January health inspection of Renaissance Hospital Terrell

7/28/2019 January health inspection of Renaissance Hospital Terrell

1/20

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(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 01/28/20

FORM APPROV

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-03

450683 01/09/2013

C

TERRELL, TX 75160

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

RENAISSANCE HOSPITAL TERRELL1551 HWY 34 S

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

A 000 INITIAL COMMENTS A 000

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 Rights42 CFR 482.23 Nursing Services

An exit conference was conducted on 1/10/13 at

ABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

ny deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

ther safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

ollowing 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

ays following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

rogram participation.

ORM CMS-2567(02-99) Previous Versions Obsolete IEGE11Event ID: Facility ID: 810260 If continuation sheet Page 1 o


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A 000 Continued From page 1 A 000

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:

A 115

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 beimmediately 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



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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:

A 144

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



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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 patientwas 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



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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 wasfound, 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 #60was 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



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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."



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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 tothe 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


11/18/2012, and 12/9/2012) for the 7 AM to 7 PMshift 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.






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



8/20

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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 dated01/05/13 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 andweakness 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.



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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 thenext 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:

A 385

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

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.



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B. WING _____________________________

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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.


A 392

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 AMwhere there were no RNs scheduled to be

immediately available to the medical unit to



11/20

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B. WING _____________________________

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450683 01/09/2013

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TERRELL, TX 75160






DEFICIENCY)

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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







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.



12/20

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(X3) DATE SURVEY

COMPLETED

PRINTED: 01/28/20

FORM APPROV


B. WING _____________________________

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450683 01/09/2013

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TERRELL, TX 75160






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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. Noorder 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



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B. WING _____________________________

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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. Nodocumentation 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. Immediateclosing 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 ..... "



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B. WING _____________________________

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450683 01/09/2013

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TERRELL, TX 75160






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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.


A 397

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.

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



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(X3) DATE SURVEY

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B. WING _____________________________

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assume responsibility for the unit with a

Registered Nurse immediately available to the

unit."



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.



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




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




and 12/30/2012 for the 7 AM till 7 PM shift to


these staffing sheets available for review by the

surveyors.



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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.


nurse record revealed Patient #49 was a 74 yearold 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.



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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



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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, andHIV/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, ifone 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.


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



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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, intakeand 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



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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 screensection 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.


Documents

January health inspection of Renaissance Hospital Terrell