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.

WEIMAR MEDICAL CENTER 400 YOUENS DR WEIMAR, TX 78962 Sept. 14, 2016
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of documentation and interviews with staff, the hospital failed to ensure that nursing services were supervised by a registered nurse in each department (Emergency Department and the In-Patient Unit) for 17 of 75 shifts. The hospital failed to provide the immediate availability of at least one RN in the event of an emergency in the ED and at least one RN immediately available in the event of an emergency on the in-patient unit (floor). The lack of adequate nurse staffing posed a likelihood for patient harm.


Findings:


Review of the nursing schedules the morning of 9/14/16 provided to the surveyors for July, August, and September (to date) 2016 revealed the following shifts with only one RN available for the shift in the hospital, which did not provide an immediately available RN to staff the ED and an RN to be immediately available for patients admitted to the inpatient unit:

9/8/16 Day Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER
9/6/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER
8/26/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER
8/24/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER
8/22/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER
8/21/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER
8/12/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER
8/2/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER
8/1/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER
7/31/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER
7/29/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER
7/24/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER
7/23/16 Night Shift - 1 RN Charge, 2 LVNs floor, 1 LVN ER
7/22/16 Day Shift - 1 RN Charge, 2 LVNs floor
7/7/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER
7/2/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER after 11pm
7/1/16 Night Shift - 1 RN Charge, 1 LVN floor, 1 LVN ER


Hospital policy, "Nurse Staffing Plan, Guidelines" stated, in part, "An RN will be immediately available to assist and supervise patient care as well as to respond to emergency situations."


Hospital policy, "Staffing Plan" stated, in part, "Registered nurses assess, delegate and coordinate the nursing care provided throughout the hospital."


Hospital policy, "WMC Emergency Department Nursing Roles and Responsibility" stated, in part, "The DON/ADON is a registered nurse responsible for staffing the ED with qualified personnel ...The ED manager is a registered nurse with experience in emergency nursing."


Hospital policy, "Assignments of Patient Care in ED" stated, in part, "1. ED patients are assessed initially by an RN 2. Subsequent treatment will be administered by either an RN or LVN (to be determined by the RN based upon patient needs). Standard of Practice: 1. On arrival to ED, patients are triaged by an RN."


In an interview the morning of 9/14/16 in the hospital conference room, the CNO confirmed the above findings.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record review and interview, the governing body (Board of Directors) failed to ensure that the medical staff bylaws contained criteria in accordance with State law, regulations, and guidelines, delineating the qualifications a medical staff member must possess in order to be granted privileges for the supervision of the provision of emergency care services. The governing body failed to ensure that all physicians working in the Emergency Department were granted privileges for the hospital.
Cross refer: A 0046

Based on interview, observation, and document review, the hospital failed to ensure that a physician was available at all times for emergencies, on duty or on call at all times and the hospital failed to ensure that a physician on-call list was maintained for emergency call duty, including alternatives. Between 9/1/16 and 9/12/16, 17 individuals presented to the Weimar Medical Center Emergency Department for examination and treatment and were not seen by a physician as no physician was available and no physician was on emergency call duty. This presents a risk of patient harm and is in violation of facility policy.
Cross refer: A0067


Based on interview, observation, and document review, the hospital failed to ensure a safe setting for patients in that a physician was no available, on duty or on call at all times to meet the emergency needs of patients. Review of physician schedules for 9/1/16 through 9/12/16 revealed there was no physician in the hospital or on call or able to respond within 30 minutes. Between 9/2/16 and 9/12/16, 17 individuals presented to the Weimar Medical Center Emergency Department for examination and treatment and were not seen by a physician as no physician was available or contacted. The 17 individuals did not receive a medical screening examination or a nursing assessment. The facility failed to ensure each patient had the right to make informed decisions regarding his or her care, failed to provide a safe and sanitary environment for staff and patients, and failed to implement policy for patient rights for confidentially; as verbal orders are taken out of the hospital to the doctors clinic to obtain the physicians signatures.
Cross refer: A0115


Based on a review of documentation, observation, and interview, the hospital failed to ensure that current standards of nursing were followed and failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient as nurses failed conduct nursing assessments and obtain vital signs of patients presenting to the hospital emergency department, failed to notify a physician of a patient presenting to the emergency department for medical screening examination and treatment, failed to obtain a physician order prior to arranging a transfer of a patient, failed to accurately and completely report and document: patient's status including signs and symptoms; nursing care rendered, patient response(s); failed to document or communicate when a patient was transferred, failed to ensure a medical record was maintained on every patient seeking emergency care, failed to ensure that verbal orders were used infrequently, and failed to comply with hospital EMTALA policies. The hospital failed to ensure that nursing services were supervised by a registered nurse in each department (Emergency Department and the In-Patient Unit) for 17 of 75 shifts. The hospital failed to provide the immediate availability of at least one RN in the event of an emergency in the ED and at least one RN immediately available in the event of an emergency on the in-patient unit (floor).
Cross refer: A0385

Based on interview, observation, and document review, the hospital failed to ensure that a physician was available at all times to meet the emergency needs of patients. Review of physician schedules for 9/1/16 through 9/12/16 revealed there was no physician in the hospital or on call or able to respond within 30 minutes. Between 9/2/16 and 9/12/16, 17 individuals presented to the Weimar Medical Center Emergency Department for examination and treatment and were not seen by a physician as no physician was available or contacted. The 17 individuals did not receive a medical screening examination. The hospital failed to ensure that a medical record indicating patient identification, complaint, physician, nurse, time admitted to the emergency suite, treatment, time discharged , and disposition was maintained for every individual who presented to the hospital emergency department for evaluation or treatment. This was not in compliance with facility policy. The hospital failed to ensure that the Emergency Department was organized under a qualified member of the medical staff, who is the medical director or clinical director. This presents a risk that the quality, safety and appropriateness of patient care services provided are not monitored and evaluated on a regular basis and deficiencies addressed.
Cross refer: A1100




Based on observation, review of documentation and staff interview the facility governing body failed to enforce the hospital patient transfer policy as 17 persons that presented on 9 of 12 days did not receive a personal examination and evaluation by a hospital physician before transfer to another hospital or being told by hospital nurses to go to the clinic while the hospital's emergency department was on diversion. This deficient practice could have caused potential harm to all presenting to the emergency department. The governing body failed to ensure that the hospital maintained a concise Patient Safety Program (PSP), in writing, approved by the governing body, and made available for review by the Texas Department of State Health Services, as specified in 25 Texas Administrative Code Operational Requirements, 133.48(a)(2).

Findings were:

A tour was conducted of the Emergency Department the afternoon of 9/12/16, accompanied by Staff #19, Infection Control. During an interview on 9/12/16 at approximately 1:35 pm Staff #16, RN was asked for a verbal process of how persons that present to the emergency department are received and provided treatment. Staff #16 stated the nurse gives them a clip board with registration information the person is asked to complete. Staff #16 stated the nurse takes the person's vital signs and then they notify the doctor. When the surveyor asked who the doctor was in the emergency department on 09/12/16 at approximately 1:35 pm Staff #16 stated "We don't have a doctor for today. If the person has an emergent condition we will call 911. If the person is not emergent we transfer them." When asked who makes the determination Staff #16 stated the nurses have been since the emergency department went on diversion. When asked how the person is transferred if it is determined they don't have an emergent condition, Staff #16 stated if the person was brought to the hospital by someone else they are told to go to Columbus hospital ER or the nearest ER. Staff #16 stated they also tell them to go to the clinic next door if it is open. When Staff #16 was asked when she would call a physician to the emergency department for a person during the diversion, Staff #16 stated "If they are coding, whatever doctor is covering the clinic we would call them." Staff #16 stated the clinic hours are 8:00 am -5:00 pm Monday - Friday but the doctors may be there until 6:00 pm: Saturday clinic hours are 9:00am - 12:00pm.

Facility policy, "Transfer Policy" dated "January, 1991" stated, in part, "A. The Governing Body of Colorado-Fayette Medical Center, after consultation with the Medical Staff, has adopted the following policy according to rules adopted by the Texas Department of Health regarding the evaluation, treatment, and transfer of patients from this hospital to another hospital in a medically appropriate manner. B. PATIENT EVALUATION When a patient (patient defined as an individual seeking medical treatment) arrives on hospital property (including a non-hospital owned ambulance or private care on hospital property) who: 1. may or may not be under the immediate supervision of a personal attending physician; 2. has one or more undiagnosed or diagnosed medical conditions; and 3. within reasonable medical probability, requires immediate or continuing hospital services and medical care.
The patient must be: 1. evaluated by a physician who is present in the hospital at the time the patient presents or is presented; or 2. evaluated by a physician on call who: a. is physically able to reach the patient within thirty (30) minutes, after being informed that a patient is present at the hospital who requires immediate medical attention, or b. is available by direct telephone or radio communication within thirty (30) minutes with authorized personnel at the hospital under orders to assess and report the patient's condition to the physician.
The transferring physician will personally examine and evaluate the patient before an attempt to transfer is made;" The policy also stated "E. ENFORCEMENT The Governing Body will enforce its patient transfer policy in the same fair manner as it enforces the other policies and procedures that the governing body has adopted for the governance of the hospital."

During an interview on 9/12/16 at approximately 2:10 pm in the hospital emergency department Staff #2, CNO was asked if any of the 18 persons that presented on the "Diversion Log" received a medical screening examination (MSE) by a physician. Staff #2 stated "None of them received a MSE because there was no physician available to do it. The physicians at the clinic stated they didn't feel they were able to assist us on a 24 hour basis. I did attempt to find a solution. They did not tell us until 5:00 pm on 8/31. We had no time to make a plan. I sent out an email to our nursing staff and to the agency nursing Hopewell Staffing and Medical Staffing Network. Initially I told them to call the doctors at the clinic and then I had to change that when the doctors said they could not do it."

During an interview on 9/13/16 at approximately 8:52 am in the hospital emergency department Staff #28, RN PRN, was asked what she was told to do for anyone that came to the hospital emergency department during the diversion. Staff #28 stated "I am here to respond to any person seeking ER care and determine if I need to do a 911 call. I had a lady come in and she had sinus congestion and a headache. Her son drove her to the ER. It was Saturday with 1 doctor at the clinic so I told her to go to the clinic. Staff #28 was asked if the person was given a medical screening examination. Staff #28 stated "No. I could just do a well check."

Review of 25 TAC 133.48(a)(2) stated, in part, "The hospital must develop, implement and maintain an effective, ongoing, organization-wide, data-driven Patient Safety Program (PSP).
(A) The governing body must ensure that the PSP reflects the complexity
of the hospital's organization and services, including those services furnished under contract or arrangement, and focuses on the prevention and reduction of medical errors and adverse events.
(B) The PSP must be in writing, approved by the governing body and made available for review by the department. It must include the following components:
(i) the definition of medical errors, adverse events and reportable events;
(ii) the process for internal reporting of medical errors, adverse events and reportable events;
(iii) a list of events and occurrences which staff are required to report internally;
(iv) time frames for internal reporting of medical errors, adverse events and reportable events;
(v) consequences for failing to report events in accordance with hospital policy;
(vi) mechanisms for preservation and collection of event data;
(vii) the process for conducting root cause analysis;
(viii) the process for communicating action plans; and
(ix) the process for feedback to staff regarding the root cause analysis and action plan."

In the entrance conference for the survey the afternoon of 9/12/16 in the facility conference room, a request was made by the survey team to review the hospital Patient Safety Program.
The afternoon of 9/13/16, a second request was made to Staff #1, President, for the facility Patient Safety Program. The regulation, 25 TAC, Chapter 133.48 was reviewed with Staff #42, RN, PRN and Staff #19, Infection Control. Staff #19 presented a Safety Manual and a document titled "Safety Management Plan". In reviewing the plan, it was determined that all the required components of 133.48(a)(2) were not included in the plan. This was confirmed with Staff #42 and Staff #19.

Review of the policy titled Safety Management Plan on the morning of 9/14/16, Staff #19 presented the policy, "Safety Management Plan". The plan did not document definitions of medical errors or adverse events. There was no documented evidence in the plan provided to the surveyor of consequences for failing to report events. There was no documented evidence for the process for communicating action plans and process for feedback to staff regarding the root cause analysis and action plan. The plan did not document that within 45 days of becoming aware of the specified reportable events, the hospital must complete a root cause analysis to examine the cause and effect of the event through an impartial process and develop an action plan that identifies the strategies that the hospital intends to employ to reduce the risk of similar events occurring in the future with specified time frames for implementation. The plan did not include an action plan that included a strategy for measuring the effectiveness of actions taken.

There was no Patient Safety Program, maintained as a concise program that contained all components of 133.48 readily available for review at the time of the survey. The above findings were confirmed in an interview the morning of 9/14/16 with Staff #42 in a facility office.
VIOLATION: MEDICAL STAFF Tag No: A0044
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interviews with the staff, the governing body failed to enforce and implement the medical staff rules and regulations. In 3 of 5 in-patient medical records reviewed revealed the patients were discharged without discharge orders from the physician. In addition there was only one progress note on patient #9 medical record and no progress notes on patient # 13 medical records.

Findings were:

In 3 of 5 (# 11, 12, 13) in-patient medical records reviewed, there were no physician orders for the patient to be discharged . Patient # 11 admitted [DATE] discharge 8/8/16. Patient # 12 admitted [DATE] discharge 7/11/16. Patient # 13 admitted ,d+[DATE]-[DATE].

Patient # 9 admitted [DATE] discharge 9/11/16, medical record contain 1 progress notes and patient # 13 record contain no progress notes.

Review of Weimar Medical Center Medical Staff Rules and Regulations Admissions and Discharges of Patients stated, "1.5, Patients may be discharged on ly on written order of the Attending Physician. At the time of discharge, the Attending Physician will see that the medical record contains a final diagnosis. 7. Medical Records 7.1, the attending physician will be responsible for preparation of the complete medical record of each patient. This record will include (a) the identification data, chief complaint, personal history, family history, history of present illness, physical examination, special reports, such as consultations, clinical history, x-rays, and others; (b) provisional findings, progress notes, final diagnosis, condition on discharge including diet, medication, and activity of patient; and (c) summary or discharge note, follow-up, and autopsy when available. No medical records will be filed until it is complete, except on the order of the Chief Executive Officer. 7.2, All original medical records are Hospital property and cannot be removed from the Hospital ' s safekeeping without the permission of the Hospital Chief Executive Office. "

Review of Weimar Medical Center Discharge Planning-Role of Nursing Staff Policy stated, "RN are expected to identify discharge requirements at the time of admission assessment and on an ongoing basis through tout the hospital stay. 4. The RN or LVN should consult with the physician and Social Services during the patient ' s hospitalization to coordinate any post-discharge continued care requirements or availability of required equipment."

Discharge Instructions Standard of Practice stated, "6. The Physician orders specific discharge instructions and prescribes which medications are to be taken regularly and as needed upon discharge from the hospital."

In an interview with staff # 37 at the facility in the small conference room on 9/13/16, at 2:55 pm, staff # 37 stated, some of the physicians do not write all of their orders and staff # 37 was not aware these patients had been discharged without physician's orders. During the interview it was revealed the nurses write all of the verbal orders when the doctors make rounds, the physicians rarely write any orders. The verbal orders are taken to doctor's clinic next door. The nurse will wait for the orders to be sign, then bring the verbal orders back to the hospital. In an interview with staff # 2 CNO, and staff # 1 president, the surveyor asked if they were aware of this, both staff said yes they are having a problem, but it will be fixed.
VIOLATION: MEDICAL STAFF - APPOINTMENTS Tag No: A0046
Based on record review and interview, the governing body (Board of Directors) failed to ensure that the medical staff bylaws contained criteria of medical staff membership in accordance with State law, regulations, and guidelines, delineating the qualifications a medical staff member must possess in order to be granted privileges for the supervision of the provision of emergency care services. The governing body failed to ensure that all physicians working in the Emergency Department were granted privileges for the hospital.


Findings included:


Weimar Medical Center Medical Staff Bylaws stated, in part, "Membership of the Medical Staff of the Hospital is a privilege that shall be extended only to Practitioners who continuously meet the qualifications, standards, and requirements set forth in these Bylaws. No Practitioner ...shall admit or provide medical or health-related services to patients in the Hospital unless he or she is a Member of the Medical Staff, and has been granted Clinical Privileges in accordance with the procedures set forth in these Bylaws."


Review of the Board of Directors meeting minutes for the Weimar Hospital provided to the surveyor the morning of 9/13/16 revealed no documented evidence that the Board granted privileges to 2 physicians who had practiced at the hospital, including Staff #34 ED Physician, and Staff #35 ED Physician. Staff #34 worked at least 3 shifts in the Emergency Department between February and August 2016. Staff #35 worked at least 9 shifts in the Emergency Department between February and August 2016.


Hospital policy, "Emergency Physicians" stated, in part, "1. The provision of emergency services will be supervised by a qualified member of the medical staff during all times the hospital makes emergency services available ...3. The medical staff must establish criteria, in accordance with State law, regulations, and guidelines, delineating the qualifications a medical staff member must possess in order to be granted privileges for the supervision of the provision of emergency care services. Qualifications include necessary education, experience and specialized training, consistent with State law and acceptable standards of practice. (Done through physician credentialing)."


Review of the Weimar Medical Center Medical Staff Bylaws revealed no documented evidence of criteria delineating the qualifications a medical staff member must possess in order to be granted privileges for the supervision of the provision of emergency care services.


An interview was conducted the morning of 9/14/16 in the hospital conference room with the hospital administrator who confirmed the above findings.
VIOLATION: CARE OF PATIENTS - MD/DO ON CALL Tag No: A0067
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, observation, and document review, the hospital failed to ensure that a physician was available at all times for emergencies, on duty or on call at all times, and the hospital failed to ensure that a physician on-call list was maintained for emergency call duty, including alternatives. Between 9/1/16 and 9/12/16, 17 individuals presented to the Weimar Medical Center Emergency Department for examination and treatment, were not seen by a physician as no physician was available and no physician was on emergency call duty. This presents a risk of patient harm and is in violation of facility policy.


Findings included:


An interview was conducted the afternoon of 9/12/16 in the hospital conference room with the Chief Nursing Officer (CNO), who stated that there was currently no physician in the Emergency Department as the ED was "on diversion" and there had not been a physician in the Emergency Department since 9/1/16.


An interview was conducted the afternoon of 9/12/16 in the administrator's office with the hospital administrator, who stated that there had not been an ED physician in the hospital or on call for the emergency department since 9/1/16 due to a "contract dispute."


In a subsequent interview conducted with the hospital administrator at 9:00 am the morning of 9/14/16 in the hospital conference room, he stated that the hospital did not maintain an on-call list of physicians. There was no documented evidence of an on-call list of physicians provided to the surveyors.


Review of the Emergency Department physician staffing schedule for the month of September 2016 provided to the surveyors revealed no physician scheduled for September 1 - 11, 2016. A physician was scheduled for September 12, 2016, beginning at 23:55 (11:55 pm).


Review of the "Physician Time Sheet, ER Physician Sign In Log" provided to the surveyors revealed no physicians signing in for September 1 - 11, 2016. A physician signed in on 9/12/16 at 11:45 PM.


Hospital policy, "Emergency Physicians" stated, in part, "1. The provision of emergency services will be supervised by a qualified member of the medical staff during all times the hospital makes emergency services available. 2. The aforementioned medical supervisor may be briefly absent from the emergency department, but is expected to be in the hospital and immediately available to provide direction and/or direct care during the operating hours of the emergency department."


Hospital policy, "Medical Staff Coverage of the Emergency Department" stated, in part, "1. there is 24 hour physician coverage in the ED. 2. Also, there are physicians "on call" who receive "unassigned" patients who require admission. Those positions are also available to come in if the ED Dr. needs back-up."


Hospital policy, "EMTALA", stated, in part, "The Emergency Medical Treatment and Active Labor Act ("EMTALA") requires Medicare participant hospitals to provide medical screening examinations to all persons who present on Weimar Medical Center's (WMC) property and request service ...
E. Miscellaneous ...
5. List of On-Call Physicians. The Weimar Medical Center must maintain a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition."


An interview was conducted the afternoon of 9/12/16 in the hospital conference room with the Chief Nursing Officer (CNO), who stated that there was currently no physician in the Emergency Department as the ED was "on diversion" and there had not been a physician in the Emergency Department since 9/1/16. The CNO provided a 2 page document entitled, "Diversion Log" to the surveyors.


Review of the Diversion Log provided to the surveyors the afternoon of 9/12/16 in the hospital conference room revealed that 17 individuals (Patients #25, 26, 27, 28, 29, 30, 31, 32, 36, 37, 38, 39, 40, 41, 42, 43, and 44) presented to the Emergency Department for examination and treatment between 9/2/16 and 9/12/16. These individuals did not receive a medical examination and were not seen by a physician. The 17 individuals included an [AGE] year old patient with dehydration, a [AGE] year old patient with fever, an [AGE] year old patient with a chief complaint of "fall", a patient having "difficulty breathing," another patient with "shortness of breath," a patient with left shoulder pain radiating to the left jaw, a patient with a right hand injury, a patient with a foreign object in the right eye, back pain, and individuals with other complaints including sinus/sneezing, a cat scratch to finger, generalized weakness, and a patient with abdominal and c-section complaints.


In an interview with the CNO the afternoon of 9/12/16, she confirmed that the 17 individuals listed on the Diversion Log presented to the hospital ED between 9/2/16 and 9/12/16 for examination and treatment. The CNO stated that the 17 individuals were not seen by a physician and did not receive a medical examination or treatment by a physician. The CNO stated that there was no physician available and a physician was not contacted to perform a medical examination or provide treatment for these 17 individuals. In addition, the 17 individuals were not assessed by an RN or other hospital staff member. Eight of the 17 individuals were informed to "Go to Columbus." The CNO confirmed that "Columbus" meant Columbus Community Hospital, approximately 15 miles from the Weimar Medical Center. Another individual was advised to "Go to closet (sic) ER." EMS was contacted for 3 patients and the 3 patients (Patients #30, 31, and 32) departed the hospital via EMS.


In an in-person interview conducted with the hospital administrator at 9:00 am the morning of 9/14/16 in the hospital conference room, he stated that the hospital did not maintain an on-call list of physicians. There was no documented evidence of an on-call list of physicians provided to the surveyors.


The above findings were confirmed in an interview the afternoon of 9/14/16 in the hospital conference room with the administrator and the CNO.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, observation, and document review, the hospital failed to ensure a safe setting for patients in that a physician was not available, on duty, or on call at all times to meet the needs of patients. Review of physician schedules for 9/1/16 through 9/12/16 revealed there was no physician in the hospital or on call or able to respond within 30 minutes. Between 9/2/16 and 9/12/16, 17 individuals presented to the Weimar Medical Center Emergency Department for examination and treatment were not seen by a physician as no physician was available or contacted. The 17 individuals did not receive a medical examination or a nursing assessment. This presents a risk for serious patient harm or death..
Cross refer: A0144


Based on review of medical records and interview, the facility failed to ensure each patient had the right to make informed decisions regarding his or her care.
Cross refer: A0131


Based on review of facility documents, observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patients.
Cross refer: A0144


Based on interviews with nursing staff #37 and staff #2, the hospital failed to implement policy for patient rights for confidentially; as verbal orders are taken out of the hospital to the doctors clinic to obtain the physicians signatures.
Cross refer: A0146
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on review of medical records and interview, the facility failed to ensure each patient had the right to make informed decisions regarding his or her care.

Findings included:

Facility policy titled "Against Medical Advice, Leaving Hospital" stated in part, "Policy: If a patient insists on being discharged against the advice of the attending physician, the hospital must allow the patient to leave. An attempt should be made to fully explain to the patient or to the responsible parent or legal guardian the dangers of such a decision.

Procedure:

A. The physician and/or hospital staff should attempt to fully explain the consequences ofd leaving the hospital to the patient or the responsible parent or legal guardian. This should be documented in the progress notes by the physician, in the Nurses' Notes by the nurse or on the emergency room form by either the physician or the nurse ...

B. Secure 'Leaving Hospital Against Advice' form and fill in the blanks.

C. The hospital should try to get the patient to sign the AMA (Against Medical Advice) form acknowledging that he/she is leaving against the physician's advice. If the patient refuses to sign such a statement, note on the form that the patient has refused to sign, date it as of the day of refusal and witness by hospital personnel present (at least 2) who have heard the patient refuse.

D. This form whether signed by patient or refused and properly witnessed should be placed in the chart to become a part of the medical record ..."


A. Review of the medical record for patient #20 revealed patient #20 left AMA on 7/27/16, there was no AMA paperwork and no documentation of refusal to sign.

Review of the medical record for patient #22 revealed patient #22 left AMA on 7/27/16, there was no AMA paperwork and no documentation of refusal to sign.

In an interview with the CNO on the afternoon of 9/14/16, she verified there were no documentation of the patient's consenting or refusing to sign the AMA form.


B. Review of the medical record for patient #18 revealed patient #18 was transferred from the facility on 8/26/16. The patient signed the consent for treatment and other documents. Consent for transfer stated in part, "Verbal consent from patient/his mother by phone" and was signed by one registered nurse. In an interview with the CNO on the afternoon of 9/14/16, she stated, "The policy is you must have two nurses sign off when there is a verbal consent."


C. Review of the medical record for patient #23 revealed patient #23 was admitted and treated in the emergency department for approximately two hours. The consent for treatment was unsigned.


In an interview with the CNO on the morning of 9/14/16, she verified the consent for treatment should be signed by the patient before any treatment begins.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, observation, and document review, the hospital failed to ensure a safe setting for patients in that a physician was not available, on duty, or on call at all times to meet the needs of patients. Review of physician schedules for 9/1/16 through 9/12/16 revealed there was no physician in the hospital or on call or able to respond within 30 minutes. Between 9/2/16 and 9/12/16, 17 individuals presented to the Weimar Medical Center Emergency Department for examination and treatment and were not seen by a physician as no physician was available or contacted. The 17 individuals did not receive a medical examination or a nursing assessment. This presents a risk for serious patient harm or death.


Findings included:


An interview was conducted the afternoon of 9/12/16 in the hospital conference room with the Chief Nursing Officer (CNO), who stated that there was currently no physician in the Emergency Department as the ED was "on diversion" and there had not been a physician in the Emergency Department since 9/1/16. The CNO provided a 2 page document entitled, "Diversion Log" to the surveyors.


Review of the Diversion Log provided to the surveyors the afternoon of 9/12/16 in the hospital conference room revealed that 17 individuals (Patients #25, 26, 27, 28, 29, 30, 31, 32, 36, 37, 38, 39, 40, 41, 42, 43, and 44) presented to the Emergency Department for evaluation and treatment between 9/2/16 and 9/12/16. These individuals did not receive a medical examination. The 17 individuals included an [AGE] year old patient with dehydration, a [AGE] year old patient with fever, an [AGE] year old patient with a chief complaint of "fall", a patient having "difficulty breathing", another patient with "shortness of breath", a patient with left shoulder pain radiating to the left jaw, a patient with a right hand injury, a patient with a foreign object in the right eye, back pain, and individuals with other complaints including sinus/sneezing, a cat scratch to finger, generalized weakness, and a patient with abdominal and c-section complaints.


In an interview with the CNO the afternoon of 9/12/16, she confirmed that the 17 individuals listed on the Diversion Log presented to the hospital ED between 9/2/16 and 9/12/16 for examination and treatment. The CNO stated that the 17 individuals were not seen by a physician and did not receive a medical examination or treatment by a physician. The CNO stated that there was no physician available and a physician was not contacted to perform a medical examination or provide treatment for these 17 individuals in the event of a medical emergency. In addition, the 17 individuals were not assessed by an RN or other hospital staff member. Eight of the 17 individuals were informed to "Go to Columbus". The CNO confirmed that "Columbus" meant Columbus Community Hospital, approximately 15 miles from the Weimar Medical Center. Another individual was advised to "Go to closet (sic) ER." EMS was contacted for 3 patients and the 3 patients (Patients #30, 31, and 32) departed the hospital via EMS.


An interview was conducted at 9:45 am on 9/14/16 in the Emergency Department with Staff #13 RN, who stated that she was working in the ED when Patient #32 (MDS) dated [DATE] with a chief complaint of "difficulty breathing." Staff #13 stated that she did not perform or document a nursing assessment on Patient #32, that she did not take or document vital signs on Patient #32, and she did not contact a physician about Patient #32 as "there were no physicians to call." Staff #13 stated that she did not create a medical record or ensure there was a memorandum of transfer for Patient #32. Staff #13 stated that she called 911 per the request of Patient #32. Staff #13 stated that she did not provide any documentation on Patient #32 to EMS and she did not contact another hospital or physician about receiving Patient #32. Staff #13 stated that there was no patient consent or physician certification signed for transfer.


A tour was conducted of the Emergency Department the afternoon of 9/12/16, accompanied by Staff #19, Infection Control staff. During an interview on 9/12/16 at approximately 1:35 pm Staff #16, RN was asked for a verbal process of how persons that present to the emergency department are received and provided treatment. Staff #16 stated the nurse gives them a clip board with registration information the person is asked to complete. Staff #16 stated the nurse takes the person's vital signs and then they notify the doctor. When the surveyor asked who the doctor was in the emergency department on 09/12/16 at approximately 1:35 pm Staff #16 stated "We don't have a doctor for today. If the person has an emergent condition we will call 911. If the person is not emergent we transfer them." When asked who makes the determination, Staff #16 stated the nurses have been since the emergency department went on diversion. When asked how the person is transferred if it is determined they don't have an emergent condition, Staff #16 stated if the person was brought to the hospital by someone else they are told to go to Columbus hospital ER or the nearest ER. Staff #16 stated they also tell them to go to the clinic next door if it is open. When Staff #16 was asked when she would call a physician to the emergency department for a person during the diversion, Staff #16 stated "If they are coding, whatever doctor is covering the clinic we would call them." Staff #16 stated the clinic hours are 8:00 am -5:00 pm Monday - Friday but the doctors may be there until 6:00 pm: Saturday clinic hours are 9:00am - 12:00pm.


During an interview on 9/13/16 at approximately 8:52 am in the hospital emergency department Staff #28, RN PRN, was asked what she was told to do for anyone that came to the hospital emergency department during the diversion. Staff #28 stated "I am here to respond to any person seeking ER care and determine if I need to do a 911 call. I had a lady come in and she had sinus congestion and a headache. Her son drove her to the ER. It was Saturday with 1 doctor at the clinic so I told her to go to the clinic. Staff #28 was asked if the person was given a medical examination. Staff #28 stated "No. I could just do a well check."


During an interview on 9/12/16 at approximately 2:10 pm in the hospital emergency department Staff #2, CNO, was asked if any of the 17 persons that presented on the "Diversion Log" received a medical examination by a physician. Staff #2 stated "None of them received an examination because there was no physician available to do it. The physicians at the clinic stated they didn't feel they were able to assist us on a 24 hour basis. I did attempt to find a solution. They did not tell us until 5:00 pm on 8/31/16. We had no time to make a plan. I sent out an email to our nursing staff and to the agency nursing Hopewell Staffing and Medical Staffing Network. Initially I told them to call the doctors at the clinic and then I had to change that when the doctors said they could not do it."


An interview was conducted the afternoon of 9/12/16 in the administrator's office with the hospital administrator, who stated that there had not been an ED physician in the hospital or on call for the emergency department since 9/1/16 due to a "contract dispute."


Review of the Emergency Department physician staffing schedule for the month of September 2016 provided to the surveyors revealed no physician scheduled for September 1 - 11, 2016. A physician was scheduled for September 12, 2016, beginning at 23:55 (11:55 pm).


Review of the "Physician Time Sheet, ER Physician Sign In Log" provided to the surveyors revealed no physicians signing in for September 1 - 11, 2016. A physician signed in on 9/12/16 at 11:45 PM.


Hospital policy, "Emergency Physicians" stated, in part, "1. The provision of emergency services will be supervised by a qualified member of the medical staff during all times the hospital makes emergency services available. 2. The aforementioned medical supervisor may be briefly absent from the emergency department, but is expected to be in the hospital and immediately available to provide direction and/or direct care during the operating hours of the emergency department."


Hospital policy, "Medical Staff Coverage of the Emergency Department " stated, in part, "1. there is 24 hour physician coverage in the ED. 2. Also, there are physicians "on call" who receive "unassigned" patients who require admission. Those positions are also available to come in if the ED Dr. needs back-up."


Hospital policy, "EMTALA" stated, in part, "The Emergency Medical Treatment and Active Labor Act ("EMTALA") requires Medicare participant hospitals to provide medical screening examinations to all persons who present on Weimar Medical Center's (WMC) property and request service, regardless of the person ' s ability to pay for medical services. If the person has an emergency medical condition, the Weimar Medical Center must treat or stabilize the person or provide for an appropriate transfer to another facility. Weimar Medical Center, it's employees and any physician providing services at the hospital will comply fully with the requirements of EMTALA.

Standard of Practice: ...1. Rights to Treatment ...Weimar Medical Center recognizes the right of the individual to receive, within the capabilities of the WMC ' s staff and facilities:

a. An appropriate medical screening examination ( " MSE " );

b. necessary stabilizing treatment for an emergency medical condition ...

c. if necessary, an appropriate transfer to another facility ...

2. "Comes to the Emergency Department" means the individual: a. has presented on Weimar Medical Center property, including the WMC ' s Emergency Department and requests examination or treatment for a medical condition, or has such a request made on his/her behalf.

6. "Transfer" means the movement (including the discharge) of an individual outside Weimar Medical Center ' s facility at the direction of any person employed (or affiliated or associated, directly or indirectly with) the hospital) ..."


Hospital policy, "Transfer Policy" last reviewed January, 2000 provided to the surveyor, stated, in part, " The Governing Body of Colorado-Fayette Medical Center ...has adopted the following policy according to rules adopted by the Texas Department of Health regarding the evaluation, treatment and transfer of patients from this hospital to another hospital in a medically appropriate manner. This policy must be adhered to whenever a patient arrives at the hospital seeking medical treatment ...The transferring physician will personally examine and evaluate the patient before an attempt to transfer is made ...The hospital will provide a memorandum of transfer, as prescribed by the Texas Department of health, to be completed for every patient who is transferred ....The Governing Body will enforce its patient transfer policy in the same fair manner as it enforces the other policies and procedures that the governing body has adapted for the governance of the hospital."


Review of the "Diversion Log" included the following documentation:
Date: 9/2/16
Patient #37. Name: "Unknown". DOB: [blank]. Arrival time: 2200. CC: "Shoulder Pain". Suggested Action: "EMS - AH Hosp they refused " .


Date: 9-3-16
Patient #25. DOB: [blank]. Arrival time: [blank]. CC: "ABD". Suggested Action: "Go To Closet (sic) ER" .
Patient #36. DOB: 11-18-1935. Arrival time: 1811. CC: "Fall". Suggested Action: "Go to Columbus" .
Patient #38. Name: "Unknown". DOB: "82". Arrival time: 1844. CC: "dehydration". Suggested Action: "Go To Columbus."


Date: 9-4-16
Patient #39. Name: "Unknown". DOB [blank] Arrival: 0115. CC: "Looking to buy E cylinder Regulatory " Suggested Action: "Sent with police to EMS " .
Patient #26. DOB: [blank]. Arrival: 1055. CC: "Pain". Suggested Action: "Go to nearest ER Dept or EMS" .
Patient #27. DOB: 4-21-15 Arrival: 1635. CC: "Fever". Suggested Action: [None].
Patient #40. Name: "Unknown". DOB: blank. CC: "Rt hand injury". Suggested Action: "Go to Columbus"


Date: 9-5-16
Patient #28. DOB: 4/21/69. Arrival: 1250. CC: "Foreign object in eye R eye." Suggested action: Referred to Columbus or clinic next door.
Patient #29. DOB: [blank]. Arrival: 2120. CC: "back pain". Suggested action: Columbus.
Patient #41. Name: "Unknown". DOB: [blank]. Arrival 2325. CC: "shortness of breath". Suggested action: Offered to call EMS. They stated No. Suggested Columbus.


Date 9-7-16
Patient #42. Name: "Unknown". DOB: [blank]. Arrival 0730. CC: "sinus/sneezing". Suggested action: go to clinic.
Patient #43. Name: "Unknown". DOB: [blank]. Arrival 1945. CC: "cat scratch to L index finger". Suggested action: Referred to Columbus ED.


Date 9-9-16
Patient #44. Name: "Unknown". DOB: [blank]. Arrival 1509. CC: "generalized weakness". Suggested action: "Go to Columbus ER."


Date 9-10-16
Patient #30. DOB: 12/62. Arrival 1235 (POV). CC: " Lft pos shoulder pain radiating to lft jaw " . Suggested action: Called Colorado EMS. Date 9/10/ at 1240. Departure: per EMS.


Date 9-11-16
Patient #31. DOB: 12/15/87. Arrival 1510. CC. "RL ABD and C-Section Area". Suggested Action: "Called 911 @ pt request " . Departure: Colorado EMS.


Date 9-12-16
Patient #32. DOB: 4/19/1982 34YF. Arrival POV 0314. CC: "Difficulty breathing". Suggested Action: " Call 911 per patient request " Departure CCMS 0325.


The above findings were confirmed in an interview the afternoon of 9/14/16 in the hospital conference room with the administrator and the CNO.






Based on review of facility documents, observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patients.


Findings included:

"OSHA/Blood Borne Pathogen Regulations Policy #138-030-060" stated in part, "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."


Facility policy titled, "Infection Prevention in the ED [Emergency Department]" stated in part,
"Purpose:
1. To prevent spread of infection.
2. To provide safe environment for the ED patient.

Policy: ...
5. The housekeeping department is responsible for daily cleaning of the emergency room . This consists of floor care, work surfaces, and restrooms."


Facility policy titled, "Infection prevention for dietary" stated in part, "Labeling: Food and non-food supplies are clearly labeled with name and date."


Facility policy titled "Responsibility for Preparation, Storage, Distribution, and Administration of Food" stated in part, "All food and beverages will be prepared, stored and delivered to the nursing units under a safe and sanitary conditions [sic] by the Dietary Department Emplyees [sic]."


Facility policy titled "Ancillary Areas" stated in part, "4. All visible ledges and surfaces in the room should be checked daily for dust. Perform necessary dusting of the ledges that can be easily reached. Clean hard to reach items on a periodic schedule ...
5. Check such areas as:
...f. floor corners
g. lamp shades
h. furniture, including lower rungs ..."


Facility policy titled "Cleaning Procedures" stated in part, "e. Damp dusting all fixtures, dispensers, furnishings, and permanently attached equipment ...
f. Cleaning lights above beds, include all call lights, buzzers and cords ..."


Tour of the facility on the afternoon of 09/12/16 revealed the following:

emergency room [ER] 1:

Four holes and crack in the wall above the crash cart

Three 21 gauge 1.25 inch blood collection needles with luer adapters were opened and available for patient use

One ceiling tile bowing out revealing the area above

Three ceiling tiles with holes exposing the area above

Layer of dust on overbed light

Vent with visible dirt

Visible dirt and dust on several ceiling tiles


ER hallway:

Five ceiling tiles with holes exposing the area above

One stained ceiling tile

Rust throughout metal trimming on the ceiling

Wires hanging out of a wall socket [picture 5]

Chipped wall corner

Fire exit with exterior light shining through

Visible dirt on floor underneath chairs

Visible dirt on four out of five chairs

One dead cricket

Wireless internet unit wire up to the ceiling, not sealed, exposing the area above


Radiology room:

Three ceiling tiles with holes exposing the area above

Two outlet holes uncovered on the wall

Two dead c[DIAGNOSES REDACTED] on the ground

One stained ceiling tile

Hole in the ceiling around CT equipment, not sealed, exposing the area above

Three floor tiles missing making it impossible to clean


Laboratory room:

Visible dirt on two vents

Three stained ceiling tiles

Ceiling tile around vent cracked and bowing down


Dry foods storage in the kitchen:

Cracks in two ceiling tiles

One stained ceiling tile

12 vanilla snack pack puddings expired 07/18/2016

Seven very vanilla glucose control drinks expired 05/24/2016

Two creamy strawberry glucose control drinks expired 05/04/2016

Three boxes of complete pancake mix expired 08/20/2016


Kitchen:

Four sugar-free snack pack puddings expired 07/18/2016

One creamy vanilla Swiss miss pudding expired 08/07/2016

Sugar and flour Rubbermaid containers with no date

Visible dirt build-up on wall and floor by three-compartment sink [Pitcures 1-4]

Visible dirt build-up on wall and floor behind oven and fryer [Pictures 1-4]


The above was verified during the tour on 09/12/16 with the infection control officer.


In an emergency treatment room two, excessive dust was observed on top of a wall mounted suction container, an otoscope charger, passport 2 Datascope monitor, overhead light, the ceiling vent, and horizontal counter surfaces during the tour on the afternoon of 9/12/2016. In addition there was 1 Dinamap machine without a biomedical inspection sticker.
The above findings were confirmed in an interview with staff #19, Infection Control, during the hospital tour on the afternoon of 9/12/2016.


In the central supply department a large ceiling opening with blue wires, three metal bars, and exposed insulation was observed in a side corner [pictures 7 and 8]. The above opening was confirmed in an interview with staff #36, Central Supply Manager during the tour on the morning of 9/13/2016. Staff #36 stated "It's been opened for 2-3 months now. I requested to have it fixed or just put some plywood up there within the last month." In an interview with staff #8, Plant Operations, on the morning of 9/13/2016 in the Central Supply room, when asked about the request to fix the ceiling opening, Staff #8 stated, "I haven't done it yet. There were some contractors that went up there to fix the AC compressor and knocked that down. We didn't have the funds to buy anything to fix it with. That's also the roof access."


In the central supply department, a corner with telephone wires had eight two-inch circular holes and 25 two-millimeter circular holes allowing for dust to accumulate [picture 6]. This was verified by Staff #8, Plant Operations, on the morning of 9/13/2016.


Tour of the rehabilitation room on the morning of 9/13/2016 revealed the following:
Four stained ceiling tiles
Holes in three ceiling tiles
One dead bug on the window sill
One dead bug on the ground


The above was verified with the Chief Nursing Officer on the morning of 9/13/2016.


The following expired supplies were found in the facility available for use:
In the emergency department on 9/12/2016, 2 foley catheter trays expired 8/2016. These were confirmed in an interview with staff #16, ED RN, the afternoon of 9/12/2016 in the hospital emergency department.


Tour of the facility on the morning of 9/13/2016 revealed the following expired supplies in the laboratory:

23 purple-top pediatric tubes expired 07/2016
Six gray-top tubes expired 08/2016
Total PSA CalCheck box expired 08/2016
Ferritin CalCheck 5 box expired 08/2016
Four T-uptake CalSet boxes expired 07/2016
Two Ferritin CalSet boxes expired 07/2016
FT 411 box expired 08/2016
Three Complete Metabolic Panel analyzer boxes expired 08/06/2016
Carbamazepine reagent box expired 06/2016
Gentamicin calibrator set expired 07/31/2016
Amm/ETOH/Co2 control normal vial expired 02/2016
Amm/ETOH/Co2 control abnormal vial expired 02/2016
Amm/ETOH/Co2 calibrator vial expired 05/2016
Instrument check box expired 07/2016
Serum index gen.2 box expired 07/2016


The above expired supplies were confirmed in an interview on 9/13/2016 with staff #5, the laboratory director.
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0146
Based on interviews with nursing staff #37 and staff #2, the hospital failed to implement policy for patient rights for confidentiality. Verbal orders are taken out of the hospital to the doctors clinic to obtain the physicians signatures.

Findings were:

In an interview with staff # 37 and staff # 2 at the facility in the small conference room on 9/13/16 at 2:55 pm, staff # 37 stated nurses write all of the verbal orders when the doctors make rounds, they rarely write any orders. The verbal orders are taken to doctor's clinic next door. The nurse will wait for the orders to be sign, then bring the verbal orders back to the hospital.

In an interview with staff # 2 CNO, and staff # 1 president, the surveyor asked if they were aware of this, both staff said yes they are having a problem, but it will be fixed.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on review of documentation and interview, the governing body failed to ensure that the Quality Improvement Committee maintained an ongoing Quality Assessment and Performance Improvement program as the committee had not met in over 4 months. This was not in compliance with the Quality Assessment/Performance Improvement Plan for Weimar Medical Center.


Findings included:


The Quality Assessment/Performance Improvement Plan for Weimar Medical Center stated, in part, "Quality improvement activities are reflected throughout the organization by Board of Governors, CEO/administration, Medical Staff, Department Directors/Supervisors and employees ...The Quality Improvement Committee meets at least quarterly."


Review of Quality Management meeting minutes provided to the survey on 9/14/16 in the hospital conference room revealed the last meeting was held on Monday, April 25, 2016, greater than 4 months previously.


An interview was conducted the morning of 9/14/16 with Staff #42, Quality Manager, who confirmed the above findings, including the last Quality Management meeting held on 4/25/16 and the hospital requirement for quarterly meetings.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on a review of documentation, observation, and interview, the hospital failed to ensure that nationally accepted standards of nursing practice were followed. The hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient in that nurses failed to:

1. conduct nursing assessments and obtain vital signs of patients presenting to the hospital emergency department,

2. notify a physician of a patient presenting to the emergency department for medical examination and treatment,

3. obtain a physician's order prior to transferring of a patient to another facility,

4. accurately and completely report and document: patient's status including signs and symptoms, nursing care rendered, patient response(s) to interventions,

5. document or communicate with a physician when a patient was transferred to another facility,

6. ensure a medical record was maintained on every patient that presents to the hospital for examination and/or treatment,

7. ensure that verbal orders were used infrequently,

8. ensure that patients were discharged appropriately as 3 of 5 in-patient medical records reviewed revealed the patients were discharged without discharge orders from the physician,

9. ensure progress notes were written consistently on all patients,

10. comply with hospital EMTALA policies.

These deficient practices were not consistent with nationally accepted standards of nursing practice, hospital policy, and state regulations and have the likelihood to cause serious harm to all patients.
.
Cross refer: A0386



Based on review of documentation and interviews with staff, the hospital failed to ensure that nursing services were supervised by a registered nurse in each department (Emergency Department and the In-Patient Unit) for 17 of 75 shifts. The hospital failed to provide the immediate availability of at least one RN in the event of an emergency in the ED and at least one RN immediately available in the event of an emergency on the in-patient unit (floor). The lack of adequate nurse staffing posed a likelihood for patient harm to patients.

Cross refer: A0392
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of documentation, observation, and interview, the hospital failed to ensure that nationally accepted standards of nursing practice were followed. The hospital failed to:

1. ensure that a registered nurse supervised and evaluated the nursing care for each patient in that nurses failed conduct nursing assessments and obtain vital signs of patients presenting to the hospital for examination and/or treatment,

2. notify a physician of a patient presenting to the hospital for medical examination and treatment,

3. to obtain a physician's order prior to transferring a patient to another facility,

4. to accurately and completely report and document: patient's status including signs and symptoms, nursing care rendered, patient response(s) to interventions,

5. to document in the medical record or communicate with a physician when a patient was transferred,

6. to ensure a medical record was maintained on every patient that comes to the hospital for examination and/or treatment,

7. to ensure that verbal orders were used infrequently,

8. to ensure that patients were discharged appropriately as 3 of 5 in-patient medical records reviewed revealed the patients were discharged without orders from a physician;

9. to ensure progress notes were written,

10. to comply with the hospital's EMTALA policies.

These deficient practices were not consistent with nationally accepted standards of nursing practice, hospital policy, and state regulations and have the likelihood to cause serious harm to all patients.


Findings:


An interview was conducted the afternoon of 9/12/16 in the hospital conference room with the Chief Nursing Officer (CNO), who stated that there was currently no physician in the Emergency Department as the ED was "on diversion" and there had not been a physician in the Emergency Department since 9/1/16. The CNO provided a 2 page document entitled, "Diversion Log" to the surveyors.


Review of the Diversion Log provided to the surveyors the afternoon of 9/12/16 in the hospital conference room revealed that 17 individuals (Patients #25, 26, 27, 28, 29, 30, 31, 32, 36, 37, 38, 39, 40, 41, 42, 43, and 44) presented to the Emergency Department for examinatin and/or treatment between 9/2/16 and 9/12/16. These individuals did not receive a medical examination and were not seen by a physician.


When asked, the CNO stated that the Emergency Department nursing staff did not perform a nursing assessment, but instructed the patients to seek care at another facility or call 911, or the nursing staff contacted 911 for the individuals to be transported to another facility. The 17 individuals included an [AGE] year old patient with dehydration, a [AGE] year old patient with fever, an [AGE] year old patient with a chief complaint of "fall," a patient having "difficulty breathing," another patient with "shortness of breath," a patient with left shoulder pain radiating to the left jaw, a patient with a right hand injury, a patient with a foreign object in the right eye, a patient with back pain, and other patient with complaints including sinus/sneezing, a cat scratch to finger, generalized weakness, and a patient with abdominal and c-section complaints. The CNO stated that there was no medical record initiated for any of the 17 patients.


In an interview with the CNO the afternoon of 9/12/16, she confirmed that the 17 individuals listed on the Diversion Log presented to the hospital between 9/2/16 and 9/12/16 for examination and/or treatment. The 17 individuals were not assessed by an RN or other hospital staff member, but were provided with a "suggested action" instead. Eight of the 17 individuals were informed by nursing staff to "Go to Columbus". The CNO confirmed that "Columbus" meant Columbus Community Hospital, approximately 15 miles from the Weimar Medical Center. Another individual (Patient #25) was advised to "Go to closet (sic) ER." EMS was contacted for 3 patients by the ED nurse and the 3 patients (Patients #30, 31, and 32) were taken to other hospitals via EMS. None of the above patients were assessed by an RN.


An interview was conducted at 9:45 am on 9/14/16 in the Emergency Department with Staff #13, RN, who stated that she was working in the ED when Patient #32 (MDS) dated [DATE] with a chief complaint of "difficulty breathing." Staff #13 stated that she did not perform or document a nursing assessment on Patient #32, that she did not take or document vital signs on Patient #32, and she did not contact a physician about Patient #32 as "there were no physicians to call". Staff #13 stated that she did not create a medical record for Ptient #32. Staff #13 stated that she called 911 per the request of Patient #32. Staff #13 stated that she did not provide any documentation on Patient #32 to EMS and she did not contact the other hospital regarding Patient #32. Staff #13 stated that there was no patient consent or physician certification signed for transfer.


A tour was conducted of the Emergency Department the afternoon of 9/12/16, accompanied by Staff #19, Infection Control staff. During an interview on 9/12/16 at approximately 1:35 pm Staff #16, RN was asked for a verbal process of how persons that present to the hosptal are received and provided treatment. Staff #16 stated the nurse gives them a clip board with registration information the person is asked to complete. Staff #16 stated the nurse takes the person's vital signs and then they notify the doctor. When the surveyor asked who the doctor was in the emergency department on 09/12/16 at approximately 1:35 pm Staff #16 stated "We don't have a doctor for today. If the person has an emergent condition we will call 911. If the person is not emergent we transfer them." When asked who makes the determination Staff #16 stated the nurses have been since the emergency department went on diversion. When asked how the person is transferred if it is determined they don't have an emergent condition, Staff #16 stated if the person was brought to the hospital by someone else they are told to go to Columbus hospital ER or the nearest ER. Staff #16 stated they also tell them to go to the clinic next door if it is open. When Staff #16 was asked when she would call a physician to the emergency department for a person during the diversion, Staff #16 stated "If they are coding, whatever doctor is covering the clinic we would call them." Staff #16 stated the clinic hours are 8:00 am -5:00 pm Monday - Friday but the doctors may be there until 6:00 pm: Saturday clinic hours are 9:00am - 12:00pm.


During an interview on 9/13/16 at approximately 8:52 am in the hospital emergency department Staff #28, RN PRN, was asked what she was told to do for anyone that came to the hospital emergency department during the diversion. Staff #28 stated "I am here to respond to any person seeking ER care and determine if I need to do a 911 call. I had a lady come in and she had sinus congestion and a headache. Her son drove her to the ER. It was Saturday with 1 doctor at the clinic so I told her to go to the clinic. Staff #28 was asked if the person was given a medical screening examination. Staff #28 stated "No. I could just do a well check."


During an interview on 9/12/16 at approximately 2:10 pm in the hospital emergency department Staff #2, CNO was asked if any of the 17 persons that presented on the "Diversion Log" received a medical examination by a physician. Staff #2 stated "None of them received an examination because there was no physician available to do it. The physicians at the clinic stated they didn't feel they were able to assist us on a 24 hour basis. I did attempt to find a solution. They did not tell us until 5:00 pm on 8/31. We had no time to make a plan. I sent out an email to our nursing staff and to the agency nursing Hopewell Staffing and Medical Staffing Network. Initially I told them to call the doctors at the clinic and then I had to change that when the doctors said they could not do it."


Facility policy "General Standards of Care" stated, in part, "A. All patients presenting to the ED for evaluation and treatment will receive an assessment performed by a registered nurse ...D. The assessment and treatment of the patient will be documented on the ED record per RN, LVN and physician."


Hospital policy, "Admission to the Emergency Department" stated, in part, "3. All patients presenting to the ED will have an ED record completed. 4. All patients will be assessed by an RN."


Hospital policy, "ED Record" stated, in part,

"1. A medical record is maintained on every patient seeking emergency care and is incorporated into the patient's permanent hospital record.

2. Every time a patients visits the emergency department/service, the following information is entered in the patient's medical record.

a. Patient identification (when not obtainable, the reason is entered in the medical record)

b. Time and means of arrival

c. Pertinent history of the illness or injury and physical findings, including the patient's vital signs (Data)

d. Emergency care given to the patient prior to arrival

e. Diagnostic and therapeutic orders (Action)

f. Clinical observations, including the results of treatment (Response)

g. Reports of procedures, tests, and results

h. Diagnostic impression

i. Conclusion at the termination of evaluation/treatment, including final disposition, the patient's condition on discharge or transfer, and any instructions given to the patient and/or family for follow-up care

j. The ambulance record of the patient is available to the physician and is filed with the ED record.

3. The medical record is authenticated by the practitioner who is responsible for its clinical accuracy.

4. All ED records, upon completion, area electronically filed as a part of the permanent medical record.

5. If a patient leaves AMA, that fact is recorded in the ED Record.

6. The nursing process is utilized in the Emergency Department in the following manner:

a. Data is gathered from the patient or family. (If the patient is in the ED as the result of an accident, the nurse will determine when and where the accident occurred.) The nurse records (in the space marked chief complaint) a pertinent history of the patient's illness or accident.

b. The nurse records any action taken.

c. The patient's response is recorded (where appropriate)."


Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,

" (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:

(A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;

(B) Implement measures to promote a safe environment for clients and others; ...

(D) Accurately and completely report and document:

(i) The client's status including signs and symptoms;

(ii) Nursing care rendered ...

(v) Client response(s); and

(vi) Contacts with other health care team members concerning significant events regarding client's status; "


Hospital policy, "EMTALA", stated, in part, "The Emergency Medical Treatment and Active Labor Act ("EMTALA") requires Medicare participant hospitals to provide medical screening examinations to all persons who present on Weimar Medical Center's (WMC) property and request service, regardless of the person ' s ability to pay for medical services. If the person has an emergency medical condition, the Weimar Medical Center must treat or stabilize the person or provide for an appropriate transfer to another facility. Weimar Medical Center, its employees and any physician providing services at the hospital will comply fully with the requirements of EMTALA.

Standard of Practice: ...

1. Rights to Treatment ...Weimar Medical Center recognizes the right of the individual to receive, within the capabilities of the WMC ' s staff and facilities:

a. An appropriate medical screening examination ( " MSE " );

b. necessary stabilizing treatment for an emergency medical condition ...

c. if necessary, and appropriate transfer to another facility ...

B. 2. " Comes to the Emergency Department " means the individual: a. Has presented on Weimar Medical Center property, including the WMC ' s Emergency Department and requests examination or treatment for a medical condition, or has such a request made on his/her behalf ...

3. "Emergency medical condition " means a medical condition manifesting it's self by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and symptoms of substance abuse) that in the absence of immediate medical attention could reasonably be expected to result in: a. placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; b. serious impairment to any bodily functions; c. serious dysfunction of any bodily organ or part ...

4. " Hospital property " means the entire main Weimar Medical Center campus, including the parking lot, sidewalks, and driveway ...

5. " Stabilized " means, with respect to an emergency medical condition that no material deterioration of the condition is likely, within reasonable medical probability and, to result from or occur during the transfer of the individual from a facility, or, with respect to a pregnant woman in labor, that the woman has delivered the child and the placenta.

6. " Transfer " means the movement (including the discharge) of an individual outside Weimar Medical Center ' s facility at the direction of any person employed (or affiliated or associated, directly or indirectly with) the hospital, but does not include such a movement of an individual who has been declared dead, or who leaves the facility without the permission of any such person (i.e., leaves against medical advice) ...

C. Patient Evaluation and Treatment

1. When an individual comes to the Emergency Department seeking medical treatment, the individual must receive a medical screening examination to determine whether the individual has an emergency medical condition ..."


The above findings were confirmed in an interview with the CNO and the hospital administrator the afternoon of 9/14/16 in the hospital conference room.


Review of patient medical records revealed that 3 of 5 (Patient # 11, 12, 13) in-patient medical records reviewed did not have physician's orders for the patient to be discharged . Patient # 11 admitted [DATE], discharge 8/8/16. Patient # 12 admitted [DATE], discharge 7/11/16. Patient # 13 admitted ,d+[DATE]-[DATE].

Patient # 9 admitted [DATE], discharge 9/11/16, the medical record contained only 1 progress note and patient # 13 record contained no progress notes.


Review of Weimar Medical Center Medical Staff Rules and Regulations Admissions and Discharges of Patients stated,

"1.5 Patients may be discharged on ly on written order of the Attending Physician. At the time of discharge, the Attending Physician will see that the medical record contains a final diagnosis.

7. Medical Records

7.1 the attending physician will be responsible for preparation of the complete medical record of each patient. This record will include

(a) the identification data, chief complaint, personal history, family history, history of present illness, physical examination, special reports, such as consultations, clinical history, x-rays, and others;

(b) provisional findings, progress notes, final diagnosis, condition on discharge including diet, medication, and activity of patient; and

(c) summary or discharge note, follow-up, and autopsy when available. No medical records will be filed until it is complete, except on the order of the Chief Executive Officer. 7.2 All original medical records are Hospital property and cannot be removed from the Hospital ' s safekeeping without the permission of the Hospital Chief Executive Office. "


Review of Weimar Medical Center Discharge Planning-Role of Nursing Staff Policy stated, "RN are expected to identify discharge requirements at the time of admission assessment and on an ongoing basis throughout the hospital stay. 4. The RN or LVN should consult with the physician and Social Services during the patient's hospitalization to coordinate any post-discharge continued care requirements or availability of required equipment. "


Discharge Instructions Standard of Practice stated, "6. The Physician orders specific discharge instructions and prescribes which medications are to be taken regularly and as needed upon discharge from the hospital."


In an interview with staff # 37 at the facility in the small conference room on 9/13/16 at 2:55 pm, staff # 37 stated some of the physicians do not write all of their orders and staff # 37 was not aware these patients had been discharged without physician's orders. During the interview it was revealed the nurses write all of the verbal orders when the doctors make rounds, the physicians rarely write any orders. The verbal orders are taken to doctor ' s clinic next door. The nurse will wait for the orders to be sign, then bring the verbal orders back to the hospital. In an interview with staff # 2 CNO, and staff # 1 president the surveyor asked if they were aware of this, both staff said yes they are having a problem, but it will be fixed.
VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interviews with facility staff, the facility failed to ensure that verbal orders were used infrequently. Verbal orders should be used only to meet the care needs of the patient when it is impossible or impractical for the ordering practitioner to write the order or enter an order without delaying treatment. The frequent use of verbal orders poses an increased risk of miscommunication that could contribute to a medication or other error, resulting in a patient adverse event. The hospital also failed to implement policy for patients' rights for confidentially; as verbal orders are taken out of the hospital to the doctors clinic to obtain the physicians signatures.


The findings were:


In an interview with staff # 37 and staff # 2 at the facility in the small conference room on 9/13/16 at 2:55 pm, staff #37 stated nurses write all of the verbal orders when the doctors make rounds, they rarely write any orders. The verbal orders are taken to doctor's clinic next door. The nurse will wait for the orders to be signed, then bring the verbal orders back to the hospital.


In an interview with staff # 2 CNO, and staff # 1, President, the surveyor asked if they were aware of this, both staff said yes they are having a problem, but it will be fixed.


The facility's general rules and regulations of the Medical Staff that were adopted and recommended by the Board of Directors on 10/27/15 states, "All treatment orders for medication and all treatment orders which pose an inherent risk to the patient will be signed, dated and timed by the Physician within 24 hours and will be in writing ..."


Patient medical records were reviewed on 9/13/16 and revealed that the following patient records contained multiple verbal orders. In addition verbal orders were not authenticated within 48 hours by the prescriber or another practitioner who was responsible for the care of the patient. Verbal orders not authenticated within 48 hours July through September 7, 2016 included the following:


Patient #10 admitted on [DATE] and discharged on [DATE]:

- On 7/22/16, set of verbal orders were given to an RN. No documentation was presented to the surveyor to indicate that the verbal orders were cosigned by the physician

- On 7/23/16, set of verbal orders were given to an RN. No documentation was presented to the surveyor to indicate that the verbal orders were cosigned by the physician

- On 7/24/16, set of verbal orders were given to an RN. No documentation was presented to the surveyor to indicate that the verbal orders were cosigned by the physician


Patient #11 admitted on [DATE] and discharged on [DATE]:

- On 8/5/16, set of verbal orders were given to an RN. No documentation was presented to the surveyor to indicate that the verbal orders were cosigned by the physician

- On 8/7/16, set of verbal orders were given to an RN. No documentation was presented to the surveyor to indicate that the verbal orders were cosigned by the physician


Patient #14 admitted on [DATE] and discharged on [DATE]:

- On 7/29/16, 3 different sets of verbal orders were given to an RN. No documentation was presented to the surveyor to indicate that the verbal orders were cosigned by the physician


Patient #15 admitted on [DATE] and discharged on [DATE]:

- On 8/23/16, 1 set of verbal orders were given to an RN. No documentation was presented to the surveyor to indicate that the verbal orders were cosigned by the physician

- On 8/24/16, 2 different sets of verbal orders were given to an RN. No documentation was presented to the surveyor to indicate that the verbal orders were cosigned by the physician


Patient #16 admitted on [DATE] and discharged on [DATE]:

- On 9/6/16, 1 set of verbal orders were given to an RN. No documentation was presented to the surveyor to indicate that the verbal orders were cosigned by the physician

- On 9/7/16, 1 set of verbal orders were given to an RN. No documentation was presented to the surveyor to indicate that the verbal orders were cosigned by the physician


Patient #17 admitted on [DATE] and discharged on [DATE]:

- On 7/2/16, 2 different sets of verbal orders were given to an RN. No documentation was presented to the surveyor to indicate that the verbal orders were cosigned by the physician


In an interview with Staff #2 on the morning of 9/13/16, Staff #2 acknowledged the findings above.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, observation, and document review, the hospital failed to ensure that a physician was available at all times to meet the needs of patients. Review of physician schedules for 9/1/16 through 9/12/16 revealed there was no physician in the hospital or on call or able to respond within 30 minutes. Between 9/2/16 and 9/12/16, 17 individuals presented to the Weimar Medical Center Emergency Department for examination and/or treatment and were not seen by a physician as no physician was available or contacted. The 17 individuals did not receive a medical examination and/or treatment.


The hospital failed to ensure that a medical record indicating patient identification, complaint, physician, nurse, time admitted to the emergency suite, treatment, time discharged , and disposition was maintained for every individual who presented to the hospital emergency department for evaluation or treatment. This was not in compliance with facility policy.


The hospital failed to ensure that the Emergency Department was organized under a qualified member of the medical staff, who is the medical director or clinical director. This presents a risk that the quality, safety, and appropriateness of patient care services provided are not monitored and evaluated on a regular basis and deficiencies addressed. This presents a risk for serious patient harm or death and is in violation of facility policies.


Findings included:


An interview was conducted the afternoon of 9/12/16 in the hospital conference room with the Chief Nursing Officer (CNO), who stated that there was currently no physician in the Emergency Department as the ED was "on diversion" and there had not been a physician in the Emergency Department since 9/1/16. The CNO provided a 2 page document entitled, "Diversion Log" to the surveyors.


Review of the Diversion Log provided to the surveyors the afternoon of 9/12/16 in the hospital conference room revealed that 17 individuals (Patients #25, 26, 27, 28, 29, 30, 31, 32, 36, 37, 38, 39, 40, 41, 42, 43, and 44) presented to the Emergency Department for examination and/or treatment between 9/2/16 and 9/12/16. These individuals did not receive a medical examination and were not seen by a physician. The 17 individuals included an [AGE] year old patient with dehydration, a [AGE] year old patient with fever, an [AGE] year old patient with a chief complaint of "fall," a patient having "difficulty breathing," another patient with "shortness of breath," a patient with left shoulder pain radiating to the left jaw, a patient with a right hand injury, a patient with a foreign object in the right eye, back pain, and individuals with other complaints including sinus/sneezing, a cat scratch to finger, generalized weakness, and a patient with abdominal and c-section complaints.


In an interview with the CNO the afternoon of 9/12/16, she confirmed that the 17 individuals listed on the Diversion Log presented to the hospital ED between 9/2/16 and 9/12/16 for evaluation and treatment. The CNO stated that the 17 individuals were not seen by a physician and did not receive a medical screening examination or treatment by a physician. The CNO stated that there was no physician available and a physician was not contacted to perform a medical screening examination or provide treatment for these 17 individuals in the event of a medical emergency. In addition, the 17 individuals were not assessed by an RN or other hospital staff member. Eight of the 17 individuals were informed to "Go to Columbus". The CNO confirmed that "Columbus" meant Columbus Community Hospital, approximately 15 miles from the Weimar Medical Center. Another individual was advised to "Go to closet (sic) ER." An offer was made to call EMS for one patient and the individual declined. 911/EMS was contacted for 3 patients and the 3 patients (Patients #30, 31, and 32) departed the hospital via EMS.

An interview was conducted at 9:45 am on 9/14/16 in the Emergency Department with Staff #13, RN, who stated that she was working in the ED when Patient #32 (MDS) dated [DATE] with a chief complaint of "difficulty breathing". Staff #13 stated that she did not contact a physician about Patient #32 as there were no physicians available to contact.

An interview was conducted the afternoon of 9/12/16 in the administrator's office with the hospital administrator, who stated that there had not been an ED physician in the hospital or on call for the emergency department since 9/1/16 due to a "contract dispute."

Review of the Emergency Department physician staffing schedule for the month of September 2016 provided to the surveyors revealed no physician scheduled for September 1 - 11, 2016. A physician was scheduled for September 12, 2016, beginning at 23:55 (11:55 pm).

Review of the "Physician Time Sheet, ER Physician Sign In Log" provided to the surveyors revealed no physicians signing in for September 1 - 11, 2016. A physician signed in on 9/12/16 at 11:45 PM.

Hospital policy, "Emergency Physicians" stated, in part, "1. The provision of emergency services will be supervised by a qualified member of the medical staff during all times the hospital makes emergency services available. 2. The aforementioned medical supervisor may be briefly absent from the emergency department, but is expected to be in the hospital and immediately available to provide direction and/or direct care during the operating hours of the emergency department."

Hospital policy, " Medical Staff Coverage of the Emergency Department " stated, in part, " 1. there is 24 hour physician coverage in the ED. 2. Also, there are physicians "on call" who receive "unassigned" patients who require admission. Those positions are also available to come in if the ED Dr. needs back-up. "

Hospital policy, "EMTALA" stated, in part, "The Emergency Medical Treatment and Active Labor Act ("EMTALA") requires Medicare participant hospitals to provide medical screening examinations to all persons who present on Weimar Medical Center's (WMC) property and request service, regardless of the person ' s ability to pay for medical services. If the person has an emergency medical condition, the Weimar Medical Center must treat or stabilize the person or provide for an appropriate transfer to another facility. Weimar Medical Center, it's employees and any physician providing services at the hospital will comply fully with the requirements of EMTALA.
Standard of Practice: ...1. Rights to Treatment ...Weimar Medical Center recognizes the right of the individual to receive, within the capabilities of the WMC ' s staff and facilities:
a. An appropriate medical screening examination ( " MSE " );
b. necessary stabilizing treatment for an emergency medical condition ...
c. if necessary, an appropriate transfer to another facility ...
2. " Comes to the Emergency Department " means the individual: a. has presented on Weimar Medical Center property, including the WMC ' s Emergency Department and requests examination or treatment for a medical condition, or has such a request made on his/her behalf.
6. " Transfer " means the movement (including the discharge) of an individual outside Weimar Medical Center ' s facility at the direction of any person employed (or affiliated or associated, directly or indirectly with) the hospital) ..."

Hospital policy, " Transfer Policy " last reviewed January, 2000 provided to the surveyor, stated, in part, " The Governing Body of Colorado-Fayette Medical Center ...has adopted the following policy according to rules adopted by the Texas Department of Health regarding the evaluation, treatment and transfer of patients from this hospital to another hospital in a medically appropriate manner. This policy must be adhered to whenever a patient arrives at the hospital seeking medical treatment ...The transferring physician will personally examine and evaluate the patient before an attempt to transfer is made ...The hospital will provide a memorandum of transfer, as prescribed by the Texas Department of health, to be completed for every patient who is transferred ....The Governing Body will enforce its patient transfer policy in the same fair manner as it enforces the other policies and procedures that the governing body has adapted for the governance of the hospital."

Review of the "Diversion Log" included the following documentation:
Date: 9/2/16
Patient #37. Name: "Unknown". DOB: [blank]. Arrival time: 2200. CC: "Shoulder Pain". Suggested Action: "EMS - AH Hosp they refused " .

Date: 9-3-16
Patient #25. DOB: [blank]. Arrival time: [blank]. CC: "ABD". Suggested Action: " Go To Closet (sic) ER " .
Patient #36. DOB: 11-18-1935. Arrival time: 1811. CC: "Fall". Suggested Action: " Go to Columbus " .
Patient #38. Name: "Unknown". DOB: "82". Arrival time: 1844. CC: "dehydration". Suggested Action: " Go To Columbus. "

Date: 9-4-16
Patient #39. Name: "Unknown". DOB [blank] Arrival: 0115. CC: "Looking to buy E cylinder Regulatory " Suggested Action: " Sent with police to EMS " .
Patient #26. DOB: [blank]. Arrival: 1055. CC: "Pain". Suggested Action: " Go to nearest ER Dept or EMS " .
Patient #27. DOB: 4-21-15 Arrival: 1635. CC: "Fever". Suggested Action: [None].
Patient #40. Name: "Unknown". DOB: blank. CC: "Rt hand injury". Suggested Action: "Go to Columbus"

Date: 9-5-16
Patient #28. DOB: 4/21/69. Arrival: 1250. CC: "Foreign object in eye R eye. " Suggested action: Referred to Columbus or clinic next door.
Patient #29. DOB: [blank]. Arrival: 2120. CC: "back pain". Suggested action: Columbus.
Patient #41. Name: "Unknown". DOB: [blank]. Arrival 2325. CC: "shortness of breath". Suggested action: Offered to call EMS. They stated No. Suggested Columbus.

Date 9-7-16
Patient #42. Name: "Unknown". DOB: [blank]. Arrival 0730. CC: "sinus/sneezing". Suggested action: go to clinic.
Patient #43. Name: "Unknown". DOB: [blank]. Arrival 1945. CC: "cat scratch to L index finger". Suggested action: Referred to Columbus ED.

Date 9-9-16
Patient #44. Name: "Unknown". DOB: [blank]. Arrival 1509. CC: "generalized weakness". Suggested action: "Go to Columbus ER."

Date 9-10-16
Patient #30. DOB: 12/62. Arrival 1235 (POV). CC: " Lft pos shoulder pain radiating to lft jaw " . Suggested action: Called Colorado EMS. Date 9/10/ at 1240. Departure: per EMS.

Date 9-11-16
Patient #31. DOB: 12/15/87. Arrival 1510. CC. "RL ABD and C-Section Area". Suggested Action: "Called 911 @ pt request " . Departure: Colorado EMS.

Date 9-12-16
Patient #32. DOB: 4/19/1982 34YF. Arrival POV 0314. CC: "Difficulty breathing". Suggested Action: " Call 911 per patient request " Departure CCMS 0325.

Cross refer: A1104, A111.


The above findings were confirmed in an interview the afternoon of 9/14/16 in the hospital conference room with the administrator and the CNO.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, document review, and staff interview, the facility failed to ensure that a medical record indicating patient identification, complaint, physician, nurse, time admitted to the emergency suite, treatment, time discharged , and disposition was maintained for every individual who presented to the hospital emergency department for examination and/or treatment. This was not in compliance with facility policy.


Findings included:


Facility policy "General Standards of Care" stated, in part, "A. All patients presenting to the ED for evaluation and treatment will receive an assessment performed by a registered nurse ...D. The assessment and treatment of the patient will be documented on the ED record per RN, LVN and physician."


Facility policy, "Admission to the Emergency Department" stated, in part, "3. All patients presenting to the ED will have an ED record completed ...Standards of Practice ...3. A medical record will be completed on all Emergency Department patients."


Review of facility document, "Diversion Log" provided to the surveyors the afternoon of 9/12/16 by the CNO revealed that 17 individuals (Patients #25, 26, 27, 28, 29, 30, 31, 32, 36, 37, 38, 39, 40, 41, 42, 43, and 44) presented to the Emergency Department seeking evaluation and treatment between 9/2/16 and 9/12/16.


An interview was conducted the afternoon of 9/12/16 with the CNO in the facility conference room who confirmed that the 17 individuals listed on the "Diversion Log" presented to the ED between 9/1/16 and 9/12/16 for examination and/or treatment. When asked, the CNO stated that there was no medical record initiated for any of the 17 patients, as the Emergency Department nursing staff instructed the patients to seek care at another facility or call 911, or the nursing staff contacted 911 for the individuals to be transported from the facility.


An interview was conducted at 9:45 am on 9/14/16 in the Emergency Department with Staff #13, RN, who stated that she was working in the ED when Patient #32 (MDS) dated [DATE] with a chief complaint of "difficulty breathing". Staff #13 stated that she did not perform an examination or document a nursing assessment on Patient #32, that she did not take or document vital signs on Patient #32, she did not contact a physician about Patient #32, and she did not create a medical record or a transfer document for Patient #32. Staff #13 stated that she called 911 per the request of Patient #32. Staff #13 stated that she did not provide any documentation on Patient #32 to EMS and she did not contact the other hospital or physician about Patient #3 being transfered. 2. Staff #13 stated that there was no patient consent or physician certification signed for transfer.


Hospital policy, "ED Record" stated, in part,

"1. A medical record is maintained on every patient seeking emergency care and is incorporated into the patient's permanent hospital record.

2. Every time a patients visits the emergency department/service, the following information is entered in the patient's medical record.

a. Patient identification (when not obtainable, the reason is entered in the medical record)

b. Time and means of arrival

c. Pertinent history of the illness or injury and physical findings, including the patient's vital signs (Data)

d. Emergency care given to the patient prior to arrival

e. Diagnostic and therapeutic orders (Action)

f. Clinical observations, including the results of treatment (Response)

g. Reports of procedures, tests, and results

h. Diagnostic impression

i. Conclusion at the termination of evaluation/treatment, including final disposition, the patient's condition on discharge or transfer, and any instructions given to the patient and/or family for follow-up care

j. The ambulance record of the patient is available to the physician and is filed with the ED record.

3. The medical record is authenticated by the practitioner who is responsible for its clinical accuracy.

4. All ED records, upon completion, area electronically filed as a part of the permanent medical record.

5. If a patient leaves AMA, that fact is recorded in the ED Record.

6. The nursing process is utilized in the Emergency Department in the following manner:

a. Data is gathered from the patient or family. (If the patient is in the ED as the result of an accident, the nurse will determine when and where the accident occurred.) The nurse records (in the space marked chief complaint) a pertinent history of the patient's illness or accident.

b. The nurse records any action taken.

c. The patient's response is recorded (where appropriate)."


There was no documented evidence of a medical record for the above individuals provided to the surveyors. This was confirmed the morning of 9/14/16 by the CNO in the facility conference room.
VIOLATION: SUPERVISION OF EMERGENCY SERVICES Tag No: A1111
Based on review of documentation and interview, the hospital failed to ensure that the Emergency Department was organized under a qualified member of the medical staff, who is the medical director or clinical director. This presents a risk that the quality, safety, and appropriateness of patient care services provided are not monitored and evaluated on a regular basis and deficiencies addressed.


Findings included:


Hospital policy, "Medical Director of ED" stated, in part, "A physician with special training in emergency medicine and acquired experience will serve as Director of the unit with the following duties and responsibilities: ...2. To oversee overall operations of ED ...6 The director is responsible for implementing policies established by the medical staff for the continuing operation of the unit ...7.The director assures that the quality, safety and appropriateness of patient care services provided with the unit are monitored and evaluated on a regular basis and that appropriate actions based on findings are taken.


An interview was conducted the afternoon of 9/13/16 in the hospital conference room with the Administrator who stated that the hospital did not have a medical director of the emergency department. There was no documented evidence provided to the surveyors indicating the hospital had a medical director of the Emergency Department.