| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 670071 | (X3) Date Survey Completed 02/28/2012 |
| Name of Provider or Supplier Texas Health Heart & Vascular Hospital Arlington | Street Address, City, State 811 Wright Street, Arlington, 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 citations(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of Inspector general (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Agency (SA) should be notified immediately. An unannounced entrance conference was held the afternoon of 2/27/12 with facility chief nursing officer in an office of Texas Health Heart & Vascular Hospital located at 811 Wright Street, Arlington, TX 76012. The purpose and process of the complaint investigation survey were explained and an opportunity given for questions. The survey was conducted to determine the facility's compliance with 42 CFR ยง482, Conditions of Participation for Hospitals. TX00155631 - Substantiated with a standard-level deficiency cited. An exit conference was held the morning of 2/28/12 with facility administrative staff in a conference room of Texas Health Heart & Vascular Hospital located at 811 Wright Street, Arlington, TX 76012. Preliminary findings of the survey and next steps in the survey process were presented and an opportunity given for questions and discussion. All questions were answered. An opportunity was also provided for the facility to provide evidence of compliance with those requirements for which non-compliance was found during the survey. No such evidence was either alleged or proffered. |
| A0817 | DISCHARGE PLAN CFR(s): 482.43(c) Discharge Plan This STANDARD is not met as evidenced by: Based on observation, review of documentation, and interviews with facility staff, the facility failed to ensure that specific discharge plan requirements are met as there was no physician's order for discharge of the patient in the medical record of 1 of 1 patient records reviewed. The findings were: The Rules and Regulations of the Medical Staff of Texas Health Heart & Vascular Hospital dated 9/10 were reviewed on the afternoon of 2/27/12 and reflected "10. Patient Discharge: a. Patients shall be discharged only on written order from the physician or another individual with privileges to write orders." The medical record of patient #1 was reviewed on 2/27/12, and revealed that there was no physician order in the record for the patient's discharge. In an interview with staff #2 on 2/27/12 at 4:50 pm, the physician orders in the record of patient #1 were reviewed with her and she stated that there was no physician order in the record for the patient's discharge. She further stated that the usual procedure would be for the physician or physician's assistant to enter the discharge order into the electronic record system, or a nurse could enter a verbal order into the system. The facility "Safety Action Learning Tool Form" dated 8/1/11 was reviewed on the afternoon of 2/27/12. The form was regarding patient #1; the date and time of the incident was 4/20/11 at 7:49 pm; the general location was the Telemetry Unit; and the reporting department was Cardiac Telemetry. The incident description reflected "Discharge planning was done by social worker, case manager, and physician's assistant. DC (discharge) summary written by PA (physician's assistant) and cosigned by physician. No discharge orders written. Husband called and wanted to know how we can discharge a patient without an order or notifying him. He feels we did something illegal. All paperwork is in order, third party transfer and MOT (Memorandum of Transfer) done, report called to rehab center. Discussion of transfer to rehab center held by CM (case manager)/SW (social worker)/PA/NP (nurse practitioner) and all documentation showed patient was to be transferred. Order for discharge never written." |