St Joseph Medical Center

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 50678 Review of Fire Alarm System indicated Inspection and Repairs are delinquent. In review of the Fire Alarm documents, last annual inspections are as follows: “ Strake Building 12/17/24 (Blue and Red Tag) “ Pavillion 12/17/2024 (Blue and Red Tag) “ Central Plant 12/17/24 (Blue Tag) “ Women’s Center 12/17/2024 (Blue and Red Tag) “ No report was provided for the GWS building Of note, the facility has a Behavioral Health Center. This building is not occupied, however the Fire Alarm Annual Inspection was conducted 12/17/24 and is Red Tagged.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 50678 In review of the Fire Sprinkler System, the Facility was in the process of replacing the Shunt Trip (part of the Automatic Transfer Switch associated with the EES) while the inspector was at the site. The system will be tested within the next two days, and the Facilities Director will send the inspector an email once completed on the outcome of the test. Inspector requested the Fire Sprinkler System Annual Survey documents and what was provide is below. Systems are behind in their reiview and survey and have multiple yellow tags associated with components of the system. Documents were provided as requested, and upon inspection it was determined the Fire Sprinkler System was last inspected as follows: “ GWS Building 2/03/25 through 2/15/25 5th Year Inspection (Blue Tag) 2/11/25 PRV (Blue Tag) “ Central Plan 2/20/25 5th Year Inspection (Blue Tag) “ Pavillion 2/19/25 PRV (Blue Tag) Loading Dock (pendants), 09/30/24 Annual Sprinkler and Hose Valve, (Yellow Tag) 10/28/24 last Annual Fire Pump (Yellow Tag) 10/15/24 Annual Sprinkler and Hose Valve (Yellow Tag) “ Women’s Center 11/01/24 Annual Fire Pump (Yellow tag for transfer switch) “ Strake Building 12/13/24 last Annual Sprinkler and Hose Valve (Yellow Tag) In summary each system has some concerns and an have received both Yellow and Blue tags, with Yellow Tags indicating issues with the particular components of the system.”

“A Life Safety Code (LSC) complaint survey was conducted at the facility on 6/9/2026. An entrance conference was conducted on the afternoon of 6/9/2026 with the Administration representative, Chief Quality Officer, and Facilities Manager to discuss the purpose of the LSC complaint and the survey process. An opportunity was provided to the hospital attendees for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital ’ s compliance. A LSC exit conference was conducted on the afternoon of 6/10/2026, with the Administration representative, Chief Quality Officer, Facilities Manager and Hospital Facilities Director. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 45092 Based on observations during the tour of the facility on 6/9/2026 and 6/10/2026 with the Administration representative, Chief Quality Officer, and Facilities Manager, the facility failed to maintain the fire sprinkler system. Annual testing per NFPA 20 and NFPA 25 were not being performed. Multiple yellow tags on multiple systems including tags for lack of inspection, tags for a Fire Pump not maintaining pressure, and a tag for a Fire Control Transfer Switch being non-operable were seen in the Pavillion tower of the hospital. The Fire Sprinkler Pump last inspection was 2023, with a yellow tag on the Pump Controller dated 2025 where the non-functioning transfer switch was located. The Fire Pump was blue tagged with a 2025 tag in the SKS tower of the hospital. The Fire Pump Controller box had a yellow tag from 2024, and the Pump had a yellow tag from 2024. Facilities Manager indicated that based on the facility test, the pump would not maintain pressure in the Women’s Pavillion tower of the hospital. Based on review of the records on 6/9/2026 with the Administration representative, Chief Quality Officer, and Facilities Manager, the facility failed to show records to indicate that specific annual tests and inspections were conducted, and these specific test/inspections are dated 2024 and 2025. The sprinkler system was not completely tested. Based on review of the records on 6/9/2026 with the Administration representative, Chief Quality Officer, and Facilities Manager, the facility failed to show records of the facility’s Fire Watch Policy associated with a component of the Fire Protection System being non-functional. The emergency policy was presented and dated 2023 (reviewed 12, 2025 by facilities with no recommended change.) The Facility shall implement a Fire Watch immediately in that a critical component of the Fire Protection System is non-functioning. Provide the Fire Watch logs to Texas HHSC for review each week.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 45092 Based on observations during the tour of the facility on 6/9/2026 with the Administration representative, Chief Quality Officer, and Facilities Manager, the facility failed to maintain the Automatic Transfer Switch (ATS) in the Pavillion Building. This non-functioning ATS is designed to provide electricity to the Fire Pump in the event a fire occurs when the Essential Electrical System (EES) is engaged due to loss of normal power.”

“PROTOCOLS CFR(s): Protocols must be consistent with nationally recognized and evidence-based guidelines for the care of patients with emergency conditions, including but not limited to patients with obstetrical emergencies, complications, and immediate post-delivery care. This Standard is not met as evidenced by: 46010 Based on interviews and records review, the facility failed to follow accepted standards and protocols for safe discharge for an emeregncy department patient, by discharging the patient home with an accessed dialysis fistula. This failed practice could result in serious harm or death to a patient (Patient ID #1). Findings Included: HHSC Intake stated Patient ID #1 arrived to the facility via EMS ambulance on 1/27/26 from a dialysis facility after having a seizure while hemodialysis treatment was in progress. The complaint stated the dialysis facility “had left the needles in the arm” and transferred the patient via ambulance. The complaint alleged the patient was seen in the ED and discharged with the needles in place. The complaint alleged the patient had “arm pain” and returned on 1/28/26 to the dialysis center and they found “the patient still had the same needles in his arm.” Medical record review of Patient ID #1 showed he arrived via HFD EMS to the facility ED on 1/27/26 at 3:29 pm. He had chief complaint of seizures while receiving hemodialysis. He had complete blood count, CBC and EKG completed. He was given keppra IV for seizure medication. Staff RN # 68 documented on 1/27/26 at 5:25 pm in discharge note “patient given discharge information and verbalized understanding, IV removed. ambulated to exit with steady gait. dialysis line still intact per MD instructions, patient will follow up with dialysis center.” 6/2/26 at 10:40 am medical record reviewed with nurse informaticist staff ID # 61. She confirmed she could not locate a physician assessment or nursing assessment revealing that the patient had an accessed dialysis fistula in the ED. She confirmed that she could not locate an order to discharge patient with dialysis fistula accessed. Interview with ED Nurse Manager staff ID #58 on 6/2/26 at 8:45 am. She stated that if a patient arrived to the facility with a dialysis hemodialysis fistula accessed, the ED staff should call one of the dialysis nurses from their dialysis team to safely remove the access prior to discharge. She confirmed there is no standard policy or procedure governing this nursing practice.”

“MEDICAL STAFF CFR(s): 482.12(a) The governing body must: This Standard is not met as evidenced by: 37322 Based on record review and interview, the Governing body failed to ensure the appointment of the temporary emergency medical staff, met the criteria stated in the medical staff bylaws. Record review of the Medical Bylaws, ARTICLE 2 - STAFF MEMBERSHIP & CLINICAL PRIVILEGES Review and Approval: Medical Executive Committee Approved 12/15/2021, page 17 Hospital Board of Directors Approved 12/29/2021 Stated “Emergency Medicine: Applicants for Medical Staff membership who will provide Emergency Medicine services in the Hospital’s Emergency Department shall meet the following additional criteria: a. Board certification, or evidence of being on track for board certification, by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine, or b. Board certification by the American Board of Medical Specialties in either Internal Medicine, Family Practice, or General Surgery; and certification on the “Provider” level in the American Heart Association’s Advanced Cardiac Life Support (ACLS) program and the American College of Surgeons Advanced Trauma Life Support (ATLS) program; and at least five years’ experience in the practice of Emergency Medicine on a full time basis, with a minimum of 7,000 hours in the practice of Emergency Medicine” This was verified on 05/18/2025 by record review and interview with (staff# 2), and that all board certified and two of the appointed physicians have ACLS. None have Trauma certification, but they already had a trauma provider on call and were on trauma divert.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 37322 Based on observation, record review and interview, the facility failed to ensure 3 of 5 crash carts were checked daily, ensuring the patients right to have a functioning crash cart in the emergency department, and functioning elevators for patient transport. Findings Included: Record review of the facility policy “Crash Cart Replenishment-Adult, Pediatrics, Neonatal” ORIGINATION DATE: 08/08/2025 FINAL APPROVAL DATE: 08/18/2025 3. Each department will check their crash cart on a daily basis (or departmental requirements) for availability, security and operational functionality (defibrillators). 4. Each department will maintain documentation of crash cart checks. During rounds on 05/15/2026 at 1000 in the emergency department, 3 of the 5 crash carts were not checked consistently by staff. In the Pyxis room the crash cart was not checked on 05/02, 05/08, 05/11,12,13/2026 In the Intake area, it was noted the crash cart was not checked on 05/13/2026. The Pediatric cart was not checked on 05/03/2025, 05/10-11/2026. Observation of the elevators 38,39, 41, 42, was noted by signage, that they were out of service. Interview with nurse (staff #6), during rounds, verified the findings, regarding the crash cart Interview on 05/15/2026 at 1105 with staff (#9) vertified that the elevators 38,39, 41, 42 were not working and had not been working for several months.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 46010 Based on interview and record review, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CF R 489.24, Special responsibilities of Medicare hospitals in emergency cases. The facility transferred a patient for specialty orthopedic surgery consultation and management, when they had the capacity and capability of providing orthopedic care for Patient ID #25. Refer to tag A 2409 for additional information.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 46010 Based on record review and interviews, the facility failed to utilize it’s specialized on call orthopedic surgical services, to provide consultation and management, for a patient who presented to the Emergency Department with a tibia and fibula fracture. This resulted in the transfer of a patient to another facility, for orthopedic surgical consultation and management. Therefore, the risk of transfer, appeared to have outweighed its benefit for Patient ID # 25. Findings Included: Record review of Patient ID #25 medical record note that the patient presented on 4/21/25 at 21:37 to the facility ED with complaints of fall on a bike with isolated ankle pain and inability to bear weight. ED provider staff ID # 58 evaluated the patient and noted “Right lower extremity with aluminum splint in place from EMS. There is noted swelling to the medial and lateral aspect of the right ankle. Superficial abrasions without laceration present. Range of motion of toes to right foot as well as to right knee. Distal pedal pulse 2+. Capillary refill less than 2 seconds. Sensation intact distal to injury. Does have mild reported tenderness to palpation of proximal tibia.” ED Staff physician ID #58 note stated “Case discussed with orthopedics surgeon staff ID #79 (name redacted). After case discussion and imaging review, orthopedic surgeon recommends transfer to Ben Taub for management of patient’s injury.” Record review of “Orthopaedics Call Schedule 4/1-4/30 (2025)”, Orthopedic Surgeon Staff ID # 79 is listed on call from 4/17/2025 - 04/25/2025. Record review of facility policy titled “Patient Transfer Policy”, origination date 9/30/24, stated “HOSPITAL CAPABILITY- The hospital shall, within its capability, provide treatment to minimize the risks to the health of the individual or, in the case of a woman in labor, the health of the woman or her unborn child.” The policy further stated “The hospital may not transfer an individual with an emergency medical condition unless the benefits of such a transfer outweigh the risks.” Interview with CNO Staff ID # 52 on 4/22/25 at 4:15 pm. Discussed Patient ID #25. She stated the facility did have the capacity and capability of caring for Patient ID #25. She stated that the transfer out from the Emergency Department did not get escalated to the administrator, as per facility policy. She stated the orthopedic surgeon involved is “newer to the facility.” She confirmed the facility has multiple orthopedic surgeons available, in the event that a specific case surpasses the expertise or skill of a particular specialist. Interview with ED Physician Practice Medical Director Staff ID # 57 on 4/22/25 at 11:00 am with medical record review. Medical record for patient ID # 25 on date of service 4/21/25 was reviewed. He stated he believed the facility had the capability and capacity to care for the distal tibia/fibula fracture which Patient ID #25 presented with. He confirmed the ED physician Staff ID # 58, had consulted orthopedics staff ID #79, by telephone, and been instructed by him to transfer the patient for higher level of care. He confirmed that he did not see an order placed for orthopedic surgery consultation. However, he stated that the process in the ED was for the physician to personally call the consult to the specialist. He confirmed he could not locate an orthopedics consult note discussing Staff ID # 79 involvement in case or medical decision making for the transfer. Telephone interview with Orthopedic Surgeon Staff ID # 79 on 4/23/25 at 09:00 am to discuss the process for orthopedic consultation and specific questions related to care of ED patient ID #25. Orthopedic Surgeon Staff ID # 79 confirmed that he is an orthopedic surgeon who takes call for the facility, as well as 2 other “trauma centers.” He confirmed that he had received a call from the ED physician Staff ID #58 on 4/22/25 “near midnight” regarding Patient ID #25, who had presented to the facility ED with an isolated ankle injury. He stated he spoke with the ED physician staff ID # 58 and reviewed the patient’s imaging during the call. He stated that he recommended transfer to an orthopedic trauma surgeon because he felt the patient had the potential need for a vascular surgeon and/or the limited availability of equipment for handling this case at St. Joseph’s. He stated this was a comminuted displaced distal tibia fracture with fibula fracture. He confirmed that he did not write an official consultation note or document his involvement or medical decision making in the case. He stated that he typically does not write consult notes, on patients for which he is consulted and recommends transfer. He stated he performs consultation notes, if the patient is kept at the facility for definitive treatment. He was asked whether the facility has other orthopedic surgeons or orthopedic trauma surgeons who may have felt comfortable with surgical management of Patient ID #25’s case. He stated “Yes, Orthopedic Surgeon Staff ID # 78 (redacted name).” He was asked whether there is a process for admitting patients for observation, if appropriate, and referring to colleagues available at the facility, and he stated “no, he could not assume Orthopedic Surgeon Staff ID # 78 was available.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 37490 Based on observation, interview and record review, the facility failed to ensure the patient’s right to care in a safe setting for 1 of 6 patients receiving care in the Emergency department (ID# 3). Findings include: Review of facility policy titled “Patient’s Rights and Responsibilities,” dated 2/21/2023 showed the following: Procedure: 2. Patient’s Rights: -Receive considerate and respectful care provided in a safe environment, free from all forms of abuse, neglect, harassment or exploitation. Observation in the Emergency Department (ED) Disposition area on 4/3/2025 at 11:15 AM showed a patient restroom with no working call light and a rusty metal toilet, 6 patient care areas (recliners) with no call lights available, and a nurses’ station behind partial wall/glass enclosure and not all patient care areas were visible. When surveyor tried to get the attention verbally of survey team and administrative staff behind the glass enclosure, the surveyor could not be seen or heard. Interview with staff #ID 56 on 4/3/25 at 10:30 stated that the ED disposition area is not always in use. It is used for lower acuity patients (with ESI 4 or 5) on days when staffing allows. Interview with facility CNO #ID 55 on 4/3/25 at 11:20 stated that the area would not be utilized until patient safety issues were addressed.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 46010 Based on document review and interview, the facility failed to ensure the medical staff followed the bylaws/rules and regulations of the medical staff, which included ensuring an order for specialty consultation was placed in the medical record and ensuring documentation of the consultation occurred in 1 of 5 patient records reviewed (Patient ID #11). Findings Included: Record review of medical record for Patient ID #11 for date of service 10/25/24 until 11/1/24. Critical care progress note written by Staff Physician ID #87 stated “It was at this time that vascular surgery was as the bedside in which the decision was made to transfer the patient to the Cath lab emergently for re-evaluation and exploration ...” . Cath lab procedure note 10/28/24 stated “Primary surgeon: (Redacted)/Vascular surgeon Staff ID #76). Record review of facility “General Rules of the Medical Staff”, last approved 07/27/2020, stated “CONSULTATIONS: A. General 1. It is the responsibility of the Department Chairman to see that the members of his department call consultants as needed. The call for a consultant must be either physician to physician, or physician’s office to physician’s office. The consultant must be appropriately delineated and qualified to give an opinion in the field in which consultation is sought. 2. As soon as possible, the referring physician will document in the orders or the progress notes the date and time the consult was requested ... 5. For emergency consultations requested by services other than the Emergency Department, residents or fellows may respond to the request for consultation and prepare the consultant note. However, the consultation must be reviewed and confirmed within two hours in person or by telephone with the attending physician. The consultation should be documented in the medical record and counter-signed by the attending physician. 6. Consultants will not postpone their initial evaluation of the patient pending the ordering or obtaining test results. 7. An acceptable consultation includes the examination of the patient and the record, and a written opinion signed by the consultant. When invasive procedures are involved, the consultation report shall be documented prior to the procedure.” Interview with Staff Informaticist ID # 77 on 4/4/24 at 10:25 am. She confirmed there was no evidence of an order placed for Cardiothoracic vascular surgery staff ID # 76, no evidence of progress note or consultation note by Staff ID #76. She stated there had been no chart entries by Physician Staff ID #76 placed in Patient ID #11 medical record which she could locate. Interview with CNO Staff ID #55 on 4/4/24 at 10:30 am. She confirmed that she would expect an order to be placed for consultation for physician consultation/engagement in medical record. She confirmed she would expect any physician who had performed an evaluation and/or procedure on a patient to document their encounter in the medical record per policy.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 46010 Based on interview and record review, the facility failed to ensure nursing assessed, documented and acted on the rapidly changing needs of a patient who was receiving care at the facility in 1 of 13 sampled patients (Patient #11). The facility failed to ensure: 1)Nurses accurately assessed and acted on vital sign changes for Patient ID #11 in the post-cath lab procedure area (Patient ID #11). 2)Failed to activate the rapid response team in a timely manner for Patient ID #11 who displayed signs of hemorrhagic shock post-invasive cath lab procedure (Patient ID #11). Findings Included: Record review of Patient ID #11 medical record with Nurse Informaticist Staff ID # 77 on 4/4/24 at 10:25 am. Medical Record entry placed by Staff RN ID # 75 on 10/28/24 at 09:15 am “heart rate 100,” 09:45 Vascular access site “Hematoma” 10:15 am stated “heart rate 116 ...” at 10:30 am stated “heart rate 118 and blood pressure 89/45.” 10:45 am stated “heart rate 102. Charge nurse contacted MD. Recheck 78/61. Fluids & trendelenberg.” 11:00 “heart rate 118”. 11:15 am “heart rate 118”. 12:30 BP 91/43, HR 101, RR 31, 02 sat 98% on 4L. Pt BP cont. to drop. Pt breathing has become labored. Contacted MD again.” 12:40 “RRT called. BP 65/51, HR 98, RR 30, 02 sat 99% on 10L.” Record review of facility policy titled, “Patient Assessment, Reassessment and Documentation of Care”, last revised 08/15/2023, stated “Policy: Patients are assessed on admission and at a minimum each shift to determine care, treatment and services that will meet the patient’s initial and continuing needs. The process of assessment includes: 1. Collecting information about the patient’s health history as well as physical, functional, and psychosocial status. 2. Analyzing the information in order to understand the patient’s needs for care, treatment and services. 3. Making care, treatment, and services decision based on analysis of information collected. Depth and frequency of reassessment is dictated by patient’s needs, program goals and the care, treatment and services provided .... C. Reassessments are performed and documented in the medical record as necessary based on patient’s plan of care or changes in the patient’s condition.” Record review of facility policy titled, “Rapid Response Team”, last revised 07/18/23, stated “Policy: Rapid Response Team is to improve patient care and outcomes through response to early warning signs of clinical instability. Procedure: 1. A staff member, patient or family may call the team to address a change in a patient’s condition. 2. Triggers for a call to RRT may include but are not limited to: a. Significant change in heart rate b. Change in systolic blood pressure (systolic BP less than 90 mm Hg, SBP 30 mmHg below usual, systolic BP over 200 mmHg) c. Change in respiratory rate to ( less than 8 or greater than 30), or respiratory distress, or change in respiratory pattern (dyspnea) ... h. Acute bleed ...” Interview with CNO Staff ID #55 on 4/4/25 at 10:40 am. She confirmed she would expect nursing staff to act on vital sign changes which are > 10% from patient’s baseline, taking into account patient assessment and situation. She confirmed that the acquisition of a groin hematoma on assessment, heart rate elevations and blood pressure decreasing could be signs of hemorrhage. She confirmed that she would expect rapid response team to be initiated in the post-cath lab procedure area per policy to assist with timely patient care and intervention.”

“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: 46010 The facility failed to ensure that the medical staff operated under the current bylaws, rules and regulations. The facility failed to ensure that patients were seen by an approved, teaching attending physician within 24 hours of being seen by a teaching resident and failed to ensure that documentation by the teaching resident had co-signatures/attestations within 24 hours (Patient ID #1). Findings Included: Record Review of electronic health record for Patient ID #1 performed with Nurse Informaticist Staff ID #62 on 9/4/24 at 1:30 pm. She confirmed that Patient ID #1 had a plastic surgery consult ordered and had been seen by Plastic Surgery Resident physician staff ID # 67 on 1/28/24 at 8:15 pm. Patient ID #1 had been seen by plastic surgery resident staff ID # 68 on 1/29/24 at 07:58 am. She confirmed the medical record reflected an attestation/co-signature for both notes which was signed on 2/13/24 at 10:15 am by Attending Physician Staff ID #66. Record Review of facility “General Rules of the Medical Staff”, last approved 9/23/2019, stated “Supervision of Residents. D. A note and signature by the attending physician, with whom the resident is working or who is supervising the resident, is required every 24 hours and/or a daily basis ...” Record Review of facility policy “Graduate Medical Education (GME) Resident Supervision Policy and Guidelines”, last revised 10/9/2020 stated “Supervision in the setting of graduate medical education provides safe and effective care to patients; ensures each resident’s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishes a foundation for continued professional growth. ... Documentation of supervision is required by the ACGME and the Hospital Medical Staff By-Laws. The Medical Staff By-Laws require that documentation of the supervision of the resident must occur on a daily basis in the patient’s medical record.” Telephone Interview 9/6/2024 at 10:55 am with Graduate Medical Education Coordinator Staff ID #74. She confirmed that plastic surgery resident physician staff ID #67 was a qualified and approved plastic surgery resident from 7/1/2021 through 06/30/2024. She confirmed that the “Graduate Medical Education (GME) Resident Supervision Policy and Guidelines”, last revised 10/9/2020, were the guidelines which are set forth by the facility for supervision of medical residents. Telephone Interview 9/6/2024 at 10:30 am with Director of Medical Staff Administration Staff ID #75 was conducted. She reviewed medical staff rules and regulations and document titled “General Rules of the Medical Staff.” She confirmed that medical staff rules required that patients who were seen by teaching residents and fellows, would need to have consult or progress notes signed every 24 hours or on a daily basis. She confirmed that a note performed by a resident physician on 1/28/2024 and 1/29/2024 and signed by an attending physician on 2/13/2024 would not meet this requirement.”

“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: 37490 Based on interview and record review, the facility failed to fully uphold the patients’ right to informed decision-making regarding their care and treatment. Three (3) of 3 sampled patient records failed to contain current anesthesia consents as required by 25 TAC §604.5(1). (Patient IDs # 1, 14, and 15). Findings included: Review of the Texas Medical Disclosure Panel showed the following: Effective Dec. 26, 2023, the TMDP repealed and replaced certain portions of the Texas Administrative Code (TAC), as listed below ... adopted new 25 TAC Chapter 604, concerning Disclosure Forms Medical record review for patient (ID#1) for procedure date of service 1/30/2024, 2/2/2024 and 2/5/2025 showed anesthesia consent not as required in 25 TAC §604.5(1). Medical record for patient (ID#14) for procedure date of service 9/4/2024 showed anesthesia consent not as required in 25 TAC §604.5(1). Medical record for patient (ID#15) for procedure date of service 9/4/2024 showed anesthesia consent not as required in 25 TAC §604.5(1). The above findings were verified by Quality staff ID# 51 on 9/4/2024 at 2:25 PM. She stated that corporate has the ability to change forms that are utilized at the facility, it cannot be done at the local level.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 46010 Based on interviews and record review, the facility failed to ensure patient’s discharge plans were re-evaluated and updated to reflect occurrences/care provided at the facility. Therefore, the patient failed to receive: 1) comprehensive specialty follow-up instructions 2) wound care/post-operative dressing instructions and 3) failed to include home health services provider and contact information for IV antibiotic infusion therapy (Patient ID #1). Findings included: Record review of electronic health record for Patient ID #1 performed with Nurse Informaticist Staff ID #62 on 9/4/24 at 1:30 pm. The medical record for Patient ID #1 “Discharge Summary”, dated 2/9/2024, and provided by RN Staff ID #70 on Date of Service 2/9/2024 stated “Follow up with Physician ID # 69 (primary care).” Nurse Informaticist Staff ID #62 confirmed she was unable to locate the plastic surgeon’s name (Physician ID # 65) who had operated on the patient, his clinic information, contact information or when to make a follow-up appointment in the instructions. She confirmed there were no wound care instructions in the discharge instructions. She was unable to locate the name of the post-acute home health agency and contact information for the home health provider for which home antibiotic infusion therapy had been arranged in the discharge summary/instructions, which had been provided to the patient at discharge. Record review of facility policy “Discharge of Patients Policy and Procedure”, approved 10/23/23, stated “Procedure: ... d. Provide patient and family/caregiver(s) with the discharge instruction sheet on prescribed treatments, medications, diet, activity level, and scheduled follow-up appointments, if any.” Record review of facility policy “Discharge/Transition of Care Planning Department”, Policy #CM02, last revised 08/31/2021, stated “General Guidelines 1. Discharge planning is completed and documented in a timely manner to ensure the continuity of patient care by developing an adequate post-hospital care plan which considers the medical, social, emotional and financial needs of the patient and family .... 3. A written, comprehensive individualized discharge plan consistent with medical discharge orders and identified patient needs will be provided to each patient and/or family/representative at the time of discharge ... 8. Members of the healthcare team will provide and document in-hospital education/training to the patient or patient’s representative relative to the discharge plan, self-care, arrangements post-discharge.” Interview 9/4/2024 at 12:15 pm with Nursing Director Staff ID #58. She stated it was the provider and nurse’s responsibility to ensure comprehensive discharge instructions were completed in the electronic medical record and provided to the patient in writing prior to discharge home.”

“DISCHARGE PLANNING PROGRAM REVIEW CFR(s): The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This Standard is not met as evidenced by: 46010 Based on interview and record review, the facility failed to assess its discharge planning process, by failing to re-assess and analyze a patient who was re-admitted within 30 days of a previous admission, to ensure that the plans were responsive to the patient post-discharge needs (Patient ID #1). Findings Included: Record Review of electronic health record for Patient ID #1 performed with Nurse Informaticist Staff ID #62 on 9/4/24 at 1:30 pm. She confirmed that that Patient ID #1 had been admitted to the facility from 01/28/2024 until discharge 02/09/2024. She confirmed the patient re-presented to the ED on 2/16/2024 and was re-admitted to the facility. The patient was discharged 02/20/2024. The plastic surgery consult completed on 2/16/2024 at 1:41 pm by Physician ID # 68 stated “patient did not get antibiotics for 4 days.” Informaticist Staff ID #62 confirmed she could not locate a case management assessment or re-assessment which assessed for prior discharge barriers and etiologies for non-compliance with home antibiotic infusions. Record Review of facility policy “Discharge/Transition of Care Planning Department”, Policy #CM02, last revised 08/31/2021, stated “8. Members of the healthcare team will provide and document in-hospital education/training to the patient or patient’s representative relative to the discharge plan, self-care, arrangements post-discharge. 9. Monitoring and Evaluation of the Discharge Planning Process are reported to the Utilization Management Committee and include, but are not limited to the following metrices: a. Readmission rates. B. Utilization and referrals to transition partners including tele-monitoring. C. Patient satisfaction comments, complaints, or grievances received related to the Discharge planning process ...” Interview 9/6/24 at 12:25 pm with Case Manager Staff ID #73 performed with record review. She was unable to locate case management re-admission assessment in Patient ID #1 medical record from 2/16/24 - 2/20/24 hospitalization/re-admission, which assessed patient’s etiology for non-compliance with home health IV antibiotic regimen.”