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.

TEXAS GENERAL HOSPITAL 2709 HOSPITAL BLVD GRAND PRAIRIE, TX 75051 April 1, 2015
VIOLATION: QAPI Tag No: A0263
Based on record review and interview, the hospital did not implement and maintain an effective, on-going, hospital-wide, data driven quality assessment and performance improvement program (QAPI) in that:


(1) There was no evidence that the hospital monitored, analyzed, and tracked quality indicators to improve health outcomes for 27 of 27 months (from January 2013 through March 2015). The hospital did not collect data and/or relevant information to monitor the effectiveness and safety of services and quality of care. During this period of time, eight of eight patient death records (Patient #1, #2, #3, #5, #35, #86, #87, and #88) were not reviewed, analyzed, or trended by the Morbidity and Mortality Committee as required by facility policy;

CROSS REFER TO TAG 0273


(2) There was no evidence that the hospital analyzed and tracked adverse patient events and other aspects of performance that assessed processes of care for 5 of 5 patients (Patient #2, Patient #38, Patient #82, Patient #83, and Patient #85) from January 2014 through March 2015.

CROSS REFER TO TAG 0286
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on interview and record review, the hospital did not have an ongoing quality assurance and performance improvement program in that the hospital did not monitor, analyze, and track quality indicators to improve health outcomes, effectiveness and safety of services, and quality of care for 27 of 27 months (from January 2013 through March 2015) in that:

(1) eight of eight patient death records (Patient #1, #2, #3, #5, #35, #86, #87, and #88) were not reviewed, analyzed, or trended by the Morbidity and Mortality Committee as required by facility policy;

(2) three of six nursing agencies (Agency #4, #5, and #6) that provided clinical personnel for patient care did not have contracts with the facility;

(3) the facility did not provide the hospital's resuscitation results for 15 of 15 months (from January 2014 through March 2015);

(4) the facility did not provide results of the discharge planning process that improved the quality of care for patients and reduced chances of readmission, citing 11 of 11 months (from May 2014 through March 2015): and

(5) the emergency department's medical records indicated 3 of 3 patients (Patient #72, #77, and #78) were treated without orders for laboratory (lab) work and/or lab tests were not reviewed by a physician and/or the patient was not notified of the lab result after discharged .

Findings included:

During the entrance conference on 3/23/15, at approximately 10:45 AM, Personnel #1 was asked to provide documentation of the hospital's performance improvement plan and activities from January 2013 through March 2015.

The documentation provided did not include the status of identified problems and action plans that were tracked to assure improvement or problem resolution that included the following:

(1) review of mortality and morbidity,
(2) patient care and services provided by nursing contracts,
(3) review of resuscitation results,
(4) social work services and discharge planning (case management), and
(5) services provided by the emergency department.


(1) From January 2013 through March 2015, there were 8 of 8 patient deaths (Patient #1, #2, #3, #5, #35, #86, #87, and #88). There was no evidence that the Performance Improvement Committee had monitored and trended morbidity and mortality rates for these 8 deaths.

In an interview on 3/25/15, at approximately 2:30 PM, Personnel #3 was asked if they review medical records of expired patients. She replied that each department conducts their own review. Personnel #3 was asked to provide evidence of reviews and if the information collected in the reviews was included in the hospital's Performance Improvement Program. Personnel #3 replied "no." Personnel #3 was informed that the review of morbidity and mortality was included in the hospital's "Performance Improvement Plan." Personnel #3 stated the hospital never reviewed morbidity and mortality. No documentation was provided to the surveyor.


(2) Review of contracts of 6 nursing agencies that provided clinical personnel for patient care indicated that Agency #4, #5, and #6 did not have contracts with the facility. Non-employee personnel that worked in the facility did not have documented credentialing, licensing, training and competencies to work as a licensed nurse, certified surgical technician (CST), or medical assistant (MA) in the hospital.


(3) Documentation of resuscitation results were not provided. Review of Performance Improvement Committee meeting minutes on 2/5/14, 5/8/14, and 9/24/14, did not include review of the hospital's resuscitation results. The hospital's "Performance Improvement Plan" revised on 4/13/14, required review of the "Results of Resuscitation" and this finding was confirmed by Personnel #3 on 3/26/15 at approximately 3:00 PM.


(4) From May 2014 through March 2015, there were 9 of 9 patients (Patient #81, #83, #89, #90, #91, #92, #93, #94, and #95) who were readmitted to the hospital within 30 days of the previous admission. Review of Performance Improvement Committee meeting minutes on 2/5/14, 5/8/14, and 9/24/14, did not include a review of these 9 patient readmissions. On 04/01/15, at 1:15 PM, in the conference room, Personnel #10, Assistant Chief Nursing Officer who was over Discharge Planning confirmed the hospital does not monitor, track, and trend patient readmissions within 30 days.


(5) Review of the emergency department's medical records indicated patients were treated with diseases without orders for laboratory (lab) work and/or lab tests were not reviewed by a physician and/or the patient was not notified of the lab results after discharged , citing Patient #72, Patient #77, and Patient #78.


Policy "Organizational Performance Improvement Plan" revised 4/13/14, required "Goals of Performance Improvement...primary goals...are to continually and systematically plan, design, measure, assess, and improve performance of critical focus...contract services...Scope of Activities...findings of Performance Improvement/Quality Committee...will review, assess, and evaluate: Operative/Invasive procedures...Mediation Management...Adverse Events...Mortality and Morbidity Review, the Results of Resuscitation...Emergency Department services..."


Policy "Discharge Planning" revised 2/27/15, required "Purpose...The plan is expected to employ a discharge planning process that improves the quality of care for patients and reduces the chances of readmission."
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on interview and record review, the hospital did not have an ongoing quality assurance and performance improvement program that showed measurable improvement of indicators; there was no evidence that the hospital analyzed and tracked adverse patient events and other aspects of performance that assessed processes of care for 5 of 5 patients (Patient #2, Patient #38, Patient #82, Patient #83, and Patient #85) from January 2014 through March 2015, in that:

1) incident reports that required root cause analysis were not conducted;

2) Medical Staff did not review the incident report cases that was referred to them;

3) appropriate root cause analysis corrective actions were not established; and

4) there was no evidence of peer review.


Findings included:

During the entrance conference on 3/23/15, at approximately 10:45 AM, Personnel #1 was asked to provide documentation of the hospital's identified medical error information and performance improvement plan from January 2014 through March 2015.

From January 2014 through March 2015, there were 5 unfavorable patient outcomes that potentially injured the patients from the surgery department and other patient care areas. No root cause analyses (RCA) was conducted on the unfavorable events and no medical staff review was performed after referred. No peer review was conducted and no corrective actions were planned and/or implemented, citing Patient #2, #38, #82, #83 and #85.


On 1/15/14, Patient #2 underwent laparoscopic revision of hiatal hernia repair. During Patient #2's "laparoscopic hiatal hernia repair" severe hemorrhage started. The procedure was changed to an "open abdominal exploration and left thoracotomy...due to laceration of the anterior wall of the thoracic aorta apparently due to suture fixation of the fundoplication to the anterior aortic wall with secondary severe hemorrhage and eventual exsanguination and death..." Patient #2 expired during the surgery.


On 11/14/14, Patient #38 underwent gastric sleeve and hiatal hernia repair. During Patient #38's "laparoscopic sleeve resection" bleeding started. The procedure was changed to an "open abdominal sleeve gastrectomy due to the inability of the vessel to be ligated..." Patient #38 expired during the surgery.


On 11/17/14, Patient #82 underwent "laparascopic vertical gastric sleeve resection." On 11/18/14 Patient #82 returned for a "surgical intervention" for laparoscopic evacuation of a hematoma in the abdominal cavity.


On 11/24/14, Patient #83 returned to the OR (operating room) for "revision of sleeve to bypass" due to "intractable nausea and vomiting and dysphagia." Patient #83 underwent a gastric sleeve procedure the previous month.


On 3/11/15, Patient #85 underwent a "laparoscopic vertical gastric sleeve resection..." Patient #85 returned to the OR on 3/13/15 for "exploratory laparoscopy..." for a "gastric outlet obstruction."


There was no documentation provided for root cause analyses and/or evidence to support Medical Staff review and/or that root cause analyses corrective actions were established and/or evidence of peer review for Patient #2, #38, Patient #82, Patient #83, and Patient #85.


In an interview on 3/31/15, at 2:10 PM, in the conference room, Personnel #3 (Director of Performance Improvement) was informed of the above findings. She was asked if appropriate root cause analyses were conducted. Personnel #3 replied "no." She was asked if all the events were referred to the Medical Staff to review. Personnel #3 replied "yes." She was asked to provide evidence that the events were reviewed by the Medical Staff. Personnel #3 stated she could not provide evidence because there was none. She was asked if any of the events had peer reviews. Personnel #3 replied there were no peer reviews.


In an interview on 4/1/15, at 11:00 AM, in the conference room, Physician #45 (Chief of Staff) was informed of the above findings. He was asked if Medical Staff reviewed the events since they were referred to the Medical Staff. After Physician #45 reviewed the above events, he replied the Medical Staff and himself were not aware of these incidents. He stated "these should have been reviewed and not stopped" at the Performance Improvement Committee.


Policy "Organizational Performance Improvement Plan" revised 4/13/14, required "The status of identified problems and action plans is tracked to assure improvement...Information...and the findings of discrete performance improvement activities and adverse patient events are use to detect trends...or potential problems..."


Policy "Peer Review" revised 3/13/15, required "Intent...to promote continuous improvement of quality of care provided by the medical staff...The role of the medical staff...is to provide evaluation and performance to ensure effective and efficient assignments...of the physician."
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on record review and interview, the hospital and the Director of Nursing (Personnel #2) failed to provide evaluations of clinical activities of non-employee nursing personnel in that, non-employee registered nurses that worked in the hospital did not have documented credentialing, licensing, training and competencies to work as a licensed nurse, certified surgical technician (CST), or medical assistant (MA) in the hospital, citing:

(A) 13 of 13 agency registered nurses (Personnel #25, #31, #32, #33, #78, #79, #80, #81, #82, #85, #86, #87, and #88); and

(B) 2 of 15 certified and non-certified agency clinical personnel (Personnel #83 and Personnel #84)

Findings included:

(A) The following 13 non-employee licensed nurses who worked at the hospital between October 2014 and March 2015 did not have in their personnel records the required current documentation as noted below:

-Agency RNs did not have training or competencies : Agency RN #25, #31, #32, #33, #78, #79, #80, #81, #82, #85, #86, #87, and #88.

-Agency RNs #81, #82, #86 had expired Texas Nursing License.

-Agency RNs #78, #85, #87 and #88 did not have a Texas Nursing License on file.

-Agency RNs #33, #80, #82, #86 had expired ACLS.

-Agency RNs #31, #78, #85, #87, #88 did not have documentation of ACLS.

-Agency RNs #79 and #82 had expired BLS.

-Agency RNs #78, #85, #86, #87, #88 did not have documentation of BLS.


(B) Personnel #84 (agency CST) and Personnel #83 (agency MA) did not have any certification or registration and documentation of CPR on file respectively.


An interview with Personnel #2 on 4/1/2015 at 2:15 PM in the Board Room confirmed that the documents for the agency nurses is all the information that they have on the agency nurses. Personnel #2 confirmed the non-employee personnel did not have appropriate job descriptions.


"New Hire Policy" revised 3/6/15 required "... this policy sets standards for temporary employees, contract, agency and any other personnel providing services...Guidelines...Staff that provide patient care, treatment and services shall possess a license, certification or registration as required...and as defined in job descriptions...licensure and certifications will be verified prior to employment...one (1) copy is placed in the employee's personnel file, and one (1) copy sent to the department manager..."
VIOLATION: CONTRACTED SERVICES Tag No: A0084
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the governing body failed to ensure that contracted services were provided in a safe and effective manner in that 3 of 6 agencies (Agency #4, #5, and #6) that provided nursing staff at the hospital, did not have a contract with the hospital to address quality of services provided, qualification and training of staff, as well as orientation to hospital systems and processes.

Findings included:

Review of the notebooks of contracted services (MDS) dated [DATE], at 1:00 PM, in the Board Room of the hospital, did not include contracts for Agency #4, #5, and #6. The hospital had used nurses from Agency #4, #5, and #6 during the months of October 2014 through March, 2015.

An interview with Personnel #2 on 4/1/2015 at 1:30 PM in the Board Room confirmed that there were no contracts for Agency #4, #5, and #6.

This practice exposed patients to the likelihood of recieving patient care services from unlicensed and unqualified staff, and absence of oversight and monitoring of services provided.
VIOLATION: CONTRACTED SERVICES Tag No: A0085
Based on record review and interview, the hospital failed to maintain a list of contracted services, including the scope and nature of the services provided for the period between October 2014 through March, 2015.

Findings included:

The contracts for services were maintained in binders organized in alphabetical order. There was no list of contracted services provided at the hospital for the period between October 2014 through March, 2015.

During an interview with Personnel #1 on 3/24/2015, at 11 AM, in the Board Room, Personnel #1 stated that the contracts were in the binders and there was no list that summarized the contracts that included the scope and nature of the services provided.
VIOLATION: LICENSURE OF PERSONNEL Tag No: A0023
Based on record review and interview, the hospital failed to ensure that 9 of 26 hospital employees (Personnel #7, #13, #19, #21, #23, #24, #68, #70, and #71), and 15 of 15 non-employee (agency) personnel (Personnel #25, #31, #32, #33, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, and #88) were licensed or met other applicable standards that are required by State or local laws.

Findings included:

1. Review of personnel records indicated the following 9 personnel did not have competencies and/or training. These personnel worked in the facility during the months of October, 2014 to March, 2015:

-#7 RN (registered nurse), Performance Improvement Manager/Physician Peer Review Officer Date of Hire (DOH) 6/30/14;

-#13 RN, Infection Control/Employee Health, DOH 8/11/14;

-#19 RN, Emergency Department (ED), DOH 4/30/2014 and became ED manager on 2/22/15;

-#21 Certified EMT-Paramedic, DOH 5/9/13;

-#23 RN, Preoperative Nursing Services DOH 2/13/14 and resignation date 3/27/15;

-#24 RN, ED, DOH 3/20/14;

#68 RN, ED PRN (as needed), DOH 3/31/14;

#70 RN, ED, DOH 3/17/14; and

#71 ICU (intensive care unit) Patient Care Technician (PCT), DOH 10/21/14


2. Non-employee registered nurses that worked in the hospital did not have documented credentialing, licensing, training and competencies to work as a licensed nurse, certified surgical technician (CST), or medical assistant (MA) in the hospital, citing:

(A) 13 agency registered nurses (Personnel #25, #31, #32, #33, #78, #79, #80, #81, #82, #85, #86, #87, and #88); that worked in the hospital between October, 2014 and March, 2015:

-Agency RNs did not have training or competencies : Agency RN #25, #31, #32, #33, #78, #79, #80, #81, #82, #85, #86, #87, and #88.

-Agency RNs #81, #82, #86 had expired Texas Nursing License.

-Agency RNs #78, #85, #87 and #88 did not have a Texas Nursing License on file.

-Agency RNs #33, #80, #82, #86 had expired ACLS.

-Agency RNs #31, #78, #85, #87, #88 did not have documentation of ACLS.

-Agency RNs #79 and #82 had expired BLS.

-Agency RNs #78, #85, #86, #87, #88 did not have documentation of BLS.


(B) Two clinical personnel (Personnel #83 and Personnel #84) did not have any certification or registration and documentation of CPR on file respectively.


An interview with Personnel #2 on 4/1/2015, at 2:15 PM, in the Board Room confirmed that the documents for the agency nurses presented to the surveyors were all the information that they have on the agency nurses. Personnel #2 confirmed that the non-employee personnel did not have appropriate job descriptions.


In an interview on 4/1/15, at 1:00 PM, in the Board Room, Personnel #17 confirmed that the above employees did not have evidence of training and/or competencies in their respective personnel records.


"New Hire Policy" revised 3/6/15 required "... this policy sets standards for temporary employees, contract, agency and any other personnel providing services...Guidelines...Staff that provide patient care, treatment and services shall possess a license, certification or registration as required...and as defined in job descriptions...licensure and certifications will be verified prior to employment...one (1) copy is placed in the employee's personnel file, and one (1) copy sent to the department manager..."
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record review and interview, the Governing Body failed to provide effective oversight for the conduct of the hospital's functions in that:

(1) the governing body failed to ensure that patients admitted to the hospital were provided quality of the medical care, citing incidents of 2 of 2 patients (Patient #1 and #2) who were admitted and eventually expired the same day;

CROSS REFER TO TAG 0049


(2) 27 of 27 months (from January 2013 through March 2015), Quality Assessment and Performance Improvement (QAPI) did not monitor, analyze, and track quality indicators to improve health outcomes. During this period of time, eight of eight patient death records (Patient #1, #2, #3, #5, #35, #86, #87, and #88) were not reviewed, monitored, or trended by the Morbidity and Mortality Committee as required by facility policy;

CROSS REFER TO TAG 0273


(3) the quality assurance and performance improvement department did not have an ongoing program that showed measurable improvement of indicators in that there was no evidence that the hospital analyzed and tracked adverse patient events and other aspects of performance that assessed processes of care for 5 of 5 patients (Patient #2, Patient #38, Patient #82, Patient #83, and Patient #85) from January 2014 through March 2015;

CROSS REFER TO TAG 0286


(4) the registered nurse (RN) did not effectively supervise and evaluate the nursing care of 1 of 1 patient (Patient #1) who was admitted to the intensive care unit (ICU) on 7/5/13. No neurological checks were conducted after the initial 11:50 PM neurological check was completed by the nurse. Patient #1 expired on e hour after she was admitted to the ICU;

CROSS REFER TO TAG 0395


5) the Director of Nursing failed to ensure that nursing personnel had competencies and specialized qualifications before assigning care for each patient in accordance with the individual needs of each patient, citing 9 of 26 personnel (Personnel #7, #13, #19, #21, #23, #24, #68, #70, and #71); and

CROSS REFER TO TAG 397


6) the Director of Nursing failed to provide evaluations of clinical activities of non-employee nursing personnel in that, non-employee registered nurses that worked in the hospital did not have documented credentialing, licensing, training and competencies to work as a licensed nurse, certified surgical technician (CST), or medical assistant (MA) in the hospital, citing:

(A) 13 of 13 agency registered nurses (Personnel #25, #31, #32, #33, #78, #79, #80, #81, #82, #85, #86, #87, and #88); and

(B) 2 of 15 certified and non-certified agency clinical personnel (Personnel #83 and Personnel #84).

CROSS REFERENCE TO TAG 0398
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on record review and interviews, the facility's medical staff failed to ensure the quality of the medical care provided to the patients. The Medical Staff did not review the incidents, citing 2 of 2 patients (Patient #1 and #2) who expired in the hospital. The Medical Staff failed to conduct a review of patients with adverse events. The Medical Staff failed to apprise the Governing Body of the patient's adverse events.

Findings included:

Patient #1 presented in the emergency department (ED) on 7/5/13. At 9:24 PM, triage assessment by a nurse indicated the patient was brought by a man who stated she might have taken an overdose of "Seroquel and Gabapentin after fighting with the boyfriend. Time of ingestion was unknown."

Physician notes at 9:10 PM indicated "General Appearance: severe distress and obtunded...Neuro/ Psych: no response to commands...Abdomen: normal bowel sounds..."

At 11:43 PM Patient #1 was "admitted as inpatient to ICU (intensive care unit), Condition of Discharge: guarded." Vital Signs (VS) were as follows: BP 128/79, O2 sat 95%, R 13, P 95, and T 97.6.

On 7/5/13, at 11:50 PM, the patient arrived in the ICU. Physician's orders included VS every 4 hours, O2 at 2 LPM and keep sats above 92%, and normal saline at 125 milliliters per hour (ml/hr). The Nursing Physical Assessment indicated "Breath sounds: crackles...Critical Care Assessment indicated the patient "does not respond to painful stimuli...Glasgow Coma Scale-Eyes open: not at all...Verbal Response: none...Motor Response: none...Glasgow Coma Scale Total: 3..Level of Consciousness: unresponsive...Foley catheter."

Neurological checks were not performed after the initial one was done at 11:50 PM. On 7/6/13, at 12:05 AM, a code was activated. The team responded at 12:10 AM, the patient was intubated at 12:15 AM. The code was terminated at 12:50 AM. The patient expired.


On 1/15/14, Patient #2 underwent laparoscopic revision of hiatal hernia repair. During Patient #2's "laparaoscopic hiatal hernia repair" severe hemorrhage started. The procedure was changed to an "open abdominal exploration and left thoracotom...due to laceration of the anterior wall of the thoracic aorta apparently due to suture fixation of the fundoplication to the anterior aortic wall with secondary severe hemorrhage and eventual exsanguination and death..." Patient #2 expired during the surgery.

There was no documentation provided to support Medical Staff review for Patient #1 and #2.

In an interview on 3/31/15, at 2:10 PM, in the conference room, Personnel #3 (Director of Performance Improvement) was asked if the events were referred to the Medical Staff to review. Personnel #3 replied "yes." She was asked to provide evidence that the event was reviewed by the Medical Staff. Personnel #3 stated she could not provide evidence because there was none.

In an interview on 4/1/15, at 11:00 AM, in the conference room, Physician #45 (Chief of Staff) was informed of the above finding. He was asked if Medical Staff reviewed the above incidents. He replied the Medical Staff and himself were not aware of the incidents. He stated "these should have been reviewed and not stopped" at the Performance Improvement Committee.

Medical Staff Bylaws, approved by the Board of Directors 11/10/14 revealed: "...it is recognized that the Medical Staff is responsible for the quality of patient care delivered by its members..."


From January 2014 through March 2015, there were 5 unfavorable patient outcomes that potentially injured the patients from the surgery department and other patient care areas. No root cause analyses (RCA) was conducted on the unfavorable events and no medical staff review was conducted. No peer review was conducted and no corrective actions were planned and/or implemented, citing Patient #38, #82, #83 and #85.


On 11/14/14, Patient #38 underwent gastric sleeve and hiatal hernia repair. During Patient #38's "laparoscopic sleeve resection" bleeding started. The procedure was changed to an "open abdominal sleeve gastrectomy due to the inability of the vessel to be ligated..." Patient #38 expired during the surgery.


On 11/17/14, Patient #82 underwent "laparascopic vertical gastric sleeve resection." On 11/18/14 Patient #82 returned for a "surgical intervention" for laparoscopic evacuation of a hematoma in the abdominal cavity.

On 11/24/14, Patient #83 returned to the OR (operating room) for "revision of sleeve to bypass" due to "intractable nausea and vomiting and dysphagia." Patient #83 underwent a gastric sleeve procedure the previous month.

On 3/11/15, Patient #85 underwent a "laparoscopic vertical gastric sleeve resection..." Patient #85 returned to the OR on 3/13/15 for "exploratory laparoscopy..." for a "gastric outlet obstruction."

There was no documentation provided for root cause analyses and/or evidence to support Medical Staff review and/or that root cause analyses corrective actions were established and/or evidence of peer review for Patient #38, Patient #82, Patient #83, and Patient #85.

In an interview on 3/31/15, at 2:10 PM, in the conference room, Personnel #3 (Director of Performance Improvement) was informed of the above findings. She was asked if appropriate root cause analyses were conducted. Personnel #3 replied "no." She was asked if all the events were referred to the Medical Staff to review. Personnel #3 replied "yes." She was asked to provide evidence that the events were reviewed by the Medical Staff. Personnel #3 stated she could not provide evidence because there was none. She was asked if any of the events had peer reviews. Personnel #3 replied there were no peer reviews.

In an interview on 4/1/15, at 11:00 AM, in the conference room, Physician #45 (Chief of Staff) was informed of the above findings. He was asked if Medical Staff reviewed the events since they were referred to the Medical Staff. After Physician #45 reviewed the above events, he replied the Medical Staff and himself were not aware of these incidents. He stated "these should have been reviewed and not stopped" at the Performance Improvement Committee.

Policy "Organizational Performance Improvement Plan" revised 4/13/14 required "The status of identified problems and action plans is tracked to assure improvement...Information...and the findings of discrete performance improvement activities and adverse patient events are use to detect trends...or potential problems..."

Policy "Peer Review" revised 3/13/15 required "Intent...to promote continuous improvement of quality of care provided by the medical staff...The role of the medical staff...is to provide evaluation and performance to ensure effective and efficient assignments...of the physician."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review and interview, the hospital did not have a nursing services with an effective oversight in that:

1. the registered nurse (RN) failed to supervise and evaluate the nursing care of 1 of 1 patient (Patient #1) who was admitted to the intensive care unit (ICU) on 7/5/13. No neurological checks were conducted after the initial 11:50 PM neurological check. Patient #1 expired on e hour after she was admitted to the ICU.

CROSS REFER TO TAG 395


2. the Director of Nursing failed to ensure that nursing personnel had competencies and specialized qualifications before assigning care for each patient in accordance with the individual needs of each patient, citing 9 of 26 personnel (Personnel #7, #13, #19, #21, #23, #24, #68, #70, and #71).

CROSS REFER TO TAG 397


3. the Director of Nursing (Personnel #2) failed to provide evaluations of clinical activities of non-employee nursing personnel in that, non-employee registered nurses that worked in the hospital did not have documented credentialing, licensing, training and competencies to work as a licensed nurse, certified surgical technician (CST), or medical assistant (MA) in the hospital, citing:

(A) 13 of 13 agency registered nurses (Personnel #25, #31, #32, #33, #78, #79, #80, #81, #82, #85, #86, #87, and #88); and

(B) 2 of 15 certified and non-certified agency clinical personnel (Personnel #83 and Personnel #84).

CROSS REFERENCE TO TAG 398
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and interview, the facility's registered nurse (RN) failed to supervise and evaluate the nursing care of 1 of 1 patient (Patient #1) who was admitted to the intensive care unit (ICU) on 7/5/13. No neurological check was completed after Patient #1 received the first neurological check by the nurse at 11:50 PM. Patient #1 expired on e hour after she was admitted to the ICU.

Findings included:

Patient #1 presented in the emergency department (ED) on 7/5/13. At 9:24 PM, triage assessment by a nurse indicated the patient was brought by a man who stated she might have taken an overdose of "Seroquel and Gabapentin after fighting with the boyfriend. Time of ingestion was unknown."

Physician notes on 7/5/13, at 9:10 PM, indicated "General Appearance: severe distress and obtunded ...Neuro/ Psych: no response to commands...Abdomen: normal bowel sounds..." At 11:43 PM Patient #1 was "admitted as inpatient to ICU (intensive care unit), Condition of Discharge: guarded." Vital Signs (VS) were as follows: BP 128/79, O2 sat 95%, R 13, P 95, and T 97.6.

On 7/5/13, at 11:50 PM, the patient arrived in the ICU. Physician's orders included VS every 4 hours, O2 at 2 LPM and keep sats above 92%, and normal saline at 125 milliliters per hour (ml/hr). The Nursing Physical Assessment indicated "Breath sounds: crackles...Critical Care Assessment indicated the patient "does not respond to painful stimuli...Glasgow Coma Scale-Eyes open: not at all...Verbal Response: none...Motor Response: none...Glasgow Coma Scale Total: 3..Level of Consciousness: unresponsive...Foley catheter." Neurological checks were not performed after the initial one was done at 11:50 PM.

On 7/6/13, at 12:05 AM, a code was activated. The team responded at 12:10 AM, the patient was intubated at 12:15 AM. The code was terminated at 12:50 AM. The patient expired.

In an interview on 4/1/15 at 1:30 PM, Personnel #2 and #15 were informed of the above findings. Both personnel confirmed that the neurological checks were not performed by the nurse.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record review and interview, the hospital and the Director of Nursing failed to ensure that nursing personnel had competencies and specialized qualifications before assigning care for each patient in accordance with the individual needs of each patient, citing 9 of 26 personnel (Personnel #7, #13, #19, #21, #23, #24, #68, #70, and #71)

Findings included:

Review of personnel records indicated the following 9 personnel did not have competencies and/or training. These personnel worked in the facility during the months of October, 2014 to March, 2015:

-#7 RN (registered nurse), Performance Improvement Manager/Physician Peer Review Officer Date of Hire (DOH) 6/30/14;

-#13 RN, Infection Control/Employee Health, DOH 8/11/14;

-#19 RN, Emergency Department (ED), DOH 4/30/2014 and became ED manager on 2/22/15;

-#21 Certified EMT-Paramedic, DOH 5/9/13;

-#23 RN, Preoperative Nursing Services DOH 2/13/14 and resignation date 3/27/15;

-#24 RN, ED, DOH 3/20/14;

#68 RN, ED PRN (as needed), DOH 3/31/14;

#70 RN, ED, DOH 3/17/14; and

#71 ICU (intensive care unit) Patient Care Technician (PCT), DOH 10/21/14


In an interview on 4/1/15, at 1:00 PM, in the Board Room, Personnel #17 confirmed that the above employees did not have evidence of training and/or competencies in their respective personnel records.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on record review and interview, the infection control officer (Personnel #13) failed to develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients. There was no evidence that 3 of 3 patients (Patient #72, #77, and #78) in the emergency department (ED) were identified to have infections that were potential or actual communicable reportable diseases.

Findings included:

-Patient #72, Date of Service (DOS): 12/17/14, at 9:47 AM, Chief Complaint (CC): Vaginal discharge with itching and burning, yellow brown discharge...active. At 11:07 AM, the physician ordered a culture and wet mount smear. The physician ordered Diflucan 150 mg. oral tab and Rocephin 1 gram IM (intramuscularly). Patient #72 was discharged on the same day.

On 12/18/14, at 5:35 PM, the culture was negative. Patient #72 was treated for a communicable disease before lab results were received. There was no documentation that the physician reviewed the result and that the patient was notified of the results.


-Patient #77, DOS: 1/8/15 at 6:05 PM ...was diagnosed with a communicable reportable disease. No physician orders for lab or results were documented in the medical record. Orders for Zithromax 1000 mg PO was given. Patient was treated for a communicable reportable disease. No lab test was ordered and there was no evidence that this was reported to the county health department as required.


-Patient #78, DOS: 1/12/15 at 8:38 AM, Vaginal discharge (yellow) with foul odor for 2-3 days; Nurses Notes indicated..."Patient refuses pelvic exam and will follow up with her PCP." At 8:51 AM, the physician ordered Rocephin 250 mg. IM x 1, Azithromycin 1 gram PO x 1, and Flagyl 500 mg PO x 1. There were no orders for lab tests. Discharge Diagnosis was "...likely communicable reportable disease." There was no evidence that this was reported to the county health department as required.


In an interview with Personnel #3 on 3/25/15, in the Board Room, she confirmed that the hospital does not have a policy on how to handle or report communicable reportable diseases.

An interview with Personnel #13 on 3/25/2015, in the Board Room stated that she received the lab results and reported the results to the County Health Department via fax.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on record review and interview, the hospital failed to meet the emergency needs of patrients in accordance with acceptable standards for 2 of 2 patients (Patient #64 and Patient #107). The hospital failed to provide examination as required by the patients' presenting symptomatologies and failed to arrange for appropriate transfer to a higher level of care.

Findings included:

(1) The medical record for Patient #64 dated 2/8/15 documented the following:

Chief Complaint: "Patient agitated, reports being raped multiple times for months and stated I must speak with the FBI now or I will either kill myself right here or go crazy and kill somebody else."

Threats to self and others were witnessed by two paramedics. Patient also stated he had body aches, fever, and nasal discharge for 2 days. Past Medical History: "anxiety, bipolar, depression..."

Patient was taken to room 3 after threatening harm to self and others. Patient was loud, agitated, and swearing..."must contact the FBI right now." Stated if we do not call FBI, he will leave. Informed patient that we cannot allow him to leave after he threatened self/others.

The Police Department was notified. Security was at the bedside. At 6:15 PM, the Police was at the bedside. Patient #64 was taken into custody for transport to Hospital B. At 6:22 PM, a report was called to an RN at Hospital B.

There was no evidence of examination by a physician. There was no documentation of arrangement for the tranfser to another facility.



(2) The medical record of Patient #107 on 3/20/15 documented:

Chief Complaint: Sugar is high, upper back and chest hurting into both arms for 3 days, also complaining of nausea. The physician saw patient #107 at 4:45 PM. The physician noted pain in upper back and elevated BS for 3 days. Labs were ordered. Blood sugar was 569 and "elevated D-Dimer." Clinical impression: Chest pain, coronary artery disease, abnormal EKG, an uncontrolled Diabetes.

The physician ordered the patient to be admitted . The patient was transferred to another hospital. There was no order to transfer Patient #107. At 9:05 PM, a telephone report was given to a nurse in the receiving hospital. At 9:16 PM, Patient #107 left via ambulance. Reports and all pertinent documents/papers and a disc were given to family members and they were instructed to follow the ambulance.


During an interview on 3/25/15 at 3:00 PM in the Board Room, Personnel #2 confirmed that the above patients were not provided appropriate examination and/or transfers.

The hospital policy revised 2/27/15 required the facility would provide to any one who presents in the emergency department an appropriate examination and transfer.