| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 670068 | (X3) Date Survey Completed 03/18/2014 |
| Name of Provider or Supplier Texas Health Presbyterian Hospital Flower Mound | Street Address, City, State 4400 Long Prairie Road, Flower Mound, TX | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| A0000 | Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation (s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately. An unannounced complaint investigation was conducted on site. An entrance conference was held with the Director of Quality on the morning of 03/14/14 to explain the purpose and process of the investigation. The hospital representative was informed that this investigation would be conducted according to the State Operations Manual 42 CFR 482-Hospital Conditions of Participation. Survey findings were presented at an exit conference on the afternoon of 03/18/14 with the Chief Nursing Officer and other hospital representatives. The administrative representatives were given an opportunity to provide evidence of compliance with those requirements of which non-compliance had been found. None was provided to the surveyor. The hospital representatives were informed TX 00191167 was substantiated with deficiencies cited. |
| A0395 | RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This STANDARD is not met as evidenced by: Based on interviews and record reviews, the hospital failed to ensure Registered Nurses (RN's) evaluated and provided treatment for 1 of 10 patients (Patient #1's) altered skin integrity to the sacrum and/or coccyx identified on admission to Hospital A on 07/15/13. Findings Included: Hospital A: (Patient #1's) ED (emergency department) physician note dated 07/15/13 timed at 20:37 PM, reflected, "Tiny skin split...sacrum..." The 07/17/13 patient progress note timed at 13:45 PM, reflected, "Wife at bedside...states patient has a small healing ulcer on his coccyx and that she put DuoDerm on when he was admitted and wishes to have us address this if necessary...information given to nurse..." The 07/17/13 decubitus body picture timed at 17:45 PM, reflected, "Redness coccyx..." The 07/23/13 patient progress note timed at 07:35 AM, reflected, "Skin condition intact..." The 07/23/13 decubitus body picture timed at 07:35 AM, reflected, "Whole sore unstageable, blanchable reddened bottom..." No documentation was found which indicated treatment was applied to the pressure ulcer to the sacrum and/or coccyx. (Patient #1) discharged 07/23/13 to Hospital B. The physician orders dated 07/15/13 through 07/23/13 reflected no treatment orders for the wound to (Patient #1's) sacrum and/or coccyx. Hospital B's progress note dated 07/24/13 timed at 18:45 PM, for (Patient #1) reflected, "Initial asssessment performed by...wound nurse...deep tissue injury to coccyx, linear shaped lighter purple discoloration to bilateral gluteus...sloughing epidermis at coccyx site...site measures 10.0 (cm) by 2.0 cm...probable depth involvement...xenaderm ointment to deep tissue injury twice daily...side to side positioning..." On 03/14/13 at 01:00 PM, Personnel #1 was interviewed. Personnel #1 was asked to review (Patient #1's) medical record. Personnel #1 verified the medical record did not contain any documentation which indicated treatment was provided to (Patient #1's) coccyx and/or sacrum. On 03/18/14 at 09:41 AM, Personnel #4 was interviewed. Personnel #4 stated she could not provide the surveyor nursing education and/or competency regarding pressure ulcer prevention for the nursing personnel. The policy and procedure entitled, "Pressure Ulcer Prevention and Management" with a revision date of 06/10 reflected, "The pressure ulcer prevention and treatment program will include...identifying pressure ulcers at the time of admission, informing the physician of need for wound care...education programs for staff..." The policy and procedure entitled, "Patient assessment/Reassessment with an origination date of 03/10 reflected, "Purpose...to ensure each patient's physical status is assessed to determine the patient's care needs and to ensure patient's changing needs are reassessed in response to treatment and care provided...information generated via a patient's assessment will be integrated with other disciplines to identify and prioritize the patient's need for care and treatment..." |
| A0837 | TRANSFER OR REFERRAL CFR(s): 482.43(d) The hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care. This STANDARD is not met as evidenced by: Based on interviews and record reviews, Hospital A failed to ensure 1 of 10 patients (Patient #1's) necessary medical record information was provided to Hospital B which addressed (Patient #1's) altered skin integrity which was identified on admission to Hospital A on 07/15/13. Findings Included: Hospital A: (Patient #1's) ED (emergency department) physician note dated 07/15/13 timed at 20:37 PM, reflected, "Tiny skin split...sacrum..." The 07/17/13 decubitus body picture timed at 17:45 PM, reflected, "Redness coccyx..." The 07/23/13 decubitus body picture timed at 07:35 AM, reflected, "Whole sore unstageable, blanchable reddened bottom..." The physician orders dated 07/23/13 timed at 08:45 AM, reflected, "Discharge to rehabilitation today...follow-up with primary care physician one week after rehabilitation discharge..." No documentation was found which indicated Hospital B was informed regarding (Patient #1's) altered skin integrity. On 03/14/13 at 01:00 PM, Personnel #1 was interviewed. Personnel #1 said she could not find any documentation in the case management notes and transfer documentation which indicated Hospital B (Patient #1) was transferred to was informed (Patient #1) had altered skin integrity. The Medical Staff Rules and Regulation with an approval date of 04/17/13 reflected, "The discharge summary shall concisely include...final diagnosis, evaluated and treated during encounter...hospital course...medical care, treatment and services provided and how patient responded to care, treatment...provisions for follow-up care...complications and all other treated diagnosis and procedures shall be recorded in full...additional diagnosis must also be recorded which may exist prior to the admission of the patient or develop after the patient's admission..." |