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Based on observation, review of documentation, and interview with staff, it was determined the Governing Body failed in its responsibilities. The Governing Body failed to ensure that the staff responsible for the conduct of the facility carried out their assigned functions.

Findings included:

The Governing Body failed to ensure that it has a well-organized service with a plan of authority and delineation of responsibilities for patient care. The CNO failed in his responsibilities for the service.

Cross Reference:
A0385 CFR 482.23
A0386 CFR 482.23(a)
A0393 CFR 482.23(b)(1)
A0395 CFR 482.23(b)(3)
A0397 CFR 482.23(b)(5)

Based on observation, review of documentation, and interview with staff, it was determined the Chief Nursing Officer (CNO) failed to have a well-organized service with a plan of authority and delineation of responsibilities for patient care. The CNO failed in its responsibilities for the service.

Findings included:

1) The CNO failed in his responsibilites. Cross reference A0386 CFR 482.23(a).

2) Staffing schedules revealed a Licensed Vocational Nurse was assigned as the House Supervisor for multiple days in May and June 2012. The CNO failed to follow facility policies and procedures. Cross Reference A0393 CFR 482.23(b)(1).

3) The nursing staff failed to evaluate and supervise the nursing care of each patient. Cross reference A0395 CFR 482.23(b)(3).

4) The CNO failed to have a licensed nurse as the Staffing Coordinator as outlined in the job description. Cross reference A0397 CFR 482.23(b)(5).

Based on review of documentation and interview with staff, it was determined the facility failed to ensure the patients received care in a safe setting.

Finding included:
Review of the facility's NURSING PRACTICE STANDARDS stated, "1. The nurse participates in quality of care activities as appropriate to the individual's position, education, and practice environment."

Review of the facility's NURSE STAFFING PLAN, Polices and Procedures, revealed "The Nursing Services Department at Renaissance Hospital supports the provision of quality patient care in a safe, cost effective manner by appropriately using qualified and skilled personnel."

Review of the Emergency Department (ED) patient's triage levels revealed the following:
Level 1- Cardiopulmonary Resuscitation (CPR)
Level 2- Emergent- Unstable, vitals compromised, will deteriorate if untreated
Level 3- Urgent- 2 sources, needs labs, EKG, Sutures, (ex: Abdominal Pain)
Level 4- 1 Resource- Needs Rx (prescription), Lab or X-ray, (ex: Ankle Pain)
Level 5- No Emergency- Needs little or No treatment, Medications or Contact

During a review of 4 medical records (#1, #2, #7, #8), the following was revealed:

1) Patient #7 was a 21 year old female who presented to the ED on 3/15/2012 at 4:35pm with lower abdominal and pelvic pains. The triage nurse stated on the assessment sheet the patient's pain level was a 10 on a scale of 1 to 10. Patient #1 was made a level 3 which was urgent. Nurse's notes revealed the patient was taken to bed 4 at 6:30pm per the physician's request. Further review of the ED form revealed the IV was started at 7:35pm (3 hours from the time the patient presented to the ED). The ED physician examined the patient and diagnosed a Ruptured Ovarian Cyst and Anemia. The physician also noted the patient had modified fluid in the pelvis. The physician documented at 8:45pm a consultation with a physician at Medical City Dallas Hospital. Nurse's documentation also revealed the patient received the first dose of pain medication at 10:25pm. Patient #7 received pain medication almost 6 hours after presenting to the ED. The Memorandum of Transfer (MOT) for the patient revealed the initial contact the Registered Nurse (RN) made with the receiving hospital (Medical City Dallas) was at 10:20pm. The RN contacted the receiving hospital 1 hour and 35 minutes after the ED physician consulted the physician at Medical City Dallas for the transfer. The MOT also revealed the patient was transferred by ambulance. The RN contacted the ambulance at 11:30pm (one hour and 10 minutes after notifying Medical City Dallas). The record revealed the patient was scheduled to arrive to Medical City Dallas at 11:59pm. Further review of the MOT revealed the patient was transferred due to "Needs OB/GYN Specialty" and that the transfer was an emergency. Patient #7 was in the ED at Renaissance Hospital in Terrell for 7 hours and 5 minutes before she was transferred to Medical City Dallas to a higher level of care. The facility delayed transfer to a more appropriate tertiary care setting.

2) Patient #8 was a 50 year old male who presented to the ED on 3/15/2012 at 5:30pm and stated on the triage form "bad food." Nurse's notes revealed patient #8 had a history of Hypertension and had not taken his medication in 2 days. The triage nurse documented at 5:30pm the blood pressure was 199/108, pulse 88, respirations 16, temperature was 98.6 and the oxygen saturation was 98%. Patient #8 was made a level 5. Nurse's notes revealed the patient complained of cramping and denied nausea, vomiting, and diarrhea. The nurse documented the patient's pain level was an 8. Further review revealed an IV was started at 7:50pm (2 hours and 20 minutes later). The physician examined patient #8 at 8:20pm and was diagnosed with Acute Pancreatitis, Hypokalemia, and Hypertension Urgency (2 hours and 50 minutes later after presenting the ED). The physician admitted the patient to the Intensive Care Unit (ICU).

3) Patient #1 was an 80 year old with a history of Lung Cancer who presented to the ED via a private vehicle with a family member on 5/2/2012 at 4:48pm unresponsive. The nurse noted a "0" for vital signs. CPR was initiated. At 5:24pm, the physician stopped the code and patient #1 had expired. The family member stated the patient started "breathing funny" just after having an injection for blood clots. At 6:47pm, the nurse noted the patient's Primary Care Physician called and stated the patient had a CT scan early that morning that showed a Pulmonary Embolism. All staff members at a code blue must have a current Basic Cardiac Pulmonary Resuscitation (CPR) course and that was not the case at this code. The Radiology Director did not have a current CPR card in the personnel file. This was confirmed by staff member #29 on the afternoon of 6/26/2012. The Radiology Director failed to take the renewal course. Staff member #28 who worked in the ED recorded the code blue and stated in an interview on 6/26/2012 at 4:50pm that the patient entered through the front entrance.

4) Patient record #2 was a 72 year old who presented to the ED on 5/2/2012 at 12:43pm with abdominal pain in the right groin area. The patient's pain level was a 10. The patient was made a level 3 which was urgent. The ED physician examined the patient at 12:50pm, and was diagnosed with Abdominal pain and Right Inguinal Hernia. The physician documented "will transfer." The documentation revealed the patient's IV was started at 12:52pm. The record revealed the patient was having testing done prior to being transferred. The patient also received pain medication at 1:00pm. Further review of the nurse's notes revealed the patient was transferred to Baylor Dallas Hospital at 4:45pm.

The above was confirmed in multiple interviews with the Chief Nursing Officer (CNO) on 6/25-26/2012.

Based on review of documentation and interview with staff, it was determined the facility failed to ensure the staff had the required licensure and / or certifications required.

Findings included:

Review of facility's RN HOUSE SUPERVISOR policy revealed, the staff member must be a Registered Nurse and have Advanced Cardiac Life Support certification. The policy also stated, "Responsible for promoting and maintaining quality patient care through effective management of the activities of the total patient care services during his/her assigned shift."

Review of the facility's NURSING ORGANIZATIONAL PLAN revealed, "House Supervisors: 1) Registered Nurse's with requisite clinical and managerial experience selected by the Chief Nursing Officer. Licensed Vocational Nurse: a. Licensed Vocational Nurses are assigned directly to patient care on medical and surgical units or may function as Charge Nurse under the overall responsibility of the Supervisor."

Review of the facility's NURSING PRACTICE STANDARDS stated, "1. The nurse participates in quality of care activities as appropriate to the individual's position, education, and practice environment."

Review of the facility's NURSE STAFFING PLAN, Polices and Procedures, revealed "The Nursing Services Department at Renaissance Hospital supports the provision of quality patient care in a safe, cost effective manner by appropriately using qualified and skilled personnel."

Review of the facility's job description for the ICU RN (ACLS) stated, "Registered Nurses working in ICU must be advance cardiac life support (ACLS) certified, a graduate of an accredited school of nursing, with 3 years RN experience within the last 48 months and 18 months of acute/critical care experience."

Review of the facility's job description for the Staffing Coordinator stated, "The nurse staffing coordinator is responsible for providing nursing staff for various medical care facilities ...Assisted and supervisor by the CNO and RN supervisor. Reviewing daily schedules and filling in for inadequate coverage is part of the daily (sic-responsibilities end here). The Education and Experience stated the Nurse Staffing Coordinator must have experience working with Nursing Department and may be a RN or LVN or (sic) and supervised by RN or CNO or decision making (sic). The personnel file of staff member #30 did not have any evidence of a RN or LVN license.

1. Review of the May 2012 House Supervisor staffing schedule revealed a LVN was on the scheduled 5 times as the RN House Supervisor. Review of the June schedule revealed the same LVN was on the schedule 4 times. There was no documentation in the personnel file the LVN having a current Advanced Cardiac Life Support (ACLS) certification.

2. Review of the June 2012 staffing schedule # 1 revealed 3 registered nurses worked as house supervisors with expired advance cardiac life support certification. 5 licensed vocational nurses worked in the intensive care unit without registered nurse supervision. 1 license vocational nurse worked as house supervisor four 7 pm- 7 am shifts in June 2012.

3. Review of the personnel file of Staff member #30 revealed the staff member did not have a RN or LVN license as outlined in the job description.

In an in-person interview conducted with the staff # 10 and staff # 13 on the afternoon of 06/25/12, it was confirmed that licensed vocational nurses had worked in intensive care unit without registered nurse supervision.

In an in-person interview conducted with the Chief Nurse Officer on the afternoon of 06/25/12, it was confirmed that LVN's had been assigned to work as the House supervisor on the 7:00pm- 7:00am shifts. The facility was unable to provide documentation the RNs had the requirement certifications according to the job description. The CNO confirmed all the findings above.

Based on review of documentation and interview with staff, it was determined the facility scheduled a Licensed Vocational Nurse (LVN) as the Registered Nurse (RN) House Supervisor. The facility failed to follow its own policies and procedures.

Findings included:

Review of facility's RN HOUSE SUPERVISOR policy revealed, the staff member must be a Registered Nurse and have Advanced Cardiac Life Support certification. The policy also stated, "Responsible for promoting and maintaining quality patient care through effective management of the activities of the total patient care services during his/her assigned shift."

Review of the facility's NURSING ORGANIZATIONAL PLAN revealed, "House Supervisors: 1) Registered Nurse's with requisite clinical and managerial experience selected by the Chief Nursing Officer. Licensed Vocational Nurse: a. Licensed Vocational Nurses are assigned directly to patient care on medical and surgical units or may function as Charge Nurse under the overall responsibility of the Supervisor."

Review of the facility's NURSING PRACTICE STANDARDS stated, "1. The nurse participates in quality of care activities as appropriate to the individual's position, education, and practice environment."

Review of the facility's NURSE STAFFING PLAN, Polices and Procedures, revealed "The Nursing Services Department at Renaissance Hospital supports the provision of quality patient care in a safe, cost effective manner by appropriately using qualified and skilled personnel."

Review of the facility's job description for the ICU RN (ACLS) stated, "Registered Nurse's working in ICU must be advance cardiac life support (ACLS) certified, a graduate of an accredited school of nursing, with 3 years RN experience within the last 48 months and 18 months of acute/critical care experience."

1. Review of the May 2012 House Supervisor staffing schedule revealed a LVN was on the scheduled 5 times as the RN House Supervisor. Review of the June schedule revealed the same LVN was on the schedule 4 times. There was no documentation in the personnel file the LVN having a current Advanced Cardiac Life Support (ACLS) certification.

2. Review of the June 2012 staffing schedule revealed, 3 registered nurses worked as house supervisors with expired advance cardiac life support certification. 5 license vocational nurses worked in the intensive care unit without register nurse supervision. 1 license vocational nurse worked as house supervisor four 7 pm- 7 am shifts in June 2012.

In an in-person interview conducted with the staff # 10 and staff # 13 on the afternoon of 06/25/12 at the facility, it was confirmed that license vocational nurses had worked in intensive care unit without direct registered nurse supervision.

In an in-person interview conducted with the Chief Nurse Officer on the afternoon of 06/25/12, it was confirmed that LVN's had been assigned to work as the House supervisor on the 7:00pm- 7:00am shifts. The facility was unable to provide documentation the RN's had the requirement certifications according to the job description. The CNO confirmed all the findings above.

Based on review of documentation and interview with staff, it was determined the Registered Nurse failed to supervise and evaluate the care of patients in the Emergency Department.

Finding included:
Review of the NURSING PRACTICE STANDARDS stated, "1. The nurse participates in quality of care activities as appropriate to the individual's position, education, and practice environment."

Review of the NURSE STAFFING PLAN, Polices and Procedures, revealed "The Nursing Services Department at Renaissance Hospital supports the provision of quality patient care in a safe, cost effective manner by appropriately using qualified and skilled personnel."

Review of the Emergency Department (ED) patient's triage levels revealed the following:
Level 1- Cardiopulmonary Resuscitation (CPR)
Level 2- Emergent- Unstable, vitals compromised, will deteriorate if untreated
Level 3- Urgent- 2 sources, needs labs, EKG, Sutures, (ex: Abdominal Pain)
Level 4- 1 Resource- Needs Rx (prescription), Lab or X-ray, (ex: Ankle Pain)
Level 5- No Emergency- Needs little or No treatment, Medications or Contact

During a review of 4 medical records (#1, #2, #7, #8), the following was revealed:

1) Patient #7 was a 21 year old female who presented to the ED on 3/15/2012 at 4:35pm with lower abdominal and pelvic pains. The triage nurse stated on the assessment sheet the patient's pain level was a 10 on a scale of 1 to 10. Patient #1 was made a level 3 which was urgent. Nurse's notes revealed the patient was taken to bed 4 at 6:30pm per the physician's request. Further review of the ED form revealed an IV was started at 7:35pm (3 hours from the time the patient presented to the ED). The ED physician examined the patient and was diagnosed with a Ruptured Ovarian Cyst and Anemia. The physician also noted the patient had modified fluid in the pelvis. The physician documented at 8:45pm a consultation with a physician at Medical City Dallas Hospital. Nurse's documentation also revealed the patient received the first dose of pain medication at 10:25pm. Patient #7 received pain medication almost 6 hours after presenting to the ED. The Memorandum of Transfer (MOT) for the patient revealed the initial contact the Registered Nurse (RN) made with the receiving hospital (Medical City Dallas) was at 10:20pm. The RN contacted the receiving hospital 1 hour and 35 minutes after the ED physician consulted the physician at Medical City Dallas for the transfer. The MOT also revealed the patient was transferred by ambulance. The RN contacted the ambulance at 11:30pm (one hour and 10 minutes after notifying Medical City Dallas). The record revealed the patient was scheduled to arrive to Medical City Dallas at 11:59pm. Further review of the MOT revealed the patient was transferred due to "Needs OB/GYN Specialty" and that the transfer was an emergency. Patient #7 was in the ED at Renaissance Hospital in Terrell for 7 hours and 5 minutes before she was transferred to Medical City Dallas to a higher level of care. The facility delayed transfer to a more appropriate tertiary setting.

2) Patient #8 was a 50 year old male who presented to the ED on 3/15/2012 at 5:30pm and stated on the triage form "bad food." Nurse's notes revealed patient #8 had a history of Hypertension and had not taken his medication in 2 days. The triage nurse documented at 5:30pm the blood pressure was 199/108, pulse 88, respirations 16, temperature was 98.6 and the oxygen saturation was 98%. Patient #8 was made a level 5. Nurse's notes revealed the patient complained of cramping and denied nausea, vomiting, and diarrhea. The nurse documented the patient's pain level was an 8. Further review revealed an IV was started at 7:50pm (2 hours and 20 minutes later). The physician examined patient #8 at 8:20pm and was diagnosed with Acute Pancreatitis, Hypokalemia, and Hypertension Urgency (2 hours and 50 minutes later after presenting the ED). The physician admitted the patient to the Intensive Care Unit (ICU).

3) Patient #1 was an 80 year old female with a history of Lung Cancer who presented to the ED via a private vehicle with a family member on 5/2/2012 at 4:48pm unresponsive. The nurse noted a "0" for vital signs. CPR was initiated. At 5:24pm, the physician stopped the code and patient #1 had expired. The family member stated the patient started "breathing funny" just after having an injection for blood clots. At 6:47pm, the nurse noted the patient's Primary Care Physician called and stated the patient had a CT scan early that morning that showed a Pulmonary Embolism. All staff members at a code blue must have a current Basic Cardiac Pulmonary Resuscitation (CPR) course and that was not the case at this code. The Radiology Director did not have a current CPR card in the personnel file. This was confirmed by staff member #29 on the afternoon of 6/26/2012. The Radiology Director failed to take the renewal course. Staff member #28 who worked in the ED recorded the code blue and stated in an interview on 6/26/2012 at 4:50pm that the patient entered through the front entrance.

4) Patient record #2 was a 72 year old male who presented to the ED on 5/2/2012 at 12:43pm with abdominal pain in the right groin area. The patient's pain level was a 10. The patient was made a level 3 which was urgent. The ED physician examined the patient at 12:50pm, and was diagnosed with Abdominal pain and Right Inguinal Hernia. The physician documented "will transfer." The documentation revealed the patient's IV was started at 12:52pm. The record revealed the patient was having testing done prior to being transferred. The patient also received pain medication at 1:00pm. Further review of the nurse's notes revealed the patient was transferred to Baylor Dallas Hospital at 4:45pm.

The above was confirmed in multiple interviews with the Chief Nursing Officer (CNO) on 6/25-26/2012.

Based on review of documentation and interview with staff, it was determined the CNO failed to staff the position of Staffing Coordinator with a licensed nurse as per the facility's job description.

Findings included:

Review of NURSE STAFFING PLAN, Polices and Procedures, Revised March 1, 2010, page 1 of 4 revealed "The Nursing Services Department at Renaissance Hospital supports the provision of quality patient care in a safe, cost effective manner by appropriately using qualified and skilled personnel."

Review of the job description for the Staffing Coordinator stated, "The nurse staffing coordinator is responsible for providing nursing staff for various medical care facilities ...Assisted and supervisor by the CNO and RN supervisor. Reviewing daily schedules and filling in for inadequate coverage is part of the daily (sic-responsibilities end here). The Education and Experience stated the Nurse Staffing Coordinator must have experience working with Nursing Department and may be a RN or LVN or (sic) and supervised by RN or CNO or decision making (sic). The personnel file of staff member #30 did not have any evidence of a RN or LVN license.

The responsibilities of the Staff Coordinator stated was to fill in for inadequated coverage and the staff member may be a RN or LVN. The Staff Coordintor in the current position at the facility did not have a RN or LVN license. The staff member does not meet the responsibilities per the job description. The staff member would not be able to fill in for inadequate coverage as the staff member would not be able to assess patients, administer medications, etc. in a safe manner. This was a patient safety issue since the staff member did not have a RN or LVN license.

The facility had unqualified personnel as Staffing Coordinator.

The above was confirmed in multiple interviews with the Chief Nursing Officer (CNO) on 6/25-26/2012.

Based on observation, review of documentation, and interview with staff, it was determined the facility had expired medication available for patient use.

Findings included:

During a brief tour of the Surgery Department on 6/25/2012 at 3:25pm with the CNO and the Surgical Assistant, the following was revealed:

1. Demerol 50mg/ml, one vial, expired 3/2012.
2. Morphine 10mg/ml, three vials, expired 4/2012.
3. Versed 5mg/5ml, one vial, expired 3/2012.

The above was confirmed with the Chief Nursing Officer (CNO) on 6/25/2012 at 3:25pm. In an interview the afternoon of 6/26/2012 with the Pharmacist, it was confirmed the Pharmacy Department was responsible for checking and removing expired medications from the units.

Based on observation, review of documentation, and interview with staff, it was determined the Chief Nursing Officer (CNO) failed to ensure the nursing staff proper documentation of narcotics of the missing narcotics.

Findings included:

1. During a brief tour of the ED on 6/25/2012 at 3:00pm with the CNO revealed the narcotic count for the Morphine did not match the number of vials in the cabinet. During a the narcotic count with the CNO, the documentation revealed that Morphine 2 mg had 15 vials. The count in the cabinet revealed 13 vials. Further review revealed Morphine 4mg, the narcotic sheet revealed 8 vials and the count in the cabinet revealed 10 vials. This was confirmed with staff member #31 who had possession of the narcotic keys and stated it was a mistake and documented on the wrong Morphine line. The nursing staff failed to properly document narcotics and keep and accurate count. In the same interview the CNO also confirmed the finding's above.

2. A review of the occurrence reports from January 2012 to June 2012, the facility was unable to provide the report for the missing narcotics. In multiple interviews with the CNO on 6/25-26/2012, staff member confirmed the occurrence happened at the beginning of the year but could not remember the exact date. The CNO recalled that the staff members involved who worked that shift had labs drawn. The CNO was unable to provide documentation of the lab reports or the date the lab was drawn.