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.

UT HEALTH EAST TEXAS ATHENS HOSPITAL 2000 SOUTH PALESTINE ST ATHENS, TX 75751 Feb. 7, 2017
VIOLATION: GOVERNING BODY Tag No: A0043
Based upon document review and interview, the governing body failed to:


1. supervise the contracted Management Service Company. The Management Company withheld information from the CEO and Medical Staff that an ER Physician could have been providing care to patients while under the influence of drugs and/or alcohol.

Refer to tag A0049, A0083, A0084


2. hold the Chief Executive Officer responsible for supervising the Management Service Company that was contracted to manage the facility's off campus emergency room (ER). The Chief Executive Officer was not informed by the contract Management Service Company that:

A. a Registered Nurse was allowed to intubate patients in the off-site ER, and

B. an ER physician was reportedly under the influence of drug and/or alcohol while caring for patients in the off-site ER.

Refer to tag A0057


3. protect patients' rights for those patients seeking health care at the facility's off campus emergency room .
A contracted Management Service was not following the hospital's policies and allowed a Registered Nurse to intubate patients.
An ER physician at the off campus Emergency Department was reported to be under the influence of drug and/or alcohol while caring for patients.
The contracted Management Service failed to report these incidents to the hospital's CEO and CNO.

Refer to tag A0144



4. ensure the Chief Nursing Officer (CNO) provided administrative authority to the off campus emergency room 's (ER) nursing staff. The emergency room (ER) nursing staff reported to the Regional Director (an employee of the contracted Management Service Company). The Regional Director (an employee of the contracted Management Service Company) reported to the VP of the Management Service Company. The CEO and the CNO was unable to provide evidence of a direct line of administrative authority to and from the Management Service Company. The lack of administrative authority and supervision placed patients at the likelihood of harm when the contracted management service allowed a nurse to intubate patients.

Refer to tag A0386
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based upon document review and interview, the governing body failed to supervise the contracted Management Service Company. The Vice President (VP) of the contracted Management Service required the off campus ER Medical Director to report medical staff concerns directly to the VP. The Management Company withheld information from the CEO and Medical Staff of the hospital that an ER Physician could have been providing care to patients while under the influence of drugs and/or alcohol.


A review of the documents titled "Bylaws of the Medical Staff" and "Medical Staff Rules and Regulations" revealed the document did not address an impaired physician.


An interview with the Regional Director (an employee of the contracted Management Service Company) on 02/3/17 revealed physician #14 was no longer seeing patients at the off campus ER. The Regional Director revealed there had been complaints from the ER staff that physician #14 was acting as if the physician may have been under the influence of drugs/alcohol while caring for patients. The contracted physician staffing agency was asked not to schedule physician #14 at the off campus ER. The Regional Director was asked if physician #14 was tested for drugs. The Regional Director replied "No, we just asked that the physician not be scheduled at the facility".



An interview with physician #6 revealed accusations had been reported that physician #14 was acting strangely by ER staff who were working with the physician. Physician #14 was recorded by ER staff on a phone and the recording was sent to physician #6 for review. Physician #6 revealed the video showed nothing out of the normal that would suggest physician #14 was under the influence of drugs and/or alcohol. Physician #6 revealed parking lot camera footage was reviewed that showed physician #14 had parked the car at an angle blocking more than one parking space but not conclusive the physician was under the influence. Physician #6 revealed the findings were reported to the Vice President (VP) of the contracted Management Service. Physician #6 was asked if the findings were reported to Medical Staff of the hospital and the reply was, "No". Physician #6 revealed any problems or concerns at the off campus ER were reported to the Vice President (VP) of the contracted Management Service.


An interview on 2/3/2017 with the CNO confirmed he was not informed by the Management Service that the ER nursing staff had concerns a physician was caring for patients while possibly under the influence of drugs and/or alcohol.


An interview on 2/3/2017 with the CEO confirmed he was not informed by the Management Service that a physician was caring for patients while possibly under the influence of drugs and/or alcohol.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on document review and interview, the Chief Executive Officer appointed by the Governing Body failed to effectively discharge his reponsibility to supervise the contracted Management Service Company that manage the facility off campus emergency room (ER). The Chief Executive Officer was not informed by the contract Management Service Company that:


A. a Registered Nurse was allowed to intubate patients in the off-site ER, and


B. an ER physician was reportedly under the influence of drug and/or alcohol while caring for patients in the off-site ER.



A. A review of an email dated 1/13/2017 from staff #4 to staff #1 revealed the following: "I spoke with XXX (staff #10) this morning over the concerns of nursing intubation. A year ago, XXX (staff #10) was approached by Air One about a PRN opportunity. At the time, XXX (staff #10) did not meet the minimum hiring criteria because he was lacking an EMT certification. In May of 2016, he obtained his EMT. In the fall of 2016, XXX(staff #10) completed the interviewing process and began the hiring process with Air One. At that time, he worked with XXX (Physicians #6, #8 and #15) and voiced his opportunity with Air One. He asked if they could work with him to teach the intubation process. XXX(Staff #10) has never intubated independently without an ED physician at bedside overseeing. Part of Air One's clinical experience training is for their flight nurses to complete 10 intubation in a clinical environment with a physician or anesthesiologist at side. I hope this addresses the concerns related to XXX (staff #10)".


A review of an email dated 1/13/2017 from staff #1 to the VP of the Management Service revealed this statement: "This addresses XXX (physician #14) accusation toward XXX (staff #10) intubating patients".


A review of an email dated 1/13/2017 from the VP of the Management Service to staff #1 revealed this response: "Makes perfect sense".


A phone interview on 2/3/2017 at approximately 4:00pm with staff #10 confirmed four patients (patient#1, #2, #3 and #4) were intubated by staff #10.




B. An interview with the Regional Director (an employee of the contracted Management Service Company) on 02/3/17 revealed physician #14 was no longer seeing patient at the off campus ER. The Regional Director revealed there had been complaints from the ER staff that physician #14 was acting as if the physician may have been under the influence of drugs/alcohol while caring for patients. The contracted physician staffing agency was asked not to schedule physician #14 at the off campus ER. The Regional Director was asked if physician #14 was tested for drugs. The Regional Director replied "No, we just asked that the physician not be scheduled at the facility".


An interview with physician #6 revealed accusations had been reported that physician #14 was acting strangely by ER staff who were working with the physician. Physician #14 was recorded by ER staff and sent to physician #6 for review. Physician #6 revealed the video showed nothing out of the ordinary that would suggest physician #14 was under the influence of drugs and/or alcohol. Physician #6 revealed parking lot camera footage was reviewed that showed physician #14 had parked the car at an angle blocking more than one parking space but not conclusive the physician was under the influence. Physician #6 revealed the finding were reported to the Vice President (VP) of the contracted Management Service. Physician #6 was asked if the finding were reported to Medical Staff and the reply was, No. Physician #6 revealed any problems or concerns at the off campus ER were reported to the Vice President (VP) of the contracted Management Service.


A review of the document, "Agreement between the Management Services and the Hospital" revealed:

"2.01 - Services, The Management Service agrees to, and is able to, provide the services as set forth in this Agreement, efficiently and economically, consistent with Hospital Policies.

2.03 - Quality Assurance

a. Compliance with Hospital Policies and Certifying Agencies and Accrediting Organizations. The Management Service agrees to provide Services to the Hospital in such a manner as will ensure that all duties are performed and Services provided to the Hospital as may be required by, and in compliance with, any standards, ruling, or regulation of Joint Commission, the Center for Medicare and Medicaid Services, Medicare Condition or Participation or any other Federal, State or local government agency, corporate entity, or individual exercising authority with respect to, or affecting the Hospital."



An interview on 2/7/2017 with the CEO confirmed he was not informed by the Management Service that staff #10 was intubating patients in the offsite ER. The CEO revealed it is the facility's practice that RNs do not intubate patients. The CEO confirmed the facility did not have an arrangement with Air One to train flight staff to intubate patients. The CEO confirmed he was not informed by the Management Service that nursing staff had voiced concerns that a physician was caring for patient while under the influence of drugs and/or alcohol. The CEO confirmed he was not aware medical staff concerns were not being reported to Medical Staff Committee for review.
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on document review and interview, the governing body failed to supervise the contracted Management Service Company that manage the facility's off campus emergency room (ER). The Vice President (VP) of the contracted Management Service required the off campus ER Medical Director to report medical staff concerns directly to the VP. The VP of the Management Service required the ER Manager to report daily concerns and nursing concerns to the Regional Director (an employee of the contracted Management Service Company). The CEO and/or CNO of the hospital was not informed by the Management Company of accusations being made by staff that a physician could have been providing care to patients while under the influence of drugs and/or alcohol. The CEO and/or CNO was not informed by the Management Company that an RN was intubating patients.


A review of the document, "Agreement between the Management Services and the Hospital" revealed:

"2.01 - Services, The Management Service agrees to, and is able to , provide the services as set forth in this Agreement, efficiently and economically, consistent with Hospital Policies.

2.03 - Quality Assurance

a. Compliance with Hospital Policies and Certifying Agencies and Accrediting Organizations. The Management Service agrees to provide Services to the Hospital in such a manner as will ensure that all duties are performed and Services provided to the Hospital as may be required by, and in compliance with, any standards, ruling, or regulation of Joint Commission, the Center for Medicare and Medicaid Services, Medicare Condition or Participation or any other Federal, State or local government agency, corporate entity, or individual exercising authority with respect to, or affecting the Hospital."


An interview, at approximately 9:45am, with staff #1 revealed her immediate supervisor was the VP of the Management Service. Staff #1 confirmed all facility issues, whether they be medical staff or nursing staff issues, were routed through the VP. The staff member confirmed that physician #14 was terminated. Staff confirmed there were concern by the nursing staff that the physician was caring for patient while under the influence of drugs and/or alcohol. Staff revealed the physician was not tested he was terminated. Staff #1 was asked if physician #14 had ever made a complaint to her that a nurse staff #10 was intubating patients. Staff #1 first denied receiving a complaint from physician #14 and denied having knowledge of nurses intubating patients. Staff #1 revealed nurse staff #10 was becoming a flight nurse and may be intubating as part of his education.


A follow up interview with staff #1 at approximately 4:30 pm revealed there had been an email communication between staff #1, the VP of the Management Service and the ER Director in regards to physician #14's accusation toward nurse staff #10 intubating patients.


A review of an email dated 1/13/2017 from staff #4 to staff #1 revealed the following: "I spoke with XXX (staff #10) this morning over the concerns of nursing intubation. A year ago, XXX (staff #10) was approached by Air One about a PRN opportunity. At the time, XXX (staff #10) did not meet the minimum hiring criteria because he was lacking an EMT certification. In May of 2016, he obtained his EMT. In the fall of 2016, XXX(staff #10) completed the interviewing process and began the hiring process with Air One. At that time, he worked with XXX (Physicians #6, #8 and #15) and voiced his opportunity with Air One. He asked if they could work with him to teach the intubation process. XXX(Staff #10) has never intubated independently without an ED physician at bedside overseeing. Part of Air One's clinical experience training is for their flight nurses to complete 10 intubation in a clinical environment with a physician or anesthesiologist at side. I hope this addresses the concerns related to XXX (staff #10)".


A review of an email dated 1/13/2017 from staff #1 to the VP of the Management Service revealed this statement: "This addresses XXX (physician #14) accusation toward XXX (staff #10) intubating patients".


A review of an email dated 1/13/2017 from the VP of the Management Service to staff #1 revealed this response: "Makes perfect sense".


A review of the document titled "Medical Staff Rules and Regulations" revealed: "Section 4, Subsection 7, If a nurse has any reason to doubt or question the care provided to any patient or believes that appropriate consultation is needed and has not been obtained, he/she shall call this to the attention of his superior who, in turn, may refer the matter to the Chief Nursing Officer or the Administrator who may bring the matter to the attention of the Chief of Staff. Where the circumstances are such as to justify such action, the Charge Nurse or House Supervisor may request an opinion from a member of the Medical Executive Committee directly if he feels that in reporting would be detrimental to the care of the patient ....."


An interview on 2/3/2017 with the CNO confirmed he was not informed by the Management Service that staff #10 was intubating patients in the offsite ER. The CNO revealed it is the facility's practice that RNs do not intubate patients. The CNO confirmed the facility did not have an arrangement with Air One to train flight staff to intubate patients. The CNO confirmed he was not informed by the Management Service that nursing staff had voiced concerns that a physician was caring for patient while under the influence of drugs and/or alcohol.


An interview on 2/7/2017 with the CEO confirmed he was not informed by the Management Service that staff #10 was intubating patients in the offsite ER. The CEO revealed it is the facility's practice that RNs do not intubate patients. The CEO confirmed the facility did not have an arrangement with Air One to train flight staff to intubate patients. The CEO confirmed he was not informed by the Management Service that nursing staff had voiced concerns that a physician was caring for patient while under the influence of drugs and/or alcohol.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on document review and interview, the governing body failed to ensure that the contracted Management Service that manages the off campus emergency room (ER) provided care in a safe and effective manner. The Management Service Company bypassed the Hospital's established practice when an RN was allowed to intubate four patients. The Management Service did not communicate with the Hospital's CEO, Medical Staff Committee and/or CNO about this practice and placed patients at risk of potential harm and possible death by allowing a Registered Nurse to intubate patients.


A review of the document titled Performance Improvement Plan January 2017 revealed the plan did not address Contracted Services and/or how those contracted service are to be evaluated.


A review of the document titled Medical Executive Committee Meeting Minutes July14, 2014 was the document provided by the facility as proof contracted services were evaluated. The document provide no evidence the contracted Management Service that was manage the off campus emergency room (ER) was participating in Performance Improvement (QAPI) and/or was it evaluated.


A review of an email dated 1/13/2017 from staff #4 to staff #1 revealed the following: "I spoke with XXX (staff #10) this morning over the concerns of nursing intubation. A year ago, XXX (staff #10) was approached by Air One about a PRN opportunity. At the time, XXX (staff #10) did not meet the minimum hiring criteria because he was lacking an EMT(Emergency Medical Technician) certification. In May of 2016, he obtained his EMT. In the fall of 2016, XXX(staff #10) completed the interviewing process and began the hiring process with Air One. At that time, he worked with XXX, XXX, XXX (Physicians #6, #8 and #15) and voiced his opportunity with Air One. He asked if they could work with him to teach the intubation process. XXX (Staff #10) has never intubated independently without an ED physician at bedside overseeing. Part of Air One's clinical experience training is for their flight nurses to complete 10 intubation in a clinical environment with a physician or anesthesiologist at side. I hope this addresses the concerns related to XXX (staff #10)."


A review of an email dated 1/13/2017 from staff #1 to the VP of the Management Service revealed this statement: "This addresses XXX (physician #14) accusation toward XXX (staff #10) intubating patients".


A review of an email dated 1/13/2017 from the VP of the Management Service to staff #1 revealed this response: "Makes perfect sense".


A phone interview on 2/3/2017 at approximately 4:00pm with staff #10 confirmed four patients (patient#1, #2, #3 and #4) were intubated by staff #10.


An interview on 2/3/2017 with the CNO confirmed he was not informed by the Management Service that staff #10 was intubating patients in the offsite ER. The CNO revealed it is the facility's practice that RNs do not intubate patients.


An interview on 2/3/2017 with the CEO confirmed he was not informed by the Management Service that staff #10 was intubating patients in the offsite ER. The CEO revealed it is the facility's practice that RNs do not intubate patients.



It was determined that the deficient practices found posed an Immediate Jeopardy to the health and safety of patients that caused harm, likelihood of harm, serious injury, and/or death.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview, the facility failed to protect patients' rights for those patients seeking health care at the facility off campus emergency room .


A contracted Management Service was not following the hospital's policies and allowed a Registered Nurse to intubate patients in the off campus Emergency Department.


An ER physician at the off campus Emergency Department was reported to be under the influence of drug and/or alcohol while caring for patients.


The contracted Management Service failed to report these incidents to the hospital's CEO and CNO.


Refer to tag A0144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document review and interview the facility failed to provide a safe setting for patients to receive care.

A. A contracted Management Service was not following the hospital's policies and allowed a Registered Nurse to intubate patients.

B. An ER physician was reported to be under the influence of drug and/or alcohol while caring for patients.



A. A review of an email dated 1/13/2017 from staff #4 to staff #1 revealed the following: "I spoke with XXX (staff #10) this morning over the concerns of nursing intubation. A year ago, XXX (staff #10) was approached by Air One about a PRN opportunity. At the time, XXX (staff #10) did not meet the minimum hiring criteria because he was lacking an EMT certification. In May of 2016, he obtained his EMT. In the fall of 2016, XXX(staff #10) completed the interviewing process and began the hiring process with Air One. At that time, he worked with XXX (Physicians #6, #8 and #15) and voiced his opportunity with Air One. He asked if they could work with him to teach the intubation process. XXX(Staff #10) has never intubated independently without an ED physician at bedside overseeing. Part of Air One's clinical experience training is for their flight nurses to complete 10 intubation in a clinical environment with a physician or anesthesiologist at side. I hope this addresses the concerns related to XXX (staff #10)".


A review of an email dated 1/13/2017 from staff #1 to the VP of the Management Service revealed this statement: "This addresses XXX (physician #14) accusation toward XXX (staff #10) intubating patients".


A review of an email dated 1/13/2017 from the VP of the Management Service to staff #1 revealed this response: "Makes perfect sense".


A phone interview on 2/3/2017 at approximately 4:00pm with staff #10 confirmed four patients (patient#1, #2, #3 and #4) were intubated by staff #10.


An interview on 2/3/2017 with the CNO confirmed he was not informed by the Management Service that staff #10 was intubating patients in the offsite ER. The CNO revealed it is the facility practice that RN's do not intubate patients.


An interview on 2/3/2017 with the CEO confirmed he was not informed by the Management Service that staff #10 was intubating patients in the offsite ER. The CEO revealed it is the facility's practice that RNs do not intubate patients.



B. An interview with the Regional Director (an employee of the contracted Management Service Company) on 02/3/17 revealed physician #14 was no longer seeing patient at the off campus ER. The Regional Director revealed there had been complaints from the ER staff that physician #14 was acting as if the physician may have been under the influence of drugs/alcohol while caring for patients. The contracted physician staffing agency was asked not to schedule physician #14 at the off campus ER. The Regional Director was asked if physician #14 was tested for drugs. The Regional Director replied "No, we just asked that the physician not be scheduled at the facility".


An interview with physician #6 revealed accusations had been reported that physician #14 was acting strangely by ER staff who were working with the physician. Physician #14 was recorded by ER staff and sent to physician #6 for review. Physician #6 revealed the video showed nothing out of the ordinary that would suggest physician #14 was under the influence of drugs and/or alcohol. Physician #6 revealed parking lot camera footage was reviewed that showed physician #14 had parked the car at an angle blocking more than one parking space but not conclusive the physician was under the influence. Physician #6 revealed the finding were reported to the Vice President (VP) of the contracted Management Service. Physician #6 was asked if the finding were reported to Medical Staff and the reply was, No. Physician #6 revealed any problems or concerns at the off campus ER were reported to the Vice President (VP) of the contracted Management Service.


An interview on 2/3/2017 with the CNO confirmed he was not informed by the Management Service that the ER nursing staff had concerns a physician was caring for patients while possibly under the influence of drugs and/or alcohol.


An interview on 2/7/2017 with the CEO confirmed he was not informed by the Management Service that a physician was caring for patients while possibly under the influence of drugs and/or alcohol.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on document review and interview, the facility failed to ensure that the chief Nursing Officer (CNO) provided effective administrative supervision to the off campus emergency room 's (ER) nursing staff. The emergency room (ER) nursing staff reported to the Regional Director (an employee of the contracted Management Service Company). The Regional Director (an employee of the contracted Management Service Company) reported to the VP of the Management Service Company. The CEO and the CNO of the hospital were unable to provide evidence of a direct line of administrative authority to and from the Management Service Company. The lack of administrative authority and supervision placed patients at the likelihood of harm when the contracted management service allowed a nurse to intubate patients.

Refer to tag A0386
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on document review and interview, the facility failed to ensure that the chief Nursing Officer (CNO) provided effective administrative supervision to the off campus emergency room 's (ER) nursing staff. The emergency room (ER) nursing staff reported to the Regional Director (an employee of the contracted Management Service Company). The Regional Director (an employee of the contracted Management Service Company) reported to the VP of the Management Service Company. The CEO and the CNO was unable to provide evidence of a direct line of administrative authority to and from the Management Service Company.



A review of an email dated 1/13/2017 from staff #4 to staff #1 revealed the following: "I spoke with XXX (staff #10) this morning over the concerns of nursing intubation. A year ago, XXX (staff #10) was approached by Air One about a PRN opportunity. At the time, XXX (staff #10) did not meet the minimum hiring criteria because he was lacking an EMT certification. In May of 2016, he obtained his EMT. In the fall of 2016, XXX(staff #10) completed the interviewing process and began the hiring process with Air One. At that time, he worked with XXX (Physicians #6, #8 and #15) and voiced his opportunity with Air One. He asked if they could work with him to teach the intubation process. XXX(Staff #10) has never intubated independently without an ED physician at bedside overseeing. Part of Air One's clinical experience training is for their flight nurses to complete 10 intubation in a clinical environment with a physician or anesthesiologist at side. I hope this addresses the concerns related to XXX (staff #10)".


A review of an email dated 1/13/2017 from staff #1 to the VP of the Management Service revealed this statement: "This addresses XXX (physician #14) accusation toward XXX (staff #10) intubating patients".


A review of an email dated 1/13/2017 from the VP of the Management Service to staff #1 revealed this response: "Makes perfect sense".


An interview on 2/3/2017 with the CNO confirmed he was not informed by the Management Service that staff #10 was intubating patients in the offsite ER. The CNO revealed it is the facility's practice that RNs do not intubate patients. The CNO denied having knowledge of an educational arrangement with staff #10 and Air One. The CNO denied having knowledge of an educational arrangement with physicians #6, #8 and #15 that would allow staff #10 to intubate patients.




Based on interviews and document review it was determined that the deficient practices found posed an Immediate Jeopardy to the health and safety of patients that caused harm, likelihood of harm, serious injury, and/or death.