HospitalInspections.org

Based on interview and record review the Hospital failed to have an effective governing body as follows:

-Failed to conduct a physician peer review for a physician (ID# 88) after the physician discharged a patient (ID# 25) in unstable condition

-Failed to ensure two contracted nursing staff received orientation and competency checks prior to working. (ID# 61 and 62)

-Failed to monitor the billing practices of the contracted management / billing company
(Contracted Billing company ID# 91)

-Failed to ensure the contracted Dietitian fulfilled her contract


Findings include:

The Governing Body Bylaws state under heading SOURCE OF AUTHORITY, that the Governing Body shall assume full legal responsibility ....to support safe and quality patient care, treatment, and services. " Also, the bylaws state under the same heading that " The leadership of this facility assumes responsibility for determining, implementing and monitoring policies to provide quality patient care in a safe environment. "

During the entrance conference conducted at 1 PM on 8/22/2011, the facility Administrator, Staff # 50, reported that the facility does not provide respiratory therapy services, CAT scan services, or MRI services.

Patient #25, age 73, was admitted to the facility for elective surgery on 6/22/11. The patient had a mass on the left kidney. The patient was medically cleared for surgery, and had no chronic diseases other than high blood pressure. Vital signs were within normal limits prior to surgery. The operative report indicated that the surgery was successful, the mass was removed, and was not malignant.

Pot-operatively, Patient #25 was unable to maintain adequate blood oxygen saturation on room air and required supplemental oxygen therapy. There was a physician order for the night of 6/22/11 only for supplemental oxygen. However, oxygen therapy continued throughout her hospital stay. Review of nursing notes revealed that the nurses were independently deciding the amount of supplemental oxygen administered and the method of delivery to keep the patient's oxygen saturation within normal limits. There was no documented training of the nurses in supplemental oxygen administration/management or parameters to be used by nurses to maintain a patient's adequate oxygenation level. The patient's saturation levels fluctuated between 84%-94%. A physician's order was written to discontinue the supplemental oxygen after clearance by the anesthesiologist. However, no documentation was found that this occurred. The patient also had increasing abdominal pain and distension which was treated with Milk of Magnesia, and Magnesium Citrate that the family was told to purchase at a nearby store. The symptoms did not improve.

The hospital internal investigation notes indicated that the medical and nursing staff attempted to get the attending surgeon to transfer the patient to another hospital for a higher level of care, but the surgeon refused. The surgeon refused to order diagnostic tests other than chest x-rays that reported lung abnormalities that needed follow-up. At the request of the nursing staff, the emergency room physician examined the patient and ordered diagnostic tests, including an x-ray of the abdomen, on 06/26/2011 at 09:30 AM. The surgeon canceled the order for an abdominal x-ray during his rounds and was not done. On 6/27/2011, the physician discharged the patient who continued to need oxygen, but there were no discharge planning notes or orders for home health or home oxygen.

Upon discharge, the patient was taken directly to the hospital's emergency department by the nursing staff because of the patient's shortness of breath and distended abdomen.. The ED physician examined the patient, ordered diagnostic tests and initiated an appropriate transfer to the nearest hospital. The patient was admitted to the nearest hospital where she had a surgical intervention for a perforated bowel and treated for peritonitis and pleural effusion.

The Performance Improvement Director, Staff # 2, conducted an investigation and provided a written account of the incidents. Multiple issues were identified. However, there were no hospital procurements to show that the Governing Body and Medical Executive Committee conducted a review of the appropriateness of the medical management of Patient #25 by physician (ID# 88).

According to the Medical Staff Bylaws, Section 5, 5.1.1, whenever a practitioner with clinical privileges engages in behavior likely to be detrimental to patient safety or to the delivery of care to patients, corrective action against the provider may be requested by any person. The Internal Investigation notes regarding the care of patient #25 indicated that the nursing staff and other physician staff members agreed that the patient was not receiving adequate care by the attending surgeon and needed to be transferred to a higher level of care. The attending surgeon refused to transfer the patient, who continued to have poor respiratory status and had increasing bowel distension and pain.

An in-person interview was conducted with the facility Medical Director, Staff #60, at 1:15 PM on 8/24/2011. When questioned about the case, the Medical director stated that the issues were discussed and the nurse was asked to place the incident in writing. This was done 7/6/2011 by the Performance Improvement Director. The Medical Director stated this case was verbally discussed but nothing was in writing.


NURSING CONTRACTED SERVICES

Record review of two contracted nursing staff personnel files and hospital sign-in sheets revealed that nurses worked at the hospital without prior orientation or competency checks.
(Nursing Staff member ID#'s 61 and 62)

Nurse ID# 61
Record review of agency nurse sign-in logs revealed this registered nurse worked on the in-patient unit on 8/22/11. Record review of her personnel file revealed the orientation post test was blank and the competency assessment was also blank.

Nurse ID# 62
Record review of agency nurse sign-in logs revealed this licensed vocational nurse worked on the in-patient unit 8/12; 8/17; and 8/19/11. Record review of her personnel file revealed the orientation post test was blank and the competency assessment was also blank.

Record review of a policy titled "Employee New Hire" no date, stated "Contract agency staff and technical vendors will meet minimum qualifications and be deemed competent to perform the assigned job function. Orientation for contract agency staff will include the following:
- Emergency Preparedness
-Fire/Disaster Safety
-Universal Precautions
-Bloodborne Pathogens
-Department orientation to the specific department assigned."

The In-patient Nursing Director (ID# 52) stated 8/24/11 at 11:45 a.m. that she is responsible to ensure that contract nurses have completed orientation and competencies prior to working at the hospital. The Nursing Director stated unfortunately she has recently been on maternity leave and no one was assigned to ensure orientation of contract agency nurses. The nursing director further stated the hospital only has two full time nurses on the day shift for the in-patient unit and contracted agency nurses cover the night shifts.

(History: This deficient practice was previously cited during the 7/22/11 survey. A patient went into cardiac arrest post-operatively on 1/29/11 and was being cared for by a contracted agency nurse who had no orientation or competency evaluation completed.)



BILLING CONTRACTED SERVICES
The Administrator (ID# 50) acknowledged 8/22/11 at 1 p.m. that Billing services is a contracted service.

The Texas Department of State Health Services has received two billing complaints from patients at Humble Surgical Hospital.
(TX00145929 - Patient ID# 3)
(TX00145697 - Patient ID# 33)

TX00145697
Interview 8/24/11 at 5:30 p.m. with the complainant (ID# 34) revealed his wife (ID# 33) had sinus surgery on an out-patient basis at Humble Surgical Hospital on 9/9/10. The complainant was mad that the hospital billed their insurance company $215,481.50 for a two hour out-patient surgical procedure. The complainant stated he complained to several people at the hospital once he received the bill a couple of months after the surgery. He was referred to a contracted billing company (Billing company ID# 91). The complainant stated the only thing the billing company did was send him a copy of the hospital bill.

TX001456929
The complaint intake stated that patient ID# 3 had out-patient sinus surgery on 1/6/11 at Humble Surgical Hospital. The complainant was upset that the hospital billed her insurance company $241,670.75 for an out-patient procedure. The patient's operating room record dated 1/6/11 confirmed the sinus surgery procedure lasted one-hour and 32 minutes. The "Explanation of Benefits" (EOB) for patient ID# 3 further confirmed her insurance company was billed $241,670.75.

Interview 8/24/11 at 1:50 p.m. with the Vice President (ID# 58) of the contracted billing company (Contracted Billing company ID# 91) revealed the billing company "carried out an analysis" of billing practices for ear, nose and throat (ENT) procedures. The Vice President acknowledged that the billing fees were "higher in general and could be reduced by 25%." The Vice President stated the lower billing fees were implemented February 1st, 2011, but would not be retroactive for any complainants prior to February 1, 2011. The VP stated otherwise he would have to reduce the rates for everyone.

Interview 8/24/11 at 2 p.m. with the Administrator (ID# 50) revealed she was unable to demonstrate how the contracted billing company is monitored by the hospital.

The VP of the Contracted Billing company acknowledged 8/24/11 at 3 p.m. that an analysis of the ENT billing was done but he only had e-mails and notes. The VP did not provide an analysis of the billing practices before the survey exit 8/24/11 at 4 p.m.

The VP further stated that billing was discussed in a "Board Meeting" dated 2/22/11.

Record review of a meeting titled "Board Meeting" dated 2/22/11 stated:
"Additional Review of Billing and Collections and Case Costing: The VP of billing identified reductions that were made to the billed charges for ENT, Spine, and Podiatry and while it was noted that collections were strong, these numbers would be sensitive to case volumes and would vary accordingly." The "Board Meeting" did not have any supporting documentation in relation to the billing practices.

Record review of Governing Body Meeting Minutes dated 1/24/11, 4/18/11, 7/1/11, and 8/11/11 revealed no discussion regarding contracted billing services or discussion of the billing complaints.

Record review of Governing Body Bylaws (no date) stated "5. The Governing Body shall be responsible for services furnished in the Facility whether or not they are furnished directly or by contractual agreement, consultation, or other agreements. The Governing Body shall ensure that a contractor of services furnishes services in a safe and effective manner that permits the Facility to comply with all applicable rules and standards for contracted services."


Contracted Dietitian
Record review of the " Agreement to provide consultant services " between the Hospital and the Registered Dietitian revealed all responsibilities of the contract have not been fulfilled by either party.

Under section II, Responsibilities of the Consultant, of the above listed agreement, part 1. " provides consultation ...regarding policy development " . Interview with staff #50 and #69 on 8/23 revealed that there were no policies available for the food and nutrition department of the hospital available for review. On requesting such policies, surveyor was informed that no such policies existed for the facility. Under section III Responsibilities of the Facility part 2. " Identifies the person designated as the dietetic services manager " . Interview with staff #50 and #69 in the facility conference room on 8/23/11 revealed that there was not a dietetic services manager.

Based on record review and interview the hospital failed to protect and promote the rights of Patient #25, as the patient was administered treatments by untrained staff and was discharged in an unstable condition.

It was determined that this deficient practice created an Immediate Jeopardy situation and placed patients at risk to inadequate medical care management thus potentially causing them to worsen or possibly die.

Findings include:

Review of the medical record, Humble Surgical Hospital Inpatient
Patient #25, age 73, was admitted to the hospital for elective surgery due to a mass on the left kidney and discharged to home on 6/27/2011. The patient History and Physical indicated that the patient had a 13 year history of high blood pressure and a hiatal hernia, but no other serious diseases. During the pre-surgery assessment, vital signs were within normal limits, and the patient's assessment was normal. The operative report stated that the mass was removed from the kidney and was not malignant. The surgeon reported that the patient tolerated the procedure well and was taken to the post anesthesia care unit (PACU) for recovery. The patient was then admitted to the inpatient unit. The patient began having difficulty keeping blood oxygen saturation within normal limits upon admission (saturation levels between 95-100% at sea level are considered "normal"). The PACU physician ordered to continue oxygen treatment at 3 liters per minute overnight. The nursing staff made independent decisions in providing supplemental oxygen therapy for the patient in an attempt to maintain adequate oxygen saturation levels. The nursing staff administered between 2 and 10 liters of oxygen delivered by either a nasal cannula or face tent throughout the hospitalization. These changes in oxygen therapy were not based on physician orders or oxygen therapy protocols. There was no documentation in the nurses personnel files that indicated the nurses caring for Patient #25 were trained in delivering nebulizer treatments.

For example, nursing notes indicated that on the morning of 6/23/11, the patient was using a face tent with 10 liters of oxygen, but that the saturation level dipped to the "upper 80s" when the patient was taken off supplemental oxygen and placed on room air. The face tent was immediately replaced by the nurse. On 6/25/11, the nurse noted that the patient began a productive cough and had diminished breath sounds. The nurse placed a nasal cannula on the patient with 2 liters of oxygen per minute, and oxygen saturation was 89%. The nurse wrote "will continue to monitor." Nebulizer treatments were ordered 1 ? hour later.

On 6/25/2011 at 0800, the patient was "tried" on room air, but the oxygen saturation dropped to 85%. Supplemental oxygen was replaced. An order had been written earlier in the day to discontinue oxygen therapy with approval from anesthesiologist. There was no order written by the anesthesiologist for the discontinuation of the supplemental oxygen. At 1900, the nurse wrote that the patient's oxygen saturation was 88% on 3 liters but no intervention was noted to increase oxygen saturation to within normal limits until nebulizer treatments an hour later. At 2130, the patient began to complain of abdominal distension and tenderness. The physician was informed at 2215, and ordered milk of magnesia.

On 6/26/11, magnesium citrate was ordered and the family was instructed to "pick up" the medication at a nearby store. The night of 6/26/11, the patient awoke several times coughing up sputum and having shortness of breath. The patient also continued to complain of abdominal discomfort and distension. At 1500 on 6/26/11, the patient complained of being extremely uncomfortable and reported abdominal pain intensity at 8 on a scale of 1-10. An x-ray of the abdomen was ordered by the ED physician on 6/26/2011, but canceled by the attending physician on the same day when he made his rounds. No rationale was documented for canceling the test.

The day of the patient ' s discharge, 6/27/2011, nursing notes indicated that the patient was on 3-4 liters of oxygen with a saturation of 91% and continued having abdominal distension and pain. At 0930, the physician was on the unit writing discharge orders for the patient to "go home on O2." There was no discharge planning documentation or instructions given to the patient about how to obtain the needed oxygen. The nurse instructed the patient and the family to "go to the ER for complications associated with difficulty breathing, uncontrolled pain, signs of infection near incision site." At 1145, the patient was discharged home via wheelchair with walker in care of family. Although the patient had required oxygen the entire time of the hospital stay and was ordered to have oxygen at home, the oxygen supply was removed and the patient was left on room air. Physician progress notes written 6/27/11 state that the chest x-ray shows resolved respiratory problems, although the report indicated that follow-up exam was needed due to pleural effusion noted.

On 6/27/2011, the patient's attending physician ordered discharge to home with access to nasal oxygen and a urinary catheter. There was no discharge planning documented in the medical record and no resources for obtaining home oxygen were given to the patient or family. The oxygen was removed prior to the patient ' s discharge, although the physician ordered access to oxygen. The discharge instructions were written on the facility PACU Discharge Instruction sheet, routinely given to patients having outpatient surgical procedures and discharged on the same day from recovery. The form stated "no bath tubs (showers ok); follow-up with Dr. in office tomorrow." There were no notes regarding the need for home oxygen, where to obtain the oxygen, or indwelling urinary catheter care. The patient was taken by the nursing staff and patient's family immediately to the hospital's ED from the inpatient room.


ER Record, Humble Surgical Hospital
Patient #25 was admitted to the ER on 6/27/11 at 12:22 as a new admission. The chief complaint was "shortness of breath 4 days." The triage assessment revealed mild wheezing bilaterally with decreased breath sounds on the left side and a productive cough. The patient arrived without supplemental oxygen and on room air had blood oxygen saturation of 87-89%. Patient #25 had a temperature of 99.2. The abdomen was rigid, distended, with increased bowel sounds. Three liters of oxygen delivered per nasal cannula increased the blood oxygen to 92%. Patient #25 had 2 nebulizer treatments and a dose of Solumedrol, a steroidal medication to reduce lung inflammation. The physician's clinical impressions based on the diagnostic studies performed in the ER included pleural effusion (excess fluid that accumulates in pace that surrounds the lungs, which can limit ability to breathe), dyspnea (shortness of breath), and ileus (decreased activity of the gastrointestinal tract). The patient was then transferred to a nearby acute care hospital via ambulance.

Medical record from other hospital
Patient #25 arrived at the receiving acute care hospital's ED and was assessed by the receiving physician. The assessment findings included bilateral pleural effusions, and a CT scan revealed an ileus. Surgery was performed on 7/1/2011 and the postoperative diagnosis was "perforated right colon with fecal peritonitis" (inflammation that results from the presence of feces in the abdomen). The Discharge Summary prepared by the attending physician included discharge diagnoses of Colon Perforation, Peritonitis, and Extreme debilitation. The Summary reiterated the course of the hospitalization, including the colon surgery and ileostomy (a surgical opening constructed by bringing the end or loop of small intestine out onto the surface of the skin). The patient ' s respiratory symptoms also resolved during the stay. Patient #25 was then transferred to a long-term acute care hospital for further IV antibiotics, physical therapy and other rehabilitation.

In an in-person interview conducted at 3 PM on 8/24/2011, the facility Administrator, Staff #50, acknowledged the above findings.

Based on interview and record review the hospital failed to have an effective quality assessment and performance improvement program (QAPI). The hospital failed to evaluate an adverse / sentinel patient event (Patient ID# 25).

It was determined that this deficient practice created an Immediate Jeopardy situation and placed patients at risk to inadequate medical care management thus potentially causing them to worsen or possibly die.

Findings include:

The facility Performance Improvement/Risk Management /Patient Safety Plan states under II. OBJECTIVES, that the facility will facilitate improvements that will achieve patient care delivery that is efficacious and appropriate and accessible, timely, effective, continuous, safe, efficient, respectful and caring. Also, under III., METHODOLOGY, the Plan states that the facility model effectively promotes an interdepartmental and/or multidisciplinary team approach to improving care and services.

An internal investigation was conducted by the facility Quality Improvement Director, Staff #2, regarding the incidents that occurred during the hospitalization of patient #25. The timeline begins on 6/22/11, and stated that "Pt was having difficulty breathing in PACU prior to INPT admission ...Admitted without ability to wean off of O2 from PACU."

On 6/23/11, the physician was notified of the patient's status, including the difficulty maintaining adequate oxygen saturation level and productive cough. The Quality Improvement Director indicated that the physician "refused to order" a chest x-ray, and ordered nebulizer treatments.

On 6/26/11, the day shift RN called the Inpatient Director, Staff #52, and expressed concerns about the patient's unimproved status. The Inpatient Director called the ED physician to the patient's room and several tests were ordered to determine why the patient was continuing to exhibit the abdominal and respiratory symptoms. When the attending physician, Staff #88, arrived, all the ED Physician's orders were canceled. The Inpatient Director along with other physicians attempted to have the attending physician transfer the patient to a higher level of care, but he refused.

On 6/27/11, the surgeon discharged the patient against the family and nursing staff wishes, as no arrangements had been made for post hospital care. The patient was immediately taken from the inpatient room to the ED down the hallway by the family and the staff nurse.

Patient #25 was subsequently transferred to an acute care hospital. The QA Director, Staff #2, identified the issues and problems; however, there was no documentation that any follow-up actions were taken by multidisciplinary staff members regarding these incidents to ensure quality patient care.

Record review of the Quality Assurance meeting dated 7/18/11 revealed no discussion regarding patient ID# 25.

Facility Policy SE.01, entitled, SENTINEL EVENTS, defined a sentinel event as an occurrence involving death or the risk thereof that carries a significant chance of a serious adverse outcome. Patient #25 was discharged from the hospital in an unstable condition, as evidenced by the immediate need for emergency services following the patient ' s discharge. This event was not treated as a sentinel event and not reported, tracked, or reviewed according to policy.

The Facility PERFORMANCE IMPROVEMENT/RISK MANAGEMENT/PATIENT SAFETY PLAN states on page 16 that " When addressing sentinel events, root cause analysis and near misses ....reporting must be completed within 45 days of the event. " Patient #25 was discharged 6/27/2011, 58 days as of 8/24/2011, the date of the survey. A sentinel event has not been identified or reported.

Based on interview and record review the Hospital failed to have an organized nursing service as follows:

-Failed to ensure two contracted nursing staff members received orientation and competency checks prior to working. (ID# 61 and 62) and nurses caring for Patient #25 had no training documented for respiratory therapy treatments administered to the patient.

-Failed to ensure Nursing staff were provided training and policies related to respiratory services

It was determined that this deficient practice created an Immediate Jeopardy situation and placed patients at risk to inadequate mediconursing care management thus potentially causing them to worsen or possibly die.


Findings include:

Contracted Nurses
Record review of two contracted nursing staff personnel files and hospital sign-in sheets revealed the nurses worked at the hospital without orientation or competency checks.
(Nursing Staff member ID#'s 61 and 62)

Nurse ID# 61
Record review of agency nurse sign-in logs revealed this registered nurse worked on the in-patient unit on 8/22/11. Record review of her personnel file revealed the orientation post test was blank and the competency assessment was also blank.

Nurse ID# 62
Record review of agency nurse sign-in logs revealed this licensed vocational nurse worked on the
in-patient unit 8/12; 8/17; and 8/19/11. Record review of her personnel file revealed the orientation post test was blank and the competency assessment was also blank.

Record review of a policy titled "Employee New Hire" no date, stated "Contract agency staff and technical vendors will meet minimum qualifications and be deemed competent to perform the assigned job function. Orientation for contract agency staff will include the following:
- Emergency Preparedness
-Fire/Disaster Safety
-Universal Precautions
-Bloodborne Pathogens
-Department orientation to the specific department assigned."

The In-patient Nursing Director (ID# 52) stated 8/24/11 at 11:45 a.m. that she is responsible to ensure that contract nurses have completed orientation and competencies prior to working at the hospital. The Nursing Director stated unfortunately she has recently been on maternity leave and no one was assigned to ensure orientation of contract agency nurses. The nursing director further stated the hospital only has two full time nurses on the day shift for the in-patient unit and contracted agency nurses cover the night shifts.

(History: This deficient practice was previously cited during the 7/22/11 survey. A patient went into cardiac arrest post-operatively on 1/29/11 and was being cared for by a contracted agency nurse who had no orientation or competency evaluation completed.)


PATIENT ID# 25
Patient #25, age 73, was admitted to the facility on 6/22/2011 for elective surgery due to a mass on the left kidney and discharged to home on 6/27/2011. The patient began having difficulty keeping blood oxygen saturation within normal limits upon admission (saturation levels between 95-100% at sea level are considered "normal."). Throughout the hospitalization, nursing staff made independent decisions to maintain adequate oxygen saturation levels by using between 2 and 10 liters of oxygen delivered by either a nasal cannula or face tent. The facility administrator, Staff #50, stated on 8/24/2010 at 2 PM that there was no formal training/policies for nursing personnel on respiratory treatments, such as oxygen and nebulizer treatments. During an interview conducted at 8 am on 8/24/2011, the Director of Anesthesia, Staff #59, stated that anesthesia was in charge of any respiratory needs of patients. When questioned about after-hours coverage for inpatient respiratory needs, Staff #59 stated that there are no written policies or protocols regarding titration of oxygen.

During the entrance conference conducted at 1 PM on 8/22/2011, the facility Administrator, Staff # 50, reported that the facility does not provide respiratory therapy services.

Record review of nursing assessments of patient ID# 25's breathing and breath sounds during her hospitalization revealed the following:
6/22/11 even unlabored shallow, diminished bilateral bases
6/23/11 shallow unlabored, shallow diminished
6/24/11 mild dyspnea with exertion,, diminished bilateral bases
6/25/11 shallow wheezing, bilateral crackles throughout B
6/26/11 shallow labored, diminished bilateral bases wheezing bilateral crackles all lobes throughout
6/27/11 shallow even, wheezing bilateral crackles all lobes throughout
Record review of physician orders for patient ID# 25 revealed the attending physician (#88) was aware of the patients respiratory status per the orders. The orders were as follows:
6/24/11 at 8:30 a.m. "Albuterol 2.5 mg per nebulizer now, every 4-6 hours as needed for chest congestion"
6/25/11 "Discontinue oxygen if OK with anesthesia"
6/25/11 at 22:15 p.m. "Chest X-ray in a.m."
(the chest X-ray results dated 6/26/11 stated "impression: interval development of left pleural effusion and left lower lobe infiltrate. This may likely beyond the bases of compressive atelectasis.)"
6/26/11 "Repeat chest x-ray in a.m."
(the chest X-ray results dated 6/27/11 stated "impression: left pleural effusion. Follow-up exam is recommended.)"
6/27/11 "Discharge home with access to nasal oxygen"

The nursing assessments revealed the nursing staff were frequently adjusting the patients oxygen and also provided the patient with a suction to suction herself. The nursing assessments were as follows:
6/22/11 at 19:00 p.m. "Oxygen 10 liters per minute per face shield, oxygen saturations at 99%"
6/23/11 at midnight "Oxygen saturation 82%"
6/24/11 at 7 a.m. "Oxygen saturation 98% on face tent. Education provided on goal to wean off of face tent, to cannula, to room air. oxygen 2 liters placed on patient oxygen saturations 89%."
6/24/11 at 8:30 a.m. "Primary Physician (#88) notified of lung congestion / phlegm. Oxygen saturations continue to dip into 80's. Applied oxygen 10 liters per minute. Incentive Spirometer encouraged."
6/24/11 at 20:00 p.m. "Short of breath with exertion. oxygen saturations less than 90% on room air and following exertion. Uses oral suction by self."
6/25/11 at 1:15 a.m. "Patient oxygen saturation on nasal cannula at 4 liters decreased to 72% when attempting to rest. changed to 98% humidified face tent."
6/25/11 at 6 a.m. "Patient changed to 4 liter oxygen nasal cannula to eat. noted oxygen saturation down to 84% while eating. Patient stated I can't breathe when I eat. Patient placed on humidified 35% at 8 liters of oxygen per minute face mask at this time."
6/25/11 at 19:00 p.m. "Oxygen saturations 88% on 3 liters of nasal cannula oxygen."
6/25/11 at 22:15 p.m. "Primary surgeon (#88) called, updated on patient's condition, informed of abdominal distention and respiratory status."
6/25/11 at 23:30 p.m. "Albuterol treatment administered for audible wheezing and increased respiratory effort."
6/26/11 at 8 a.m. "Simple mask 8 liters oxygen at 35%."
6/26/11 at 12:00 noon "Nasal cannula at 3 liters."
6/26/11 at midnight "Nasal cannula at 4 liters. Patient verbalized discomfort and increasing anxiety with nebulizer facemask and removed."
6/26/11 at 8 a.m. "encouraged patient to deep breathe, patient producing sputum cream colored and moderate amounts using yanker for suctioning. Patient desaturated to low 80's on room air."
6/26/11 at 15:00 p.m. "Called primary surgeon (#88) to address patients lack of progress."
6/26/11 at 19:30 p.m. "Patient tolerating nasal cannula at 3 liters per minute."
6/26/11 at 1 a.m. "Oxygen saturations maintaining on nasal cannula at 4 liters per minute."
6/26/11 at 4 a.m. "Increased wheezing and crackles throughout and diminished at bilateral bases, continue to monitor."
6/27/11 at 7 a.m. "oxygen at 2.5 liters per minute nasal cannula."
6/27/11 at 9:30 a.m. "Primary surgeon (#88) at bedside with patient and discharge orders written. To go home with oxygen and leg bag Foley."
6/27/11 at 11 a.m. "Oxygen at 3 liters per minute nasal cannula."
6/27/11 at 11:30 a.m. "Patients daughter encouraged to take patient to emergency room for complications associated with difficulty breathing, uncontrolled pain, and signs of infection."
6/27/11 at 12:22 p.m. the patient presented down the hall to the emergency room with a chief complaint of "shortness of breath, started 4 days ago. Patient states increased shortness of breath since surgery (6/22) with increased rigidity of abdomen and distention. Oxygen saturations 87 to 89% on room air."
The emergency room physicians clinical impression listed "pleural effusion with dyspnea." The patient was transferred to another hospital.
Interview with the Medical Director (ID# 60) revealed he requested the quality assurance nurse make a written report regarding the hospitalization of patient ID# 25.
Record review of the written report by the Quality Assurance nurse (ID# 51) read as follows:
"6/22/11 - Patient ID# 25 was scheduled for a 3 night stay. Patient was having difficulty breathing in the recovery room prior to inpatient hospital admission. Admitted without ability to wean off oxygen from the recovery room
6/23/11 - Primary Surgeon (#88) was notified of patient's status - unable to maintain oxygen saturations without at least 3 liters of nasal cannula oxygen and has wet lungs., productive, thick cough. Refused to order chest X-ray and ordered nebulizer treatments.
6/24/11 - Nursing in-patient director (# 52) notified that the patients surgeon decided to keep the patient another night for urinary retention and low oxygen.
6/25/11 - Nursing in-patient director informed the patient still not breathing well
6/26/11 - Day shift nurse called the Nursing in-patient director at home at 8:30 a.m. and expressed concerns regarding the patient's unimproved status. Nursing in-patient director arrived at hospital that morning at 9:30 a.m. to ensure patient was seen by emergency room physician / hospitalist and transferred to another facility for respiratory therapy, if necessary. The emergency room physician had assessed the patient and felt that she would benefit from at least a bipap machine which Humble Surgical Hospital does not have. The emergency room physician ordered laboratory and X-ray tests. The attending physician (#88) showed up and was furious to see another doctor's name on his patient's chart and canceled all of the emergency room physicians orders. The Nursing Inpatient director explained to the surgeon that the nurses have been asking him to address her respiratory status since Friday (6/24/) but he didn't seem concerned. Patient required a minimum of 3 liters of oxygen via nasal cannula to maintain oxygen saturations at 92%. Lung sounds were diminished to left lower lung and expiratory wheezing noted when patient slightly reclined. The surgeon stated "She's fine! Sitting up and without distress. She can hold a conversation no problem. Unless there is a pneumothorax, there is no reason she can't go home, so we'll wait and see what the chest X-ray shows and I'll make my decision from there." The Nursing director expressed how she felt there is no way the patient can safely go home without oxygen because she can barely walk a few steps with oxygen in place and still gets dizzy, light-headed and short of breath. The chest X-ray showed worsening pleural effusion from pre-op films, to which the surgeon replied "Okay, now that I see that, I agree she needs to stay and she can't go home." The Nursing Director inquired to the physician about transferring her to an appropriate facility with respiratory therapy/pulmonary management. He said "because it's Sunday and Doctors don't work on Sundays, it will be a lot easier to get her accepted tomorrow." The Inpatient Nursing Director informed the Administrator that the doctor was keeping the patient and the Administrator called to inform the Medical Director and the CEO to keep them informed. Then the Medical Director of the emergency room came to see the patient and consult on their feelings of keeping the patient overnight again. The ER Medical Director arrived at 12:00 and thought it was "ridiculous she was still at Humble Surgical Hospital and not transferred to another facility." He called the Surgeon to offer his professional opinion and recommendation - to which the surgeon did not change his mind. The Administrator was updated.
6/27/11 - Patient still had pronounced abdominal distention. The surgeon showed up around 9 a.m. to round and looked at the repeat chest X-ray that was done that morning. It showed slight improvement of left lower lobe pleural effusion but the patient was still distressed and severely distended. He wrote discharge orders for home. The daughter demanded that her mother not be discharged because she couldn't breathe without oxygen. The doctor said to send her home with an oxygen tank (which we can't do) but refused to write orders for home health / medical equipment. The surgeon discharged the patient to go home and wrote in his progress notes "Patient requested to be discharged home." The patient was in no condition to go home due to her respiratory status and distended abdomen. She was given discharge instructions per the order and wheeled down to the emergency room where she had already developed shortness of breath from being off oxygen for a short period. The patient was transferred to another hospital.
7/1/11 - The daughter called back to give update on patient, 40% of her colon was removed and she has an open abdomen and is on a ventilator for several days.

Based on observation during a tour of the facility and interviews with staff, the hospital failed to have an organized Food and Nutrition department as there was not a Food service supervisor documented as being responsible for the department.

Findings were:

1.
There was no job description for any food service staff and there was no one appointed to be the director of the food service operations.
2.
During a tour on 8/22/11 with staff #56 and #86, the room described as patient nourishment was observed to have a freezer, refrigerator, microwave, ice machine, coffee maker and dry food storage. There were plastic silverware and napkins available. There was no stove, only the microwave, and no three compartment sink for dish washing; this room had only one all purpose sink.

An interview at 0930 on 8/23/11 with staff #69, the contract dietitian, revealed this was the "kitchen and food preparation" area. She stated when asked "that there were no policies or procedures for the department." When asked about a food service supervisor, it was revealed that the "contact" was the Inpatient Director. The Inpatient Director brought any concerns regarding diets or food preparation to the contract dietitian when she was present in the facility. Staff #69 added there was no in-service held for the preparation of the meals, there was no one taking and recording the food temperatures of patient food. She had not performed any nutritional assessments of patients, although this hospital began operation in July of 2010.
The above was confirmed in interviews at 0930 with staff #50 and #69 in the conference room on 8/23/11.

Based on review of available policies, inpatient records for 3 of 3 patients and staff interview, the facility failed to have any written policies or procedures that applied to the discharge planning process. (Patient ID#'s 22, 23 and 25)

Findings were:

1.
Interview with staff #51 revealed that there were no policies with any specific process describing discharge planning for inpatients. When asked who was responsible, staff replied that the individual patients nurse was responsible for any discharge planning.
2.
Patient #25, age 73, was admitted to the hospital on 6/22/11 for elective surgery due to a mass on the left kidney; and discharged on 6/27/2011. She began having difficulty keeping blood oxygen saturation level within normal limits throughout her hospitalization, and required supplemental oxygen treatment. On 6/27/2011, the attending surgeon, Staff #88, discharged the patient home. There was no discharge planning documented; the patient needed home oxygen but there were no instructions about where or how to obtain the treatment. The oxygen was removed, the patient discharged, and staff and family walked the patient down the hall to the ED. Patient #25 was transferred to another hospital for care for further stabilizing treatment.
3.
Review of the record for patient # 22 revealed that this patient had a total knee replacement. Upon discharge, the patient was given the phone number to a durable medical equipment company, for the patient to call and have a CPM machine (continuous passive motion) delivered.
4.
Review of the record for patient #23 revealed that this patient also had a total knee replacement. Upon discharge this patient also was given the phone number to a durable medical equipment company for the patient to call and have the CPM machine delivered.
Neither of these patients was given a choice as to which durable medical equipment company could meet their needs and provide the required machine.

The above was confirmed in interview in the morning in the conference room on 8/24/11 with staff # 50.

Based on review of documents and interviews with staff, the facility failed to meet the needs of a patient in accordance with acceptable standards of practice for respiratory care for 1 of 1 patient. Patient #25 received respiratory treatments with no protocols, policies, training of staff, or physician oversight.

It was determined that this deficient practice created an Immediate Jeopardy situation and placed patients at risk to inadequate medical care management thus potentially causing them to worsen or possibly die.


Findings were:

During the entrance conference conducted at 1 PM on 8/22/2011, the facility Administrator, Staff # 50, reported that the facility does not provide respiratory therapy services.

Patient #25, age 73, was admitted to the facility on 6/22/2011 for elective surgery due to a mass on the left kidney; and discharged to home on 6/27/2011. Post operatively, the patient had difficulty keeping blood oxygen saturation level within normal limits (saturation levels between 95-100% at sea level are considered "normal."), and the PACU physician ordered supplemental oxygen at 3 liters per minute overnight. Throughout the hospitalization, nursing staff made independent decisions to maintain adequate oxygen saturation levels by using between 2 and 10 liters of oxygen delivered by either a nasal cannula or face tent. For example, nursing notes indicated that on the morning of 6/23/11, the patient was using a face tent with 10 liters of oxygen, but that the saturation level dipped to the "upper 80s" when patient was put on room air. The face tent was replaced by the nurse.

On 6/25/11, the nurse noted that the patient began a productive cough and had diminished breath sounds. The nurse placed a nasal cannula on the patient with 2 liters of oxygen per minute, and oxygen saturation was 89%. The nurse wrote "will continue to monitor." Nebulizer treatments were ordered 1 ? hour later. On 6/25/2011 at 0800, the patient was " tried " on room air, but the oxygen saturation dropped to 85%. Oxygen was replaced. An order had been written earlier in the day to discontinue oxygen therapy with approval from anesthesiologist. There was no note regarding removal of oxygen written by the anesthesiologist. At 1900, the nurse wrote that the patient ' s oxygen saturation was 88% on 3 liters; no intervention was noted to increase oxygen saturation to within normal limits until nebulizer treatments an hour later.

The Administrator stated on 8/24/2010 at 2 PM that there was no formal training of nursing personnel on respiratory treatments, such as oxygen and nebulizer treatments.

During an interview conducted at 8 am on 8/24/2011, the Director of Anesthesia, Staff #59, stated that anesthesia was in charge of any respiratory needs of patients. When questioned about after-hours coverage for inpatient respiratory needs, Staff #59 stated that there are no written policies or protocols regarding titration of oxygen.

Meeting minutes of the 8/1/2011 Quality Council for the facility included the statement " The following services are not available at Humble Surgical Hospital: Respiratory Therapy; Social Work. " Patient #25 required respiratory care for the 5-day stay on the inpatient unit.

Based on review of the " Agreement to provide consultant services " between the Hospital and the Registered Dietitian, all responsibilities of the contract have not been fulfilled by either party.

Findings were:

Under section II, Responsibilities of the Consultant, of the above listed agreement, part1. " provides consultation ...regarding policy development " . Interview with staff #50 and #69 on 8/23 revealed that there were no policies available for the food and nutrition department of the hospital available for review. On requesting such policies, surveyor was informed that no such policies existed for the facility. Under section III Responsibilities of the Facility part 2. " Identifies the person designated as the dietetic services manager " . Interview with staff #50 and #69 in the facility conference room on 8/23/11 revealed that there was not a dietetic services manager.

Based on review of records and interviews with staff, the facility failed to ensure that Patient #25 received care in a safe setting, as the patient was treated by untrained staff and discharged in an unstable condition.

Findings were:
Patient #25, age 73, was admitted to the facility for elective surgery on 6/22/11. The patient had a mass on the left kidney. The patient was medically cleared for surgery, and had no chronic diseases other than high blood pressure. Vital signs were within normal limits prior to surgery. The operative report indicated that the surgery was successful, the mass was removed, and was not malignant. The patient was unable to maintain adequate blood oxygen saturation on room air and required oxygen therapy. The physician ordered supplemental oxygen for the night of 6/22/11 only, however, oxygen therapy continued throughout her hospital stay. Review of nursing notes revealed that the nurses were independently deciding what amount of supplemental oxygen administered to the patient and the delivery method to use to keep the patient's oxygen saturation level within normal limits. There was no documented training of the nursing staff in the administration and management of oxygen therapy. The patient's blood oxygen saturation levels fluctuated between 84%-94%. A physician order was written to discontinue the patient from supplemental oxygen after clearance by the anesthesiologist. However, no documentation was found that this occurred. The patient also had increasing abdominal pain and distension which was treated with Milk of Magnesia, and Magnesium Citrate that the family was told to purchase at a nearby store. The symptoms did not improve. Internal investigation notes indicated that the medical and nursing staff attempted to get the attending physician to transfer the patient to another hospital for a higher level of care, but the surgeon refused. The surgeon refused to order diagnostic tests other than chest x-rays that reported lung abnormalities that needed follow-up. The attending physician canceled another physician's order for an abdominal x-ray.

On 6/27/2011, the attending physician discharged the patient inspite of the troublesome respiratory status of the patient and unresolved abdominal issues. There were no discharge planning notes or orders for post hospital care. The patient was taken directly to the hospital's ED by the staff and patient's family. After conducting diagnostic tests, the ED physician transferred the patient to a nearby hospital where surgery was performed to correct a bowel perforation and peritonitis.

In an in-person interview conducted at 3 PM on 8/24/2011, the facility Administrator, Staff #50, acknowledged the above findings.

Based on observation during a tour of the facility and interviews with staff, the hospital failed to have a full time employee who serves as the director of the food and dietetic department.

Findings were:

Interview with staff #50 on 8/23/11 during the tour revealed that there was no employee appointed as the director of the food and dietetic services, there was a contract Dietitian. When asked who was responsible for preparing patient meals it was revealed that the patient's nurse prepared their meals. There was no one appointed to oversee the daily patient food preparation and management of the department. There was no job description for a director of food services.

The above was confirmed at 0930 in interviews with staff #50 and #69 in the conference room on 8/23/11.

Based on observation during a tour of the facility and interviews with staff, the hospital failed to have a qualified Dietitian who maintained professional standards of practice as there were no department policies or procedure, no food service staff nor was there a Director of the department.

Findings were:

1.
In interview on 8/23/11 at 0930, staff #69 stated when asked what were the flooder department polices "there were no policies or procedures for the department ." Staff #69 added "the patients nurse prepared and serves the meals."
2.
Also in interview, staff #69 stated there was no in-services held for the preparation of the meals, there was no one taking and recording the food temperatures of patient food.
Review of documentation from 11/1/10 from staff #69 revealed that mealtimes were listed as " when the patient wants to eat ," also listed was that the serving temperatures were less than 40 and above 140 the units of temperature ( for example - Fahrenheit or centigrade ) were not listed.
3.
When asked about patient services, staff #69 revealed that she had not performed any nutritional assessments of facility patients, although this hospital began operation in July of 2010.
4.
There was no job description for any food service staff and there was no one as appointed to be the Director of the food service day to day operations.
5.
Between November 1, 2010 and 8/4/2011 the contract Dietitian spent a total of 12.5 hour consulting for this hospital; no visit was conducted in June of 2011.

The state statue -25 TAC133.41 (d) (1) (B) requires that "There shall be a qualified dietitian who works full-time, part-time, or on a consultant basis. If by consultation, such services shall occur at least once per month for not less than eight hours."

The above was confirmed in interviews at 0930 with staff #50 and #69 in the conference room on 8/23/11.
.
.

Based on observation during a tour of the hospital on 8/22/11 in surgery, the sterile processing area, pre op and post op areas and interview with staff, the hospital failed to ensure that equipment for patient use or to be used on patients, including surgical instruments was maintained to ensure safety and quality.

Findings were:

1.
In the sterile processing area a review of the sterilizer logs revealed that the Flash Sterilization method was used routinely, as there were more cases planned than the hospital had surgical instrument sets to accommodate. In interview with staff #53 on 8/23 in the morning, it was revealed that for example there are four " eye " sets and the physician routinely schedules 8 to 12 patients. Additionally, there is one instrument set for a dilation and curettage; however the physician often has three patients scheduled; necessitating the use of " Flash " sterilization. The rates of Flash sterilization for the past nine months were as follows:
December 2010 63%,
January 2011 59%
February 2011 50%
March 2011 60%
April 2011 45.3%
May 2011 51.5%
June 2011 46.8%
July 2011 48%
August 2011 41%
Interview with staff #56, Infection control director, on 6/23 in the afternoon, revealed that she was not aware of the Flash sterilization practices.
2.
In the Cardiac catheterization room the table pad was observed to be wet in a right angle area 5 inches in each direction along two seams. The area was a darker color by the edge and out towards the pad middle the color changed to a rusty red brown color. Staff #89 working in the area revealed that a patient had a cardiac pacemaker placed in the room with some blood spill. Additionally there were two decorative vases observed on the counter with dust accumulated inside of them. There was an ornamental decoration and a clock with multiple protruding projections that were high on the walls and could only be cleaned by standing on a ladder. These areas are a potential for contamination.
3.
-In the pre op area there were 4 - 1000 ml bags of 5% dextrose solution that expired 4/11 and were available for patient use.
-There were scissors stored in the cabinet that were in an open sterilizer bag, it was not determined if they had been used but were no longer sterile and were available for patient use.
-In patient room #2 there was a three inch hole in the wall under the bathroom sink
-In the anesthesia room there were four boxes stored on the floor.
-In operating room #2 there were 2 arm boards and a table pad that were not intact with ripped and torn areas, that were not able to be cleaned and were available for patient use.
-The operating table in the hall had areas with stains and multiple taped areas, not able to be cleaned. In addition all operating room tables were observed to have multiple pieces of tape adhering to them not being able to be effectively cleaned and therefore a source of possible contamination and/or infection and were available for patient use.
4.
In nuclear medicine there was a staff member coat stored on top of the clean linen cart, (which was covered by a mesh type material) presenting a means of contamination of the clean linen available for patient use.
There were empty boxes stored on the floor near the CT machine; therefore the floor of the room could not be effectively cleaned.
There was a table in the CT area that had a blue absorbent pad taped to the top, this is an infection problem as it is not able to be cleaned.
5.
Positioning equipment stored in the hall outside the sterile corridor was observed to be stored with stains -the beach chairs and four assorted positioning wedges; this equipment was available for patient use. Purple gel positioning rolls (3) were stored with tape adhering, and not able to be cleaned; two thigh protectors had torn seams and were not cleanable and these were available for patient use. Also there were two knee holders made of a foam material that was in a shredded condition and available for patient use.
The above was confirmed in multiple interviews with staff #50, #53, and #56 throughout the tour of these areas.