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Based on observation, it was determined that the governing body was not responsible for services provided in the hospital in that staff failed to follow established facility policy and procedure in the care of a patient. The facility also failed to follow established requirements set forth in 25 TAC 133.41 (o).

Findings were:

Facility policy & procedure titled " Emergency treatment/Change of Patient Condition " stated, in part, " Purpose: The attending physician shall be notified immediately upon any significant changes in his/her patient's condition which may warrant immediate intervention or change in present therapy. "
Per this policy " The charge Nurse or licensed personnel caring for the patient is responsible for notifying the primary physician immediately upon any significant changes in patient 's condition which may warrant immediate intervention or change in present therapy....Changes in patient condition may include but are not limited to:
1. Significant changes in vital signs
2. Significant changes in neurological
3. Significant changes in intake and output
The nurse caring for the patient is responsible for documenting the date and time of notification, including documentation of when the physician returned the call, in the patient 's chart. "

The review of a patient record #1 revealed a significant change in patient output documented in the Daily Nursing assessment:

Documentation of patient bowel movements in Daily Nursing Assessment revealed:

? On 4-12-11 pt. had one small, soft stool at 0500 and one medium, loose stool at 1400.
? On 4-14-11 patient had one large, soft stool at 2400, two medium soft stools at 0400 and 0600, and two large loose stools at 0900 and 1200.
? On 4-15-11 patient had one medium loose stool.
? On 4-16-11 the patient had three medium soft stools at 0100, 0300, and 0500.
? On 4-17-11 patient had one small soft stool at 0300.
? On 4-18-11 patient had one large loose stool at 0300 and one large soft stool at 1200.
? On 4-15-11 the narrative in the Daily Nursing Assessment notes at 1300 the patient has blood in the stool.

The clinical record of patient # 1 contained no documentation of physician notification regarding the change in patient condition.

Facility policy entitled " Nursing Staffing Plan " stated, in part, " Purpose: To develop a Nursing Staffing Plan that will support the provision of quality patient care in a safe, cost-effective manner using qualified, skilled personnel as well as meet the conditions for Texas State Legislature S.B. 476. " This policy stated that, " The committee shall meet at least quarterly. "

Review of meeting documentation revealed the Nursing Staffing Committee last met in 2010. No Nursing Staffing Committee meetings had occurred in 2011.

The above was confirmed in an interview with the Director of Quality and Risk and CEO on the afternoon of 6/7/11 in the facility's conference room.

Based on observation, it was determined that the facility failed to complete medical records within 30 days following discharge as evidenced by a chart review which was incomplete as of survey date 6/7/11. Patient # 1 had been discharged to another facility on 4/18/11. The chart remained incomplete as it was missing necessary signatures and forms had not been completed. The chart was considered by the facility to be closed and complete record.

Findings were:

A review of the clinic record for patient # 1 revealed:
? Missing Physician signature for a telephone order dated 4/13/11 at 1540.
? Missing Clinician Signature on Outcome Measurement FILM Form 3.7
? Missing information on the Short Term Goal/Status Updates.

The above was confirmed in an interview with the Director of Quality and Risk and the CEO on the afternoon of 6/7/11 in the facility conference room.