HospitalInspections.org

Based on observation, review of records and interviews, the Governing Body did not:

1)Monitor to ensure safe patient care was provided by failing to ensure the rights of each patient were protected.
Cross Reference A0115

2)Failed to ensure the hospital implemented and enforced policies and procedures to ensure the hospital is in compliance with 482.11 Compliance With Federal Laws, Patient Rights, EMTALA (Emergency Medical Treatment and Active Labor Act) and Emergency Services.
Cross Reference A2400 and A1100

3) Failed to ensure the medical staff is accountable to the Governing Body for the quality of care provided to patients by enforcing the Medical Staff Bylaws.
Cross Reference A0353

Based on observation, record reviews and interviews, the hospital failed to ensure each patient's rights were promoted and protected.

Findings Included:

Cross Refer: A0117 and A0144

Based on observation, interviews and record reviews, the hospital did not meet the emergency needs of patients presenting to the ED by failing to:

1) Ensure all patients presenting to the Emergency Department (ED) from 02/20/08 to 09/23/11 received an appropriate medical screening examination to determine whether or not an emergency medical condition existed, stabilizing treatment was provided and appropriate transfers were initiated if needed. The Registered Nurse's (RN's) who performed the medical screening examinations (MSE's) in the ED were not appointed through the hospital's credentialing process as Qualified Medical Providers (QMP). The RN's performing MSE's were not recommended by the Medical Staff, nor appointed by the Governing Board to provide MSE as QMP.

Cross refer to Tag-A0022.

2) Adopt and enforce a hospital policy to ensure EMTALA requirements are met in order to provide for all patients presenting to the ED for emergency care an appropriate medical screening examination by a QMP to determine whether or not an emergency medical condition exists, provide stabilizing treatment and appropriate transfers.

Cross Refer to Tag A-2400.

3) Ensure an appropriate transfer is initiated for patient's who are transferred to another facility for further screening and/or stabilizing treatment. The medical records did not reflect continued monitoring and documentation of stabilization prior to transfer after a MSE was performed and a possible EMC (emergency medical condition) was determined to exist.

Cross refer to Tag A-2409.

4) Did not ensure appropriate emergency signage was posted at the front entrance of the hospital or the Emergency Department (ED) entrance that was prominent and conspicuous and likely to be noticed by all individuals entering the ED or hospital which specified the rights of individuals with respect to examination and treatment of emergency medical conditions and women in labor as required by the Emergency Medical Treatment and Labor Act (EMTALA).

Cross refer to Tag A-2402.

5) Did not ensure an adequate on-call list of specialty physicians and emergency physicians and their alternates for 9 of 9 months (from 01/01/11 - 09/27/11) was maintained and posted. In addition the hospital did not have policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control or if the on call physician is permitted to have simultaneous on-call duties.

Cross refer to Tag-2404.

6) Ensure the Emergency Room Log was accurate and complete for 43 of 43 months (February 2008 - September 2011) in that it did not contain the required elements on each individual presenting to the ER seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, staiblized and transferred, and/or discharged.

Cross refer to Tag-2405.


These findings have the potential to cause harm to the patient population and community presenting to the facility seeking help for an emergent medical condition and stabilizing treatment.

Based on observation, record review and interview, the hospital emergency suite does not comply with 25 Texas Administrative Code, Part 1, §133.161(a)(1)(A) of Hospital Licensing Rules (relating to Requirements for Buildings in Which Existing Licensed Hospitals are Located) or §133.163(f) of this title, and the following:

1. The hospital does not have a fully functioning emergency treatment area to treat emergency medical conditions in the event someone presents to the hospital with an emergent condition. The hospital signage indicates the facility is a hospital with emergency capabilities.

2. The emergency room doors are locked at night and does not have the required Emergency Room Signage that is clearly visible to direct patients where to present or how to contact someone for help in the event of an emergency medical condition.

3. The emergency room does not have age appropriate supplies and equipment. The hospital did not have basic infant and pediatric age appropriate supplies and equipment available and in readiness for use for infant and pediatric patients that present to the hospital ER in the event of a life threatening emergency.

These findings have the potential to cause harm to the patient population and community presenting to the facility seeking help for an emergent medical condition and stabilizing treatment.

Findings Included:

1) On arrival at the hospital at 8:30 A.M. the surveyors observed the hospital is located adjacent to and clearly visible from a major interstate highway in a highly populated area of Dallas. Located across from the hospital is a large multi-family apartment complex and approximately one-quarter mile down the road from the hospital, an elementary school is located. The surveyors also observed numerous businesses and shopping complexes close to the hospital.

The surveyors observed large signage that was clearly visible at the top of the building and in front of the building entrance that stated "Triumph Hospital." There was a sign posted at the driveway entrance into the hospital parking lot showed "Ambulance" entrance. Located at the southwest corner of the building, a pole with the words "Emergency" was partially obscured at the bottom of the pole by large foliage. Another sign was observed with the words "Ambulance" located in the parking lot area adjacent to the pole with "Emergency" on it.

During a tour of the facility on 09/27/11 at approximately 10:00 A.M., the surveyors toured the outside of the building. The outside entrance to the emergency room had a large sign posted above the doors that showed "Ambulance" entrance. A sign was posted on the glass doors that showed, "AUTHORIZED PERSONNEL ONLY. Due to patient safety and privacy, we are asking all non-employees or contracted agents to use the front entrance. Cafeteria visitors; we appreciate your business and welcome you. This directive is about our patients and their needs. FOR PATIENT SAFETY; HOSPITAL STAFF AND CONTRACTED AGENTS ONLY, ALL OTHERS, PLEASE USE THE FRONT ENTRANCE."
A call box with a push button was located adjacent to the door entry with no instructions posted. The entrance did not have any signage directing the public on how to contact anyone in the event of an emergency medical condition. The surveyors waited approximately 4 minutes before any hospital personnel appeared and asked if they needed any assistance.

The emergency room entrance and the front entrance of the hospital did not have any of the required signs posted specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA - Emergency Medical Treatment and Active Labor Act.)

During a separate tour of the facility at 3:13 P.M. on 09/27/11, the surveyors returned to the ambulance entrance of the hospital. The surveyors did not observe any personnel available. The surveyors then pressed the button and could hear a telephone ringing sound. After 4 rings, a person answered the call. The person asked, "Can I help you?" The surveyor stated, "I have an emergency. Can someone help me?" At 3:18 P.M., a Security Guard (Personnel #33) appeared at the door and asked if we needed help. Personnel #33 was asked if this was an emergency, what would he do? He stated he would call the House Supervisor. He was then asked to contact the House Supervisor. He stated he would get the supervisor and be right back.
At 3:20 P.M., Personnel #33 returned with the Nurse Manager (Personnel #6) and CCO (Chief Clinical Officer, Personnel #2). Personnel #6 was asked if this is the emergency entrance. He stated it is for ambulances. He was asked how would someone who is presenting for emergency care treatment know to contact someone for assistance. He stated that most people would come through the front entrance of the hospital. He was asked if someone presented to the emergency entrance, how would they know how to get help. He stated they could press the button on the call box. He was then asked if there are any instructions by the call box or any signs posted designating the call box as a way to contact someone in the event of an emergency. He stated, "No." He was then asked if there was any signs showing the emergency entrance. He stated, "Yes." He pointed to the pole at the corner of the building. He was asked if it is partially obscured by a plant. He stated, "Yes." He also pointed out the "Ambulance" sign in the parking lot and above the side entrance. He was then asked about the "Authorized Personnel Only" sign posted on the glass doors. He stated that the sign was there to keep people from coming in the side door. Personnel #6 was asked if a nurse is assigned to the emergency room. He stated, "Yes. The House Supervisor." He was asked if there are any signs at the front door of the hospital indicating to patient's presenting with an emergency where to go. He stated, "No." He was asked who answers the call bell at the entrance to the emergency area. He stated, "A unit clerk on the patient care unit who is scheduled 24/7."

2) Personnel #33 was asked if the doors are ever locked. He stated they are locked at night.

The surveyors then entered the emergency entrance doors. Personnel #6 was asked where the emergency treatment room is located. He stated it is located in the first room to the right by the emergency entrance doors. The door had one small EMTALA sign affixed to the door which is not clearly visible from 20 feet away. The surveyors then attempted to open the door and the door was locked. Personnel #6 was then asked to open the door. Personnel #6 did not have a key and asked Personnel #33 to open the door. Personnel #33 did not have a key to the door and left to go obtain a key. At this time, a Radiology Technician (Personnel #18) came out of Radiology and stated he had a key and opened the door with his key.

The "Emergency Services" Policies and Procedures "PC 450 Emergency Services" dated "12/2008" requires, "It is the policy...to provide for the assessment of patients presenting for emergency care. The facility shall perform a medical screening evaluation (MSE) to determine if an emergency medical condition (EMC) exists and if further care and treatment is needed...The nursing supervisors must be educated and deemed competent regarding EMTALA, state regulations and the policies pertaining to the Emergency Treatment area, to be designated a qualified medical personnel..."

The "Clinical" Policy "Plan for the Provision of Patient Care" dated "April 2011" requires, "The hospital is a full services provider of specialized services available twenty-four (24) hours/day, seven (7) days a week...The Hospital CEO (Chief Executive Officer) is directly responsible for the operations...direct reports are...7) Emergency Services...Providing a safe, functional, and effective environment for patients, visitors, staff...Patient Care Areas and Departments...Emergency Services...The hours of operation of the Front Desk Receptionist are from 8 a.m. to 8 p.m. weekdays and weekends..." The Plan for Provision of Patient Care did not address the Scope of Services, Staffing or Personnel requirements for Emergency Services.

The "Medical Staff Bylaws" dated "08/2010" defines emergency as "a condition in which serious permanent harm would result to a patient or in which the life of a patient is in immediate danger, and any delay in administering treatment would add to that danger..." The Medical Staff Bylaws did not address the provision of Emergency Services.

The "Operational Bylaws" dated "06/30/09" did not address the provision of Emergency Services.

The "Governing Board Meeting Minutes" dated "February 25, 2010" reflected "Policies and Procedures...The Board was given the opportunity to review the policies and procedures for the hospital. These had all been through the MEC (Medical Executive Committee) on 02/05/10...Upon recommendation of the MEC, the Board approved the policies and procedures noted below...Emergency Services...Hospital Wide Plans...Emergency Services..."


3) During a tour of the ER (emergency room) treatment area at 3:30 P.M. on 09/27/11, the surveyors observed one crash cart and a supply cart. Upon inspection of the crash cart and supply cart, the surveyors did not observe any emergency or stabilizing equipment or supplies for infants or pediatric patients.

Personnel #6 was interviewed at this time and verified the hospital did not have any infant or pediatric emergency or stabilizing equipment. He was asked if the hospital has a Broselow's Bag (a pediatric resuscitation system which is a bag containing emergency resuscitation equipment), Pediatric medication box or pediatric emergency medications, or pediatric airway box or any capabilities to provide cardiac or oxygen monitoring for pediatric patients. He stated, "No." He was asked if hospital personnel have and maintain PALS (Pediatric Advanced Life Support) certification. He stated "No. We are an adult hospital and licensed as a specialty hospital. We are not required to treat pediatric patients or have PALS."

He was asked what the hospital personnel would do in the event someone presented to the hospital with an infant or pediatric emergency. He stated the hospital only treats the adult population and only keeps adult emergency supplies and equipment. He stated "We are a specialty hospital and only treat adults." He was asked if visitors or family members ever visit patients with children. He stated, "Yes." He was asked if there is a multi-family apartment complex across the street from the hospital which possibly houses children. He stated, "Yes."

He was then asked how would hospital personnel treat and stabilize an infant or pediatric patient in the event of an emergency. He stated hospital personnel would call 911. He was then asked what would the personnel do to treat the pediatric patient while awaiting the arrival of EMS (emergency medical services). He did not answer.

At approximately 4:30 P.M. on 09/28/11, the surveyors observed a female guest sitting in the front lobby with 3 young children who all appeared to be pre-school age. The children were laughing and playing with each other and climbing on the chairs.

The "Emergency Services" Policies and Procedures "PC 450 Emergency Services" dated "12/2008" requires, "It is the policy...to provide for the assessment of patients presenting for emergency care. The facility shall perform a medical screening evaluation (MSE) to determine if an emergency medical condition (EMC) exists and if further care and treatment is needed...Purpose: To outline the roles and responsibilities of the emergency treatment area and to assure appropriate supplies and equipment to safely care for those that present for emergency care...The Emergency Treatment Area renders life-sustaining treatment to those who present to the hospital for emergency care in order to stabilize emergencies...and, if appropriate, arrange for transfer to the nearest hospital capable of providing the needed services...An emergency medical condition is defined as "a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individuals health (or the health of an unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs...Adequate supplies and equipment will be available and ready for use in this area...Emergency call system, oxygen, mechanical ventilatory assistance equipment - including airways, manual breathing bag and mask, cardiac defibrillator, laryngoscopes and endotracheal tubes, suction equipment, emergency drugs and supplies specified by the medical staff..."

The hospital policy "Cardiopulmonary Resuscitation (Pediatric Patient)" not dated, requires "All Nursing Personnel are required to be certified in CPR, preferable American Heart Association (AHA) Standards for Pediatric Patients. Immediate actions are to: 1. Call Code over paging system...2. Designate a person to prepare emergency equipment including suction, cardiac board, resuscitation bag, oxygen equipment, broslow bag and pediatric emergency drug box. 3. Begin external cardiac compression...4. Establish an airway per AHA and PALS (Pediatric Advanced Life Support) Guidelines: Ventilate with bag-valve mask...establish venous access...push medications as ordered...after stabilization of patient arrange for transfer to the nearest hospital capable of providing the needed services..."

The hospital policy "Code Blue" dated "February 2010" requires "To assure optimal patient care during a medical crises, respiratory distress, respiratory arrest or cardiac arrest...All patient care staff will maintain current CPR (cardiopulmonary resuscitation) certification. Advanced Cardiac Life Support (ACLS), PALS certification (as appropriate) is required for all licensed nurses responding to a Code Blue or working in a critical area...An emergency medication box, pediatric compatible defibrillator and a pediatric airway box will be available...ACLS/PALS RN's will manage the Code Blue..."

The "Clinical" Policy "Plan for the Provision of Patient Care" dated "April 2011" requires, "The hospital is a full services provider of specialized services available twenty-four (24) hours/day, seven (7) days a week...The Hospital CEO (Chief Executive Officer) is directly responsible for the operations...direct reports are...7) Emergency Services...Providing a safe, functional, and effective environment for patients, visitors, staff...Patient Care Areas and Departments...Emergency Services...The hours of operation of the Front Desk Receptionist are from 8 a.m. to 8 p.m. weekdays and weekends..." The Plan for Provision of Patient Care did not address the Scope of Services, Staffing or Personnel requirements for Emergency Services.

Based on record review and interview the facility failed to assure that all personnel were licensed as required by regulation. These findings were noted in 6 out of 6 nursing personnel records (#HD 1 through #HD 6) reviewed. These findings have the potential to cause harm to all patients receiving care in the facility.

Finding included:

Review of the nursing personnel records of staff # HD 1, #HD 2, #HD 3, #HD 4, #HD 5, and #HD 6 revealed that the facility had only verified the nurse's licensure status at the Texas State Board of Nursing web site by searching the nurse's name. The site was not searched by either licensure number or Social Security Number and date of birth in order to verify that the nurse working was the same licensed nurse found on the board site. (When the site was searched for a nurse by name only, a list of nurses with that name is all that is available to the person running the verification. In order to obtain the nurse's license number, the site must be searched by either the license or social security number and the nurse's date of birth.) In review of the hospital record, the personnel used a black marker to mark out the names that they believed were not the person employed or contracted by the facility.

Review of the Texas Board of Nursing website Texas Nursing Bulletin Volume 39, No 3 dated July 2008 stated, "After September 1, 2008 Nurses and employers should go to the agency website at www.bon.state.tx.us and verify licenses on line. The verification, once printed, will resemble a license and will allow the nurse to have the document laminated for the purpose of carrying the license with them."

Interview with staff #2 on 09/27/2011 at 2:30 PM, confirmed the hospital did not verify the nurse's licensure status by license number or social security number and date of birth. In addition, Staff #2 confirmed the nurse had not been required to show proof of licensure with the license number and the correct expiration date as required by the Texas Board of Nursing.

Based on record review and interview, the hospital failed to ensure 12 of 12 patients (Patients #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and #23) who presented to the emergency room (ER) for emergency care for 18 of 18 months (April 2010 through September 2011) did not contain a signed copy of the hospital's patient's bill of rights from each patient prior to evaluation or treatment.

Findings Included:

Review of the following patient emergency room medical records reflected:

Patient #12 presented to the ER on 03/05/11 for the chief complaint abdominal pain for 2 weeks. The MR did not contain a signed copy of the hospital's patient's bill of rights from the patient prior to evaluation and treatment.

Patient #13 presented to the ER on 12/20/10 for the chief complaint of tingling down the arm and decreased appetite. The MR did not contain a signed copy of the hospital's patient's bill of rights from the patient prior to evaluation and treatment.

Patient #14 presented to the ER on 09/23/11 for the chief complaint of headache post fall. The MR did not contain a signed copy of the hospital's patient's bill of rights from the patient prior to evaluation and treatment.

Patient #15 presented to the ER on 07/06/11 for the chief complaint of left arm pain radiating with pressure to the chest. The MR did not contain a signed copy of the hospital's patient's bill of rights from the patient prior to evaluation and treatment.

Patient #16 presented to the ER on 05/26/11 for the chief complaint of radiating left arm pain. The MR did not contain a signed copy of the hospital's patient's bill of rights from the patient prior to evaluation and treatment.

Patient #17 presented to the ER on 05/20/11 for the chief complaint of chest pain. The MR did not contain a signed copy of the hospital's patient's bill of rights from the patient prior to evaluation and treatment.

Patient #18 presented to the ER on 04/27/11 for the chief complaint of right supraorbital headache. The MR did not contain a signed copy of the hospital's patient's bill of rights from the patient prior to evaluation and treatment.

Patient #19 presented to the ER on 04/07/11 for the chief complaint of high blood pressure. The MR did not contain a signed copy of the hospital's patient's bill of rights from the patient prior to evaluation and treatment.

Patient #20 presented to the ER on 02/05/11 for the chief complaint of left shoulder pain after fall. The MR did not contain a signed copy of the hospital's patient's bill of rights from the patient prior to evaluation and treatment.

Patient #21 presented to the ER on 10/05/10 for the chief complaint of left upper quadrant abdominal pain. The MR did not contain a signed copy of the hospital's patient's bill of rights from the patient prior to evaluation and treatment.

Patient #22 presented to the ER on 04/07/10 for the chief complaint of dizziness and light headed accompanied by nausea and vomiting. The MR did not contain a signed copy of the hospital's patient's bill of rights from the patient prior to evaluation and treatment.

Patient #23 presented to the ER on 04/01/10 for the chief complaint of weakness and dizziness. The MR did not contain a signed copy of the hospital's patient's bill of rights from the patient prior to evaluation and treatment.

During an interview at 10:30 A.M. on 09/29/11 with Personnel #35, she verified the patient ER medical records did not contain the required documentation and did not follow hospital policies and procedures.

Based on observation, interview, and record review, the facility failed to;
(A) ensure that the Medical Director of the Dialysis Unit reviewed the results of the water quality testing and directed corrective action when indicated. In addition there was no evidence the reports of equipment testing were trended and analyzed over time through the hospitals Quality Improvement meeting. This deficient practice created the potential of harm to all patients that were dialyzed in this dialysis unit. Citing 8 of 8 months of equipment and machines, laboratory reports. and Quality Improvement Committee minutes reviewed.
(B) ensure bicarbonate was timed and initialed when opened and was discarded after 24 hours from opening. These findings have the potential to cause harm to patients by the use of expired bicarbonate.
(C) determine if administration of the hepatitis B vaccine was indicated for 1 out of 1 patient (#HD 4 ). This patients was hepatitis antibody negative (HBsAb meaning the patient is not protected for the hepatitis). These findings have the potential to cause harm to all patients receiving care in the dialysis unit that are not immune to the hepatitis B virus.
(D) provide evidence that they provided 1 out of 1 patient (#HD 4) Hepatitis Antibody negative patient literature describing the risk and benefits of the hepatitis B vaccination in order for the patient to make an informed decision to take the vaccination. These finding have the potential to cause harm to all high risk dialysis patients that are antibody negative by failure to give the hepatitis B vaccine information in order for them to make an informed decision.
(E) provide evidence they screened for or knew of the hepatitis B surface antigen (HBsAg) prior to admission or drawn at the time of admission for 6 out of 6 dialysis patient records reviewed (#HD 1, #HD 2, #HD 3, #HD 4, #HD 5, and #HD 6). These findings have the potential to cause harm to all non immune patients being treated in the dialysis unit at the facility by exposing them to unknown hepatitis B positive patient equipment. In addition the facility failed to ensure and provide evidence that the dialysis machines used by these unknown patients were given intermediate level disinfection prior to use by another patient.
(F) establish and follow an appropriate plan of care for the assessment and establishment of the estimated dry weight (EDW) for 2 (#HD1 and #HD2) out of 6 dialysis patients. These findings have the potential to cause harm to all patients receiving dialysis at the facility by failing to evaluate the effectiveness of the patient's dialysis treatment.
(G) provide adequate space for the separation of clean and dirty for the dialysis unit. These findings have the potential to cause cross contamination of clean equipment and supplies which could increase the risk of infection to the patient by allowing clean equipment to come in contact with a dirty equipment and supplies environment.

(A) Findings Medical Director:

Review of microbiological culture reports and endotoxin (LAL) reports on 09/27/2011 or the dialysis machine 2008 K2, serial Number (SN) #161430, 2008K SN #168069 and 2008K SN #168052, and portable RO systems SN # 6497. SN #1291009 and SN #129018: There was no documentation that the Medical Director reviewed results and/or advised corrective action if one was required for abnormal results.

Review of the hospital's organizational chart revealed the dialysis unit was not on the chart and there was no evidence the unit was Directed by a Medical Director who held privileges at the facility.

Review of the Quality Improvement Committee (QA) minutes for the months of January - August 2011 revealed the only QA dialysis data presented to the QA Committee was the percent of rejection of the portable RO machines at the hospital.

Interview with Staff #3 on 09/28/2011, confirmed there was no evidence of the review by the Medical Director. In addition staff #3 confirmed there was no evidence the culture and Endotoxin (LAL) reports were taken to the committee and information was presented to the Quality Improvement Committee meetings. In addition staff #2 confirmed the facility had not appointed a Medical Director and the Medical Director was not part of the Quality Improvement Committee. Staff # 2 and #3 stated they have a new dialysis contractor that began providing service on 08/29/2011 and they will begin trending with the new contractor.

(B) Findings Bicarbonate:

During tour of the facility on 09/27/2011 at 09:00 a.m., an opened jug of bicarbonate was found sitting on the floor of the dialysis machine rack. The jug was dated but was not timed or initialed in order to determine who and what time it was opened.

Interview with staff #2 on 09/27/2011 at 09:00 a.m., confirmed the jug of bicarbonate was not initialed by the person opening it or timed.

(C) Findings for Hepatitis B Vaccine:
On 09/29/11 review of #HD 4's medical record revealed that on 08/19/2011 the facility received results of the Hepatitis B antibody laboratory results indicating the patient's Hepatitis Antibody level (HBsAb) was non-reactive. There was no evidence documented in the medical record that indicated the physician or patient was notified of the antibody status and provided the immunization if indicated.

Interview with staff #4 on 09/29/2011 at 2:30 p.m. revealed the facility did not have a process in place to provide the patients with the Hepatitis B immunization.

(D) Hepatitis B Literature Findings:
On 09/29/11 review of #HD 4's medical record revealed that on 08/19/2011 the facility received results of the Hepatitis B antibody laboratory results indicating the patient's Hepatitis Antibody level (HBsAb) was non-reactive. There was no evidence documented the patient was provided the literature describing the risk and benefits of the hepatitis B vaccination in order for the patients to make an informed decision of whether of not to take the vaccination to prevent contacting the Hepatitis B virus.

Interview of staff #4 on 09/29/2011 at 2:30 p.m., confirmed there was no evidence documented in the medical record or any other record maintained by the hospital that this HBsAb negative patient was provided the immunization if indicated. According to staff #4 they had never been informed they were to offer the immunization if indicated. Staff #4 also stated they have a new dialysis contractor and will be working with them to come into compliance with the regulations.

(E) Patients Screened for HBsAG findings:

On 09/29/11 review of the medical record at the facility, patient #HD 1's record revealed the patient was admitted and began dialysis at the facility 09/13/2011. The patient's hepatitis B status was not drawn until 09/24/2011 and the results were not known until 09/26/2011. There was no indication the facility drew the level at the time of admission or obtained the results from the previous facility.

On review of the medical record on 09/29/2011, at the facility, patient #HD 2's record revealed the patient was admitted and began dialysis at the facility between the dates 09/01/2011 through the date of the survey 09/29/2011. The hepatitis B Antigen and antibody level was not drawn as of 09/29/2011. There was no indication the facility drew the level at the time of admission or obtained the results from the previous facility.

On review of the medical record on 09/29/2011, at the facility, patient #HD 3's record revealed the patient was admitted and began dialysis at the facility between the dates 09/01/2011 through the date of the survey 09/29/2011. The hepatitis B Antigen and antibody level was not drawn as of 09/29/2011. There was no indication the facility drew the level at the time of admission or obtained the results from the previous facility.

On review of the medical record on 09/29/2011, at the facility, patient #HD 4's record revealed the patient was admitted and began dialysis at the facility 07/21/2011 through 09/02/2011. The patient's hepatitis B status was not drawn until 08/19/2011. There was no indication the facility drew the level at the time of admission or obtained the results from the previous facility.

On review of the medical record on 09/29/2011, at the facility, patient #HD 5's record revealed the patient was admitted and began dialysis at the facility 08/17/2011 through 09/12/2011. The patient's hepatitis B status was not drawn until 08/31/2011. There was no indication the facility drew the level at the time of admission or obtained the results from the previous facility.

On review of the medical record on 09/29/2011, at the facility, patient #HD 6's record revealed the patient was admitted and began dialysis at the facility between the dates 08/05/2011 through 08/17/2011. The hepatitis B Antigen and antibody level was not drawn as of the date of discharge. There was no indication the facility drew the level at the time of admission or obtained the results from the previous facility.

Review of the facilities disinfection record for the dialysis machines there was no evidence the facility conducted terminal disinfection of the equipment for the patients that the Hepatitis B antigen level was not known prior to admission and prior to use on any Hepatitis B antibody negative patient.

Interview with staff #4 on 09/29/2011 at 2:30 p.m., revealed the facility was unaware they were required to have the Hepatitis B antigen and antibody level had to be on the chart at the time of admission or ordered on admission.

(F) Findings plan of care dialysis patients:

Patient #HD1, admitted on 09/13/11, had no pre and post weight documented in the treatment record of 09/23/11 and no post assessment for Blood Pressure (BP), Heart Rate (HR), Respirations (R), or Temperature (T) . On 09/26/11 there was no post treatment assessment that included BP, HR, R T, and post weight. On 09/21/11 there was no post assessment for BP, HR, R, and T. On 09/07/11 there was no pre or post weight.

Patient #HD2, admitted on 08/01/11, had no post assessment in the treatment record of 09/26/11 that included BP, HR, R, T, and no post weight. On 09/23/11 there was no pre and post weight. On 09/07/11 there was no pre or post weight.

Cross refer to Tag A396.

(G) Findings regarding the separation of clean and dirty for the dialysis unit:

Observation in the dialysis set up area on 09/27/11 at 09:00 AM indicated the space was extremely small less than a total floor space of approximately 4 ft by 6 ft. The room held all clean and sterile supplies plus 3 dialysis machines which were attached to 3 WRO 300 RO systems (a system that makes purified water for dialysis). In the same area there was a toilet that was covered with a white garbage bag. The space was so small while surveyor was attempting to read the serial number on the machines the surveyor ran into the toilet. The area is unsafe for clean supplies or for the staff attempting to get the machine ready for dialysis.

Cross refer to Tag A749.

Definitions:
Hepatitis- (HBsAG) - virus that attacks the liver.
Hepatitis antibody- HBsAB) means the patient has protected immunity to the virus.

Based on observation, review of records and interviews, the Medical Staff failed to enforce the Medical Staff Bylaws in that it did not:

1)Monitor to ensure safe patient care was provided by failing to ensure the rights of each patient were protected.
Cross Reference A0115

2)Failed to ensure the hospital implemented and enforced policies and procedures to ensure the hospital is in compliance with 482.11 Compliance With Federal Laws, Patient Rights, EMTALA (Emergency Medical Treatment and Active Labor Act) and Emergency Services.
Cross Reference A0043, A0022, A1100, A2400, A2402, A2404, A2405, A2406, and A2409

Based on record review and interview, the facility failed to establish and follow an appropriate plan of care for the assessment and establishment of the estimated dry weight (EDW) for 2 (HD 1 and HD 2) out of 6 dialysis patients. These findings have the potential to cause harm to all patients receiving dialysis at the facility by the facilities failure to evaluate the effectiveness of the patient's dialysis treatment and by following the standards of Nephrology Nursing.

Findings:

Review of all Dialysis records was conducted in the conference room of the facility on 09/27/2011.

Review of patient #HD 1, date of admission 09/13/2011 the medical record revealed that the treatment records reviewed for the treatment dates 09/23/2011 there was no pre and post weight. On 09/26/2011 revealed there was no post treatment assessment including a Blood Pressure (BP), Heart Rate (HR), Respirations (R), temperature (T) and post weight. On 09/21/2011 there was no post assessment for BP, HR, R, and T. On 09/23/2011 there was no post assessment for BP, HR, R, or T. On 09/07/2011 there was no pre or post weight.

Review of patient #HD 2, date of admission 08/01/2011 the medical record revealed that the treatment records reviewed for the treatment date of 09/26/2011 there was no post assessment including BP, HR, R, T and no post weight. On 9/23/2011 revealed there was no pre and post weight. On 09/07/2011 there was no pre or post weight.

Review of the manual Contemporary Nephrology Nursing: Principles and Practice copyright 2006, Editor Anita E. Molzahan, PHD, RN and Evelyn Butera, MS, RN, CNN assistant Editor, American Nephrology Association, page 585, that sets the standards of practice for nephrology nurses, in the section listed as "Estimated Dry Weights". "Ensuring accurate weights before and after hemodialysis (HD) is critical to the ongoing assessment of the EDW."

Interview with staff #2 on 09/28/2011, confirmed the medical record findings. Staff #2 stated that all the dialysis patients are placed in rooms that have the Hill-ROM beds (a type of hospital bed) that have capabilities of weighing the patients. Staff #2 confirmed that patients #HD 1 and #HD 2 were in a room with the beds that weigh the patients.

Based on record review, the facility failed to ensure physician verbal orders were dated, timed, and countersigned in 5 of 17 charts (Chart HD4, HD5, HD6, #1, and #2).

Findings Included:

A review of patient charts revealed the following dates missing on physician orders (Chart # x number of missing dates in the chart):

Chart HD4 x 13
Chart HD5 x 6
Chart HD6 x 8
Chart #1 x 2
Chart #2 x 7

A review of patient charts revealed the following times missing on physician orders (Chart # x number of missing times in the chart):

Chart HD4 x 21
Chart HD5 x 18
Chart HD6 x 15
Chart #1 x 2
Chart #2 x 9

Review of medical records revealed 5 charts where verbal orders were not countersigned, as follows (Chart# x number of verbal orders not countersigned):

Chart HD4 x 10
Chart HD5 x 3
Chart HD6 x 4
Chart #1 x 2
Chart #2 x 6

Based on record review and interview the facility failed to ensure that 6 out of 6 dialysis patients (#HD 1, HD 2, HD 3, HD 4, HD 5, and HD 6) records reviewed, that the patient was provided with information concerning the name of the practitioner responsible for the dialysis treatments, physician that conducted the informed consent discussion; the risk, benefits and alternatives to dialysis treatment. These findings have the potential to cause the patient to make an uninformed decision regarding the options, risk and benefits of dialysis.

Findings:

Review of records was conducted in the facility on 09/28/2011

Review of patient HD 1, date of admission 09/13/2011, the medical records revealed that the informed consent found in the record for the hemodialysis treatments stated under diagnosis "ARF" with no indication written, as to what the initials meant. In addition patient HD 1 record did not include the name of the physician responsible for dialysis and who conducted the informed consent discussion. The consent also failed to list the risk, benefits and alternatives treatment to dialysis.

Review of patient HD 2, date of admission 09/01/2011, the records revealed that the informed consent found on the record did not include the name of the physician responsible for the dialysis treatment responsible for the informed consent discussion. The consent also failed to list the risk, benefits and alternative treatments to dialysis.

Review of patient HD 3, date of admission 09/01/2011, the records revealed that the informed consent found on the record did not include the name of the physician responsible for the dialysis treatment responsible for the informed consent discussion. The consent also failed to list the risk, benefits and alternative treatments to dialysis.

Review of patient HD 4, date of admission 7/21/2011, the records revealed that the informed consent found on the record did not include the name of the physician responsible for the dialysis treatment responsible for the informed consent discussion. The consent also failed to list the risk, benefits and alternative treatments to dialysis.

Review of patient HD 5, date of admission 08/17/2011, the records revealed that the informed consent found on the record did not include the name of the physician responsible for the dialysis treatment responsible for the informed consent discussion. The consent also failed to list the risk, benefits and alternative treatments to dialysis.

Review of patient HD 6, date of admission 08/05/2011, the records revealed that the informed consent found on the record did not include the name of the physician responsible for the dialysis treatment responsible for the informed consent discussion. The consent also failed to list the risk, benefits and alternative treatments to dialysis.

Interview with staff #2 on 09/28/2011 confirmed the informed consents found in the record were not complete.

Based on observation and interview the facility failed to provide adequate space for the separation of clean and dirty for the dialysis unit. These findings have the potential to cause cross contamination of clean equipment and supplies which could increase the risk of infection to the patient by allowing clean equipment to come in contact with a dirty equipment and supplies environment.

Findings:

Observation in the dialysis set up area on 09/27/2011 at 09:00 a.m., the space was extremely small less than a total floor space of approximately 4 ft by 6 ft. The room held all clean and sterile supplies plus 3 dialysis machines which were attached to 3 WRO 300 RO systems (a system that makes purified water for dialysis). In this same area there was a toilet that was covered with a white garbage bag. The space was so small while surveyor was attempting to read the serial number on the machines the surveyor ran into the toilet. The area is unsafe for clean supplies or for the staff attempting to get the machine ready for dialysis.

Interview with staff # 2 on 09/27/2011 at approximately 9:00 a.m., confirmed the equipment and supply area is small and staff # 2 agreed the space held both clean and sterile supplies and that there was a toilet in the clean area. Interview with staff # 6 indicated this was all the space allowed for the clean and dirty dialysis equipment, staff # 6 stated they wipe down the machines in the patients room and then return them to a clean room without disinfecting them after removing them from the patients room. Staff # 6 confirmed the room was not large enough to disinfect the equipment or perform the required preventive maintenance.

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

A. follow their policy on High Level Disinfection of Endoscopes.

Review of policy titled "High Level Disinfection of Endoscopes" revealed
"I. PURPOSE: To prevent cross contamination of patients when using the endoscope for multiple procedures.
II POLICY:
Endoscopes, which pass through normally sterile tissue, should be sterilized before each
procedure. If this is not possible, at least high-level disinfection must be done. Following disinfection, the endoscope shall be rinsed with sterile water.
Endoscopes that come in contact with mucous membranes are considered semicritical and should receive high-level disinfection at a minimum (12 minutes for Cidex O.P.A.)
All endoscopes will be terminally disinfected at the end of each day's use and again before the first and each subsequent use throughout the next day.
III. PROCEDURE:
All endoscopes shall receive mechanical cleaning prior to disinfection. Flexible endoscopes
shall be cleaned with a manufacturer-approved enzymatic cleaner immediately following use.
The channels will be irrigated and brushed, if accessible.
Rinse all immersible parts of the endoscope with water.
Discard all detergent solutions after each use. Use disposable brushes for cleaning
the channels or clean and sterilize or disinfect the brushes after each use.
Conduct leak testing on flexible endoscopes prior to immersion. Remove endoscope
from service, if it leaks, before it is cleaned then contact manufacturer. See policy
and procedure.
An EPA-registered sterilant/disinfectant shall be used on all endoscopes, per
manufacturer's instructions.
Immersible surfaces, both internal and external, shall be in contact with the
sterilant/disinfect for a minimum of 12 minutes.
All non-immersible parts shall be cleaned with water and detergent and wiped with
70% alcohol.
Following chemical disinfection, rinse the endoscope with sterile water.
Thoroughly air-dry the endoscope with compressed air.
Do not store the endoscope coiled. Store endoscopes in a manner which will protect
the endoscope.
All reusable accessories (i.e., cytology brushes, biopsy forceps) which penetrate
mucosal barriers will be mechanically cleaned and sterilized between each patient or
discarded.
Fill the water bottle with sterile water. Sterilize or high-level disinfect the water
bottle and its connecting tube at a minimum daily."

On observation tour 9/28/2011 at 2:00 PM, it was observed the scopes were coiled and stored in the original suitcases. Endoscopes were coiled in the suitcase for storage after usage. When questioned staff # 9 about the scopes being coiled and stored in the suitcases, he stated " I thought the scopes would be better protected in the suitcase."

Hang Time of Scopes Prior to Reprocessing
Published by: The University of Chicago Press on behalf of The Society for Heath Epidemiology of America
ASGE-SHEA Guideline
Multisociety Guideline on Reprocessing Flexible GI Endoscopes: 2011

"American Society for Gastrointestinal Endoscopy (ASGE) and the Society for Healthcare Epidemiology of America (SHEA) collaborated with multiple physician and nursing organizations, infection prevention and control organizations, federal and state agencies, and industry leaders to develop evidence-based guidelines for reprocessing GI endoscopes.
They include endoscope shelf life or " hang time " (the interval of storage after which endoscopes should be reprocessed before use), the role of microbiological surveillance testing of endoscopes after reprocessing, and questions regarding endoscope durability and longevity from the standpoint of infection prevention.
In the interest of utmost caution, Association of perioperative Registered Nurses (AORN) and the Association for Professionals in Infection Control and Epidemiology (APIC) espouse maximal storage intervals without reprocessing of 5 and 7 days, respectively."

During the tour of the scope processing room on 9/28/2011 at 2:00 PM questioned staff #9 are the scopes washed prior to use on a patient. Staff #9 reported no, the scopes are washed after use on the patient but not prior to usage on a patient.

On observation tour 9/28/2011 at 2:00 PM in the sterilization room was a written procedure for sterilization of Olympus Scopes. The facility uses Pentax brand scopes.

During an interview with staff # 9 on 9/28/2011 at 2:00 PM confirmed the policy on High Level Disinfection of Endoscopes was not being followed and the facility uses Pentax scopes. Staff #9 reported he was unaware that scopes should be reprocessed if not used within a 5-7 day time period and stored in straight hanging position not coiled.

B. provide and follow their policy and procedure for the decontamination and sterilization of instruments.

Review of policy titled Decontamination: Instruments Policy#: ICI 02 revealed
"GOAL: To insure safety of personnel
PROCESS: It is the policy of Triumph Hospital to insure the safety of its personnel while they are handling contaminated instruments. Using the approved enzyme solution to decontaminate soiled instruments will insure this.
The following procedure will be used to decontaminate soiled instruments:
1. OSHA regulations require the following to be worn when cleaning instrumentation in
order to protect personnel from blood borne pathogens:
waterproof gowns that cover arms
face shield or goggles
cuffed rubber or plastic gloves
2. Fill a leak-proof, puncture proof container with one gallon of water.
3. Mix the one (1) ounce of approved enzyme solution in one gallon of water presoak dirty
instrument into the gallon of water mixed with approved enzyme solution. Soak the
contaminated instrument for 2 to 5 minutes or longer if the instrument have dried blood.
4. Agitate the enzyme solution with a clean instrument.
5. Place soiled surgical instruments into enzyme presoak solution the end of the surgical
procedure; making sure instruments are in the open and unlocked positions.
6. Transport the container to the dirty work room.
7. When the soak is done, remove the instrument from the container. Thoroughly rinse
instruments with water.
8. Carefully inspect all instruments for any further contamination and defects.
9. Place all instruments into the dishwasher."

Review of records found no policy for a procedure on the sterilization process. The only policy found in the facility was the "Decontamination: Instruments" which provided decontamination of instruments. The policy is written that the instruments will be placed in a dishwasher.

During an interview with staff #1, and staff # 4 on 9/29/2011 at 2:00 PM, confirmed this was the only policy in the facility written for decontamination and sterilization of instruments.

Based on record review and interview the facility failed

Findings Included:

A. to approve staff to administer conscious sedation during surgical procedures.

Review of facilities polices found no policy for approval of staff administering conscious sedation to patients having surgical procedures.

Interview with Staff #1 on 9/30/2011 at 9:00 AM confirmed the facility does not have a policy for approving staff to administer conscious sedation.

B. to provide training for staff administering conscious sedation.

Review of personnel files on staff #12, #13, and # 14 (the staff assigned to give conscious sedation in the facility) revealed the staff members had not received any training from the facility on administering conscious sedation to patients.

During an interview with staff #12 on 9/29/2011 at 10:30 AM, confirmed he had not received training from the facility on conscious sedation.

During an interview with staff #13 on 9/28/2011 at 1:30 PM, confirmed he had not received training from the facility on conscious sedation.

During an interview with staff #14 on 9/30/2011 at 10:00 AM, confirmed she had not received training from the facility on conscious sedation.

C. to provide a policy for administering conscious sedation to a patient.

Review of the facilities polices found no evidence of a policy on conscious sedation to a patient.

During an interview with staff #1 on 9/30/2011 at 9:00 AM, confirmed the facility did not have a policy on administering conscious sedation to a patient.

Based on observation, interviews and record reviews, the hospital's Governing Board failed to:

1) Ensure all patients presenting to the Emergency Department (ED) from 02/20/08 to 09/23/11 received an appropriate medical screening examination to determine whether or not an emergency medical condition existed, stabilizing treatment was provided and appropriate transfers were initiated if needed. The Registered Nurse's (RN's) who performed the medical screening examinations (MSE's) in the ED were not appointed through the hospital's credentialing process as Qualified Medical Providers (QMP). The RN's performing MSE's were not recommended by the Medical Staff, nor appointed by the Governing Board to provide MSE as QMP.
Cross refer to Tag A2406

2) Adopt and enforce a hospital policy to ensure EMTALA requirements are met in order to provide for all patients presenting to the ED for emergency care an appropriate medical screening examination by a QMP to determine whether or not an emergency medical condition exists, provide stabilizing treatment and appropriate transfers.
Cross refer to Tag A2406

3) Ensure an appropriate transfer is initiated for patient's who are transferred to another facility for further screening and/or stabilizing treatment. The medical records did not reflect continued monitoring and documentation of stabilization prior to transfer after a MSE was performed and a possible EMC (emergency medical condition) was determined to exist.
Cross refer to Tag A2409

4) Did not ensure appropriate emergency signage was posted at the front entrance of the hospital or the Emergency Department (ED) entrance that was prominent and conspicuous and likely to be noticed by all individuals entering the ED or hospital which specified the rights of individuals with respect to examination and treatment of emergency medical conditions and women in labor as required by the Emergency Medical Treatment and Labor Act (EMTALA).
Cross refer to Tag A2402

5) Did not ensure an adequate on-call list of specialty physicians and emergency physicians and their alternates for 9 of 9 months (from 01/01/11 - 09/27/11) was maintained and posted. In addition the hospital did not have policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control or if the on call physician is permitted to have simultaneous on-call duties.
Cross refer to Tag 2404

6) Ensure the Emergency Room Log was accurate and complete for 43 of 43 months (February 2008 - September 2011) in that it did not contain the required elements on each individual presenting to the ER seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, and/or discharged.
Cross refer to Tag 2405


These findings have the potential to cause harm to the patient population and community presenting to the facility seeking help for an emergent medical condition and stabilizing treatment.

Based on observation, record review and interview, the hospital did not post signage at the front entrance of the hospital or the Emergency Department (ED) entrance that was prominent and conspicuous and likely to be noticed by all individuals entering the ED or hospital which specified the rights of individuals with respect to examination and treatment of emergency medical conditions and women in labor as required by the Emergency Medical Treatment and Labor Act (EMTALA).

Findings Included:

On arrival at the hospital at 8:30 A.M. the surveyors observed the hospital is located adjacent to and clearly visible from a major interstate highway in a highly populated area of Dallas. Located across from the hospital is a large multi-family apartment complex and approximately one-quarter mile down the road from the hospital, an elementary school is located. The surveyors also observed numerous businesses and shopping complexes close to the hospital.

The surveyors observed large signage that was clearly visible at the top of the building and in front of the building entrance that stated "Triumph Hospital." There was a sign posted at the driveway entrance into the hospital parking lot that indicated "Ambulance" entrance. Located at the southwest corner of the building, a pole with the words "Emergency" was partially obscured at the bottom of the pole by large foliage. Another sign was observed with the words "Ambulance" located in the parking lot area adjacent to the pole with "Emergency" on it.

During a tour of the facility on 09/27/11 at approximately 10:00 A.M., the surveyors toured the outside of the building. The outside entrance to the emergency room had a large sign posted above the doors that showed "Ambulance" entrance. A sign was posted on the glass doors that showed, "AUTHORIZED PERSONNEL ONLY. Due to patient safety and privacy, we are asking all non-employees or contracted agents to use the front entrance. Cafeteria visitors; we appreciate your business and welcome you. This directive is about our patients and their needs. FOR PATIENT SAFETY; HOSPITAL STAFF AND CONTRACTED AGENTS ONLY, ALL OTHERS, PLEASE USE THE FRONT ENTRANCE."
A call box with a push button was located adjacent to the door entry with no instructions posted. The entrance did not have any signage directing the public on how to contact anyone in the event of an emergency medical condition. The surveyors waited approximately 4 minutes before any hospital personnel appeared and asked if they needed any assistance.

The emergency room entrance and the front entrance of the hospital did not have any of the required signs posted specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA - Emergency Medical Treatment and Active Labor Act.)

During a separate tour of the facility at 3:13 P.M. on 09/27/11, the surveyors returned to the ambulance entrance of the hospital. The surveyors did not observe any personnel available. The surveyors then pressed the button and could hear a telephone ringing sound. After 4 rings, a person answered the call. The person asked, "Can I help you?" The surveyor stated, "I have an emergency. Can someone help me?" At 3:18 P.M., a Security Guard (Personnel #33) appeared at the door and asked if we needed help. Personnel #33 was asked if this was an emergency, what would he do? He stated he would call the House Supervisor. He was then asked to contact the House Supervisor. He stated he would get the supervisor and be right back.

At 3:20 P.M., Personnel #33 returned with the Nurse Manager (Personnel #6) and CCO (Chief Clinical Officer, Personnel #2). Personnel #6 was asked if this is the emergency entrance. He stated it is for ambulances. He was asked how would someone who is presenting for emergency care treatment know to contact someone for assistance. He stated that most people would come through the front entrance of the hospital. He was asked if someone presented to the emergency entrance, how would they know how to get help. He stated they could press the button on the call box. He was then asked if there are any instructions by the call box or any signs posted designating the call box as a way to contact someone in the event of an emergency. He stated, "No." He was then asked if there was any signs showing the emergency entrance. He stated, "Yes." He pointed to the pole at the corner of the building. He was asked if it is partially obscured by a plant. He stated, "Yes." He also pointed out the "Ambulance" sign in the parking lot and above the side entrance. He was then asked about the "Authorized Personnel Only" sign posted on the glass doors. He stated that the sign was there to keep people from coming in the side door. Personnel #6 was asked if a nurse is assigned to the emergency room. He stated, "Yes. The House Supervisor." He was asked if there are any signs at the front door of the hospital indicating to patient's presenting with an emergency where to go. He stated, "No." He was asked who answers the call bell at the entrance to the emergency area. He stated, "A unit clerk on the patient care unit who is scheduled 24/7."

Personnel #33 was asked if the doors are ever locked. He stated they are locked at night.

The surveyors then entered the emergency entrance doors. Personnel #6 was asked where the emergency treatment room is located. He stated it is located in the first room to the right by the emergency entrance doors. The door had one small EMTALA sign affixed to the door which is not clearly visible from 20 feet away. The surveyors then attempted to open the door and the door was locked. Personnel #6 was then asked to open the door. Personnel #6 did not have a key and asked Personnel #33 to open the door. Personnel #33 did not have a key to the door and left to go obtain a key. At this time, a Radiology Technician (Personnel #18) came out of Radiology and stated he had a key and opened the door with his key.

The "Emergency Services" Policies and Procedures "PC 450 Emergency Services" dated "12/2008" required, "It is the policy...to provide for the assessment of patients presenting for emergency care. The facility shall perform a medical screening evaluation (MSE) to determine if an emergency medical condition (EMC) exists and if further care and treatment is needed...The nursing supervisors must be educated and deemed competent regarding EMTALA, state regulations and the policies pertaining to the Emergency Treatment area, to be designated a qualified medical personnel..."

The "Clinical" Policy "Plan for the Provision of Patient Care" dated "April 2011" required, "The hospital is a full services provider of specialized services available twenty-four (24) hours/day, seven (7) days a week...The Hospital CEO (Chief Executive Officer) is directly responsible for the operations...direct reports are...7) Emergency Services...Providing a safe, functional, and effective environment for patients, visitors, staff...Patient Care Areas and Departments...Emergency Services...The hours of operation of the Front Desk Receptionist are from 8 a.m. to 8 p.m. weekdays and weekends..." The Plan for Provision of Patient Care did not address the Scope of Services, Staffing or Personnel requirements for Emergency Services.

The "Medical Staff Bylaws" dated "08/2010" defined emergency as "a condition in which serious permanent harm would result to a patient or in which the life of a patient is in immediate danger, and any delay in administering treatment would add to that danger..." The Medical Staff Bylaws did not address the provision of Emergency Services.

The "Operational Bylaws" dated "06/30/09" did not address the provision of Emergency Services.

The "Governing Board Meeting Minutes" dated "February 25, 2010" reflected "Policies and Procedures...The Board was given the opportunity to review the policies and procedures for the hospital. These had all been through the MEC (Medical Executive Committee) on 02/05/10...Upon recommendation of the MEC, the Board approved the policies and procedures noted below...Emergency Services...Hospital Wide Plans...Emergency Services..."

Based on observation, record review and interview, the hospital did not maintain an adequate on-call list of specialty physicians and emergency physicians and their alternates for 9 of 9 months (from 01/01/11 - 09/27/11). In addition the hospital did not have policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control or if the on call physician is permitted to have simultaneous on-call duties.

Findings Included:
During a tour of the ED approximately 2:30 P.M. on 09/27/11, the surveyor did not observe a physician on-call schedule posted in the Emergency Treatment room.

During a tour of the ED approximately 2:30 P.M. on 09/27/11, the surveyor interviewed Personnel #6. He was asked if he knew where the physician on-call schedule for emergency and specialty physicians for consultations was located. He stated, "Yes, it is in the House Supervisor's book. It is a list of the hospitalist that is on-call for the hospital. They are in-house 24 hours a day, 7 days a week in case of an emergency." He was then asked to produce the on-call schedules. He was asked if the schedules included any specialists for consultations. He stated, "No. The in-house Hospitalist covers for any emergencies. The Hospitalist will call the patient's physician if needed."

Personnel #6 produced unnamed printed calendars dated January 2011 through June 2011 and August 2011 through October 2011. The July 2011 calendar was not included.

Review of the on-call calendars contained the last name of the physician on-call with the telephone numbers of the physicians on call listed at the bottom of the calendars. The calendars did not include the specialty of the physicians or any alternate physicians on-call in the event the primary on-call physician is not available.

The "Emergency Services" Policy and Procedure dated "12/2008" requires, "An on-call schedule will be posted in the Emergency Treatment Area, notating availability of physicians - including phone numbers and alternates. These schedules will be maintained for no less than one year. One or more physicians shall be available at all times..."

Review of the "Medical Staff Bylaws" dated "8/2010" did not address the hospital response to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control or if the on call physician is permitted to have simultaneous on-call duties.

During an interview at approximately 10:30 A.M. on 09/28/11, Personnel #27 verified the above information.

Based on review of records and interviews, the Emergency Room Log was incomplete for 43 of 43 months (February 2008 - September 2011) in that it did not contain the required elements on each individual presenting to the ER seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, and/or discharged.

Findings Included:

Review of the Emergency Room Log dated February 2008 until September 2011 reflected the dates in the log were not in consecutive order and there were many missing gaps and one patient (Patient #12) was not listed in the log.

Patient #12 presented to the ER on 03/05/11 at 5:25 P.M. for complaints of "pain to LLQ (left lower quadrant) x 2 weeks. Worse activity, worse with R.M. (range of motion) intermittent."

The log reflected the following as listed (in order as listed in the log):

1) 10/05/10 at 8:00 A.M. Patient # 21 presented for complaints of left upper quadrant pain. The log did not reflect if the patient was treated or not treated prior to transfer to another facility.

2) 12/20/10 at 4:20 P.M. Patient #13 (see entry #13) presented for complaints of left tingling arm. The log did not reflect if the patient was treated or not treated prior to transfer to another facility.

3) 02/03/11 at 9:30 A.M. Patient #20 (see entry #16) presented for complaints of left arm pain after fall. The log did not reflect the time the patient was discharged or if the patient was stable upon discharge home.

4) 03/01/11 the presentation time was obliterated, Patient # 19 (see entry #17) presented for complaints of elevated blood pressure. The log did not reflect if the patient was treated or not treated prior to discharge home.

5) 05/20/11 at 8:05 A.M. Patient #17 presented for complaints of chest pain. The log did not reflect if the patient was treated or not treated and if the patient was stable upon transfer to another facility. Review of Patient #17's medical record reflected patient to be transferred to another facility and left AMA (Against Medical Advice).

6) 05/26/11 at 10:45 A.M. Patient #16 presented for complaints of chest pain and left arm pain. The log did not reflect if the patient was treated or not treated prior to transfer to another facility. Review of Patient #16's medical record reflected patient to be transferred to another facility and left AMA.

7) 07/06/11 at 7:49 A.M. Patient #15 presented for complaints of chest pain and left arm pain. The log did not reflect the nurse assigned and if the patient was treated or not treated prior to transfer to another facility. Review of Patient #15's medical record reflected patient to be transferred to another facility and left AMA.

8) 02/20/08 at 2:15 P.M. Patient #25 presented for complaints of a laceration. The log did not reflect the discharge diagnosis and if the patient was treated or not treated prior to discharge home or the time patient was discharged home.

9) 03/01/10, no presentation time, Patient #26 presented for complaints of a fall. The log did not reflect a discharge diagnosis, if the patient was treated or not treated and time transferred to another facility.

10) 04/01/10, no presentation time, Patient #23 presented for complaints of weakness and dizziness. The log did not reflect a discharge diagnosis, the time the patient was discharged and if the patient was stable upon discharge home. Review of Patient #23's medical record reflected patient was not seen by an attending physician and was discharged to "proceed directly to ER."

11) 04/07/11, no presentation time, Patient #22 presented for complaints of weakness. The log did not reflect the discharge diagnosis, if the patient was stable upon discharge, time discharged or disposition of patient.

12) 07/29/11, no presentation time, Patient #24 presented for complaints of a laceration. The log did not reflect the treating physician, discharge diagnosis, if the patient was stable upon discharge, time discharged or disposition of patient.

13) 12/20/10, no presentation time, Patient #13 (see entry #2) was logged in but did not reflect the age, sex, nurse, treating physician, chief complaint, whether it was an emergency or non-emergency, if treated or not treated, stabilized or not stabilized, discharged, admitted or transferred, disposition of patient or time patient was discharged. Review of Patient #13's medical record reflected the chief complaint as tingling down arm and patient was transferred to another facility.

14 and 15) The next two lines in the log book were left blank.

16) 02/03/11, no presentation time, Patient #20 (same patient as entry #3) presented with complaints of left shoulder pain. The log did not reflect the discharge diagnosis or if the patient was stable upon discharge or disposition of the patient.

17) 04/07/11, no presentation time, Patient #19 (see entry #4, same patient on presentation date 03/07/11) presented with complaints of high blood pressure. The log did not reflect the discharge diagnosis or if the patient was stable upon discharge or the disposition of the patient.

18) 04/27/11, no presentation time, Patient #18 presented with complaints of headache and dizziness. The log did not contain the discharge diagnosis, if the patient was stable or unstable, treated or not treated, if the patient was transferred, disposition or time patient was discharged. The log book reflected "911 Called." Review of Patient #18's medical record reflected the patient was "Transferred to ER for CT (computerized tomography) Stroke workup." The medical record also reflected patient #18 signed out AMA.

19) 09/18/11, 11:00 A.M., Patient #27 presented to the ER. There was no other information logged in other than patient's sex.

20) 09/23/11, 12:20 P.M. Patient #14 presented with complaints of fell and hit head. The reason reflected "headache." The log did not reflect if the patient was treated or not treated, stabilized or not stabilized, discharged, admitted, or transferred, disposition of patient or time patient was discharged.

Review of the hospital policy "Emergency Room Register (Logbook)" not dated required, "All patients who present to the ER for treatment must be recorded in the register. This book is kept in the ER. When the register (logbook) is filled, send to Medical Records Department for permanent keeping. The register is considered a legal document; therefore, you must follow the correction of errors policy. Handwriting in the logbook must be legible...If a patient presents and decides not to register, does not stay for services, leaves AMA etc., you must register them in the logbook with as much information as possible including time and description of the person if you do not get a name. Documentation of the visit must be forwarded to medical records...Time of arrival to ER, Date of Arrival, Name..., Age, Sex, Nurse caring for patient, house physician or on call physician name, Nature of Injury (not medical diagnosis), Service rendered (brief description), Disposition will be logged as Admit, Released, Expired, Transfer, DOA (Dead on Arrival), Mode of Transportation includes which ambulance service, Private automobile, Depart time is when the patient left the Emergency Department/Room."

During an interview at 10:30 A.M. on 09/28/11 with Personnel #6 and Personnel #27, they were asked to review the ER Logbook with the surveyor. Both Personnel #6 and Personnel #27 verified the ER logbook was incomplete and did not contain the required documentation and did not follow hospital policies and procedures. Personnel #6 was asked about the entries not being in date order. He stated the original logbook had been misplaced and they could not find it so they started a new logbook and tried to find the ER records to put the records in a log.

Based on observation, interviews and record reviews, the hospital failed to:

1) Ensure all patients presenting to the Emergency Department (ED) from 02/20/08 to 09/23/11 received an appropriate medical screening examination to determine whether or not an emergency medical condition existed, stabilizing treatment was provided and appropriate transfers were initiated if needed. The Registered Nurse's (RN's) who performed the medical screening examinations (MSE's) in the ED were not appointed through the hospital's credentialing process as Qualified Medical Providers (QMP). The RN's performing MSE's were not recommended by the Medical Staff, nor appointed by the Governing Board to provide MSE as QMP.

2) Adopt and enforce a hospital policy to ensure EMTALA requirements are met in order to provide for all patients presenting to the ED for emergency care an appropriate medical screening examination by a QMP to determine whether or not an emergency medical condition exists, provide stabilizing treatment and appropriate transfers.

3) Ensure an appropriate transfer is initiated for patient's who are transferred to another facility for further screening and/or stabilizing treatment. The medical records did not reflect continued monitoring and documentation of stabilization prior to transfer after a MSE was performed and a possible EMC (emergency medical condition) was determined to exist.

These findings have the potential to cause harm to the patient population and community presenting to the facility seeking help for an emergent medical condition and stabilizing treatment.

Findings Included:

Review of the following patient emergency room medical records reflected:

Patient #12 presented to the ER on 03/05/11 for the chief complaint abdominal pain for 2 weeks. RN #37 performed the initial triage. The MR did not contain documentation of a medical screening including a history and physical examination (H&P) and/or ancillary services to determine if an EMC existed or if the patient was stable upon discharge home.

Patient #13 presented to the ER on 12/20/10 for the chief complaint of tingling down the arm and decreased appetite. RN #14 performed the initial triage. The H&P reflected the patient has a past medical history (PMH) of HTN (hypertension) and CHF (congestive heart failure) with current dyspnea (shortness of breath), increased JVP (jugular venous pressure), and basilar crackles in the lungs (possible fluid in the lungs). There was only one set of vital signs (VS) documented during triage which reflected a heart rate (HR) of 103 (heart rate above 100 is tachycardia, fast heart rate), respiratory rate (RR) of 22 (normal resting respiratory rate 14-20, tachypnea is increased RR above 20) and BP (blood pressure) 153/93 (elevated, normal range 120/80). The MR contained a copy of the MOT reflecting the patient was transferred to another facility. The MR did not contain any ongoing assessments, progress notes, ongoing vital signs, physician orders, discharge vitals signs or if the patient was stable upon transfer.

Patient #14 presented to the ER on 09/23/11 for the chief complaint of headache post fall. RN #6 performed the initial triage. The MR reflected the patient fell in the parking lot and reported pain of 6 out of 10 (0 is no pain and 10 is the worst imaginable pain) to the right temporal area of the head with mild nausea and increased light headedness. VS reflected an initial BP that was elevated at 180/90 with subsequent elevated BP's of 177/94 and 180/91. An elevated Blood Sugar (BS) reflected 368 (normal BS ranges 80-110). The MR did not contain any documentation of ongoing nursing assessments, ongoing neurological assessments, ongoing physician progress notes, treatments and/or interventions, discharge assessments, discharge vital signs, patient disposition or if the patient was stable upon discharge.

Patient #15 presented to the ER on 07/06/11 for the chief complaint of left arm pain radiating with pressure to the chest and chest pain. The MR reflected a PMH of HTN and an elevated BP of 141/98 at triage by RN #13. The EKG (electrocardiogram) was abnormal reflecting a t-wave inversion in leads II, III and AVF along with LVH (left ventricular hypertrophy). The cardiac labs indicated the CPK was elevated at 320 (Creatine Phosphokinase, normal range 39-308, indicator of cardiac muscle damage) and the Troponin was elevated at 0.22 (normal range 0.00 - 0.10). The MR did not contain documentation by the physician of ongoing reassessments, a discharge assessment indicating patient was stable upon transfer or contain a copy of the MOT.

Patient #19 presented to the ER on 04/07/11 for the chief complaint of high blood pressure. The MR reflected a BP of 222/124 upon triage and Clonidine 0.2 mg given by RN #13 without a physician order. The MR did not contain ongoing nursing assessments, a MSE by a QMP, treating physician, H&P performed by a physician, physician orders for medications, treatment or discharge, discharge assessment, patient disposition or if patient was stable upon discharge.

Patient #21 presented to the ER on 10/05/10 for the chief complaint of left upper quadrant abdominal pain with vomiting. RN #13 performed the initial triage assessment. The MR did not contain documentation of the physician discharge assessment, time discharged or if the patient was stable upon discharge.

Patient #23 presented to the ER on 04/01/10 for the chief complaint of weakness and dizziness. The triage nursing assessment performed by RN #12 reflected "No heart conditions...Current Medications: Lisinopril 40 mg by mouth every day (used to treat high blood pressure or in combination with other medications to treat heart failure), Verapamil 180 mg by mouth x 1 today approximately 7:00 A.M (used to treat high blood pressure and chest pain)...VS: HR 140 ((heart rate above 100 is tachycardia, fast heart rate), RR of 21 (normal resting respiratory rate 14-20, tachypnea is increased RR above 20) and BP 179/110(elevated, normal range 120/80)..." The nursing progress notes reflected, "Patient c/o (complains of) weakness and some dizziness with tingling noted to bilateral lower extremities...Patient in ER monitoring VS at this time...awaiting arrival of family for D/C (discharge) to ER...MD #36 paged awaiting call back...Updated MD #36 at length. No orders noted. Stated will attempt to have another MD come by to see the patient...Spoke with MD #36. Stated "OK to DC with instructions to F/U (follow up) care in ER...DC instructions to patient and husband..." The Discharge Instructions reflected, "Proceed directly to ER. F/U care...Diagnosis: Elevated BP...TORB (telephone order read back): MD #36..."The MR did not contain documentation of a signed patient release from responsibility AMA (leave against medical advice), an MSE by a QMP to determine if an EMC existed, any physician orders, treatment, H&P, treatment or stabilization, attending physician, risks and benefits of transfer, authorization for transfer, disposition or if the patient was stable upon transfer/discharge to another facility.

During an interview at 10:30 A.M. on 09/28/11 with Personnel #6 and Personnel #27, they were asked to review the ER medical records with the surveyor. Both Personnel #6 and Personnel #27 verified the ER patient medical records were incomplete and did not contain the required documentation and did not follow hospital policies and procedures. Personnel #6 was asked if the RN's are individually designated by the Governing Body as QMP's to perform MSE's to determine if an EMC exists. He stated, "The Governing Body and Medical Staff has determined it is ok for RN's to perform Medical Screening Examinations." He was asked if the individual RN personnel files have a letter of appointment from the Governing Body designating each RN as a QMP who performs medical screening examinations. He stated, "No."


Review of Hospital Personnel Files reflected the following findings:

The personnel files for RN #6, RN #12, RN #13, RN # 14, and RN #37 who provides triage and medical screening in the ED did not contain privileges as a QMP or a recommendation from the Medical Staff or an appointment letter from the Governing Board designating them as a QMP to provide MSE's in the ED. In addition, the personnel files did not contain training or competencies as a QMP to provide MSE's in the ED for EMC's.

The hospital policy and procedure "Documentation: Emergency Record" not dated requires, "To provide documentation of assessment and treatment on all patient seen in the Emergency Department/Emergency Treatment Room...the date of the patient's arrival will be listed along with the actual time the patient present themselves and is seen by the triage nurse...the physicians evaluation will be documented on the appropriate order form to include the patient's final diagnosis, time of discharge, condition, disposition. The physician will sign the record in the area provided...Patient discharge information will be provided at the bottom of the nurses record. The date, time and initial of person discharging the patient will be listed. The disposition, condition upon discharge and mode of discharge will be noted..."

The "Emergency Services" Policies and Procedures "PC 450 Emergency Services" dated "12/2008" requires, "It is the policy...to provide for the assessment of patients presenting for emergency care. The facility shall perform a medical screening evaluation (MSE) to determine if an emergency medical condition (EMC) exists and if further care and treatment is needed...Purpose: To outline the roles and responsibilities of the emergency treatment area and to assure appropriate supplies and equipment to safely care for those that present for emergency care...The Emergency Treatment Area renders life-sustaining treatment to those who present to the hospital for emergency care in order to stabilize emergencies...and, if appropriate, arrange for transfer to the nearest hospital capable of providing the needed services...The Medical Staff has designated the nursing supervisor to be the qualified medical personnel to perform the medical screening evaluation to determine if an emergency medical condition exists and to coordinate with the on-call physicians in providing needed care. The nursing supervisors must be educated and deemed competent regarding EMTALA, state regulations and the policies pertaining to the emergency treatment area, to be designated a qualified medical personnel...An emergency medical condition is defined as "a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individuals health (or the health of an unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs...Adequate supplies and equipment will be available and ready for use in this area...Emergency call system, oxygen, mechanical ventilatory assistance equipment - including airways, manual breathing bag and mask, cardiac defibrillator, laryngoscopes and endotracheal tubes, suction equipment, emergency drugs and supplies specified by the medical staff..."

The "Clinical" Policy "Plan for the Provision of Patient Care" dated "April 2011" requires, "The hospital is a full services provider of specialized services available twenty-four (24) hours/day, seven (7) days a week...The Hospital CEO (Chief Executive Officer) is directly responsible for the operations...direct reports are...7) Emergency Services...Providing a safe, functional, and effective environment for patients, visitors, staff...Patient Care Areas and Departments...Emergency Services..." The Plan for Provision of Patient Care did not address the Scope of Services, Staffing or Personnel requirements for Emergency Services.

The "Medical Staff Bylaws" dated "08/2010" requires "The Medical Staff is responsible for the quality of medical care, treatment and services delivered by its members and AHP's (Allied Health Professionals) in the hospital, is responsible for the ongoing evaluation of the current competency of it members and AHP's and delineating the scope of clinical privileges that are granted to its members and AHP's...subject to the ultimate authority of the Governing Board...Clinical Privileges means the permission granted to members and AHP's by the Governing Board to render specific diagnostic, therapeutic, medical...services in the hospital...Current Competence means the education, training, experience, quality of care and current ability to perform the Clinical Privileges requested and/or granted...Responsibilities of the Medical Staff...Determining the mechanisms for establishing and enforcing criteria and patient care standards for Medical Staff membership and AHP appointment through a credentialing process for appointment and reappointment that delineates privileges based on documented evidence...Assuring that the management of patient care is the responsibility of a member with appropriate clinical privileges...Developing, administering, and enforcing the Bylaws, Rules and Regulations, other medical staff policies, hospital policies and procedures, accreditation requirements, and federal, Texas and local laws and regulations...Membership on the Medical Staff is a privilege which shall be extended only to Applicants and Members, who meet the qualifications...set forth in these bylaws and Rules and Regulations...Professional and Ethical Responsibilities and Standards...comply with...Providing appropriate and necessary emergency medical treatment within the scope of the Member's Privileges to any patient seeking emergency medical care at the hospital...The Medical Executive Committee (MEC) will make...recommendations to the Governing Board...Every member is entitled to exercise only those privileges granted by the Governing Board...Emergency Privileges. In the case of an emergency, any Practitioner, to the degree permitted by his license and regardless of service or staff status or lack of it, shall be permitted and assisted to do everything possible to save the life of a patient, using every facility of the hospital necessary, including the calling for any consultation necessary or desirable. Once the emergency condition is treated, the member of record shall resume responsibility for the patient. For the purpose of this section,an emergency is defined as a condition in which serious permanent harm would result to a patient or in which the life of a patient is in immediate danger, and any delay in administering treatment would add to that danger...AHP's...No AHP regardless of his/her designation is eligible for medical staff membership or entitled to the privileges or prerogatives of medical staff members...Among the responsibilities of the medical staff for AHP's are to: review and, when appropriate, recommend for adoption by the Governing Board those specific categories of AHP's that are necessary and appropriate to provide services...review and recommend approval, denial or modification of AHP applications for appointment, reappointment and clinical privileges...AHP's may only care for the patients of their supervising or sponsoring members. AHP's may not independently admit or discharge patients from the hospital. AHP's may not substitute for the medical staff member...Dependent AHP's. Employees of medical staff members who have documented their qualifications and current competence for the dependent AHP catagory being requested and who have been approved by the Governing Body to work with an employing/sponsoring staff member shall be designated as Dependent AHP's. Dependent AHP's shall be limited to the following categories...Registered Nurses...Each AHP applicant is required to submit a list of requested privileges pertinent to the category for which they are applying and which have been delegated to the AHP pursuant to standing delegation order, protocols, or standing medical orders. Requested privileges must be within the scope of the AHP's professional licensure, certification, registration, or training..." The Medical Staff Bylaws did not address the provision of Emergency Services or the provision of QMP's performing MSE's to determine if an EMC exists.

The "Operational Bylaws" dated "06/30/09" did not address the provision of Emergency Services or the provision of QMP's performing MSE's to determine if an EMC exists.

The "Governing Board Meeting Minutes" dated "February 25, 2010" reflects "Policies and Procedures...The Board was given the opportunity to review the policies and procedures for the hospital. These had all been through the MEC (Medical Executive Committee) on 02/05/10...Upon recommendation of the MEC, the Board approved the policies and procedures noted below...Emergency Services...Hospital Wide Plans...Emergency Services..."

The hospital policy and procedure "Memorandum of Transfer" dated "07/2009" requires "Policy: Every patient, either transferred to or from (direct admit acute, long term care, skilled nursing facility or nursing home) our hospital must have a completed Memorandum of Transfer (MOT) as prescribed by the Illinois Department of Health. Purpose: To establish the policy and procedure for handling patients transferred to or from Dallas Triumph Hospital in accordance with the Illinois Department of Health requirements. Procedure...When we transfer a patient to another facility: 1. The physician orders life support measures medically appropriate to stabilize/sustain patient during transfer, along with appropriate personnel and equipment for the transfer. 2. The Physician/Clinical Supervisor secures a receiving physician and hospital that will accept responsibility for the patients medical treatment and hospital care. 3. Nursing prints/requests copies of the medical record to contain a minimum of the following: History and Physical, Physician Progress Notes,, last 48 hours of lab work, x-rays, EKG's (electrocardiogram) and last 48 hours of medication records. 4. Nursing completes Section A of MOT. 5. The physician or hospital staff member action under the physician's orders signs. 6. Hospital Administration, Nursing Director or Clinical Supervisor also signs. 7. Nursing send original MOT with the patient to receiving facility. 8. Copy of MOT is filed in file folders by month in the Health Information Management Department." The hospital "Memorandum of Transfer" policy and procedure did not reflect the need for documentation by the physician to the patient the informed consent process which includes discussion of the risk and benefits of transfer to another facility.

The "Emergency Services Manual" not dated reflects "Section V: EMTALA (Emergency Medical and Active Labor Act). The EMTALA policy and procedure was requested on 09/27/11, 09/28/11 and 09/29/11. The requested EMTALA policy and procedure was not produced during the survey to the surveyors.

During an interview at 10:30 A.M. on 09/29/11 with Personnel #35, she verified the hospital "Memorandum of Transfer" policy and procedure dated "07/2009" is the only transfer policy and procedure the hospital has at this time.

Based on observation, interviews and record reviews, the hospital's Governing Board failed to ensure an appropriate transfer is initiated for patient's who are transferred to another facility for further screening and/or stabilizing treatment. The medical records did not reflect continued monitoring and documentation of stabilization prior to transfer after a MSE was performed and a possible EMC (emergency medical condition) was determined to exist.

These findings have the potential to cause harm to the patient population and community presenting to the facility seeking help for an emergent medical condition and stabilizing treatment.

Findings Included:

Review of the following patient emergency room medical records reflected:

Patient #13 presented to the ER on 12/20/10 for the chief complaint of tingling down the arm and decreased appetite. RN #14 performed the initial triage. The H&P reflected the patient has a past medical history (PMH) of HTN (hypertension) and CHF (congestive heart failure) with current dyspnea (shortness of breath), increased JVP (jugular venous pressure), and basilar crackles in the lungs (possible fluid in the lungs). There was only one set of vital signs (VS) documented during triage which reflected a heart rate (HR) of 103 (heart rate above 100 is tachycardia, fast heart rate), respiratory rate (RR) of 22 (normal resting respiratory rate 14-20, tachypnea is increased RR above 20) and BP (blood pressure) 153/93 (elevated, normal range 120/80). The MR contained a copy of the MOT reflecting the patient was transferred to another facility. The MR did not contain documentation the patient is aware of the risks and/or benefits of the transfer or consent to transfer. The MR did not contain any ongoing assessments, progress notes, ongoing vital signs, physician orders, discharge vitals signs or if the patient was stable upon transfer.

Patient #15 presented to the ER on 07/06/11 for the chief complaint of left arm pain radiating with pressure to the chest and chest pain. The MR reflected a PMH of HTN and an elevated BP of 141/98 at triage by RN #13. The EKG (electrocardiogram) was abnormal reflecting a t-wave inversion in leads II, III and AVF along with LVH (left ventricular hypertrophy). The cardiac labs indicated the CPK was elevated at 320 (Creatine Phosphokinase, normal range 39-308, indicator of cardiac muscle damage) and the Troponin was elevated at 0.22 (normal range 0.00 - 0.10). The MR did not contain documentation by the physician of ongoing reassessments, a discharge assessment indicating patient was stable upon transfer or contain a copy of the MOT. The MR did not contain documentation the patient is aware of the risks and/or benefits of the transfer or consent to transfer.

Patient #23 presented to the ER on 04/01/10 for the chief complaint of weakness and dizziness. The triage nursing assessment performed by RN #12 reflected "No heart conditions...Current Medications: Lisinopril 40 mg by mouth every day (used to treat high blood pressure or in combination with other medications to treat heart failure), Verapamil 180 mg by mouth x 1 today approximately 7:00 A.M (used to treat high blood pressure and chest pain)...VS: HR 140 ((heart rate above 100 is tachycardia, fast heart rate), RR of 21 (normal resting respiratory rate 14-20, tachypnea is increased RR above 20) and BP 179/110(elevated, normal range 120/80)..." The nursing progress notes reflected, "Patient c/o (complains of) weakness and some dizziness with tingling noted to bilateral lower extremities...Patient in ER monitoring VS at this time...awaiting arrival of family for D/C (discharge) to ER...MD #36 paged awaiting call back...Updated MD #36 at length. No orders noted. Stated will attempt to have another MD come by to see the patient...Spoke with MD #36. Stated "OK to DC with instructions to F/U (follow up) care in ER...DC instructions to patient and husband..." The Discharge Instructions reflected, "Proceed directly to ER. F/U care...Diagnosis: Elevated BP...TORB (telephone order read back): MD #36..."The MR did not contain documentation of a signed patient release from responsibility AMA (leave against medical advice), an MSE by a QMP to determine if an EMC existed, any physician orders, treatment, H&P, treatment or stabilization, attending physician, risks and benefits of transfer, authorization for transfer, disposition or if the patient was stable upon transfer/discharge to another facility. The MR did not contain documentation the patient is aware of the risks and/or benefits of the transfer or consent to transfer.

During an interview at 10:30 A.M. on 09/28/11 with Personnel #6 and Personnel #27, they were asked to review the ER medical records with the surveyor. Both Personnel #6 and Personnel #27 verified the ER patient medical records were incomplete and did not contain the required documentation and did not follow hospital policies and procedures.

The hospital policy and procedure "Documentation: Emergency Record" not dated requires, "To provide documentation of assessment and treatment on all patient seen in the Emergency Department/Emergency Treatment Room...the date of the patient's arrival will be listed along with the actual time the patient present themselves and is seen by the triage nurse...the physicians evaluation will be documented on the appropriate order form to include the patient's final diagnosis, time of discharge, condition, disposition. The physician will sign the record in the area provided...Patient discharge information will be provided at the bottom of the nurses record. The date, time and initial of person discharging the patient will be listed. The disposition, condition upon discharge and mode of discharge will be noted..."

The "Governing Board Meeting Minutes" dated "February 25, 2010" reflects "Policies and Procedures...The Board was given the opportunity to review the policies and procedures for the hospital. These had all been through the MEC (Medical Executive Committee) on 02/05/10...Upon recommendation of the MEC, the Board approved the policies and procedures noted below...Emergency Services...Hospital Wide Plans...Emergency Services..."

The hospital policy and procedure "Memorandum of Transfer" dated "07/2009" requires "Policy: Every patient, either transferred to or from (direct admit acute, long term care, skilled nursing facility or nursing home) our hospital must have a completed Memorandum of Transfer (MOT) as prescribed by the Illinois Department of Health. Purpose: To establish the policy and procedure for handling patients transferred to or from Dallas Triumph Hospital in accordance with the Illinois Department of Health requirements. Procedure...When we transfer a patient to another facility: 1. The physician orders life support measures medically appropriate to stabilize/sustain patient during transfer, along with appropriate personnel and equipment for the transfer. 2. The Physician/Clinical Supervisor secures a receiving physician and hospital that will accept responsibility for the patients medical treatment and hospital care. 3. Nursing prints/requests copies of the medical record to contain a minimum of the following: History and Physical, Physician Progress Notes,, last 48 hours of lab work, x-rays, EKG's (electrocardiogram) and last 48 hours of medication records. 4. Nursing completes Section A of MOT. 5. The physician or hospital staff member action under the physician's orders signs. 6. Hospital Administration, Nursing Director or Clinical Supervisor also signs. 7. Nursing send original MOT with the patient to receiving facility. 8. Copy of MOT is filed in file folders by month in the Health Information Management Department." The hospital "Memorandum of Transfer" policy and procedure did not reflect the need for documentation by the physician to the patient the informed consent process which includes discussion of the risk and benefits of transfer to another facility.

The "Emergency Services Manual" not dated reflects "Section V: EMTALA (Emergency Medical and Active Labor Act). The EMTALA policy and procedure was requested on 09/27/11, 09/28/11 and 09/29/11. The requested EMTALA policy and procedure was not produced during the survey to the surveyors.

During an interview at 10:30 A.M. on 09/29/11 with Personnel #35, she verified the hospital "Memorandum of Transfer" policy and procedure dated "07/2009" is the only transfer policy and procedure the hospital has at this time.