Foundation Surgical Hospital of San Antonio

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 21863 Based on observations, interviews and record reviews, the facility failed to protect and promote patient’s rights to receive care in a safe setting; affecting all patients receiving treatment in the facility. Specifically, the facility failed to have a functional communication system and emergency call system for patient safety in the patient’s rooms in the event of a medical need, medical event and/or emergency. This failure resulted in Patient #1 having a fall with injury and could affect patient safety for all current 13 patients (Patient’s #2-#14) in the facility. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Patient Rights. Refer to tag A-0144 for specific findings.”

“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: 21863 Based on observations, interviews and record reviews, the facility failed to ensure patients rights to receive care in a safe setting; affecting all patients receiving treatment in the facility. Specifically, the facility failed to have a functional communication system and emergency call system for patient safety in the patient’s rooms in the event of a medical need, medical event and/or emergency. This failure resulted in Patient #1 having a fall with injury and could affect patient safety for all current 13 patients (Patient’s #2-#14) in the facility. Findings included: Review of the intake information for complaint TX00509201 dated 7/16/24 revealed the following, in part: For two months, the facility’s call lights have not been working. The phone jacks are holes in the walls or other malfunctioning/unrepaired hardware. This includes the entire hospital. The patients cannot call for a nurse if there is an emergency. Nurses have no way to communicate with the patients or each other in an emergency. Most telephones in the rooms do not work either. There are Patients who are elderly and do not have cell phones. One Patient had Macular Degeneration and could not see the numbers on the phones. The staff are handed a walkie talkie that stays at the front desk. It is not on; it is unknown if it is even charged. Observations conducted on 7/17/24 at 10:05 AM of the inpatient hall of the facility revealed the nurse call bell system was not working. Surveyor verification was conducted in rooms; 104, 105, 107, and 116. The Nurse call button at bedside did not activate the call light or call to the nurses’ station. The separate Code Blue/Pull Cord wall alarm system was pulled in rooms 104, 105 and 116. The alarm did activate after a variable amount of time of at least one to two minutes delay from the time it was pulled/activated until the audible alarm was heard at the nurses station. Bedside phones in room 104 and 105 did not work and had no dial tone. Review of the facility’s Interim Life Safety Measures for Nurse Call System, dated 5/24/24 revealed the following, in part; Staff Communication: Immediately inform all staff about the nurse call system outage. Highlight alternative communication methods for patients to request assistance. Patient Communication: Inform patients upon admission and during rounds about the outage and alternative ways to reach staff. Alternative Communication Methods: Phones: Train staff on how to respond to calls from patients. Walkie-Talkies: Equip staff with walkie-talkies for immediate communication during rounds or emergencies. Review of the facility’s internal incident reporting system (MIDAS) for Patient # 1 in part, revealed on 6/21/24 at 4:20 AM, nightshift Registered Nurse (RN) stated that Patient #1 fell at 04:20 AM. RN heard patient yelling out, presented to patient room, patient was found on floor in bathroom, unwitnessed fall, patient stated he got up to empty his foley leg bag, fell and hit head on wall. RN noticed a small quarter size red mark on right forehead. No other injuries noted. Patient re-educated to call for help prior to OOB (out of bed) attempts for safety and to use his cell phone at bedside if he needed to call the nurses desk as well. Dayshift RN added that patient complained to her this AM that his right arm also hurts and that per treating MD, to monitor head for increased swelling. Patient stated that his cell phone is not working very well which is why he didn’t call for help. Received x-ray orders from physician. X-ray returned with no abnormalities. Interview on 7/17/24 at 9:45 AM with the facility’s Chief Nursing Officer (CNO) during an entrance conference stated the following: the nurse call lights work; but are at the “end of life.” The Code Blue/Pull Cord alarms are working but the nurse call lights at the bed side are having issues that is currently trying to be resolved, and it has been months of trouble shooting with two different vendors. The Nurse Call for assistance light uses a different alarm than the Code Blue/Pull Cord. There is extra beeping alarming and there has been feedback that it is annoying. Because of the periodic beeping it has been turned off. Interview on 7/17/24 at 10:20 AM with Patient #3, room 116 stated the call light button for the nurse on the remote did not work; “they said it was out, it didn’t work.” Patient #3 further stated, “it beeps and beeps and won’t go off;| so it’s turned off. When Patient #3 was asked how she communicates with staff for her needs; she presented surveyor with a note card that stated, “For Help Call: (210) 478- [XXXX] Nurse’s Station. Patient #3 also pointed to the wipeable information board on the wall that had written, For Help: Call (210) 478-[XXXX]. Interview on 7/17/24 at 11:10 AM with Patient #2, room 107 stated the call light button for the nurse on the remote did not work. Patient #2 stated he has arthritis in his hands that is so bad that he is unable to use a phone; as Patient #2 showed the surveyor his arthritic hands. Patient #2 stated he was not able to reach or access the bedside phone. Patient #2’s spouse was present and stated she was concerned to leave the hospital and to leave her husband alone because he is not able to call for help if needed. Interview on 7/17/24 at 10:30 AM with RN #5 stated today was her first shift back since the end of May (2024). RN #5 said her last shift in May, that the call lights were not working. RN #5 said she was told today at the start of her shift that the nurse call lights were not working at patient bedside and to have patients use the bed side phones or their personal cell phones to call the nurses station for assistance; as well as completing hourly rounding to each of the patient rooms. Interview on 7/17/24 at 10:45 AM with RN #7 stated the nurse call lights are not functional and have not been working for a while now. RN #7 said that staff have been told several times it was a part that was needed to fix the problem, then it was the internet, and then it was that a new system was needed because it could not be fixed. RN#7 said the system is outdated, it freezes and constantly restarts/reboots. RN#7 said he had concerns for patient safety because most patients are older, are post operative, or do not even have a cell phone for them to call in to the nurses station. RN#7 said one of his patients had a sling on their arm and could not use a cell phone to call in. RN#7 said a few weeks ago there was one Patient (#1) in Room 120 that got up out of bed by his self and fell. He was an older patient post Ortho surgery. Patient #1 did not call when getting up out of bed and the nurse call light was not working. Patient #1 was x-rayed and negative for findings. Interview on 7/17/24 at 11:00 AM with RN #6 stated the Nurse Call lights have been down for more than a month, and patients have to use their bedside phones; if they work, or personal cell phones to call the nurses station when they need assistance. RN#6 said this has worked fairly well, although some family members get upset about it when we are explaining to the patient on intake. Interview on 7/17/24 at 1:30 PM with the Facility Director (FD) stated the Call Bell system has a connectivity/server issue. The facility has been in contact with the two vendors to get the system back working. The vendor for the call lights/alarms cannot fix them until the server problem is fixed. The FD stated there is an error in the system which causes it to continuously reboot for connectivity, and then there’s an error during the checks and balances, which alarms. This causes a constant alarming at the console that upsets the nurses and beeping in the patient rooms every 30 minutes and therefore it has been disabled. The FD stated the plan for immediate repair is to fix the server and then replace the system down the road. Review of the facility’s Patient Rights and Responsibilities policy No. 4.90, effective 4/25/12 revealed in part, patients have; “b. the right to receive care in a safe setting.””