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.

UNIVERSITY OF TEXAS M D ANDERSON CANCER CENTER,THE 1515 HOLCOMBE BLVD HOUSTON, TX March 31, 2022
VIOLATION: EMERGENCY SERVICES Tag No: A0092
Based on record review and interview the facility was not preforming medical screen examinations on three of (ID#5,6,7) of five emergency room patients (ID#4,5,6,7,15) files reviewed.

Findings Include: Facility policy Emergency Medical Screening Examination (MSE), Stabilization, and Appropriate Transfer Policy, published 07/09/2019 stated screening should be conducted to the extent necessary, by Physicians or other Qualified Medical Person ....to determine whether an MSE exist.

Record review on 03/29/2022 at 1400 of five patient records (ID#4,5,6,7,15), revealed three patients (ID#5,6,7) did not have a medical screen documented in the medical record.

Record review on 03/29/2022 of patient (ID#5) medical record revealed an arrival time of 1056 with a complaint of a swollen neck, triaged 1058, physician was assigned 1100, no MSE was noted in the patient record.

Record review on 03/29/2022 of patient (ID#6) medical record revealed an arrival time of 2149 with a complaint of a right rib pain, triaged 2153, physician was assigned 2202, no MSE was noted in the patient record.

Record review on 03/29/2022 of patient (ID#7) medical record revealed arrival time of 2014 with a complaint of abdominal pain and vomiting, triaged 2015, physician was assigned 2022, no MSE was noted in the patient record.

Interview on 03/20/2022 at 1450 with the medical director of the ED (ID#65), stated after 1900 doctors are assigned and orders are written. The MSE is not necessarily completed.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based upon record review, observation and interview, the facility failed to ensure that 2 out of 2 (ID #3, 18) Limited English Proficiency (LEP) patients were informed of their rights related to care, treatment and disposition in a language they could understand.

Review of Patient (ID# 3) medical records revealed he was a Chinese male who required Chinese written and verbal translation. His electronic medical record demographics stated "Need Chinese Translator." The medical record showed record of numerous phone calls from clinical and business office staff between August 2019 and December 2019. There was no documentation of Interpretive Services staff or translators. The electronic messaging portal (MyChart) has numerous messages from business and clinical staff in English, with no documentation of translation services.

The patient (ID#3) arrived on 12/13/19 for scheduled outpatient chemo infusion number 8 of 12 planned treatments. There was no record of communication by clinical staff for change to treatment plan or discontinuation of therapy on this date or subsequently thereafter. The patient gained new insurance funding and sought care at another facility on 12/26/19.

Review of Patient (ID #18) medical record revealed she was a female who sought care in the emergency department. Her electronic medical record demographics stated "Needs Arabic translator." The consent to diagnose and treatment was done in English without use of translation services or video translation services. There was no evidence that Interpretive services staff or a translator were used at any point during her hospital encounter. The patient left Against Medical Advice (AMA).

Review of "Consent to Diagnosis and Treatment" Handout (revised 12/1/2021) stated "Translator information can be located in the designated location of the patient's chart."

Review of "Patient Registration Policy" (revised 1/31/2017) stated "Informed Consent Documentation... The document consists of verifying the following five elements ... the patient received explanation of the protocol, utilization of an interpreter, if applicable, that all of the questions were answered, confirmation that the patient signed and dated the informed consent document AND confirmation that a copy of the informed consent was given to the patient."

Review of the Language Assistance Policy (dated 6/27/2017) stated the "purpose of the policy is to .... Provide an open channel of communication for an accurate exchange of medical information between patients. Protect the patient's right to informed consent. The policy statement stated "It is the policy of MD Anderson to provide quality medical interpretation services to all LEP patients. Compliance with this policy is the responsibility of all faculty, trainees/students, and other members of the MD Anderson workforce."

The policy stated the "resources provided by Language Assistance are utilized whenever translation or interpretation services are needed. Some situations of high importance include: obtaining initial patient history, discussion of diagnosis and disposition of patient, treatment options, changes in status or treatment plan, the informed consent process ...."

Observation in emergency department 3/30/22 at 1223 revealed Staff (ID# 61) and Staff (ID# 62) triaging Patient (ID# 18) in ED triage area. The electronic medical record was displayed and being utilized by Staff (ID# 62). The electronic medical record stated "Needs Arabic Interpreter." All triage questions were performed in English. Three (3) questions were rephrased when patient does not appear to fully understand question. Male family member accompanying her answered two (2) questions for her.

Interview with Staff (ID #62) 3/30/22 at 1227 conducted after patient triage completed. He confirmed seeing the "Needs Arabic Interpreter" statement on demographics. He pointed to the visual electronic translation iPad in the front left corner of the triage room and said "we have it here if we need it." When asked how he determined which patients with demographics stating "Needs translator" have those services provided, he said "we asked the patient before your came in."

Interview with Staff (ID #87) Registration Associate on 3/30/22 1310 confirmed Patient (ID #18) did not have translation services for consent to treatment or patient rights.

Interview with Staff (ID #60) Chief Nursing Officer on 03/30/2022 1145 validated staff were not to use family members as interpreters or translators.

Interview with Staff (ID #64) ED Medical Director) on 3/31/2022 at 1330 confirmed "ED staff are supposed to utilize translation services as stated in policy." She confirmed that it would be concerning for a Limited English Proficiency patient to have care for potential sepsis and planned admission to leave Against Medical Advice without ensuring they fully understood medical plan of care and risks to leaving against medical advice.

Interview on 3/31/22 at 1305 with Staff (ID #91) Nursing Informatics Specialist confirmed there was no evidence or documentation of interpretive services or translator use during Patient's (ID #18) ED encounter on 3/30/22. She also confirmed there was no documentation of patient encounter, communication or plan of care change for Patient (ID #3) on 12/13/19.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on record review and interview the facility failed to ensure that nursing staff maintained required qualifications for care of patients for one (ID #80) of five registered (ID#61,71,79,80,84) nurse (RN) files reviewed.

Findings Include: Policy:
Cardiopulmonary Resuscitation (CPR) Nursing Staff Education Requirement Policy
Publish Date: 07/19/2019 Version #36.0
Procedure:
1.0 BLS Provider Certification and Recertification Requirements
Note: An American Heart Association (AHA) certification/recertification may not be replaced or substituted by competency validations/affirmations from other organizations.

1.3 Registered Nurses (RN), Licensed Vocational Nurses (LVN), Nursing Assistants (NA), Patient Care Attendants (PCA) and Medical Assistants (MA) must complete an AHA provider recertification course at least every two years.
Compliance:
3.0 The immediate manager will verify that the employee maintains a current certification of annual competency validation at the time of the employee's annual performance review.

On 03/30/22 at 1500 employee personnel files for review were requested for review the following day due the need for an electronic record navigator. The request included Clinical Charge RN employee (ID# 80). During review of the personnel file for RN employee (ID# 80) on 03/31/22 at 1100 with employee (ID# 89) Human Resource (HR) representative it was observed that expired cardiac support requirements were in employee's (ID #80), record. Dates were:

Advanced Cardiac Life Support (ACLS) renew by date of 09/2020, Pediatric Cardiac Life Support (PALS) renew by date of 09/2021 and Basic Life Support (BLS) renew by date of 09/2020.

Record revie of the Annual Evaluation 09/01/2020 to 08/31/ 2021 by Manager (ID# 88) rated Accountability- Exceptional Performance.

Interview on 03/31/22 at 1114 with HR representative (ID# 89) stated current cardiac support certifications should have been in the record and texted an unknown entity. She then added that RN (ID# 80) failed to provide the updated certifications and had been called in that morning for suspension.

On 03/31/22 at approximately 1130 employee (ID# 92) Compliance brought a copy of RN employee (ID# 80) ACLs, PALs, and BLS dated 03/31/2022.

Interview 03/31/22 at 1137 HR representative (ID# 89) revealed the updated cardiac support certifications were brought in that morning by RN (ID#80) after he was informed the prior day due to this surveyors' record request which prompted a facility preemptive record review. She confirmed they had been out of compliance, that the manager failed to recognize it when doing the employee evaluation and compliance also "missed it."