initialed as administered
-There was no order for the patient to take medications brought from home
-There is no evidence that a pharmacist informed the physician that Xopenex and Symbicort were not on the formulary and unavailable in the facility.

Review of the facility's document titled, "Renaissance Hospital Groves-Pharmacy Department Hospital Drug Formulary," approved by the Medical Executive Committee in 2011, revealed that Xopenex and Symbicort were not on the formulary.

During an interview on 1/9/12 at 4:30 PM in the conference room, the Chief of Staff reviewed the chart for patient #4 and agreed that there was no order for the patient to take medications brought from home. He also reported that the charting of drug administration was inconsistent in this case. He reported that this was a process that needs to be corrected.
VIOLATION: PHARMACEUTICAL SERVICES Tag No: A0490
Based on records review and interviews, the facility failed to assure medications on the formulary were available for patients. The facility also failed to assure medications on the formulary were available for stocking emergency crash carts throughout the facility. 10 of 18 emergency carts were missing medications that were available from the facility's medication supplier.

Refer to Tag A0511


The pharmacy and nursing staff failed to assure medications ordered by physicians were administered to 4 of 4 patients (#1, 2, 3, and 4).

Refer to Tag A0404
VIOLATION: GOVERNING BODY Tag No: A0043
Based on records review and interviews the Governing Board:

A. failed to enforce the Governing Board Bylaws for the appointment of appropriate members to the Governing Board therefore leaving the facility without an organized and effective Governing Body legally responsible for the conduct of the hospital.

B. failed to make recommendations and provides management staff and professional staff to render safe and quality patient care.

C. failed to protect patients from potential harm and protects patients' rights.

Refer to tag A0115

D. failed to provide an organized nursing service and failure to do so places patients at risk for potential harm.

Refer to tag A0385

E. failed to provide pharmaceutical service that met the need of the patients and failure to do so placed patients at risk for potential harm.

Refer to tag A0490

A. Review of the Governing Board Bylaws revised 10/23/2011 and contains hand written changes revealed, Article III, Section 1, " The number of members on the Governing Board shall be at least two. The Governing Board may include (1) physician on the Medical Staff and two (2) representatives of the Hospital's Administration.

Review of the Organizational Chart for the facility, approved 8/04/2011, revealed all hospital departments report to the Chief Executive Officer. The Organizational Chart does not reflect the Medical Staff or the Governing Board.

The owner #12 was interviewed on 1/5/2012 at 10:19 AM in the conference room. Owner #12 was asked do "you hold an administrative position with the hospital" and owner #12 stated " no, I'm one of the owners." Owner #12 was asked "do you serve as a member of the Governing Board" and owner #12 stated " yes." Owner #12 was asked "do you have a medical back ground or experience managing a medical facility", owner #12 stated "no."

The CEO/owner #1 was interviewed on 1/5/2012 at 10:30 AM in the conference room. The CEO was asked to name the members of the Governing Board. The Governing Board consisted of two members CEO/owner #1 and owner #12; there was no Medical Staff representation serving as a Governing Board member. The CEO/owner #1 confirmed the Governing Board Bylaws containing hand written changes were current and the changes made during the Governing Board Meetings held on 10/23/2011.



B. Review of the staffing showed that the facility failed to have a Dietician, Social Worker, Director of Case Management, Director of Human Resources, Director of the emergency room , Director of Material Management, Director of Medical Records, Director of Surgery and Director of Outpatient Services.

Review of the Governing Board Bylaws, revised 10/23/2011, Article VI: Administration, Section 1: Chief Executive Officer, " The authority and duties of the Chief Executive Officer shall include: D. Provide the hospital professional staff with the administrative support and personnel reasonably required to render quality care and the review and evaluation of activities; N. Ensure the quality and appropriateness of patient care is rendered to all patients, and; O. Select other key management staff.

Interview with CEO/owner #1 on 1/5/2012 at 10:45 AM in the conference room, confirmed the Director of Human Resources, Director of the Surgical Department were terminated by the CEO. The Director of Medical Records quit in July 2011, Director of Materials Management quit in January 2012, Dietician quit in November 2011, the Director of Case Managements and the Social Worker were reported to have quit.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations and interviews the facility:

A. failed to protect patients from potential harm by allowing patients to remain in the pre-operative area without nursing supervision.

B. failed to follow the acceptable standard of practice for staffing of the seven scheduled surgical procedures on 1/4/2012.

C. failed to implement corrective action when the shortage of surgical staff was identified, leaving the three preoperative patients unattended by licensed nursing staff and allowed patients to be placed at risk for potential harm.

D. failed to follow the acceptable standard of practice for staffing for the preoperative department by not providing a registered nurse and leaving three scheduled surgical patients unattended.

Refer to tag A0392

E. failed to provide pharmaceutical service that met the need of the patients. 4 of 4 patients (#1, 2, 3, and 4) did not receive medications as ordered by the physician due to facility's failure to maintain pharmaceutical supplies set forth in the hospital's formulary.

Refer to tag A0404

A. On 01/04/2012 at approximately 10:10 AM, interview with staff #4 confirmed there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department. Staff #4 was working in the surgical room with a patient and staff #5 was in the recovery room with a patient.

During a tour of the preoperative area on 01/04/2012 at approximately 10:15 AM with staff #3, three patients were observed awaiting their surgical procedures with no licensed surgical personnel present to care for patients.

On 01/04/2012 at approximately 9:30 AM, interview with staff #3 confirmed there were three patients in the pre-operative area awaiting surgery and there were no licensed surgical staff present to care for the patients. Staff #3 also confirmed there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department. Staff #5 was working in the surgical room with a patient and staff #6 was in the recovery room with a patient.



B. During a tour of the preoperative area on 01/04/2012 at approximately 10:15 AM with staff #3, three patients was observed awaiting their surgical procedures with no licensed surgical personnel present to care for patients. Further investigation revealed that three surgical procedures had been completed. One procedure was the removal of hardware from both of the patient's ankles. Two patients that received Lumbar Epidural Blocks were in the post anesthesia area. There was only one RN on duty at the post anesthesia area.
A review of the acceptable standards of practice for perioperative staffing, the Association of Perioperative Registered Nurses (AORN) standards requires at a minimum the following: 1 RN in the preoperative area, and 1 RN per patient per OR in the role of the circulating nurse. The postoperative area requires two licensed nurses, one of whom is a RN competent in post anesthesia nursing and must be present whenever a patient is receiving post anesthesia care. The AORN recommendation for post anesthesia staffing reflects the acceptable standard of practice of the American Society of Perianesthesia Nurses (ASPAN's) for Patient classification/recommended staffing guidelines. "An RN assesses the discharge readiness of the patient and confirms the order from anesthesiologist/surgeon for discharge according to facility protocol."
A review of the acceptable standards of practice for staffing, American Society of Perianesthesia Nurses ' (ASPAN's), requires the following: two registered nurses, one of whom is an RN competent in Post anesthesia Nursing, are in the same room/unit where the patient is receiving post anesthesia care.
On 01/04/2012 at approximately 10:10 AM interview with staff #4 confirmed there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department. Staff #4 was working in the surgical room with a patient and staff #5 was in the recovery room with a patient.
During a tour of the preoperative area on 01/04/2012 at approximately 10:15 AM with staff #3, three patients were observed awaiting their surgical procedures with no licensed surgical personnel present to care for patients.

On 01/04/2012 at approximately 10:15 AM interview with staff #3 confirmed there were three patients in the pre-operative area awaiting surgery and there were no licensed surgical staff present to care for the patients. Staff #3 also confirmed there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department. Staff #5 was working in the surgical room with a patient and staff #6 was in the recovery room with a patient.

On 01/04/2012 at approximately 10:30 AM, the Director of Nursing (DON) staff #2 was interviewed. The DON was also acting as the House Supervisor due to shortage of staff. The DON confirmed that there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department. The DON confirmed that she was aware of the shortage in staffing but did not stop the surgery cases.

The Chief Executive Officer (CEO) staff #1 informed the surveyors on 01/04/2012 at approximately 10:45 AM that she had not been made aware of the shortage of staffing. The surveyors informed the CEO that there was immediate jeopardy to patient's health and safety of surgical patients.

C. During a tour of the preoperative area on 01/04/2011 at approximately 10:10 AM with staff #3, three patients were observed awaiting their surgical procedures with no licensed surgical personnel present to care for patients. Further investigation revealed that three surgical procedures had been completed. One procedure was the removal of hardware from both of the patient ' s ankles. Two patients received Lumbar Epidural Blocks. There was only one RN on duty at the post anesthesia area.
A review of the acceptable standards of practice for perioperative staffing, AORN required the minimum staffing as follows: 1 RN in the preoperative area, and 1 RN per patient per OR in the role of the circulating nurse. The postoperative area will have two licensed nurses, one of whom is a RN competent in post anesthesia nursing and must be present whenever a patient is receiving post anesthesia care.
A review of the acceptable standards of practice for staffing, American Society of Perianesthesia Nurses (ASPAN's), revealed the recommended staffing guidelines are as follows: two registered nurses, one of whom is an RN competent in Post anesthesia Nursing, are in the same room/unit where the patient is receiving post anesthesia care.
The Director of Nursing (DON) staff #2 was interviewed on 01/04/2011 at approximately 10:30 AM. The DON was also acting as the House Supervisor due to shortage of staff. The DON confirmed that there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department. Staff #5 was working in the surgical room with a patient and staff #6 was in the recovery room with a patient. The DON confirmed that she was aware of the shortage in staffing and did not stop the surgery cases.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations and interviews the facility:

A. failed to protect patients from potential harm by allowing patients to remain in the pre-operative area without nursing staff in attendance.

B. failed to provide adequate staffing for the Surgical Department to safely care for patients placing them in an situation for potential harm.

C. failed to provide qualified staff to monitor the patients on telemetry. The lack of qualified staff to monitor patients on telemetry placed the patients' health and safety in jeopardy.


A. On 01/04/2012 at approximately 10:10 AM interview with staff #4 confirmed there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department.

During a tour of the preoperative area on 01/04/2012 at approximately 10:15 AM with staff #3, three patients were observed awaiting their surgical procedures with no licensed personnel present to care for them.

On 01/04/2012 at approximately 10:15 AM, interview with staff #3 confirmed there were three patients in the pre-operative area awaiting surgery and there were no licensed staff present to care for the patients. Staff #3 also confirmed there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department. Staff #4 was working in the surgical room with a patient and staff #5 was in the recovery room with a patient.

B. A review of the acceptable standards of practice for perioperative staffing, Association of Perioperative Registered Nurses (AORN), required a minimum staffing as follows: 1 RN in the preoperative area, 1 RN per patient per OR in the role of the circulating nurse. The postoperative area will have two licensed nurses, one of whom is a RN competent in post anesthesia nursing and must be present whenever a patient is receiving post anesthesia care.
A review of the acceptable standards of practice for staffing, American Society of Perianesthesia Nurses (ASPAN), recommended staffing guidelines are as follows: two registered nurses, one of whom is an RN competent in Post anesthesia nursing, are in the same room/unit where the patient is receiving post anesthesia care.
On 01/04/2012 at approximately 10:10 AM staff #4 confirmed there were only two licensed staff (staff#5 and staff #6) working in the Surgical Department. Staff #5 was in the surgery room with a patient and staff #6 was in the post anesthesia area with two patients.
During a tour of the preoperative area on 01/04/2012 at approximately 10:15 AM with staff #3, three patients were observed awaiting their surgical procedures with no licensed surgical personnel present to care for patients.

On 01/04/2012 at approximately 10:15 AM, interview with staff #3 confirmed that there were three patients in the pre-operative area awaiting surgery and there were no licensed surgical staff present to care for the patients. Staff #3 also confirmed there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department. Staff #5 was in the surgery room with a patient and staff #6 was in the post anesthesia area with two patients.

C. Review of the record titled "Organizational Chart" reveals Nursing Supervisors, Emergency Department, Medical ICU/Cardiovascular ICU/ Cardiac Cath Lab, Surgery/PACU/ Endoscopy/ Pre-OP Holding, and Medical Surgical Telemetry /Outpatient Day Surgery all report to the Director of Nursing.

On 1/4/2012 at approximately 9:00 AM, surveyor observed on medical surgical floor (station 2) that the telemetry monitor was not being monitored by nursing staff on the floor. Three patients were observed on the telemetry monitor. At approximately 9:30 AM, the surveyors observed staff #8 sitting in front of the telemetry monitor.

An interview with staff #4 on 1/4/2012 at approximately 9:45 AM confirmed that staff #8 was not a telemetry monitor (a person qualified by training to monitor cardiac patients and able to identify potentially fatal cardiac arrhythmias).

An interview with staff #8 on 1/4/2012 at approximately 10:00 AM confirmed that she had no experience monitoring telemetry patients. Questioned staff #8 is this in your job description or in your assignment for today and she answered "no".
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, records review, and interviews, the facility failed to provide qualified staff to monitor the patients on telemetry (a person qualified by training to monitor cardiac patients and able to identify potentially fatal cardiac arrhythmia's). The lack of qualified staff to monitor patients placed on telemetry was a potential for harm. The facility also failed to protect patients from potential harm by allowing patients to remain in the pre-operative area without nursing supervision and/or provide adequate staffing for the Surgical Department. The facility failed to ensure that there are adequate qualified staff on duty to care for the patients scheduled for surgical procedures.

The condition and practices found pose an immediate jeopardy to patient's health and safety.


On 1/4/2012 at approximately 9:00 AM, surveyor observed on medical surgical floor (station 2) that the telemetry machine was not being monitored by nursing staff. Three patients were observed on the telemetry monitor. At approximately 9:30 AM, surveyor observed staff #8 sitting in front of the telemetry monitor.

An interview with staff #8 on 1/4/2012 at approximately 10:00 AM confirmed that she had no experience monitoring telemetry patients. Consequently, staff #8 was unable to recognize abnormal telemetry patterns particularly those are are deemed critical. The surveyor questioned staff #8 if telemetry monitoring is in your job description or in her assignment for the day and she answered "no."

An interview with staff #4 on 1/4/2012 at approximately 9:45 AM confirmed that staff #8 was not a telemetry monitor (a person qualified by training to monitor cardiac patients and able to identify potentially fatal cardiac arrhythmia's).

On 01/04/2012 at approximately 10:10 AM staff #4 confirmed there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department. Staff #5 was working in the actual operating room with the patient. Staff #6 was the only Registered Nurse in the Perianesthesia area with the patients.

During the tour of the preoperative area on 01/04/2012 at approximately 10:15 AM with staff #3, three patients were observed awaiting their surgical procedures with no licensed personnel present to care for the patients.

On 01/04/2012 at approximately 10:15 AM staff #3 confirmed there were three patients in the pre-operative area awaiting surgery and there were no licensed staff present to care for them. Staff #3 also confirmed there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department on 1/4/2012. Staff #5 was working in the actual operating room with the patient. Staff #6 was the only Registered Nurse in the Perianesthesia area with the patients.

A review of the accepted standards of practice for perioperative staffing, Association of Perioperative Registered Nurses (AORN), requires a minimum staffing as follows: 1 RN in the preoperative area, and 1 RN per patient per OR in the role of the circulating nurse. The postoperative area will have two licensed nurses, one of whom is a RN competent in postanesthesia nursing and must be present whenever a patient is receiving postanesthesia care.

A review of the accepted standards of practice for staffing, American Society of Perianesthesia Nurses (ASPAN), requires a minimum staffing as follows: two registered nurses, one of whom is an RN competent in Postanesthesia Nursing, are in the same room/unit where the patient is receiving postanesthesia care.

During the tour of the preoperative area on 01/04/2012 at approximately 10:15 AM with staff #3, three patients were observed awaiting their surgical procedures with no licensed personnel present to care for them. Further investigation revealed that three surgical procedures had been completed. One procedure was the removal of hardware from both of the patient's ankles. Two patients received Lumbar Epidural Blocks. There was only one RN on duty in the postanesthesia area.

On 01/04/2012 at approximately 10:30 AM, the Director of Nursing (DON) staff #2 was interviewed. She was also acting as the House Supervisor due to shortage of staff. The DON informed the surveyors that there were only two licensed staff members (staff#5 and staff #6) working in the Surgical Department. The DON confirmed that she was aware of the shortage in staffing but did not stop the surgery cases.

The Chief Executive Officer (CEO) staff #1 was interviewed on 01/04/2012 at approximately 10:45 AM. The CEO informed the surveyors that she had not been made aware of the shortage of staffing. The surveyors informed the CEO that the practices and the situation in the hospital was determined to be an immediate jeopardy to the health and safety of patients.
VIOLATION: FORMULARY SYSTEM Tag No: A0511
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records review and interviews, the facility failed to assure medications on the formulary were available for patients. The facility also failed to assure medications on the formulary were available for stocking emergency crash carts throughout the facility. 10 of 18 emergency carts were missing medications that were available from the facility's medication supplier.


Findings include:

Review of Pharmacy Policy 08.02, "Formulary: Development and Maintenance," revealed the following: "The formulary system shall include a formulary or list of legend and nonlegend drugs accepted for use by the medical staff and available at all times for prescribing/ordering."

On 1/5/12, Staff #13 and #15 prepared a list of drugs currently unavailable in the facility. This list of unavailable drugs was compared against the facility's document titled, "Renaissance Hospital Groves-Pharmacy Department Hospital Drug Formulary," approved by the Medical Executive Committee in 2011. The following is the list of medications on the formulary that were not available in the facility:
Acyclovir 50 mg
Advair 100/50
Advair 250/50
Advair 500/50
Allegra D 12 hr
Amphadase 150 IU/ml
Ampicillin 1 gm
Amvisc plus
Aurodex otic drops
Azactam 1 gm
Breviblock 100 mg/10 ml
Compazine 10 mg/2 ml
Flonase
Heparin 100 u/ml 1 ml vial
Lovenox 100 mg
Lovenox 30 mg
Minocin 50 mg
Sinemet CR 25/100
Spiriva
Tetracycline 250 mg
Urispas 100 mg
Zyvox 600 mg/300 ml bag

Review of Pharmacy Policy 16.04, "Emergency Drugs," revealed the following:
"The Director of Pharmacy shall ensure the availability of a sufficient inventory of medical staff approved emergency drugs in the pharmacy and patient care areas."
AND
"The pharmacy shall maintain drugs in the containers at predetermined (par) levels."
AND
"The pharmacy shall replace missing, expired, and unusable drugs as soon as possible."

On 1/5/12, 17 crash carts and 1 [DIAGNOSES REDACTED] cart were checked for emergency medications. 10 carts were missing medications that were available from the facility's supplier. The following medications were on the facility's formulary, but were missing from various carts (some carts had these and some did not). All were available from the facility's supplier:
Calcium Gluconate 10 mg via
Adenocard 6 mg/2 ml syringe
8.4% Sodium Bicarbonate (Pediatric) 10 meq/10 ml syringe
Atropine 1 mg/10 ml
Dopamine HCL 400 mg/D5%W 250 ml
Lasix 20 mg/2 ml vial

During an interview on 1/5/12 at 10:24 am, staff #13 revealed that the process of ordering medications was for a request to be submitted to the CEO for approval. Once the CEO approves the order, it is sent to the supplier to be filled.

Staff #13 reported that the most recent pharmacy order was submitted to the CEO for approval on 12/23/11. The order was approved and sent to the supplier on 12/28/11. On 1/5/12, the CEO reported that the order remains on hold at the supplier, pending payment.