Texas Health Arlington Memorial Hospital

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 45521 Based on a review of documentation, policies and interviews with the Facility Staff, the facility failed to provide vital sign assessment after administration of hydromorphone solution 1mg, Once IV on 12/17/2023 from 4:30 PM to 5:16 PM. Hold for Resp Rate < 10 or Systolic BP < 100. The Findings were: A review of the document titled Patients Medical Record dated 12/14/2023 documents administration of hydromorphone solution 1mg, Once IV on 12/17/2023 from 4:30 PM to 5:16 PM. Hold for Resp Rate < 10 or Systolic BP < 100. Vital Signs on 12/17/2023 at 4:19: BP: 171/92, Pulse: 131, Resp: 20, Temp: 98F Temporal artery, SpO2: 99% on room air. Pain was documented by Staff # 2, RN-ED as a level 10 at 4:18 PM. Pain was at a level 10 at 4:55 PM. No additional pain assessments, interventions or vital signs was documented. Effectiveness of medication was not documented. Pulse was documented at 95 at 8:13 PM. No additional vitals documented. A review of the facility’s Policy titled, “Assessment, Reassessment, and Documentation - Attachment B, Emergency Department (ED)” section 1.3.3 and 1.3.3 subsect c, page 2 “Vital signs are defined as: blood pressure, temperature (temporal artery only appropriate for those minor complaint ESI 4 & 5), pulse, respiratory rate, oxygen (02) saturation percentage and 02 delivery type, Glasgow Coma Scale (GCS), and pain level. c. ESI 3- stable, requiring multiple resources needed to treat. Vital signs(*** Core temperature recommended) and Glasgow Coma Scale (GCS) during triage and subsequently every two hours at a minimum, or at discharge. Patient condition may require more frequent reassessments. *Reassessment completed with any change in patient condition.” The facility failed to follow this policy when nursing did not obtain vital signs every two hours at a minimum or at discharge. An interview with Staff # 6, John Dinnen, RN-ED on 02/13/2024 at approximately 10:35 AM revealed the following: Surveyor: What is an auto restart of vitals timer? RN-ED: I can set a timer for vital signs to be rechecked for anywhere from 15 min to every two hours. Surveyor: When would you document the effectiveness of Dilaudid? RN-ED: I would check in 5 to 10 minutes. That is a very strong narcotic. Surveyor: If a patient reported a pain level of 10/10 twice in an hour, what would your next step be? RN-ED: I would notify the doctor. Surveyor: Would you continue to assess the patient for pain? RN-ED: Yes, I would assess the pain level at different time intervals depending on the medication administered, or every 2 hours if the patient is stable. A phone interview with Staff # 1, Dr. Justin Brady Evans, MD-ED on 02/13/2024 at approximately 12:45 PM revealed the following: Surveyor: Why did you make the choice to discharge the patient home rather than admit to the hospital for surgery? MD-ED: After medication she was stable, she no longer had pain to her abdomen. I felt she was low for an emergency surgery risk. I knew a surgeon would not see her at the ED and maybe not the following day if symptoms remained relieved. Her labs and lactic acid were good. She was discharged home with a surgeon referral and instructions to return to the ED if symptoms change or worsen. Surveyor: Did the patient ask for her surgeon to be called? MD-ED: Not that I remember. She did say she was unable to contact her surgeon. “I believe I put the surgeon referral in as urgent, to speed up the process but her case was not an emergency at that time.” Surveyor: Do you recall the patient requesting her discharge medication to be sent to a different pharmacy than the one on the discharge sheets? MD-ED: No, there were no concern or changes requested or made. If I make a change, I make a note in the patient’s medical chart. If she called the ED at a later time the unit clerk or Charge Nurse has a form for the MD-ED to follow-up with the next morning.”

“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: 45847 . Based on record review and interviews, the facility failed to comply with §489.24(2) when they did not stabilize one of 20 (Patient #1) patients whose records were reviewed. . Based on record review and interview, Facility A failed to stabilize, protect, and prevent one (Patient #1) of twenty patients from injuring or harming him/herself or others when Facility A allowed Patient #1 to elope from the Emergency Department (ED) and leave against medical advice (AMA) while experiencing a psychiatric emergency. . Cross reference to Tag A2407 CFR §489.24(d)(1-3). .”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 45847 Based on record review and interview, Facility A failed to stabilize, protect, and prevent one (Patient #1) of twenty patients from injuring or harming him/herself or others when Facility A allowed Patient #1 to elope from the Emergency Department (ED) and leave against medical advice (AMA) while experiencing a psychiatric emergency. . Findings included: . Client Record Review: Facility A’s Emergency Department (ED) Nursing Documentation indicated that on 10/01/2023, at 3:25 AM Patient #1 arrived at the Emergency Department (ED) at Facility A via EMS with Arlington Police Department (APD) Officer due to a sexual assault referral. . Facility A’s ED Nursing Documentation indicated that on 10/01/2023, at 4:48 AM while awaiting a SANE (Sexual Assault Nurse Examiner) exam, Patient #1 exhibited disconnected thinking when the following was documented: “When asking pt (patient) when assault occurred, pt stated “tomorrow.” When asked pt what time assault occurred, pt stated “pick a time.” . Facility A’s ED Crisis Clinician Assessment Documentation indicated that on 10/01/2023, at 8:21 AM Patient #1 was noted to be at a “Moderate” Suicide Risk Level, and the Plan of Care was for a “Voluntary Inpatient Psych Admission. The Crisis Clinician documented, “Pt is not mentally stable and is agreeable to Inpatient BH (Behavioral Health) for mental health stabilization.” . Facility A’s Crisis clinician documented further in the same note that Patient #1 was experiencing Homicidal Ideation precipitated by sexual abuse. . Facility A’s Crisis Clinician documented further in the same note that Patient #1 has a past medical history of Bipolar, Schizoaffective Disorder, and substance abuse and again stated that Patient #1 was not mentally stable. . Facility A’s ED Nursing Documentation showed that on 10/01/2023, at 2:13 PM: “Pt witnessed walking out of ED. Charge RN walked out to make sure the patient did not have an IV catheter in place. Pt was standing in the ambulance bay outside. When asked the patient about the IV the pt stated she wanted to go smoke. RN informed her that this is a non-smoking facility. Pt proceeded to remove the IV herself. RN informed the patient she was going to help you with the IV removal Pt started yelling and started to follow RN back into the main ED entrance. RN informed security she was leaving, pt proceeded to walk right up to me within inches and stated, “I hope your family is well”. The on-duty police officer (Staff #A14) walked up to pt and removed her from the emergency room. Pt proceeded to walk towards Randol Mill. APD notified since pt eloped from ED while waiting for placement for moderate risk suicidal ideation and homicidal ideation.” . Facility A’s ED Nursing Documentation indicated that on 10/01/2023, at 2:14 PM Patient #1 eloped, and left against medical advice (AMA) with Police Notification. . Policy Review: The facility’s policy titled, “Psychiatric Disturbances in the Emergency Department”, last reviewed and implemented on 11/03/2021 was reviewed. The policy stated on pages 1 & 2 of 3: “ ... 4.1 When a patient presents to the ED requesting mental health services or is exhibiting a psychiatric disturbance, the patient’s medical and psychiatric history including medications, previous admissions and stressors precipitating current event should be obtained. The nurse should complete the Suicide Risk Assessment Tool in CareConnect. . 4.2 The patient should be placed in a safe non-threatening treatment area with visual monitoring capabilities or placed under Visual Observation as defined below. . 4.3 The patient should be placed in paper scrubs, if available, and all personal belongings should be placed in a belongings bag, including clothing, shoes and any implements or objects that may cause patient to injure himself/herself or others. Belongings should be removed from the room and given to an accompanying adult. If patient is unaccompanied, the belongings will be secured until patient’s disposition is evaluated and considered stable. . 4.4 Patients considered to be a flight risk should be under Visual Observation at all times .... . 5.1 Visual Observation - Maintaining visual contact of the patient ....” . Interviews: In an interview on the morning of 11/14/2023, at 10:15 AM, the ED Charge Nurse (Staff #A3) indicated that she called APD because Patient #1 was not safe to leave and she (Staff #A3) could not follow Patient #1 any further away from the facility for her safety. . In an interview on the afternoon of 11/15/2023, at 3:08 PM, APD Staff #1 indicated that Staff #A3 had informed him that they (Facility A) did not want Patient #1 back in the ED and said that they (Facility A) were done with her (Patient #1). The interview further indicated that was when APD Staff #1 decided to transport Patient #1 to another facility. . In the same interview on the afternoon of 11/15/2023, at 3:08 PM, APD Staff #1 indicated that Patient #1 was “talking all wrong” and wanted to hurt the people who assaulted her. APD Staff #1 also stated that Patient #1 threatened his safety when she threatened to hit him. .”