Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 670029 (X3) Date Survey Completed 03/15/2011
Name of Provider or Supplier First Surgical Hospital Street Address, City, State 4801 Bissonnet Blvd, Bellaire, 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)
A1076 OUTPATIENT SERVICES
CFR(s): 482.54

If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice.


This CONDITION is not met as evidenced by:
Based on interview and record review the Hospital failed to appropriately admit 4 of 4 sampled indigent patients with a diagnoses of appendicitis from out-patient emergency centers. (Patient ID#'s 10, 15, 19, and 35) The hospital also failed to ensure that 4 employees at Bellaire out-patient emergency center received hospital orientation. (Staff ID#'s 150, 151, 152, 153) Findings include: Four indigent out-patient emergency room patients were inappropriately transferred to other hospitals for higher level of care. (Patient ID#'s 10, 15, 19, 35). Record review of emergency room patient transfers for patient ID#'s 10, 15, 35 and 41 revealed each patient was seen in out-patient provider based emergency departments and each was diagnosed with appendicitis. Each patient was indigent with no insurance and all were transferred to other hospitals for higher level of care / surgical intervention. In each case, the hospital had the capability and the capacity to care for these patients but the out-patient emergency centers did not consult with the hospital prior to the transfers. Record review of a policy titled "Emergency Department Scope of Service" dated 12/09 stated "Emergency Department patients are evaluated for response to treatment and are either admitted, transferred for further treatment that requires a higher level of care or is not provided by First Street Hospital......." Record review of a policy titled "Scope of Services" dated 07/2010 stated "Perioperative Services - Surgery: Surgical services include a full range of general surgical procedures as well as surgical specialties.........The primary focus of service is to provide surgical support for in-patients and out-patients." Patient ID# 10: Record review revealed this patient was seen 10/22/10 at St. Michaels Emergency Room Westheimer. The face sheet stated the patient was unemployed with no insurance. The Memorandum of Transfer form stated the patient was transferred to Hospital #90 with a diagnoses of Appendicitis. The Memorandum of Transfer stated the patient was being transferred for "Medical necessity / Upgrade in care." The patient record failed to document if the emergency room contacted First Street Hospital prior to transferring the patient to another hospital. First Street Hospital had the capability and the capacity to care for patient # 10. Record review of the surgery on-call schedule dated 10/22/10 revealed a general surgeon (ID# 57) was on-call at First Street Hospital. Review of the general surgeon's credential file revealed one of the approved delineation of privileges was "appendectomy." Record review of the daily Census on 10/22/10 revealed the hospital had a census of 2 in-patients with a total capacity of 5 beds. Patient ID# 15: Record review revealed this patient was seen on 12/26/10 at St. Michaels Emergency Room Woodlands. The face sheet stated the patient was uninsured. The Memorandum of Transfer form stated the patient was transferred to Hospital # 89 with a diagnoses of Appendicitis. The Memorandum of Transfer stated the patient was being transferred for "Medical necessity / Upgrade in care." The patient record failed to document if the emergency room contacted First Street Hospital prior to transferring the patient to another hospital. First Street Hospital had the capability and the capacity to care for patient # 15. Record review of the surgery on-call schedule dated 12/26/10 revealed a general surgeon (ID# 54) was on-call at First Street Hospital. Interview 3/15/11 at 10 a.m. with the Chief Executive Officer (ID# 50) revealed the hospital had no in-patients on 12/26/10 and 19 beds available. The CEO stated the hospital completed construction on an expansion 12/20/10 and added 14 additional beds to the existing 5 beds for a total of 19 beds. Patient ID# 19: Record review revealed this patient was seen on 12/13/10 at River Oaks Emergency Center. The face sheet stated the patient was uninsured. The Memorandum of Transfer form stated the patient was transferred to Hospital #87 with a diagnoses of "acute appendicitis." The Memorandum of Transfer form did not state the reason for the transfer. The patient record failed to document if the emergency room contacted First Street Hospital prior to transferring the patient to another hospital. First Street Hospital had the capability and the capacity to care for patient # 19. Record review of the surgery on-call schedule dated 12/13/10 revealed a general surgeon (ID# 57) was on-call at First Street Hospital. Record review of the daily Census on 12/13/10 revealed the hospital had a census of 4 in-patients with a total capacity of 5 beds. The patient record failed to document if the emergency room contacted First Street Hospital prior to transferring the patient to another hospital. Patient ID# 35: Record review revealed this patient was seen on 9/23/10 at Bellaire Emergency Center. The face sheet stated the patient was uninsured. The Memorandum of Transfer form stated the patient was transferred to the County Hospital (ID# 88) for "Medical Necessity / Upgrade in care and Patient Request." Interview 3/16/11 at 3 p.m. with patient ID# 35 revealed the patient did not request to be transferred to the County hospital, that the emergency room made all the arrangements. The patient record failed to document if the emergency room contacted First Street Hospital prior to transferring the patient to the County hospital. First Street Hospital had the capability and the capacity to care for patient ID# 35. Record review of the surgery on-call schedule dated 9/23/10 revealed a general surgeon (ID# 57) was on-call at First Street Hospital. Record review of the daily census on 9/23/10 revealed the hospital had a census of 4 in-patients with one bed available. Record review of a policy titled "Patient Transfer Policy" dated 8/29/06 stated "Introduction: The Governing Board of First Street Hospital, after consultation with the Medical Staff, has adopted the following policy according to rules adopted by the Texas Department of State Health Services regarding the evaluation, treatment, and transfer of patients from this hospital to another hospital in a medically appropriate manner......The transfer of a patient may not be predicated upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, gender, physical condition or economic status." The policy further stated "Administrative Protocols: If a patient has an emergency condition which has not been stabilized or when stabilization of the patient's vital signs is not possible because the hospital or emergency department does not have the appropriate equipment or personnel to correct the underlying process, evaluation and treatment shall be performed and transfer shall be carried out as quickly as possible." ORIENTATION: Record review of nine full time employees at Bellaire out-patient emergency room revealed four staff members never received general hospital orientation. (Staff member ID#'s 150, 151, 152, 153) The Human Resources Director (ID# 154) acknowledged 3/15/11 at 1 p.m. that staff member #'s 150, 151, 152, and 153 had not received general hospital orientation. Record review of the employee files revealed the following: Employee ID# 150 was hired 12/20/09 as a Registered Nurse Employee ID# 151 was hired 8/1/2010 as a Registered Nurse Employee ID# 152 was hired 8/25/2009 as a Registered Nurse Employee ID# 153 was hired 2/22/2010 as a Radiology Technician Record review of a policy titled "General Orientation" dated 8/30/2006 stated "All employees will attend General Orientation for new hires within thirty days of employment."