Round Rock Medical Center

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 51738 Based on a review of facility documents, medical records, observations, and interviews, the facility failed to follow policies and procedures governing medical care provided in the emergency department (ED) by: A. Not providing sanitary accommodations for 2 of 10 patients (#1, #3). B. Not reassessing patients’ pain levels and/or vital signs per facility policy for 3 of 10 patients (#3, #6, #7). Findings were: A. A review of facility policy “Patient Rights and Responsibilities” (Revised 12/2025) partially reveals: “PURPOSE: To provide a hospital policy on patient’s rights and responsibilities and to provide care and treatment that is respectful and courteous ....Access to Services ... [the right] To safe, secure and sanitary accommodation ...” A review of the “Infection Prevention Plan” (Revised 4/2026) partially reveals: “IP Program Overview: The Infection Prevention (IP) program is hospital-wide and utilizes a multidisciplinary, systematic approach to quality patient care that emphasizes disease transmission risk reduction in the health care environment ...D. The Infection Prevention Manager and/or Coordinator use a collaborative role with department directors in planning for safe and effective patient management with minimal risk of infection.” A review of the Grievance letter sent to Patient #1 and his family member from Staff #17, Patient Safety Coordinator, on 3/5/2026, partially reveals: “ ...our investigation ...included a review of his [patient #1] medical record and discussions with staff regarding his care ... Our review identified opportunities for improvement regarding the cleaning process of patient rooms ...” A review of the medical record for Patient #1 partially reveals: Significant past medical history for Patient #1: Coronary artery disease (CAD) with stent, Diabetes mellitus, chronic kidney disease (CKD) stage 3, Hypertension, Dyslipidemia, prior myocardial infarction (MI = “heart attack”), Atrial Fibrillation (A-fib), and complete heart block with pacemaker. On 1/31/2026 at 3:36 PM, Patient #1 presented to the ED with a chief complaint of slurred speech and left-sided facial droop. Patient #1’s CT scan revealed no evidence of an acute stroke but did reveal possible pneumonia. He had an elevated troponin (a cardiac enzyme that can indicate an MI), and was positive for influenza. He was admitted due to his syncope possibly of an infectious or cardiac origin. During this admission patient #1 was diagnosed with an ESBL UTI (Extended-Spectrum Beta-Lactamase urinary tract infection caused by antibiotic resistant bacteria), and was placed on contact precautions. Patient #1 was discharged to Facility B, Surgical Rehabilitation Hospital. On 2/18/2026 at 3:25 PM, Patient #1 was brought in by ambulance from Facility B, Surgical Rehabilitation Hospital, where he was found unresponsive in his wheelchair. Staff #3 triaged and completed an initial assessment of patient #1. In his Emergency Provider Report, Staff #16, MD, documents patient #1’s “known left-sided deficits from recent stroke”, his recent ESBL UTI which staff #16 treated with antibiotics, and noted that his hypotension had resolved. Staff # 15 assumed care of Patient #1 at 7:16 PM. In her “Emergency Note” at 7:18 PM, on 2/18/2026, Staff #15, ED NS RN, wrote “UPON ENTERING PT [patient] ROOM, PT IS SOILED WITH STOOL, DRIPPING ONTO FLOOR ...PT ROOM HAS TRASH ON BEDSIDE TABLE. PT CARE ASSUMED AT THIS TIME FROM RN [STAFF #3].” Patient #1 was admitted to the Internal Medicine Service. Observations of the ED on 4/13/2026 reveal: Unsanitary conditions were noted in several areas. In the ambulance bay, there was a bedside commode (BSC) partially blocking egress. Staff #6, DS (Dayshift) ED manager, reported that BSCs should be wiped down by nurses and placed in the soiled utility room. Behind the stretcher in patient #3’s ED room 20, there was a suction canister full of urine with a used purewick (external urinary catheter for women) attached to the end of the suction tubing. The sink in the triage bay had dried residue and staining in the basin. In the clean supply room, there was an opened roll of gauze on the floor. On the bedside table in Room 23 were open IV insertion kits, a tourniquet, and other used supplies. Other examples of unsanitary conditions included alcohol pads, telemetry stickers, and caps for normal saline syringes on the floor throughout the department; an open bag of normal saline and empty packaging in the medication room; a “clean bed” with rumpled/used linens; and trash on the rolling cart in the ambulance bay. During the tour of the ED on 4/13/2026, Staff #6, Staff #10, Patient Safety Director and staff #14, Regulatory Compliance Coordinator, verified these findings. Interviews: On the afternoon of 4/13/2026, in interviews conducted while reviewing the findings of the tour of the ED (Emergency Department)along with a discussion regarding the videos and photo provided by patient #1’s family member, Staff #6, DS (Dayshift) ED Manager, Staff #7, ED Director, Staff #11, Quality Director, and Staff #14, Regulatory Compliance Coordinator verified that the facility failed to provide a safe and sanitary accommodation to Patient #1 per facility policy. B. A review of facility policy “Patient Rights and Responsibilities” (Revised 12/2025) partially reveals: “PURPOSE: To provide a hospital policy on patient’s rights and responsibilities and to provide care and treatment that is respectful and courteous ...Information regarding Health Status and Care ...[the right] To appropriate assessment and management of pain ... A review of facility policy “Pain Management” (Revised 7/2025) partially reveals: *”PURPOSE: To establish guidelines in the assessment, diagnosis, treatment, evaluation, and prevention of pain, and to ensure that the dignity and comfort of the patient is optimized. * POLICY: ...2. It is the patient’s right to receive ...continued pain management in a manner appropriate to the medical condition. * PROCEDURE: ... ...2. Every patient will be assessed on admission for the presence of pain ....3. Ongoing assessments will occur throughout the patient’s hospital stay ....16. Pain assessments will be repeated after an intervention to determine its effectiveness ....a. Oral: approximately 1 hour. b. IM/IV/SQ (Intramuscular/Intravenous/Subcutaneous: approximately 30 minutes ...” A review of facility policy “Emergency Department Assessment Reassessment” (Revised 9/2023) partially reveals: * Purpose: To provide guidelines for Triage, assessment, reassessment, and continued monitoring, as changes in the patient’s condition warrants ... * Reassessment - A periodic re-evaluation process based on the patient’s chief complaint, acuity, condition, and symptoms or treatments. The frequency of reassessment performed for patients during their treatment may be determined by the patient’s chief complaint, acuity, condition, symptoms, treatments, and orders. * Guidelines for the reassessment of patients who have received a Medical Screening Exam ...Triage Level 3 - Every 120 minutes ... * Vital signs - Usually refer to temperature, pulse rate, respiratory rate, and blood pressure ... A pain scale may also be included for those patients with pain as a component of their presenting complaint. Vital signs, including pulse oximetry and pain scale, should be monitored when initial vital signs are abnormal and /or as the patient’s condition warrants.” A review of the medical records for patients #3, #6, and #7 reveals: Patient #3: At 10:47 PM on 4/12/2026, patient #3 arrived at RRMC as a transfer from Facility C, Medical Center, for an MRI due to compression fractures in her spinal column. Patient #3 reported that her chief complaint was back pain. In her triage note for patient #3 at 10:47 PM, Staff #18, ED RN documented Patient #3 had a history of hypertension and Diabetes Mellitus, ambulated with a cane, and had increased pain with movement “for a while now”. Staff #18 also documented a first set of vital signs (VS), a pain level of 6/10, and priority level 3. Only three additional sets of VS were documented for patient #3 until her transfer to the telemetry unit on 4/13/2026 at 12:00 PM. At 12:03 AM on 4/13/2026, Staff #19, MD placed orders for acetaminophen, tramadol, and morphine, to be used as needed for pain. There is no documentation that patient #3’s pain level was reassessed while a patient in the ED or that pain medication was administered. Per policy, patient #3 had the “right to receive ...continued pain management” and her vital signs including her pain level should have been reassessed every 2 hours. Patient #6: On 3/10/2026 at 7:36 AM, Patient #6 presented to the ED with a chief complaint of back and leg pain since 2/26/2026 that resulted from lifting boxes. She had a history of hypertension, multiple myeloma with lesions to her left hip and skull, and multiple vertebral compression fractures. A CT of her lumbar spine from 10:28 AM on 3/10/2026 revealed new compression deformities since her previous CT in 2021. In her triage note at 7:42 AM, staff #20, ED RN documented a pain level of 7/10, priority level 3, and the only set of VS recorded at 7:36 AM. Ordered pain medications were administered at 8:00 AM and 8:06 AM. There is no documentation in the medical record that patient #6’s pain level was reassessed after pain medication was administered. Patient #6 was discharged home at 12:14 PM on 3/10/2026. Per policy, patient #6’s pain level should have been reassessed 30 minutes and 1 hour after receiving pain medications, and her VS should have been documented every 2 hours. Patient #7: Patient #7 had a history of hypertension, Diabetes Mellitus, epilepsy, and hyperlipidemia. At 3:36 PM on 4/5/2026, she presented to the ED via ambulance with altered mental status (AMS), abdominal pain since December 2025, and left-sided weakness. Per EMS (Emergency Medical Services) staff who transported patient #7 to the ED, her family reported her last known well was at 10:00 PM on 4/4/2026. EMS staff administered pain medications en route to the hospital. In her triage note at 3:36 PM on 4/5/2026, Staff #21, ED RN documented a set of VS (including BP 201/37), pain level 8/10, and priority level 2. Patient #7 was transferred to the floor at 8:45 PM. This medical record review from 4/5/2026 reveals that ED staff failed to follow facility policy by not ordering or administering pain medications and by not reassessing patient #7’s pain while she was in the ED from 3:36 PM to 8:45 PM. Interviews: In an interview conducted during the review of medical records on the afternoon of 4/13/2026, Staff #7, ED Medical Director, verified that patients #3, #6, and #7 were not reassessed per facility policy.”

“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: 30250 Based in a review of documentation and interview, the facility failed to ensure the right to receive care in a safe setting, by not performing skin assessments at the frequency indicated in facility policy. Findings included: Facility based policy entitled, “Pressure Injury Prevention” stated in part, “PURPOSE: Outline expectations for risk assessment, physical assessment, application of interventions, and documentation for the prevention of pressure injuries. TOOLS: Adult patients 2: 18 years of age will be assessed using the Braden II scale o AT RISK= score ? 18 o NOT AT RISK = score > 18 ... PROCEDURE STATEMENTS: 1. Skin risk assessment will be documented in the Electronic Health Record (EHR) for each patient. 2. Ongoing, skin assessments will be as follows: a. For patients determined NOT to be at risk (per risk scale), skin assessments are completed with daily, comprehensive patient assessments. b. For patients determined to be AT RISK (per risk scale), skin assessments are completed at a minimum of twice per shift, or at a prescribed cadence as ordered by a licensed practitioner. 3. Skin assessment changes and presence of any skin alterations or wounds will be documented in the EHR for all patients. a. Skin alteration documentation should include the following, as applicable: 1. Skin alteration location and type;” Review of medical records revealed the following: 3 of 5 patients were high risk for pressure injury per their Braden scale scores and did not have skin assessment completed twice per shift per facility policy. * Patient #1 had an initial Braden Scale score of 11 on 06/28/24, placing them at high risk for pressure injury. From 06/28/24 through 08/22/24, skin assessments were only performed on this patient once, not twice per shift per facility policy. Patient #1 had pressure injury develop while inpatient. * Patient #6 had an initial Braden Scale score of 12, placing them at high risk for pressure injury. On 10/01/24 their Braden score increased to 19, placing them not at risk. From 09/29/24 - 09/30/24 skin assessments were only performed on this patient once, not twice per shift per facility policy. * Patient #8 had an initial Braden Scale score of 11, placing them at high risk for pressure injury. From 09/30/24 - 10/01/24 skin assessments were only performed on this patient once, not twice per shift per facility policy. Staff members #1 and 2 verified that the above high risk patients for developing pressure injury did not have skin assessments completed at a minimum of twice per shift, per facility policy.”