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 | April 5, 2017 |
| VIOLATION: CHIEF EXECUTIVE OFFICER | Tag No: A0057 | |
| Based on document review and interview the Chief Executive Officer (CEO) failed to carry out the responsibilities for assuring that the Hospital is in conformity with the requirements of planning, regulatory and inspecting agencies; reviewing, advising, and acting promptly upon the reports of such agencies. The CEO failed to provide the Medical Staff with the 01/31/2017 survey findings affecting patient care. The report was withheld from the Medical Staff. The Medical Staff was unable to review and evaluate activities to assess, preserve and improve the overall quality and efficiency of patient care in the Hospital. The Medical Staff did not make recommendations to the Board. The Board was not able to consider the recommendations of the Medical Staff and the other health care professionals providing patient care services. As a result the Board was unable to consider Medical Staff's recommendations. The Board did not receive the required findings and recommendations in writing, signed by the persons responsible for conducting the review activities, and supported and accompanied by documentation upon which the Board can take informed action. A review of the document titled Medical Executive Committee Minutes and dated March 22. 2017 revealed starting on page 2 of 5, the Agenda Topic: Outside Audits/Surveys, Discussion: Discussed the final report from State survey. Corrections being addressed. Recommendation/Action: Blank no documentation, Follow-up: Blank no documentation. A review of the document titled Board of Trustees dated February 7, 2017 revealed Agenda Topic: Outside Audits/Surveys, Discussion: We had state surveyor here January 23rd-26th. They were here for a return visit from a patient complaint that originated back in November ... We will continue to wait on final reports and get action plans started. Recommendation/Action: None, Follow-up: Blank no documentation. A review of the document titled Board of Trustee Bylaws revealed on page 2, Definition 4, "Chief Executive Officer" or "CEO" means the individual appointed by the Corporation to provide for the overall management of the Hospital. Article VI Chief Executive Officer 5.1, Appointment of the Chief Executive Officer. The CEO shall be selected and employed by Corporation, after consultation with the Board, and shall be its direct executive representative in the management of the Hospital. The CEO shall have authority, and be held responsible for administering the Hospital in all of its activities, subject only to such policies as may be adopted and such orders as may be issued by Corporation. He/She shall act as the authorized representative of the Board and Corporation... 5.3 Chief Executive Officer's Responsibility The authority and duties of the CEO shall include responsibility for the following: 5.3(i) Cooperating with the Medical Staff and others concerned with the rendering of professional services, to the end that optimal achievable care may be rendered to patients, and identifying the proper mix of programs and services of the Hospital; 5.3(m) Being responsible for assuring that the Hospital is in conformity with the requirements of planning, regulatory and inspecting agencies; reviewing, advising, and acting promptly upon the reports of such agencies; Article VIII Medical Care Evaluations 7.1 Board Responsibility for the Quality of Professional Services After considering the recommendations of the Medical Staff and the other health care professionals providing patient care services, the Board shall implement specific review and evaluation activities to assess, preserve and improve the overall quality and efficiency of patient care in the Hospital. The Board, through the CEO, shall provide whatever administrative assistance is reasonably necessary to support and facilitate activities contributing to continuous quality assessment and improvement. 7.3 Professional Accountability to the Board The Medical Staff and the other health care professional staffs providing patient care services shall conduct, and be accountable to the Board for conducting activities that contribute to the preservation and improvement of the quality and efficiency of patient care provided in the Hospital. These activities shall include these functions; 7.3(b) On-going review, evaluation and monitoring of patient care practices through a systematic process of overall quality assessment and improvement; 7.3(g) Review the competency of care providers who are not subject to the Medical Staff privilege delineation process; and reporting to the governing body of findings with regards to such care providers; 7.3(i) Such other measures as the Board may, after receiving and considering the advice of the Medical Staff, the other professional services, and the CEO, deem necessary for the preservation and improvement of the quality and efficiency of patient care. 7.4 Documentation The Board shall consider and act upon the findings and recommendations from the required review, evaluation, and monitoring activities. All findings and recommendations shall be in writing, signed by the persons responsible for conducting the review activities, and supported and accompanied by documentation upon which the Board can take informed action. An interview on 04/05/2017 in the CEO's office, in the presence of the CEO and the Chairman of the Governing Board, the Chief of Staff confirmed the Medical Staff was not provided a copy of the survey results for the 01/31/2017 survey. The Chief of Staff confirmed the details of the report were not conveyed by the CEO. An interview on 04/05/2017 in the CEO's office, in the presence of the CEO and the Chairman of the Governing Board, the Chief of Staff confirmed the Medical Staff and the Board had no interactions and/or discussions regarding the 01/31/2017 survey. The Chief of Staff and the Chairman of the Governing Board confirmed the results of the 01/31/2017 survey had only been made available to them on 04/04/2017. The Chief of Staff and the Chairman of the Governing Board confirmed the Medical Staff and The Board of Trustees did not participate or review the Plan of Correction that was submitted to the State on Friday, March 03, 2017 12:43 PM. An interview on 04/05/2017 in the CEO's office, in the presence of the CEO, with the Chairman of the Governing Board confirmed during the meeting on 2/7/2017 the Board was notified the State had been in the facility. No State report was available and no action was taken by the board. The Chairman of the Governing Board confirmed there was not another meeting of the Governing Board until 04/04/2017. The Governing Board was provided a copy of the State findings and the Plan of Correction (POC) on 04/03/2017, a day before meeting. |
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| VIOLATION: EXECUTIVE RESPONSIBILITIES | Tag No: A0309 | |
| Based on document review the governing body, medical staff and administrative officials failed to ensure an effective Quality Program. The administrative officials: A. did not provide quality oversite and monitoring of blood product being administered to patients. B. allowed an unapproved policy (Medication Administration Guidelines) to be implemented facility wide. A. A follow up survey for a previous survey conducted on 01/31/2017 revealed the emergency room director will monitor 100% of blood transfusions in that department and the medical-surgical director will monitor 100% of the blood transfusion in that department. A review of the document titled Quality and Patient Safety Council dated March 23, 2017 revealed no evidence of the monitoring of blood transfusions or discussion of the plan to monitor blood transfusions. B. Review of the facility policy titled "Medication Administration Guidelines" revealed a revision date of 03/2017. A review of the document titled Medical Executive Committee Minutes and dated March 22. 2017 revealed no evidence the policy titled Medication Administration Guidelines was approved. An interview on 4/5/2017 with staff #9, 10, and staff #11confimed the policy titled "Medication Administration Guidelines" with the revision date of 3/2017 had been implemented through out the facility. An interview on 4/5/2017 with staff #9 revealed the policy had not been to Medical Staff for approval. Staff #9 confirmed the policy required Medical Staff approval before it could be implemented. |
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| VIOLATION: PATIENT RIGHTS: GRIEVANCES | Tag No: A0118 | |
| Based on interview and record review, the facility failed to ensure a thorough review and prompt resolution of patient grievances concerning care and treatment in 1 of 24 sampled patients (Patient #2). This deficient practice had the likelihood to cause harm in all patients. Findings include: Review of the facility's complaint/grievance "Tracking Log" revealed a complaint was received about Patient #2 on 01/17/2017 about quality of care. Review of the complaint form dated 01/17/2017 revealed complaints about the staff being "rude and unprofessional. They were more interested in playing around instead of caring for the patients." According to the complaint Patient #2 was discharged home and "He was still in a lot of pain and could not move his arms, only a little movement at the fingertips." Patient #2 followed up with his primary physician and was sent to another hospital. Patient #2"s findings were "both shoulder were fractured." Review of the facility's response letter dated 01/24/2017 revealed a statement that the medical director had investigated the matter thoroughly. The following was also documented " ....The nursing issues have been dealt with by the director of the emergency department. We do unfortunately have to limit the amount of visitors to no more than two per patient. It makes it hard to care for patients when they are too many people in the room, and we must also be considerate of out other patients ..... I have reviewed all of the x-ray reports from both visits and our findings were negative for any fracture or dislocation of either shoulder ..." During an interview on 04/04/2017 after 10:00 a.m., Staff #2 (Emergency Director) confirmed receipt of the complaint and that she was in charge of investigating the nursing portion of the complaint and the allegation of staff being rude. Staff #2 reported she had not talked to the nursing staff about the allegation. There was no other documentation about the investigation. When asked what the final results were about the nursing portion of the complaint. Staff #2 talked about limiting the amount of family going back into the rooms and negative results of the x-rays. Staff #2 offered no additional information on the lack of nursing assessment of the level of pain on discharge. By not addressing all of the nursing part of the grievance, there still was no resolution. During an interview on 04/04/2017 after 2:40 p.m., Staff #27 confirmed she took care of Patient #2 and spent the most time with him and the family. Staff #27 confirmed she was not asked anything about Patient #2's care by anyone. Staff #27 confirmed she had failed to document an assessment of Patient #2's pain level. Review of a facility's policy named "Patient Complaints/Grievances" approved 01/2016 revealed the following: a. Any grievance that places the patient in immediate jeopardy endangers the patient or has the potential for patient harm shall be investigated immediately. b. The target for completion of investigation of all other grievances shall be seven (7) working days of receipt of the grievance. |
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| VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION | Tag No: A0133 | |
| Based on observation, interview and document review the facility failed to establish a process that provided and insured patients were given an oportunity to provide informed consent upon admission to the facility for 1 (labor and Delivery) of 5 (Nursing, Outpatient Surgery, Medical Surgical, and Emergency) departments reviewed. This deficient practice had the likelihood to effect all patients of the hospital. Findings included: On the morning of 4/4/2017 an interview with the Director of the Health Information's Management Department confirmed the Labor and Delivery department of women's services had been identified as not consistently providing an oportunity for informed consent to women admitted to the unit. Over the month of March 2017, 17 patients who were treated in the L&D unit failed to receive informed consent upon admission. On the morning of 4/4/2017, in the conference room an interview with staff #2, the Emergency Department (ED) Director confirmed all patient's (Pt/pt) who came through the ED for direct admission to the Labor and Delivery (L&D) unit were given oportunity to provide informed consent for admission and treatment signed in the ED, prior to transfer to the L&D unit. On the morning of 4/4/2017 an interview with L&D staff Registered Nurse (RN) #6 indicated, "They (the nurses) did not do the admission paper work and admission consent. They called an admission clerk who would come to the unit and complete the consent and admission process with the patient". On the morning of 4/4/2017 in the office of the Admission Coordinator, an interview with the Director, staff #3 confirmed "no admission staff went to the Labor and Delivery unit to complete patient admission information or provide oportunity for informed consent". She further explained that all pt's, who were preadmitted by a physician's order, would be completely registered by the admission department prior to their arrival to the L&D unit. All information obtained during that process was scanned into the electronic medical record system. However, any patient who might walk into the hospital (after hours or by-pass the ED) could walk directly to the L&D unit. They could be admitted with a telephone order from their physician, without being preadmitted or the admissions department being aware of it. On the morning of 4/4/2017, in the L&D unit, interview with staff RN #5 revealed the process for admission and consent for a newly admitted patient to the Labor and Delivery unit. Staff #5 accessed the computer data base and printed a consent to admit and treat with patient #12's name printed on the form. The form was not signed by the patient. Staff #5 then explained she printed the form to show they had access to the form. Staff #5 confirmed the L&D unit used a paper medical record. When asked to review patient #12's medical record there was no consent to admit or treat found in the paper medical record. Staff #5 was asked, "Wouldn't completion of the consent to admit and treat be the responsibility of the admitting nurse"? Staff #5 replied "Well, I suppose". She then recalled that pt #12 had been pre-registered and they would have already obtained the consent. However, staff #5 could not verify that an informed consent had been obtained for pt #12. On 4/4/2017 in the late morning an interview with the Admission Coordinator, staff #3, indicated the nurses had received admission packets from their unit supervisor. Staff #3 indicated the L&D unit supervisor had inserviced her staff on the use of the admission packets. The L&D unit supervisor, staff #4 was working nights to fill in for a vacancy and was not present for interview. On 4/4/2017 in the afternoon, an interview with staff #9, the Quality Manager, confirmed she had not received any education from the L&D unit supervisor on the use of admission packets for her staff or department. She could not confirm education had in fact occurred. On 4/5/2017 in the conference room the policies for the facility revealed there was no policy found that included "Informed Consent" upon admission as a part of the required chart content. On the afternoon of 4/4/2017 in the conference room a review of the Medical Record Quality data indicated on2/21/2017 and again on 3/28/2017 "Informed consent obtained: Consent for procedure-not informed consent" the facility was aware through it's Quality program that for 60 days the L&D Department was not consistently obtaining informed consent upon admission. |
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| VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES | Tag No: A0283 | |
| Based on document review and interview the facility failed to take action on data collected for 60 days (February and March 2017) which indicated the Labor and Delivery unit failed to provide opportunity for informed consent upon admission, for patients who failed to pre-admit or did not admit through the Emergency Department. This deficient practice had the likelihood to effect all obstetrical patients of the hospital. Findings included: On the morning of 4/4/2017 an interview with the Director of the Health Information's Management Department confirmed the Labor and Delivery (L&D) department of women's services had been identified as not consistently providing opportunity for informed consent to women admitted to the unit. Over the month of March 2017, 17 patients who were treated in the L&D unit failed to receive opportunity to provide informed consent upon admission. On the afternoon of 4/4/2017 in the conference room a review of the Medical Record Quality data indicated on 2/21/2017 and again on 3/28/2017 seen at the following heading, "Informed consent obtained: Consent for procedure-not informed consent". The facility was aware through it's Quality program that for 60 days the L&D Department was not consistently providing opportunity for informed consent from patients upon admission. On 4/4/2017 in the afternoon, an interview with staff #9, the Quality Manager, confirmed she had not received any staff education from the L&D unit supervisor or any other documentation of corrective action taken within the Labor and delivery unit to insure women who came into the unit for delivery of their child would be provided opportunity to provide informed consent prior to delivery of their baby. On the afternoon of 4/5/2017 a review of data collected and documented in the Quality program review, confirmed, that the Director of Quality was aware provision of opportunity to provide informed consent upon admission in the L&D unit was not being consistently obtained. A review of documentation to correct the lack of informed consent upon admission was found to be a verbal coaching submitted on the L&D Department manager for February and March. No other corrective action was identified or referenced in the Quality meeting minutes. There was no evidence of investigation or problem solving into why the consents were not being obtained. On 4/5/2017 in the conference room the policies for the facility revealed there was no policy found that included "Informed Consent" upon admission as a part of the required chart content. |
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| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a registered nurse provided continual supervision and evaluation of the nursing care of a patient presenting to Emergency department with severe pain in 1 of 24 sampled patients (Patient #2) This deficient practice had the likelihood to cause harm in all patients. Findings include: Review of emergency room notes revealed Patient #2 (MDS) dated [DATE] at 11:58 p.m. with complaints of bilateral should pain. Patient #2 was given an acuity level of 2 (Emergent). This assessment was performed by a registered nurse. The last documentation in the chart by the registered nurse was at 12:01 a.m. On 01/07/2017 at 1:02 a.m, Staff #27 (licensed vocational nurse) documented that Patient #2 complained of pain in the left scapular and right scapular. At worst, pain level was 10 out of 10 on a pain scale. Patient #2 was given some of the following medications by Staff #27 (licensed vocational nurse): At 12:47 a.m., the anesthetic Viscous gel; At 2:06 a.m., the anti- inflammatory agent Ibuprofen and the muscle relaxant Flexeril; And at 3:53 a.m. the pain/ nonsteroidal anti-inflammatory agent Toradol. Staff #27 documented that there was no adverse reaction for a response after the first three medication administration. On the last medication administration there was documentation that the pain was decreased. There was no documentation of how much. Patient #2 was discharged at 4:17 a.m. by Staff #27. There was no documentation of an assessment of the pain level in the shoulders. Review of another hospital's records dated 01/14/2017 (7 days later) revealed Patient #2 presented with complaints of pain in the shoulders. Patient #2 was admitted after more test determined he had bilateral shoulder fracture-dislocations. During an interview on 04/04/2017 after 2:40 p.m., Staff #27 confirmed she took care of Patient #2 and spent the most time with him and the family. Staff #27 confirmed she had not been asked about Patient #2's care by anyone. Staff #27 confirmed she had failed to document an assessment of Patient #2's pain level. |
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| VIOLATION: PATIENT RIGHTS: GRIEVANCES | Tag No: A0118 | |
| Based on interview and record review, the facility failed to ensure a thorough review and prompt resolution of patient grievances concerning care and treatment in 1 of 24 sampled patients (Patient #2). This deficient practice had the likelihood to cause harm in all patients. Findings include: Review of the facility's complaint/grievance "Tracking Log" revealed a complaint was received about Patient #2 on 01/17/2017 about quality of care. Review of the complaint form dated 01/17/2017 revealed complaints about the staff being "rude and unprofessional. They were more interested in playing around instead of caring for the patients." According to the complaint Patient #2 was discharged home and "He was still in a lot of pain and could not move his arms, only a little movement at the fingertips." Patient #2 followed up with his primary physician and was sent to another hospital. Patient #2"s findings were "both shoulder were fractured." Review of the facility's response letter dated 01/24/2017 revealed a statement that the medical director had investigated the matter thoroughly. The following was also documented " ....The nursing issues have been dealt with by the director of the emergency department. We do unfortunately have to limit the amount of visitors to no more than two per patient. It makes it hard to care for patients when they are too many people in the room, and we must also be considerate of out other patients ..... I have reviewed all of the x-ray reports from both visits and our findings were negative for any fracture or dislocation of either shoulder ..." During an interview on 04/04/2017 after 10:00 a.m., Staff #2 (Emergency Director) confirmed receipt of the complaint and that she was in charge of investigating the nursing portion of the complaint and the allegation of staff being rude. Staff #2 reported she had not talked to the nursing staff about the allegation. There was no other documentation about the investigation. When asked what the final results were about the nursing portion of the complaint. Staff #2 talked about limiting the amount of family going back into the rooms and negative results of the x-rays. Staff #2 offered no additional information on the lack of nursing assessment of the level of pain on discharge. By not addressing all of the nursing part of the grievance, there still was no resolution. During an interview on 04/04/2017 after 2:40 p.m., Staff #27 confirmed she took care of Patient #2 and spent the most time with him and the family. Staff #27 confirmed she was not asked anything about Patient #2's care by anyone. Staff #27 confirmed she had failed to document an assessment of Patient #2's pain level. Review of a facility's policy named "Patient Complaints/Grievances" approved 01/2016 revealed the following: a. Any grievance that places the patient in immediate jeopardy endangers the patient or has the potential for patient harm shall be investigated immediately. b. The target for completion of investigation of all other grievances shall be seven (7) working days of receipt of the grievance. |
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