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.

GREEN OAKS HOSPITAL 7808 CLODUS FIELDS DRIVE DALLAS, TX Aug. 1, 2014
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record review, Hospital A failed to initiate and/or follow the discharge instructions from Hospital B for 1 of 10 patients (Patient #1). (Patient #1) had a compression fracture to the spine, fractured bilateral feet and a fractured wrist of his dominant hand and was non-weight bearing (NWB). Hospital A's RN's (registered nurses) failed to identify and/or evaluate (Patient #1's) non-weight bearing status.

Findings Included:

Hospital B's physician note for (Patient #1), electronically signed 06/27/14, at 0950, reflected "[AGE] year old suicide attempt...jumped from a second story...had an extension cord wrapped around his neck which broke during the jump...brought to ED (emergency department) intubated...positive for high level of Tylenol and cocaine...opiates screen positive, acetaminophen...urine cocaine screen positive..."

Hospital's B's Discharge Summary dated 07/10/14, timed at 1318, reflected "Right distal radius and ulnar styloid process fracture, T12 (thoracic) compression fracture, bilateral calcaneal fractures, tylenol overdose...chronic problems...previous suicide attempts, substance abuse...underwent evaluation by Orthopedic's and Spine...to psych hospital for further evaluation then will require rehabilitation facility...non-weight bearing all extremities..."

Hospital B's Discharge Instructions dated 07/03/14, for (Patient #1) reflected "Bilateral Calcaneal fractures, right radius ulnar styloid, process fracture, T12 compression fracture, non-weight bearing, transfer to wheelchair...transfer to Hospital A (psychiatric hospital) ...Dr...in 2 weeks call for appointment...do not change dressing, do not get wet, do not submerge in water..." It was noted the above discharge instructions were also found in (Patient #1's) medical record for Hospital A.

Hospital A's 7/03/14, Inpatient Physician's admitting orders for (Patient #1) dated 07/03/14, and initial treatment plan timed at 2030, reflected "Axis...depression...Axis III...status post fall from height in suicide attempt...admit to level one...special precautions...suicide, fall, monitoring level...close observation..." It was noted no orders and/or documentation was found which addressed (Patient #1's) non-weight bearing status.

Hospital A's Internal Medicine History and Physical dated 07/04/14, timed 0710, reflected "Bilateral ankle fracture, right wrist fracture and T12 compression fracture...cleared from (medical hospital)...gait deferred, tandem walking deferred and pathological reflexes deferred ...place on lovenox, pain control..."

Hospital A's initial hospital assessment (physician's) dated 07/04/14, timed at 1030, reflected "Depression, Multiple Orthopedic Injuries, Status Post Tylenol OD (overdose) requiring intubation...opiates, heroin times three months..."

Hospital A's physician's orders dated 07/04/14 through 07/17/14, revealed no physician orders which addressed (Patient #1's) non-weight bearing status during his inpatient stay.

Hospital A's nursing notes dated 07/04/14 through 07/17/14, revealed no nursing notes which addressed (Patient #1's) non-weight bearing status.

On 07/24/14, at 1240, RN Personnel #7 was interviewed. RN #7 stated he did not know (Patient #1) was supposed to be NWB (non-weight bearing). RN Personnel #7 stated (Patient #1) had ace wraps on his feet, a soft padded cast on his wrist and a corset on his thorax. RN Personnel #7 stated (Patient #1) would propel himself with feet and his free arm. RN Personnel #7 stated he reviewed (Patient #1's) medical record and could find nothing in the medical record that indicated (Patient #1) was supposed to be non-weight bearing.

The policy and procedure entitled, "Continum of Care/Discharge Planning and Referral Social Work Services" with a review date of 12/11 reflected, "Assessing the likelihood that the patient will need post-hospital services and assessing the patient's capacity for self-care or the care received in the environment...physical and psychiatric needs..."
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on interviews and record review, the hopital failed to ensure 1 of 10 patients (Patient #1's) discharge plan was appropriate to meet his medical needs upon discharge from the hospital as evidenced by:

(Patient #1) had a compression fracture to the spine, fractured bilateral feet, a fractured wrist of his dominant hand, and was non-weight bearing (NWB). The hospital failed to identify during the hospital stay and/or address (Patient #1's) medical needs upon discharge. (Patient #1) was discharged to a boarding home where his medical needs and NWB status could not be ensured, supported or maintained.

Findings Included:

(Patient #1), with multiple fractures, was discharged to a boarding home and was to care for himself medically. The boarding home that (Patient #1) was discharged to was not wheelchair accessible and could not meet (Patient #1's) medical needs. (Patient #1) was then taken to a second temporary boarding home, by the transport van driver, on the night of 07/17/14. (Patient #1) was then picked up the morning of 07/18/14, and taken to an acute care hospital due to complaints of pain. (Patient #1's) NWB status was not identified and/or addressed by Hospital A during the hospital stay and prior to discharge. (Cross refer to A800)
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record review, Hospital A failed to identify and/or follow discharge instructions from Hospital B for 1 of 10 patients (Patient #1). (Patient #1) had a compression fracture to the spine, fractured bilateral feet and a fractured wrist of his dominant hand and was non-weight bearing (NWB) from a prior suicide attempt. Hospital A's discharge plan did not address (Patient #1's) medical needs which included (Patient #1's) non-weight bearing status.

Findings Included:

Hospital B's physician note for (Patient #1), electronically signed 06/27/14 at 0950, reflected "[AGE] year old suicide attempt...jumped from a second story...had an extension cord wrapped around his neck which broke during the jump...brought to ED (emergency department) intubated...positive for high level of Tylenol and cocaine...opiates screen positive, acetaminophen...urine cocaine screen positive..."

Hospital's B's Discharge Summary dated 07/10/14, timed at 1318, reflected "Right distal radius and ulnar styloid process fracture, T12 (thoracic) compression fracture, bilateral calcaneal fractures, tylenol overdose...chronic problems...previous suicide attempts, substance abuse...underwent evaluation by Orthopedic's and Spine...to psych hospital for further evaluation then will require rehabilitation facility...non-weight bearing all extremities..."

Hospital B's Discharge Instructions dated 07/03/14, for (Patient #1) reflected "Bilateral Calcaneal fractures, right radius ulnar styloid, process fracture, T12 compression fracture, non-weight bearing, transfer to wheelchair...transfer to Hospital A (psychiatric hospital) ...Dr...in 2 weeks call for appointment...do not change dressing, do not get wet, do not submerge in water..." It was noted the above discharge instructions were also found in (Patient #1's) medical record for Hospital A.

Hospital A's 7/03/14, Inpatient Physician's admitting orders for (Patient #1) dated 07/03/1,4 and initial treatment plan timed at 2030, reflected "Axis ...depression...Axis III...status post fall from height in suicide attempt...admit to level one...special precautions...suicide, fall, monitoring level...close observation..." It was noted no orders and/or documentation was found which addressed (Patient #1's) non-weight bearing status.

Hospital A's Internal Medicine History and Physical dated 07/04/14, timed 0710, reflected "Bilateral ankle fracture, right wrist fracture and T12 compression fracture...cleared from (medical hospital)...gait deferred, tandem walking deferred and pathological reflexes deferred ...place on lovenox, pain control..."

Hospital A's initial hospital assessment (physician's) dated 07/04/14, timed at 1030, reflecte, "Depression, Multiple Orthopedic Injuries, Status Post Tylenol OD (overdose) requiring intubation...opiates, heroin times three months..."

Hospital A's physician's orders dated 07/04/14 through 07/17/14, revealed no physician orders which addressed (Patient #1's) non-weight bearing status during his inpatient stay.

Hospital A's nursing notes dated 07/04/14 through 07/17/14, revealed no nursing notes which addressed (Patient #1's) non-weight bearing status.

Hospital A's Discharge Instructions dated 07/17/14, timed at 1539, reflected "Your activity resume as tolerated..." (Patient #1) was discharged to a boarding home. The discharge instructions did not address his medical issues which included (Patient #1's) non-weight bearing status.

On 07/24/14, at 1230, SW (Social Worker) Personnel #6 was interviewed. SW Personnel #6 stated (Patient #1) was discharged to a boarding home but she did not know he was supposed to be non-weight bearing.

On 07/24/14, at 1240, RN Personnel #7 was interviewed. RN #7 stated he did not know (Patient #1) was supposed to be NWB (non-weight bearing). RN Personnel #7 stated (Patient #1) had ace wraps on his feet, a soft padded cast on his wrist and a corset on his thorax. RN Personnel #7 stated (Patient #1) would propel himself with feet and his free arm. RN Personnel #7 stated he reviewed (Patient #1's) medical record and could find nothing in the medical record that indicated (Patient #1) was supposed to be non-weight bearing.

On 07/30/14, at 0914, Non-Hospital Staff #26 was interviewed by telephone. Non-Hospital
Staff #26 stated he picked up (Patient #1) when (Patient #1) was discharged from Hospital A on 07/17/14. He stated (Patient #1) was in a wheelchair with ace wraps to his bilateral feet, cast on his right hand/arm and he wore a chest corset. Non-Hospital Staff #26 stated he did not know (Patient #1) was supposed to be non-weight bearing and was not informed by Hospital A that (Patient #1) had special needs. Non Hospital Staff #26 stated the boarding home he took (Patient #1) to was not wheelchair accessible. He stated he found a boarding room that accepted (Patient #1) on an emergency basis for the night. Non-Hospital Staff #26 stated (Patient #1) did have to bear weight and he was in pain. Non-Hospital Staff #26 stated he picked (Patient#1) up the next morning 07/18/14, and took him to an acute care hospital for complaints of pain. Non-Hospital Staff #26 stated Hospital A did not communicate (Patient #1's) medical status and/or needs

The policy and procedure entitled, "Continuum of Care/Discharge Planning and Referral Social Work Services" with a review date of 12/11 reflected, "To provide discharge planning in order to ensure continuity of care...discharge planning begins at admission and continues to be evaluated as necessary...assessing the likelihood that the patient will need post-hospital services and assessing the patient's capacity for self-care or the care received in the environment...physical and psychiatric needs..."
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview and record review, the Governing Body failed to ensure 1 of 10 patients (Patient #1's) discharge plan was appropriate to meet his medical needs in that,

(Patient #1) had a compression fracture to the spine, fractured bilateral feet, a fractured wrist of his dominant hand, and was non-weight bearing (NWB). The hospital failed to identify and/or address (Patient #1's) medical needs upon discharge and the discharge placement was appropriate. (Patient #1) was discharged to a boarding home where his medical needs and NWB status could not be ensured, supported or maintained.

Findings Included:

(Patient #1), with multiple fractures was discharged to a boarding home and was to care for himself medically. The boarding home, that (Patient #1) was discharged to, was not wheelchair accessible and could not meet (Patient #1's) medical needs. (Patient #1's) NWB status was not identified and/or addressed by Hospital A during hospitalization and prior to discharge. (Cross refer to A395 and A800)
VIOLATION: CONTRACTED SERVICES Tag No: A0083
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the Governing Body failed to ensure 1 of 10 patients (Patient #1's) discharge plan was appropriate to meet his medical needs in that,

(Patient #1) had a compression fracture to the spine, fractured bilateral feet, a fractured wrist of his dominant hand, and was non-weight bearing (NWB). (Patient #1), with multiple fractures, was discharged to a boarding home and was to care for himself medically. The boarding home that (Patient #1) was discharged to was not wheelchair accessible and could not meet (Patient #1's) medical needs. (Patient #1) was then taken to a second temporary boarding home, by the transport van driver, on the night of 07/17/14. (Patient #1's) NWB status was not identified during the hospital stay and/or addressed by Hospital A prior to discharge.

Findings Included:

Hospital B's physician note for (Patient #1), electronically signed 06/27/14 at 0950, reflected "[AGE] year old suicide attempt...jumped from a second story...had an extension cord wrapped around his neck which broke during the jump...brought to ED (emergency department) intubated...positive for high level of Tylenol and cocaine...opiates screen positive, acetaminophen...urine cocaine screen positive..."

Hospital's B's Discharge Summary dated 07/10/14, timed at 1318, reflected "Right distal radius and ulnar styloid process fracture, T12 (thoracic) compression fracture, bilateral calcaneal fractures, tylenol overdose...chronic problems...previous suicide attempts, substance abuse ...underwent evaluation by Orthopedic's and Spine...to psych hospital for further evaluation then will require rehabilitation facility...non-weight bearing all extremities..."

Hospital B's Discharge Instructions dated 07/03/14, for (Patient #1) reflected, "Bilateral Calcaneal fractures, right radius ulnar styloid, process fracture, T12 (thoracic) compression fracture, non-weight bearing, transfer to wheelchair...transfer to Hospital A (psychiatric hospital) ...Dr...in 2 weeks call for appointment...do not change dressing, do not get wet, do not submerge in water..." It was noted that the above discharge instructions were also found in (Patient #1's) medical record for Hospital A.

Hospital A's 7/03/14, Inpatient Physician's admitting orders for (Patient #1) dated 07/03/14, and initial treatment plan timed at 2030, reflected "Axis ...depression...Axis III...status post fall from height in suicide attempt...admit to level one...special precautions...suicide, fall, monitoring level...close observation..." .

Hospital A's Internal Medicine History and Physical dated 07/04/14, timed 0710, reflected "Bilateral ankle fracture, right wrist fracture and T12 compression fracture...cleared from (medical hospital)...gait deferred, tandem walking deferred and pathological reflexes deferred ...place on lovenox, pain control..."

Hospital A's Discharge Instructions dated 07/17/14, timed at 1539, reflected "Your activity resume as tolerated..." (Patient #1) was discharged to a boarding home. The discharge instructions did not address his medical issues which included (Patient #1's) non-weight bearing status.

On 07/24/14, at 1230, SW (Social Worker) Personnel #6 was interviewed. SW Personnel #6 stated that (Patient #1) was discharged to a boarding home but she did not know he was supposed to be non-weight bearing.

On 07/24/14, at 1240, RN Personnel #7 was interviewed. RN #7 stated he did not know (Patient #1) was supposed to be NWB (non-weight bearing). RN Personnel #7 stated (Patient #1) had ace wraps on his feet, a soft padded cast on his wrist and a corset on his thorax. RN Personnel #7 stated (Patient #1) would propel himself with feet and his free arm. RN Personnel #7 stated he reviewed (Patient #1's) medical record and could find nothing in the medical record that indicated (Patient #1) was supposed to be non-weight bearing.

On 07/30/14, at 0914, Non-Hospital Staff #26 was interviewed by telephone. Non-Hospital
Staff #26 stated he picked up (Patient #1) when (Patient #1) was discharged from Hospital A on 07/17/14. He stated that (Patient #1) was in a wheelchair with ace wraps to his bilateral feet, cast on his right hand/arm and he wore a chest corset. Non-Hospital Staff #26 stated he did not know (Patient #1) was supposed to be non-weight bearing and was not informed by Hospital A that (Patient #1) had special needs. Non Hospital Staff #26 stated the boarding home he took (Patient #1) to was not wheelchair accessible. He stated he found a boarding room that accepted (Patient #1) on an emergency basis for the night. Non-Hospital Staff #26 stated (Patient #1) did have to bear weight and he was in pain. Non-Hospital Staff #26 stated he picked (Patient#1) up the next morning (07/18/14) and took him to a medical hospital for complaints of pain. Non-Hospital Staff #26 stated Hospital A did not communicate (Patient #1's) medical status and/or needs.

The policy and procedure entitled, "Continuum of Care/Discharge Planning and Referral Social Work Services" with a review dated of 12/11 reflected, "To provide discharge planning in order to ensure continuity of care...discharge planning begins at admission and continues to be evaluated as necessary...assessing the likelihood that the patient will need post-hospital services and assessing the patient's capacity for self-care or the care received in the environment...physical and psychiatric needs..."

Hospital A's undated Bylaws of the Medical Staff reflected, "The purpose and responsibilities of the Medical Staff are...to provide patients with the quality of care that is commensurate with acceptable standards and available community resources..."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record review, Hospital A's nursing services failed to initiate and/or follow Hospital B's discharge instructions for 1 of 10 patients (Patient #1) in that,

(Patient #1) had a compression fracture to the spine, fractured bilateral feet and a fractured wrist of his dominant hand and was non-weight bearing (NWB). Hospital A's RN's (registered nurses) failed to identify and/or evaluate (Patient #1's) non-weight bearing status.

Findings Included:

(Patient #1), with multiple fractures, was discharged to a boarding home and was to care for himself medically. (Patient #1's) NWB status was not identified during the hospital stay and/or evaluated by nursing services. (cross refer to A395)