Medical City Arlington

“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: 28637 Based on record review, and interviews, the facility registered nurse (RN) failed to supervise the nursing care in accordance with patient safety needs for 1 (Patient #1) of 10 patients reviewed. Patient #1 had been identified as high risk for falls after her left hip procedures. On the evening of 06/22/2025, staff failed to activate an alarm in the patient’s room. Later that shift, Patient #1 fell in her room, broke her right hip, and required surgical intervention. Findings included: During an interview and record on 9/3/25 at 10:00 AM, Personnel A stated Patient #1 was found on the floor in her room at 5:50 AM on 6/23/25. She stated Patient #1’s bed alarm had not been set as required to alert staff if she was attempting to exit the bed. Personnel A stated Patient #1’s bed alarm should have been activated as she was a “huge fall risk.” The reason the bed alarm had not been activated was unknown. Record review of Patient #1’s orthopaedic surgery consultation note, dated 6/16/25, reflected she was an 83-year-old with a past medical history including status post left hip arthroplasty on 6/3/25. She presented to the emergency room on 6/16/25 after a fall at home with a left prosthetic hip dislocation and closed fractures of the left greater trochanter and posterior acetabular wall. She was admitted for a closed reduction under anesthesia, evaluation of fractures, and overall post reduction stability of the hip. Record review of Patient #1’s Safety Risk nurse’s notes dated 6/22/25 at 7:39 PM revealed she had a history of falls, used ambulatory aids, and her Morse Fall Scale score was “85-High Risk”. Interventions included, Bed/chair alarm; Assistive Devices; Gait Belt; and low bed. Record review of Patient #1’s Orthopaedic Surgery consulting Physician Note dated 6/23/25 at 2:09 PM revealed, “1. Fracture of femoral neck, right ... Patient had a ground-level fall when ambulating after closed reduction of left hip prosthesis. CT scan was reviewed after the fall demonstrating persistent reduction of left hip with new right femur neck fracture. Treatment options were discussed at length with patient and family. Diagnosis and imaging reviewed. Plan is to proceed with surgery for partial hip replacement ...”. Record review of the facility’s Patient Fall Prevention policy, dated October 2021 revealed: “ ... Policy: A. All patients will be evaluated for fall potential through completion of the appropriate Falls Risk Assessment. This will occur during the admission assessment process; initial, daily nursing assessment; at minimum of once per shift; following a change in medical condition and/or level of care; and post fall. B. Based on the level of fall risk, nursing interventions will be initiated and will be captured on the patient’s plan of care. C. Regardless of risk stratification, standard of care fall prevention elements will be implemented on all patients. Record Review of the facility’s Morse Fall Risk Assessment tool, Updated 11/1/24 revealed the following interventions based on the patient’s fall risk High Risk 45+ oAll low and medium risk interventions oBed/chair Posey alarm at all times (verify connection to call light) oPatient to be accompanied at all times when out of bed or chair oPlace patient close to nursing station if possible oPlace fall risk indication/signage outside patient door”

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 51905 . Based on observation, record review, and staff interviews, Facility A failed to provide a document recording the patient’s informed consent for procedures and treatment in the medical record for six (6) of twenty-six (26) patients. (Patients #10, 12, 23, 24, 25, and 26). . 1.Record Review: . a.Review of Incident Report . Upon review of Facility A’s incident reports, Patients #23, #24, #25, and #26 were reported for not having a consent for treatment form in the medical record. . b.Review of Patient #10’s medical record from Facility A: . On 02/27/2025 at 4:53 P.M., Patient #10 presented to Facility A’s obstetric emergency department with a complaint of their mucus plug coming out at thirty-three (33) weeks. Patient #10 received a medical screening exam, assessment of vital signs, fetal monitoring, and a cervical exam. Patient #10 was discharged home at 7:15 P.M. No consent for treatment form was located in the patient’s chart. . c.Review of Patient #12’s medical record from Facility A: . On 03/14/2025 at 1:00 A.M., Patient #12 presented to Facility A’s obstetric emergency department with complaints of severe cramping and loss of mucus plug at thirty (30) weeks. Patient #12 received a medical screening exam, assessment of vital signs, fetal monitoring, urine analysis, rupture of membranes assessment, and a cervical exam. Patient #12 was discharged home at 2:37 A.M. No consent for treatment form was located in the patient’s chart. . d.Review of Patient #23’s medical record from Facility A: . On 05/19/2025 at 4:48 P.M., Patient #23 presented to Facility A’s obstetric emergency department with complaints of leakage of fluid and lower extremity weakness. Patient #23 received a medical screening exam, assessment of vital signs, fetal monitoring, rupture of membranes assessment, and a cervical exam. Patient #23 was transferred to the main emergency department at 7:00 P.M. for lower extremity weakness unrelated to pregnancy. No consent for treatment form was located in the patient’s chart. . e.Review of Patient #24’s medical record from Facility A: . On 05/19/2025 at 3:39 P.M., Patient #24 presented to Facility A’s obstetric emergency department with a complaint of decreased fetal movement. Patient #24 received a medical screening exam, assessment of vital signs, fetal monitoring, rupture of membranes assessment, bedside glucose testing, and a cervical exam. Patient #24 was discharged home at 5:40 P.M. No consent for treatment form was located in the patient’s chart. . f.Review of Patient #25’s medical record from Facility A: . On 05/19/2025 at 4:40 P.M., Patient #25 presented to Facility A’s obstetric emergency department with a complaint of abdominal pain at thirty-eight (38) weeks. Patient #25 received a medical screening exam, assessment of vital signs, fetal monitoring, rupture of membranes assessment, and a cervical exam. Patient #25 was discharged home at 7:00 P.M. No consent for treatment form was located in the patient’s chart. . g.Review of Patient #26’s medical record from Facility A: . On 05/20/2025 at 3:10 P.M., Patient #26 presented to Facility A’s obstetric emergency department with a complaint of vaginal bleeding. Patient #26 received a medical screening exam, assessment of vital signs, fetal monitoring, rupture of membranes assessment, a cervical exam, an ultrasound, and an urine analysis. Patient #26 was discharged home at 7:45 P.M. No consent for treatment form was located in the patient’s chart. . h.Review of Assessment - Reassessment of the Emergency Department Patient policy - Effective August 7. 2024: . III. Policy (page 1): Each patient is assessed by appropriate disciplines beginning with pre-admission, admission and progressing through the continuum of care to discharge. The patient’s relevant assessment includes physical, nutritional, functional, psychological, and social status, as well as educational and discharge needs are. The data collected is analyzed and utilized to determine further assessment and treatment. The type of assessment performed is dependent upon the patient’s status, diagnosis, care setting, response to treatment, scope of the discipline, and the patient’s consent. Assessments, data, information, plan of care and the addressing of identified needs are documented in the patient’s medical record. . IV:Procedure (page 2): D. Admitting Department Assessment: 1. Patients entering the facility via c. The assessment process for patients entering the hospital in a non-emergent situation may include: iv. Written consent for treatment is required at the time of admission and prior to any operative or invasive procedure. . 2.Interview . On 06/27/2025 at 9:06 A.M, in an interview with the Vice President of Quality, Staff A, Staff A stated that staff reviewed the obstetric emergency department patients’ charts the previous day and found that Patient #10, #12, #23, #24, #25, #26 did not have a consent for treatment form. Additionally, Staff A stated there were additional charts without the form as well. Staff A indicated that audits would begin immediately. .”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 51905 . Based on observation, record review, and staff interviews, Facility A failed to provide staff who possess the skills, education, certifications, specialized training, and experience in emergency care to meet emergency needs anticipated by the facility for seven (7) of thirty-three (33) staffed registered nurses. . 1.Record Review . a. Review of Personnel Files: . On 06/27/2025, the Obstetric Emergency Department and Labor and Delivery unit Manager, Staff H provided qualified medical provider forms for all staff working in the obstetric emergency department. In order to be a qualified medical provider and perform medical screening exams in the emergency department, the registered nurse must have one (1) year of labor and delivery experience, complete a fetal monitoring course, and have a form signed by a physician. Upon review, one form was incomplete without a physician’s signature. Staffing schedules from the obstetric emergency department were then compared to the received qualified medical provider forms. Seven (7) of thirty-three (33) obstetric emergency department nurses did not have completed qualified medical provider forms. These seven (7) registered nurses have been working in the obstetric emergency room. . b.Review of the Obstetric Emergency Department Schedule: . Staff K worked six (6) shifts between April 2025 and June 2025 without a qualified medical provider form. Staff M worked three (3) shifts between April 2025 and June 2025 without a qualified medical provider form. Staff N worked five (5) shifts between April 2025 and June 2025 without a qualified medical provider form. Staff O worked one (1) shift between April 2025 and June 2025 without a qualified medical provider form. Staff P worked twenty-four (24) shifts between April 2025 and June 2025 without a qualified medical provider form. Staff Q worked three (3) shifts between April 2025 and June 2025 without a qualified medical provider form. Staff R worked three (3) shifts between April 2025 and June 2025 without a qualified medical provider form. . c.Review of EMTALA - Texas Medical Screening Examination and Stabilization Policy - Revised August 2017: . V. PROCEDURE (page 8): D. Who May Perform the MSE 2. Qualified Medical Personnel. QMPs may perform an MSE if licensed and certified, approved by the hospital’s governing board through the hospital’s by-laws, and only if the scope of the EMC is within the individual’s scope of practice c. Labor and Delivery QMP. QMPs in the labor and delivery DED may be appropriately approved RNs and must communicate their findings as to whether or not a woman is in labor to the obstetrician on call, the laborist, or the ED physician. . d.Review of Facility A’s Rules and Regulations - Revised 06/25/2024: . ARTICLE 3: EMERGENCY SERVICES (page 13): 3.13 Medical and Obstetrical Screening Examinations (4) Those who may perform obstetrical screening evaluations (Note: Obstetrical screening is limited to the diagnosis relative to determining whether or not a patient is in labor): b) Qualified medical personnel are defined as Labor/Delivery Registered Nurses with evidence of special education and training and validation by credentialed physician in obstetrics, working within the scope of their licensure and in compliance with any applicable state, medical/nurse practice acts and working under specified screening protocols developed and authorized by OB/GYN medical staff department that outlines the examination and/or diagnostic evaluation required to determine if an emergency medical condition exists. These protocols should be complaint-specific and limited to those presenting complaints that lend themselves to screening by such non-physician personnel. (i) Competencies should be documented and validated by qualified physicians in the emergency medicine department and made a part of the credential file of the medical personnel. (ii) An education plan is in place for measuring and developing core competencies in qualified medical screening examinations. . 2.Interview . On 06/26/2025 at 11:03 A.M., an interview with Obstetric Emergency Department and Labor and Delivery unit Manager, Staff H, was conducted. Staff H was asked about Staff K’s incomplete qualified medical provider form. Staff H stated that Staff K has one (1) year of labor and delivery, has completed the fetal monitoring course, and the physician had verbally approved the qualified medical provider form. When asked if Staff K has continued to provide medical screening exams for patients, Staff H indicated that they did not know if Staff K had been scheduled to work in the obstetric emergency department since orientation. Staff H indicated that nurses in orientation will complete medical screening exams in the department without a cosign from a qualified medical provider. . On 06/26/2025 at 1:14 P.M. an interview with Obstetric Emergency Department and Labor and Delivery unit Manager, Staff H, was conducted. Staff H verified that to be a qualified medical provider, the staff have to have one (1) year of labor and delivery experience as well as complete a fetal monitoring course. Staff H indicated that all nurses in the obstetric emergency department are qualified medical providers and do perform medical screening exams. Staff H stated that all qualified medical provider forms were provided and that if any staff member was not located in the forms, Staff H did not have them. .”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50856 Based on record review and interview, the facility failed to ensure patient C was informed of the patient’s rights (or when appropriate, the patient’s representative as allowed under State law) as the Important Message from Medicare (IMM) was not presented or signed until day 5 of the admission when it is to be completed within 48 hours of admission. Findings included: Admission date for Patient C was 04/12/2025. The IMM was dated 04/17/2025. According to the Director of Patient Access, the IMM must be obtained within 48 hours of admission. Staff #1 confirmed the IMM was signed more than 48 hours after Patient C’s admission.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 50856 Based on the record review and interview, the facility failed to provide an organized nursing service in that there was no evidence that patient B was turned every two hours as ordered. Findings included: Lack of every two hour turning documentation in the medical record. Lack of every two hour turn documentation on the paper turn team records for 4 North during Patient B’s hospitalization. Staff #1 verified that the turning documentation was not completed as expected in the medical record or on the paper records. During the interview, Staff #8 stated that staff are expected to document turns in the medical record. As such, there was no evidence that Patient B was turned every two hours as ordered.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 39057 Based on document review and interview the hospital failed to follow their policy to secure 1 of 3 (patient #3) patient’s home medication as evident of home medications were found in patient #3’s room over 24 hours after admission. These medications included narcotics, chemotherapy, and antipsychotic drugs, raising concerns about potential drug tampering and diversion. Patient #3, a 74-year-old male with a recent diagnosis of cancer who was admitted on August 8, 2024, at 12:05 pm after experiencing a ground-level fall, resulting in a right arm fracture. Finding included: Record review of patient #3’s Clinical Documentation Record HPF dated 08/09/2024 at 9:42 pm reflected “patient medications were found in patient’s room, including two controlled substances. Family agreed to store medication in the security office. Controlled substances counted with [2 staff] in front of family. All medications taken to the security office for storage ...” Record review of patient #3’s Medication Inventory - Patient’s Own Medications form dated 08/10/2024 reflected patient’s medications included: hydromorphone (narcotic); morphine sulfate (narcotic); lenalidomide (chemotherapy); chlorpromazine (antipsychotic) ... Patient #3 and staff #D signed the form. Security staff signed receipt of medication on 08/10/2024 at 3:14 am. During an interview with staff #E on 09/24/2024 at 10:30 am revealed the policy for when patient/family brings in medications from home, the staff will request for medications be taken home or secured in the security office. Some home medication may be used during admission, these medications are sent to the pharmacy to be relabeled for inpatient use. During an interview with staff #B on 9/24/2024 at 10:37 am revealed the staff is expected to complete reconciliation of home medication and medications should be sent home or secured. Staff #B confirmed that patient #3’s home medication was found in the patient’s room and not secured; these medications included controlled substances. Review of facility’s policy RX623 Patient’s Own Medication (Inpatient Home Medication Brought to the Hospital) revised 04/2024, reflected patient’s own medication must be secured and stored for safekeeping with Security.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 47578 Based on observation and interviews, the facility failed to ensure appropriate signage was posted conspicuously in the Emergency Room Department addressing a statement patient’s bill of rights and complaint information. The findings were as follows: Observations: On 03/11/2024 at approximately 10:42 AM, a guided tour of the emergency department was conducted with the VP of Quality, Staff #7 and Manager of Emergency Services, Staff #5. There were no signs observed on the walls to detail or inform patients of the patient’s bill of rights. There were no signs to address a complaint hotline or how to make a complaint. Interviews: On 03/11/2024 at approximately 10:45 AM, an interview with Staff # 7 VP of Quality, Staff # 5 Director Emergency Department, and Staff # 6 Manager Emergency Department, agreed that the patient’s bill of rights signs are missing in the Emergency department lobby 1&2. The administrative staff were not aware of the missing postings. Staff #5 and Staff #6 indicated they were aware the postings should be up at all times.”

“Standard-level Tag for Pharmaceutical Service CFR(s): 482.25 Standard-level Tag for §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients... This Standard is not met as evidenced by: 46427 Based on observation, record review and interview the facilities pharmaceutical services failed to: A. Ensure nursing staff were educated on pharmacy policy and procedure titled “Patients Own Medications-(Inpatient Home Medications Brought to The Hospital).” B. Implement a process to ensure staff were notified a patient’s home medications are secured with security personnel and ensure home medications are returned to the patient/ designated caregiver upon discharge. Policy and Procedure titled “Patients Own Medications (Inpatient medications brought to the hospital), Policy # RX623, effective date 10/2016, date revised 02/2023. Purpose: To establish a procedure for identification, storage, dispensing, and administration of patients “own” medication. Policy: Use of patients own medication is generally discouraged. When a patients own medication cannot be returned home or with a caregiver they must be secured and stored for safekeeping in Security ...When approved by the patients physician, a patient’s own non-controlled medication, including patient’s own sample medications, may be used by the patient while in the hospital. This only applies to the inpatient setting. III Procedures: 1. Sending Patient’s Own Medications Home ...If a patient has brought his/her own personal medication to the hospital, if appropriate the nurse returns the medication home with an authorized family member or designated caregiver. 2. Storage of patients Own medications from home ...If the medications cant be sent home or is a sample that is demmed medically necessary by a physician. The nurse secures the medications, completes a Medication Storage Register (see Appendix A), places them in a sealed opague envelope, and sends to Security for storage ( See Appendix B). 1. If patient is conscious or an authorized family is present but not able to take the medication home: a. Nurse is to place the medication in an opague envelope while in the presence of the patient and/or authorized family member. It is then sealed and the Patients Own Medication Inventory form is signed by BOTH the nurse and the patient or the authorized family member. d. Prior to patient being discharged from the hospital: i. the patients nurse contacts Security to retrieve the patients own medications from storage ...ii. The patients own medication is then returned by the nurse to the patient or patients authorized family member and signed for by patient or patients authorized family member and nurse returns the Medication Inventory form to Security ...iii.Document in Meditech that the patients medication were sent home and with whom they were sent home. Findings included: During an observation on 02/27/2024 it was noted Patient #1’s medication was located in the security department. Fifty-five days after patient #1 was discharged. Record review of The Medication Inventory Form on 01/03/2024 listed the medication name, dosage, and quantity of pills. The form was signed by Patient #1, Personnel #10 and Personnel #12. Record review of nursing orientation packet for Personnel #9 and #10 did not include education on the facilities policy and procedure for “Patients Home Medications Brought to the Hospital.” In an interview with Personnel #6 on 02/27/2024 at 10:45 AM stated the facility policy is as follows ...if a patient brings their home medications to the hospital and the medication is not a controlled substance or the patient is not being administered the medication, our process is to complete The Medication Inventory Form which is a 2-part form, the medication is sealed in a bag and taken to security. The original form is kept with the medication and the copy is placed on the patient’s chart. The copy of the Medication Inventory Form that is placed on the chart would notify the nurse the patients home medications are being secured in our security department. The pharmacy department does not inspect or follow up with medications currently stored with security personnel. Our security department does not currently notify patients of unclaimed medications.” In an interview with Personnel #10 on 02/29/2024 at 4:45PM stated she was not aware of the process for securing medications. The policy “Patients Own Medications (Inpatients Home Medication Brought to the Hospital ) is a new policy effective January of 2024. She stated she had not received education or training on this policy. Personnel #10 stated she was not aware the copy of the Medication Inventory Form that is placed on the chart is the process for notifying the nurse that a patient’s home medications are being secured with security personnel. In an interview with Personnel #9 on 02/28/2024 at 12:30 AM, stated she was not aware the copy of the Medication Inventory Form that is placed on the chart is the process for notifying the nurse that a patient’s home medications have been secured by security. Personnel #9 stated there is not a process notifying staff that patients medications are being held with security. In an interview with Personnel #1 on 02/28/2024 at 12:00 PM confirmed the nursing orientation packet for agency personnel does not include education on the facilities policy and procedure for Patients Home Medications brought to the hospital. In an interview with Personnel #2 on 02/29/2024 at 5:00 PM confirmed there was a failure in the facilities process for educating the nursing staff of new pharmacy policies and procedures, ensuring staff are aware of patients whose home medications are being safely secured in the security department and a process to ensure patients are returned their home medications upon discharge. Personnel #2 confirmed staff had not been educated on the new policy and procedure. Personnel #2 confirmed all the above findings.”