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Based on observation, interview and record review, the Governing Body failed to ensure:

B. that there was an organized nursing service to ensure 4 of 4 (#'s 6, 7, 8, and 9) telemetry technicians monitoring cardiac patients were qualified, telemetry technicians and other nursing personnel were supervised by a registered nurse, and failed to have sufficient numbers of nursing staff in the ER and Medical Surgical unit at all times to ensure care was provided in a safe setting. Nursing staff failed to provide ongoing assessments and provide timely medical interventions to 4 of 11 patients presenting to the hospital (#'s 5, 7, 8, and 10).
Refer to A144, A385, and A392
C. registered nurses assigned nursing care of cardiac patients to competent and qualified staff. This deficient practice was found in 4 of 4 (#'s 6, 7, 8, and 9) telemetry monitor technicians and 1 of 1 CNAs (#8).
Refer to A397
D. the Medical Staff Credentialing committee received the appointments for staff privileges for 2 of 2 ER physicians (#3 and 4).
Refer to A 046 and A341
E. drugs and biologicals were secure before and after a drug diversion.
Refer to A502 and A506.
F. adequate numbers and qualified ER personnel to meet the needs of patients. The facility also failed to ensure the physician covering the ER worked safe hours and had qualified back-up coverage.
Refer to A1112

Based on observation, interview and record review the facility failed to ensure:
A. patient care was provided in a safe setting by failing to have an organized nursing service to ensure 4 of 4 (#'s 6, 7, 8, and 9) telemetry monitor technicians watching cardiac patients were qualified, telemetry technicians and other nursing personnel were supervised by a registered nurse. The facility also failed to have a sufficient number of nursing staff in the ER and Medical Surgical unit at all times. Nursing staff failed to provide ongoing assessments and provide interventions to 4 of 11 patients presenting to the hospital (#'s 5, 7, 8 and 10).
Refer to A144 and A392
B. registered nurses assigned nursing care of cardiac patients to competent and qualified staff. This deficient practice was found in 4 of 4 (#'s 6, 7, 8, and 9) telemetry monitor technicians and 1 of 1 CNAs (#8). Untrained telemetry technicians were allowed to monitor patients. They were not provided supervision by nursing. A CNA with an expired certification was allowed to provide direct patient care.
Refer to A397

Based on observation, interview and record review the facility failed to ensure:
A. there was an organized nursing service to ensure 4 of 4 (#'s 6, 7, 8, and 9) telemetry technicians monitoring cardiac patients were qualified, telemetry technicians and other nursing personnel were supervised by a registered nurse, and failed to have sufficient numbers of nursing staff in the ER and Medical Surgical unit at all times to ensure care was provided in a safe setting. Nursing staff also failed to provide ongoing assessments and provide timely medical interventions to 4 of 11 patients presenting to the hospital (#'s 5, 7, 8, and 10).
Refer A392
B. registered nurses assigned nursing care of cardiac patients to competent and qualified staff. This deficient practice was found in 4 of 4 (#'s 6, 7, 8, and 9) telemetry monitor technicians and 1 of 1 CNAs (#8). Untrained telemetry technicians were allowed to monitor patients on telemetry and were not provided supervision by nursing. A CNA with an expired certification was allowed to provide direct patient care.
Refer to A397

Based on observation, interview and record review the facility failed to ensure:

A. emergency services were organized and under the direction of a qualified medical
B. timely emergency intervention was provided to 3 of 11 patients (#'s 5, 7 and 10).
Refer to A1102
C. there was adequate numbers of medical and nursing personnel present in the ER at all times.
D. medical doctors worked safe hours and had on-call back up at all times.
Refer to A 1112

Based on interview and record review the Governing Body failed to ensure a medical staff examined the credentials of 2 of 2 physicians (Staff #3 and #4).
This deficient practice had the potential to cause harm to all patients.
Findings included:
Review of "Medical Staff Bylaws" dated 02/25/2013 revealed the following:
"The responsibilities of the medical staff are to account for the quality and appropriateness of patient care rendered by all practitioners and allied health professionals authorized to provide patient care services in the hospital by:
A. processing credentials in a manner that matches verified qualifications, performance, and competence with clinical privileges for all medical staff applicants and members, and practice prerogatives for all allied health professionals.
B. Membership on the medical staff of this hospital and /or clinical privileges is a privilege that shall only be granted and maintained by those professionally qualified and currently competent practitioners who continuously meet the qualifications, standards, and requirements set forth in these bylaws, rules and regulations and the bylaws and policies of the hospital. Appointment to the membership on the medical staff shall confer on the member only such clinical privileges and rights as have been granted by the Governing Board in accordance with these bylaws.
Temporary privileges for new applicants may be granted following submission of a complete application and while awaiting review and approval by the medical executive committee upon verification of all information required by these Bylaws. Such privileges may be granted for an initial period of sixty (60) days, and may be renewed for one additional period of sixty (60) days. At the minimum there must be verification of the following in order for an applicant to be granted temporary privileges:
Current licensure
Relevant training or experience
Current competence
Ability to perform the privileges requested
Other criteria required by the Bylaws
NPBD query and evaluation of the information
No current or previously successful challenge to licensure of registration
No subjection to involuntary termination of medical staff member ship at another organization
No subjection to involuntary limitation, reduction, denial or loss of clinical privileges at another organization
Provisional Status. All initial appointments to any category of the medical staff shall be provisional for twelve (12 months)."

Review of the July 2013 physician schedule for the ER revealed from 07/07 to 07/31/2013 (25 days straight ) the same two physicians were scheduled to work on a daily basis (Staff #3 and #4). There were no back-up physicians listed on the schedule in the event of an emergency.
During an interview on 07/19/2013 at 9:15 a.m., Staff #1 (CNO/Administrator) confirmed Staff #3 and #4 were the only two doctors working. The doctors stay in a house on campus and were on duty 24 hours/7 days. Staff #4 had been on duty alone from 07/07 to 07/18/2013 (12 days straight around the clock). Staff #3 took over around 7:00 p.m. on 07/18/2013.
During an interview on 07/19/2013 Staff #3 confirmed Staff #4's hours. Staff #3 reported he had taken over on 07/18/2013 and would work until 08/31/2013 (14 days straight). They wanted to work 5 days on and 5 days off but that was not occurring. During the timeframe, Staff #4 was on duty Staff #3 was his back-up. Staff #3 reported he and Staff #4 had been fired by the previous owner (#14) in March 2013 and they had just returned on 07/07/2013.
Review of personnel file on Staff #3 revealed his most current required "Texas Standardized Credentialing application" was dated 10/2012. Staff #3 granted himself Internal Medicine/Emergency Medicine temporary privileges on 10/11/2012. Members from the Governing Board approved the temporary privileges 02/25/2013.
Staff #3 recommended himself a provisional six-month appointment on 10/31/2012 and members of the Governing Board approved it on 02/25/2013.
Review of the personnel file on Staff #4 revealed his most current required "Texas Standardized Credentialing application" was dated 11/01/2012.
Staff #3 granted Staff #4 Internal Medicine/Emergency Medicine temporary privileges on 10/12/2012. Members from the Governing Board approved the temporary privileges 02/25/2013.
During an interview on 07/31/2013, Staff #15 reported she was responsible for ensuring credentialing for the physicians. The process was for her to check the backgrounds, take the information to the administrator, who would take it to medical staff, then it would proceed to the Governing Board for approval. Staff #15 reported she knew of no medical staff meetings occurring since October 2012. Current CNO/Administrator confirmed no medical staff meetings were occurring. Staff #15 reported they had gotten behind on the paperwork and they were due to go back to medical staff meeting in August 2013. Staff #15 reported Staff #3 was through with his temporary status and was up for his provisional review. Staff #15 confirmed the applications and request had been performed in February 2013 before the two physicians were fired. There were no current applications or request for privileges processed for their return in July 2013.

Based on observation, interview and record review, the facility failed to ensure patients received care in a safe setting. They failed to have an organized nursing service to ensure 4 of 4 (#'s 6, 7, 8, and 9) telemetry technicians monitoring cardiac patients were qualified, telemetry technicians and other nursing personnel were supervised by a registered nurse, and failed to have sufficient numbers of nursing staff in the ER and Medical Surgical unit at all times. Nursing staff also failed to provide ongoing assessments and provide interventions to 4 of 11 patients presenting to the hospital (#'s 5, 7, 8 and 10).
This deficient practice had the potential to cause harm to all cardiac patients admitted into the hospital.
Findings include:
Review of an undated "Medical Nursing Unit Scope of Service" policy revealed:
"The patient population consists of individuals including Pediatric, Adolescent, Adult and Geriatric.
Some of the diagnoses treated included, but were not limited to: S/P Myocardial Infarction, Unstable Angina, Telemetry monitoring-Cardiac dysrhythmias, neurological disorder, respiratory disorder and ongoing assessments.
The Medical nursing staff includes the Nurse Director (who completes the schedule) and permanently assigns Medical floor staff nurses. The patient nurse ratio is based on patient census and acuity as outlined in the staffing matrix. Medical floor nurses are knowledgeable regarding emotional, psychosocial, educational and rehabilitative needs of the Medical floor patient and can provide necessary therapeutic interventions.
The nurse to patient ratio will be determined by the Nurse Director or charge nurse based on the patient's needs and the capabilities of the nursing staff. A back up or on call nurse may be provided as applicable."
Review of an undated "Position Description, Telemetry/Monitor Technician" revealed the following:
"The Telemetry/Monitor Tech is responsible for accurate record keeping, observation of monitors and prompt reporting of cardiac rhythm changes. The Telemetry/Monitor Tech must possess effective communication skills. This position will routinely perform Unit Secretary duties for the unit as assigned."
Department Core Competencies
#30 Performs ongoing observation of the cardiac monitors and interpret cardiac rhythms correctly;
#32 Prioritize and assist with unit activities based on patient needs under the direction of the RN;
#34 Detect and promptly report changes in parameters monitoring cardiac rhythms;
#36 Ensure timely and accurate communication of patient information with all members of the health care team.
#38 Arrhythmias-maintain strips and reporting changes

1. During an observation on 07/19/2013 at 9:55 a.m., a loud commotion could be heard coming from behind the door of room #104 which was midway down the hall. Staff #13 (charge nurse) was in the hallway near a medication cart. The CNO reported the commotion was a CNA and the telemetry technician (Staff #8) assisting a patient with a bath. The CNO confirmed no one was at the nursing station watching the telemetry monitors and there should have been. The door (#104) was approximately 20-30 feet from the nursing station. Patient #'s 7 and 8 were both on telemetry monitors.
During an interview on 07/19/2013 at 10:00 a.m., Staff #8 reported she was the ward clerk/ telemetry technician and had been in the position for 5 months. She had not received a training class for it at the facility nor had she ever worked as a telemetry technician anywhere. She had only been informed by nursing to watch for when the heart rate goes less than 50 or above 120. Staff #8 reported she did not know the different heart rhythms and pulled out a folded sheet of paper she had been given by the facility to refer to. The paper was a "Cardiac Rhythm Study Guide".
During an interview on 07/19/2013 at 10:10a.m, Staff # 1 (CNO) reported prior to February 2013 there was no one watching the telemetry monitors. Two consultants came into the facility and told them they had to have someone watching the monitors. The person monitoring only needed to be able to say "hey nurse" when the heart rate was too high or low". Staff # 14 (former owner/Dr) would not let them hire qualified telemetry technicians. Staff #8 was the first telemetry technician they hired and there were three other ladies working as telemetry technicians (#'s 6, 7 and 9). Staff #8 was the only one who was a CNA, the others had no medical background. Staff #1 reported none of the ladies were qualified telemetry technicians. Staff #1 reported Staff #11 (former ADON) had given the telemetry technicians their orientation. Staff #1 called Staff #11 with the surveyor present and asked about the training. Staff #1 reported the training was 15-20 minutes and none of the techs had taken the required testing to prove they were proficient.
During an interview on 07/19/2013 at 11:00a.m, Staff #11 reported the average daily census for the ER for July 2013 had been 6-12 patients and on last Tuesday (07/09/2013) it was 14.
During an interview on 07/19/2013 at 11:13 a.m., Staff #1 (CNO) reported during an emergency code sometimes they could "beg" the local EMS staff in the area to help. She confirmed if there was no EMS to help, the RNs would assist each other, thereby leaving their unit unsupervised.
During an interview on 07/19/2013 at 12:20 p.m., Staff #13 reported they usually have a RN, CNA and telemetry technician working. The telemetry technicians cannot tell if anything is irregular because they are not trained in rhythms. They need to know what they are looking at. Before the telemetry technicians there was no watching the monitors. During the timeframe of 7-11 a.m. when there was not a LVN they were not that busy. If there was a code in the ER that she had to assist with, the aide was there on the medical/surgical unit. If Staff #1 (CNO) and Staff #2 (QA\UR) were there during the week they could assist.

2. Review of an "Emergency Nursing Record" dated 07/14/2013 revealed Patient #5 presented to the ER at 1:25 p.m with a chief complaint of altered level of consciousness. The patient had a medical history of mental retardation, atrial flutter, diabetes and hypertension. On admission Patient #5 had the following vital signs (B/P) 90/30, (P)96, (Respiratory rate)24 and (T) 99.3 degrees F.
Review of an "Emergency Physician Record" dated 07/14/2013, 1:40 p.m., revealed Patient #5 was assessed and his clinical impression was chronic dementia, confusion, hypoglycemia, pneumonia, urinary tract infection, sepsis, hyperkalemia, and dehydration.
Review of the "Emergency Nursing Record" dated 07/14/2013, 2:05 p.m revealed Patient #5 received 1000cc of fluids intravenously.
The following critical lab values dated 07/14/2013 were reported to Staff # 4 (the physician):
At 2:15 p.m. a WBC of 66.2 (RR 4.5-10.1), HGB 7.0(12.0-16.0), HCT 20.3 (36.0-50.0)
At 2:25 p.m. a Potassium of 6.5 (RR 3.5-5.1)
Review of physician admission orders dated 07/14/2013 at 3:00 p.m., revealed some of the following:
*Admit to telemetry
*Dextrose 5 percent normal saline at 125 cc per hour
*Type and cross for 3 units and transfuse and to hold intravenous fluids while transfusing
*Hemoglobin and Hematocrit every 6 hours
*Lasix 20 mg intravenously between transfusion if systolic B/P greater than 120, otherwise hold
There was no mention of treatment for the elevated Potassium level.
Review of the "Emergency Nursing Record" dated 07/14/2013 revealed at 3:15 p.m. Dextrose 5 percent normal saline at 125 cc per hour was started. At 3: 19 p.m. Patient #5 B/P dropped to 87/31. According to documentation at 3:35 p.m. the doctor was aware of the B/P.
Nursing "narrative notes" dated 07/14/2013, 3 hours after the initial critical lab results, revealed the following:
At 5:15 p.m, Patient #5 was admitted from ER to the floor and her B/P was 101/32 and at 6:00 p.m there was a drop to 61/32.
At 7:15 p.m. and 8:15 p.m. calls were made to the family to obtain consent to administer the blood and there was no answer.
Review of a critical lab value dated 07/14/2013 revealed nursing was informed at 8:15 p.m. of the HGB of 6.7 (RR 12.0-16.0) and HCT of 19.7 (RR 36.0-50.0) dropping even more.
Nursing "narrative notes" dated 07/14/2013 revealed the following:
At 8:45 p.m. the MD gave emergency transfusion orders for "O" negative blood stat because he felt the patient was critically ill and he could not wait to transfuse. The lab was ordering 2 more units of "O" negative through the blood bank in case of an emergency.
At 9:00 p.m., the MD was trying to gain intravenous access through neck-subclavian vein.
At 9:45 p.m., the MD asked the RN to run blood with the IV in the left hand and to run each unit in over 4 hours.
Review of the blood administration record dated 07/14/2013, 10:20 p.m. revealed the first unit of blood was started over 8 hours after receiving the initial critical lab values (at 2:15 p.m.). At 1:10 a.m. the unit of blood was ended. Staff #'s 16 and 17 (RN) signed as performing the checks on the blood at the time of start and ending. Staff #16 was the Medical /Surgical nurse and Staff #17 was the ER nurse.
Review of the "Daily Staffing Master" sheet dated 07/14/2013 revealed Staff #17 was the only staff scheduled for the ER from 7p.m.-7:00 a.m.
Review of the "Emergency Room Register" dated 07/14/2013 revealed Staff #17 (ER nurse) had a patient present to the ER at 9:35 p.m. and was not discharged until 11:00 p.m. At 11:33p.m., Staff #17 (ER nurse), had another patient come in with possible aspiration and had to be transferred to another hospital at 1:30 a.m..
Nursing "narrative notes" dated 07/15/2013 revealed the following:
"At 06: 00 a.m., the 3rd unit of blood was checked by 2 RNs and is now infusing. The EKG shows atrial fibrillation and patient's am KCL level is 6.7 and critically high at 6.7."
Review of a physician order dated 07/14/2013 (actual date was 07/15/2013) at 6:55 a.m. revealed to "please repeat KCL and call result to the Dr. Give 0.25mg IV digoxin and if KCL level is greater than 6.0 give 60 gm Kayexalate by straw."
Review of a critical lab value dated 07/15/2013 revealed nursing was informed at 6:45 a.m. of a Potassium level of 6.7 (RR 3.6-5.1).
Review of a "Medication Administration Record" dated 07/14/2013 revealed the cardiac agent Digoxin was administered at 8:00 a.m.
Nursing "narrative notes" dated 07/15/2013 at 9:00 a.m., revealed Patient #5 was given Kayexalate 60 GM. This was the first treatment for the elevated potassium which was identified over 19 hours prior on 07/14/2013 at 2:15 p.m.
Nursing "narrative notes" dated 07/16/2013 revealed the following:
At 3:00 a.m. Patient #5 had a B/P 83/47 and a HR of 103.
At 3:10 a.m., the doctor was notified. The documentation in the notes read to see new orders for Dopamine 2 mcg/kg/min started for renal dose.
There was no complete physician order for this dosage of Dopamine.
Review of the physician orders dated 07/16/2013 at 3:10 a.m revealed the following:
"Dopami ...gtt. Titrate to SBP greater than or equal to 90."
Review of a "Medication Orders and Administration" form dated 04/2008 revealed orders must include the name of the drug, dose, route, concentration or strength, frequency and licensed physician signature. All orders for microgram amounts shall be clearly written as mcg. to distinguish from milligrams (mg).
There was no physician signed protocol addressing titration of the Dopamine nor were there parameters on when to stop the drip.
Review of physician orders dated 07/17/2013 revealed the Dopamine was discontinued on 07/17/2013.
Review of a case management plan dated 07/17/2013 revealed Patient #5 would be returning to the nursing home on hospice care when she was stable.
3. Review of an "Emergency Nursing Record" dated 07/18/2013 revealed Patient # 7 was a 57 year old male who presented to the ER at 8:50 p.m. with complaints of chest pain. Patient #7 had a history of diabetes, coronary artery disease, chronic obstructive pulmonary disease and peripheral vascular disease. He had a pain level of 9 out of 10 and complained of pressure to his chest (pain scale level of 0 being no pain and 10 being severe pain).
Review of an "Emergency Physician Record" dated 07/18/2013 revealed a physician assessment on Patient #7 indicating he was being admitted with acute chest pain. The assessment was not timed.
Review of an "Emergency Department Record, Physician Order Sheet" revealed orders for lab, cardiac monitor, pulse oximeter and oxygen. The order for oxygen was incomplete and did not indicate the liters of oxygen needed and what parameters for oxygen saturation. The physician orders were not dated or timed.
Physician orders dated 07/18/2013, 9:30 p.m. revealed Patient #7 was admitted to the telemetry unit for observation to rule out Myocardial infarction (heart attack). There was an order for aspirin, nitroglycerin 0.4 mg sublingual every 5 minutes (medications which cause vasodilation and which increased blood flow), morphine 2 mgs IVP (pain medication) every 4 hours prn (whenever needed).
Review of an "Emergency Nursing Record" dated 07/18/2013 revealed Patient #7 was not given any pain medication until 10:56 pm, over 2 hours after presenting to the ER. There was no assessment of how severe the pain was. There was no documentation of any nitroglycerin being administered at all.
Review of EKG strips revealed one was printed on 07/18/2013 at 8:49 p.m. which indicated it was abnormal. The next EKG strip was not printed until 07/19/2013 at 4:13a.m over 7 hours later.
During an interview on 07/19/2013 at 6:15 p.m., Staff #2 confirmed the missing dates and times, lack of assessment, no nitroglycerin being administered and the late administration of pain medication. Staff #2 reported their in-house policy was for the telemetry technicians to print off an EKG strip every 4 hours.

4. Review of an "Emergency Nursing Record" dated 07/18/2013 revealed Patient # 10 was a 53 year old male who presented to the ER at 2:00 a.m. with complaint of chest pain. Patient #10 had a history of chronic obstructive pulmonary disease and schizophrenia. Patient #10 had a blood sugar reading of 362. The assessment revealed lab was drawn, intravenous fluid started, EKG performed, oxygen placed on and a chest X-ray performed.
Review of an "Emergency Physician Record" revealed an assessment performed by Staff #4 (MD) which was dated incorrectly 03/18/2013 and not timed. Staff #4 documented Patient #10 was having sternal pain which was radiating to the right side and he was borderline Diabetes mellitus. Staff #4 documented he interpreted the EKG strip but did not document the results in the designated area on the form. Underneath the progress section the time was left blank and Staff #4 documented the patient was chest pain free and 2 sets of Troponin were negative. The patient was advised to take medications for Diabetes mellitus.
Review of phyisician orders dated 07/18/13 at 2:55 a.m.revealed an order for 10 units of regular insulin to be administered but did not include parameters of when to give. There was no documentation of the medication being administered by nursing.
During an interview on 07/19/2013 at 11:00 a.m., Staff #11 reported Staff #4 (MD) was on duty from 07/07-07/18/2013 (11 consecutive days/24 hours a day ).
Review of an "Emergency Nursing Record" dated 07/18/2013 revealed at 4:32 a.m., Patient #10 had a blood sugar reading of 371. There was no documentation of any intervention provided.
Review of a lab report dated 07/18/2013 at 5:55 a.m. revealed Patient #10 had a blood sugar reading of 218 (with reference range being 70-105). There was no mention of what was done about the blood sugar before discharging the patient.
Review of an "Emergency Nursing Record" dated 07/18/2013 at 6:30 a.m. revealed the patient was discharged home. A prescription for the diabetic agent Glucophage was attached.
During an interview on 07/19/2013 at 6:15 p.m., Staff #2 confirmed the missing dates and times, lack of assessment, problems with the blood sugar. Staff #2 reported she could not find any documentation showing insulin was administered to Patient #10.
5.Review of the "Temporary Low Census Staffing Guide For Med/Surg Unit " dated 04/11/2013 revealed the following:
*5 plus patients
1 RN, 1 LVN, 1 Aide
*1-5 patients:
1RN, 1 Aide
The LVN is placed on call until the census reaches greater than 5 patients.
*Less than 2 patients :
1RN, 1 Aide
The LVN is cancelled for that shift.
Teletech/ward clerk:
If any patients are on telemetry, the tech will function as the teletech and the ward clerk regardless of census. If there are no telemetry patients, the tech will (be) placed on call.

Review of the "Department of Nursing Daily Staffing Master" (time sheets) for July 2013 revealed the following:
*Nursing day shift was 7:00 a.m-7:00 p.m.;
*Nursing night shift was 7:00 p.m. -7:00 a.m.;
*Nursing day/evening shift for 1 LVN shift for the ER from 11:00 am-11:00 pm.

From 11:00 p.m.-11:00 a.m., a 12 hour timeframe the following nursing staff was documented for the the ER:
*1 RN and one tech on 07/01, 07/02, 07/03, 07/04, 07/05, 07/08, 07/09, 07/10, 07/11, 07/12, 07/15, 07/16, 07/17, and 07/18.
*1 RN on 07/13 and 07/14/2013.

From 11:00 p.m.-11:00 a.m., a 12 hour timeframe, the following nursing staff was documented for the medical/surgical unit:
*1 RN, 1 CNA, 1WC/telemetry technician on 07/01/07/02, 07/03,07/04, 07/09, 07/10, 07/11, 07/12, 07/14, 07/15, 07/16, and 07/19/2013
*1RN, 1 WC on 07/04 from 11:00 p.m. to 7:00 a.m.
*1 RN and 1 CNA on 07/05, 07/13, from 11:00 p.m.-7:00 a.m.
*1 RN on 07/08 from 7:00 a.m-7:00 p.m. and 1 RN and 1 WC 07/08 from 7:00 p.m. -7:00 a.m.
* The patient average daily patient census was 1-5.
During an interview on 07/19/2013 at 1:30 p.m. Staff #1 confirmed the above staffing numbers. Staff #1 reported her job duties were administrator, CNO, order supplies, human resources, over tuberculosis testing, and fill in when they were short of staff. Staff #2 reported her job duties were QA, UR, discharge planning and filling in when they were short of staff. They could not get all of their job duties done nor do quality work because of all the job duties.

6. Review of the Governing Board minutes dated 02/25/2013(prior to the above mentioned schedule) revealed the following:
"Recommendation/Action
Staffing for the ER is being changed to two RN in the ER at nights and an RN and LVN during the day with an RN available in the building to relieve the RN. Telemetry technician's are also in the process of being hired.
Follow-up
Applications will be reviewed to hire additional full time RN's. Telemetry technicians have been hired and are currently being trained."
The above mentioned scheduling evidence revealed the Governing Board's recommendations were not implemented.

Based on interview and record review the Governing Body failed to ensure a medical staff examined the credentials of 2 of 2 physicians (Staff #3 and #4).
This deficient practice had the potential to cause harm to all patients.
Findings included:
Review of "Medical Staff Bylaws" dated 02/25/2013 revealed the following:
"The responsibilities of the medical staff are to account for the quality and appropriateness of patient care rendered by all practitioners and allied health professionals authorized to provide patient care services in the hospital by:
A. processing credentials in a manner that matches verified qualifications, performance, and competence with clinical privileges for all medical staff applicants and members, and practice prerogatives for all allied health professionals.
B. Membership on the medical staff of this hospital and /or clinical privileges is a privilege that shall only be granted and maintained by those professionally qualified and currently competent practitioners who continuously meet the qualifications, standards, and requirements set forth in these bylaws, rules and regulations and the bylaws and policies of the hospital. Appointment to the membership on the medical staff shall confer on the member only such clinical privileges and rights as have been granted by the Governing Board in accordance with these bylaws.
Temporary privileges for new applicants may be granted following submission of a complete application and while awaiting review and approval by the medical executive committee upon verification of all information required by these Bylaws. Such privileges may be granted for an initial period of sixty (60) days, and may be renewed for one additional period of sixty (60) days. At the minimum there must be verification of the following in order for an applicant to be granted temporary privileges:
Current licensure
Relevant training or experience
Current competence
Ability to perform the privileges requested
Other criteria required by the Bylaws
NPBD query and evaluation of the information
No current or previously successful challenge to licensure of registration
No subjection to involuntary termination of medical staff member ship at another organization
No subjection to involuntary limitation, reduction, denial or loss of clinical privileges at another organization
Provisional Status. All initial appointments to any category of the medical staff shall be provisional for twelve (12 months)."

Review of the July 2013 physician schedule for the ER revealed from 07/07 to 07/31/2013 (25 days straight ) the same two physicians were scheduled to work on a daily basis (Staff #3 and #4). There were no back-up physicians listed on the schedule in the event of an emergency.
During an interview on 07/19/2013 at 9:15 a.m., Staff #1 (CNO/Administrator) confirmed Staff #3 and #4 were the only two doctors working. The doctors stay in a house on campus and were on duty 24 hours/7 days. Staff #4 had been on duty alone from 07/07 to 07/18/2013 (12 days straight around the clock). Staff #3 took over around 7:00 p.m. on 07/18/2013.
During an interview on 07/19/2013 Staff #3 confirmed Staff #4's hours. Staff #3 reported he had taken over on 07/18/2013 and would work until 08/31/2013 (14 days straight). They wanted to work 5 days on and 5 days off but that was not occurring. During the timeframe, Staff #4 was on duty Staff #3 was his back-up. Staff #3 reported he and Staff #4 had been fired by the previous owner (#14) in March 2013 and they had just returned on 07/07/2013.
Review of personnel file on Staff #3 revealed his most current required "Texas Standardized Credentialing application" was dated 10/2012. Staff #3 granted himself Internal Medicine/Emergency Medicine temporary privileges on 10/11/2012. Members from the Governing Board approved the temporary privileges 02/25/2013.
Staff #3 recommended himself a provisional six-month appointment on 10/31/2012 and members of the Governing Board approved it on 02/25/2013.
Review of the personnel file on Staff #4 revealed his most current required "Texas Standardized Credentialing application" was dated 11/01/2012.
Staff #3 granted Staff #4 Internal Medicine/Emergency Medicine temporary privileges on 10/12/2012. Members from the Governing Board approved the temporary privileges 02/25/2013.
During an interview on 07/31/2013, Staff #15 reported she was responsible for ensuring credentialing for the physicians. The process was for her to check the backgrounds, take the information to the administrator, who would take it to medical staff, then it would proceed to the Governing Board for approval. Staff #15 reported she knew of no medical staff meetings occurring since October 2012. Current CNO/Administrator confirmed no medical staff meetings were occurring. Staff #15 reported they had gotten behind on the paperwork and they were due to go back to medical staff meeting in August 2013. Staff #15 reported Staff #3 was through with his temporary status and was up for his provisional review. Staff #15 confirmed the applications and request had been performed in February 2013 before the two physicians were fired. There were no current applications or request for privileges processed for their return in July 2013.

Based on observation, interview and record review the facility failed to ensure patients received care in a safe setting. They failed to have an organized nursing service to ensure 4 of 4 (#s ' 6, 7, 8, and 9) telemetry technicians monitoring cardiac patients were qualified, telemetry technicians and other nursing personnel were supervised by a registered nurse and failed to have a sufficient numbers of nursing staff in the ER and Medical Surgical unit at all times.
Nursing staff failed to provide ongoing assessments and provide interventions to 4 of 11 patients presenting to the hospital (#'s 5, 7, 8 and 10).
This deficient practice had the potential to cause harm to all cardiac patients admitted into the hospital.
Findings include:
Review of an undated "Medical Nursing Unit Scope of Service" policy revealed:
"The patient population consists of individuals including Pediatric, Adolescent, Adult and Geriatric.
Some of the diagnoses treated included, but were not limited to: S/P Myocardial Infarctions, Unstable Angina, Telemetry monitoring-Cardiac dysrhythmias, neurological disorder, respiratory disorder and ongoing assessments.
The Medical nursing staff includes the Nurse Director (who completes the schedule) and permanently assigns Medical floor staff nurses. The patient nurse ratio is based on patient census and acuity as outlined in the staffing matrix. Medical floor nurses are knowledgeable regarding emotional, psychosocial, educational and rehabilitative needs of the Medical floor patient and can provide necessary therapeutic interventions.
The nurse to patient ratio will be determined by the Nurse Director or charge nurse based on the patient ' s needs and the capabilities of the nursing staff. A back up or on call nurse may be provided as applicable."

Review of an undated "Position Description, Telemetry/Monitor Technician" revealed the following:
"The Telemetry/Monitor Tech is responsible for accurate record keeping, observation of monitors and prompts reporting of cardiac rhythm changes. The Telemetry /Monitor Tech must possess effective communication skills. This position will routinely perform Unit Secretary duties for the unit as assigned.
Department Core Competencies
#30 Performs ongoing observation of the cardiac monitors and interpret cardiac rhythms correctly;
#32 Prioritize and assist with unit activities based on patient needs under the direction of the RN;
#34 Detect and promptly report changes in parameters monitoring cardiac rhythms;
#36 Ensure timely and accurate communication of patient information with all members of the health care team.
#38 Arrhythmias-maintain strips and reporting changes"

1. During an observation on 07/19/2013 at 9:55 a.m., a loud commotion could be heard coming from behind the door of room #104 which was midway down the hall. Staff #13 (charge nurse) was also in the hallway near a medication cart. The CNO reported the commotion was a CNA and the telemetry technician (Staff #8) assisting a patient with a bath. The CNO confirmed no one was at the nursing station watching the telemetry monitors and there should have been. The door (#104) was approximately 20 -30 feet from the nursing station. Patient #' s 7 and 8 were both on telemetry monitors.
During an interview on 07/19/2013 at 10:00 a.m., Staff #8 reported she was the ward clerk/ telemetry technician and had been in the position for 5 months. She had not received a training class for it at the facility nor had she ever worked as a telemetry technician anywhere. She had only been informed by nursing to watch for when the heart rate goes less than 50 or above 120. Staff #8 reported she did not know the different heart rhythms and pulled out a folded sheet of paper she had been given by the facility to refer to. The paper was a "Cardiac Rhythm Study Guide ".
During an interview on 07/19/2013 at 10:10a.m, Staff # 1 (CNO) reported before February 2013 there was no one watching the telemetry monitors. Two consultants came into the facility and told them they had to have someone watching the monitors. The person only needed to be able to say "hey nurse" when the heart rate was too high or low." Staff # 14 (Former owner/Dr) would not let them hire qualified telemetry technicians. Staff #8 was the first telemetry technician they hired and there were three other ladies working as telemetry technicians(#'s 6, 7 and 9). Staff #8 was a CNA and the others had no medical background. Staff #1 reported none of the ladies were qualified telemetry technicians. Staff #1 reported Staff #11 (former ADON) had given the telemetry technicians their orientation. Staff #1 called Staff #11 with the surveyor present and asked about the training. Staff #1 reported the training was 15-20 minutes and none of the techs had taken the required testing to prove they were proficient.

During an interview on 07/19/2013 at 11:00a.m, Staff #11 reported the average daily census for the ER for July 2013 was 6-12 patients and on 07/09/2013 it was 14.
During an interview on 07/19/2013 at 11:13 a.m., Staff #1 (CNO) reported during an emergency code sometimes they could "beg" the local EMS staff in the area to help . She confirmed if there was no EMS to help, the RNs would assist each other, thereby leaving their unit unsupervised.
During an interview on 07/19/2013 at 12:20 p.m., Staff #13 reported they usually have a RN, CNA and telemetry technician working. The telemetry technicians cannot tell if anything is irregular because they are not trained in rhythms. They need to know what they are looking at. Before the telemetry technicians there was no watching the monitors. During the timeframe of 7-11 a.m. when there was not a LVN they were not that busy. If there was a code in the ER that she had to assist with, the aide was there on the medical/surgical unit. If Staff #1 (CNO) and Staff #2 (QA\UR) were there during the week they could assist.

2. Review of an "Emergency Nursing Record" dated 07/14/2013 revealed Patient #5 presented to the ER at 1:25 p.m with a chief complaint of altered level of consciousness. The patient had a medical history of mental retardation, atrial flutter, diabetes and hypertension. On admission Patient #5 had the following vital signs (B/P) 90/30, (P)96, (Respiratory rate)24 and (T) 99.3 degrees F.
Review of an "Emergency Physician Record " dated 07/14/2013, 1:40 p.m., revealed Patient #5 was assessed and his clinical impression was chronic dementia, confusion, hypoglycemia, pneumonia, urinary tract infection, sepsis, hyperkalemia, and dehydration.
Review of the "Emergency Nursing Record" dated 07/14/2013, 2:05 p.m revealed Patient #5 received 1000cc of fluids intravenously.
The following critical lab values dated 07/14/2013 were reported to Staff #4 (the physician):
At 2:15 p.m. a WBC of 66.2 (RR 4.5-10.1), HGB 7.0(12.0-16.0), HCT 20.3 (36.0-50.0)
At 2:25 p.m. a Potassium of 6.5 (RR 3.5-5.1)
Review of physician admission orders dated 07/14/2013 at 3:00 p.m., revealed some of the following:
*Admit to telemetry
*Dextrose 5 percent normal saline at 125 cc per hour
*Type and cross for 3 units and transfuse and to hold intravenous fluids while transfusing
*Hemoglobin and Hematocrit every 6 hours
*Lasix 20 mg intravenously between transfusion if systolic B/P greater than 120, otherwise hold
There was no mention of treatment for the elevated potassium level.
Review of the "Emergency Nursing Record" dated 07/14/2013 revealed at 3:15 p.m. Dextrose 5 percent normal saline at 125 cc per hour was started. At 3: 19 p.m. Patient #5 B/P dropped to 87/31. According to documentation at 3:35 p.m. the doctor was aware of the B/P.

Nursing "narrative notes" dated 07/14/2013 revealed the following, 3 hours after the initial critical lab results:
At 5:15 p.m, Patient #5 was admitted from ER to the floor and her B/P was 101/32 and at 6:00 p.m there was a drop to 61/32.
At 7:15 p.m. and 8:15 p.m. calls were made to the family to obtain consent to administer the blood and there was no answer.

Review of a critical lab value dated 07/14/2013 revealed nursing was informed at 8:15 p.m. of the HGB of 6.7 (RR 12.0-16.0) and HCT of 19.7 (RR 36.0-50.0) dropping even more.

Nursing "narrative notes" dated 07/14/2013 revealed the following:
At 8:45 p.m. the MD gave emergency transfusion orders for "O" negative blood stat because he felt the patient was critically ill and he could not wait to transfuse. The lab was ordering 2 more units of "O" negative through the blood bank in case of an emergency.
At 9:00 p.m., the MD was trying to gain intravenous access through neck-subclavian vein.
At 9:45 p.m., the MD asked the RN to run blood with the IV in the left hand and to run each unit in over 4 hours.
Review of the blood administration record dated 07/14/2013, 10:20 p.m. revealed the first unit of blood was started over 8 hours after receiving the initial critical lab values (at 2:15 p.m.). At 1:10 a.m. the unit of blood was ended. Staff #s' 16 and 17 (RN) signed as performing the checks on the blood at the time of start and ending. Staff #16 was the Medical /Surgical nurse and Staff #17 was the ER nurse.
Review of the "Daily Staffing Master" sheet dated 07/14/2013 revealed Staff #17 was the only staff scheduled for the ER from 7p.m.-7:00 a.m.
Review of the "Emergency Room Register" dated 07/14/2013 revealed Staff #17 (ER nurse) had a patient present to the ER at 9:35 p.m. and was not discharged until 11:00 p.m. At 11:33p.m., Staff #17 (ER nurse) had another patient come in with possible aspiration had had to be transferred to another hospital at 1:30 a.m..
Nursing "narrative notes" dated 07/15/2013 revealed the following:
At 06: 00 a.m., the 3rd unit of blood was checked by 2 RNs and is now infusing. The EKG shows atrial fibrillation and patient's am KCL level is 6.7 and critically high at 6.7.
Review of a physician order dated 07/14/2013 (actual date was 07/15/2013) at 6:55 a.m.revealed to "please repeat KCL and call result to the Dr. Give 0.25mg IV Digoxin and if KCL level is greater than 6.0 give 60 gm Kayexalate by straw "
Review of a critical lab value dated 07/15/2013 revealed nursing was informed at 6:45 a.m. of a potassium level of 6.7 (RR 3.6-5.1).
Review of a "Medication Administration Record" dated 07/14/2013 revealed the cardiac agent Digoxin was administered at 8:00 a.m.
Nursing "narrative notes" dated 07/15/2013 at 9:00 a.m., revealed Patient #5 was given Kayexalate 60 GM. This was the first treatment for the elevated Potassium which was was identified over 19 hours ago on 07/14/2013 at 2:15 p.m.
Nursing "narrative notes" dated 07/16/201d revealed the following:
At 3:00 a.m. Patient #5 had a B/P 83/47 and a HR of 103.
At 3:10 a.m., the doctor was notified. The documentation in the notes read to see new orders for Dopamine 2 mcg/kg/min started for renal dose.
There was no complete physician order for this dosage of Dopamine.
Review of the physician orders dated 07/16/2013 at 3:10 a.m revealed the following:
"Dopami ...gtt. Titrate to SBP greater than or equal to 90."
Review of a "Medication Orders and Administration" dated 04/2008 revealed orders must include the name of the drug, dose. Route, concentration or strength, frequency and licensed physician signature. All orders for micrograms amounts shall be clearly written as mcg. To distinguish from milligrams (mg).
There was no physician signed protocol addressing titration of the Dopamine nor were their parameters on when to stop the drip.
Review of physician orders date 07/17/2013 revealed the Dopamine was discontinued on 07/17/2013.
Review of a case management plan dated 07/17/2013 revealed Patient #5 would be returning to the nursing home on hospice care when she was stable.
3. Review of an "Emergency Nursing Record" dated 07/18/2013 revealed Patient # 7 was a 57 year old male who presented to the ER at 8:50 p.m. with a diagnosis of chest pain. Patient #7 had a history of diabetes, coronary artery disease, chronic obstructive pulmonary disease and peripheral vascular disease. He had a pain level of 9 of 10 and complaining of pressure to this chest (Pain scale level of 0 being no pain and 10 being severe pain).
Review of an "Emergency Physician Record" dated 07/18/2013 revealed a physician assessment on Patient #7 indicating he was being admitted with acute chest pain. The assessment was not timed.
Review of an "Emergency Department Record, Physician Order Sheet" revealed orders for lab, cardiac monitor, pulse oximeter and oxygen. The order for oxygen was incomplete and did not indicate the liters of oxygen needed and what parameters for oxygen saturation. The physician orders were not dated or timed.
Physician orders dated 07/18/2013, 9:30 p.m. revealed Patient #7 was admitted to the unit for observation to telemetry for a diagnosis of chest pain rule out Myocardial infarction (heart attack). There as an order for aspirin, nitroglycerin 0.4 mg sublingual every 5 minutes (medications which cause vasodilation and which increased blood flow), morphine 2 mgs IVP (pain medication) every 4 hours prn (whenever needed).
Review of an "Emergency Nursing Record" dated 07/18/2013 revealed Patient #7 was not given any pain medication until 10:56 pm, over 2 hours after presenting to the ER. There was no assessment of how severe the pain was. There was no documentation of any nitroglycerin being administered at all.
Review of EKG strips revealed one was printed on 07/18/2013 at 8:49 p.m. which indicated it was abnormal. The next EKG strip was not printed until 07/19/2013 at 4:13a.m over 7 hours later.
During an interview on 07/19/2013 at 6:15 p.m., Staff #2 confirmed the missing dates and times, lack of assessment, no Nitroglycerin being administered and the late administration of pain medication. Staff #2 reported their in-house policy was for the telemetry technician's to print off a strip every 4 hours.

4. Review of an " mergency Nursing Record" dated 07/18/2013 revealed Patient # 10 was a 53 year old male who presented to the ER at 0200 a.m. with a diagnosis of chest pain. Patient #10 had a history of chronic obstructive pulmonary disease and schizophrenia. Patient #10 had a blood sugar of 362. The assessment revealed lab was drawn, intravenous fluid started, EKG performed, oxygen placed on and a chest X-ray performed.
Review of an "Emergency Physician Record" revealed an assessment performed by Staff #4 (MD) which was dated incorrectly 03/18/2013 and not timed. Staff #4 documented Patient #10 was having sternal pain which was radiating to the right side and he was borderline Diabetes mellitus. Staff #4 documented he interpreted the EKG strip but did not document the results in the designated area on the form. Underneath the progress section the time was left blank, and Staff #4 documented the patient is chest pain free, 2 sets of Troponin are negative. The patient was advised to take medications for Diabetes mellitus.
Review of a phyisician orders dated 07/18/13 at 2:55 a.m.revealed an order for 10 units of regular insulin to be administered but did not include parameters of when to give. There was no documentation of the medication being administered by nursing.
During an interview on 07/19/2013 at 11:00 a.m, Staff #11 reported Staff #4 (MD) was on duty from 07/07-07/18/2013 (11 days/24 hours a day ).
Review of an "Emergency Nursing Record" dated 07/18/2013 revealed at 4:32 a.m., Patient #10 had a blood sugar of 371. There was no documentation of any intervention provided.
Review of a lab report dated 07/18/2013 at 5:55 a.m. revealed Patient #10 had a blood sugar reading of 218 ( with reference range being 70-105). There was no mention of what was done about the blood sugar before discharging the patient.
Review of an "Emergency Nursing Record" dated 07/18/2013 at 6:30 a.m. revealed the patient was discharged home. A prescription for the diabetic agent Glucophage was attached.
During an interview on 07/19/2013 at 6:15 p.m., Staff #2 confirmed the missing dates and times, lack of assessment, problems with the blood sugar. Staff #2 reported she could not find any documentation showing insulin was administered to Patient #10.

5.Review of the " Temporary Low Census Staffing Guide For Med/Surg Unit " dated 04/11/2013 revealed the following:
"*5 plus patients
1 RN, 1 LVN, 1 Aide
*1-5 patients:
1RN, 1 Aide
The LVN is placed on call until the census reaches greater than 5 patients.
*Less than 2 patients :
1RN, 1 Aide
The LVN is cancelled for that shift.
Teletech/ward clerk:
If any patients area on telemetry, the tech will function as the teletech and the ward clerk regardless of census. If there are no telemetry patients, the tech will (be) placed on call."

Review of the " Department of Nursing Daily Staffing Master " (time sheets) for July 2013 revealed the following:
*Nursing day shift was 7:00 a.m-7:00 p.m.;
*Nursing night shift was 7:00 p.m. -7:00 a.m.;
*Nursing day/evening shift for 1 LVN shift for the ER from 11:00 am-11:00 pm.

From 11:00 p.m.-11:00 a.m., a 12 hour timeframe the following nursing staff was documented for the the ER:
*1 RN and one tech on 07/01/, 07/02, 07/03, 07/04, 07/05, 07/08, 07/09, 07/10, 07/11, 07/12, 07/15, 07/16, 07/17, and 07/18.
*1 RN on 07/13 and 07/14/2013.

From 11:00 p.m.-11:00 a.m., a 12 hour timeframe the following nursing staff was documented for the medical/surgical unit:
*1 RN, 1 CNA, 1WC/telemetry technician on 07/01/07/02, 07/03,07/04, 07/09, 07/10, 07/11, 07/12, 07/14, 07/15, 07/16, and 07/19/2013
*1RN, 1 WC on 07/04 from 11:00 p.m. to 7:00 a.m.
*1 RN and 1 CNA on 07/05, 07/13, from 11:00 p.m.-7:00 a.m.
*1 RN on 07/08 from 7:00 a.m-7:00 p.m. and 1 RN and 1 WC 07/08 from 7:00 p.m. -7:00 a.m.
* The patient average daily patient census was 1-5.
During an interview on 07/19/2013 at 1:30 p.m. Staff #1 confirmed the above staffing numbers. Staff #1 reported her job duties were administrator, CNO, order supplies, human resources, over tuberculosis testing, and fill in when they were short of staff. Staff #2 reported her job duties were QA, UR, discharge planning and filling in when they were short of staff. They could not get all of their job duties done nor do quality work because of all the job duties.

6. Review of the Governing Board minutes dated 02/25/2013 (prior to the above mentioned scheduling) revealed the following:
"Recommendation/Action
Staffing for the ER is being changed to two RN in the ER at nights and an RN and LVN during the day with an RN available in the building to relieve the RN. Telemetry technician's are also in the process of being hired.
Follow-up
Applications will be reviewed to hire additional full time RN's. Telemetry technicians have been hired and are currently being trained."

The above mentioned scheduling evidence revealed the Governing Board's recommendations were not implemented.

Based on observation, interview and record review the facility failed to ensure registered nurses assigned nursing care of cardiac patients to competent and qualified staff. This deficient practice was found in 4 of 4 (#'s 6, 7, 8, and 9) telemetry monitor technicians and 1 of 1 CNAs (#8). Untrained telemetry technicians were allowed to monitor patients on telemetry and were not provided supervision by nursing. A CNA with an expired certification was allowed to provide direct patient care.
This deficient practice had the potential to cause harm to all patients admitted into the hospital.
Findings include:
Review of an undated "Medical Nursing Unit Scope of Service" policy revealed:
"The patient population consist of individuals including Pediatric, Adolescent, Adult and Geriatric.
Some of the diagnoses treated included, but were not limited to: S/P Myocardial infarctions, unstable angina, telemetry monitoring-cardiac dysrhythmias, neurological disorder, respiratory disorder and ongoing assessments.
The Medical nursing staff includes the Nurse Director (who completes the schedule) and permanently assigns Medical floor staff nurses. The patient nurse ratio is based on patient census and acuity as outlined in the staffing matrix. Medical floor nurses are knowledgeable regarding emotional, psychosocial, educational and rehabilitative needs of the Medical floor patient and can provide necessary therapeutic interventions.
The nurse to patient ration will be determined by the Nurse Director or charge nurse based on the patient's needs and the capabilities of the nursing staff. A back up or on call nurse may be provided as applicable."

Review of an undated "Position Description, Telemetry/Monitor Technician" revealed the following:
"The Telemetry/Monitor Tech is responsible for accurate record keeping, observation of monitors and prompt reporting of cardiac rhythm changes. The Telemetry/Monitor Tech must possess effective communication skills. This position will routinely perform Unit Secretary duties for the unit as assigned.
Department Core Competencies
#30 Performs ongoing observation of the cardiac monitors and interpret cardiac rhythms correctly;
#32 Prioritize and assist with unit activities based on patient needs under the direction of the RN;
#34 Detect and promptly report changes in parameters monitoring cardiac rhythms;
#36 Ensure timely and accurate communication of patient information with all members of the health care team.
#38 Arrhythmias-maintain strips and reporting changes"

1. During an observation on 07/19/2013 at 9:55 a.m., a loud commotion could be heard coming from behind room #104 which was midway down the hall. Staff #13 (charge nurse) was also in the hallway near a medication cart. The CNO reported the commotion was a CNA and the telemetry technician (Staff #8) assisting a patient with a bath. The CNO confirmed no one was at the nursing station watching the telemetry monitors and there should have been. The door (#104) was approximately 20-30 feet from the nursing station. Patient #'s 7 and 8 were both on telemetry monitors.
During an interview on 07/19/2013 at 10:00 a.m., Staff #8 reported she was the ward clerk/ telemetry technician and had been in the position for 5 months. She had not received a training class for it at the facility nor had she ever worked as a telemetry technician anywhere. She had only been informed by nursing to watch for when the heart rate goes less than 50 or above 120. Staff #8 reported she did not know the different heart rhythms and pulled out a folded sheet of paper she had been given by the facility to refer to. The paper was a "Cardiac Rhythm Study Guide".
During an interview on 07/19/2013 at 10:10a.m, Staff # 1 (CNO) reported before February 2013 there was no one watching the telemetry monitors. Two consultants came into the facility and told them they had to have someone watching the monitors. The person only needed to be able to say "hey nurse" when the heart rate was too high or low. Staff # 14 (Former owner/Dr) would not let them hire qualified telemetry technicians. Staff #8 was the first telemetry technician they hired and there were three other ladies working as telemetry technicians(#'s 6, 7 and 9). Staff #8 was the only one who was a CNA, the others had no medical background. Staff #1 reported none of the ladies were qualified telemetry technicians. Staff #1 reported Staff #11 (former ADON) had given the telemetry technicians their orientation. Staff #1 called Staff #11 with the surveyor present and asked about the training. Staff #1 reported the training was 15-20 minutes and none of the techs had taken the required testing to prove they were proficient.
During an interview on 07/19/2013 at 12:20 p.m., Staff #13 reported they usually have a RN, CNA and telemetry technician working. The telemetry technicians cannot tell if anything is irregular because they are not trained in rhythms. They need to know what they are looking at. Before the telemetry technicians, there was no watching the monitors. During the timeframe of 7-11 a.m. when there was not a LVN they were not that busy. If there was a code in the ER that she had to assist with, the aide was there on the medical/surgical unit. If Staff #1 (CNO) and Staff #2 (QA\UR) were there during the week they could assist.
2. Review of the personnel files on Staff #'s 6, 7, 8, and 9 revealed no documentation of training or competency to be a telemetry technician. Review of the personnel file on Staff #8 revealed her CNA certification expired on 05/26/2013.

Based on observation, interview and record review the facility failed to ensure the security of drugs and biological.
This deficient practice had the potential to affect all patients.
Findings include:
Review of a pharmacy policy and procedure dated 03/2013 "Roster license personnel after hours" revealed no documented procedure for after hour access. It just contained a list of RN staff.
On 07/19/2013 at 10:30 a.m., the narcotic lock-up area was observed to be located inside the pharmacy. Staff #10 (pharmacy tech) provided a copy of the list of staff who had after hour access to the pharmacy.
Review of an incident report dated 06/04/2013 revealed the facility had an incorrect narcotic count which occurred on 06/03/2013. Documentation of the investigation revealed there was a possible drug diversion and staff were drug tested. One staff member was terminated for refusal to comply with the testing.
During an interview on 07/19/2013 at 10:30 a.m., Staff #10 reported the pharmacy hours were Monday, Wednesday and Friday 8:00 a.m.-4:30 p.m. She confirmed some of the nurses listed on the "license personel after hours" list were no longer employed and that it needed to be updated. As of 07/19/13, the staff member who was terminated at the time of the 06/04/2013 incident was still listed on the access list.
During an interview on 07/19/2013 at 11:35 a.m., Staff #1 (CNO) reported ER staff (RN and LVN) had one set of narcotic keys. The RN keeps the keys and sends the LVN to get the medication. Staff #1 (CNO) reported the LVN should be on the pharmacy access list.
During an interview on 07/19/2013 at 11:13 a.m, Staff #12 (LVN) reported the charge nurse on the floor usually keeps the narcotic keys and she usually gets her to go into the pharmacy with her.
There were no LVNs on the list to enter the phamarcy after hours.

Based on observation, interview and record review the facility failed to ensure the security of drugs and biologica by not having a current list of staff with after hour access to the pharmacy.
This deficient practice had the potential to affect all patients.
Findings include:
Review of a pharmacy policy and procedure dated 03/2013 "Roster license personnel after hours" revealed no documented procedure for after hour access. It just contained a list of RN staff.
On 07/19/2013 at 10:30 a.m., the narcotic lock-up area was observed to be located inside the pharmacy. Staff #10 (pharmacy tech) provided a copy of the list of staff who had after hour access to the pharmacy.
Review of an incident report dated 06/04/2013 revealed the facility had an incorrect narcotic count which occurred on 06/03/2013. Documentation of the investigation revealed there was a possible drug diversion and staff were drug tested. One staff member was terminated for refusal to comply with the testing.
During an interview on 07/19/2013 at 10:30 a.m., Staff #10 reported the pharmacy hours were Monday, Wednesday and Friday 8:00 a.m.-4:30 p.m. She confirmed some of the nurses listed on the "license personel after hours" list were no longer employed and that it needed to be updated. As of 07/19/13, the staff member who was terminated at the time of the 06/04/2013 incident was still listed on the access list.
During an interview on 07/19/2013 at 11:35 a.m., Staff #1 (CNO) reported ER staff (RN and LVN) had one set of narcotic keys. The RN keeps the keys and sent the LVN to get the medication. Staff #1 (CNO) reported the LVN should be on the pharmacy access list.
During an interview on 07/19/2013 at 11:13 a.m, Staff #12 (LVN) reported the charge nurse on the floor usually keeps the narcotic keys and she usually gets her to go into the pharmacy with her.
There were no LVNs on the list to enter the phamarcy after hours.

Based on interview and record review the facility failed to ensure Emergency Services was organized and under the direction of a qualified medical staff. Facility staff failed to ensure timely emergency intervention was provided to 3 of 11 patients (#'s 5, 7 and 10).
This deficient practice had the potential to affect all patients presenting to the ER.
Findings include:

1. Review of the "Emergency Room Register" for the timeframe from 07/08/2013 at 8:37 a.m. to 07/19/2013 10:40 a.m. there were 167 patients seen in the ER.
Review of the "Emergency Room Register" for the timeframe from 07/08/2013 at 8:37 a.m. to 07/18/2013 at 7:00 p.m. Staff #4 (ER physician) saw 162 patients. Staff #4 was on duty 24 hours a day during this timeframe.
2. Review of personnel files for Staff #3 and #4 revealed they did not have current ER privileges. Staff #3 was the Chief of Staff and an ER physician, he was rehired to work for the facility on 07/07/2013.
Review of "Medical Staff Bylaws" dated 02/25/2013 revealed the following:
"The responsibilities of the medical staff are to account for the quality and appropriateness of patient care rendered by all practitioners and allied health professionals authorized to provide patient care services in the hospital by:
A. processing credentials in a manner that matches verified qualifications, performance, and competence with clinical privileges for all medical staff applicants and members, and practice prerogatives for all allied health professionals.
B. Membership on the medical staff of this hospital and /or clinical privileges is a privilege that shall only be granted and maintained by those professionally qualified and currently competent practitioners who continuously meet the qualifications, standards, and requirements set forth in these bylaws, rules and regulations and the bylaws and policies of the hospital. Appointment to the membership on the medical staff shall confer on the member only such clinical privileges and rights as have been granted by the Governing Board in accordance with these bylaws.
Temporary privileges for new applicants may be granted following submission of a complete application and while awaiting review and approval by the medical executive committee upon verification of all information required by these Bylaws. Such privileges may be granted for an initial period of sixty (60) days, and may be renewed for one additional period of sixty (60) days. At the minimum there must be verification of the following in order for an applicant to be granted temporary privileges:
Current licensure
Relevant training or experience
Current competence
Ability to perform the privileges requested
Other criteria required by the Bylaws
NPBD query and evaluation of the information
No current or previously successful challenge to licensure of registration
No subjection to involuntary termination of medical staff member ship at another organization
No subjection to involuntary limitation, reduction, denial or loss of clinical privileges at another organization
Provisional Status. All initial appointments to any category of the medical staff shall be provisional for twelve (12 months)."

Review of the July 2013 physician schedule for the ER revealed from 07/07 to 07/31/2013 (25 days straight ) the same two physicians were scheduled to work on a daily basis (Staff #3 and #4). There were no back-up physicians listed on the schedule in the event of an emergency.
During an interview on 07/19/2013 at 9:15 a.m., Staff #1 (CNO/Administrator) confirmed Staff #3 and #4 were the only two doctors working. The doctors stay in a house on campus and were on duty 24 hours/7 days. Staff #4 had been on duty alone from 07/07 to 07/18/2013 (12 days straight around the clock). Staff #3 took over around 7:00 p.m. on 07/18/2013.
During an interview on 07/19/2013 Staff #3 confirmed Staff #4's hours. Staff #3 reported he had taken over on 07/18/2013 and would work until 08/31/2013 (14 days straight). They wanted to work 5 days on and 5 days off but that was not occurring. During the timeframe, Staff #4 was on duty Staff #3 was his back-up. Staff #3 reported he and Staff #4 had been fired by the previous owner (#14) in March 2013 and they had just returned on 07/07/2013.
Review of personnel file on Staff #3 revealed his most current required "Texas Standardized Credentialing application" was dated 10/2012. Staff #3 granted himself Internal Medicine/Emergency Medicine temporary privileges on 10/11/2012. Members from the Governing Board approved the temporary privileges 02/25/2013.
Staff #3 recommended himself a provisional six-month appointment on 10/31/2012 and members of the Governing Board approved it on 02/25/2013.
Review of the personnel file on Staff #4 revealed his most current required "Texas Standardized Credentialing application" was dated 11/01/2012.
Staff #3 granted Staff #4 Internal Medicine/Emergency Medicine temporary privileges on 10/12/2012. Members from the Governing Board approved the temporary privileges 02/25/2013.
During an interview on 07/31/2013, Staff #15 reported she was responsible for ensuring credentialing for the physicians. The process was for her to check the backgrounds, take the information to the administrator, who would take it to medical staff, then it would proceed to the Governing Board for approval. Staff #15 reported she knew of no medical staff meetings occurring since October 2012. Current CNO/Administrator confirmed no medical staff meetings were occurring. Staff #15 reported they had gotten behind on the paperwork and they were due to go back to medical staff meeting in August 2013. Staff #15 reported Staff #3 was through with his temporary status and was up for his provisional review. Staff #15 confirmed the applications and request had been performed in February 2013 before the two physicians were fired. There were no current applications or request for privileges processed for their return in July 2013.
3. Review of an "Emergency Nursing Record" dated 07/14/2013 revealed Patient #5 presented to the ER at 1:25 p.m with a chief complaint of altered level of consciousness. The patient had a medical history of mental retardation, atrial flutter, diabetes and hypertension. On admission Patient #5 had the following vital signs (B/P) 90/30, (P)96, (Respiratory rate)24 and (T) 99.3 degrees F.
Review of an "Emergency Physician Record" dated 07/14/2013, 1:40 p.m., revealed Patient #5 was assessed and his clinical impression was chronic dementia, confusion, hypoglycemia, pneumonia, urinary tract infection, sepsis, hyperkalemia, and dehydration.
Review of the "Emergency Nursing Record" dated 07/14/2013, 2:05 p.m., revealed Patient #5 received 1000cc of fluids intravenously.
The following critical lab values dated 07/14/2013 were reported to Staff #4 (the physician):
At 2:15 p.m. a WBC of 66.2 (RR 4.5-10.1), HGB 7.0 (12.0-16.0), HCT 20.3 (36.0-50.0)
At 2:25 p.m. a Potassium of 6.5 (RR 3.5-5.1)
Review of physician admission orders dated 07/14/2013 at 3:00 p.m., revealed some of the following:
*Admit to telemetry
*Dextrose 5 percent normal saline at 125 cc per hour
*Type and cross for 3 units and transfuse and to hold intravenous fluids while transfusing
*Hemoglobin and Hematocrit every 6 hours
*Lasix 20 mg intravenously between transfusion if systolic B/P greater than 120, otherwise hold
There was no mention of treatment for the elevated potassium level.
Review of the "Emergency Nursing Record" dated 07/14/2013 revealed Dextrose 5 percent normal saline at 125 cc per hour was started at 3:15 p.m. At 3:19 p.m., Patient #5's B/P dropped to 87/31. According to documentation at 3:35 p.m. the doctor was aware of the B/P.

Nursing "narrative notes" dated 07/14/2013, 3 hours after the initial critical lab results, revealed the following:
At 5:15 p.m, Patient #5 was admitted from ER to the floor and her B/P was 101/32 and at 6:00 p.m there was a drop to 61/32.
At 7:15 p.m. and 8:15 p.m. calls were made to the family to obtain consent to administer the blood and there was no answer.

Review of a critical lab value dated 07/14/2013 revealed nursing was informed at 8:15 p.m. of the HGB of 6.7 (RR 12.0-16.0) and HCT of 19.7 (RR 36.0-50.0) dropping even more.

Nursing "narrative notes" dated 07/14/2013 revealed the following:
At 8:45 p.m. the MD gave emergency transfusion orders for "O" negative blood stat because he felt the patient was critically ill and he could not wait to transfuse. The lab was ordering 2 more units of "O" negative through the blood bank in case of an emergency.
At 9:00 p.m., the MD was trying to gain intravenous access through neck-subclavian vein.
At 9:45 p.m., the MD asked the RN to run blood with the IV in the left hand and to run each unit in over 4 hours.
Review of the blood administration record dated 07/14/2013, 10:20 p.m. revealed the first unit of blood was started over 8 hours after receiving the initial critical lab values(at 2:15 p.m.). At 1:10 a.m. the unit of blood was ended. Staff #'s 16 and 17 (RN) signed as performing the checks on the blood at the time of start and ending. Staff #16 was the Medical/Surgical nurse and Staff #17 was the ER nurse.
Review of the "Daily Staffing Master" sheet dated 07/14/2013 revealed Staff #17 was the only staff scheduled for the ER from 7p.m.-7:00 a.m.
Review of the "Emergency Room Register" dated 07/14/2013 revealed Staff #17 (ER nurse) had a patient present to the ER at 9:35 p.m. and was not discharged until 11:00 p.m. At 11:33p.m., Staff #17 (ER nurse) had another patient come in with possible aspiration had had to be transferred to another hospital at 1:30 a.m..
Nursing "narrative notes" dated 07/15/2013 revealed the following:
At 06: 00 a.m., the 3rd unit of blood was checked by 2 RNs and was infusing. The EKG showed atrial fibrillation and patient's am KCL level was 6.7 and critically high at 6.7.
Review of a physician order dated 07/14/2013 (actual date was 07/15/2013) at 6:55 a.m.revealed to "please repeat KCL and call result to the Dr. Give 0.25mg IV digoxin and if KCL level is greater than 6.0 give 60 gm Kayexalate by straw."
Review of a critical lab value dated 07/15/2013 revealed nursing was informed at 6:45 a.m. of a potassium level of 6.7 (RR 3.6-5.1).
Review of a "Medication Administration Record" dated 07/14/2013 revealed the cardiac agent Digoxin was administered at 8:00 a.m.
Nursing "narrative notes" dated 07/15/2013 at 9:00 a.m., revealed Patient #5 was given Kayexalate 60 GM. This was the first treatment for the elevated potassium which was identified over 19 hours prior on 07/14/2013 at 2:15 p.m.
Nursing "narrative notes" dated 07/16/201d revealed the following:
At 3:00 a.m. Patient #5 had a B/P 83/47 and a HR of 103.
At 3:10 a.m., the doctor was notified. The documentation in the notes read to see new orders for Dopamine 2 mcg/kg/min started for renal dose.
There was no complete physician order for this dosage of Dopamine.
Review of the physician orders dated 07/16/2013 at 3:10 a.m revealed the following:
"Dopami ...gtt. Titrate to SBP greater than or equal to 90"
Review of a "Medication Orders and Administration" dated 04/2008 revealed orders must include the name of the drug, dose, route, concentration or strength, frequency and licensed physician signature. All orders for micrograms amounts shall be clearly written as mcg. To distinguish from milligrams (mg).
There was no physician signed protocol addressing titration of the Dopamine nor were their parameters on when to stop the drip.
Review of physician orders date 07/17/2013 revealed the Dopamine was discontinued on 07/17/2013.
Review of a case management plan dated 07/17/2013 revealed Patient #5 would be returning to the nursing home on hospice care when she was stable.
4. Review of an "Emergency Nursing Record" dated 07/18/2013 revealed Patient # 7 was a 57 year old male who presented to the ER at 8:50 p.m. with a diagnosis of chest pain. Patient #7 had a history of diabetes, coronary artery disease, chronic obstructive pulmonary disease and peripheral vascular disease. He had a pain level of 9 out of 10 and complaining of pressure to this chest (Pain scale level of 0 being no pain and 10 being severe pain).
Review of an "Emergency Physician Record" dated 07/18/2013 revealed a physician assessment on Patient #7 indicating he was being admitted with acute chest pain. The assessment was not timed.
Review of an "Emergency Department Record, Physician Order Sheet" revealed orders for lab, cardiac monitor, pulse oximeter and oxygen. The order for oxygen was incomplete and did not indicate the liters of oxygen needed or parameters for oxygen saturation. The physician orders were not dated or timed.
Physician orders dated 07/18/2013, 9:30 p.m. revealed Patient #7, was admitted to the telemetry unit for observation to rule out Myocardial infarction (heart attack). There was an order for aspirin, Nitroglycerin 0.4 mg sublingual every 5 minutes (medications which cause vasodilation and which increased blood flow), Morphine 2 mgs IVP (pain medicine) every 4 hours prn (whenever needed).
Review of an "Emergency Nursing Record" dated 07/18/2013 revealed Patient #7 was not given any pain medication until 10:56 p.m., over 2 hours after presenting to the ER. There was no assessment of how severe the pain was. There was no documentation of any nitroglycerin being administered at all.
Review of EKG strips revealed one was printed on 07/18/2013 at 8:49 p.m. which indicated it was abnormal. The next EKG strip was not printed until 07/19/2013 at 4:13 a.m., over 7 hours later.
During an interview on 07/19/2013 at 6:15 p.m., Staff #2 confirmed the missing dates and times, lack of assessment, no nitroglycerin being administered and the late administration of pain medication. Staff #2 reported their in-house policy was for the telemetry technician's to print off a strip every 4 hours.

5. Review of an "Emergency Nursing Record" dated 07/18/2013 revealed Patient # 10 was a 53 year old male who presented to the ER with a complaint of chest pain at 0200 a.m. Patient #10 had a history of chronic obstructive pulmonary disease and schizophrenia. Patient #10 had a blood sugar of 362. The assessment revealed lab was drawn, intravenous fluid started, EKG performed, oxygen placed on and a chest X-ray performed.
Review of an "Emergency Physician Record" revealed an assessment performed by Staff #4 (MD) which was dated incorrectly 03/18/2013 and not timed. Staff #4 documented Patient #10 was having sternal pain which was radiating to the right side and he was borderline Diabetes mellitus. Staff #4 documented he interpreted the EKG strip but did not document the results in the designated area on the form. Underneath the progress section the time was left blank and Staff #4 documented the patient was chest pain free and 2 sets of Troponin were negative. The patient was advised to take medications for Diabetes mellitus.
Review of phyisician orders dated 07/18/13 at 2:55 a.m.revealed an order for 10 units of regular insulin to be administered but had no parameters of when to give. There was no documentation of the medication being administered by nursing.
During an interview on 07/19/2013 at 11:00 a.m, Staff #11 reported Staff #4 (MD) was on duty from 07/07-07/18/2013 (11 days/24 hours a day ).
Review of an "Emergency Nursing Record" dated 07/18/2013 revealed at 4:32 a.m., Patient #10 had a blood sugar reading of 371. There was no documentation of any intervention provided.
Review of a lab report dated 07/18/2013 at 5:55 a.m. revealed Patient #10 had a blood sugar reading of 218 (with reference range being 70-105). There was no mention of what was done about the blood sugar before discharging the patient.
Review of an "Emergency Nursing Record" dated 07/18/2013 at 6:30 a.m. revealed the patient was discharged home. A prescription for the diabetic agent Glucophage was attached.
During an interview on 07/19/2013 at 6:15 p.m., Staff #2 confirmed the missing dates and times, lack of assessment, problems with the blood sugar. Staff #2 reported she could not find any documentation showing insulin was administered to Patient #10.

Based on interview and record review the facility failed to ensure there was adequate medical and nursing personnel present in the ER at all times.
This deficient practice had the potential to affect all patients presenting to the ER.
Findings include:
1. Review of the " Emergency Room Register " for the timeframe from 07/08/2013 at 8:37 a.m. to 07/19/2013 10:40 a.m. there was 167 patients seen in the ER.
2. Review of the July 2013 physician schedule for the ER revealed from 07/07 to 07/31/2013 (25 days straight) the same two physicians were scheduled to work on a daily basis (Staff #3 and #4). There were no back-up physicians listed on the schedule in the event of an emergency.
During an interview on 07/19/2013 at 9:15 a.m., Staff #1 (CNO/Administrator) confirmed Staff #3 and #4 were the only two doctors working. The doctors stay in a house on campus and were on duty 24hours/7days. Staff #4 had been on duty alone from 07/07 to 07/18/2013 (12 days straight). Staff #3 took over around 7:00 p.m. on 07/18/2013 because he had to go and get his ACLS certification updated
During an interview on 07/19/2013 Staff #3 confirmed they Staff #4 ' s hours. Staff #3 reported he had taken over on yesterday 07/18/2013 and would work until 08/31/2013 (14 days straight). They wanted to work 5 days on and 5 days off that was not occurring. During the timeframe Staff #4 was on duty he was his back-up.
Review of the personnel file of Staff #3 revealed his ACLS certification expired on 07/01/2013. The new ACLS certification was renewed on 07/18/2013.
3. Review of the " Department of Nursing Daily Staffing Master " (time sheets) for July 2013 revealed the following:
*Nursing day shift was 7:00 a.m-7:00 p.m.;
*Nursing night shift was 7:00 p.m. -7:00 a.m.;
*Nursing day/evening shift for 1 LVN shift for the ER from 11:00 am-11:00 pm.
From 11:00 p.m.-11:00 a.m., a 12 hour timeframe the following nursing staff was documented for the ER:
*1 RN and one tech on 07/01/, 07/02, 07/03, 07/04, 07/05, 07/08, 07/09, 07/10, 07/11, 07/12, 07/15, 07/16, 07/17, and 07/18.
*1 RN on 07/13 and 07/14/2013.
During an interview on 07/19/2013 at 1:30 p.m. Staff #1 confirmed the above staffing numbers. Staff #1 reported her job duties was Administrator, CNO, orders supplies, human resources, over tuberculosis testing, and fills in when they are short of staff. Staff #2 reported her job duties was QA, UR, discharge planning and filling in when they are short of staff. They could not get all of their job duties done nor do quality work because of all the job duties.
4. Review of the Governing Board minutes dated 02/25/2013 revealed the following:
Recommendation/Action
" Staffing for the ER is being changed to two RN in the ER at nights and an RN and LVN during the day with an RN available in the building to relieve the RN. Telemetry technician ' s are also in the process of being hired. "
Follow-up
" Applications will be reviewed to hire additional full time RN ' s. Telemetry technician ' s have been hired and are currently being trained. "
These interventions were not implemented.