January health inspection of Renaissance Hospital Terrell
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Transcript of January health inspection of Renaissance Hospital Terrell
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7/28/2019 January health inspection of Renaissance Hospital Terrell
1/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
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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7/28/2019 January health inspection of Renaissance Hospital Terrell
2/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
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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7/28/2019 January health inspection of Renaissance Hospital Terrell
3/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 115 Continued From page 2 A 115
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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7/28/2019 January health inspection of Renaissance Hospital Terrell
4/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 144 Continued From page 3 A 144
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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7/28/2019 January health inspection of Renaissance Hospital Terrell
5/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 144 Continued From page 4 A 144
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
ORM CMS-2567(02-99) Previous Versions Obsolete IEGE11Event ID: Facility ID: 810260 If continuation sheet Page 5 o
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7/28/2019 January health inspection of Renaissance Hospital Terrell
6/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 144 Continued From page 5 A 144
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."
ORM CMS-2567(02-99) Previous Versions Obsolete IEGE11Event ID: Facility ID: 810260 If continuation sheet Page 6 o
-
7/28/2019 January health inspection of Renaissance Hospital Terrell
7/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 144 Continued From page 6 A 144
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
Sheets" revealed 3 dates (11/15/2012,
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.
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
ORM CMS-2567(02-99) Previous Versions Obsolete IEGE11Event ID: Facility ID: 810260 If continuation sheet Page 7 o
-
7/28/2019 January health inspection of Renaissance Hospital Terrell
8/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 144 Continued From page 7 A 144
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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7/28/2019 January health inspection of Renaissance Hospital Terrell
9/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 144 Continued From page 8 A 144
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.
ORM CMS-2567(02-99) Previous Versions Obsolete IEGE11Event ID: Facility ID: 810260 If continuation sheet Page 9 o
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7/28/2019 January health inspection of Renaissance Hospital Terrell
10/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
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:
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
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11/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 392 Continued From page 10 A 392
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.
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A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 392 Continued From page 11 A 392
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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13/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 392 Continued From page 12 A 392
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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A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 392 Continued From page 13 A 392
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:
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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15/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 397 Continued From page 14 A 397
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.
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A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 397 Continued From page 15 A 397
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 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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17/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 397 Continued From page 16 A 397
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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18/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 397 Continued From page 17 A 397
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.
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
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19/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 397 Continued From page 18 A 397
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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20/20
A. BUILDING
(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 _____________________________
______________________
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)
(X5)
COMPLETIO
DATE
ID
PREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 397 Continued From page 19 A 397
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.
ORM CMS-2567(02-99) Previous Versions Obsolete IEGE11Event ID: Facility ID: 810260 If continuation sheet Page 20 o