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.

PALESTINE REGIONAL MEDICAL CENTER 2900 S LOOP 256 PALESTINE, TX 75801 Oct. 15, 2015
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview:
A. the Governing Body failed to enforce their Medical Staff Rules and Regulations for 1 (#16) of 1 physicians with medical staff privileges at the facility.
A review of Patient #1 medical record revealed no documented consult or progress note in the medical record.
A History and Physical was documented by Physician #17 as follows:
"This is going to be a short note. For complete details, please refer to the admitting history and physical that was dictated a few hours ago. Patient #1 is an [AGE]-year-old Caucasian gentleman with past medical history significant for myelodysplasti[DIAGNOSES REDACTED] and refractory anemia and [DIAGNOSES REDACTED] requiring weekly blood transfusions. He was in the day care surgery center for a blood transfusion at which time he was found to be bradycardic. EKG showed a 2:1 AV block. Cardiology was consulted. The patient was initially scheduled to be taken in for a permanent pacemaker placement; however, his platelet count was low in the 30's. I discussed the case with Physician #16. He suggested that we discharge the patient home today and follow up with him in the office on Monday. He will be admitted on Monday as a direct admit. Will receive his platelet transfusions and will go in for a permanent pacemaker placement the same evening. At the current time the patient is completely asymptomatic from his AV block. He has been cleared for discharge by cardiology. The patient has no unanswered questions or concerns."
Further review of the chart revealed an order was written on 7/2/2015 at 9:15 for Physician #16 to consult on the decreased heart rate. There was no consulting notes or progress notes in the chart from the cardiologist (Physician #16). The only signed document in the chart was an electrocardiogram where Physician #16 had interrupted the readings. Patient went home with an 8.8 Hemoglobin, 34 platelet count, Heart rate 42, and in 3rd degree heart block.
An interview with Staff #11 on 10/14/2015 at 3:30 PM confirmed she had observed Physician #16 in Patient #1's room and at the nursing station stating this patient was going for a pacemaker today. Staff #11 had received the critical lab valves on Patient #1 with the platelet count 34. Staff #11 had called Physician #17 and informed her about the pacemaker procedure and the low platelet count. Physician #17 then called Physician #16 and informed him of the low platelet count. After some time had gone by, Physician #16 was observed back in Patient#1's room and came out to the nursing station and told Staff #9 to tell Physician #17 to discharge Patient #1 and for him to come back on Monday for a pacemaker placement.
A review of the Patient's #1 medical record and interview with Staff #4 on 10/14/2015 at 11:30 AM confirmed the medical record had no consult notes or progress notes.
A review of the Patient's #1 medical record and interview with Staff #3 10/14/2015 at 2:30 PM confirmed the medical record had no consult notes or progress notes.
Staff #4 and Staff #3 signed a letter stating there were no type of notes from Physician #16 in the medical record.
A review of the letter revealed the following:
"At the request of DHSH Surveyors, we are confirming that we reviewed the medical record with them and were unable to locate a consultation note for Physician #16 within the EMR of Patient #1 despite a verbal statement from Physician #16 that a two page handwritten note was done."
A review of the record titled, "Medical Staff Rules & Regulations, Article III General Conduct of Care, and 3.11 Consultations revealed the following:
"Consultations in the ICU will be answered within six (6) hours of notification and twenty-four (24) hours in a non-ICU environment. "
Patient #1 was admitted on [DATE] and discharged on [DATE]. As of 10/14/2015 there are no consult or progress notes from the cardiologist (Physician #16). Patient expired at home less than 24 hours from discharged from the facility.
An interview with Staff #1 and Staff #13 revealed no action had taken place to resolve the complaint written by Staff # 9. Physician #16 had not written any consult or progress notes in the record and that no corrective action had been taken by the governing body to hold the Physician #16 accountable for the quality of care provided to the patient.

B. the facility's medical record department failed to obtain consult notes from the cardiologist (Physician #16) where an order was written for the physician to consult on Patient #1.
A review of Patient #1 medical record revealed no documented consult or progress note in the medical record.
A History and Physical was documented by Physician #17 as follows:
"This is going to be a short note. For complete details, please refer to the admitting history and physical that was dictated a few hours ago. Patient #1 is an [AGE]-year-old Caucasian gentleman with past medical history significant for myelodysplasti[DIAGNOSES REDACTED] and refractory anemia and [DIAGNOSES REDACTED] requiring weekly blood transfusions. He was in the day care surgery center for a blood transfusion at which time he was found to be bradycardic. EKG showed a 2:1 AV block. Cardiology was consulted. The patient was initially scheduled to be taken in for a permanent pacemaker placement; however, his platelet count was low in the 30s. I discussed the case with Physician #16. He suggested that we discharge the patient home today and follow up with him in the office on Monday. He will be admitted on Monday as a direct admit. Will receive his platelet transfusions and will go in for a permanent pacemaker placement the same evening. At the current time the patient is completely asymptomatic from his AV block. He has been cleared for discharge by cardiology. The patient has no unanswered questions or concerns. "
Further review of the chart revealed an order was written on 7/2/2015 at 9:15 for Physician #16 to consult on the decreased heart rate. There was no consulting notes or progress notes in the chart from the cardiologist (Physician #16). The only signed document in the chart was an electrocardiogram where Physician #16 had interrupted the readings. Patient went home with an 8.8 Hemoglobin, 34 platelet count, Heart rate 42, and in 3rd degree heart block.
An interview with Staff #11on 10/14/2015 at 3:30 PM confirmed she had observed Physician #16 in Patient #1's room and at the nursing station stating this patient was going for a pacemaker today. Staff #11 had received the critical lab valves on Patient #1 with the platelet count 34. Staff #11 had called Physician #17 and informed her about the pacemaker procedure and the low platelet count. Physician #17 then called Physician #16 and informed him of the low platelet count. After some time had gone by, Physician #16 was observed back in Patient#1's room and came out to the nursing station and told Staff #9 to tell Physician #17 to discharge Patient #1 and for him to come back on Monday for a pacemaker placement.
A review of the Patient's #1 medical record and interview with Staff #4 on 10/14/2015 at 11:30 AM confirmed the medical record had no consult notes or progress notes.
A review of the Patient's #1 medical record and interview with Staff #3 10/14/2015 at 2:30 PM confirmed the medical record had no consult notes or progress notes.
Patient #1 was admitted to the hospital as an observation patient on7/2/2015 and discharged on [DATE]. As of 10/14/2015 there are no consult or progress notes from the cardiologist (Physician #16). Patient expired at home less than 24 hours from discharged from the facility.
An interview with Staff #1 and Staff #13 confirmed no action had taken place to resolve the complaint written by Staff # 9. Physician #16 had not written any consult or progress notes in the record.

C. the facility failed to conduct and complete an incident report on 1 (#2) of 21 patients.

A review of Patient #2 medical record revealed it was written in history and physical that patient #2 was allergic to Zofran. The pre-anesthesia record completed by the anesthesiologist revealed Patient #2 was allergic to Zofran. The Certified Registered Nurse Anesthetist (CRNA) signed the pre anesthesia record under the column PACU which was right under the allergy column which stated she was allergic to Zofran. Further review of the record titled, "Anesthesia Record" it was written that the CRNA #18 administered Patient #2 Zofran 4 mg during her surgical case (Right Elbow Dislocation).
A review of the incident report logs revealed no incident filed in "RL Solutions" which is the computer process system used by the facility to file incident reports.

An interview with Staff #3 on 10/15/2015 at approximately 11:00 AM confirmed no incident report was in the system.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the Governing Body failed to enforce their Medical Staff Rules and Regulations for 1 (#16) of 1 physicians with medical staff privileges at the facility.
A review of Patient #1 medical record revealed no documented consult or progress note in the medical record.
A History and Physical was documented by Physician #17 as follows:
"This is going to be a short note. For complete details, please refer to the admitting history and physical that was dictated a few hours ago. Patient #1 is an [AGE]-year-old Caucasian gentleman with past medical history significant for myelodysplasti[DIAGNOSES REDACTED] and refractory anemia and [DIAGNOSES REDACTED] requiring weekly blood transfusions. He was in the day care surgery center for a blood transfusion at which time he was found to be bradycardic. EKG showed a 2:1 AV block. Cardiology was consulted. The patient was initially scheduled to be taken in for a permanent pacemaker placement; however, his platelet count was low in the 30's. I discussed the case with Physician #16. He suggested that we discharge the patient home today and follow up with him in the office on Monday. He will be admitted on Monday as a direct admit. Will receive his platelet transfusions and will go in for a permanent pacemaker placement the same evening. At the current time the patient is completely asymptomatic from his AV block. He has been cleared for discharge by cardiology. The patient has no unanswered questions or concerns."
Further review of the chart revealed an order was written on 7/2/2015 at 9:15 for Physician #16 to consult on the decreased heart rate. There was no consulting notes or progress notes in the chart from the cardiologist (Physician #16). The only signed document in the chart was an electrocardiogram where Physician #16 had interrupted the readings. Patient went home with an 8.8 Hemoglobin, 34 platelet count, Heart rate 42, and in 3rd degree heart block.
An interview with Staff #11 on 10/14/2015 at 3:30 PM confirmed she had observed Physician #16 in Patient #1's room and at the nursing station stating this patient was going for a pacemaker today. Staff #11 had received the critical lab valves on Patient #1 with the platelet count 34. Staff #11 had called Physician #17 and informed her about the pacemaker procedure and the low platelet count. Physician #17 then called Physician #16 and informed him of the low platelet count. After some time had gone by, Physician #16 was observed back in Patient#1's room and came out to the nursing station and told Staff #9 to tell Physician #17 to discharge Patient #1 and for him to come back on Monday for a pacemaker placement.

A review of the Patient's #1 medical record and interview with Staff #4 on 10/14/2015 at 11:30 AM confirmed the medical record had no consult notes or progress notes.
A review of the Patient's #1 medical record and interview with Staff #3 10/14/2015 at 2:30 PM confirmed the medical record had no consult notes or progress notes.
Staff #4 and Staff #3 signed a letter stating there were no type of notes from Physician #16 in the medical record.
A review of the letter revealed the following:
"At the request of DHSH Surveyors, we are confirming that we reviewed the medical record with them and were unable to locate a consultation note for Physician #16 within the EMR of Patient #1 despite a verbal statement from Physician #16 that a two page handwritten note was done."
A review of the record titled, "Medical Staff Rules & Regulations, Article III General Conduct of Care, and 3.11 Consultations revealed the following:
"Consultations in the ICU will be answered within six (6) hours of notification and twenty-four (24) hours in a non-ICU environment. "

Patient #1 was admitted on [DATE] and discharged on [DATE]. As of 10/14/2015 there are no consult or progress notes from the cardiologist (Physician #16). Patient expired at home less than 24 hours from discharged from the facility.
An interview with Staff #1 and Staff #13 revealed no action had taken place to resolve the complaint written by Staff # 9. Physician #16 had not written any consult or progress notes in the record and that no corrective action had been taken by the governing body to hold the Physician #16 accountable for the quality of care provided to the patient.
VIOLATION: CONTENT OF RECORD - CONSULTS Tag No: A0464
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility's medical record department failed to obtain consult notes from the cardiologist (Physician #16) where an order was written for the physician to consult on Patient #1.
A review of Patient #1 medical record revealed no documented consult or progress note in the medical record.
A History and Physical was documented by Physician #17 as follows:
"This is going to be a short note. For complete details, please refer to the admitting history and physical that was dictated a few hours ago. Patient #1 is an [AGE]-year-old Caucasian gentleman with past medical history significant for myelodysplasti[DIAGNOSES REDACTED] and refractory anemia and [DIAGNOSES REDACTED] requiring weekly blood transfusions. He was in the day care surgery center for a blood transfusion at which time he was found to be bradycardic. EKG showed a 2:1 AV block. Cardiology was consulted. The patient was initially scheduled to be taken in for a permanent pacemaker placement; however, his platelet count was low in the 30s. I discussed the case with Physician #16. He suggested that we discharge the patient home today and follow up with him in the office on Monday. He will be admitted on Monday as a direct admit. Will receive his platelet transfusions and will go in for a permanent pacemaker placement the same evening. At the current time the patient is completely asymptomatic from his AV block. He has been cleared for discharge by cardiology. The patient has no unanswered questions or concerns. "
Further review of the chart revealed an order was written on 7/2/2015 at 9:15 for Physician #16 to consult on the decreased heart rate. There was no consulting notes or progress notes in the chart from the cardiologist (Physician #16). The only signed document in the chart was an electrocardiogram where Physician #16 had interrupted the readings. Patient went home with an 8.8 Hemoglobin, 34 platelet count, Heart rate 42, and in 3rd degree heart block.
An interview with Staff #11on 10/14/2015 at 3:30 PM confirmed she had observed Physician #16 in Patient #1's room and at the nursing station stating this patient was going for a pacemaker today. Staff #11 had received the critical lab valves on Patient #1 with the platelet count 34. Staff #11 had called Physician #17 and informed her about the pacemaker procedure and the low platelet count. Physician #17 then called Physician #16 and informed him of the low platelet count. After some time had gone by, Physician #16 was observed back in Patient#1's room and came out to the nursing station and told Staff #9 to tell Physician #17 to discharge Patient #1 and for him to come back on Monday for a pacemaker placement.
A review of the Patient's #1 medical record and interview with Staff #4 on 10/14/2015 at 11:30 AM confirmed the medical record had no consult notes or progress notes.
A review of the Patient's #1 medical record and interview with Staff #3 10/14/2015 at 2:30 PM confirmed the medical record had no consult notes or progress notes.
Patient #1 was admitted to the hospital as an observation patient on7/2/2015 and discharged on [DATE]. As of 10/14/2015 there are no consult or progress notes from the cardiologist (Physician #16). Patient expired at home less than 24 hours from discharged from the facility.
An interview with Staff #1 and Staff #13 confirmed no action had taken place to resolve the complaint written by Staff # 9. Physician #16 had not written any consult or progress notes in the record.
VIOLATION: CONTENT OF RECORD: COMPLICATIONS Tag No: A0465
Based on record review and interview, the facility failed to conduct and complete an incident report on 1 (#2) of 21 patients.

A review of Patient #2 medical record revealed it was written in history and physical that patient #2 was allergic to Zofran. The pre-anesthesia record completed by the anesthesiologist revealed Patient #2 was allergic to Zofran. The Certified Registered Nurse Anesthetist (CRNA) signed the pre anesthesia record under the column PACU which was right under the allergy column which stated she was allergic to Zofran. Further review of the record titled, "Anesthesia Record" it was written that the CRNA #18 administered Patient #2 Zofran 4 mg during her surgical case (Right Elbow Dislocation).
A review of the incident report logs revealed no incident filed in "RL Solutions" which is the computer process system used by the facility to file incident reports.

An interview with Staff #3 on 10/15/2015 at approximately 11:00 AM confirmed no incident report was in the system.