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.

PARIS REGIONAL MEDICAL CENTER 820 CLARKSVILLE ST PARIS, TX 75460 Feb. 10, 2015
VIOLATION: CONTENT OF RECORD Tag No: A0458
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart review, policy and procedures, and interviews the facility failed to follow its own medical staff rules and regulations to ensure a current history and physical was on the chart within 24 hours after admission, prior to surgery, or a procedure requiring anesthesia services in 3(#1, #9, and #10) out of 13 (1-13) charts reviewed.


Review of the "Medical Staff Rules and Regulations" stated, " 6.1.2 A complete history and physical shall in all cases be recorded within 24 hours after admission of the patient, and may have been recorded with in (30) days prior to admission."


Review of the policy and procedure "Medical Staff Rules and Regulations" stated, "the history and physical are not in the patients chart before the time stated for the operation or procedure, the physician shall write a progress note, giving pertinent history and physical findings along with a statement that the history and physical has been completed and the patient is an acceptable candidate for the proposed anesthesia."


Review of patient #9's chart revealed she was admitted for a surgical procedure on 1/5/2015. A history and physical was found on the chart dated 12/10/2014. There was no evidence of a addendum to the history and physical dated 12/10/2014. There was no progress note found prior to the administration of anesthesia, confirming patient #9 had no changes to her history and physical, and was an acceptable candidate for the proposed anesthesia.


Review of patient chart #10 revealed an admission date of [DATE]. A progress note by the physician was found on the chart dated 1/5/2015. There was no history and physical or pre-anesthetsia assessment note found prior to the administration of anesthesia confirming patient #10 was an acceptable candidate for the proposed anesthesia.


Review of patient #1's chart on 2/10/15 revealed there was no history and physical found on patient #1's chart for the visit of 1/22/15 through 1/23/15.


An interview with staff #4 revealed the facility did not have a policy or procedure on history and physical requirements. The facility followed the guidelines in the "Medical Staff Rules and Regulations" referring to history and physicals.
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
Based on chart reviews, policy and procedure review, and interviews, the facility failed to follow their own policy and procedures and complete discharge instruction forms in 7 (#1, #11, #4, #2, #7, #8, and #9) out of 13 (1-13) charts reviewed.


Review of the facility's policy and procedure, "Discharge Planning", stated, "Any patient regardless of race, color, creed, or financial status receiving medical care through the facilities of the hospital is entitled to discharge planning services. 4.5 The patient care RN shall complete the "Discharge Instructions" or "Transfer Record".


Review of patient #1's chart revealed an incomplete discharge instruction sheet. The pneumonia and influenza immunization information was blank.


Review of patient #11's chart revealed the copy of "Discharge Medication Reconciliation Form given to patient, original retained for record" and "Printed Information for new prescriptions given to patient." were blank.


Review of patient #4's chart revealed "accompanied by" and "room check" were blank.


Review of patient #2's chart revealed the copy of "Discharge Medication Reconciliation Form given to patient, original retained for record" and "Printed Information for new prescriptions given to patient." were blank. There was no documentation of discharge time or who accompanied the patient at discharge. There was no time documented with nurse signature.


Review of patient #7's chart revealed the copy of "Discharge Medication Reconciliation Form given to patient, original retained for record" and "Printed Information for new prescriptions given to patient." were blank. There was no documentation of discharge time. There was no time documented with nurse signature.


Review of patient #8's chart revealed the "Room Check" was blank. Review of the Nurse Signature line revealed no documentation of credentials, date or time.


Review of patient #9's chart revealed the copy of "Discharge Medication Reconciliation Form given to patient, original retained for record" and "Printed Information for new prescriptions given to patient." were blank.


An interview was conducted with staff #2 and #4 on 2/10/2015. Staff #2 reported training had recently been implemented to the nursing staff on discharge planning. Staff #2 stated, "I can't believe there are this many charts that are incomplete". Staff #2 and #4 confirmed the above incomplete discharge forms.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on records review, policy and procedures, and interviews the facility failed to ensure:


A. a grievance was initiated, and investigated with a prompt resolution in 1 (#1) of 13 (#1-13) charts reviewed.

Refer to tag A0118


B. the patient received consents for treatment and information on patient rights in 4 (#2, 4, 12, and 13) of 13 (#1-13) patients reviewed.

Refer to tag A0131


C. to notify the patients physician on patient's request in 1 (#1) out of 13 (1-13) charts reviewed.

Refer to tag A0133


D. its own policy and procedure were followed for Code White. The facility failed to document the safety and status of the patient in 1 (#1) of 13 (#1-13) charts reviewed.

Refer to tag A0144
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on chart reviews, policy and procedures, and interviews, the facility failed to ensure a grievance was initiated, and investigated with a prompt resolution in 1 (#1) of 13 (#1-13) charts reviewed.


Review of patient #1's chart revealed a physician progress note dated 1/23/15 at 10:55 am. The note revealed patient #1's family had requested patient #1 be transferred to another hospital and patient's family had arranged for an accepting physician. Staff #11 called the family referred physician and discussed patient #1's case. The referred physician did not accept patient #1 for transfer and recommended that staff #11 call the hospitalist at the hospital of choice. Staff #11 documented, "I went back to the room to discuss this with family. Daughter and son were in the room. Patient has a 2:15 appointment with another physician today. They wanted me to call that physician to come see the patient at the hospital. I advised that it would be best if they kept the 2:15 appointment, and that she could go by wheelchair. Son got very angry and was yelling and slamming doors. He said, he had just had her in the hospital (since her discharge from here 1/5/15), and that she had been admitted and checked out there and they still had no answers.


I advised with her multiple admissions and evaluations, that I did not think further inpatient work up here would benefit, but I would be happy to facilitate out patient work up, or provide them with any data they needed. Family expressed that they would hire a private ambulance and take her to the suggested ER as they thought they could not take her by car."


There was no further documentation found in patient #1's chart concerning this incident.


Review of the "Occurrence/Complaint Report" revealed staff #14 initiated the report on 1/23/2015 at 9:00 a.m. The "Describe Event In Details" stated, "Patient daughter called PRMC at approximately 9 a.m. and told me that she wanted Staff #11 to transfer her mother to a physician in Dallas and that she wasn't going to do it and she needed to just call the doctor." The "Initial Intervention" stated, "I called staff #11 cell phone and spoke with her. At this time, she was awaiting a return phone call from the accepting physician office. I headed to the floor to speak with the patient. When I got to the floor, the physician had called staff #11 back and said this is something he would probably follow up on in 6 months or so and that he wouldn't accept patient and she needed to find hospitalist to accept patient. Staff #11 and I went to inform patient of this. Patient #1's son and daughter were in the room at this time. Made aware of no accepting physician. Complaint was resolved to the best of our ability. We did speak with the physician as family had requested and did not get transfer acceptance. Family was immediately notified. Situation escalated. Security was called. See security report." There was no grievance process initiated.


Review of the facility's Policy and procedures, "Patient Complaint/Grievance" REVISION DATE: 10/20/14 stated, "DEFINITIONS:

Patient Complaint: a verbal expression of dissatisfaction with some aspect of care and/or services that can be resolved immediately by staff present, manager or their designee. Most complaints will have simple and obvious causes that can be promptly addressed to the patient's satisfaction between the patient, hospital staff, and the Patient Relations Coordinator.

Patient Grievance: a formal, written or a verbal complaint by patient or the patient's representative, regarding the patient's care, abuse or neglect. If it cannot be resolved promptly by the staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution then the complaint is classified as a grievance. Patient grievances will be sent through the process defined in this policy and will require a written response. A complaint received by email or fax is considered "written." Information obtained during a phone call initiated by Paris Regional Medical Center is not considered a grievance.


An interview on 2/10/2015 with staff #14 revealed there was no grievance process initiated on this complaint. Staff #14 stated, "I felt it was handled and did not require any further action."


A phone interview was conducted on 2/5/2015 with patient #1's son and daughter. Patient #1's son stated, "the complaint was not handled and it escalated to the point that Paris Police Department (PPD) was contacted. I was taken out in handcuffs. There was no resolution on getting my mother to a hospital that was willing to treat her." Patient #1's daughter confirmed that the complaint was not handled and their mother was very ill and felt the hospital was not trying to help them.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on chart reviews and interviews the facility failed to ensure the patient received consents for treatment and information on patient rights in 4 (#2, 4, 12, and 13) of 13 (#1-13).


Review of patient #13, #2 and #4 charts revealed there was no consents to treat, information of patient rights given, or financial acknowledgement found.


Review of patient #12's chart revealed a consent form "General Conditions of Treatment" was on the chart incomplete. Patient #12 had signed the form. The consent had a check box that stated, "I do or do not want my name listed in the hospital directory." The boxes were left blank.


Review of patient #12's chart revealed a consent form "General Conditions of Treatment" on "Patient Notices Packet" acknowledging acceptance of privacy notice, information on rights and responsibilities, and advanced directives were left blank.


Interview with staff #2 and #4 confirmed the consents were missing and incomplete on the above charts reviewed.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
Based on chart reviews and interviews the facility failed to notify the patients physician on request in 1(#1) out of 13 (1-13) charts reviewed.


Review of patient #1's chart revealed the nurses notes dated 1/23/15 stated, "would you like your primary physician notified of admission ( the question was marked "yes") if yes, notify the physician and document the name of the physician notified." There was no documentation found of patient #1's physician notified and when.


A phone interview with patient #1's son was conducted on 2/08/2015. Patient #1's son revealed he and patient #1 had requested her cardiologist be informed that patient #1 was in the hospital.


An interview with staff #4 and #2 on 2/10/2015 was conducted. Staff #4 stated, "more than likely they were not notified."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on chart reviews, policy and procedures, security and grievance logs, and interviews the facility failed to follow its own policy and procedure for Code White. The facility failed to document the safety and status of the patient. This deficient practice had the likelihood to result in harm to all patients in this facility.


Review of policy and procedure "Code White" stated,

"Purpose: To establish guidelines for safe and effective intervention with either patients, family members, or visitors when physical means are required to protect the individual from self harm or to protect others that the individual poses a threat of harm toward."

The facility failed to initiate the "Code White" evaluation form and the following procedures:

"1. To initiate the hospitals "Code White" system and dial 7777.

2. To assign individuals after hours, on weekends and holidays by the hospital House Supervisor.

3. To have staff available with current CPI (Crisis Intervention) training.

4. To remove all uninvolved patients, visitors or bystanders to a safe location.

Failure to follow the "Code White" policy and procedure, may lead to potential patient injury or even death. "


Review of the "Security Department North Campus Daily Activity Log" revealed staff #9 documented the following statement on 1/23/2015 at 10:30 a.m., "Disorderly family member (patient #1's son). This person has disorderly this month already. See incident report 01-05-15. He was warned from that incident that if he was disorderly again he would be issued a Criminal Trespass Warning." At 10:34 a.m., "Call Paris PD to issue (patient #1's son) the Criminal Trespass Warning and escort (patient #1's son) out." At 10:40 a.m., "Paris PD arrives and takes over the incident." At 10:50 a.m., "Criminal Trespass Warning given to (patient #1's son) and he is escorted out of the front lobby by Paris PD." At 11:00 a.m., "Give staff #14 and staff #11 witness statements forms to fill out for record keeping." At 11:20 a.m., "In ER Security office writing Incident Report."


Review of the Incident Report on 1/5/2015 revealed staff #9 documented patient #1's son had threatened a physician. Staff #9's report revealed, "Staff #22 stated that the son of the patient in room 547 had come to the nurse's station and told the nursing staff that when he sees him (staff #22), he will beat him. I asked staff #22 if he wanted the police called and he stated he did." Paris Police Department arrived and took over the situation. The police handcuffed patient #1's son but, allowed him to stay with his mother until she was discharged .


Review of the "Occurrence/Complaint Report" revealed staff #14 initiated the report on 1/23/2015 at 9:00 a.m. The "Describe Event In Details" stated, "Patient daughter called PRMC at approximately 9 a.m. and told me that she wanted Staff #11 to transfer her mother to a physician in Dallas and that she wasn't going to do it and she needed to just call the doctor."The Initial Intervention" stated, "I called staff #11 cell phone and spoke with her. At this time, she was awaiting a return phone call from the accepting physician office. I headed to the floor to speak with the patient. When I got to the floor, the physician had called staff #11 back and said this is something he would probably follow up on in 6 months or so and that he wouldn't accept patient and she needed to find hospitalist to accept patient. Staff #11 and I went to inform patient of this. Patient #1's son and daughter were in the room at this time. Made aware of no accepting physician. Complaint was resolved to the best of our ability. We did speak with the physician as family had requested and did not get transfer acceptance. Family was immediately notified. Situation escalated. Security was called. See security report." there was no grievance process initiated.


Review of patient #1's nurses notes for 1/23/2015 at 11:00 AM revealed the patient was medicated with Xanax .25 mg by mouth for complaint of anxiety. There was no further assessment or documentation of earlier event or patients condition post medication.


No further documentation was found of the escalated situation or the patient's condition, environment, or safety status during the incident dated 1/23/2015.


Interview with staff #1 on 2/10/15 revealed that there was a phone conversation 2 to 3 days after the incident on 1/5/2015, between patient #1's son and staff #1. Staff #1 reported that patient #1's son apologized for his behavior on 1/5/2015 and reported he would not behave that way again. Staff #1 agreed not to file Criminal Trespass charges against patient #1's son for the 1/5/2015 incident. Staff #1 reported he informed patient #1's son that if this type of behavior occurred again, charges would be pressed against him.


Interview with staff #2, #4, and #14 was conducted on 2/10/2015 confirmed a "Code White" was not initiated on 1/23/2015 and the facility did not follow its own policy and procedure.


Interview with staff #26 on 2/10/2015 confirmed there was no teams assigned for "Code White" and multiple key staff was not currently trained in CPI (Crisis Prevention). Staff #26 stated, "we are working on a new policy and will mandate that it's part of the current education."


Interview with staff #10 on 2/10/2015 revealed that he did not have current CPI training and a "Code White" has only occurred once in 5 years that he was aware of. Staff #10 reported he does not receive a list of "Code White" team members for each shift. Staff #10 reported when a disruptive event occurs, security and staff #10 investigate the situation and contact Paris Police Department if needed.