Christus Southeast Texas- St Elizabeth

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 32143 Based on document review and interview the facility failed to ensure patients were informed of the risk and benefits, side effects, potential problems, or reasonable alternatives by their physician or provider before the administration of blood and blood products in 3 (Patients #1, 9, and 10) of 3 (Patients #1, 9 and 10) patient charts reviewed. A review of patient #1’s chart revealed a physician order for 1 unit of Red Blood Cell (RBC) on 10/12/24 at 1403. The blood was administered at 1542. A blood consent was signed by the patient and a nurse on 10/12/24 but there was no physician signature and there was no mention in the physician progress notes or History and Physical that the patient was explained the benefits and risks of blood administration. Staff # 8 RN confirmed there was no documentation by a physician. A review of patient #9’s chart revealed an order to transfuse 1 unit of RBC on 12/12/24 at 12:00 pm. A blood consent was signed on 12/12/24 at 1750. There was no physician’s signature on the consent. There was no mention in the physician’s progress notes or History and Physical that the patient was explained the benefits and risks of blood administration. Staff # 8 RN confirmed there was no documentation by a physician. Staff # 8 RN confirmed there was no documentation by a physician. A review of patient #10’s chart revealed the nurse’s note on 12/09/24 at 7:20 am stated, “ Pt states that d/t chronic anemia, he sees a hematologist outpatient and receives iron infusions. On discussing POC for blood transfusion, he states that he would like to wait for his wife to arrive at the hospital before making a decision on receiving blood. _______ (physician) is aware. He says that he is not opposed to receiving blood if that is what is needed, but that his wife will be included in that decision.” The patient signed a consent for blood administration on 12/9/24 at 9:15 am. The nurse signed the consent but there was no physician signature. There was no line for the physician to sign the consent. There was no documentation that the patient was given risks and benefits by the physician. The nurse documented transfusions were administered on 12/9/24 at 9:42 am. Staff # 8 RN confirmed there was no documentation by a physician. An interview was conducted with Staff # 3 CMO on 12/16/24 at 10:54. Staff #3 stated that the corporate level had decided to remove the signature line from the consent around February or March of this year. The physicians were supposed to document in their notes that the patient was given risks and benefits. Staff #3 stated that education was pushed out in March to the physicians. Staff #3 was unaware that the physicians were not documenting risks and benefits of blood administration. A review of the policy “Informed Consent for Invasive/Surgical Procedure” stated, “POLICY STATEMENT: A competent adult patient or a surrogate decision-maker acting on the patient’s behalf has the right to receive from the patient’s physician/practitioner information necessary to make informed choices and decisions regarding the patient’s medical care and treatment. The primary purpose of the informed consent process is to ensure that the patient or his/her surrogate decisionmaker is provided information in a manner that the patient and/or the patient’s surrogate decisionmaker can understand to enable the patient and/or the patient’s surrogate decision-maker to effectively exercise the right to make informed decisions. IV. PROCESS OR PROCEDURES: A. Informed Consent for Invasive Procedures Responsibility The law places the duty to obtain informed consent upon the physician/licensed practitioner and it is nondelegable. The physician or licensed practitioner ordering or performing the medical treatment, procedure, surgery, or administration of anesthesia has a duty to the patient to disclose the nature of treatment(s), procedure(s), or surgery(s) to be performed as well as the risks, hazards, and benefits of the treatment(s), procedure(s), surgery(s) and/or administration of anesthesia including possible alternatives and risks of non-treatment. The informed consent process is not delegated ... 2. The physician or licensed practitioner responsible for the procedure is responsible for the discussion of the risks, hazards, and benefits of the procedure(s) including possible alternatives and risks of non-treatment as defined by state statute and additional best practice risks as designated by the physician/practitioner. 1 a. The consent is communication between the physician or practitioner and the patient. b. The acknowledgment confirms the patient has had the opportunity to discuss risks, hazards, and benefits of the procedure(s) including possible alternatives and risks of non-treatment, plan of care, and has had questions answered by the practitioner. The physician or practitioner must, at a minimum, discuss with the patient: i. The nature of the proposed care, treatment, services, medications, interventions, or procedures ii. Potential benefits, risks, or side effects, including potential problems related to recuperation iii. The likelihood of achieving care, treatment, and service goals iv. Reasonable alternatives to the proposed care, treatment, and service v. The relevant risks, benefits, and side effects related to alternatives, including the possible results of not receiving care, treatment, and services vi. When indicated, any limitations on the confidentiality of information learned from or about the patient c. The witness is verifying the signature is of the patient or surrogate decisionmaker acknowledgment of the communication. d. The patient has the right to withhold consent until the opportunity to communicate with the physician or practitioner ... 7. There must be indication on the consent form concerning the use of blood products. This is done by indicating “DO” or “DO NOT” on the blood product statement on the consent. If the patient states “DO NOT”, the nurse will notify the surgeon as soon as possible prior to the surgery ... F. “Informed Consent Process” includes a discussion about the following: 1) the patient’s proposed care, treatment, and services; 2) potential benefits, risks, and side effects of the patient’s proposed care, treatment, and services; 3) the likelihood of the patient achieving his or her goals; 4) any potential problems that might occur during recuperation; and 5) reasonable alternatives to the patient’s proposed care, treatment, and services. The discussion encompasses risks, benefits, and side effects related to the alternatives and the risks related to not receiving the proposed care, treatment, and services.””

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 40989 Based on observation, document review, and interview the hospital failed to ensure there were adequate numbers of providers available to ensure the emergency needs were met in 7 (Patients #1,#2, #5, #7, #9, #10, and #11) of 7 patients reviewed. Also, the hospital failed to follow its policies and report data to Quality of an ongoing identified problem of patients leaving the Emergency Department against medical advice (AMA). Refer to Tag A1112”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 40989 Based on observation, document review, and interview the hospital failed to ensure there were adequate numbers of providers available to ensure the emergency needs were met in 7 (Patients #1,#2, #5, #7, #9, #10, and #11) of 7 patients reviewed. Also, the hospital failed to follow its policies and report data to Quality of an ongoing identified problem of patients leaving the Emergency Department against medical advice (AMA). Findings: Patient #1 A review of patient #1’s medical record revealed the following: Patient #1 was a 56-year-old female who arrived at the Emergency Department (ED) by ambulance on 12/31/2023 at 11:18 AM with complaints of bilateral wrist pain. She was placed in a room at 11:20 and a Medical Screening Exam (MSE) was completed at 11:47 AM by Physician Assistant (PA) Staff #12. She was triaged by the RN at 12:07 PM with an Emergency Services Index (ESI) of 3. ESI is a numeric triage level from 1 (most urgent) to 5 (least urgent) based on patient acuity and resource needs. A review of the ED note documented by PA Staff #12 on 12/31/2023 at 11:47 and was as follows: “ ...Patient is a 56-year-old female that presents to emergency room after a fall while roller skating. She fell backwards putting both wrists out. She landed on her tailbone and hit her head. No loss of consciousness. She is complaining of pain in her neck and her back ... Comprehensive physical exam to be obtained by additional provider ... As a way to help expedite this patient’s encounter, I served as the provider in triage. I will order any necessary testing which will be followed up on by the next provider who will assume responsibility of this patient, will re-examine, add any testing they deem necessary, follow up on all results, and appropriately disposition the patient ...” Vital signs were assessed on arrival at 11:49 AM that read; Temperature 98.1 F, Pulse Rate 92, Respiratory Rate, 18, Blood Pressure 120/63, Pulse Oximetry 100%. Vital signs were reassessed at 5:15 PM that read; Temperature 98.1 F, Pulse Rate 75, Respiratory Rate, 18, Blood Pressure 124/68, Pulse Oximetry 100%. The reassessment of vital signs taken at 5:15 PM was greater than 5 hours after the initial set of vital signs were taken. No other vital signs were documented before patient #1 left Against Medical Advice (AMA) at 7:50 PM. RN Staff #16 confirmed a patient with a triage level of ESI-3 should have had vital signs assessed every 4 hours and 30 minutes prior to discharge. A review of the documentation by Registered Nurse (RN) Staff #19 on 12/31/2023 at 12:07 PM was as follows: “ ...Pt arrives via EMS from home. Pt fell while rollerblading yesterday, went to an urgent care and was told she broke bilateral wrist, has splints prior to arrival (PTA). Says she hit her head and her tailbone. States they only x-rayed her hands. States they did not give her any pain meds to take home ...Generalized pain assessment intensity 10 ... 12:13 PM Pain Assessment: Pain Intensity 10 on pain scale (a pain scale is a numeric scale documented as 1-10 with 10 being the worst pain) in bilateral arms ...” At 12:18 PM-PA Staff #12 wrote an order for 1 tablet of Norco 7.5/325 (a narcotic pain medication) for pain control. The medication was administered at 12:36 PM by Licensed Vocational Nurse (LVN) Staff #20. The patient’s pain level at the time of medication administration was an 8. There was no reassessment of the patient’s pain level documented after the pain medication was administered until 3:37 PM when another pain medication was administered. At 3:20 PM PA Staff #13 wrote an order for 1mg(milligram) of Dilaudid (a narcotic pain medication used to treat moderate to severe pain) IM (intramuscular). The medication was administered by the nurse at 3:37 PM for pain a scale of 10. There was no reassessment of the patient’s pain level after the IM Dilaudid was administered at 3:37 PM until the disposition assessment was completed by LVN Staff #20 at 7:50 PM. The patient disposition assessment was documented at 7:50 PM by LVN Staff #20. Vital signs were documented at this time and were the same as the vital signs taken at 5:15 PM. Vital signs read; Temperature 98.1 F, Pulse Rate 75, Respiratory Rate, 18, Blood Pressure 124/68, Pulse Oximetry 100%. An ED reassessment was documented on 12/31/2023 at 7:50 PM by LVN Staff #20 that read; “ ...Patient crying at nurse’s station stating I need pain medicine. Informed patient Physician #17 ordered 1000mg Tylenol PO (by mouth). Patient refusing Tylenol stating that doesn’t work, Tylenol for two broken wrists. They gave me Dilaudid earlier and that worked. Informed Physician #17 of patient request. Verbal recommendation for Tylenol, Motrin, and ice packs and patient is allowed to sign AMA paper. Informed patient on Dr’s orders and patient states, I am leaving this place, ya’ll aren’t helping me. I’m not signing a damn thing. Patient Disposition: Against Medical Advice ...” Patient #1 left the ED without seeing a second provider after the MSE was complete. Patient #1 was in the ED for more than 7 hours and did not see a second provider for examination or treatment. Patient #1 left the facility AMA at 8:04 PM. RN Staff #7 confirmed there was no AMA form in the medical record of patient #1. An interview was conducted on 4/10/2024 at 1:00 with PA Staff #13. PA Staff #13 was asked if she was the provider assigned to the RMA treatment area on 12/31/2023. She confirmed she was assigned for patient care in the RMA on 12/31/2023 until 5:00 PM. PA Staff #13 was asked if she ordered the IM Dilaudid before or after she examined Patient #1. PA Staff #13 confirmed the medication order was written by her and then stated, “Most likely the nurse was asking for pain medication, and I put the order in, and I usually see the patient, but I don’t know what happened. I don’t see a note by me anywhere.” PA Staff #13 was asked if she examined the patient before she left the hospital after her scheduled shift on 12/31/2023. PA Staff #13 confirmed she did not see Patient #1 before she left the hospital. A review of the ED Physician schedule dated 12/31/2023 revealed PA Staff #13 was scheduled from 7:00 AM-5:00 PM. Further review revealed 2 Physicians and 2 APP’s were also scheduled. RN Staff #16 confirmed that 2 of the APP’s schedule ended at 5:00 and the other APP was scheduled until 9:00 PM but she was responsible for the MSE (medial screening exam) in the triage area. It was also confirmed that after 5:00 PM there was no APP assigned to the RMA treatment area and it would fall on the responsibility of the 2 physicians scheduled. An interview was conducted with LVN Staff #30 and #31 on 4/11/2024 at 9:10 AM. LVN Staff #30 was asked what they do if a patient wants to leave AMA. LVN Staff #30 stated, “We notify the doctor and try and talk to the patient and have them stay.” She was then asked if they had the patients sign the AMA form before they left. LVN Staff #30 said they try but sometimes the patient won’t sign it. She was asked if they printed the form and document that the patient refused to sign. Staff #30 stated, “No we do not do that, but we do document that the patient left AMA in their record”. LVN Staff #31 was asked if the physicians come to the RMA area to treat the patients. LVN Staff #31 stated, “They will but sometimes it’s hard to get them to come back here and see the patients.” LVN Staff #31 was asked if there was always a provider in the RMA treatment area. LVN Staff #30 and #31 confirmed there is not always a provider in the treatment area. LVN Staff #30 stated, “There is usually an APP here during the day but when that shift ends and especially overnight, it’s just the doctors in the main ED and we monitor the patients until one of them comes to see them.” An interview was conducted with Physician #17 on 4/11/2024 at 11:53 AM. Physician #17 was asked if he treats patients in the RMA treatment area. Physician #17 stated, “Yes, we do if the (Advanced Practice Provider) APP asks us to come and see a patient. Sometimes it does take us a while to go and see them because the main ED gets so busy, but yes, we do.” Patient #5 Patient #5 was a 45-year-old female who arrived at the ED on 4/09/2024 at 3:12 AM with a chief complaint of Abdominal Pain. She was triaged at 3:24 AM by the RN and determined to be an ESI 3-Urgent. Vital signs were taken at 3:14 that read; Temperature 98.2, Pulse rate 87, blood pressure 137/77, respirations 18, and pulse oximetry of 97% on room air, and she was placed in the waiting room pending room assignment. She was transferred to a room at 6:20 AM. Vital signs were taken again at 8:01 AM that read, Temperature 97.5, Pulse rate 75, blood pressure 116/81, respirations 16, and pulse oximetry of 100% on room air. RN Staff #16 confirmed Patient #5 was in the waiting room from 3:24 AM until 6:20 AM. RN Staff #16 confirmed Patient #5 should have had vital signs assessed in the waiting room every 2 hours. . A review of the ED note dated 4/09/2024 at 8:29 AM by Physician #17 was as follows: “ ...Patient is a 45-year-old female with a past medical history of acid reflux who presents to the ER with abdominal pain. Patient was in no distress while in the ED and was hemodynamically stable. Patient was offered blood work and imaging at this time however the patient declined. Patient was informed that there is risk that she may be having coronary artery disease versus bowel obstruction versus pancreatitis. Patient was alert and oriented and understood these risks. Patient deferred workup at this time and preferred outpatient follow-up and decided to leave AMA ...” RN Staff #16 confirmed Patient #5 did not have a documented MSE or provider note for greater than 5 hours after arrival to the ED. Patient #9 Patient #9 was a 52-year-old female who arrived at the ED on 12/31/2023 at 11:45 AM with complaints of chest pain and left-side numbness. She was placed in the Rapid Medical Assessment Area (RMA) Treatment area at 12:52 PM. She was triaged by the RN at 12:23 PM as an ESI-3 Urgent. A review of the Triage assessment documented by RN Staff #19 was as follows: “ ...Patient states on December 21 her left hand went numb. Later that night her left arm went numb. States on December 27 patient started having pain in her back and bilateral shoulders, aching in her arms. Says having some pain in her chest today ...” A review of the ED noted documented by PA #12 on 12/31/2023 at 12:29 was as follows: “ ...Patient is a 52-year-old female who presents to the emergency room with multiple complaints. On December 21 she had some left hand numbness. Later on that same day, her left arm was numb. Then on December 27, she had numbness in her left hand. No numbness today. She has had some chest pain on and off the past few days. She had some that radiated to her left jaw ...As a way to help expedite this patient’s encounter, I served as the provider in triage. I will order any necessary testing which will be followed up on by the next provider who will assume full responsibility of the patient, will re-examine, add any testing they deem necessary, follow up on all results, and appropriately disposition the patient ...”. Vital signs were assessed at 12:01 PM and 5:16 PM. LVN Staff #20 assessed the patient for chest pain at 2:14 PM. At 5:18 she documented, “Updated patient on wait time”. There was no further documentation of assessment or reassessment by a nurse or provider until 8:45 PM when the patient left AMA. At 8:45 PM LVN Staff #20 documented, “Pt stated they want to leave AMA, spoke with PA #32 about how ERP (Emergency Room Physician) Physician #17 has signed up for them and that they have to wait for Physician #17 to give results and pt stated, I don’t care I’m leaving. Pt signed AMA form. Pt AAOx4 (awake, alert, oriented x 4). Pt ambulatory and accompanied by spouse ...” During an interview on 4/11/2024 after 1:00 PM, RN Staff #16 confirmed Patient #9 did not have vital signs taken within 30 minutes of their departure. Also, RN Staff #16 confirmed Patient #9 was in the facility for more than 8 hours and did not see a provider or physician before leaving AMA after the initial MSE. During an interview with RN Staff #16, she was asked what did “Updated on wait time” mean?” RN Staff #16 replied, “They were giving the patient an update on when the provider was going to see them.” RN Staff #16 was asked how could she ensure the patient wasn’t updated on wait times for test results. RN Staff #16 stated, “I guess I wouldn’t know because the documentation was not clear on what was being updated.” Patient #10 Patient #10 was a 52-year-old female who arrived at the ED on 12/31/2023 at 11:48 AM with complaints of chest pain. She was triaged by RN Staff #19 on 12/31/2023 at 12:32 PM as an ESI-3 Urgent. She was placed in a room at 1:16 PM. A review of the ED noted documented by PA #12 on 12/31/2023 at 12:29 was as follows: “ ...Patient is a 52-year-old female that presents to the emergency room with chest pain since Christmas. Got really bad today. Feels like a brick is sitting on her chest. She has shortness of breath associated with it ...As a way to help expedite this patient’s encounter, I served as the provider in triage. I will order any necessary testing which will be followed up on by the next provider who will assume full responsibility of the patient, will re-examine, add any testing they deem necessary, follow up on all results, and appropriately disposition the patient ...”. RN Staff #21 documented on 12/31/2023 at 3:00 PM that an IV was started and at 3:01 PM she documented, “Cardiovascular parameters within defined limits”. No further documentation was in the medical record of a patient assessment by the nurse or a provider until 6:50 PM when the patient left the hospital AMA. During and interview on 4/11/2024 after 1:00 PM, RN Staff #16 confirmed Patient #10 was in the ED for more than 6 hours and she did not see a second provider for examination and treatment after the initial MSE. Patient #11 Patient #11 was a 34-year-old female who arrived at the ED on 12/31/2023 at 12:00 PM with a complaint of body aches. She was triaged by RN Staff #19 on 12/31/2023 at 12:52 PM as an ESI-4 Semi-urgent. A review of the triage assessment documented by RN Staff #19 was as follows: “ ...Pt reports sore throat, body feels weak, sore lower abdomen for 2 days. Denies any fevers ...” She was placed in a room at 1:52 PM. A review of the ED noted documented by PA #12 on 12/31/2023 at 12:29 was as follows: “ ...Patient is a 34-year-old female that presents to the emergency room with body aches and, sore throat for the past 2 days. Has been having some lower abdominal pain for the past several weeks ....As a way to help expedite this patient’s encounter, I served as the provider in triage. I will order any necessary testing which will be followed up on by the next provider who will assume full responsibility of the patient, will re-examine, add any testing they deem necessary, follow up on all results, and appropriately disposition the patient ...”. Vital signs were assessed at 12:48 PM and 5:19 PM on 12/31/2023. At 5:19 PM on 12/31/2023, LVN Staff #20 documented a general ED assessment was completed and she updated the patient on wait time. No further assessment or reassessment was documented by a nurse or provider until 9:50 PM on 12/31/2023 when the patient left AMA. The vital signs documented on the disposition assessment were the same vital signs documented at 5:19 PM. RN Staff #16 confirmed Patient #11 was in the ED on 12/31/2023 for more than 9 hours and she did not see a second provider for examination and treatment after the initial MSE. Also, RN Staff #16 confirmed Patient #11 did not have vital signs reassessed within 30 minutes of discharge. An interview was conducted with the Administrative Director of Nursing for Emergency Services (ADON) Staff #9 on 4/11/2024 at 9:20 AM. ADON Staff #9 was asked if there had been a problem with the number of patients leaving AMA. She confirmed there was an increase in the number of patients leaving after the MSE had been completed and before the patient saw a second provider for examination and treatment. ADON Staff #9 stated, “We have been looking at all the patients that leave AMA and if they fit the criteria, I call them and talk to them about their experience in the ED.” She was then asked if there was documentation regarding the call and what criteria a patient had to meet to get a call back from the hospital after they left AMA. ADON Staff #9 stated, “If a patient has to wait a long time to see a provider, then I call them but there’s not a certain process for calling patients back”. ADON Staff #9 was asked how the ED was monitoring the patients leaving AMA. ADON Staff #9 stated, “The information gets put into the micro strategy program and we look at the patients to see what caused them to leave AMA”. She was asked if any of the information or conversations with patients that she talked with got documented for tracking purposes. She confirmed there was no documentation of any of the conversations with patients and the information was only available for 30 days. We look at it by the month”. ADON Staff #9 was asked if any of the data regarding the AMA patients was reported to Quality. She stated, “We discuss the AMA patients in our ED meeting, and someone is there from Quality”. Again, ADON Staff #9 was asked if any data was reported to Quality. She stated, “No, there is no process to do that”. On 4/11/2024 ADON Staff #9 confirmed incident reports were not completed on patients who left the ED AMA. An interview was conducted with RN Staff #16 on 4/11/2024 after 11:00 AM. RN Staff #16 was asked if she was looking at all the AMAs from the ED. RN Staff #16 stated, “I look at the micro strategy program every day and make sure the patients disposition is correct. Sometimes I have to correct the disposition to make things clear for the billing department. The micro strategy program only has patients with certain dispositions. It doesn’t show the admissions or the patients that were discharged home. It shows patients who left AMA, patients who left after a MSE but before they saw a second provider (LAMS), patients who left without being seen after triage (LWOBS), and patients who left without treatment, they signed in but were never triaged or had a MSE (LWOT). Sometimes the disposition on the ED Log will say the patient left AMA, but they actually left before they saw a 2nd provider. So that is when I change the disposition for the billing department. Staff #16 was asked if she reported this data to anyone. She replied ADON RN Staff #9, and the ER Physician group had access to the information. She confirmed that Staff #9 could access the information whenever she wanted, and she would send a text to Physician #6 inform him the data was ready for him to review. RN Staff #16 also confirmed the information was only kept for 30 days. A review of the micro strategy report dated 4/1/2024-4/9/2024 provided by RN Staff #16 revealed 155 patients had left after an MSE and before seeing a second provider. The report only provided an arrival time and did not include the disposition time of the patient. RN Staff #16 was asked if the patients were leaving because of the wait time to see a provider. RN Staff #16 stated, “Yes most of the time that was the reason. The staff try and keep the patients updated on the wait time but sometimes it was too long, and they just left.” RN Staff #16 was asked how long the patients were waiting to see a second provider. RN Staff #16 stated, “You would have to look into each chart to be able to tell because it is not on this report”. An interview was conducted with Physician #6 on 4/11/2024 at 1:40 PM. Physician #6 was asked if he was aware of the patients leaving the ED after the MSE because of the wait time to see a second provider. Physician #6 confirmed he was aware but there was not much that he was allowed to do. He stated, “We are already over budget and can’t get that changed. I had 3 physicians leave recently for other hospitals because of the workload here. We are going to take care of the sickest patients first. Sometimes I ask to go on divert and I’m told by the charge nurse that they could ask but they are usually always told no. There’s a lot of red tape when it comes to going on divert. There are 2 physicians here 24 hours a day and we could use at least 1 other physician at minimum”. Physician #6 was asked if it was difficult to find physicians to work at the facility or if it was the budget from corporate that would not allow the change. Physician #6 stated, “Both. The staff are just moving patients from 1 place to another because it gives the patient the perception that something is happening. That does not mean they are going to be seen any faster because there are still those that need to be seen before them. If a trauma comes in, a stroke code is called, patients need to be transferred, phone calls with other specialists, and so on. This is an ED and things like this are going to happen. We do not have the resources to always handle it. I’m telling you it’s going to happen again today. The upper echelons are going to have to take care of this, it’s out of my hands.” Physician #6 was asked if they see patients in the RMA treatment area. He replied they do if the APP requests that a physician see the patient. Sometimes it takes a while for us to go back there and see the patient so a lot of times the patient gets tired of waiting and leaves.” An interview was conducted on 4/11/2024 at 12:20 PM with ADON RN Staff #9, Interim Regional Quality Director Staff #1, Quality RN Staff #7, Quality Director Staff #4, and Interim DON Staff #11. The above staff were notified that ADON RN Staff #9 had identified a problem with an increase in patients leaving AMA and they were asked if any of the information was being reported to Quality. Staff #4 and #7 confirmed there was no data reported to the Quality Department. Interim DON #stated, “We had a meeting in March to try and come up with answers regarding this problem. I am having the Corporate Six Sigma PI Team come and evaluate this problem and help us improve on the process”. She was asked if there was a date that was scheduled for them to be at the hospital. She said she would have to check on it. Also, Staff #11 confirmed the last meeting was held on 3/06/2024. Staff #1, Staff #4, and Staff #7 confirmed no information was being reported to the Quality Department. ADON Staff #7 also confirmed there was no process to report any data to Quality for the identified and ongoing problem with patients leaving the ED AMA. A review of the policy titled, “Pain Management-Care of the Patient with Pain” with a revised date of 1/22 was as follows: “ ...PURPOSE: To assure that the staff of CHRISTUS Hospital properly identify, assess, manage, and monitor all patients with pain ... Ongoing Management of Pain ... RN/LVN 1. Identify and document pain, including effect and adverse effect of therapy. Assess for intended and unintended effects: “ At regular intervals after starting the pain treatment regimen: minimally every 4 hours. “ With each report of pain “ At a suitable interval after each pharmacological or non-pharmacological intervention, such as 15-30 minutes after parenteral drug therapy and one hour after oral administration ...” ADON Staff #9 confirmed Patients #1 and #5 were not reassessed in an appropriate time after pain medications had been administered. 47892 Findings: Patient #7 Patient #7 was a 20-year-old male who arrived at the ED by ambulance on 04/09/2024 at 3:44 PM. Patient #7 was admitted for sickle cell crisis (a pain crisis by abnormal blood cells that can cause death to tissue). He was triaged by the RN on 04/09/2024 at 3:53 PM with an ESI of 3-Urgent. Vital signs were taken on 04/09/2024 at 3:53 PM. Vital signs were as follows: Temperature 97.9, Pulse 89, Respirations 26 (normal respirations for an adult patient are 12 to 16 breaths per minute), and Blood Pressure 126/79. His pain scale was a 10. The MSE was started on 04/09/2024 at 4:10 PM by PA #13. A review of the ED note dated 4/09/2024 at 4:10 PM by PA #13 was as follows: “ ...20-year-old male patient presents to emergency room today with complaints of sickle cell crisis. Patient was seen here in the ED and discharged about 2 hours ago. He states that his pain has not been controlled ...I have performed a medical screening exam on the patient and have determined that the patient does have an emergent medical condition that warrants further work-up. I have initiated patient care in triage and placed orders on the patient. Continued care of the patient to be seen by the clinician in the treatment area. Exam to be done and further testing/treatment to be determined by other provider ...”. PA #13 ordered lab work, IV (intravenous) fluids, and Toradol 30mg (non-narcotic pain medication) to be given IV. A review of the nurse note documented by LVN Staff #29 on 4/09/2024 at 5:54 PM revealed the IV was started in the forearm after 4 attempts and Toradol 30mg was administered IV at 5:51 (sic) PM. Patient #7’s pain scale at the time the Toradol was administered was a 9 on a scale of 1-10. There was no reassessment of the patient’s pain level after the IV Toradol was administered for pain control. There were no further interventions, assessments, or re-assessments documented by a nurse or provider until 04/10/2024 at 5:43 AM when the disposition assessment was completed by RN staff #25. A review of the disposition assessment was as follows: “ ...Patient Disposition: Against Medical Advice ...” Patient #7 was in the ED for more than 12 hours without a nursing or provider assessment and left the ED AMA on 04/10/2024 at 5:44 AM. There was no signed AMA form in Patient #7’s medical record. An interview was conducted with RN Staff #7 on 04/11/2024 at 1:00 PM. Staff #7 confirmed Patient #7 left the hospital AMA. RN Staff #7 confirmed Patient #7 was not reassessed by a nurse or examined by a provider for more than 12 hours before leaving the hospital AMA. Also, RN Staff #7 confirmed that there was no AMA form in the medical record for Patient #7. Patient #2 Patient #2 was a 40-year-old male who arrived at the ED by ambulance on 04/09/2024 at 2:05 AM. He was triaged by the RN at 2:09 AM with a complaint of abdominal distention and shortness of breath (SOB). He was an ESI 2-Emergent. Vital signs were taken on 04/09/2024 at 2:09 AM. Vital signs were Temperature 98.0, Pulse 120 (normal pulse range for an adult is 60-100 beats per minute), Respirations 16, Blood Pressure 148/92(normal blood pressure for an adult is 120/80), and Pulse Ox (amount of oxygen in the blood) 96%. He was placed in a patient room at 2:13 AM. Verbal orders were given on 4/09/2024 at 2:13 AM from Physician #24. The verbal orders included the following: IV line to be placed, labs to be drawn, ECG (echocardiogram-picture of how the heart is beating), chest x-ray, sepsis screening (screening for infection), and antibiotics to be given IV. Physician #17 puts in orders for IV fluids and a CT (computed tomography) scan of the pelvis and abdomen. A review of the ED note dated 4/09/2024 at 6:43 AM documented by Physician #17 revealed there was a consult with the interventional radiologist at 10:26 AM and a plan for a paracentesis (a procedure that uses a needle to drain fluid from the abdomen) on 4/09/2024. At 4:30 PM Physician #17 documented, “Attempted to find patient appears he has eloped. Multiple attempts to call patient and have him return to ER (Emergency Room) however was unable to get in contact with patient.” A review of the nursing documentation dated 4/09/2024 at 11:09 AM by RN Staff #27 was as follows: “ ...Pt lying on stretcher awake, Respiratory Rate (RR) even and unlabored, no s/s (signs and symptoms) of distress noted. Safety measures and monitors in place, informed of pending paracentesis, pt verbalized understanding ...” No further nursing or provider documentation was found in the medical record until 3:16 PM. A review of the nursing note dated 4/9/2024 at 3:16 PM was as follows: “ ...Unable to find patient for USDN (ultrasound) paracentesis. Attempted to call pts phone. Does not take calls ...” RN Staff #23 documented on 4/09/2024 at 3:35 PM, “ ...Patient disposition: Eloped ...” During an interview on 4/10/2024 at 1:00 PM RN Staff #7 confirmed Patient #2 was still in the ED at 11:09 AM. No further nursing or provider documentation was in the medical record until 4/09/2024 at 3:16 PM. That was more than 4 hours between assessments or reassessments by nursing staff or a provider. RN Staff #7 could not confirm or deny if Patient #2 left the hospital with an IV in place. Also, Staff #7 confirmed the staff did not know the exact time when the patient eloped and there was no AMA form in the patient’s medical record. A review of the facility policy titled “Vital Signs Reassessment in the Emergency Department per ESI Level, Number 5.061, and Created 3/2021” stated: “ ...II. Objective: To provide guidance related to the frequency of vital sign monitoring in the emergency department. IV. Process or Procedure A. ESI Level 1 ... B. ESI Level 2: 1. No less frequently than every hour X 4 hours, THEN 2. Every 2 hours if clinically stable 3. Vital sign assessment should be current within 30 minutes of discharge C. ESI Level 3: 1. Patients with normal vital signs should be reassessed at the discretion of the nurse BUT 2. No less frequently than every 4 hours 3. Patients with abnormal vital signs should be reassessed no less frequently than every 2 hours X 4 hours, then every 4 hours if clinically stable 4. Vital sign assessment should be current within 30 minutes of discharge ... D. ESI level 4: 1. Vital signs should be reassessed per acuity and clinical assessment BUT 2. No less frequently than every 4 hours 3. Vital sign assessment should be current within 30 minutes of discharge E.ESI level 5 ... F ... G. Patient triaged in the waiting room should have vital signs reassessed at a minimum of every 2 hours until brought back to the emergency department. H. The primary nurse will be responsible to ensure that vital signs are documented appropriately ...” A review of the policy titled, “Against Medical Advice (AMA): Patient absent without Leave” with a revised date of 1/22 was as follows: “PURPOSE: To provide guidance when a patient is to leave the hospital without discharge orders or their physician’s approval. POLICY: Each patient admitted to the hospital will be discharged by doctor’s order. PROCEDURE: When a patient insists upon leaving without a doctor’s order or against medical advice (AMA): 1. Effort should be made to persuade the patient to remain and receive care. 2. Notify the provider of the request and encourage the patient discuss AMA decision with the provider. 3... 4. Call the Clinical Director or the House Supervisor. Encourage the patient to discuss their reason for leaving and ensure patient is educated on the risks of leaving AMA. 5. All patients who choose to leave should be requested to sign the AMA form. If the patient refuses, the AMA form should be completed with indication of the patient’s refusal to sign the form. The form should be placed in the medical record. 6. Detailed documentation should be made in the medical record regarding the events that transpired, such as attempts to persuade the patient to stay, pertinent observations regarding the patient’s departure, risks and benefits of leaving and any informationprovided to the patient prior to their leaving. 7... 8. Complete a safety event to notify Risk Management of the AMA. When a patient is Absent without Leave or Elopes from the hospital without the knowledge of healthcare proveders: 1. The associate discovering the absence should immediately notify their charge nurse/immediate supervisor, clinical director/administrative supervisr, and security. 2. A search will be conducted in the facility and grounds and attempt to call the patient to determine location. 3. The clinical director/administrative will determine the need to notify the patient’s physician, nearest relative and law enforcement.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 40989 Based on observation, document review, and interview the facility failed to ensure the required signage (per section 1867 of the Social Security Act) specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC), women in labor, and whether or not the hospital participated in the Medicaid program under a State plan (under Title XIX) was posted conspicuously for all patients entering the Emergency Department (ED) for health care services Findings: An observation tour of the ED was conducted on 4/10/2024 at 12:30 PM. The main lobby was a large open area that had chairs that were placed along each wall and in the center of the waiting room. This surveyor observed 13 signs posted on a wall in the main lobby. Each sign was 8x10 in size with a small font that made it difficult for a patient to read and understand their rights as a patient receiving treatment in the ED. The signs were written in English and Spanish. The signs could not be read by a patient in the waiting room pending medical treatment due to their placement and the font size of the words printed on the signs. During a tour of the ED ambulance entrance, the patient rights and responsibilities sign was posted on the wall next to the registration clerk in the ED. The required sign for EMTALA was posted around the corner on an inside wall registration area. The signs were only posted in English. This surveyor observed EMS bring in a patient for medical treatment. The EMS personnel stopped at the registration window turning the patient away from the sign. This did not allow the patient to have access or visibility of the required patient rights and EMTALA signage. An interview was conducted with ADON Staff # 9 on 4/10/2024 at 12:45 PM. ADON Staff #9 was asked how the facility ensured that patients brought in by ambulance were able to read the required patient rights sign. ADON Staff #9 confirmed the patient was facing away from the patient rights and required EMTALA signs and stated, “Well they just rolled the patient that way because ya’ll are down here”. A review of the facility policy titled, “Emergency Medical Treatment & Active Labor Act (EMTALA) and Patient Transfer Policy” with a reviewed date of 9/19 was as follows: “ ...PURPOSE: 1. To comply with Emergency Medical Treatment & Active Labor Act (EMTALA), 42 U.S.C. § 1395 and subsequent federal interpretive guidelines and state regulations. 2. To comply with Texas Administrative Code Title 25, Rule §133.44 Hospital Patient Transfer Policy rules and regulations. This policy supports our commitment to the Core Values of Dignity of Person, Integrity, and Stewardship utilized in our Value Decision Making Model. POLICY: 1. CHRISTUS Hospital (CH) will provide, without regard to the ability to pay for services, to an individual who comes to CH requesting assistance for a potential emergency medical condition an appropriate medical screening examination within the capability of CH. 2. CH will provide an individual with an emergency medical condition necessary stabilizing treatment or will transfer the individual to another hospital through a transfer process that is in compliance with federal and state rules and regulations. 3. CH will accept the transfer of an individual who requires CH’s specialized capabilities and where CH has the capacity to provide the required medical care for the individual ... EMTALA Signage CH shall post signs, in English and Spanish, in conspicuous locations likely to be noticed by all individuals entering the emergency departments, Labor and Delivery/OB triage areas, and other areas where patients are screened stating the rights of individuals with emergency medical conditions and women in labor. Signage will indicate that CH participates in the Medicaid program ...” During an interview on 4/10/2024 at 1:00 PM, RN Staff #7 confirmed the patient rights signs and EMTALA signs were not readily visible in the main lobby of the ED for patients seeking medical treatment. Also, RN Staff #7 confirmed the signs at the ED ambulance entrance were only posted in English and no second language.”

“MEDICAL STAFF - BYLAWS AND RULES CFR(s): 482.12(a)(4) [The governing body must] approve medical staff bylaws and other medical staff rules and regulations. This Standard is not met as evidenced by: 40989 The facility failed to ensure the Governing Body (GB) reviewed, adapted, and implemented corporate policy and procedures to confirm they were specific to the facility in 1 of 1 (Blood Product Administration) policies reviewed. A review of the policy titled, “Blood Product Administration” Number 3.120 with a revised date of 9/23 did not have any statement that it was for this specific facility. The policy gave information for two states (TX and LA). A review of the Blood Product Administration was as follows: “ ...II. OBJECTIVE: To provide guidelines for the administration of blood and blood products in CHRISTUS Health ministries in non-emergent situations that do not require rapid infusion or massive transfusion guidelines. GUIDELINE STATEMENT: Blood product transfusion is one of the most common invasive procedures performed in the health care setting. Transfusion involves the introduction of active biological products (cells and proteins) from a living donor to a patient, and thus, complex biological reactions may occur. Completing key safety elements can help ensure that the risk of an adverse event involving blood administration is minimized. Additionally, understanding the possible complications of transfusion and recognizing reactions at the bedside contribute to the best patient outcomes. This document establishes the guidelines for the key elements of safe blood administration. ... B. Initiating and continuing the transfusion: ... 2. Prior to initiating the transfusion, all identifying information for the blood component and the patient must be validated at the bedside using a two-person verification process completed by licensed caregivers, one being an RN, or a one-person verification process accompanied by automated identification technology as defined in facility/ministry policy completed by the licensed caregiver initiating the transfusion ... ...V. REGULATIONS/REQUIREMENTS: The Joint Commission ... CMS CoP ... Texas Administrative Code ... Louisiana Admin Code ...” An interview was conducted with Staff #15 on 11/30/2023 after 1:00 PM. Staff #15 was asked why the blood administration policy for the hospital was using recommendations and requirements that referred to another state. Staff #15 stated, “There is nothing that says another state cannot be in the policy. You need to show me where that says that in a rule.” Staff #15 was asked why a facility in Texas would be required to adopt a policy that referred to other state laws. Staff #15 was asked what part of the policy referred to the Texas Rule and what part referred to the Louisiana rule. Staff #15 stated, “I would not put anything in the policy that contradicted the Texas rules.” Again, she was asked what part of the policy referred to the Louisiana rule. Staff #15 did not answer the question after multiple requests. An interview was conducted with Staff #3 on 11/29/2023 after 1:00 PM. Staff #3 was asked what facility/ministry policy was the policy referring to under the “B. Initiating and continuing the transfusion” section of the policy. Staff #3 confirmed Policy Number 3.120 was the facility/ministry policy. Staff #3 stated, “This is the facility policy. There is not another one. Corporate is referring this policy to itself. We are not allowed to change the policies in any form. Our policy here is to have two nurses confirm any blood products at the bedside of the patient. We have always done it that way and it will not change because that is the safest.” An interview was conducted with Staff #1 and Staff #3 on 11/29/2023 after 2:00 PM. Staff #1 was informed that during the interview with Staff #15, it was confirmed the policy referred to another state as part of its requirements and regulations. Staff #1 confirmed the policy would be corrected to fit the needs of the facility, adopted, and implemented in this specific facility. Staff #1, #2, and #3 confirmed the facility policy was not specific to the hospital campus.”