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Based on interview and record review the hospital failed to have an effective governing body. The governing body failed to ensure nursing services were organized according to hospital policy.

Refer to Condition of Participation: Nursing Services 482.23

Findings include:

Record review of the " Medical Staff By-Laws " dated 1/20/11 stated " Purposes: (b) serve as the primary means for accountability to the Governing Body for the quality and appropriateness of the professional performance and ethical conduct of its Members as well as of all Allied Health Professionals, and to strive for quality patient care ...The Medical Executive Committee is responsible for reviewing and reporting to the Governing Body on the following topics: ...(f) patient safety;..(h) performance improvement; (i) program evaluations / outcomes; (j) quality of care ... ' '

The President (ID# 51) of the Hospital acknowledged 4/27/12 at 3:45 p.m. the hospital needed to improve nurse staffing to meet the regulatory requirements. The President stated the Hospital had recently hired Registered Nurses for the inpatient unit.

Record review of " Medical Executive Committee Meeting " minutes dated 1/6/12 and 3/28/12 revealed no discussion regarding inpatient nurse staffing.

NURSING REASSESSMENT OF PATIENT ID# 1
Medical record review revealed Patient ID# 1 ' s condition deteriorated on 2/15/12 and the Registered Nurse failed to properly assess the patient (vital signs were not reassessed / documented regularly per policy). After the initial Triage vital signs were taken at 10:38 a.m. the patient ' s vital signs were not reassessed again for 6 hours and 22 minutes when the patient was admitted to the medical unit (5 p.m.). The patient coded at 6:05 p.m.

The Chief Medical Officer (ID# 52) evaluated the incident of patient ID# 1 on a " Nonconformity Report " that identified the following " It was noted a patient was moved to the inpatient side without having a dedicated nurse for the inpatient unit and the Emergency Room. The ER nurse continued to provide appropriate care to both the inpatient and outpatient sides of the hospital. Our policy requires that a dedicated nurse be present on the inpatient unit at all times when there are patients admitted to the unit. At no time was the care of the patient compromised. " The " Correction " stated " The nurse managers at the hospital have been informed of the nursing requirements for the inpatient unit. We are working towards maintaining full-time nurse staffing for the inpatient side. "

Complaint Intake TX00159333

Based on observation, interview and record review the hospital failed to provide a organized nursing services and failed to ensure nursing services were supervised by a registered nurse in each department on 2/15/12, 3/3/12, 3/4/12, 3/6/12, 3/9/12, 3/10/12 and 3/11/12 (The Emergency Room and the In-patient unit).

1) The hospital failed to ensure the Chief Nursing Officer (CNO# 53) manages appropriately to assure patients are supervised and provided quality services by Registered Nurses. The CNO failed to ensure the nursing department established a nurse staffing committee that meets quarterly according to their policy. (The Chief Nursing Officer is only present 1 and 1/2 days per week at the hospital managing Nursing services)

2) The hospital failed to ensure a registered nurse was assigned to supervise each department, the emergency department and the in-patient medical unit. (On February 15th, 2012 the hospital nursing staff only consisted of one registered nurse covering 2 (two) in-patients (ID # ' s 1 and 5) on the medical unit and the nurse was also responsible for the emergency department) Patient ID# 1 coded (arrested) on the in-patient unit on this date and a Registered Nurse was not available during this time if a patient presented to the emergency department.

3) The Hospital failed to ensure a registered nurse was immediately available to supervise a Licensed Vocation Nurse caring for in-patients on the medical unit 3/4/12, 3/9/12, 3/10/12 and 3/11/12. Hospital nursing staffing consisted of a Registered Nurse assigned to the emergency department and only a Licensed Vocational Nurse assigned to care for in-patients on the medical unit on these dates. On 3/10/12 inpatient ID# 6 was found unresponsive by a Licensed Vocational Nurse caring for the inpatient.

4) The Hospital failed to ensure emergency room patients were Triaged by a Registered Nurse according to their Triage Policy on 2/15/12 (Patient ID# 4 and 5), 3/3/12 (Patient ID# 8). Emergency Medical Technicians and Radiology Technicians were noted to be performing Triage nursing assessments on patients presenting to the emergency room.

5) The Hospital failed to ensure that a Registered Nurse appropriately evaluated the changing condition of Patient ID# 1 per their policy. The patient ' s condition deteriorated on 2/15/12 and the Registered Nurse failed to properly assess the patient (vital signs were not reassessed per policy).

Findings include:

Observation 4/26/12 at 9:30 a.m. revealed Emerus Hospital has a four bed in-patient medical unit and a 24-hour emergency room. Hospital services provided include Emergency Services and in-patient services that do not require operating room services or intensive care services. Laboratory and radiology services (x-ray and CT scan) are also provided at this hospital.

CHIEF NURSING OFFICER
Interview 4/27/12 at 12:30 p.m. with the Chief Nursing Officer (CNO# 53) revealed he typically spends 1 and ? days a week at Emerus Hospital. The CNO stated that he is also a Regional Representative for a hospital system in San Antonio and divides his time. The CNO acknowledged that the Governing Board thought having one staff Registered nurse in the hospital at all times met the regulatory requirements of a Registered Nurse being immediately available to supervise care in the emergency department and the in-patient unit.

Interview 4/27/12 at 9:30 a.m. with the Chief Nursing Officer revealed the hospital does not have a Nurse Staffing Committee that meets quarterly per their facility policy.

Record review of a job description titled " Chief Nursing Officer " stated " Major Duties / Critical Task: Organizes, directs, manages, and coordinates various departments, programs and services related to managing resources, assuring quality services, and managing cases.. "

Record review of a policy titled " Nursing Advisory Committee Staffing Plan " dated 5/1/11 stated " Purpose: The Nursing Services Department of our hospital supports the provision of quality patient care in a safe, cost-effective manner by appropriately using qualified and skilled personnel. The Advisory Committee is established in accordance with Health and Safety Code 161.031-161.033 to solicit and receive input from nurses on the development, on-going monitoring and evaluation of the staffing plan. The committee will be representative of multiple areas of nursing. The Advisory Committee will meet at least quarterly. The Advisory Committee will report to the Board of Directors at least annually. "

REGISTERED NURSE SUPERVISION:
Record review of the hospital staffing assignment for February 15th, 2012 on the 7 a.m. to 7 p.m. shift revealed the following staff members: A physician, a Registered Nurse, an emergency room technician, and a radiology technician. The Registered Nurse (ID# 57) was the only Nurse in the hospital responsible for two in-patients and the emergency room department.

Record review of patient record # ' s 1 and 4 revealed they were admitted to the in-patient unit on 2/15/12. Patient ID# 1 was admitted at 5 p.m. and Patient ID# 4 was admitted at 5:40 p.m. Patient ID# 1 nursing notes at 6:05 p.m. stated " called to bedside by Radiology technician, patient climbing out of bed sank to the floor, patient found with weak thready pulse, code called. The patient was subsequently transferred to another hospital and later died.

According to the Nursing Admission Assessment Patient ID# 1 was admitted 2/15/12 at 5:00 p.m. The History and Physical dated 2/15/12 at 2:18 p.m. stated " Chief Complaint: Left ankle / foot swelling / redness for the past one week, shortness of breath, cough, blood-tinged sputum for 1 day. Impression: 1) Left ankle and foot cellulitis
2) Pneumonia 3) Type 2 diabetes 4) Hypertension.

Patient ID# 4 was admitted 2/15/12 at 5:40 p.m. The physician orders stated the diagnoses were " Left Arm / Shoulder Pain. "

Interview on 4/26/12 at 1:30 p.m. with the Registered Nurse (ID# 57) working on February 15, 2012 on the 7 a.m. to 7 p.m. shift revealed she was the only Registered Nurse in the hospital caring for 2 in-patients and the emergency room when patient ID# 1 coded on the in-patient unit. The nurse stated the hospital had been waiting for a staffing agency to find another nurse to cover the in-patient unit. The Nurse further stated that fortunately there were no current patients in the emergency room when the patient arrested.

Record review of a policy titled " Nursing Advisory Committee staffing Plan " dated 5/1/11 stated " Staffing and Delivery of Care: There will be adequate number of Registered Nurses and other personnel to provide nursing care to all patients. An RN will be immediately available to assist and supervise patient care as well as to respond to emergency situations. "

LICENSED VOCATIONAL NURSE
Record review of a nursing assignment schedule for February and March 2012 revealed a Registered Nurse was not assigned to the inpatient care unit. On March 30th and 31st a Licensed Vocational Nurse was assigned to the inpatient unit.

Record review of in-patient medical record # ' s 6, 7, 8, and 14 revealed these in-patients were being supervised / cared for by a Licensed Vocational Nurse (ID# 66). According to the hospital nurse staffing sheets 3/4/12, 3/9/12, 3/10/12, and 3/11/12, a Registered Nurse was assigned to the emergency department for these dates but the hospital did not have a Registered Nurse assigned to supervise the in-patient unit.

A Licensed Vocational Nurse (ID# 66) was supervising the in-patients on the medical unit per the nursing notes on the following dates, 3/4/12 (Patient ID# 8),
3/9/12 (Patient ID# ' s 7 and 14), 3/10/12 (Patient ID# ' s 6 and 14,
3/11/12 (Patient ID# 14).

The Chief Nursing Officer verified 4/27/12 at 3 p.m. that the in-patient unit was only staffed by a contract agency Licensed Vocational Nurse on the above dates. The CNO stated a Registered Nurse was assigned to the emergency room on these dates.

Patient ID# 6 was admitted to the hospital on 3/9/12 with diagnoses of Pulmonary Embolism per the Physician Admission orders. The Triage record stated the patient was awake, alert and oriented. The in-patient nursing notes for patient ID# 6 dated 3/10/12 at 8 a.m. by a Licensed Vocational Nurse (LVN #66) stated " Doctor called back at bedside, patient not responding to verbal but is responding to painful stimuli. " At this time the LVN was also caring for another in-patient (ID# 14). The hospital did not have a Registered Nurse assigned to the in-patient unit on 3/10/12 during this incident. According to the nursing notes the patient was moved to the emergency room and intubated. The patient was transferred to another hospital. The transfer summary by the physician stated " Acute respiratory failure, altered mental status, pulmonary embolism, hyperkalemia, status post intubation. "

NURSING TRIAGE
Record review of a policy titled " Triage Medical Screening Exam " dated 5/1/11 stated " Responsibility: Registered Nurses ...Triage Assessment - The dynamic process of sorting, prioritizing, and assessing the patient and is performed by a qualified Registered Nurse at the time of presentation and before registration. "

Record review of emergency room patient record ID# ' s 4, 5, and 8 revealed the nursing triage assessment was performed by Emergency Medical Technicians and Radiology Technicians

Record review of patient ID# 4 dated 2/15/12 at 2:15 p.m. revealed that the nursing triage of this patient was completed by an Emergency Medical Technician (ID# 59). The Emergency Medical Technician listed the complaint as " Shoulder pain, numbness, Body Pain, and Dizzy. "

Record review of patient ID# 5 dated 2/15/12 at 6:54 p.m. revealed that the nursing triage of this patient was completed by a Radiology Technician (ID# 60). The Radiology Technician listed the complaint as " Urinary Tract Infection, Possible Allergic Reaction. "

Record review of patient ID# 8 dated 3/3/12 at 9 p.m. revealed that the nursing triage of this patient was completed by a Radiology Technician (ID# 65). The Radiology Technician listed the complaint as " Sickle Cell crisis. "

The Chief Nursing Officer acknowledged 4/27/12 at 3 p.m. that only Registered Nurses should be completing Triage assessments per the hospital policy.

NURSING REASSESSMENT OF PATIENT ID# 1
Patient ID# 1 ' s condition deteriorated on 2/15/12 and the Registered Nurse failed to properly assess the patient (vital signs were not reassessed / documented regularly per policy). After the initial Triage vital signs were taken at 10:38 a.m. the patient ' s vital signs were not reassessed again for 6 hours and 22 minutes when the patient was admitted to the medical unit (5 p.m.). The patient coded at 6:05 p.m.

Record review of the medical record for patient ID# 1 dated 2/15/12 revealed: This 48 year old male patient presented to the emergency room February 15, 2012 at 10:43 a.m. The emergency room nursing triage record listed the complaint as " swollen feet and legs. " The patient was classified as " 4 Urgent. " The nursing notes stated " Past Medical History includes: cardiac history, coronary artery disease, diabetes, hypertension, pulmonary disease, pulmonary embolism, and gallstones. Surgical history listed knee, heart stents x 2. The triage notes stated presenting problem stated " Foot / ankle injury - pain swelling. Feet swelling last week, then states he fell down stairs, but unable to give a day or time. Slurred speech, sleepy, falling asleep between triage questions, doesn ' t answer triage questions. " Vital signs were assessed at the time of triage at 10:38 a.m. (BP 99/75, Pulse 102, Respirations 20, Oxygen saturation 96)

Per the nursing notes the patient ' s condition deteriorated during the day:

11:00 a.m. Nursing notes stated " Unsteady gait, confused, lethargic, uncooperative, oriented to person and place. Skin dusky in color. Skin inspection includes redness to left foot, swelling to calf and ankle 3+. No vitals signs were documented.

12:05 p.m. Nursing notes stated " Patient was uncooperative, patient sleepy and would not sit still during the procedure. Patient did not want to lay down. " No vital signs were documented.

12:26 p.m. Nursing notes stated " Patient was uncooperative, patient too sleepy, would not stand still, too woobly, unable to perform lateral x-ray, had to perform repeat anterior posterior in wheelchair as patient unable to stand still. MD informed. Patient tolerated procedure with difficulty, too sleepy, having trouble following instructions. " No vital signs were documented.

1:00 p.m. Nursing notes stated " Oxygen therapy indicated for desaturation, oxygen therapy indicated for respiratory distress, Oxygen saturation 93%, 2 liters oxygen given, via nasal cannula applied, follow-up: after procedure oxygen saturation 99%, breath sounds clear. " No vital signs were documented.

2:18 p.m. The admitting physicians History and Physical stated " The History and Physical stated " Impression: 1) Left ankle and foot cellulitis 2) Pneumonia 3) Type 2 diabetes 4) Hypertension. "

3:06 p.m. Emergency room physician notes stated " Pulse tachycardic, Respiratory rate increased. Patient alert and oriented to person, place and time. Rhonchi present to the right lower lobe. Edema present, to bilateral lower extremities, pitting, +2 pitting edema bilateral lower extremities. " No vital signs were documented.

5:00 p.m. Nursing notes stated " Patient was admitted. Edema present, dependent, +3 pitting, Speech is slurred, patient very drowsy, unaware of time, day, erratic behavior, confusion, rates pain as 9 (on a scale of 0-10) but cannot specify area where pain is.
Vital signs were assessed: BP 118/76, HR 89, RR 22, Temp 98.1, O2 sat: 99 on room air. "

5:55 p.m. Nursing notes stated " Patient was uncooperative, climbing in and out of bed, over the side rails, very agitated, physician notified of above findings. " No vital signs were documented.

6:00 p.m. Nursing notes stated " Patient climbed out of bed over side rails, pulling on IV line, taking off his gown, patient repositioned and sitting up in bed. " No vital signs were documented.

6:05 p.m. Nursing notes stated " Called to bedside by Radiology technician, patient climbing out of bed sank to the floor, patient found with weak thready pulse, code called. Patient with no vital signs, showing pulseless electrical activity. "

Record review of a policy titled " Patient Assessment " dated 5/1/11 stated " Policy: The facility nurses shall initiate accurate and ongoing assessment of the physical, nutritional, psychosocial and cultural needs of patients within the facility. Procedure: Patients will be reassessed regularly throughout their course of treatment to determine their response to treatment. "

Interview 4/26/12 at 1:30 p.m. with Registered Nurse (ID# 57) caring for patient
ID# 1 on 2/15/12 revealed the patient became increasingly confused that day and " soiled " in a corner of the emergency treatment room he was in so she decided to move him to an in-patient room which had a bathroom at 5 p.m. The nurse stated upon admission to the inpatient room the patient was not on a cardiac monitor or a telemetry monitor.

The Chief Nursing Officer acknowledged 4/27/12 at 12:30 p.m. that the standard of care was to reassess urgent emergency room patients every two hours and that would include taking and documenting vital signs.

Based on observation, interview and record review the hospital failed to provide an organized nursing service.

Refer to 482.23 Condition of Participation: Nursing Services

Based on observation, interview and record review the hospital failed to have adequate numbers of licensed registered nurses to provide nursing care to all patients as needed.

Refer to 482.23 Condition of Participation: Nursing Services

Based on observation, interview and record review the hospital failed to ensure nursing services were supervised and evaluated by a Registered Nurse at all times.

Refer to 482.23 Condition of Participation: Nursing Services