DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 000 INITIAL COMMENTS An unannounced complaint survey, TX00171872, was conducted from 01/07/2013 through 01/10/2013. An entrance conference was held with the Administrator and the Director of Nurses in the Physician's Lounge on 01/07/2013 at 9:30 am. The purpose and process of the survey was explained and an opportunity was given for questions and discussion. The following was determined: The Immediate Jeopardy previously cited remained unabated on the following Conditions of Participation: 42 CFR 482.13 Patient Rights 42 CFR 482.23 Nursing Services 42 CFR 482.42 Infection Control 42 CFR 482.51 Surgery Services CFR In addition, it was determined Immediate Jeopardy situation existed in the following Conditions of Participation: 42 CFR 482.12 Governing Body 42 CFR 482.41 Physical Environment . Based upon the findings of the investigation, the facility was not in compliance with the following Conditions of Participation: 42 CFR 482.13 Patient Rights 42 CFR 482.23 Nursing Services An exit conference was conducted on 1/10/13 at
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

A 000

TITLE

(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 000 Continued From page 1 2:30 pm in the physician's lounge with the Administrator and the Director of Nurses. The preliminary findings were discussed and an opportunity was given for discussion and to provide additional information. A 115 482.13 PATIENT RIGHTS A hospital must protect and promote each patient's rights. This CONDITION is not met as evidenced by: Based on observation, document review and interview the governing body: A. Failed to provide Registered Nurses for supervision, patient assessments and timely interventions of patient care for 1of 1 (#60 ) patient experiencing changes in condition that resulted in the patient's death. The facility failed to provide Registered Nurses for supervision and assessment and to be immediately available to the nursing units. Licensed vocational nurses (LVN) were allowed to work in Intensive care unit (ICU), and Medical-Surgical unit without Registered Nurse supervision. Refer to Tag 144, 0392, 397 B. Failed to provide and maintain a safe and clean environment for patient care. Refer to Tag 0144 It was determined that this deficient practice created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failures had
FORM CMS-2567(02-99) Previous Versions Obsolete

A 000

A 115

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 115 Continued From page 2 the potential to affect all patients admitted to the facility. A 144 482.13(c)(2) PATIENT RIGHTS: CARE IN SAFE SETTING The patient has the right to receive care in a safe setting. This STANDARD is not met as evidenced by: Based on documents review and interviews, the facility failed to provide registered nurses to supervise patient care and provide assessments. These actions posed an unsafe environment for patients. A review of the documents titled "Assignment Sheets" revealed 4 dates, (12/24/2012, 12/25/2012, 12/27/2012, 12/28/2012), on the 7 PM to 7 AM where there were no RNs immediately available to the Intensive Care Unit to supervise LVN staff and patient care. An attempt was made to review the Assignment Sheets for the dates of 12/09/2012, 12/29/2012 and 12/30/2012 for the 7 AM to 7 PM shift to verify the RN staffing, but the facility did not have these staffing sheets for the surveyors to review . An interview on 01/08/2013 at approximately 11:30 AM with staff #42 and staff #57 confirmed that there were 19 dates on the Assignment Sheets for the Medical Unit where there was no RN coverage. The hospital staff confirmed during the interview that there was no RN coverage in the Intensive Care unit during the 4 dates in question. A review of patient #60's medical record revealed
FORM CMS-2567(02-99) Previous Versions Obsolete

A 115

A 144

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 144 Continued From page 3 the admission diagnosis of acute exacerbation of COPD and shortness of breath. Review of the assignment sheet revealed that patient #60 was assigned to staff #33, an LVN. The patient was admitted from the ER to the medical unit on 01/24/2013 at 10:00 PM. The Admission Record was completed by staff #33, at 2:00 AM. There was no evidence of an RN assessment. The Admission Orders read, "take vital signs every 4 hours, oxygen saturations every 4 hours, Intravenous fluid of normal saline" ( no rate was ordered). No clarification order was found for the normal saline rate. The Nursing Progress Note, dated 12/24/2012 and timed 10:00 PM, documented "Received patient from the ER with labored breathing." Respiratory was called to give a breathing treatment. The Respiratory Therapy Chart Sheet at 10:00 PM on 12/24/2012 documented a breathing treatment was given and the patient was on oxygen at 2 liter per nasal cannula. No order to place the patient on oxygen was found. The next time documented in the Nursing Progress Note was not legible. The following entries were at 2:00 AM, 2:10 AM, 4:00 AM and no oxygen saturation was documented. The next entry was at 6:15 AM and the documentation revealed "patient in bed, awake and hyperventilating, short of breath with an oxygen saturation of 84%. Called respiratory and called MD. MD said transfer to ICU." The next entry at 6:30 read "pt. transfer to ICU #4 at this time." Report was given to staff #38. Staff #38 was the only RN scheduled for the medical unit
FORM CMS-2567(02-99) Previous Versions Obsolete

A 144

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 144 Continued From page 4 and ICU during that 7 PM to 7 AM shift. A review of the ICU document titled "Nursing Observation/ Action/ Results" (ICU note), revealed that staff #38 assumed care of patient #60 at 6:35 AM the morning of 12/25/2012. At 7:00 AM, staff #38 documented giving the patient Rocephin 1 gram by IV and Solumedrol 60 milligrams IV. No order for these medications was found, nor evidence of communication with the MD. At 7:15 AM, staff #38 documented giving report and turning over the care of the patient to staff #40, an LVN that works in the surgical department. On 12/25/2012 at 7:30 AM, staff #40 documented in the ICU that MD was in the patient's room. At 8:00 AM, staff #40 documented that patient #60 was placed on Bi-Pap (Bi-Pap is a continuous positive airway pressure used to assist a patient with breathing). At 9:00 AM staff #40 documented that patient #60 was attempting to remove the Bi-Pap mask and soft wrist restraint was placed on the right wrist. No documentation was noted that the MD was notified of the use of the restraint. There was not a signed doctor's order dated 12/25/2012 for the use of restraints. At 2:00 PM staff # 40 documented the patient was intubated and placed on a ventilator (life support). A review of a written document by consulting staff #57 revealed "On 12/26/2012, after a tour of the facility an immediate recommendation to close the ICU was made ....An intense interview with the CNO was conducted and he verbalized understanding of the following: 1. Immediate closing of the ICU .... Upon returning to the
FORM CMS-2567(02-99) Previous Versions Obsolete

A 144

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 144 Continued From page 5 facility on 12/27/2012, the ICU not only remained open but more patients were admitted to the unit. During personnel record review it was found that the nursing staff did not have competencies, job descriptions, proper certifications and only one nurse was qualified to work in ICU. An intense interview was again conducted with the CNO who verbalized understanding of the following: 1. An immediate need to close down ICU ....HOWEVER: items remained unchanged throughout the three day stay. 12/28/2012 ... ... A final meeting was then held with the CNO and the following recommendations were made: 1. Close ICU ....." An interview with consultant #57 on 12/07/2013 at 11:30 AM revealed, when we left the facility the evening of 12/28/2012 there were still patients in the ICU. Review of a nursing policy "MASTER STAFFING PLAN" dated 03/2007 revealed the following: "Staffing will be sufficient to provide for adequate numbers of competent Registered Nurses to provide for initial and ongoing assessment and prompt recognition of any untoward changes in a patient's condition. " "At least one (1) Registered Nurse will be on duty on each unit for each operational shift. Operational shift is defined as the hours of shifts during which the unit is open and available for patient care. A Licensed Vocational Nurse may assume responsibility for the unit with a Registered Nurse immediately available to the unit."

A 144

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 144 Continued From page 6 Review of the documents titled, "Assignment Sheets" revealed 19 dates (11/16/2012, 11/17/2012, 11/22/2012, 11/23/2012, 11/26/2012, 11/29/2012, 11/30/2012, 12/01/2012, 12/02/2012, 12/03/2012, 12/04/2012, 12/05/2012, 12/08/2012, 12/12/2012, 12/13/2012, 12/25/2012, 12/27/2012, 12/30/2012) on the 7 PM to 7 AM shift, and on 12/7/2012 7 AM to 7 PM shift where there were no RNs scheduled to be immediately available to the medical unit to supervise LVN staff and patient care. Review of the documents titled, "Assignment Sheets", revealed 4 dates (12/24/2012, 12/25/2012, 12/27/2012, 12/28/2012) on the 7PM till 7AM shift where there were no RNs scheduled to be immediately available to the Intensive Care Unit to supervise LVN staff and patient care. Review of the documents titled "Assignment Sheets" revealed 3 dates (11/15/2012, 11/18/2012, and 12/9/2012) for the 7 AM to 7 PM shift and on 11/16/2012 for the 7 PM to 7 AM shift where there were no RNs scheduled to be immediately available to the Emergency Room to supervise LVN staff and patient care. An attempt was made to review the Assignment Sheets for the dates of 12/09/2012, 12/29/2012 and 12/30/2012 for the 7 AM to 7 PM shift to verify the RN staffing, but the facility did not have these staffing sheets for the surveyors to review . During an interview on 01/08/13 at 8:20 a.m., Staff #57 (consultant) confirmed that the assignment sheets for the Medical/Surgical Unit, Intensive Care Unit, and Emergency Room did not have RN coverage for these areas of the
FORM CMS-2567(02-99) Previous Versions Obsolete

A 144

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 144 Continued From page 7 hospital. 2. Review of the emergency department (ED) nurse record revealed Patient #49 was a 74 year old male who presented to the ED on 01/05/13 at 8:40 a.m. with complaints of his left arm being limp. Review of the ED physician assessment dated 01/05/13 revealed the initial clinical impression on Patient #49 was "weakness to the left upper arm and resolving TIA" (Transient ischemic attack). Review of the ED nurses record dated 01/05/13 at 11:45 a.m. revealed Patient #49 was being admitted to the medical-surgical floor. Review of a nursing "admission record" dated 01/5/13 revealed Patient #49 was received to the floor at 2:00 p.m. Staff #16 (LVN) performed the admitting assessment and documented Patient #49 had a blood pressure of 152/86 and weakness to his left arm. On the same assessment, Staff #16 documented Patient #49's neurological status was within normal limits. There was an assessment category for recent onset of weakness/paralysis within the "Rehabilitative medicine" section which was left blank. Instructions on the form directed the nurse, "If one or more is checked, referral required." There was no documented physical therapy referral by Staff #16. Review of the nursing "admission record" revealed an RN was supposed to complete the assessment within 12 hours of admission. There was no RN signature on the form.

A 144

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 144 Continued From page 8 Review of admission physician orders dated 01/05/13 revealed staff was to perform neurological checks every 2 hours for 12 hours and then every 4 hours. Review of nurse's notes and logs dated 01/05/13 revealed no documentation of an assessment of neurololical checks every two hours as ordered. A neurological assessment sheet was started the next day on 01/06/13 at 8:00 p.m. and continued until 01/07/13 at 4:00 p.m. with every 4 hour checks. Review of physician orders from 01/05-01/08 revealed no documentation of the neurological checks being discontinued. A 385 482.23 NURSING SERVICES The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This CONDITION is not met as evidenced by: Based on interview and record review the facility failed to ensure nursing provided RN supervision of care to 7 of 7 (#'s 35, 37, 39, 41, 44, 49 and 58) patients. Refer to A-397

A 144

A 385

It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failures had the potential to affect all patients admitted to the facility.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: IEGE11

Facility ID: 810260

If continuation sheet Page 9 of 20

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 392 482.23(b) STAFFING AND DELIVERY OF CARE The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient. This STANDARD is not met as evidenced by: During the follow-up survey from 01/07/2013 through 01/10/2013, it was determined: Based on documents review and interviews, the facility failed to provide Registered Nurses for supervision and assessments of patient care and provide an RN to be immediately available to the nursing units. Review of the document titled Master Staffing Plan revealed: 1. "At least one (1) Registered Nurse will be on duty on each unit for each operational shift. Operational shift is defined as the hours of shifts during which the unit is open and available for patient care. A Licensed Vocational Nurse may assume responsibility for the unit with a Registered Nurse immediately available to the unit. " A review of the documents titled, Assignment Sheets revealed 19 dates (11/16/2012, 11/17/2012, 11/22/2012, 11/23/2012, 11/26/2012, 11/29/2012, 11/30/2012, 12/01/2012, 12/02/2012, 12/03/2012, 12/04/2012, 12/05/2012, 12/07/2012, 12/08/2012, 12/12/2012, 12/13/2012, 12/25/2012, 12/27/2012, 12/30/2012), on the 7 PM to 7 AM where there were no RNs scheduled to be immediately available to the medical unit to
FORM CMS-2567(02-99) Previous Versions Obsolete

A 392

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 392 Continued From page 10 supervise LVN staff and patient care. A review of the documents titled "Assignment Sheets" revealed 4 dates, (12/24/2012, 12/25/2012, 12/27/2012, 12/28/2012), on the 7PM till 7 AM where there were no RNs scheduled to be immediately available to the Intensive Care Unit to supervise LVN staff and patient care. An attempt was made to review the Assignment Sheets for the dates of 12/09/2012, 12/29/2012 and 12/30/2012 for the 7 AM to 7 PM shift to verify the RN staffing, but the facility did not have these staffing sheets for the surveyors to review . An interview on 01/08/2013 at approximately 11:30 AM with staff #42 and staff #57 confirmed that there were 19 dates on the Assignment Sheets for the Medical Unit where there was no RN coverage. The hospital staff confirmed during the interview that there was no RN coverage on the 4 dates in question in the Intensive Care unit. A review of patient #60's medical record revealed the admission diagnosis of acute exacerbation of COPD and shortness of breath. Review of the assignment sheet revealed patient #60 was assigned to staff #33, an LVN. The patient was admitted from the ER to the medical unit on 01/24/2013 at 10:00 PM. The Admission Record was completed by staff #33, at 2:00 AM. There was no evidence of an RN assessment. The Admission Orders read, "take vital signs every 4 hours, oxygen saturations every 4 hours, Intravenous fluid of normal saline" ( no rate was ordered). No clarification order was found for the normal saline rate.
FORM CMS-2567(02-99) Previous Versions Obsolete

A 392

Event ID: IEGE11

Facility ID: 810260

If continuation sheet Page 11 of 20

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 392 Continued From page 11 The Nursing Progress Note dated 12/24/2012 and timed 10:00 PM, documented "Received patient from the ER with labored breathing." Respiratory was called to give a breathing treatment. The Respiratory Therapy Chart Sheet at 10:00 PM on 12/24/2012 documented a breathing treatment was given and the patient was on oxygen at 2 liter per nasal cannula. No order to place the patient on oxygen was found. The next time documented in the Nursing Progress Note was not legible. The following entries were at 2:00 AM, 2:10 AM, 4:00 AM and no oxygen saturation was documented. The next entry was at 6:15 AM and the documentation revealed "patient in bed, awake and hyperventilating, short of breath with an oxygen saturation of 84%. Called respiratory and called MD. MD said transfer to ICU." The next entry at 6:30 read, "pt. transfer to ICU #4 at this time." Report was given to staff #38. Staff #38 was the only RN scheduled for the medical unit and ICU during that 7 PM to 7 AM shift. A review of the ICU document titled "Nursing Observation/ Action/ Results" (ICU note), revealed that staff #38 assumed care of patient #60 at 6:35 AM the morning of 12/25/2012. At 7:00 AM, staff #38 documented giving the patient Rocephin 1 gram by IV and Solumedrol 60 milligrams IV. No order for these medications was found, nor evidence of communication with the MD. At 7:15 AM, staff #38 documented giving report and turning over the care of the patient to staff #40, an LVN that works in the surgical
FORM CMS-2567(02-99) Previous Versions Obsolete

A 392

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 392 Continued From page 12 department. On 12/25/2012 at 7:30 AM, staff #40 documented in the ICU that MD was in the patient's room. At 8:00 AM staff #40 documented that patient #60 was placed on Bi-Pap (Bi-Pap is a continuous positive airway pressure used to assist a patient with breathing). At 9:00 AM staff #40 documented that patient #60 was attempting to remove the Bi-Pap mask and soft wrist restraint was placed on the right wrist. No documentation was noted that the MD was notified of the use of the restraint. There was not a signed doctor's order dated 12/25/2012 for the use of restraints. At 2:00 PM staff # 40 documented the patient was intubated and placed on a ventilator (life support). A review of a written document by consulting staff #57 revealed "on 12/26/2012, after a tour of the facility an immediate recommendation to close the ICU was made ....An intense interview with the CNO was conducted and he verbalized understanding of the following: 1. Immediate closing of the ICU .... Upon returning to the facility on 12/27/2012 the ICU not only remained open but more patients were admitted to the unit. During personnel record review it was found that the nursing staff did not have competencies, job descriptions, proper certifications and only one nurse was qualified to work in ICU. An intense interview was again conducted with the CNO who verbalized understanding of the following: 1. An immediate need to close down ICU ....HOWEVER: items remained unchanged throughout the three day stay. 12/28/2012 ... ... A final meeting was then held with the CNO and the following recommendations were made: 1. Close ICU ..... "

A 392

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 392 Continued From page 13 An interview with consultant #57 on 12/07/2013 at 11:30 AM revealed, when we left the facility the evening of 12/28/2012 there were still patients in the ICU. A 397 482.23(b)(5) PATIENT CARE ASSIGMENTS 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: Based on interviews and records review, the facility failed to ensure nursing services provided RN supervision of care to 7 of 7 (#'s 35, 37, 39, 41, 44, 49 and 58) patients.

A 392

A 397

This deficient practice had the potential to cause harm in all patients.

1. Review of a nursing policy "MASTER STAFFING PLAN" dated 03/2007 revealed the following: "Staffing will be sufficient to provide for adequate numbers of competent Registered Nurses to provide for initial and ongoing assessment and prompt recognition of any untoward changes in a patient's condition." "At least one (1) Registered Nurse will be on duty on each unit for each operational shift. Operational shift is defined as the hours of shifts during which the unit is open and available for patient care. A Licensed Vocational Nurse may
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 397 Continued From page 14 assume responsibility for the unit with a Registered Nurse immediately available to the unit." Review of the documents titled "Assignment Sheets" revealed 19 dates (11/16/2012, 11/17/2012, 11/22/2012, 11/23/2012, 11/26/2012, 11/29/2012, 11/30/2012, 12/01/2012, 12/02/2012, 12/03/2012, 12/04/2012, 12/05/2012, 12/08/2012, 12/12/2012, 12/13/2012, 12/25/2012, 12/27/2012, 12/30/2012) on the 7 PM to 7 AM shift, and on 12/7/2012 7 AM to 7 PM shift where there were no RNs scheduled to be immediately available to the medical unit to supervise LVN staff and patient care. Review of the documents titled "Assignment Sheets" revealed 4 dates (12/24/2012, 12/25/2012, 12/27/2012, 12/28/2012) on the 7 PM to 7 AM shift where there were no RNs scheduled to be immediately available to the Intensive Care Unit to supervise LVN staff and patient care. Review of the documents titled "Assignment Sheets" revealed 3 dates (11/15/2012, 11/18/2012, and 12/9/2012) for the 7 AM to 7 PM shift and on 11/16/2012 for the 7 PM to 7 AM shift where there were no RNs scheduled to be immediately available to the Emergency Room to supervise LVN staff and patient care. An attempt was made to review the Assignment Sheets for the dates of 12/09/2012, 12/29/2012 and 12/30/2012 for the 7 AM till 7 PM shift to verify the RN staffing, but the facility did not have these staffing sheets available for review by the surveyors.

A 397

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 397 Continued From page 15 During an interview on 01/08/13 at 8:20 a.m., Staff #57 (consultant) confirmed that the assignment sheets for the Medical/Surgical Unit, Intensive Care Unit, and Emergency Room did not have RN coverage for these areas of the hospital. 2. Review of the emergency department (ED) nurse record revealed Patient #49 was a 74 year old male who presented to the ED on 01/05/13 at 8:40 a.m. with complaints of his left arm being limp. Review of the ED physician assessment dated 01/05/13 revealed the initial clinical impression on Patient #49 was "weakness to the left upper arm and resolving TIA" (Transient ischemic attack). Review of the ED nurses record dated 01/05/13 at 11:45 a.m. revealed Patient #49 was being admitted to the medical-surgical floor. Review of a nursing "admission record", dated 01/5/13, revealed Patient #49 was received to the floor at 2:00 p.m. Staff #16 (LVN) performed the admitting assessment and documented Patient #49 had a blood pressure of 152/86 and weakness to his left arm. On the same assessment, Staff #16 documented Patient #49's neurological status was within normal limits. There was an assessment category for recent onset of weakness/paralysis within the "Rehabilitative medicine" section which was left blank. Instructions on the form directed the nurse, "If one or more is checked, referral required." There was no documented physical therapy referral by Staff #16.

A 397

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 397 Continued From page 16 Review of the nursing "admission record" revealed an RN was supposed to complete the assessment within 12 hours of admission. There was no RN signature on the form. Review of admission physician orders dated 01/05/13 revealed staff was to perform neurological checks every 2 hours for 12 hours and then every 4 hours. Review of nurse's notes and logs dated 01/05/13 revealed no documentation of an assessment of neurological checks every two hours as ordered. A neurological assessment sheet was started the next day on 01/06/13 at 8:00 p.m. and continued until 01/07/13 at 4:00 p.m. with every 4 hour checks. Review of physician orders from 01/05-01/08 revealed no documentation of the neurological checks being discontinued. During an interview on 01/08/13 at 2:05 p.m., Staff #83 (LVN) checked Patient #49's record and confirmed she could not find any neurological checks for every 2 hours on 01/05/13 nor neurological checks for every 4 hours after 01/07/13 at 4:00 p.m. Staff #83 confirmed the physician order was not discontinued. Staff #83 reported she had not been given the information in report to continue the neurological checks when she got to work this morning at 7:00 a.m. Staff #83 confirmed an RN was supposed to complete the admission assessment. During an interview on 01/08/13 at 2:15 p.m., Staff #57 (RN consultant) reported they were having trouble getting the RNs to perform the
FORM CMS-2567(02-99) Previous Versions Obsolete

A 397

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 397 Continued From page 17 assessments. They were unwilling to take care of their patients and then perform admission assessments on the LVN's patients. 3. Review of an "admission record" revealed Patient # 35 was a 57 year old female admitted on 01/05/13 with diagnoses of atrial fibrillation. Review of the nutritional screen revealed problems with swallowing, diabetes, and HIV/AIDS were checked by nursing. According to the nutritional screen directive, if one or more categories were checked, nursing was supposed to make a referral. Nursing made no documentation of an attempt to make a referral. 4. Review of an "admission record" revealed Patient #37 was a 64 year old female admitted on 01/04/13 with diagnoses of congestive heart failure, chest pain and hypertension. Review of the nutritional screen revealed diabetes and clinically obese were checked by nursing. According to the nutritional screen directive, if one or more categories were checked, nursing was supposed to make a referral. Nursing documented that no referral was made. Review of the rehabilitative medicine screen revealed recent onset of weakness/paralysis and difficulty in walking were checked. According to the rehabilitative medicine screen directive, if one or more category was checked a referral was required. Nursing documented that no referral was made. 5. Review of the emergency department (ED) nurse record revealed Patient #58 was a 93 year old female who presented to the ED on 01/03/13 at 1:50 p.m. with complaints of a fall. Patient #58 had a pain level of 10 (out of a scale from 0
FORM CMS-2567(02-99) Previous Versions Obsolete

A 397

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 397 Continued From page 18 meaning no pain to 10 meaning severe pain) in the left hand. Review of the initial ED assessment tool dated 01/03/13 revealed it consisted of two pages. Nursing completed one page of the assessment and failed to complete the other. The second page consisted of actions taken, additional notes, medications given, procedures, vital signs, intake and outputs, property, and discharge disposition. All of these categories were not completed by nursing. There was no indication as to what happened to the patient. 6. Review of "nursing interventions" assessment dated 12/24/12 revealed Patient #44 was a 37 year old female admitted on 12/22/12. Acccording to the assessment sheets, LVN's (Staff #33, #83 and # 91) and a GN (# 92) completed the assessments from 12/24-26/12. There was a place on the assessments for a RN to sign, but this was not done. 7. Review of a "24 hour nursing flow record" revealed Patient #39 was a 75 year old male admitted on 11/26/12 with diagnoses of pneumonia and congestive heart failure. Review of a "24 hour nursing flow record", dated 11/27/12, revealed documentation that Patient #39 had a cough, shortness of breath and generalized weakness. This assessment was signed off by Staff #83 (LVN). According to the flow sheet a RN was suppose to sign off on the assessment and this was not done. 8. Review of an "admission record" dated 11/17/12 revealed Patient #41 was a 63 year old
FORM CMS-2567(02-99) Previous Versions Obsolete

A 397

Event ID: IEGE11

Facility ID: 810260

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

450683
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
01/09/2013

RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

1551 HWY 34 S

TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

A 397 Continued From page 19 female admitted on 11/17/12 with diagnoses of dizziness and hypertension. Review of the "admission record" dated 11/17/12 revealed the entire assessment was completed by Staff #90 (LVN). According to the "admission record" a RN was to perfom the assessment, but this was not done. Staff #90 (LVN) signed her name on the RN signature line. Review of the nutritional screen on the "admission record" form revealed Patient #41 followed a special diet at home, had problems with chewing, and had cancer. According to the nutritional screen directive, if one or more categories were checked, nursing was supposed to make a referral. Nursing left the referral category blank. There was no documentation of a referral being made. According to the high risk assessment for fall category, Patient #41 had an unsteady gait. Review of the rehabilitative medicine screen section revealed no documentation by nursing of an assessment of the unsteady gait. There was a category on the screen for nursing to check difficulty in walking, but this was not done. According to the rehabilitative medicine screen directive, if one or more category was checked, a referral was required. Nursing left the referral category blank. Review of physician orders dated 11/17/12 revealed neuro checks were to be performed every 2 hours on Patient #41. There was no documentation in the nurses' notes or progress notes showing they were done.

A 397

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: IEGE11

Facility ID: 810260

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