The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TEXAS HEALTH PRESBYTERIAN HOSPITAL PLANO 6200 W PARKER RD PLANO, TX 75093 Sept. 25, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview, the facility failed to:

A. keep 3 (patient #1, #2, and #6) of 7 patients reviewed free from possible abuse and neglect. Interviews confirmed, the facility tracks and reports only the number of complaints the facility receives. Interviews confirmed, the facility does not measure and/or analyze patients' adverse events/ incident reporting. Interviews confirmed, the facility did not know that staff #10 was identified by patient #1 and patient #6 as being abusive to these patients.

Refer to tag 0144.


B. to protect 1 (#2) of 7 patients reviewed from abuse. An 83-year-old, non-verbal, Alzheimer patient, needed total assistance with all activities of daily living, was allowed to stay in a room with a temperature of 68 degrees' post-surgery because the staff did not know how to operate the temperature controls. The registered nurse caring for the patient withheld scheduled medications and were not given, including post-operative pain medications.

Refer to tag 0145


C. provide 7 (patients #1, #2, #3, #4, #5, #6, and #7) of 7 patients with the results of the investigation of the grievances filed by or on behalf of these 7 patients.

Refer to tag 0123
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document review, the facility failed to provide 7 (patients #1, #2, #3, #4, #5, #6, and #7) of 7 patients with the results of the investigation of the grievances filed by or on behalf of these 7 patients. The facility used a form letter to reply to these 7 patients. This form letter does not provide the results of the investigation of the grievance to the patients.


A review of the response letters provided to patients #1, #2, #3, #4, #5, #6, and #7 revealed same letter but replacing patient name, dates, and the name of the facility representative the grievance was routed to. All of the other elements of the letter remain the same. This form letter does not provide specific results, findings, resolutions, and/or outcomes of the investigation of the grievance to the individual patients. The letters revealed:


"Dear (patient Name)

We have completed our investigation of the concerns the you had regarding your hospital stay from (date of stay). Texas Health Presbyterian Hospital Plano strives to provide excellent care, and we hope you will accept our sincere apology that we did meet your, or our, expectations. We greatly appreciate you bringing these concerns to our attention as that gives us the opportunity to review the services we provide.

After reviewing the letter from (name of person) and learning of your complaints, I forwarded your issues to (facility representative) who initiated an investigation. (facility representative) and I are sincerely sorry for any inconvenience you may have experienced due to concerns you expressed. Your comments and experiences were reviewed with the staff involved in your care. The results of, and any measures we may have taken in response to, our quality improvement investigation such as employee disciplinary action which can include employee termination, are by Texas law, confidential. However, I want to assure you that your concerns were taken seriously, and that the appropriate follow up actions were taken if required. Thank you again for bringing this issues to our attention so that we were given the opportunity to review our provision of care.

The staff of Texas Health Presbyterian Hospital Plano strives to provide quality health care services to the patient's satisfaction. We appreciate the opportunity to have confidence in the care you can expect to receive here if you or your family should need future health care services. If you have any further questions, you may contact me at (telephone number)."

An interview with staff #2, staff #5, and staff #7 confirmed the above letter is the investigation completion letter sent to patient with grievances.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document review and interview, the facility failed to provide a safe setting to receive care for 3 (patient #1, #2, and #6) of 7 patients reviewed. Patients #1, #2, and #6 were possible victims of abuse and/or neglect. Evidence provided revealed, patient #1 possibly received injuries while being cared for by staff #10. Patient #6 reported, staff #10 and staff #11 were "abusive, they pinched me and used either too hot or too cold water when they were bathing me. When I complained, they laughed and mimicked me". Patient #2's scheduled medications were withheld and the patient was not medicated for pain during a twelve-hour shift. Interviews confirmed, the facility tracks and reports only the number of complaints the facility receives. Interviews confirmed, the facility does not measure and/or analyze patients' adverse events/ incident reporting. Interviews confirmed, the facility did not know that staff #10 was identified by patient #1 and patient #6 as being abusive to them.

.
A review of patient #1's medical record revealed, no skin assessment had been performed by the registered nurse on the patient's admission assessment that would indicate the patient was without bruising, skin breaks, or other deformities.


A review of a statement documented by staff #9 revealed, "Unit Manager, Staff #8, conducted interview with employees involved in the incident and the patient. Based on the interviews conducted, those who cared for the patient did not note any bruising on the patient. Bleeding was identified near the IV site, however, it appeared there was an old wound with a scab that was loosened".


An interview with staff #9 revealed, a complaint was received from the family members of patient #1. The complaint was staff #10 was forceful during a transfer and grabbed the patient by the arms and threw the patient like a sack of potatoes on the bed. The patient advocate was asked to speak with the patient. Interview confirmed, there was no skin assessment done on admission by the admitting registered nurse and no way to confirm what the patient arms and hands looked like on admit. Staff #9 confirmed, the complaint was not substantiated by the facility. There were no actions and no failures identified by the facility.


A review of a statement documented by staff #7 revealed, the incident as it was described by the patient "I was getting off the bedside commode and staff #10 was going to help me back to bed. Staff #10 grabbed me by my arms and just threw me into the bed on my back ..." Staff #7's observation was, "Patient has multiple areas of bruising on the length of both arms and an area of broken skin and bruising on right hand ..."


An interview with staff #7 confirmed, the patient advocate spoke with patient #1 and the patient's family regarding the incident. Staff #7 confirmed, the patient had multiple areas of bruising on the length of both arms and an area of broken skin and bruising on right hand. Interview confirmed, there were no skin assessment done on admission by the admitting registered nurse and no way to confirm what the patient arms and hands looked like on admit. Staff #7 confirmed, the complaint was not substantiated by the facility. There were no actions and no failures identified by the facility.


An interview with staff #5 confirmed, patient #1 did not have an admission skin assessment documented in the medical record. Staff #5 confirmed, the conflicting statement/assessments provided by staff #7 and staff #9 regarding patient bruising and skin breakdown. Staff #5 confirmed, no actions and no failures identified by the facility.


A review of patient #2 records and the document titled "All Meds and Administrations" dated 11/3/2018 revealed, staff #4 withheld patient #2's scheduled medications on the day shift citing, "Patient struck out at nurse when attempting to give patient medications." Medications not given were:

Aricept 10mg by mouth daily. (used to treat mild to moderate dementia caused by Alzheimer's disease.)

Cymbalta 60mg by mouth daily. (used to treat depression and anxiety.)

Namenda 10mg by mouth twice daily. Patient's morning dose was not given. (indicated for the treatment of moderate to severe dementia of the Alzheimer's type.)

Toprol XL 25mg by mouth daily.

Seroquel 50mg by mouth twice daily. Patient's morning dose was not given by staff #4. (used to treat certain mental/mood conditions)

Zoloft 50mg by mouth daily. (used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder (social phobia), and a severe form of premenstrual syndrome (premenstrual dysphoric disorder).)

Normal saline 10ml IV for flushing saline lock twice a day. Patient's morning saline lock was not flushed by staff #4.

Lovenox 30mg subcutaneous twice a day. Patient's morning dose was not given by staff #4. (used to treat or prevent a type of blood clot called deep vein thrombosis (DVT), which can lead to blood clots in the lungs)

Narco one tab by mouth every six hours as needed for pain. At 8:42am staff #4 documented patient refused all the above medications citing "Patient struck out at nurse when attempting to give patient medications." No other attempts to give the medications were documented.


A review of the document titled "Vital Signs" dated 11/3/2018 and timed 8:42 revealed, Pain Scale: Breathing normal, Negative vocalization 2- repeated troubled calling out: loud moaning/groaning, crying. Facial expression 2- facial grimacing. Body Language 2- rigid: fists clenched, knees up: pushing/pulling away, strikes out.
Pain/Comfort Goals: unable to assess. Pain Management: Not indicated. Non- verbal indicators of comfort: Calm.


A review of the document titled "Elderly, Disabled Victims of Abuse Neglect and Exploitation" revealed:

4.3.2 Abuse may include, but not limited to ... medication abuse and misuse (over-medication of drugs or alcohol, withholding medications).

4.5 Neglect- the failure to provide for one's self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services. Neglect or omission may include starvation, dehydration, over-or-under-medication, lack of medical care ...


An interview with staff #6 confirmed, staff #4 reported to staff #6 that the scheduled medications and needed pain medications were not given to patient #2 because the patient was confused and combative. Staff #6 revealed, there was no follow up by staff #6 on patient #2 because of excessive workload. Staff#6 revealed, he was functioning as the Charge Nurse and the Unit Secretary.


An interview with staff #5 confirmed, patient #2 was not given ordered medication. Staff #5 confirmed, staff #6 was functioning as the Charge Nurse and the Unit Secretary. Staff #5 confirmed, the unit was budgeted for both a Charge Nurse and a Unit Secretary. Staff #5 confirmed, there was no evidence of an attempt by the facility to fill the shortage of the Unit Secretary position. Staff #5 confirmed, it would be the expectation of the facility for the Charge Nurse to function in both positions/jobs.


Staff #5 confirmed, there were no other attempts documented in patient #2's medical record by staff #4 to give the medication withheld at 8:42am. Staff #5 confirmed, staff #4's actions of withholding patient #2's medications could meet the policy definition, "Abuse may include, but not limited to ... medication abuse and misuse (over-medication of drugs or alcohol, withholding medications)." Neglect or omission may include starvation, dehydration, over-or -under-medication, lack of medical care ..."


A review of a document titled "Grievance Report" revealed, on 05/02/2018 patient #6 reported staff #10 and _______ (proper name used) were "abusive, they pinched me and used either too hot or too cold water when they were bathing me. When I complained, they laughed and mimicked me".


On 05/03/2018 the report revealed, investigation by staff #9, "Try to determine who ______(proper name used) is as I can't find the name on the chart, and not familiar with this name ...


On 05/07/2018 follow up by staff #9 with staff #10 revealed, the staff #10 response to patient #6 allegations. Staff #10 identified the unknown _______ (proper name) as staff #11.


No further follow up was conducted with staff #11. Staff #11 was not interviewed regarding patient #6 allegations. There were no actions and no failures identified by the facility.


An interview with staff #5 confirmed, the facility did not know staff #10 was identified by patient #1 and patient #6 as being abusive to these patients.


An interview with staff #2 and staff #11 confirmed, the facility tracks and reports only the number of complaints the facility receives. Interviews confirmed, the facility does not measure and/or analyze patients' adverse events/ incident reporting. Interviews confirmed, the facility did not know that staff #10 was identified by patient #1 and patient #6 as being abusive to these patients.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, the facility failed to protect 1 (#2) of 7 patients from neglect. Patient #2, an 83-year-old, non-verbal, Alzheimer patient, needing total assistance with all activities of daily living, was allowed to stay in a room with a temperature of 68 degrees' post-surgery. All of the patient's medications were withheld and not given, including post-operative pain medications. The patient had a surgical repair of a left femur fracture and the primary nurse did not give pain medications for approximately 12 hours.

A review of patient #2's daughter's (caregiver) written statement revealed:

"Patient was admitted on [DATE] with a left hip fracture. Surgery to repair the hip was performed on November 2, 2017. On November 3, 2017 at 6:00pm the daughter visited the patient to find "the patient twisted in her bed with the sheets at her waist with her legs exposed and upper body. The patient was gripping her catheter hose with all of her strength in fear and every 30 seconds her face winched and loudly said "OW", "OW". I asked for the nurse and the aid. The aid entered the room and said the patient was like this all day. I asked the aid to help me take the catheter hose from her and help me straighten her out in the bed and cover her with a blanket. It was 68 degrees in her bedroom. I asked the aid to please adjust the temperature which she attempted to. Thirty minutes later the temperature had not changed and the aid didn't know how to read the screen on the TV that showed it was 0 degrees yet the wall thermostat read 68 degrees. I had to wait until the next shift to get a nurse to call maintenance and crank the heat on in her room because no other nurse or aid knew how to solve the problem.
I asked for the nurse and told her the patient was in pain. The nurse told me that she attempted to give the meds in the AM but the patient hit her. I asked her again if the patient had any pain meds today, she is in pain and needs pain meds. Staff #2 restated the patient hit her when she attempted to give her meds. So the patient did not get her pain meds for 12 hours or her antidepressant, metoprolol, lorazepam, quetiapine, Aricept, Namenda or tramadol all day. The nurse replied 'no she didn't'. "

A review of the document titled ED Provider Note, dated 11/01/2017 and timed 7:17 am, revealed 83 y.o. female with history of dementia who comes to the ED via Emergency Medical Services from a nursing home for left hip pain.

A review of the X-ray pelvis revealed findings: There is acute displacement left intertrochanteric fracture with comminution.

A review of the document titled History and Physical revealed the patient was demented and history is not obtainable ... But most history was obtained from medical records ... review of systems not obtainable due to patient's dementia. ...

A review of the document titled "All Meds and Administrations" dated 11/3/2018 revealed staff #4 withheld patient #2's schedule medications on the day shift citing, "Patient struck out at nurse when attempting to give patient medications." Medications not given were:

Aricept 10mg by mouth daily. (used to treat mild to moderate dementia caused by Alzheimer's disease.)
Cymbalta 60mg by mouth daily. (used to treat depression and anxiety.)
Namenda 10mg by mouth twice daily. Patient's morning does was not given. (indicated for the treatment of moderate to severe dementia of the Alzheimer's type.)
Toprol XL 25mg by mouth daily.
Seroquel 50mg by mouth twice daily. Patient's morning does was not given by staff #4. (used to treat certain mental/mood conditions)
Zoloft 50mg by mouth daily. (used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder (social phobia), and a severe form of premenstrual syndrome (premenstrual dysphoric disorder).)
Normal saline 10ml IV for flushing saline lock twice a day. Patient's morning saline lock was not flushed by staff #4.
Lovenox 30mg subcutaneous twice a day. Patient's morning does was not given by staff #4. (used to treat or prevent a type of blood clot called deep vein thrombosis (DVT), which can lead to blood clots in the lungs)
Narco one tab by mouth every six hours as needed for pain. At 8:42am staff #4 documented patient refused all the above medications citing "Patient struck out at nurse when attempting to give patient medications." No other attempts to give the medications were documented.

A review of the document titled Vital Signs dated 11/3/2018 and timed 8:42 revealed Pain Scale: Breathing normal, Negative vocalization 2- repeated troubled calling out: loud moaning/groaning, crying. Facial expression 2- facial grimacing. Body Language 2- rigid: fists clenched, knees up: pushing/pulling away, strikes out.
Pain/Comfort Goals: unable to assess. Pain Management: Not indicated. Non- verbal indicators of comfort: Calm.

A review of the document titled "Elderly, Disabled Victims of Abuse Neglect and Exploitation" revealed

"4.3.2 Abuse may include, but not limited to ... medication abuse and misuse (over-medication of drugs or alcohol, withholding medications).
4.5 Neglect- the failure to provide for one's self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services. Neglect or omission may include starvation, dehydration, over-or -under-medication, lack of medical care ...

An interview with staff #6 confirmed staff #4 reported to staff #6 the scheduled medications and needed pain medications were not given to patient #2 because the patient was confused and combative. Staff #6 revealed there was no follow up by staff #6 on patient #2 because of excessive workload. Staff#6 revealed he was functioning as the Charge Nurse and the Unit Secretary.

An interview with staff #5 confirmed patient #2 was not given ordered medication. Staff #5 confirmed staff #6 was functioning as the Charge Nurse and the Unit Secretary. Staff #5 confirmed the unit was budgeted for both a Charge Nurse and a Unit Secretary. Staff #5 confirmed there was no evidence of an attempt by the facility to fill the shortage of the Unit Secretary position. Staff #5 confirmed it would be the expectation of the facility for the Charge Nurse to function in both positions/jobs. Staff #5 confirmed there were no other attempts documented in patient #2's medical record by staff #4 to give the medication withheld at 8:42am. Staff #5 confirmed staff #4's actions of withholding patient #2's medications could meet the policy definition, "Abuse may include, but not limited to ... medication abuse and misuse (over-medication of drugs or alcohol, withholding medications)." Neglect or omission may include starvation, dehydration, over-or -under-medication, lack of medical care ..."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on document review and interview, the facility failed to:

A. provide a unit secretary, a supportive position that is scheduled and built into the unit's expenditures for 16 hours per day. On November 3, 2017, the unit secretary's position was not staffed for the day shift due to a call-in. An interview confirmed there was no effort made to fill the position. The interview further confirmed the Charge Nurse, staff #6, (a full time 24 hour a day staffed position), would be expected by the facility to cover both full time positions. The interviewee explained these positions are not counted in the nurse staffing matrix, and are built in to the financial operation of the unit and therefore are not mandatory and patient safety would not be affected. On November 3, 2017, the Charge Nurse (staff #6) was not available to assist a non-employee registered nurse #4 (staffing agency nurse from outside the facility) to evaluate the care provided to patient #2 due to being tied up with performing two jobs. Patient #2 suffered from neglect/abuse (using the facility's definitions) by the staffing agency nurse #4 when scheduled medications were withheld for treatment of depression, anxiety, blood clot preventative, dementia caused by Alzheimer's disease, and pain medication for post-op surgery.

Refer to tag 0386


B. provide a Charge Nurse that was available to assist and evaluate the nursing care provided by a Central Staff Office (CSO) Registered Nurse. Central Staff Office (CSO) staff are not employees of the facility. CSO is an outside entity that the facility uses for staffing purposes. Central Staff Office (CSO) Registered Nurse #4 withheld patient #2's schedule medications. Staff #6 did not follow up on patient #2 because of excessive workload. Staff#6 was functioning as the Charge Nurse and the Unit Secretary due to a shortage in staff.

Refer to tag 0392



C. identify and evaluate the registered nurses providing nursing care to patient in the facility. Two (2) (patient #1 and #2) of 7 patients did not receive the assessment and care by the registered nurses assigned to their care. The registered nurse caring for patient #2 did not follow doctor's orders. The facility received complaints from patient #1 and patient #2's families. The facility investigated the complaints and took no action on behalf of the patients.

Refer to tag 0395



D. provide supervision of a non-employee registered nurse providing care in the facility. The facility did not maintain a personnel file on Central Staff Office (CSO) Registered Nurse, staff #4. CSO is an outside entity that the facility uses for staffing purposes. The facility relies on the CSO to maintain staffing files on the staff used by the facility. The facility is dependent on the CSO to provide and maintain competencies, license, orientation to the facility, and any other documents the CSO finds necessary. The facility relies on the CSO to provide employees to the facility at will by the CSO. The facility does not have a system for reviewing CSO staff files, evaluating CSO staff, providing a timely process to investigate occurrences involving CSO staff.

Refer to tag 0398
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on document review and interviews, the facility failed to provide adequate staffing of a unit secretary for the nursing unit for supportive needs. the Charge Nurse, staff #6 would be expected by the facility to cover both full time positions. The Charge Nurse (staff #6) was not available to assist a non-employee registered nurse #4 (staffing agency nurse from outside the facility) to evaluate the care provided to patient #2 due to being tied up with performing two jobs, Charge Nurse/Unit Secretary duties. Patient #2 suffered from neglect/abuse by the staffing nurse #4 when scheduled medication were withheld for treatment of depression, anxiety, blood clot preventative, dementia caused by Alzheimer's disease, and pain medication for post-op surgery.


A review of the Staffing Schedule dated 11/03/2017 for Friday 7am-7pm revealed no secretary was scheduled. Staff #6 was on the schedule as Unit Secretary/ Charge Nurse.


A review of patient #2's medical record revealed, the document titled "All Meds and Administrations" dated 11/3/2018 that staff #4 withheld the patient schedule medications on the day shift citing, "Patient struck out at nurse when attempting to give patient medications." Medications not given were:

Aricept 10mg by mouth daily. (used to treat mild to moderate dementia caused by Alzheimer's disease.)

Cymbalta 60mg by mouth daily. (used to treat depression and anxiety.)

Namenda 10mg by mouth twice daily. Patient's morning does was not given. (indicated for the treatment of moderate to severe dementia of the Alzheimer's type.)

Toprol XL 25mg by mouth daily.

Seroquel 50mg by mouth twice daily. Patient's morning dose was not given by staff #4. (used to treat certain mental/mood conditions)

Zoloft 50mg by mouth daily. (used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder (social phobia), and a severe form of premenstrual syndrome (premenstrual dysphoric disorder).)

Normal saline 10ml IV for flushing saline lock twice a day. Patient's morning saline lock was not flushed by staff #4.

Lovenox 30mg subcutaneous twice a day. Patient's morning dose was not given by staff #4. (used to treat or prevent a type of blood clot called deep vein thrombosis (DVT), which can lead to blood clots in the lungs)

Narco one tab by mouth every six hours as needed for pain. At 8:42am staff #2 documented, patient refused all the above medications citing "Patient struck out at nurse when attempting to give patient medications." No other attempts to give the medications were documented.


A review of the document titled "Elderly, Disabled Victims of Abuse Neglect and Exploitation" revealed 4.3.2 "Abuse may include, but not limited to ... medication abuse and misuse (over-medication of drugs or alcohol, withholding medications)" . 4.5 "Neglect- the failure to provide for one's self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services. Neglect or omission may include starvation, dehydration, over-or -under-medication, lack of medical care ..."


An interview with staff #6 confirmed, staff #4 reported to staff #6 the scheduled medications and needed pain medications were not given to patient #2 because the patient was confused and combative. Staff #6 revealed, there was no follow up by staff #6 on patient #2 because of excessive workload. Staff#6 revealed, he was functioning as the Charge Nurse and the Unit Secretary.


The review of a written statement by staff #6 revealed, I worked as Charge Nurse and Unit Secretary during this shift and was multi-tasking on preparing for on-coming admissions and discharges, assisting physicians and triaging patient and outside calls ....


An interview with staff #5 confirmed, there was no unit secretary on 11/03/2017 and no effort made to fill the position. The interview further confirmed, the Charge Nurse was a full time 24 hour a day staffed position. The interview confirmed the charge Nurse, staff #6, would be expected by the facility to cover both full time positions. The interviewee explained, these positions are not counted in the nurse staffing matrix, and are built in to the financial operation of the unit and therefore are not mandatory and patient safety would not be affected.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on document review and interview, the facility failed to provide supervision of a non-employee registered nurse providing care in the facility. The facility did not maintain a personnel file on Central Staff Office (CSO) Registered Nurse, staff #4. CSO is an outside entity that the facility uses for staffing purposes. The facility relies on the CSO to maintain staffing files on the staff used by the facility. The facility is dependent on the CSO to provide and maintain competencies, license, orientation to the facility, and any other documents the CSO finds necessary. The facility relies on the CSO to provide employees to the facility at will by the CSO. The facility does not have a system for reviewing CSO staff files, evaluating CSO staff, providing a timely process to investigate occurrence evolving CSO staff.


The grievance letter, dated received by the facility on 12-27-2017, submitted by patient #2's daughter was reviewed. One of the grievance concerns was CSO staff #4 withheld patient #2's scheduled medications and the CSO staff #4 did not medicate the patient for pain post-surgery for a femur fracture repair.


A review of the document titled ED Provider Note, dated 11/01/2017 and timed 7:17 am, revealed, an [AGE] year old female with history of dementia who comes to the ED via Emergency Medical Services from a nursing home for left hip pain.


A review of the X-ray of the pelvis revealed: There is acute displacement left intertrochanteric fracture with comminution.


A review of the document titled "History and Physical" revealed, the patient was demented and history in not obtainable ... But most history was obtained from medical records ... review of systems not obtainable due to patient's dementia ...


A review of the document titled "All Meds and Administrations" dated 11/3/2018 revealed staff #4 withheld patient #2's schedule medications on the day shift citing, "Patient struck out at nurse when attempting to give patient medications." Medications not given were:

Aricept 10mg by mouth daily. (used to treat mild to moderate dementia caused by Alzheimer's disease.)

Cymbalta 60mg by mouth daily. (used to treat depression and anxiety.)

Namenda 10mg by mouth twice daily. Patient's morning dose was not given. (indicated for the treatment of moderate to severe dementia of the Alzheimer's type.)
Toprol XL 25mg by mouth daily.

Seroquel 50mg by mouth twice daily. Patient's morning dose was not given by staff #4. (used to treat certain mental/mood conditions)

Zoloft 50mg by mouth daily. (used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder (social phobia), and a severe form of premenstrual syndrome (premenstrual dysphoric disorder).)

Normal saline 10ml IV for flushing saline lock twice a day. Patient's morning saline lock was not flushed by staff #4.

Lovenox 30mg subcutaneous twice a day. Patient's morning dose was not given by staff #4. (used to treat or prevent a type of blood clot called deep vein thrombosis (DVT), which can lead to blood clots in the lungs)

Narco one tab by mouth every six hours as needed for pain. At 8:42am staff #4 documented, patient refused all the above medications citing "Patient struck out at nurse when attempting to give patient medications." No other attempts to give the medications were documented.


A review of the document titled "Vital Signs" dated 11/3/2018 and timed 8:42 revealed, Pain Scale: Breathing normal, Negative vocalization 2- repeated troubled calling out: loud moaning/groaning, crying. Facial expression 2- facial grimacing. Body Language 2- rigid: fists clenched, knees up: pushing/pulling away, strikes out.

Pain/Comfort Goals: unable to assess. Pain Management: Not indicated. Non- verbal indicators of comfort: Calm.


An interview with staff #8 confirmed, Human Resources does not maintain staffing files on CSO employees.

An interview with staff #5 and staff #7 confirmed, the facility made a request of the CSO to follow up with the CSO staff #4 regarding patient #2's daughter's grievance on 01-02-2018. The CSO responded to the facility's request on 01/18/2017, 16 days later, Staff #2 in no longer with CSO.


An interview with staff #5 revealed, the facility had no influence over how the CSO operates. The CSO is an independent entity and is owned by the same corporation that owns the facility.