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.

SHELBY REGIONAL MEDICAL CENTER 602 HURST STREET CENTER, TX March 31, 2011
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on record review and interview the facility failed to ensure that all medical records were complete citing 1 of 1 records reviewed.

Findings: Review of medical record for patient #1 on 3/30/2011 revealed that facility "Code Blue Data Sheet" documentation was not complete.
Section 4. Adequate Ventilation: no documentation found.
Section 6. Hear Rhythm: no documentation found.
Section 11. ABG's: no documentation found.
Section 13. Respiratory Therapist present and time of arrival: no documentation found.
Section 14. Length of resuscitation: no documentation found.
Section 15. Time resuscitation discontinued: no documentation found.
Section 16. Why is was discontinued: no documentation found.
Section 17. Who made this decision: no documentation found.
Physician Signature/Date: no documentation found.
Nurse Signature/Date: no documentation found.
Presumed cause of arrest(by physician): no documentation found.
Original date of form:8/99 Revised: 4/15/02

Also missing from medical record was "T-Sheet"( form used by physician for documentation based on patient complaint.) This form is used to document all care provided to the patient by the physician.

Interview with Staff #1 and Staff #3 on 3/31/2011 confirmed missing documentation on Code Blue Data Sheet and also confirmed that Staff #7 "T-sheet" could not be located by facility medical records and/or by staff #7 office staff.
VIOLATION: ORGANIZATION OF EMERGENCY SERVICES Tag No: A1102
Based on record review and interview the facility failed to ensure that Emergency Department Services were under the direction of a qualified member of the medical staff.

Findings: Review of organizational chart for Shelby Regional Medical Center on 3/31/2011 at 2:00 pm in the administrator office revealed no delineation for Emergency Department Medical Director on chart. The organizational chart was updated November 2010 per documentation on chart.

Interview with staff #1 on 3/30/2011 at 2:00 pm revealed she thought that Medical Director over the Emergency Department was the Chief of Staff for the hospital.
Interview with staff #3 on 3/30/2011 at 2:30 pm revealed that she thought staff #6 was Medical Director over the Emergency Department.
Interview with hospital Administrator on 3/31/2011 at 9:00 am revealed that they did not have a Medical Director over the Emergency Department. He would get staff #6 appointed as soon as possible. Advised administrator the Medical Director of the Emergency Department had to be a member of the medical staff and not just a Courtesy Staff member. Adminstrator confirmed they needed to appoint a member of the medical staff to be Medical Director over the Emergency Department.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on record review and interview the facility failed to ensure an ongoing and continuing assessment of the medical care provided in the emergency department. This practice has the potential for possible harm to all patients coming for care at this facility by not assuring the policies are current and revised based on ongoing monitoring by the medical staff and quality assurance activities.

Findings:
Review of Policy and Procedure manual for the emergency department on 3/31/2011 revealed it had not been reviewed and/or updated since 12/2009 by the Director of Nursing and hospital administrator.

Interview with current Director of Nurses on 3/31/2011 at 10:00 am that the current policies and procedures had not been updated or reviewed since 12/2009. Furthermore the policies needed to be updated to meet the needs of the current community population and change in injuries related to workforce changes in area. The area has seen a great increase in oilfield workers this past couple of years and this has the potential to bring in different types of injuries and illness'. Advised that since she took over as Director of Nurses in 11/2010 she has been in the process of updating and redoing the manual to update policies and procedures and also some of the forms used in the emergency department.
VIOLATION: QUALIFIED EMERGENCY SERVICES PERSONNEL Tag No: A1112
Based on record review and interview the facility failed to establish criteria to delineate the qualifications required for each category of emergency services staff(e.g. emergency physicians,specialist MD/DO and mid-level practitioners. The facility also failed to conduct periodic assessments of its emergency needs in order to anticipate the policies, procedures, staffing, training, and other resources that may be needed to address likely demands. This has the potential to provide an environment for possible patient harm by not having the properly trained staff to meet patients needs.

Findings: Medical Staff Bylaws Section E. ACLS/ATLS Certification: If a Practitioner fails to maintain Advanced Cardiac Life Support certification, the Practitioner's privileges to attend to cardiac patients shall automatically be suspended until such time as certification is achieved. If a Practitioner fails to maintain Advanced Trauma Life Support certification, the Practitioner's privileges to act as Emergency Department Physician shall be automatically suspended until such time as ATLS certification is achieved. Action automatically imposed under this Section does not entitle the Practitioner to hearing and appeal under these bylaws.
Review of the Medical Staff Rules and Regulations and Bylaws on 3/31/2011 revealed only one qualification documented for emergency room MD/DO and/or mid-level practitioners pertaining to experience and training.

Review of Personnel file for Staff #6 revealed ACLS Certification Part 1 expired May 22, 2010 and ACLS part 2 expired June 12, 2010. No documentation of ATLS found in personnel file.

Review of Personnel file for Staff #7 revealed no documentation of ATLS in personnel file.

Review of Personnel file for Staff #14 revealed no documentation of ATLS in personnel file.

Interview with staff #1 on 3/31/2011 at 9:00 am confirmed the Medical Staff Rules and Regulations/ Bylaws did not specify qualifications for the emergency room MD/DO and/or mid-level practitioners other than the bylaw concerning ACLS/ATLS certification. Also confirmed the personnel files for staff #6, #7, and #14 were missing documentation of completion ATLS and staff #6 had no documentation of current ACLS certification.