Medical City North Hills

“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: 33589 BASED ON record review and interview, the registered nurse failed to follow their policies to supervise and evaluate the nursing care for Patient #1’s identified care needs from 4/28/2024 through 5/15/2024. Patient #1 developed a large pressure injury that did not resolve prior to discharge on 6/05/2024. FINDINGS Patient #1 admitted on 4/22/2024 to Medical Surgical 5 (MS5) for clinical overload with pitting edema in his legs, acute kidney injury versus chronic kidney disease, renal lesion, large left pleural effusion, pulmonary nodules, and deconditioning. On 4/27/2024 he had a code stroke and was ordered complete bedrest. On 5/05/2024 he was transferred to the Intensive Care Unit and discharged 6/05/2024 to a Skilled Nursing Facility. On 5/16/2024, the Wound Evaluation included photos and documented the size of the Coccyx Pressure Injury. It measured 6 x 5.5 x 0.2. (Length/width/dept; CM/Centimeters) There were no further measurements of the pressure injury after the initial Wound Evaluation to document on-going worsening/improvement of the pressure injury prior to discharge. Subsequent photos of the wound (5/20/2024; 5/24/2024, 5/27/2024 and 5/30/2024) did not follow policy including a measurement reference for the wound. Patient #1’s Nurse Shift Assessments reflected: ~ Pressure Injury Risk Score dropped below 18/AT RISK on “4/29/2024 15...Out of bed activity: 2-Chairfast In bed activity: 2-Very limited Nutrition 2-Probably inadequate Friction and sheer: 2-Potential problem...” and “5/01/2024 Out of bed activity: Bedfast” with Patient #1’s Risk becoming greater as the admission continued. ~ Skin Alteration “4/28/2024 skin alteration: present/exits...Redness Coccyx” then increasing to “5/08/2024 Stage 2” then increasing to “5/09/2024 Stage 3” then again increasing to “5/16/2024 Stage 4” until the patient discharge on 6/05/2024. The 5/08/2024 Nutrition Assessment reflected, “Nutrition intake: Not meeting estimated needs...Skin: Abscess Post Coccyx...Patient with 9% WEIGHT LOSS in past 2 weeks. Significant...Patient now meets criteria for severe malnutrition in the context of acute illness...NO BM (bowel movement) documented throughout stay (4/22/2024 to 5/8/2024: 15 days)...5/06/2024 Multiple strokes. Transferred to ICU due to lethargy...” During record review and interview on 9/25/2024 at 9:40 AM, Personnel #1, #2, and #3 verified the above information documented in the record. They were unable to find the following: There was no Physician notification documented by nursing, no Wound Care Evaluation, no photos, no orders for cleaning, enzymatic medication, or dressings for the care of the pressure injury when the skin alteration/pressure injury began from 4/28/2024 to 5/15/2024. There was no vigilance report when the skin alteration/pressure injury began from 4/28/2024 through 5/15/2024. There were no skin alteration/pressure injury intervention orders (cleaning agent, medication/enzymatic/ medihoney, dressing, frequency) for the care of the pressure injury began from 5/15/2024 to discharge. They were asked for education of the floor nurses for pressure ulcer prevention, care, and staging. Personnel #3 stated the floors have skin champions who get the information. They are to bring the information back to the floor nurses. Personnel #3 was asked for evidence of this education. Personnel #3 stated I think that has been informal. Our gap is documentation of education. It is an opportunity. The Health Stream education reports were provided. The Health Stream report for “NDNQI Pressure Injury Training” reflected only 28 learners which included management were assigned from 9/01/2022 through 9/25/2024. The Health Stream report for “Braden II Scale and Skin Alteration for Inpatient Nursing” reflected a 7.56% completion rate for 9/01/2022 through 9/25/2024. During an interview on 9/25/2024 at 1:28 PM, Personnel #5 came to help navigate for the wound photos. Personnel #1, #2, and #3 were present. Personnel #3 asked Personnel #5 about the initial wound protocol. Personnel #5 stated it is initiated on all patients, so the nurse has the ability/permission to order an evaluation and/or direct wound care needs. Personnel #5 navigated each of the wound photos. The surveyor’s description of the photos: ~ 5/30/2024 “Sacrum Wound” photo reflected no measuring reference. It showed a large full thickness pressure injury covering the coccyx up to approximately the lower back area above the top of the intergluteal cleft including the width of the right and left buttocks down to the opening level. The bed of the injury was black and brownish eschar with pink edge around the injury. ~ 5/27/2024 “Sacrum Wound” photo was similar the 5/24/2024 photo with no measurement reference. ~ 5/24/2024 “Sacrum Wound” photo reflected no measuring reference. It showed a large full thickness pressure injury covering the coccyx up to below what appears to be the top of the intergluteal cleft including the width of the right buttock and part of the left buttock just above the opening level. The bed of the injury was black and brownish eschar with peeling skin all around the wound bed/injury. ~ 5/20/2024 “Sacrum Wound” photo reflected no measuring reference. It showed a pressure injury below the top of the intergluteal cleft down to just above the opening and approximately 1 to 1 ½ inches onto the right and left buttocks. The wound bed included red epithelial tissue, areas of white, yellow slough, and brown eschar. ~ 5/16/2024 “Sacrum Wound” photo reflected the NE1 wound measurement reference tool required by the policy. It showed a measured pressure injury with pink, white, and brown wound bed. The 5/20/2024, 5/24/2024, and 5/27/2024 photos reflect the progression of the pressure injury. Personnel #5 was asked about Patient #1. Personnel #5 stated he was lethargic, not tolerating his tube feeding, and vomiting. He had to have a thoracentesis. Personnel #5 was asked for Patient #1’s wound care dressing orders. Personnel #5 stated we don’t have orders. PT (Physical Therapy) change the dressing and will leave dressing supplies at bedside for us if we have to redress it. We can look in their note to see what they determined about the wound and dressing. Personnel #5 was asked if the nurse had to redress it where would they document it. Personnel #5 stated the nurse would go back and update their shift assessment. During an interview on 9/25/2024 ending at 4:45 PM, Personnel #1 and #2 were asked for the Health Stream pressure injury training for the named nurses (Personnel #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18) in the 5/16/2024 Vigilance report. Personnel #1 stated they have not had the training assigned to them. A report for each of the nurses was not provided. Personnel #1 stated the Education Manager says they do some check offs with hire/onboarding, but Pressure Injury and Staging has not been a yearly education for the staff nurses. The printed record was reviewed on 9/26/2024, it was determined that the Pressure Injury Risk was not completed every four hours per policy. (See below: For patients determined to be AT RISK per risk scale, focused skin assessments are completed at least every four (4) hours, or more frequently if ordered.) There were no pressure relief interventions indicated in the record including timely position changes. The facility’s June 2023 reviewed/revised “Wound Evaluation Orders” required, “facilitate timely and efficient patient care in regard to skin and wound assessments...Physicians, Registered Nurses, or Physical Therapist may enter wound care orders upon patient admission should there be an indication for skilled intervention...I) Physician A) Order wound care on admission for all patients as indicated. B) Consult Physical Therapy Wound Care as needed. II) Enter wound care evaluation orders when a wound is noted during skin assessment. III) Nursing A) Notify Physical Therapist of wounds noted upon assessment. B) Regularly communicates with Physical Therapy regarding wound changes C) Perform skin assessment on admission, each shift, transfer to new unit or changes in status and perform basic wound care techniques and implement pressure injury prevention tactics...” The facility’s January 2022 reviewed/revised “Care Plan Documentation” policy required, “provide and document effective, efficient, and individualized care based on the needs identified...a registered nurse to supervise, plan and evaluate each patient’s care. Documentation reflects the plan of care is initiated within 24 hours of admission and is consistently re-evaluated to ensure the patient’s needs are met through an interdisciplinary, collaborative manner involving patients, families, and qualified healthcare individuals...identification of interventions addressing the patient’s actual or potential risk for health problem...Interventions are implemented to prevent potential problems or to intervene in actual patient problems. The patient’s record specifies what interventions are implemented, when and by whom they are performed. Documentation of interventions promotes continuity of patient care and improves communication among healthcare team members...” The facility’s January 2023 review/revised “Pressure Injury Prevention Program Requirements” required, “Braden Scale II *AT RISK = score <18; * Not at risk = score >18...Skin risk assessment will be documented...For patients determined to be AT RISK per risk scale, focused skin assessments are completed at least every four (4) hours, or more frequently if ordered...Skin assessments and presence of any skin alterations or wounds will be documented in the EHR (Electronic Health Record)...should include...Staging...alteration details...surrounding tissue appearance...wound closure...drainage description, amount, and odor...Wound cleanings...Dressing status, intervention, and type...Packing status...Photo capture...Wound measurements...New wounds should be reported to a provider and documentation capture in the Manage/Refer/Contact/Notify intervention within the EHR...Pressure Injury interventions and an individualized plan of care, including education, will be implemented and documented in the EHR, for all AT RISK patients...” The facility’s October 2022 “NE1 Wound Assessment Tool” policy required, “to increase documentation accuracy and consistency for skin and wound documentation....NE1 Tool (measurement and guidelines printed on the tool used in photos)...correct identification and assessment for level of tissue damage and healing progression and regression...clinician takes a digital image of skin injury that is caused by pressure on admission, occurrence, and at the discretion of the clinician, prior to discharge beginning with Stage 1 pressure injuries...Pressure injuries will be photographed using iMobile Shared phones in the GE Media manager application and the NE1 Tool...frame the tool around the wound...ensure the camera is perpendicular to the wound. Take a picture...Use guidelines on the tool to assist in wound evaluation...References: National Pressure Ulcer Advisory Panel www.npuap.org...American Professional Wound Care Association Proposed APWCA Photographic Guidelines for Wounds www.APWCA.org...” The facility’s undated “Skin Alteration Assessment & Documentation” teaching tool in the Skin Champion resource book required, “significant change in condition that could lead to skin breakdown. This requires removal of the dressings...taking photographs of any pressure injury...ongoing assessment shall include photograph of a newly developed skin injury utilizing the NE1 Wound Assessment Tool (measurement)...Document...Skin Alteration Assessment - the wound care team does not automatically receive notification. The nurse has to put in an order for wound consult...Patients identified as at risk for skin breakdown or those with wounds will have referrals based on their assessment to: Physician should be notified of alteration in skin integrity that may require a change to the plan of care...Wound Care should be notified of all new skin integrity issues and for guidance on skin integrity issues not responding to treatment...Physical Therapy should be consulted for any patient with decreased activity level...Turn patient as indicated for patient condition...Position using foam wedge or pillows, rotating to a 30 degree lateral position from right to left then supine...Keep HOB at 30 degrees or less unless medically contraindicated...” The facility’s 4/01/2022 effective “Facility Event and Close Call Reporting Policy and Procedure” required, “mitigate risk and improve the quality of services...Facility staff will provide the needed data elements through a formal, documented event reporting system. Events should be completed as soon as possible after the event, but no later than the end of the shift...review and actions should be thorough, credible, complete...The responsibility for reporting an event or close call rests with any person who witnesses, discovers, or has direct knowledge of that event or close call...””

“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: 48885 Based on the record review and interview, the facility failed to complete an appropriate Medical Screening Exam within the capability of the Hospital Emergency Department for one of 21 patients (Patient #16). The Hospital did not provide a medical screening exam before the patient left the emergency department from Hospital A. There is no evidence in the medical record to show that the medical screening examination addressed the potential overdose, self-harm, and vomiting. Additionally, there was no evidence that other labs or clinical tests had been completed to determine if an emergency medical condition existed. Facility A allowed Patient# 16 to leave against medical advice (AMA) while actively self-harming in the facility.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48885 Based on the record review and interview, the facility failed to complete an appropriate Medical Screening Exam within the capability of the Hospital Emergency Department for one of 21 patients (Patient #16). The Hospital did not provide a medical screening exam before the patient left the emergency department from Hospital A. Findings included: Record Review: A review of an Ambulance trip report on 03/16/2024 at 1747 PM revealed: EMS arrived at the fire department, where Patient #16 was initially located, assessed the patient’s condition, and transported her to Hospital A as per the patient’s request. The EMS documentation shows the following: “Pt walks out to the ambulance and climbs into the patient compartment. She sits on a stretcher and has an episode of emesis. Offered pt nausea medication IV, and pt said she is a hard stick but allows 1 IV attempt. Unsuccessful IV attempt. Given 4mg of Zofran ODT, the pt has another episode of emesis shortly after.” A review of the emergency department medical record at facility A Chart #1 for patient#16 visit on 3/16/2024 The emergency department medical provider notes (doctor Staff #2) revealed the following: The reevaluation section revealed the following: “ While in the waiting room lobby, the patient began to lie down on the floor, make. “Backstroke swimming motions’’ on the floor and banging head repeatedly on the floor.” “The Patient, at this point, began to slide down against a concrete pillar and then eventually ended up laying down on the floor with her head propped up against a concrete pillar, repeatedly attempting to bang the back of her head against the pillow. The security guard was very conscientious about placing his hand behind her head so that she would not injure/harm herself by banging her head against the concrete.” The Medical Decision-Making section revealed: “ Patient refused to be evaluated by me. The patient refused any medical intervention. The patient said she wanted to leave, so she got off the stretcher and left the emergency department. At this point, the patient was classified as leaving AGAINST MEDICAL ADVICE.” Patient Discharge & Departure revealed the following: “All vital signs available during this entry have been reviewed. Clinical Impression: Primary Impression: Left against medical advice. Secondary Impressions: Aggression Time of Impression 1920 PM Disposition Decision: Other “ There is no evidence in the medical record to show that the medical screening examination addressed the potential risk of overdose, self-harm, and vomiting. Additionally, there was no evidence that other labs or clinical tests had been completed to determine if an emergency medical condition existed. Facility A allowed Patient# 16 to leave against medical advice (AMA) while actively self-harming in the facility. A review of a Police report by Deputy #1 at 19:13:52 03/16/24 revealed: Patient#16 called the police department asking for help and reported that she was in the ER, and a male doctor “grabbed her hair and yanked it.” “I spoke with hospital security and medical staff, who advised me that patient#16 refused treatment and began hitting her head on concrete pillars outside of the hospital. Patient#16 eventually worked her way down a pillar and began hitting her head on the brick portion, then got on the ground and hit her head on the ground.” “Based on patient#16 ‘s reported actions to me, hitting her head against the wall multiple times due to frustration, I believed she was a danger to herself. I detained her on a detention warrant.” “While patient#16 was in the rear of my patrol vehicle, she advised me that she took approximately 30 pills of her anxiety medication earlier and was having chest pains.” A review of Chart #2 at Facility B Patient #16 revealed: “Per EMS report, the patient was drowsy, with seizure-like activity, and was given 5 mg of Versed EN route. During the ED evaluation, the patient was alert, with purposeful jerking of her entire body, which was inconsistent with seizure activity. Per chart review, the patient has been seen at multiple facilities for similar behaviors and has previously been intubated for such presentation. Per chart review from Harris, the patient has been seen for psychogenic nonepileptic seizure-like activity and admitted to that facility on 02/12/2024. The patient has been extensively evaluated for seizures, undergone continuous EEG, MRI brain, and head CT, and seen by a neurologist and psychiatrist, all of whom have concluded that symptoms.” Medications given at facility B: 03/16/24 2100 - droperidol (INAPSINE) injection 2.5 mg 03/16/24 2106 - midazolam (PF) (VERSED) injection 5 mg 03/16/24 2108 - ondansetron (ZOFRAN) IV Push 4 mg 03/16/24 2108 - electrolyte-A (PLASMA-LYTE) bolus 1,000 mL 03/17/24 1100 - ENSURE Nutritional Supplement Bolus 1 cart Final Diagnosis section at facility B: F41.1 Generalized anxiety disorder. R45.851 Suicidal ideations Z91.51 Personal history of suicidal behavior “The Medical ER Provider reports that Patient #16 needs psychiatric evaluation for Suicidal ideations and Other.” The patient was discharged home and given resources for outpatient behavioral assessment. The EMTALA Policy at Medical City North Hills, named- Texas Medical Screening Examination and Stabilization Policy: [Last revised 04/2022], states that: POLICY: “An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (“DED”) and: 2. a prudent layperson observer would conclude from the individual’s appearance or behavior that the individual needs an examination or treatment of a medical condition.” Procedure: “I. When an MSE is Required. A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the OED, to determine whether or not an EMC exists: (i} to an individual, including a pregnant woman having contractions, who requests such an examination; (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individual’s appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC or a pregnant woman is in labor. An MSE is required when: a.The individual comes to a DED of a hospital, and a request is made by the individual or on the individual’s behalf for examination or treatment for a medical condition, including where: I.The individual requests medication to resolve or provide stabilizing treatment for a medical condition. II.The individual arrives as a transfer from another hospital or health care facility. Upon the arrival of a transfer, a physician or qualified medical person (“QMP”) must perform an appropriate MSE. The physician or QMP shall provide any additional screening and treatment required to stabilize the EMC. The individual’s MSE must be documented; this type of screening cannot be performed by the triage nurse. If an EMC is determined to exist and the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under EMTALA ceases.” Interviews: During an interview with Staff#1, the ER Medical Director, at 1005 AM, states the following: Q: What prompted the involvement of the police? A: The patient prompted the involvement of the police. She called the police after she ran to the parking lot and away from the hospital premises. Q: Was the decision to discharge the patient and transfer her to Facility B based on medical necessity and evaluation of the patient’s condition? A: Facility A did not make the decision. We were unable to care for her, and triage MSE or Stabilizing treatment was not possible due to her uncooperative behavior. The patient called the police, according to our security. Police decided to take her to Facility B. During an interview with facility B Director of Patient Safety, Risk, and Community Health Quality on 05/14/2024 at 0401 PM stated the following: Q: Can you provide specific details regarding the nature of the complaint filed against Facility A? A: The patient was brought to Facility A via EMS for a potential overdose. Per their documentation, the patient was uncooperative during triage. The patient went to a breezeway and began self-harm by hitting her head on the wall and floor. The patient then moved outside, where she continued to hit her head. The patient was placed under a detention warrant by North Richland Hills Police and brought to Facility B. The patient did not receive medical clearance before departing Facility A. Q: What incidents or events prompted the filing of this complaint? A: The patient caused self-harm by hitting her head on the wall and floor multiple times in front of medical staff at Facility A. The patient was not medically cleared before being taken to Facility B. Q: Has the complaining facility identified any specific areas of concern or potential violations of EMTALA regulations that they believe need to be addressed? A: When a patient requires transfer to a higher level of care, the patient should be medically cleared or stable depending on the transferring hospital’s resources. Q: Were there any witnesses or documentation supporting the allegations outlined in the complaint? A: Medical records from Facility A support the patient’s self-harm and lack of medical clearance before transfer.”