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.

WOODLAND HEIGHTS MEDICAL CENTER 505 SOUTH JOHN REDDITT DRIVE LUFKIN, TX 75904 Sept. 22, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, review of records and interview, the hospital failed to provide complete and correct information to patients or patient representatives of their rights (including State required notices) prior to admission, at time of admission and prior to discharge as follows:

A. An Important Message From Medicare About Your Rights for 3 patients (Patient #s 31, 33, and 34) of 4 patients (Patient #s 31, 32, 33, and 34) was not delivered at admission and/or discharge. The facility failed to follow its own policy.

B. State required posting to notify patients or patient representatives of the statement of duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language with their right to contact the appropriate complaint line number was not posted at 3 of 3 entrances/waiting areas (Entrance/Main Lobby Gaslight Boulevard, Entrance/Lobby Loop 287, and Ambulance Entrance/emergency room Waiting)

C. Provided the incorrect phone number to all patients for making a Health Facility Complaint at time of admission, creating a barrier to patients from exercising their right to make a complaint.

Findings include:

A. Four patient charts (Patient #s 31, 32, 33, and 34) were selected from the Complaints and Grievances Log to be reviewed. Three of the patients (Patient #s 31, 33, and 34) did not receive proper notification.

Patient #31 was admitted on [DATE]. The patient was discharged to hospice on 8-12-2016. Review of records showed that the form, An Important Message From Medicare About Your Rights (IM) had notation in the "Signature of Patient or Representative" block "pt cannot sign". This was dated and time 8/11/16 1017 (10:17 A.M.). There was no signature of the person delivering the IM or explanation of why the patient could not sign. The chart did not contain documentation of follow-up action with a patient representative or the patient to provide them with the patient rights information. A second delivery of the IM was not necessary.

Patient #33 was admitted on [DATE]. The patient was discharged to home with home health on 8-29-2016. Review of records showed that the IM form had a patient representative's signature in the "Signature of Patient or Representative" block. It was not dated or timed. There was no IM form found in the chart with signature, date, or time of the second delivery of the IM prior to discharge.

Patient #34 was admitted on [DATE]. The patient left the hospital against medical advice on 6-19-2016. Review of the records showed that the IM form had a patient representative's signature in the "Signature of Patient or Representative" block. It was dated and timed "6 13 1900" (7:00 P.M.) There was no IM form with a signature, date, or time from the patient to show he had received a second delivery at time of discharge when he signed himself out of the hospital against medical advice.

Review of Community Health Systems Professional Services Corporation Policy Title: Important Message from Medicare Policy was completed. "Section II. Procedure" stated the following:

"Registration personnel are responsible for the following:

A. Delivery of the Important Message from Medicare (IM) at or near admission, but no later than 2 calendar days following the date of admission.

B. If the Medicare patient is admitted and/or transferred to a Distinct Part Unit within the hospital (e.g., Rehab or Psych unit), the IM specific to that Unit, which includes the DPU's Medicare provider number, should be delivered to the patient instead of the acute care IM.

C. When the IM is issued, obtain the signature of the patient or his/her representative on the IM to indicate that he/she received and understood the notice. This includes explaining the notice to the patient if necessary and providing an opportunity to ask questions ...

G. Regardless of the competency of a patient, if it is not possible to personally deliver a notice (initial IM or follow-up IM) to a representative, the attempts should be made to contact the representative by telephone to advise him or her of the patient's rights as a hospital patient, including the right to appeal a discharge decision ...

J. Place a dated copy of the notice in the patient's medical file, and document the telephone contact with the patient's representative (as in #8 above) on either the notice itself, or in a separate entry in the patient's fil or attachment to the notice...

L. If the patient refuses to sign the IM, indicate in writing on the IM the refusal. The date of refusal is considered the date of receipt of notice.

M. It is the ultimate responsibility of Registration personnel to ensure the initial IM is delivered to appropriate patients and/or their representatives, appropriate signature(s) is obtained, the original IM is given to the patient or his/her representative, and a signed and dated copy of the IM is placed in the medical record. A tracking system should be developed whereby there is certainty that the IM is delivered, as per Policy.

III. Delivery of the Follow-up IM Prior to Discharge
The Case Manager is responsible for the delivery and obtaining the patient's or the patient's representative's signature on the follow-up IM prior to discharge. When the CM is not available, the nurse manager, charge nurse or nurse assigned to patient is responsible for this process.

A. Provide the patient or his/her representative a new IM within 2 calendar days of the day of discharge. Obtain the patient's or patient's representative's signature and date on the new IM. Give the patient or the patient's representative the second signed and dated IM and place a copy of the second IM in the medical record."

Interview was conducted with Staff #51 on 9-21-2016. Staff #51 confirmed that it was the Case Management Department's responsibility along with nursing to ensure the second delivery of the IM. Staff #51 was unable to find the second delivery of the IM for Patient #33 and Patient #34.

Interview was conducted with Staff #54 on 9-22-2016. Staff #54 confirmed that registration staff was responsible for the initial delivery of the IM. Staff #54 stated the errors on the initial delivery of the IM on Patient #s 31, 33, and 34 had all been processed by the same person. Staff #54 stated the staff member that had made the mistakes was new and was to be re-educated on the process.

B. Tour of the facility was conducted on 9-19-2016 with Staff #7. State required posting to notify patients or patient representatives of the statement of duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language with their right to contact the appropriate complaint line number was not posted at 3 of 3 entrances/waiting areas (Entrance/Main Lobby Gaslight Boulevard, Entrance/Lobby Loop 287, and Ambulance Entrance/emergency room Waiting). Staff #7 confirmed that the postings were missing.

C. Review of Patient Admission Forms was conducted. The "Patient Rights and Responsibilities ADM-1901 GHMS-TX" on page 2 of 2 stated:

"You also have the right to:

Lodge a concern with the state, whether you have used the hospital's grievance process or not. If you have concerns regarding the quality of your care, coverage decisions or want to appeal a premature discharge, contact the State Quality Improvement Organization (QIO) ....

If you have a Medicare complaint you may contact

Texas Department of State Health Services

Phone: (512) 834-6700"

Review of the Patient Guide, given to patients upon admission, contained the following information on page 24:
"Regarding Problem Resolution, You Have the Right To:

Express your concerns about patient care and safety to hospital personnel and/or management without being subject to coercion, discrimination, reprisal or unreasonable interruption of care; and to be informed of the resolution process for your concerns. If your concerns and questions cannot be resolved at this level, contact the accrediting agencies indicated below:"

This also lists the phone number for the Texas Department of State Health Services as (512) 834-6700.

An attempt to call the number provider was made with Staff #3 present. The phone number provided was for the Emergency Medical Services (EMS) group. There was an automated response that provided different options to contact various EMS related services. The only option for filing a complaint was for EMS services and not hospital provided care. Staff #3 confirmed this.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on record review and interviews nursing failed to provide a clear staffing plan or grid to ensure safe nurse to patient ratio in 6 ( Medical/ Surgical, Medical/ Telemetry, Intensive Care Unit, Emergency Department, Nursery, and Obstetrics) out of 6 patient units.
Review of the nurse staffing revealed the facility uses a staffing grid with budgeted full-time equivalents (FTE) and Manhours/Stat. The grid only refers to FTE's and does not distinguish between licensed and unlicensed staff. There is no clarification of RN's and LVN's. Due to the staffing based on FTE's and not nurse/patient ratio it was unclear if staffing was adequate to meet patient care needs.
An interview was conducted with staff #37 and staff #3 on 9/22/16. Staff #37 reported that the staffing is done to the budget grid of FTE's. Review of the staffing grid revealed there was three shifts 7:00AM-3:00PM, 3:00PM-11:00PM, and 11:00PM-7:00AM. Staff #3 reported that they don't have three shifts. Staff #3 stated they have 2- 12 hour shifts 7:00AM-7:00PM and 7:00PM-7:00AM. The grid had not been updated to the 2-12 hour shifts. Staff #3 stated that have been on 2-12 hour shifts for several years now. Staff #37 was asked how she knows the staffing is at a safe level for nurse/pt. ratio, patient acuity, anticipated discharges, and admissions. Staff #37 stated, "I just know." Staff #37 was asked again where she got that information or was it just a guess. Staff #37 stated,"Well, I'm not sure, I just know. I guess you could say it looks like a guess but we just know."

Review of the policy and procedure "Plan for Patient Care: Telemetry Unit Staffing Plan" stated, "Budgeted Man Hours/Stat 10.23
2. Staffing is accomplished through coordinated scheduling by Nurse Manager with input from staff and charge nurses. Staffing may be adjusted by the house supervisor form staff input based on the patient care requirements and census."

Review of the policy and procedure "Plan for Patient Care: Women's Services" stated, "Staffing Plan: 1.) Standard 6.95 man hours/stat
2.) Shift Distribution: 7 a.m-7p.m 50%, 7p.m-7a.m 50% "

Review of the policy and procedure "Plan for Patient Care: Emergency Department" stated, "Staffing is planned to provide for an average daily census of 64 patients per day with 19.97 FTE's."

An interview with staff #34 on 9/21/16 revealed the ICU patient nurse ratio was usually 1 RN to two patients and on occasion 1 RN for three patients. Staff #34 stated, "If it looks like the acuity is changing on my patients or I'm getting a fresh heart patient, and I need more help, I just get on the phone and start calling people in." Staff #34 reported that he has been given the ability to adjust his schedule. Staff #34 stated they schedule to the FTE's but he just "knows" how many he will need.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on review of documents and interview, the director of nursing service failed to ensure non-employee licensed nurses providing care in the emergency department to sexual assault victims were properly contracted, credentialed and supervised.

Review of the Sexual Assault Nurse Examination (SANE) program revealed that no hospital nursing staff were certified as SANE nurses.

Interview was conducted with Staff #44 revealed that SANE examinations were provided by nurses employed with an outside provider. Sometimes the nurses came to the emergency department to complete the examination. Sometimes the nurses requested the patient be sent to outside provider location.

Interview with Staff # 7 was conducted. Staff #7 stated there was not a contract with the outside provider for these services. Staff #7 stated that there were no policies concerning SANE exams since the hospital did not conduct the exam. Staff #7 stated there were no credentialing files on the nurses who came in to the hospital to examine the sexual assault patients.
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart review and interview nursing failed to follow policy and procedures to ensure blood and blood products were administered to the patients in a safe manner, in 3(#55, 22, and 19) out of 3 patient charts and 17 out of 20 transfusion records reviewed.

1.) Review of patient #55's chart revealed the following;
A.) blood was ordered on [DATE] at 2255 (10:55PM). Review of the transfusion record revealed the "Order Verified" box had not been checked. There was no evidence found on the transfusion form that the physician order was checked by the nurse.
B.) The transfusion form stated, "Transfusion MUST begin within 30 minutes of removal from Blood Bank"
The policy and procedure "Blood Component Transfusions" stated, "#6 Administration of blood or blood components should be initiated within 15 minutes after obtaining blood from the laboratory." The blood was picked up from the lab on 9/19/16 at 2255 (10:55PM), however, the blood was not started until 2315 (11:15PM) 20 minutes after received from the lab. According to the policy and procedure the blood administration was started 5 minutes late.

An interview with staff #7 on 9/22/16 revealed that all nursing procedures should follow the policy and procedures.

2.) Review of patient #22's chart revealed the patient had an order for a blood transfusion on 9/19/16. On the transfusion record in the vital signs section, the nurse marked over a previous time that was put down on the "one hour after start" time. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.

3.) Review of patient #19 revealed the following issues on the blood transfusion records:
C.) 9/8/16 at 1243 (12:43PM) and 9/18/16 at 1418 (2:18PM) the signatures of the person accepting the blood from the lab and both verifier signatures and disciplines (Registered Nurse RN or Licensed Vocational Nurse LVN) were illegible.
D.) 9/8/16 at 2224 (10:24PM) the nurse failed to initial, date, and time the "Transfusion Stopped:" section.
E.) 9/9/16 at 0616 (6:16AM) the 2nd verifiers signature and discipline was illegible.
F.) 9/10/16 at 0215 (2:15AM) the 2nd verifiers discipline was illegible. The nurse failed to date and time the "Transfusion Stopped:" section.
G.) 9/10/16 at 0100 (1:00AM) the initial pre-transfusion pulse was written over another number leaving the pulse number illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
H.) 9/10/16 at 1420 (2:20PM) On the transfusion record in the vital signs section, the nurse marked over a previous time that was put down on the "one hour after start" time.
I.) 9/10/16 at 1843 (6:43PM) the signatures of the person accepting the blood from the lab and both verifiers signatures and disciplines (RN or LVN) were illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
J.) 9/10/16 at 2301 (11:01PM) the blood was picked up from the lab on 9/10/16 at 2301 (11:01PM); the blood was not started until 2330 (11:30PM) 29 minutes after received from the lab. According to the policy and procedure the blood administration was started 14 minutes late. The 1st verifier signature and discipline was illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
K.) 9/11/16 at 2152 (9:52PM): the signatures of the person accepting the blood from the lab and 2nd verifier signature and discipline (RN or LVN) was illegible. The pre-transfusion vital sign time, 15 min after start and 1 hour after start times were marked over, leaving the times illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
L.) 9/11/16 at 2017 (8:17PM) the blood was picked up from the lab on 9/11/16 at 2017 (8:17PM). The blood was not started until 2040 (8:40PM), 19 minutes after it was received from the lab. According to the policy and procedure the blood administration was started 8 minutes late. The 1st verifier discipline was illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
M.) 9/12/16 at 2324 (11:24PM): discipline of the person accepting the blood from the lab and 2nd verifier discipline (RN or LVN) was illegible. The pre-transfusion vital sign time was marked over leaving the time illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
N.) 9/12/16 0842 (8:42AM): the nurse failed to have two signatures for verification of blood before transfusion. Only the second verifier was on the form. Administering blood products and failing to have two nurses verify the patient's name, medical record number, arm band, DOB, blood type, donor's number, and expiration dates and times could cause serious injury and possible death. The blood was received from the lab at 8:42 AM and not started till 9:00AM. The blood administration was 3 minutes late.
O.) 9/12/16 at 0316 (3:16AM): the 2nd verifier signature and discipline was illegible. There was no blood pressure documented on the pre transfusion section. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
P.) 9/13/16 at 0043 (12:43AM): The date the blood was picked up from the lab was marked over another date. The nurse failed to strike through the error, initial, and write the correct date. The 2nd verifier's signature and discipline was illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
Review of the policy and procedure " Changes to the Legal Health Record" stated, "Paper records- draw a single line through the error, initial date and time the entry."
Q). 9/19/16 at 1325 (1:25PM): the nurse failed to have two signatures for verification of blood before transfusion. Only the second verifier was on the form. Administering blood products and failing to have two nurses verify the patient's name, medical record number, arm band, DOB, blood type, donor's number, and expiration dates and times could cause serious injury and possible death. The blood was received from the lab at 8:42 AM and not started till 9:00AM. The blood administration was 3 minutes late.

Review of the policy and procedure "Blood Component Transfusions" stated, "Policy #5 All blood and blood products must be checked at patient's bedside by two nurses (one of which is an RN), CPP, or physician, also known as the transfusionist) before transfusing. Together they must check the patient's name, date of birth, hospital account number and/or medical record number, blood unit number, blood type, blood expiration date, individual key transfusion/BBID number, physician's original order, and patients arm band.
#6 Administration of blood or blood components should be initiated within 15 minutes after obtaining blood from the laboratory.
#8 Blood transfusions must be completed within 4 hours after it has been issued from the Blood Bank.
Procedure:
C. Check blood/blood component with a registered nurse at the bedside immediately prior to initiating the transfusion. Together they must check the patient's name, date of birth, medical record number, blood unit number, blood type, blood expiration date, key transfusion/BBID number on blood arm band, blood bad tag, and physician's original order. The blood bag tag attached to the unit with the patient's information, patient's blood type, compatibility results, and key transfusion/BBID number must remain attached to the unit and never removed outside of the blood bank. Both nurses must sign the transfusion form.
D. record vital signs and document on these on the transfusion requisition.
K. Stay with patient and monitor for signs of reaction for the first 15-30 minutes.
L. Monitor vital signs once the transfusing has begun, vital signs must be taken 15 minutes from the start time and recorded on the transfusion form in appropriate area.
P. Vital signs must be recorded in the post vital signs area of the transfusion requisition form taken 30 minutes to 1 hour post transfusion of the blood product.
T. Complete the data requested on the transfusion record and lab requisition."