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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 survey was conducted on site. An entrance conference was held with the hospital CEO, COO, and Compliance Officer at 9:15am on the morning of 05/08/23. The hospital representatives were informed that this investigation would be conducted according to the survey protocol in the State Operations Manual, Chapter 5, section 5100 and Appendix A, and according to 42 CFR 482 the Conditions of Participation for Hospitals.
Survey findings were presented at an exit conference the afternoon of 05/10/23 at 4:30pm with hospital representatives inlcuding the COO, Managing Partner, Compliance Officer, and Director of Nursing. An opportunity was provided for the facility to provide evidence of compliance with those requirements for which non-compliance was found. None was provided.
The exit date was extended to 06/06/23 to complete review of medical records.
TX00392491, found to not be in compliance with deficiency cited.
During the investigation, deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for likelihood of harm, serious injury, and possible death. The IJ template was provided to the hospital CEO and owner on 05/09/23 at approximately 5:00pm.
An acceptable plan of abatement was received from the facility at approximately 4:00pm on 05/10/23. The IJ was verified to have been abated at 4:30pm on 05/10/23.
Immediate Jeopardy
482.13 Patient Rights
Plan of Abatement:
Effective immediately:
Face to face will be conducted by an RN who has been previously trained, regulatory requirements will be reviewed, the education will be provided via Power Presentation. Complete education copy of power point and sign in sheets as well as post- test will be attached after successful demonstration.
o The patient immediate situation
o The patient's reaction to intervention
o The patient's medical and behavioral condition
o The need to continue restraints
Upon a physician's order for IM Restraint, once the patient has been administrated an IM Restraint, the nurse will conduct an assessment, and document every 10 minutes for the first hour. Physical Assessment will be performed by a trained RN and will consist of Visual observation, and Vital signs. Documentation will be recorded on the Restraints and Seclusion packet and log.
1. Vitals (BP/TEMP/O2/respiration)
2. Visual (laying their eyes assuring the patient is not in distress)
The nurse will complete log on a daily basis of any restraint/seclusion and turn in form to DON daily, and copy sent to Compliance Officer (QAPI Measure)
Education on the levels of Restraints:
Chemical- IM voluntary patient (willing to accept injections) or Involuntary Physical Restraints- Restraining a patient physically against their will.
Seclusion- Will be placed in seclusion room and monitored.
Disruptive/Hostile Patient:
All staff will be educated on how to recognize patient who are very aggressive and disruptive, we will initiate the process to transport patient to Psychiatric Intensive Care Unit. While we are able to provide placement the Clinical team will redirect all patients to a safety area of unit till disruptive patient can be calmed or de-escalation.
More male staff and presence of CPI trained security guards.
Education will be provided to staff on site now, and will incorporate all nurses and staff. The night staff will be educated on the process, sign off acknowledgement of process and expectations, all additional staff will be educated prior to the start of their shifts.
The original forms will be maintained in the patient medical records, a copy will be placed in the compliance bin.
Quality measure MET 100%, 99 % Needs improvement.
An ad hoc board meeting was held on 05/10/23 at 6:07pm at which time the Board approved the above abatement plan and implementation.
The following Conditions of Participation were found to be out of compliance:
482.13 Patient Rights
482.22 Medical Staff
482.55 Emergency Services
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