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 June 5, 2013
VIOLATION: MEDICAL STAFF CREDENTIALING Tag No: A0341
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews the Medical Staff Credentials Committee failed to recommend to the Governing body the appointments for staff privileges at the facility for 2 (#43, #45) of 4 (#42, #43, #45, #48) physicians (radiologists).
Review of the medical staff bylaws on June 5, 2013 titled, "Article VI Clinical Privileges, Section 3 Temporary Privileges, A. New Applicants Pending Medical Staff Review, New Applicants Pending Medical Staff Review" revealed:

"Temporary privileges for new applicants may be granted following submission of a complete
application and while awaiting review and approval by the medical executive committee upon
verification of all information required by these Bylaws. Such privileges may be granted for an
initial period of sixty (60) (approved by Governing Board 4/20/2005) days, and may be
renewed for one additional period (approved by the Governing Board 4/20/2005) of sixty (60)
days. At a minimum there must be verification of the following in order for an applicant to be
granted temporary privileges:
*current licensure
*relevant training or experience
*current competence
*ability to perform the privileges requested
*other criteria required by the Bylaws
*NPDB query and evaluation of information
*No current or previously successful challenge to licensure or registration
*No subjection to involuntary termination of medical staff membership at another organization
*No subjection to involuntary limitation, reduction, denial or loss of clinical privileges at another organization."

A review of Physician #43's file revealed that a completed application for medical staff privileges was submitted to the facility, however, pages 11 and 12 (the physician's signature pages) were missing and there was no date on the application. The physician's license expired on [DATE]. This physician read X-rays at the facility starting the week of 06/03/2013 and there was no evidence a current medical license was validated and that his record was reviewed by the Chief of the Medical Staff or Governing Body. The signature on the form titled, "Medical Staff Membership Approval," by Staff # 2 (Administrator) appeared to be a copy of a signature and not the original. The "from and to period" section on the form was incomplete for the temporary appointment and not dated. There was no evidence the Chief of the Medical Staff approved the temporary appointment as required by the bylaws.

A review of Physician #45's file revealed the physician application was signed and submitted on 05/05/2012. The file revealed Staff #2 (Administrator) gave the physician temporary appointment on 11/15/2012. There was no evidence the Chief of Staff reviewed the file and agreed with the temporary appointment as required by the bylaws.

Review of the radiology call schedule and interview with the Department Manager on 06/05/2013 at 2:00 p.m. confirmed Physicians #43 and #45 had read X-rays during the week starting 06/03/2013.
In an interview on 06/05/2013 at 2:30 p.m. with Staff #6 (Interim Nursing Director) she confirmed the facility had not corrected the previous deficiencies and the temporary privileges were not completed as required by the Medical Staff Bylaws. In addition, Staff #6 stated they held a medical staff meeting and governing bodies meeting on May 24, 2013 at 12 noon, but there were no documented minutes. Staff #6 stated "the re-appointments of medical staff did not take place because Physician #47 would not approve them without the complete application being reviewed prior to the meeting."
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure nursing provided an ongoing assessment and implement interventions to address labs that were out of the reference ranges and obtain physician ordered lab timely in 2 of 2 patients ( Patient #11 and #16.
This deficient practice had the potential to cause harm in all patients.
Findings include:
1. Review of an emergency department (ED) record on Patient #11 revealed she was a [AGE] year old female (MDS) dated [DATE] at 2:46 p.m. with chief complaints of "possible seizure. "
Review of a " Medication Reconciliation Sheet" dated 06/02/13 revealed orders were written for Patient #11 to be on the anticonvulsant Dilantin Kapseals extended release 500 milligrams by mouth at bedtime.
Physician orders dated 06/2/13 3:45 p.m. revealed a lab order for a Dilantin level. At 11:05 p.m. an order was written for a urinalysis with a culture and sensitivity (UA with C &S).
During an interview on 06/03/13 at 12:55 p.m., Patient #11 reported she was in the hospital for having seizures.
Review of nurses notes dated 06/04/13 revealed Patient #11 was discharged home at 6:15 p.m.
Review of Patient #11's chart on 06/05/13 at 11:21 a.m. revealed no lab results for the Dilantin or the UA with C&S.
During an interview on 06/05/13 at 10:00 a.m., Staff #55 reported she could called the lab and the UA with C&S was not done. The results of the Dilantin was pulled off the computer and the following was noted:
Dilantin level low at <0.6 (Reference Ranges 10-20), final report dated 06/04/13 at 11:43 a.m (2 days after it was ordered).
During an interview on 06/06/13 at 10:35 a.m., Staff #29 reported nursing had not signed the UA in on the "Specimen drop off " form in the laboratory. The reason the Dilantin level was late was it had to be sent out to another lab and it was not picked up until 06/03/14.
There was no documentation in the chart of what was done about the Dilantin level or any mention of the UA.

2. Review of an ED record revealed Patient #16 was a [AGE] year old female who presented to the hospital at 10:47 p.m. on 05/31/13 with a chief complaint of vomiting. Patient #16 had a diagnoses of diabetes mellitus.
Patient #16 had undated verbal physician orders for a complete blood count, complete metabolic panel, fingerstick blood sugar, serum ketone, and a urinalysis.
Review of a " Diabetic flow sheet " revealed on 05/31/13 at 11:34 p.m Patient #16 had a glucose reading that was over the range; A CMP collected at 11:34 p.m. revealed a glucose level of 604 (Reference range being 70-105). There was no documentation of any insulin being given or ordered.
According to the ED report dated 05/31/13 the physician arrived at 11:45 p.m . (almost an hour after Patient #16 presented to the hospital).
Review of a "Diabetic flow sheet" revealed the following :
*06/01/13 at 12:08 midnight the glucose reading was 608 and 10 units of Regular insulin was administered intravenous push (IVP). The first treatment for the elevated blood sugar was administered over 1 hour and 15 minutes after Patient #16 presented to the hospital.
*06/01/13 at 1:20 a.m. the glucose reading was 375 and 2 units of Regular insulin was administered IVP.
*06/01/13 at 2:30 a.m. the glucose reading was 345 and 3 unit of Regular insulin was administered IVP.
There was no specific physician orders for the glucose levels of 375 and 345.
Review of verbal orders on a ED report revealed orders for the FSBS at 0120, 0230, 0335, Regular insulin 10 units IV, 2 liters of normal saline, and Regular insulin 2 units IV. There was no time on the order, no order for 3 units of Regular insulin nor an order for sliding scale insulin.
During an interview on 06/05/13 at 2:25 p.m., Staff #6 confirmed the orders and medications.
During an interview on 06/06/13 at approximately 2:30 p.m., Staff #6 confirmed they needed orders for insulin to address elevated blood sugars on admit.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure medications were administered as ordered by a physician in 1 of 1 patients (#16).
This deficient practice had the potential to cause harm in all patients.
Findings include:
Review of an ED record revealed Patient #16 was a [AGE] year old female who (MDS) dated [DATE] at 10:47 p.m. with a chief complaint of vomiting. Patient #16 also had a diagnosis of diabetes mellitus.
Patient #16 had undated verbal physician orders for a complete blood count, complete metabolic panel (CMP), fingerstick blood sugar (FSBS), serum ketone, and a urinalysis.
Review of a " Diabetic flow sheet " revealed on 05/31/13 at 11:34 p.m. Patient #16 had a glucose reading that was over the range. A CMP collected at 11:34 p.m. revealed a glucose level of 604 (Reference range being 70-105). There was no documentation of any insulin being given or ordered.
According to the ED report dated 05/31/13 the physician arrived at 11:45 p.m., almost an hour after Patient #16 presented to the hospital.
Review of a "Diabetic flow sheet" revealed the following:
*06/01/13 at 12:08 midnight the glucose reading was 608 and 10 units of Regular insulin was administered intravenous push (IVP). The first treatment for the elevated blood sugar was administered over 1 hour and 15 minutes after Patient #16 presented to the hospital.
*06/01/13 at 1:20 a.m. the glucose reading was 375 and 2 units of Regular insulin was administered IVP.
*06/01/13 at 2:30 a.m. the glucose reading was 345 and 3 unit of Regular insulin was administered IVP.
There was no physician orders for the glucose levels of 375 and 345, nor were there orders for sliding scale insulin.
Review of ED report revealed untimed verbal orders for the FSBS at 0120, 0230, 0335, Regular insulin 10 units IV, 2 liters of normal saline, and Regular insulin 2 units IV. There was no time on the order, no order for 3 units of Regular insulin nor an order for sliding scale insulin.
During an interview on 06/05/13 at 2:25 p.m., Staff #6 confirmed the missing insulin orders and medication errors.
During an interview on 06/06/13 at approximately 2:30 p.m., Staff #6 confirmed they needed orders for insulin to address elevated blood sugars on admit.