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 670031 (X3) Date Survey Completed 01/12/2012
Name of Provider or Supplier St Luke's Patients Medical Center Street Address, City, State 4600 East Sam Houston Parkway South, Pasadena, 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-2567L is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. If information is inadvertently changed by the provider, you should notify the state Survey Agency. If the AS notices any discrepancy in the information related to the deficiency citation (s), the AS will report this occurrence to the Dallas Regional Office. The Regional Office will make a referral of possible fraud to the Office of the Inspector General (DOING). ********************************************** An unannounced visit was made to this hospital to conduct a recertification survey and licensure inspection. An entrance conference was held on 01/10/2012 with administrative personnel. The reason for the survey and the requirements under which the survey would be conducted were explained. An exit conference was held on 01/12/2012. The facility's administrative staff present were notified of the outcome of the survey and opportunity given to provide explanation and evidence. Deficiencies were cited based on the survey. The facility is in compliance with Cop 42 CFR part 482 and the State Licensing rules 25 Texas Administrative Code Chapter 133 as surveyed this day. Glossary : Bicarbonate solution: nonpyrogenic, hypertonic solution of Sodium Bicarbonate (NaHCO3) in water. CMS: Center for Medicare Services Endoscopy: is a procedure that lets your doctor look inside your body. It uses an instrument called an endoscope, or scope for short. ER: emergency room Hemodialysis : Hemodialysis: A medical procedure that uses a special machine (a dialysis machine) to filter waste products and water from the blood . Iodosorb Jell : is a wound gel that inhibits bacterial growth as it absorbs exudate. Specially formulated for use on wet, exudating ulcers Lasix :a drug used to treat excessive fluid accumulation and swelling (edema) of the body Levaquin: a drug used to treat infections of the sinuses, skin, lungs, ears, airways, bones, and joints Morphine: is a narcotic pain reliever used to treat moderate to severe pain Protonix: is used to treat gastroesophageal reflux disease (GERD), a condition in which backward flow of acid from the stomach causes heartburn and possible injury of the esophagus (the tube between the throat and stomach). Pyxis machine: is a medication dispensing machine used in hospitals Xenaderm:a protective ointment used to treat certain types of wounds or ulcers of the skin.