| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 670068 | (X3) Date Survey Completed 01/24/2023 |
| 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 | FEDERAL 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 survey for Complaint # TX00429904 was conducted on site. An entrance conference was held the morning of 01/24/2023 with hospital administrative representatives. It was explained to them that the complaint survey would be conducted to determine the facility's compliance per Chapter 5 of the SOM, Appendix A, and applicable sections of CFR 482 - Federal Regulations for Acute Care. An exit conference was held the afternoon of the same day with hospital administrative representatives at which time the findings of the survey were explained. 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. Instructions were provided on writing plans of correction with instructions to return the plans of correction to the Arlington zone office within 10 days. This report was electronically sent to the facility. Complaint # TX00429904 was substantiated with deficiencies cited. |
| A0398 | SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This STANDARD is not met as evidenced by: Based on the interview and record review, the hospital failed to enusre that the licensed nurses who provided serviced in the hospital adhered to the policies and procedures of the hospital. Findings included: Patient #1 was admitted on 05/22/2022 and presented to an emergency department for a fall while at a baseball game. Evaluation in ER showed a right femoral neck fracture. The patient's Body mass index is 15.99 kg/m². (Classification: Underweight) IBW: 86.4 kg. The patient has physician orders for a Pressure injury prevention score less than or Equal to 18 signed on 05/24/22 at 1520. Upon interview and record review: Patient #1 Braden score is less than or equal to 18. The initiation of pressure injury prevention interventions is not according to the hospital policy. There is no Braden scale completed on 05/30/2022 at 09:03 AM. Patient #1 medical record documentation by the nursing staff revealed that the patient is not turned every 2 hours, and keeping the head of the bed elevated is not as per the pressure injury prevention score. Patient #1 is not placed on a specialty surface per the policy. Braden scores are as follows Braden Score-16 05/22/22 at 2246 Braden Score-17 05/23/22 at 08:29 AM Braden Score 17 05/24/22 at 1538 Braden Score 17- 05/24/22 at 1952 Braden Score 18- 05/25/22 at 2318 Braden Score 18- 05/26/22 at 0946 Braden Score- 17 05/27/22 at 0052 Braden Score 18- 05/27/22 at 0915 Braden Score 18- 05/27/22 at 2359 Braden Score 17 -05/29/22 at 1340 Braden Score 05/30/2022 at 0903 AM - No Braden score documentation. Braden Score 17 -06/01/22 at 2138 Skin intervention 05/23/2022 at 2035 - No turning documentation. 05/24/22 at 1021 - No turning documentation. 05/24/22 at 1952- No turning documentation. 05/25/22 at 1538- No tuning documentation 05/27/22 at 0915- No turning documentation 05/29/22 at 1340- No turning documentation Positioning HOB up 30-45 05/26/22 at 0000 HOB up 30-45 05/26/22 at 0100 HOB up 30-45 05/26/2022 0200 HOB up 30-45 05/26/22 at 0400 HOB up 30-45 05/26/22 at 0500 HOB up 30-45 05/26/22 at 0600 HOB up 30-45 05/26/22 at 0700 HOB up 30-45 05/27/22 at 0052 HOB up 30-45 05/27/22 at 0915 HOB up 30-45 05/27/22 at 2352 HOB up 45 degrees 05/29/22 at 0809 Patient #1 is placed on Specialty bed Hill- ROM bed Adbata 2 SAE kit on 06/02/2022 at 1310. Outcome: The patient developed a suspected Deep tissue injury on 06/01/2023. During and inteview on 01/24/2023 at 1300. Personnel #1 and Personnel #2 were informed of the above findings. Personnel # 1 and Personnel #2 were confirmed of the above findings. According to hospital policy: Skin breakdown Prevention, Pressure injury, Skin tear, Incontinence skin management and Photography Policy Number:PCS318 Approved by: Policy and Procedure Committee 1. Purpose: ...To provide guidance and to communicate the recommended clinical practice in the prevention of skin breakdown...To reduce the incidence of hospital acquired pressure injury...iii Policy Guidance: A role of clinician 1. Nurses a. Perform skin assessment and implement nurseing intervention to prevent skin breakdown. 1) The braden scale for predicting Pressure score risk for adults ...b. Initiate pressure injury prevention interventions for patients with Braden score 18 or below 1) Turn and reposition every 2 hours...2) Keep the head of bed elevated no greated than 30 degree...B. Nursing inteventions and interventions guidelines...2. Prevention of skin breakdown/Routine skin care...d.Request/provide appropriate offloading devices...2) Specialty bed for preventions and treatment of skin breakdown |