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.

The facility failed to ensure that patient medical record entries were completed, timed, and dated per hospital policy for 8 of 21 sampled patients (Patient ID # 8, 10, 11, 12, 13, 15, 18, and 21).

The " Memorandum of Transfer " form was incomplete for the above- listed sampled patients.

Findings include:

Intake # TX 968:

Review of the " Memorandum of Transfer " (MOT) form for 21 sampled patients who had been transferred from the facility during June and July 2012 revealed the following:

a. MOT for sampled Patients IDs # 12, 13, and 15 failed to include date and time " Accepting hospital secured by Transferring hospital " (Section A, question 8).

b. MOT for sampled Patients IDs # 8, 12, 13 failed to include signature, title, and time of " Transferring hospital administration who contacted the receiving hospital. " (Section A, question 9).

c. MOT for sampled Patients IDs# 10, 11, 18, 21 failed to include documentation of name, phone number, and address of " Next of Kin " and indication the Next of Kin was notified of the patient ' s transfer. (Section A, question 3).

Interview on 07/20/12 at 3:00 p.m. with the Interim Director of Nursing ( ID # 50) she stated all sections of the MOT form should be completed, including signatures, staff names, dates , and times. She went on to say that if a person had no " Next of Kin " or it was unknown, this should be documented in the " Next of Kin " section of the MOT and not be left blank.

Review of facility policy titled " Patient Transfer, " revised date 3/12, read: " ...F. Memorandum of Transfer: 1. The hospital shall provide that a memorandum of transfer (MOT) be completed for every patient who is transferred... "
Based on observation, interview and record review, the facility failed to conspicously post a sign indicating rights of individuals in emergency conditions.

Findings include:

Observation rounds conducted on 07/19/12 at 11:45 a.m. of the first floor intake area for all patients entering the facility revealed the following:

The intake area has two entrances, one for the ambulance drop off/walk in and the one for walk-ins. On the two entrances there were postings (8 1/2 by 11) on each door which read " emergency room IS CLOSED TO THE PUBLIC. NO EMERGENCY PERSONNEL ARE AVAILABLE. IN CASE OF AN EMERGENCY, CALL 911. "

Interview with staff #57 (personnel roster/key #2) during the observation rounds on 07/19/12 at 11:00 am in the intake unit revealed "everyone comes through both doors and the main door is for the ambulance". "We see everyone that comes through those doors for some kind of treatment" and pointed at the "EMTALA" signs at both the waiting area and in the hallway on the board.

Observation on 07/20/12 at 12:00 p.m. with employee #51, Interim DON (personnel roster #2) revealed the two signs were still posted at the doors and this employee took the signs down and said that "people will misread it because we do see everyone that comes here, stabilize them or call 911 and then make appropriate transfer if we have to". Employee #51 did confirm that the signs are not the right signs.

Review of facility policy and procedure titled "EMTALA-Texas Signature dated 5/10 and revised 4/12 on 07/20/12 revealed the following:
" The hospital must post signage that, at a minimum, meets the following requirements: "
? " signage must be conspicuously posted in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting to for examination and treatment in areas other than traditional emergency department (e.g., entrance, admitting area, waiting room, labor and delivery, treatment areas located on hospital property);
? " signage must be readable from anywhere in the area or at least twenty (20) feet " .