Medical City Fort Worth

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 33326 Based on interview, record review, and observation, the facility failed to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged when, Patient #1 was not recorded as having been in the facility’s emergency department, seeking care for a medical emergency and the facility did not record and capture all patients leaving before an emergency screening examination. Findings: During a telephone interview, on the afternoon of 12/15/24, Patient #1’s mother stated, “I took Patient #1 to the emergency room, we always go to this hospital. I tried to check her in; the person at the desk kept asking me for my daughter’s social security (SS) number and ID (identification). I asked him what would he do if they didn’t have a SS number, or if they were from another country? He answered by asking for the SS and ID. I told him to look her up by her name, again he asked for the SS and ID. I told him he was denying care and left.” When asked if Staff #7, Paramedic, recently had a patient leave because they didn’t have the SS or ID, Staff#7 stated, “I remember, it was a mother and her daughter. I asked for the SS. She (mother) gave me her (patient) name. She (mother) said why can’t you just register her? I asked if she(mother) had her birthdate. She(she) told me she had the SS number; she gave me eleven numbers. I told her it had eleven numbers. We just went back and forth. I was trying to find a way to register her. We (the facility) can’t give service without registering them.” When asked if Staff# had reported the patient leaving, Staff#7 stated, “I told the charge nurse, he just shook his head.” During an interview on 12/17/24 at 9:30 am, in an administrative office, when asked about the missing patient on the emergency room log, Staff #8, Chief Nursing Officer confirmed the patient was not on the log. When asked how and where the facility recorded patients that had left the emergency room, Staff #8 stated, “If a patient came in and wasn’t registered, they wouldn’t be on the log.””

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 33326 Based on record review, and interview, the facility failed to provide a reasonable registration process when a patient was discouraged from remaining for a medical emergency screening evaluation. Patient #1 was repeatedly asked for a social security number and identification; preventing her from being registered and advancing to triage and receiving a medical screening examination. Findings: Review of the facility provided Emergency Department Triage Guidelines (dated 12/21) reflected, “Triage is performed by a qualified RN at the time of presentation and may be done in concert with a quick registration ...C. All patients presenting to the emergency room are triaged (assessed) to determine the chief complaint and assign acuity. The acuity determines the time to treatment goals and the amount of time the patient can safely wait to be seen by a physician when no beds or caregivers are immediately available.” During a telephone interview, on the afternoon of 12/15/24, Patient #1’s mother stated, “I took Patient #1 to the emergency room, we always go to this hospital. I tried to check her in; the person at the desk kept asking me for my daughter’s social security (SS) number and ID (identification). I asked him what would he do if they didn’t have a SS number, or if they were from another country? He answered by asking for the SS and ID. I told him to look her up by her name, again he asked for the SS and ID. I told him he was denying care and left.” During a telephone interview, on the afternoon of 12/16/24, in an administrative conference room, Staff # 7, paramedic when asked how he registers patients into the emergency department stated, “I ask them if they have been here before. I get their SS and ID; I have to go to a different screen if this is their first time here. We can also use their name and date of birth.” When asked if Staff #7, Paramedic, recently had a patient leave because they didn’t have the SS or ID, Staff#7 stated, “I remember, it was a mother and her daughter. I asked for the SS. She (mother) gave me her (patient) name. She (mother) said why can’t you just register her? I asked if she(mother) had her birthdate. She(she) told me she had the SS number; she gave me eleven numbers. I told her it had eleven numbers. We just went back and forth. I was trying to find a way to register her. We (the facility) can’t give service without registering them.” When asked if Staff#7 had reported the patient leaving, Staff#7 stated, “I told the charge nurse, he just shook his head.” During an interview on the morning of 12/16/24, in an administrative conference room, when asked about the facility’s policy for registering patients in the facility’s emergency room, Staff #3, Quality Director stated, “We don’t have a policy for the registering of patients. The registering is not part of triage.” During an interview on the morning of 12/17/24, in an administrative conference room, when asked who received the training on triaging patients, Staff #2, ED Nurse manager stated, “The nurses get training on triage. Triage is the initial nursing assessment to find out why the patient is here and to decide if they need to go back immediately. The paramedics and techs do not, they will register the patients and the nurse will do the triage.” When asked if the patient is unable or refuses to give the number and ID how does the staff handle the situation? “We wouldn’t have had a system on how to handle this type of situation. Now, we are prepared for it. We had a meeting last night and decided to use the down time forms to get the patient triaged; registration can get them registered, after the medical screening examination. We get the social security number and ID so we can find them (the patient) in the electronic records, it gives the providers access to a patient’s previous admissions, medical history, and medications.””

“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: 46427 Based on record review and interview, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for 1 of 1 patient (Patient #1), in that, Patient #1 did not receive accurate assessments and care for a post-operative surgical wound as required by a physician’s order. Findings: Record Review of Patient #1’s medical record revealed Patient #1 was admitted to Medical City Fort Worth on 09/01/2023 for back pain and drainage from a lumbar surgical wound. Patient #1 underwent an Incision and Drainage to a lumbar wound on 09/02/2023. Provider order on 09/02/2023 indicated daily dressing changes and prn starting 2nd day postoperative. Record review of patient #1’s medical record reflected no documented nursing assessment of the surgical wound on 09/08/2023. Record review of patient #1’s medical record reflected no documented surgical dressing changes on 09/07/2023 and 09/08/2023. During an interview with Personnel #1, 2, 3, and 5 on 01/08/2024 confirmed the above findings.”

“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: 46427 Based on record review and interview, the registered nurse failed to supervise and evaluate the nursing care for 1 of 1 patients (Patient #1) in accordance with the patient’s needs, in that the registered nurse failed to obtain a weight upon admission and failed to assess and document the amount of meal consumption. The facility failed to follow policy. Findings included: Record review of patient #1 medical record indicated weight was not assessed and documented upon admission to the unit. During an interview with Personnel #17 on 01/04/2024, Personnel #17 confirmed Patient #1 did not have a weight assessment performed upon admission to the unit. Personnel #17 stated it is facility policy to obtain height and weight on all patients admitted to the unit. Review of patient #1 medical record reflected Strict Input & Output measurement was ordered on 12/13/2023 at 1:16 PM. A review of the medical record for patient #1 revealed the facility’s Daily Nursing Assessment, performed every 12 hours reflected no documented meal consumption on the following days: 1. 12/12/2023 No documented meal consumption for dinner. 2. 12/13/2023 No documented meal consumption for lunch or dinner. 3. 12/14/2023 No documented meal consumption for lunch or dinner. 4. 12/15/2023 No documented meal consumption for dinner. 5. 12/16/2023 No documented meal consumption for breakfast. 6. 12/17/2023 No documented meal consumption for breakfast, lunch, or dinner. 7. 12/18/2023 No documented meal consumption for breakfast, lunch, or dinner. 8. 12/19/2023 No documented meal consumption for breakfast, lunch, or dinner. During an interview with Personnel #17 on 01/04/2023, confirmed meal consumption is required and is part of the nutritional assessment. During an interview on 01/04/2024 with Personnel # 1, 2, 3, and 4 confirmed there was no documented weight upon admission and no documentation for percentage of meal consumption on patient #1. Review of facility Policy and Procedure titled Documenting the Provision of Care, CS.300, effective January 2018, “ ...documentation in the electronic health record is focused on patient care activities, clinical decisions and patient response to care ...key elements of the patient-centered electronic health record are: history, screening and risk assessment, individual considerations for care, Assessment, plan of care, care activities ...Routine care activities include: admission history, assessment, vital signs/height & weight/measurements, safety/risk/regulatory, intake & output, pain management, manage/notify/refer, teach/educate, lines/drains and airways, activities of daily living (hygiene care/meals/ambulation(repositioning). Review of facility Policy and Procedure titled Standards of Care, HAH109, effective 01/01/2020, reviewed 02/2022, “ ...I & O, twice a day for all patients including but not limited to: 1. IV Intake, 2. Oral Intake, 3. Urine output, 4. Foley output. 5. Drain output. Assessment /Reassessment ...3. Focus re-assessments are performed based on patient condition and documented when there is a change in condition.”

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 46427 Based on record review and interview the facility failed to provide necessary therapeutics to maintain healthy albumin and protein levels on 1 of 1 patient (Patient #1); after a 13-day stay the patient was transferred to a higher level of care with low levels of albumin and overall protein to sustain health for patient #1 who suffered from Sepsis, Acute on chronic hypoxic respiratory failure, Bilateral multilobar pneumonia, Hypertension, and Hypothyroidism Findings included: Record review of patient #1 medical records reflected an albumin level of 3.3 on 12/08/2023. Four days later on 12/12/2023, Albumin level was 3.2. Record review of patient #1 medical record reflected a protein level of 7.2 on 12/08/2023 and 6.9 on 12/12/2023. Review of Patient #1 medical record reflected a diet order was placed on 12/11/2023 that consisted of a regular diet with supplemental drinks three times a day (TID) with every meal. Review of patient #1 medical record from 12/11/2023 to 12/20/2023 revealed no documentation to ensure the supplemental drinks were provided. Review of Patient #1 medical record reflected a Nutrition/dietitian consult was ordered on 12/18/2023 at 3:24 PM for “Eval and Recommend, Reason: education; Comment: patient has requested supplement drinks. During an interview with Personnel #6 on 01/04/2024 confirmed he was unable to provide documentation Patient #1 received her supplemental drinks. During an interview with Personnel #6 on 01/04/2024 stated when a change in a diet order has been made the order automatically prints to the kitchen. A kitchen employee is responsible for entering the revised order into Comp Nutrition. Personnel #6 stated the order for the supplemental drinks was not modified in Comp Nutrition therefor the patient did not receive her supplemental drinks. During an interview with Personnel #10 on 01/04/2024 confirmed there was no process to ensure a nutrition consult was completed within 48 hours as policy states. During an interview with Personnel #1, 2, and 3 on 01/04/2024 confirmed the above findings. Facility policy titled “Standards of Nutrition Care”, FNS.040, effective June 1996, reviewed 12/2023,” ...Purpose: To establish basic standards of care for patients’ optimal nutrition care regardless of physical condition or disease state. Policy: All patients will receive quality nutrition care.” Facility policy titled “Modified Diets”, FNS.046, effective May 1996, reviewed 12/2023, “ ...Purpose: The purpose of this procedure is to provide diets in accordance with the patient’s physiological needs/disease state ...Policy: The Food and Nutrition Services department provides therapeutic diets as prescribed by the physicians. Procedure: A. patient is provided with the appropriate therapeutic diet as prescribed by his/her physician.””