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Based on observation, interview and record review, the hospital failed to ensure the emergency needs of patients were met in accordance with acceptable standards of practice. The hospital failed to ensure :

1. Emergency services were organized under the direction of a qualified member of the medical staff.

Refer to A-1102

2. Immediate availability of a member of the medical staff to provide care & treatment in the ER & documented supervision of nurse practitioners (NP) in the ER .

Refer to A-1111

3. On-going availability of nursing staff to the ER & delineation of ER core privileges to NPs working in the ER.

Refer to A-1112

4. Maintenance of an on-call list of physicians available to provide care, treatment; to stabilize individuals with an emergency medical condition.

Refer to A-2404

5. Completion of a ER central log to consistently include patient disposition.

Refer to A-2405

Based on observation, interview, and record review, the facility failed to fully analyze an adverse patient event and implement timely preventative actions (citing Patient # 30).

Patient # 30 had an episode of uncontrolled bleeding on 03/29/19 and had to be transferred out 911. As of 09/06/19, the patient's adverse occurrence was not fully analyzed & no additional prevention measures had been implemented.

Findings included:

TX 00319014

Review of facility's policy titled, "Incident Reporting," dated 06/13/16, showed definition of "Incident": An incident is broadly defined as any occurrence which is not consistent with the routine operation of the hospital. Also included are violations of established procedures, disturbances, significant medical events or unfavorable situations that could disrupt hospital functions. Policy: It is the policy ...that all incidents that occur in the hospital are reported to the Director of Quality/Risk Management, Chief Nursing Officer or designee.

Procedure: For significant medical incidents with a severity Level 4-5 the Director of Quality/Risk Manager, CNO, will be notified immediately.

Level 4-Major injury, occurrence is potentially life threatening, immediate physician, nurse/ other practitioner interventions required.

Level 5-Occurences resulting in death within 72 hours.

Incident investigation: a thorough investigation of the incident must be made with all the findings being recorded.

Record Review of facility's policy titled, "Event Reporting and Investigation," dated 06/13/16, showed that upon identification and decisive actions to assure the safety and well-being of the patient. Perform necessary healthcare interventions to protect, support the patient's clinical condition and assure the safety and well-being of the patient. Document the facts regarding the Event on the Event Notification Form and in the Medical record. Physician's orders directly corresponding to the care of the patient after the event. Event notification form will be given to the Quality Manager (QM) within 24 hours. If the event is a Level 4 or greater the QM will initiate an RCA.

Record Review of patient #30's medical record dated 03/29/19 showed the following information:

a. 15:30 PM patient arrived from Creek Emergency Room for a higher level of care. Employee Q, RN, triaged the patient and notified the Nurse Practitioner (NP) on call (Employee K) at 15:45 PM. EKG completed.

b 16:03 PM, Employee Q, RN documented the patient was tachypneic (increased respiratory rate), Short of breath (SOB) with minimal exertion, and fine crackles were heard at bases of lungs. The patient was also noted to have Atrial Fibrillation with a Rapid Ventricular Response in the 120's (elevated heart rate above 100).

c 17:20 PM Foley ordered and then refused by patient.

d. 18:15 PM Lovenox 150mg (a blood thinner) given by Employee Q.

e. 8:16 PM Prothrombin Time elevated 20.2 normal range (9.0-11.5)

f. 16:32 PM Employee K, NP documents the History and Physical, Patient initially seen by this provider at 13:15 PM today. Employee K, NP documents his prior history of DVT/PE and complaints of chest pain mid sternum, SOB and that the patient felt like his heart was racing for four days. Additional past medical history information included:

i. Congestive Heart Failure
ii. Irregular Heart Rate
iii.Cardiomegaly
iv.Pulmonary Embolism (PE)
v.Deep Vein Thrombosis (DVT)
vi.Hypertension (HTN)

g.Employee K, NP documented patient appeared in Moderate Distress. Employee K, NP writes in the decision-making portion of the History and Physical, after initial evaluation in the emergency department "my initial clinical impressions include the following differential diagnoses: Pulmonary Edema, Atrial Fibrillation with Rapid Ventricular Rate, Myocardial Infarction, Congestive Heart Failure.


h.18:47 PM Employee K, NP called the Cardiologist Employee R, MD ordering cardiac enzymes every 4 hours, monitor on telemetry, echo, cardiac meds, a diuretic, and Lovenox (a blood thinner).

i. 20:05 PM Employee R, RN also noted that the patient is SOB, tachypneic, tachycardic, and now is sweating in cool room. Employee R supplies the patient with a fan.

j.. 21:53 PM Critical Results of Troponin 0.177 by (WR) lab called to
Employee R, RN caring for Patient #30.

k. 22:09 PM Employee R, RN called the NP employee F.

l.2230 PM Patient #30 home meds were documented it was noted that the patient is on Coumadin (a blood thinner).

03/30/19

m. 01:06 AM Critical Troponin 0.179 result called to Employee R, RN, caring for the patient.

n. 01:25 AM no urine output, attempted to place Foley three times, on the third time without urine return the Foley was taken out at NP, Employee F's order. Employee R documents, "Once the Foley was removed, blood was flowing from the patient's penis and even with continuous pressure did not stop bleeding. Patient quickly saturated the pad and gauze."

o. 02:00 AM employee R states, "Patient is now bleeding, but bleeding profusely and saturating the bed and his gown. Changed linen x3. Patients vital signs are stable (VSS) HR 126, continued to apply pressure dressings and cold compresses penile area to cease the bleeding."

p. 02:30 AM Employee R states, "Bleeding still not slowing down, not subsiding, continue to monitor vital signs, patient denies lightheadedness". She then says, "Despite pressure applied to penile area and cold ice packs, patient is still bleeding rapidly from penis. Patient is beginning to feel weak and drowsy, NP, Employee K was present and aware."

q. 3:25 AM Employee R stated, Patient unconscious and begins to have seizure for about 30 seconds and then regains consciousness and stops seizing. At this point the patient's vitals begin to decline. Blood pressure trending down to 80/50s then to 60/40s, Heart Rate 135-145, afib with RVR, notified NP, Employee K, at this time, grabbed crash cart to be prepared. NP, Employee K, called 911.

r. 03:40 AM Employee R, RN, wrote: "City ambulance personnel arrived, patient condition is stable at this time after one-liter bolus completed, but still bleeding. Bleeding has slowed down, but patient is still bleeding losing a lot of blood. Transfer being initiated to (another acute care hospital) at this time as it would take at least two hours for blood to be delivered."

s. 04:20 AM EMT personnel still with patient started second IV with Saline boluses in in both.

t. 04:40 AM patient is being transferred out at this time.

u. 04:50 AM Vitals 124/79 pulse 135.

Record Review of facility's Monthly Event log dated 03/19, 04/19, showed that no event was logged in for patient #30.

Interview with the Director of Nursing (DON) on 09/06/19, at 14:05 PM, showed that she was unaware of the event that occurred with patient #30 on 03/29/19 and 03/30/19. She went on to say that she should have been notified immediately. DON further stated an incident report should have been completed and a root cause analysis (RCA) should have been done.

Based on interview and record review, nursing staff failed to supervise and evaluate the care of 2 of 2 sampled patients (Patient # 10, # 30).

Nursing staff failed to perform additional blood pressure monitoring on patients with abnormal blood pressure reading per facility policy.

Findings included:

Record Review of the facility's policy titled, "Patient Assessment and Reassessment", dated 06/13/19, showed the following:

a) A patient is reassessed in all settings when warranted
b) A registered nurse analyzes data, takes appropriate action and makes referrals for further assessment.
c) A response to care/treatment.
d) Documentation in the medical record serves as a communication tool to indicate that data was collected, analyzed, and resulted in the identification of appropriate care or treatment and/or need for further assessment.

Record Review of the facility's policy titled, "Vital Signs", dated 06/13/19, showed the following:

a) Please notify the physician of any abnormal vital signs as listed below:
b) Blood Pressure (B/P) of systolic >160 or diastolic >105
c) B/P of systolic <90 or Diastolic <50
d) Heart rate of >110 or <50
e) Respirations >25 or <12

Record review of patient #30's medical chart showed the following timed blood pressures and pulses dated 04/16/19.

1) 02:48 AM 170/125 Pulse 90
2) 05:39 AM 174/107 Pulse 88
3) 06:44 AM 164/85 Pulse 93
4) 07:11 AM 149/98 Pulse 93
5) 07:45 AM 161/99 Pulse 88
6) 11:58 AM 189/117 Pulse 97
7) 16:06 PM 167/101 Pulse 99
8) 19:01 PM 184/ 116 Pulse 99
9) 23:03 PM 168/98 Pulse 98

Record review of patient #10's medical chart showed the following timed blood pressures, dated 04/17/19.

a) 05:03 AM 176/108 Pulse 106
b) 06:29 AM 185/105 Pulse 101
c) 07:43 AM 170/100 Pulse 105
d) 07:53 AM 204/127 Pulse 105

Record review of patient #30's medical chart showed the following timed blood pressures and pulses dated 03/29/19.

1) 15:58 PM 125/84 Pulse 65
2) 20:11 PM 132/65 Pulse 67
3) 23:54 PM 122/65 Pulse 88

Record review of patient #30's medical chart showed the following timed blood pressures and pulses dated 03/30/19.

a) 04:30 AM 124/79 Pulse 135

Record review of patient #30's medical chart dated 3/30/19 by Employee R, showed that the patient was transferred to another hospital in critical condition.

Interview with the Director of Nursing on 09/06/19 at 14:05 showed that when a patient has abnormal vital signs the Registered Nurse should be taking the vital signs more frequently than every 4 hours, that the vital signs should evaluated and taken as frequently as necessary.

Based on record review and interview, the faciltiy failed to ensure emergency services were organized under the direction of a qualified member of the medical staff.

Findings included:

TX 00317502-EMTALA
TX 00322014-EMTALA

Review of facility "Medical Staff Rules and Regulations," not dated, showed under section D."Emergency Services" the medical director shall have overall responsibility for emergency care for patients.

During an interview on 09-05-19 at 9:35 A.M. with Staff B, Chief Nursing Officer (CNO) , she stated that Staff C , MD physician, was the emergency room (ER) medical director.

Facility was asked to provide the contract for the medical director (Staff C ). CNO verified he did not have a contract.

During an interview on 09-05-19 at 11:45 A.M with Staff C, physician , he stated he supervised the nurse practioners (NP) but he was not the ER medical director.

Based on observation, interview, and record review, the facility failed to ensure the immediate availability in the hospital of a qualified member of the medical staff to provide direct care in the emergency department if needed. The facility failed to ensure :

1. immediate availability of a physician to the emergency department;

2. signed attestation of supervision by sponsoring physician for of 7 of 7 nurse practitioners (NP) covering the ER ( NP Staff F, G, H, I, J, K, L ).

Findings included:

TX 00317502-EMTALA
TX 00322014-EMTALA

1. Physician availability :

Chief Nursing Officer (CNO) interview:

During an interview on 09-05-19 at 2:15 PM with Staff B, CNO, she stated NP performed an MSE on all patients (at the hospital location). If a patient was acuity level II or III-they would likely be admitted; Staff C, MD would be called. Patients assessed as acuity level IV and V would be sent to the "front ER." For Level I patients, 911 would be called.

CNO went on to explain the "front ER" was an off-site location [formerly a freestanding emergency center] that had recently become a hospital-based outpatient department (HOPD). She said state licensing had approved the HOPD; the hospital was still waiting on an "ER waiver." She said they had used the HOPD as an adjunct ER for a few weeks (later determined to be 08-19-19).

Observation on 09-06-19 of the HOPD showed it to be approximately 3 to 4 blocks away from the main hospital. Online mapping of the two (2) addresses showed it to be . 2 miles away. [HOPD address was 837 Cypress Creek Parkway, Houston, TX 77090]

CNO said "'If the NP needs a doctor; they have 15 to 20 minutes to get here. Anesthesia is here Monday-Friday; Staff C / MD rounds twice & he is in-call for ER; and MD Q has offices nearby. "

CNO said the facility last had physician coverage for the ER for some nights and weekends in July. She said it had been over a year since they had 24/7 physician coverage in- house for the ER.

Staff C/ MD :

During an interview on 09-05-19 at 11:45 A.M with Staff C, physician , he stated he supervised the nurse practitioners (NP). He said "if a doctor was needed in ER: the ER dr from 'up front' (HOPD) could be here in 10-15 minutes. Staff C/MD said he could be at the hospital in 30 to 45 minutes or the patient could be transferred."

Nurse Practitioner (NP): Staff F :

During an interview on 09-05-19 at 10:00 A.M. with Staff F, [NP], she stated she was covering the ER this day. There was no physician in house at present. She said the NPs did the medical screening exams. The patients were sent to the "front ER" if they were stable & needed a doctor. Staff F verified the "front ER" was "down the road a bit." Staff F said she could call Doctor C when needed.

RN Charge ( Staff N) :

During an interview on 09-06-19 at 8:30 A.M with Staff N, Registered nurse/charge., he stated it was the NP decision of a doctor was needed. If so, an ER doctor from the HOPD would come to help. Staff N said there was an ER doctor in house this morning but prior to this day, it had been NP coverage only with a supervising physician. When asked, Staff N said it had been about 1 and 1/2 years since the facility had ER physician coverage 24/ 7.

2. NP Supervision:

Record review of facility monthly ER Coverage schedules [March through August 2019] showed Staff F, G, H, I, J, K, L were NPs listed as providing ER coverage on various dates.

Review of facility "Medical Staff Bylaws,"undated, showed that each allied health professional (AHP) shall have a medical staff member that supervises the AHP in the provision of patient care.

During a telephone interview on 09-06-19 at 12:30 PM with Staff M, Credentials Director, she stated that the seven (7) NP credential files provided to surveyor were complete.

Staff M went on to say that NPs were considered allied health professionals. Their credential files were required to contain a current signed & dated attestation of supervision from their sponsoring physician. Staff M said she was aware that some of the supervising physician attestations were missing or not current.

Record review on 09-06-19 of seven (7) NP credential files showed the following:

1.NP staff F, G, H : all three (3) had an attestation signed by a supervising MD physician who was no longer affiliated with the facility. This MD was last listed on the facility ER schedule in May 2019.

[ NP Staff F was covering the ER at the time of survey on 09-05-19].

2.NP Staff I, J, K, L: none of the four (4) NPs had a signed attestation by any supervising physician.

Based on interview and record review, the facility failed to ensure there was adequate qualified medical and nursing personnel to meet anticipated needs related to emergency services. The facility failed to ensure :

*Availability of qualified nursing personnel assigned to the emergency department (ED).

* Nurse practitioners assigned to the ED had designated ED privileges to provide emergency care to patients.

Findings included:

TX 00317502-EMTALA
TX 00322014-EMTALA

Nursing availability in the emergency department:

During an interview on 09-05-19 at 2:15 P.M. with Staff B, Chief Nursing Officer (CNO) , she stated the charge nurse on the inpatient unit was always assigned to cover the ER. The charge nurse was always available to go downstairs and triage any ER patient

During an interview on 09-06-19 at 8:30 A.M. with Staff N, RN Charge said he said that most of the time he did not have inpatients assigned to him; "but sometimes I do."

When asked the frequency of an inpatient assignment to a charge nurse; Staff N, RN charge, said " about 5 % of the time."

Staff N went on to say if he was in ER and needed upstairs, he said he "would bring all the ER patients upstairs; we have some dedicated rooms for ER patients."

Delineated ER privileges for NPs covering the ER:

Review of the facility "Medical Staff Bylaws and Rules & Regulations," section 6 showed that allied health professionals (AHP) may exercise only those privileges granted to them by Medical Executive Committee and the Governing Body.

Record review on 09-06-19 of seven (7) NP credential files ( NP Staff F, G, H, I, J, K, L) showed none of the NPs had delineated core emergency room privileges.

During a telephone interview on 09-06-19 at 12:30 PM with Staff M, facility Credentials Director, she stated that the seven (7) nurse practitioner (NP) credential files provided to surveyor were complete.

Staff M went on to say that NPs were considered allied health professionals; she had previously noted the NPs did not have core emergency room privileges. The Credentials Director said that since the NPs were covering the ER, they should have core ER privileges. Staff M further stated she had brought this issue to the attention of the former Chief Executive Officer (CEO).

Based on interview and record review, the facility failed to maintain a list of on-call physicians to provide care and treatment to stabilize individuals with an emergency medical condition.

Findings include:

TX 00317502-EMTALA
TX 00322014-EMTALA

Review of facility "Medical Staff Rules and Regulations," not dated, showed under section D."Emergency Services" 1. J."Schedules, names and telephone numbers of all members and others on emergency call duty, including alternates, shall be maintained according to state and federal statue (sic)."

On 09-05-19 facility was asked to provide a list of on-call physicians for the last six (6) months.

Record review of a facility document titled "Preferred Specialist" revised date 04/06/2018, showed an alphabetical listing of medical specialties with 1 to 5 physicians' names and telephone numbers listed.

During an interview on 09-05-19 at 9:15 A.M. with Staff E, ER Director, she said the facility did not have a specialty on-call schedule.

Review of the monthly in-house schedule provided by facility for the months of March through August 2019 showed the following:

March 2019: twenty(20) of 31 days lacked 24/7 physician coverage;
April 2019 : twenty-four (24) of 30 days lacked 24/7 physician coverage;
May 2019: twenty-seven (27) of 31 days lacked 24/7 physician coverage;
June 2019: twenty-seven (27) of 30 days lacked 24/7 physician coverage;
July 2019: twenty-five (25) of 30 days lacked 24/7 physician coverage;
August 2019: thirty-one (31 of 31 days lacked 24/7 physician coverage.

Some of the days showed a physician for part of the day; majority of the days, the ER was staffed by NPs only 24/7.

During an interview with Staff C, MD he stated he supervised the three (3) nurse practitioners ( NPs). He was available by telephone to the NPs 24/7. Staff C said if he had to be gone, he would provide coverage. Staff C / MD said he could be at facility in 30-45 minutes.

Based on record review and interview, the facility failed to consistently maintain a central emergency room (ER) log that contained all regulatory requirements.

Findings included:

TX 00317502-EMTALA
TX 00322014-EMTALA

Review of facility policy titled "Admission of Patients to Emergency Room," dated 06-13-2016, showed that the facility would maintain a central log of individuals who came to the ER to include whether the individuals refused treatment were denied treatment, and /or were admitted, stabilized, and/or transferred or discharged. The registration clerk was responsible to maintain the log and perform a monthly audit.

Record review of the facility handwritten "Emergency Room Register" for the months of May 2019 through August 2019, showed the following

May 2019: eleven (11) patients without dispositon documented.

(dispostion = discharged, admitted, transferred, left against medical advice, etc..)

June 2019: twelve (12) patients without dispostion documented.

July 2019 : 27 twenty-seven (27) patients without dispostion documented.

August 2019: twenty-two( 22) patients without dispostion documented.