Baptist Medical Center

“. An unannounced investigation was commenced on 07/23/2026 at 520 Madison Oak, San Antonio, Texas 78258. An entrance conference was held on 07/23/2026 at approximately 2:15 PM with the CEO, Executive Assistant to the CEO, Facilities Manager; the Director of Accreditation & Regulatory Compliance also joined via phone. The purpose and process of the complaint investigation was explained, and opportunity for questions was given. All questions were answered. Complaint # TX00563402. No deficiencies cited, in substantial compliance. On the afternoon of 07/27/2026 the Director of Accreditation & Regulatory Compliance was informed via email of the completion of the investigation. Next steps in the survey process were presented and an opportunity given for questions and discussion. All questions were answered. .”

“. An unannounced investigation was commenced on 07/06/2026 at 7930 Floyd Curl Drive, San Antonio, Texas 78229. An entrance conference was held with the Chief Nursing Officer, Director of Accreditation & Regulatory Compliance, Chief Operating Officer, Patient Safety Officer, Administrative Director Plant Operations and Security, Chief Engineer, and the President/CEO on 07/06/2026 at 11:23 AM. The purpose and process of the complaint investigation was explained, and opportunity for questions was given. All questions were answered. Complaint # TX00563383. No deficiencies cited, in substantial compliance. An exit conference was held on the afternoon of 07/06/2026 with the Chief Nursing Officer, Director of Accreditation & Regulatory Compliance, Chief Operating Officer, Patient Safety Officer, Administrative Director Plant Operations and Security, Chief Engineer, and the President/CEO. Next steps in the survey process were presented and an opportunity given for questions and discussion. All questions were answered. .”

“ELIGIBILITY & PROCESS FOR APPT TO MED STAFF CFR(s): 482.22(a) The medical staff must be composed of doctors of medicine or osteopathy. In accordance with State law, including scope of practice laws, the medical staff may also include other categories of physicians (as listed at §482.12(c)(1)) and non-physician practitioners who are determined to be eligible for appointment by the governing body. This Standard is not met as evidenced by: 41048 Based upon record review and interviews, the medical staff and administration failed to ensure the medical staff bylaws, rules and regulations, included provision for the utilization and appointment of a medical student. A medical student was not clear to participate in clinicals and/or shadowing providers in the Operating Room. The medical staff and administration did not have clear communication with the medical student and with the departments involved in clinicals. The supervision of the medical student clearance and confirmation of a signed memorandum of understanding from the medical school was not completed and this fact was not clearly communicated to the medical student, the providers and operating room leadership. Review of the Medical Staff Bylaws, Rules and Regulations revealed the section in the Rules and Regulations titled, “Medical Students” Section 8.04, states “There is a signed Memorandum of understanding from the medical school and verification that the student has liability coverage and is in good standing.” Further review found of the section revelated that “The medical student must have appropriate identification issued by the Operating Room Director”. An interview was conducted with staff #1 on 9/12/2024 at 1:00 pm at Northeast Baptist Hospital. Staff #1 reported she remembered the issue regarding the staff member/medical student shadowing a surgeon at Northeast Baptist and North Central Baptist hospital. Staff #1 stated that the medical student had shadowed the surgeon multiple times at both facilities. Staff #1 stated that the issue was identified when a staff member asked for the medical student credentials, which he was unable to produced. Staff 1 stated that an internal investigation was conducted. Staff #1 revealed that the investigation resulted on a reprimand of the medical student/staff member, a provider peer review and education for the staff. The investigation also revealed that the Graduate Medical Education department never completed the Affiliation Agreement or Memorandum of Understating with the medical school attended by the medical student. An interview was conducted with staff #3 on 9/12/2024 at 1:35 PM at Northeast Baptist. Staff #3 stated that she had confronted the staff member/medical student once he was seen in the Operating Room area. Staff #3 stated that the medical student could not produce any credentials nor documentation to confirm that he was allowed to assist or shadow a provider on a surgical case. Staff #3 stated that management was not aware of this medical student and that it took some time to confirm that he was not cleared to participate in clinicals at the facility. An interview was conducted with staff #4 on 9/12/2024 at 2:00 pm at Northeast Baptist. Staff #4 stated that the staff did not complete the process to clear the medical student to participate in clinicals. Staff #4 stated that it was a unique case as the medical student was also a Anesthesia technician with access with his employee badge to the operating rooms. Staff #4 stated that education regarding bylaws and proper identification of students in clinicals was provided to the medical staff. Staff #4 also stated that a peer review was conducted to review the providers’ actions. Staff #4 stated that there was no previous history of such event. An interview was conducted with staff #5 on 9/13/2024 at 11:00 AM via telephone. Staff #5 stated that she manages 400 medical student a year in her department. Staff #5 stated that the medical student involved had communicated via email to obtained clearance for clinicals. Staff #5 stated that this was the first time trying to complete an affiliation agreement with this medical school in central America. Staff #5 stated that she made several attempts to complete the process, yet some documents were never completed by the medical school. Staff #5 stated that she informed the medical student the documentation was not complete by the medical school. Staff #5 stated that she was not sure if an email or communication was sent to the medical student or providers involved stating that the medical student was not cleared for clinicals. An interview was conducted with the medical student on 9/16/2024 at 9:00 AM. The student stated that he started the process to get cleared for clinicals at the facilities. The student stated that he was in contact with the school of medicine and the office of Graduate Medical Education. He stated that he never received or was aware of any email stating that he was not cleared for clinicals. He stated that he was embarrassed and troubled when he was pulled from a case and told he was not cleared for clinicals. A review of email records from the office of Graduate Medical Education (GME) revealed that emails had been exchanged between the medical student, the GME department and the school of medicine. The emails showed that there was communication with the medical school requesting the missing documents. The emails do not show a resolution and no email was found stating to the medical student that he was not cleared for clinicals. No email communication was noted with the providers involved. The review of the emails did not reveal any coordination with the Operating room management.”

“ELIGIBILITY & PROCESS FOR APPT TO MED STAFF CFR(s): 482.22(a) The medical staff must be composed of doctors of medicine or osteopathy. In accordance with State law, including scope of practice laws, the medical staff may also include other categories of physicians (as listed at §482.12(c)(1)) and non-physician practitioners who are determined to be eligible for appointment by the governing body. This Standard is not met as evidenced by: 41048 Based upon record review and interviews, the medical staff and administration failed to ensure the medical staff bylaws, rules and regulations, included provision for the utilization and appointment of a medical student. A medical student was not clear to participate in clinicals and/or shadowing providers in the Operating Room. The medical staff and administration did not have clear communication with the medical student and with the departments involved in clinicals. The supervision of the medical student clearance and confirmation of a signed memorandum of understanding from the medical school was not completed and this fact was not clearly communicated to the medical student, the providers and operating room leadership. Review of the Medical Staff Bylaws, Rules and Regulations revealed the section in the Rules and Regulations titled, “Medical Students” Section 8.04, states “There is a signed Memorandum of understanding from the medical school and verification that the student has liability coverage and is in good standing.” Further review found of the section revelated that “The medical student must have appropriate identification issued by the Operating Room Director”. An interview was conducted with staff #1 on 9/12/2024 at 1:00 pm at Northeast Baptist Hospital. Staff #1 reported she remembered the issue regarding the staff member/medical student shadowing a surgeon at Northeast Baptist and North Central Baptist hospital. Staff #1 stated that the medical student had shadowed the surgeon multiple times at both facilities. Staff #1 stated that the issue was identified when a staff member asked for the medical student credentials, which he was unable to produced. Staff 1 stated that an internal investigation was conducted. Staff #1 revealed that the investigation resulted on a reprimand of the medical student/staff member, a provider peer review and education for the staff. The investigation also revealed that the Graduate Medical Education department never completed the Affiliation Agreement or Memorandum of Understating with the medical school attended by the medical student. An interview was conducted with staff #3 on 9/12/2024 at 1:35 PM at Northeast Baptist. Staff #3 stated that she had confronted the staff member/medical student once he was seen in the Operating Room area. Staff #3 stated that the medical student could not produce any credentials nor documentation to confirm that he was allowed to assist or shadow a provider on a surgical case. Staff #3 stated that management was not aware of this medical student and that it took some time to confirm that he was not cleared to participate in clinicals at the facility. An interview was conducted with staff #4 on 9/12/2024 at 2:00 pm at Northeast Baptist. Staff #4 stated that the staff did not complete the process to clear the medical student to participate in clinicals. Staff #4 stated that it was a unique case as the medical student was also a Anesthesia technician with access with his employee badge to the operating rooms. Staff #4 stated that education regarding bylaws and proper identification of students in clinicals was provided to the medical staff. Staff #4 also stated that a peer review was conducted to review the providers’ actions. Staff #4 stated that there was no previous history of such event. An interview was conducted with staff #5 on 9/13/2024 at 11:00 AM via telephone. Staff #5 stated that she manages 400 medical student a year in her department. Staff #5 stated that the medical student involved had communicated via email to obtained clearance for clinicals. Staff #5 stated that this was the first time trying to complete an affiliation agreement with this medical school in central America. Staff #5 stated that she made several attempts to complete the process, yet some documents were never completed by the medical school. Staff #5 stated that she informed the medical student the documentation was not complete by the medical school. Staff #5 stated that she was not sure if an email or communication was sent to the medical student or providers involved stating that the medical student was not cleared for clinicals. An interview was conducted with the medical student on 9/16/2024 at 9:00 AM. The student stated that he started the process to get cleared for clinicals at the facilities. The student stated that he was in contact with the school of medicine and the office of Graduate Medical Education. He stated that he never received or was aware of any email stating that he was not cleared for clinicals. He stated that he was embarrassed and troubled when he was pulled from a case and told he was not cleared for clinicals. A review of email records from the office of Graduate Medical Education (GME) revealed that emails had been exchanged between the medical student, the GME department and the school of medicine. The emails showed that there was communication with the medical school requesting the missing documents. The emails do not show a resolution and no email was found stating to the medical student that he was not cleared for clinicals. No email communication was noted with the providers involved. The review of the emails did not reveal any coordination with the Operating room management.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 29242 Based on record reviews and interviews, the facility failed to ensure that nursing staff documented accurate assessments and events that occurred for 1 of 1 patients (Patient #1) reviewed. This deficient practice placed all patients in the facility at high risk for undetected, untreated serious illness and/or injury. Findings included: Record review of the physician’s progress notes for Patient #1, dated 10/09/2023 at 1:35 p.m. revealed the following information: 36-year-old male with a past medical history of a Status Post (s/p) craniotomy in the past, hypertension, PEG tube insertion who presented from outside ER with altered mental status and laboratory findings initially concerning for sepsis. He was intubated at the outside ER. So far infectious work-up has been negative. However history provided by the sister Indicates that he likely had a seizure. He has been extubated and is now on minimal amounts of nasal cannula. s/p VP shunt placed on 10/3/2023. Patient was seen in room 585 and he was more awake and alert today. Able to follow simple commands. RN reported that the patient had a fall earlier this morning ... Magnetic Resonance Imaging (MRI) of head-showed prior infarcts but nothing new. Overnight the patient became agitated that required physical restraints. Currently calm, will Discontinue (DC) physical restraints and monitor. Change Seroquel to 100 mg at bedtime. No reported head injury however will repeat Cat Scan (CT) of head without contrast. Record review of the nurse’s notes for Patient #1, dated 10-08-2023 to 10-10-2023, revealed that patient #1 was considered a (code Yellow) fall risk (high risk). Further review revealed no evidence that nursing staff had performed a post fall assessment of Patient #1, obtained routine vital signs, or post fall neuro-checks on patient #1 after his reported fall on 10/09/2023. Record review of the facility policy entitled: Falls Prevention Protocol (RM-PS-07), revised 08/2023, revealed the following: D. Post-Fall Management 1. Assess for injury (e.g., abrasion, contusion, laceration, fracture, head injury, bleeding). 2. Activate RRT if change in patient condition post-fall. Primary nurse leads post-fall huddle. 3. Obtain radiologic studies and lab tests as indicated by physician or licensed practitioner. 4. Document the fall in the EMR using the Nursing Narrative Ad-Hoc form. 5. Complete Post-Fall Assessment Form and return to immediate supervisor for review/follow-up. 6. Supervisor ensures form is complete and is forwarded to Quality Department. 7. Obtain vital signs (including neuro checks if applicable) and a physical assessment after every fall a. Every 30 min x4, every 2 hours x2 then per unit routine. b. If vital signs are critical or the patient is deteriorating, continue vital signs every 15 minutes and call the physician and the Rapid Response Team. c. If possibility of head injury, include Neuro Checks q 1 hour x 4 hours. 8. Notification of fall (document in Frequent Assessments > Notification in the Electronic Medical Record [EMR]): a. Physician b. Patient’s emergency contact 9. Code Yellow response team conducts a debriefing huddle using the Post-Fall Assessment Form (90448800) In an interview conducted on 01/31/2024, at 2:35 p.m. the facility Director of Accreditation and Chief Nursing Officer both verified the above findings and the facility’s non-compliance.”

“A life safety code (LSC) Compliant Investigation was conducted on site on 01/18/2024. An entrance conference was held for the CEO, CNO, COO, on the afternoon of 01/18/2024 to discuss the purpose of the LSC survey, and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided 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. An LSC exit conference was conducted on 01/18/2024 in the hospital. In attendance were the CEO, CNO, COO. 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. It was determined the compliant was substantiated due to the HVAC system damaged from the winter storm.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3 This Standard is not met as evidenced by: 32167 The inspector observed, while accompanied by the CEO, CNO, COO, during the hours of the inspection from 11:45 AM to 3:30 PM on 01/18/2024 that there were the following issues. They were the following issues. A) The busway for the normal power was damaged during the winter storm resulting the hospital Tower 1 and Tower 2 lost the normal power. The temperature was not maintained for some time, but the portable generator was obtained on site as the normal power source. B) The HVAC control unit for the ED department was damaged but it was repaired within hours to bring the temperature back up to normal range.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 32167 The inspector observed, while accompanied by the CEO, CNO, COO during the hours of the inspection from 11:45 AM to 3:30 PM on 01/18/2024 that there were the following issues. They were the following issues. A) There were two parked cars within 10’-0” of medical gas bulk storage tank. It is not permissible and please provide no parking signage post or on the ground.”