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.

CLEVELAND REGIONAL MEDICAL CTR 300 E CROCKETT CLEVELAND, TX Feb. 26, 2014
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record review and interview it was determined that the facility:

1. Failed to ensure appointment of the current Interim Chief Executive Officer (CEO) by the Governing Body.

Refer to tag 0057


2. Failed to ensure the Intensive Care Unit was safe and fully operational prior to opening for admission of patients.

Refer to tag 0144


3. Failed to ensure a well-organized nursing service.

Refer to tag 0386
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on record review and interview, the facility failed to ensure that the current Interim Chief Executive Officer (CEO) was duly appointed by the Governing Body. Citing review of Governing Body minutes for 1 of 1 months, (Last documented Governing Body Meeting minutes dated 11/22/2013).

Findings include:

Review of the minutes of the last documented meeting of the Governing Body dated 11/22/2013 revealed no documentation of the appointment of staff #1 as the interim CEO.

Interview with staff #1 in the administrative department on 2/26/2014, at 2:00 pm, confirmed that the 11/22/2013, was the last meeting of the Governing Body.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation and interview it was determined the facility failed to:

1. Ensure the Intensive Care Unit was safe and fully operational prior to opening for admission of patients.

Refer to tag 0144


2. Ensure a well-organized nursing service with the ability to adequately staff facility and provide patient care.

Refer to tag 0386
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation and interview, the facility failed to ensure that the Intensive Care Unit was staffed and fully operational prior to opening for admission of patients. The facility failed to ensure adequate nursing staff to provide patient care. This has the potential for harm for all patients that received care at the facility.

Findings Include:

While touring the facility on 2/26/2014, at 11:45 am, with the interim CEO the following observations were noted:

1. The patient call system in the intensive unit failed to function properly. The pull cord next to the patient's bed was pulled, this caused a red light to come on on the wall next to the patient bed. The light above the entrance into the patient room didn't light up. Also, there was no audible alarm and/or light that came on at the nurses' station. A silver call bell was noted on all bedside tables for patient use.


Interview with staff #11 on 3/4/2014, at 10:00 am, revealed the following:

"While I was onsite at the facility on 2/21/2014, I was advised by the owner of the facility that they were open for inpatients and have a staffed 6 bed Intensive Care Unit ready if someone needs to be admitted from the emergency Department. He shared that a new vendor is going to reactivate the call bell system. The Intensive Care Unit did not have any patients or staff. The lights were off and it appeared in disarray. Silver bells are in each room to call for assistance."


Interview with staff #1 interim CEO/CNO on 2/26/2014 at 11:30 am in the administrative offices revealed the following:

"The facility was purchased by new management on 6/2013. When the purchase went through, the new owners were not aware of the debts they would have to assume. The previous owners owed money for back taxes to IRS and property taxes.

The building was in disrepair, needing lots of money put into facility to get it up to a working hospital. The previous administration walked out last week, and I was brought in to act as interim CEO/CNO on 2/21/2014. I came in and worked all weekend to try and keep the doors of the hospital open. They also called in staff #2 to assist me since I was new to the facility. At this point, we have our emergency department open, but are on diversion for trauma. We have the intensive care unit open for inpatients admissions after outpatient procedures only. The intensive care unit was built in 1980 and has 6 beds with bedside commodes; no shower and/or bathrooms are available. Patient call bells are functioning in the intensive care unit.

Radiology had one 8 hour shift on Saturday that was not covered with staff, and the emergency room was on diversion for radiology also. The radiology staff walked out on 2/21/2014, and we had to call staff from sister hospitals to help with staffing. The pharmacy, laboratory, and kitchen are open and have supplies available and staff to provide services.

The pharmacy is under direction of a new pharmacist. The PIXIS medication dispensing system was removed by the vendor several weeks ago due to non-payment.

The second floor used for medical surgical patients is in need of repair before patients can be admitted for care. The patient call system doesn't function, the chillers on the roof are not working, and there's an odor in one of the rooms they can't get rid of or find the source of the smell.

As of today the only procedures being done is in the GI lab. We had several scope procedures that were done today, and the intensive care was just a back-up in case they needed to be admitted overnight due to problems post-op."


Interview with staff #1 on 2/26/2014 at 11:55 am confirmed the findings.

It was determined that this deficient practice created a Immediate Jeopardy and placed patients at risk of potential harm, serious injury, and subsequent death. These failures had potential to affect all patients admitted to the facility.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation and interview, it was determined that the facility failed to provide an organized nursing service supervised by a registered nurse with adequate nursing staff to provide patient care.

Refer to Tag 0386
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on record review and interview, the facility failed to ensure a well-organized nursing service. On 2/17/2014, the facility laid off 30 plus staff because the inpatient unit on the 2nd floor was closed. The following week, another 40 employees resigned including the CEO/CNO. This internal crisis has the potential for harm for all patients that received care at the facility.

Findings Include:

1. Review of Governing Body minutes on 2/26/2014, at 1:30 pm, revealed the last documented meeting of the Governing Body was dated 11/22/2013. This was confirmed by the interin CEO at the time of the survey.

No other meeting minutes were found after the 11/22/2013 meeting.


2. Staff #1 started working on 2/21/2014, as CEO/CNO with no knowledge of the status of the facility staff. The extent of the facility issues and financial crisis were also unknown.

Interview with staff #1 on 2/26/2014 at 11:30 pm revealed the following:

"The previous administration walked out last week, and I was brought in to act as interim CEO/CNO on 2/21/2014. I came in and worked all weekend to try and keep doors of the hospital open. They also called in a former employee (staff #2) to assist me since I was new to the facility.

At this point, we have our emergency department open, but are on diversion for trauma. We have the intensive care unit open for inpatients admit if any complications occur after outpatient procedures only.

The intensive care unit was built in 1980 and has 6 beds with bedside commodes; no shower and/or bathrooms are available. Patient call bells are functioning in the intensive care unit.

Radiology had one 8 hour shift on Saturday that was not covered with staff, and the emergency room was on diversion for radiology also. The radiology staff walked out on 2/21/2014, and we had to call staff from sister hospitals to help with staffing.

The pharmacy, laboratory, and kitchen are open and have supplies available and staff to provide services. The pharmcy is under direction of a new pharmacist. The PIXIS medication dispensing system was removed by the vendor several weeks ago due to non-payment.

The second floor used for medical surgical patients is in need of repair before patients can be admitted for care. The patient call system doesn't function, the chillers on the roof are not working, and there's an odor in one of the rooms they can't get rid of or find the source of the smell.

As of today, the only procedures being done are in the GI lab. We had several scope procedures that were done today, and the intensive care was just a back-up in case they needed to be admitted overnight due to problems post-op."


Interview with staff #2 on 2/26/2014 at 11:40 am revealed the following:

"The facility was purchased by new management in 6/2013. When the purchase went through the new owners were not aware of the debts they would have to assume. The previous owners owed money for back taxes to IRS and property taxes.

The building was in disrepair, needing lots of money put into facility to get it up to a fully functioning hospital. I worked at this facility in the past and feel it's very important to our community.

I was called in to help due to being familiar with the facility. I don't have a title, I'm just a Registered Nurse trying to help in any way I can.

The 2nd floor at this point cannot be used for a patient care unit. The chillers and the patient call system are not functioning. There's a danger of flooding from the chillers and there's an odor problem.

We have called in a lot of the old staff and have been able to keep the emergency department open and plan 2 outpatient procedures today. We had surgery staff and post-op care staff available. Two weeks ago when the chillers went out, the patients were transferred to another facility due to the Intensive Care Unit not ready for patient care.

The radiology department staff left 2/21/2014 and left it with no employees to provide services. Radiology staff from our sister hospital coming to assist, even though this am patients needing x-rays were having to wait 3-4 hours. A technician has arrived to help catch them up.

Several months ago, the staff were ask to take a 5% decrease in salary, then the lay-offs occurred. Two weeks ago, the staff were ask to take another 10% pay cut. That caused staff to just leave, to date the decrease in salaries has not occurred."


During interview with staff #1 on 2/26/2014, at 1:00 pm, staff #1 was advised that the patient call system in the intensive care unit was not properly functioning and was not safe for patients.

Telephone interview with staff from 2 local ambulance services on 2/27/2014, at 11:00am, revealed that the ambulance services were unaware of any diversions to the facility's emergency department.

During an interview on 2/27/2014, at 11:30 am, Staff #1 was advised of the ambulance services being unaware of any diversions to the facility's emergency department. Staff #1 reported that she had called the ambulance services herself to divert trauma patients.


Interview with staff working in administrative department on 2/26/2014 at 2:00 pm confirmed there were no other Governing Body meeting minutes. No meetings have been held this year to date.