Townsen Memorial Hospital

“HISTORY AND PHYSICAL CFR(s): 482.51(b)(1) Prior to surgery or a procedure requiring anesthesia services and except in the case of emergencies: (i) A medical history and physical examination must be completed and documented no more than 30 days before or 24 hours after admission or registration, and except as provided under paragraph (b)(1)(iii) of this section. This Standard is not met as evidenced by: 23032 Based on interview and record review, the facility failed to ensure a complete medical history and physical examination (H & P) was available in the medical record prior to surgery for one of 10 sampled patients ( Patient ID # 6). Findings included: Review of the facility’s “Medical Staff Bylaws and Rules & Regulations”, last review date 10/23/2025, showed: Section 8: Medical Records Review A Medical Record is complete when it contains information to justify admission and continued hospitalization, supports the diagnosis, and describes the patient’s progress and response to medications and services: a.All patient Medical Record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the author and the person responsible for providing or evaluating the service provided, consistent with applicable standards and regulations. b.All Medical Records must document the following, as appropriate: 1) History & Physical i. A complete admission H & P shall be recorded within twenty-four (24) hours after admission. This report should include all pertinent findings resulting from an assessment of all systems of the body. If a complete history has been recorded and a physical examination performed within thirty days 30 prior to the patient’s admission to the Hospital, a reasonable, durable, legible copy of this report may be used inpatient’s Hospital medical record in lieu of the admission H & P, provided this report was recorded by a Member and have an appropriate update of the patient’s condition. In such instances, an interval admission note that includes all additions to the history and any subsequent changes in the physical findings must always be recorded within twenty-four (24) hours after admission and prior to any procedure. i. A complete History & Physical includes at a minimum: a) Chief Complaint (reason or admission or procedure) / Admitting Diagnosis. b) Past Medical History. c) History of Present Illness. d) Family History. e) Social History. F) Medications/Allergies. g) Review of Systems. h) Physical Examination i) Laboratory and Radiological findings. j) Assessment; and k) Plan. iii.When the H & P is not dictated or recorded before any potentially hazardous diagnostic procedure, operative, non-operative or other invasive procedures, the procedure shall be canceled, unless the attending Member states in writing that such delay would be detrimental to the patient. If a dentist or podiatrist performs an invasive procedure, then a complete H & P performed by an Attending Physician must be present on the medical record, unless the dentist or podiatrist has received specific documented training in performing Histories and Physicals. The dentist or podiatrist is responsible for the pre-procedure and post-procedure evaluation of the patient. ~~~~~~~~~ Review of ten electronic medical records (emr) with Staff-B, Chief Nursing Officer (CNO) on 5/2/2026 showed one patient failed to have a complete H & P available in the medical record prior to undergoing surgery. The record review showed the following: Patient # 6: Patient # 6 was a 60 year old patient who underwent a right quadriceps tendon repair under general anesthesia on 2/5/2026. Review of Patient #6’s H & P showed a documented office visit & exam, dated 1/21/2026. This H & P failed to show: a complete review of systems; family history; social history; complete physical exam; and surgical history . The above findings were verified by Staff-B, CNO, at the time of review.”

“INFORMED CONSENT CFR(s): 482.51(b)(2) A properly executed informed consent form for the operation must be in the patient’s chart before surgery, except in emergencies. This Standard is not met as evidenced by: 23032 Based on interview and record review, the facility failed to ensure a properly executed anesthesia consent was available in the medical record prior to surgery for 8 of 11 sampled patients ( Patient IDs # 4, 5, 6, 7, 8, 9, 10, 11). Findings included: Review of facility policy titled “Obtaining Informed Consent,” revised date 03/2026, showed : Policy: All inpatient and outpatient medical records must contain a properly executed and completely written informed consent for all procedures and treatments... ’ Review of eleven (11) electronic medical records (emr) with Staff-B, Chief Nursing Officer (CNO) on 5/2/2026 showed eight (8) patient had incomplete anesthesia consent forms. Review of a form titled “Disclosure and Consent -Anesthesia” forms got thee 11 patients showed : Patient ID # 11: the patient “initialed” 3 areas: 1.) Physician Anesthesiologist 2.) Certified Anesthesiologist Assistant (CAA) , and 3.) Certified Registered Nurse Anesthesiologist (CRNA) . Each of these initialed areas are required to have the full name of the anesthesia provider documented . All 3 areas were left blank, no names provided. Patient IDs # 4 , 6, 7, 9, 10 : the patients “initialed” 2 areas: 1.) Certified Anesthesiologist Assistant (CAA) , and 2 ). Certified Registered Nurse Anesthesiologist (CRNA) . Each of these initialed areas are required to have the full name of the anesthesia provider documented . Both areas were left blank, no names provided. Patient IDs # 5, 8 : the patients “initialed” 1 area:” Certified Anesthesiologist Assistant (CAA).” This initialed area is required to have the full name of the anesthesia provider documented. The areas was left blank, no name was provided. The above findings were verified by Staff-B, CNO, at the time of review.”

“PRE-ANESTHESIA EVALUATION CFR(s): 482.52(b)(1) [The policies must ensure that the following are provided for each patient:] A pre-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, performed within 48 hours prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 23032 Based on interview and record review, the facility failed to ensure that a pre-anesthesia evaluation was completed prior to surgery for 1 of 10 sampled patients ( Patient ID # 9). Findings included: Review of facility policy titled “ Anesthesia Responsibilities,” last revised date 03/2026, showed: All patients receiving general anesthesia or local with anesthesia on standby will be seen pre-operatively by an anesthesiologist. A pre-anesthesia assessment, plan and discussion with the patient and family regarding anesthesia options and risks, shall be documented in the medical record. ~~~~~~~~~~ Patient # 9: Review if the electronic medical record of Patient # 9 showed the following: - He was a 54 year old patient who underwent an open hernia repair under general anesthesia on 5/7/2026. - The “Pre-Anesthesia Evaluation,” was dated 5/7/2026 ; performed at 2:22 PM. - The “Anesthesia Record,”dated 5/7/2026, with “Anesthesia Start time at 1:25 PM.” The above findings were verified by Staff-B, CNO, at the time of review.”

“POST-ANESTHESIA EVALUATION CFR(s): 482.52(b)(3) [The policies must ensure that the following are provided for each patient:] A post-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures, which have been approved by the medical staff and which reflect current standards of anesthesia care. This Standard is not met as evidenced by: 23032 Based on interview and record review, the facility failed to ensure that a post-anesthesia evaluation was completed for 2 of 10 sampled patients ( Patient IDs # 10,11 ). Findings included: Review of facility policy titled “ Pre and Post Anesthesia Evaluation Policy”, last revised date 03/2026, showed: “All patients receiving general , regional or monitored anesthesia shall have a posy anesthesia evaluation and documented by a practitioner qualified to administer anesthesia..no later than 48 hours after surgery or a procedure requiring anesthesia services.” Review of ten electronic medical records (emr) with Staff-B, Chief Nursing Officer (CNO) on 5/2/2026 showed two (2) patients failed to have a post-anesthesia evaluation documented prior to discharge. The record review showed: Patient ID # 10 : was a 53 year old patient who underwent a portacath insertion under general anesthesia on 5/6/2026. Staff -B was unable to locate a post-anesthesia evaluation in the medical record Patient ID # 11 :was a 43 year old patient who underwent an epidural steroid injection under intravenous (IV) sedation on 2/5/2026. Staff -B was unable to locate a post-anesthesia evaluation in the medical record”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 37490 Based on document review and interviews, the facility failed to ensure that a properly executed informed surgical consent was present in the medical record before initiating surgical treatment for 3 of 10 medical records reviewed (Patient ID#s 4, 5 and 10). Findings include: Review of facility policy titled “Informed Consent,” showed the following: POLICY: The primary purpose of the informed consent process is to ensure that the patient, or the patient’s representative, is provided the information necessary to enable him/her to evaluate a proposed procedure before agreeing to the procedure ... Informed consent is a person’s agreement to allow something to happen, made with full knowledge of the risks involved and the alternatives ... A complete informed consent process includes a discussion of the following elements ... “ potential benefits, risks, or side effects, including potential problems that might occur during recuperation. Review of medical record for patient (ID#4) for date of service 2/2/2025 showed the following: Disclosure and Consent for Right Lunate Nonunion Reconstruction; Right Free Medial Femoral Trochlear Bone Flap; Right (BACKUP) Prosthetic Lunate Implant; Right (BACKUP) Tenoarthroplasty for Late Phase KIENBOCK’S Risks of this care/procedure(s) include but are not limited to {include List A risks here and additional risks if any} None were listed or attached. Review of medical record for patient (ID#5) for date of service 2/9/2025 showed the following: Disclosure and Consent for: Right Scaphoid Nonunion Fixation and Grafting; Right Free Medial Femoral Condyle Bone Flap. Risks of this care/procedure(s) include but are not limited to {include List A risks here and additional risks if any} None were listed or attached. Review of medical record for patient (ID#10) for date of service 3/11/2025 showed the following: Disclosure and Consent for: Right Lumbar Four to Lumbar Five, Lumbar Five to Sacral One Radiofrequency Ablation Rhizotomy. Risks of this care/procedure(s) include but are not limited to {include List A risks here and additional risks if any} Not all appropriate Risk were included per the Texas Medical Disclosure Panel. Interview with facility CNO (ID# 52) on 3/11/2025 at 2:00 PM acknowledged the above findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 37490 Based on record review and interview, the hospital failed to ensure nursing staff clarified physician medication orders that did not include the specific pain parameters for narcotic pain medication in the Post Anesthesia Care unit (PACU) in 2 of 10 patients (ID#s 4 and 9). Findings include: Review of facility policy titled” Medication Administration & MAR Documentation,” showed the following: PURPOSE: To establish standards for safe and timely administration and proper documentation on the medication administration record. PROCEDURE: D. 8. The nurse shall consult with the pharmacist at any time when question arise regarding medication administration. Medical record for patient (ID#4) showed the following: Medication order 12:55 on 2/2/2025: Dilaudid 0.5 mg IVPUSH Q5min PRN, MAX dose 4 mg, PRN Reason: Pain. Medication order 12:55 on 2/2/2025: Fentanyl 100mcg/2 ML 25 mcg IV PUSH Q5min PRN, MAX dose 150 mcg, PRN Reason: Pain. Patients (ID#4) received 0.5 mg Dilaudid at 12:59. Medical record for patient (ID#9) showed the following: Medication order 06:32 on 3/11/2025: Dilaudid 0.5 mg IVPUSH Q5min PRN, MAX dose 4 mg, PRN Reason: Pain. Medication order 06:32 on 3/11/2025: Fentanyl 100mcg/2 ML 25 mcg IV PUSH Q5min PRN, MAX dose 150 mcg, PRN Reason: Pain. Patients (ID#9) received 0.5 mg Dilaudid at 08:17. Interview with facility CNO (ID# 52) on 3/11/25 at 11:00 AM stated that the order set should contain pain level parameters to know what medication to give or contain GIVE FIRST, SECOND, etc., instructions.”

“CONTENT OF RECORD: UPDATED HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(B) [All records must document the following, as appropriate:] (i) Evidence of -- (B) An updated examination of the patient, including any changes in the patient’s condition, when the medical history and physical examination are completed within 30 days before admission or registration , and except as provided under paragraph (c)(4)(i)(C) of this section. Documentation of the updated examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 37490 Based on record review and interview, the facility failed to ensure an updated examination of the patient, including any changes in the patient’s condition, when the medical history and physical examination are completed within 30 days prior to surgery or a procedure requiring anesthesia services in 2 of 10 medical records (ID#s 4 and 5). Findings include: Record review of facility Medical Staff Rules and Regulations showed the following: D. Medical Records a. The attending Physician shall be responsible for the preparation of a complete, accurate, timely, legible and verifiable medical record for each patient ... 1) A complete medical record shall include: vii. History and Physical Examination b. .... If a complete history has been recorded and a physical examination performed within 30 days prior to the patient’s admission to the hospital by a member of the medical staff, a reasonable, durable, legible copy of this report may be used in the patient’s hospital medical record in lieu of the admission history and report of the physical examination, provided this report was recorded by a member of the medical staff and has appropriate update of the patient’s condition. In such instances, an interval admission note that includes all additions to the history and any subsequent changes in the physical findings must always be recorded within 24 hours after admission, however, must be complete prior to any invasive operative procedure or any procedure which includes anesthesia. Medical record for patient (ID#4) date of service 2/2/2025 showed the following: History and Physical performed at office visit 1/7/2025, Surgeons Comment: Patient confirms no interval changes to medical status signed by physician staff (ID# 60) on 2/2/2025 at 08:16 AM. This document was faxed and scanned into the medical record 1/31/2025 (prior to date of surgery). Procedure start time on 2/2/2025 was 08:57 AM and surgery stop time was 12:20 PM. Medical record review for patient (ID# 5) date of service 2/9/2025 showed the following: History and Physical performed at office visit 2/5/2025, Surgeons Comment: Patient confirms no interval changes to medical status signed by physician staff (ID# 60) on 2/9/2025 at 10:03 AM. This document was faxed and scanned into the medical record 2/7/2025 (prior to date of surgery). Procedure start time on 2/9/2025 was 08:45 AM and surgery stop time was 11:46 PM. Interview with facility CNO (ID# 52) on 3/11/2025 at 2:00 PM acknowledged the above findings.”