Ad Hospital East, LLC

“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: 37490 Based on interview and record review, the facility failed to maintain an accurate Emergency Department Central Log for 1 of 23 patients reviewed (ID#1). Findings include: Review of facility policy titled “EMTALA GUIDELINES FOR EMERGENCY DEPARTMENT SERVICE,” Last Revised: 08/01/2023, showed the follwoing: The Emergency Department shall maintain a central log documenting the following information: -Each individual presenting to the ED for assistance -If the individual refused treatment -If the individual was refused treatment -If the individual was transferred, admitted and treated, stabilized and transferred or discharged The central log shall also include whether directly or by reference patient logs from other areas of the hospital that may be considered dedicated emergency rooms, i.e., Pediatrics, Labor and Delivery. Review of EMS run record for patient (ID#1) for date of service 10/24/2026 showed the patient was brought to the facility for possibly dislodged gastrostomy tube. Patient was transferred from the bed to the stretcher via the sheet lift method with x2 medics and secured with rails up and x3 seatbelts. Patient was transported nonemergency to Advanced Diagnostics East Houston Hospital for ER evaluation. Patient was not able to be admitted into Advanced Diagnostics East Houston Hospital due to “no one at that hospital being able to perform procedure”. Patient was then transported to another facility. Review of Central Emergency Room (ER) log for date of service 10/24/2025 showed no evidence of patient (ID#1) presenting for service. Staff ID(#57) on 1/27/2026 at 11:30 am 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: 38015 Based on record review and interview, the facility failed to ensure supervision of nursing care as shown by physician orders not implemented for 1 of 1 patient (Patient #1). Findings included: AD Hospital East location: Review of facility policy titled “Verbal and Written Orders-General”, # OW 071 last reviewed 11/17/21 showed that written or verbal orders for patient treatment will be carried out when given by a qualified practitioner. In addition, the policy stated that the healthcare professional who is implementing the order is to document that the order was implemented in the appropriate section of the medical record. Record review during time of survey of Patient #1’s medical records showed there were orders to give the patient crutches, dated 8/26/23 at 9:13 pm, written by Dr.-Staff #B. The patient had a sprained ankle which was the reason she came to the hospital (Grade II Right Sprained Ankle). In addition, records showed that RN-Staff #H was the nurse caring for Patient #1. Further review of Patient #1’s records failed to show that the order for crutches was carried out and implemented. Review of multidisciplinary notes failed to show any explanation why the order was not followed and there were no entries or explanations documented by RN-Staff #H showing the reason the order was not followed. In an interview at the time of record review, RN-Staff #I stated that after reviewing the records herself, there was no evidence the order was followed by staff and no evidence the patient ever received crutches as ordered, confirming that nothing was documented regarding this. In a prior interview on 11/10/23 at 10:45 am, materials Manager-Staff #F who was in charge of supplies stated that the facility had no problems having most necessary supplies including crutches.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 23032 Based on interview and record review, the facility failed to ensure a registered nurse (RN) assigned the care of patients according to the qualifications and competencies of nursing staff per facility policy and the Texas Board of Nursing- Standards of Nursing Practice. The facility failed to ensure the OR Manager met the qualifications required for the position, per the job description. The OR Manager is not an RN and is making patient care assignments and evaluating nursing job performance. Findings included: TX00475305 River Oaks Hospital & Clinics location: Record review of facility policy titled “Provision of Care /Scope of Services,” dated 1/03/2019 showed: Nursing Services: The Registered Nurse will be responsible and accountable for : - supervising, delegating and coordinating nursing care - making clinical decisions that are based upon licensure, educational preparation, and experience in nursing. Evaluation of Nursing Care: OR Suite: -use of the nursing process: assessment, planning, intervention, and evaluation. Medication administration, pain management, cardiac monitoring with dysrhythmia interpretation, IV therapy and fluid and electrolyte balance, blood glucose testing; administration of blood products, oxygen therapy and pulse oximeetry, hemodynamic monitoring, titration of vascular medications; maintenance of skin integrity. Patient / family education, safety management, and wound care management. ~~~~~~~~~~~~~~~~ Record review of Texas Administrative Code (TAC) Title 22; PART 11 Texas Board of Nursing ; CHAPTER 217 ; RULE §217.11 “Standards of Nursing Practice” showed: (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (S) Make assignments to others that take into consideration client safety and that are commensurate with the education, experience, knowledge, and physical and emotional ability to whom the assignments are made.... (U) Supervise nursing care provided by others for whom the nurse is professionally responsible... ~~~~~~~~~~~~~~~~~~~ During an interview on 11/10/2023 at 10 AM with Staff -F, OR Manager, he stated he had been in this position for about 2 months. When asked about his overall job duties, Staff -F said he basically “oversees everything : organizes cases, schedules, and staffing.” Staff-F went on to say that he makes nursing assignments for the cases, based on nurse’s experience. Staff F said he assesses nursing competencies and completes performance evaluations. He monitors staff performance in the OR and also receives input from the surgeons, scrub techs, & other staff. Record review of Staff-F’s personnel and training record showed: Staff-F’s Job description, signed 8/30/2023, showed the following: -TITLE: OR Manager -SUMMARY: The OR Manager has 24/7 responsibility for managing ,supervising and providing leadership for Perioperative department staff and other nursing units . The manager is responsible for ensuring a positive environment for physicians/staff relations. -DUTIES included: ensures adequate staffing and scheduling , monitors performance of staff -QUALIFICATIONS: Graduate of a school in professional nursing (Associate degree) is required/ Bachelor’s degree is preferred. Current state license to practice nursing is required Three years experience in nursing is required. Continued review of Staff -F’s personnel file showed he was a certified surgical technologist (CST). He did not possess the required current RN license and the 3 years nursing experience per the OR Manager position requirements. Record review of a form titled “Employee Evaluation Form” showed it was a performance evaluation completed for Staff-M, RN. The tile at the top of the form said “Supervisor” the name of the OR Manager ( Staff F ) was written as the supervisor. The performance evaluation covered several areas, including knowledge and quality of job. One comment written by Staff F, OR Manager was”She is efficient and helps to provide excellent patient Care.” The evaluation was signed by the RN (Staff- M) and the OR Manager on 10/26/2023. There were no other signatures on this evaluation. During an interview on 11/10/2023 at 2:30 PM with Staff-A, Chief Nursing Officer (CNO) she stated it was very challenging to find RNs who had the experience and could effectively manage the OR. She said that Staff-F had many years surgical experience and was very capable. The CNO went on to say that he was not an RN. When shown the performance evaluation completed for Staff M-RN, the CNO said that Staff-F, a surgical tech, should not be evaluating RN job performance or competency. She said surgical techs cannot supervise RNs. The signed job description for Staff-F, OR Manager, was reviewed with the CNO. Surveyor pointed out that Staff-F did not meet the required job qualifications for OR Manager: graduation from a school of professional nursing (Associate degree); current state license to practice nursing; and three (3) years experience in nursing. The CNO said there must have been a mistake in the job description; it was not the correct one.”