The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TEXOMA MEDICAL CENTER 5016 S US HIGHWAY 75 DENISON, TX 75020 Dec. 10, 2014
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and interview, the hospital failed to ensure RN supervision and evaluation of the nursing care in accordance with the patient's needs, in that,

1) Patient #1 did not receive the 8/24/14 spirometer ordered until 8/26/14 and

2) Patient #1's acute pain was not assessed for 8 hours from 8/23/14 to 8/24/14.

Findings Included

The electronic record for Patient #1 was reviewed on 12/09/14 at 9:48 AM with Personnel #8.

1) Patient #1's 8/24/14 Post-Operative orders included Spirometer Q2 (every 2 hours.)

Patient #1's 8/26/14 Spirometer documentation reflected it was given on 8/26/14 at 8:00 AM and 12:00 PM.

During an interview on 12/09/14, Personnel #3 confirmed the above findings and was asked if there was any other documentation of the Spirometer. Personnel #3 stated, "There was not."

2) Patient #1's Pain assessment reflected, "8/23/14 18:08 (6:08 PM) pain level 3..."

Patient #1's 8/23/14 assessment was documented for 8:00 PM at 9:08 PM and did not include a pain assessment.

There was no Pain assessment documented for Patient #1 after the 8/23/14 6:08 PM assessment through the 8/24/14 Nurse's Note which reflected, "8/24/14 2:45 (AM)...complained of pain at this time..."

During an interview on 12/09/14, Personnel #3 confirmed the above findings and was asked if there was documentation of the pain being assessed after the 6:08 PM assessment up to the 8/24/14 2:30 AM nurse's note. Personnel #3 stated, "There is no pain assessed in the documentation during that time."

During an interview on 12/09/14 ending at 9:47 AM, Personnel #6 was asked about the evening of 8/24/14 and the patient's pain assessment and control. Personnel #6 stated, "I talked to her about her pain, nausea and vomiting. I asked her if the pain caused the nausea or the nausea caused the pain. She told me that she thought the nausea and vomiting was causing her pain. So we decided to treat her nausea and vomiting."

The March 2012 "Patient Assessment, Admission and Ongoing, and Patient Plan of Care" policy required, "RN's will conduct a comprehension admission assessment...ongoing focused assessments every shift based on the patient's physiologic and psychosocial needs..."

The March 2010 "Pain Management" policy required, "The intended outcome of these interventions is to provide that level of pain control, which is supportive of the therapeutic interventions in progress and provides a life environment acceptable to the patient...right to have their pain assessed and treated...thorough assessment of pain will be made by the R.N. on admission...Re-assessment will be done every shift, and anytime a patient has a change in pain status..."
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on record review and interview, the hospital failed to inform the patient of Patient #1's own health status, in that, Patient #1 was not notified of the physician's decision to not place the NG (naso-gastric) tube during the 8/23/14 hospitalization .

Findings Included

The electronic record for Patient #1 was reviewed on 12/09/14 at 9:48 AM with Personnel #8.

Patient #1's record did not document notification of the physician's decision to not place the ordered NG tube.

During an interview on 12/09/14, Personnel #8 confirmed the findings.

The revised 05/05/14 "Patient Rights and Responsibilities" policy required, "Your rights include being informed of your health status and prognosis...including pain management...the right to be informed about the outcomes of care, treatment..."