(X2) MULTIPLF. CONSTRUCTION. A. auilding_~ STRE.~T AQPRESS, CITY, STATE, ZIP CODE ID PREFIX TAG AOOOI I I A 3921

Transcription

1 07/25/204 7: MLLWOOD Q DEPARTMENT OF HEALTH AND HUMAN SERVCES PR T:.. :: 07/7/204 F : ~".\!\PPROVEO ~C:.sE~NTE::!R~SwF:.::O:!.!:R~M!!!E;;.!;D!.!.:C~A;l!R.!!!E~&!!..,;M~ED!:!.!l~Co:A~D~S~E..wR~V.!..!!!lC~E~S---""T""-----~------~--;OFMJ J:!];,.,Q_ STAT~MENT OF DcFCE~Cr.s ANO Pt.AN OF CORRECTON (X) PROVDF.R/SUPPLER/C.A DENTFCATON NUMBER: (X2) MULTPLF. CONSTRUCTON A. auldng_~ (X3) l'e 3JRVEY :.),,''L.!T!::O l---:-~~:-"""":"':'~::::-:::::--l---_:4~s~40~~ j..: 8 :_: wt=ng;::=::~:::;:::;~~====-==-::::~--..l-.. ~::::!~!!l/204 NAME OF PROVDER OR SUPP,ER STRE.~T AQPRESS, CTY, STATE, ZP CODE ML..WOOO HOSPTAl. (X4) 0 PREFX fag SUMMARY ST/\Tr.MENT OF DF.FCENCES (EACH O~FCENCY MUST BE PRF.CEDEO BY FU,L REGULATORY Ort LSC DENTFYNG NFORM/\TON) A 000 NTAL COMMENTS Note: The CMS-2567 (Statement of Defcences) s an offcal, legal document All nformaton must reman unchanged except for enterng the plan of correcton, correcton dates, and the sgnature space. Any dscrepancy n the orgnal defcency ctaton (s) wll be reported to the Dallas Regonal. Offce (RO) for referral to the Offce of the nspector General (00) for possble fraud. f nformaton s nadvertently changed by the provder/suppler, the State Survey Agency (SA) should be notfed mmedately. An unannounced nvestgaton of complant TX was conducted onsta. An entrance c:onfert~nce was held on the evenng of 07/06/4. wth the House Supervsor. The hosptal representatve was nformed that ths nvestgaton would be conducted accordng to the survey protocol n the State Operatons Manual, Chapter 5, secton 500 and Appendx A, and Olccordng to 42 CFR 482 the Condtons of Partcpaton for Hosptals. The applcable survey report form was appled. Survey fndngs were presented at an ext conference on the evenng of 07/09/4 wth the Chef Executve Offcer and ather desgnated staff. members. The hosptal representatves were nformed Complant TX was substantated and defcences were cted. An opportunty was provded for the faclty to provde evdence of complance wth those recjurements for whch non"complance was found. None was provded to the surveyors A (b) STAFFNG AND DELVERY OF CARE The n~rsng servce must have ade(luate ENTATVE'S SGNA TURF- D PREFX AOOO 0 NORTH COOPeR STREET ARLNGTON, T:X 7G0 - PROVDF.R'S PLAN OF CORRECTON (EACH CORRECTVE ACTON S OULO BE CROSS-Rer-ERENCED TO T-lE APPROPRATE OEFCENCY) AOOO SJbmsslon of ths plan of correcton s not an adm~!;lon by the hosptal that the ctaton~ are correct or that tm hosptal volated the rules.that sad, a specal meetng was held wth members of Admnstraton and Leadershp upon recept of the Centers for Medcare and Medcad Statement of Oefc:encles. The report was dscm~sed and a course of acton was developed. (,,... T. (Xu) COMPLETON DATE A 392 l A392 The DON revewed the current p'oeesses for determnlg and assgnng of staff to Psychatrc ntensve Cata Unt along wth the 4 other unts...,_, ' TlflE j.>lg) OATl ---~--~--=C:.!...F0~-~--.. 2::2~-H " dnclency whch the nsttuton m;;~y be excused from corroellng provdng t a dotf,)rmlned that (See nstructons.) c:xeapt for nursng homes. tho flndlngs stated above are dl~closable 90 dayl follownq tho dlle of survey whether or not a plan of c~m e<;tlon ~ provded. For nur~ng home~, the above flmnq$ and plans of c:orreeton are dlscloseble 4 days fofowlnq ttle date these doeumont!:l are made evel!\blo to tle faclty. f defeencc$ are cted, an approv{d plan of correcton s requste to contnued program pertjc.lpatlon. FORM CMS-2557t02-99) POVOU8 Versons ObooAln Evon! D; EOU

2 07/25/204 7: MLLWOOD Q J,:.,.:c 08/ PRN' ; r:) )7/7204 DEPARTMENT 0~ HEALTH AND HUMAN SERVCES!= : ~!,!,PPROVED ~C~E.JNT.!..!E;;~.R~Su.F~O:.~.;RuMu.!E:.!!D!.!:C~A;.l.R.:,:,E...::&~M~E!!olD~.:::.CA:;.::u.::D~S~E!l..:R~V:.:=C~E~S---., O:.!..!M.!!':E,~. ::JG:~ STATEMENT OF OEFCENCES AND PLAN OF CORRECTON (X) PROVDE:A/SUPPLERCLA DENTFC\TON NUMBF.R. (X2) MULTPLE CONSTRUCTON /, BULONG (X3) [ :rr! lrvev C ~'L'reo ~----~..,...---~~=--L :4:6:40::,:~2----_J_:B.:_: W=NG:..r:~~:::::::::;;;:::::::::=::;:~------~--.J_- ;!: :'.:9:~~ _-; NAMF. OF PROVDER OR SUPPLER MLLWOOD HOSPTAL A 392 Contnued From page numbers of lcensed regstered nurses, lcensed J practcal (vocatonal) nurses, and other personnel to provde nursng care to all patents as needed. There must be supervsory end staff personnel for each department or nursng unt to ensure, when : needed, the mmedate avalablty of a regstered nurse for bedsde care of any patent. ' Ths STANDARD s not met as evdenced by: Based on ntervew and record revew the hosptal faled to ensure of 5 unts PCU (Psychatrc ntensve Care Unt) was adequately staffed based on patent needs from 07/03/4. throug 07/07/4. Fndngs ncluded: (Patent #4's) pre-admsson exam dated 06/22/4 tmed at 245 reflected, "Fatent has been prevously dagnosed wth bpolar dsorder and s currently n a manc epsode... audtory hallucnatons and s fxated on Voodo... homcdal deatons towards mother, paranod and has not slept lr, three days..." The physcan's orders dat@d 07/0/4 through 07/07/4 reflected, "Lne of sght whle awake." The nursng progress note dated tmed at 600 reflected, "Patent anxous and pacng the hallways... " The nrjrsng progress note dated 07/04/4 tmed 0700 to 00 reflected "Patent exhbtng ncreased anger... at 800 remans on LOS (Lne of Sght) whle awake... patent changes clothes [ D PREFX A392. multple tmes durng the shft wee rng ' napproprate clothng.,, she s oppostonal and STREET ADOAESS, CTY, STATE, ZP CODO 0 NORTH COOPER STREET A~LNGTON, TX 760! A392 ncludng hgh r&l< needs level$ of observatons -on gong patent care as$(!$&ments. "Superv~;~ory Report" Polcy# Patent Care Assgnment" ; Polley ff "Nursng Assgnments" ; Polley# ''P~;~tent Reassessment"; -"The Nursng Plan of Care for -204"; -Texas Saf-e Staffng Act 2009; Polcy# 200. " Methods of Determnng Educaton Needs"; - Polley # "Chan of Command" The DON wll be revsng the l.eval of Observ<l, lll Polley to ncorporate hgher levels of observat for patent safety oversght. [8/5f204 Ths revsed polcy wll be presented to the Me. : t:j Staff Commttee for approval at the next meetl 08/5/204 The DON determned that dally oenaus and b;;: ''' rlt.! acuty necesstated adjustment of the staff to patent ratos to accommodate the ncreasng, hgher acuty n the patents requrng admsslo ' ' the ntensve care unt and acute care psyclll r npatent admssons. l'l7/7/204 The DON s developng an acuty toot to furth ~ ~ augment stafflng based on teeommendatons :, n the Nursng Advsory Commtt~:~e and the new amended Level of Observaton ~ollcy. ~8/0{204 The DON/Desgnee wll educate the drect c:are RN nursng staff on the use of the new ac l ]' tool and revsed "L.evel of ObsetVaton " polc\ va nurses n-servce$, valdated by sgn n ah~ U. 08{5/204 The DON/Desgnee wll montor varances daly, adjust levels where needed, and report : Senor Management Team and P Commttee 08/5/204 monthly. Varances wll be reported Nurae Starr Advse! Commttee end Governng Board Quarterly s.. wth the next scheduled meetng. defant..." l ~------~ ~ FORM CMS.;,5B7(02 99) l"revlous V;>r~Qnr. Ob&O&le F.v~'>~D: EOU l'~clllly D: S 0454 contnu~: :ll', c;l'let F'age 2 of 5 ''tl ' :n

3 07/25/204 7: MLLWOOD Q DEPARTMENT OF HEALTH AND HUMAN SERVCES PRN [); )77/204 FC ';/~,PPROVED ~C~E;L,:N.,.wTE!::.!R~S~F!..lO.:.:R..l..l.t:M:.!!!E~D!.:::C:.:;,A~R:.=E~& 4M::!!E::.tD~C:::::A~~D;..:,S::::E:.:.:R~V.:.:;C:,::E.:.::S:... -r_--~ ~o~m~b. ~j;;~"j; STATEM!ONT OF DEFC!NCES (X) PROVDERSUPP.ER/CLA (X2) MU.TPLE CONSTRUCTON (X3) c,,r '..RVOY AND PLAN OF CORROCTON D>.NTF'CATON NUMeER: A, F.!ULDNG c: M~ll_5;!-eo '----~_:46::,:4::0_::2: J..:e::.:, M:.:::.:NG:;:::=======:: L-. ~;~~!~l!!r.;;;.20.:..._4_--4 NAMF. OF PROVDF.R OR SUPPLF.R STREET ADDR!SS, CTY, STATE, ZF' COOl: MLL.WOOD HOSPTAL (X4) 0!"REFX SUMMARY STATEMENT 0' DEFCF.NC!!S leach DOFCENCY MUST BE PAECF.OEO BY F'ULL REGU./\TOAY OR LSC DENTFYNG NFORMATON) 0 PREFX 0 NORTH COOP!R STREET ARLNGTON, TX 760 PR0VD5R'S PLAN OF CORRECTON (EACH CORRECTVE ACTON S;OULO ElF. CROSS-ReFERENCED TO TE APPROPRATE OEFCF.NCY) X&) :0M~L~TON 0'!!...J... A 392 Contnued From page 2 The 07/05/4 nursng progress note tmed at 095 reflected, "Pressured speech, dsorganzed thoughts, hyparactve, n and out of group.. -" The PCU staffng records for 07/03/4 through 07/08/4 reflected the followng: ) The staffng for 7 AM to 3 PM on 07/03/4 reflectad, RN and MHT for 2 patents and one LOS (lne of sght) for (Patent #4). 2) The staffng for 7 AM to 3 PM on 07/04/4 reflect;d, RN and MHT for 4 patents, and one LOS for (Patent #4). 3) The staffng for 7 AM to 7 PM on 07/05/4 reflected, RN and MHTfor 3 patents, end, one.0$ for (Patent #4). Eght of the 3 patents were an sucde precautons, 6 of the 3 were on fall precautons and three patents were on aggresson precautons. 4) The staffng for 7 AM to 7 PM on 07/06/4 reflected, 2 nurses and MHT for 7 patents and one LOS for (Patent #4). Nne ofthe 7 patents were on sucde precautons, 6 on fall precautons, 3 on aggresson precautons and three admssons. 5) The staffng for 7 AM to 3 PM on 07/07/4 reflected, 2 nurses, 2 MHT's for 20 patents and one LOS for (Patent #4). Nne of the 20 patents were on sucde precautons, seven on aggresson precautons and two on fall precautons. 6) The staffng for 3 PM to PM on reflected, RN. L.VN and MHT for 9 patents. FORM CM$-2557(0~-99) PrevOlS Vlor>on~ Ob&olet" F.v~~~ D; EDU A392 ~acllty D; 6H)454 f contnue! : :~'l l!el l"age 3 Of S!

4 patents. 07/25/204 7: MLLWOOD Q PR\, ;;::.7/7/204 DEPARTMENT OF -EALTH AND HUMAN SERVCES FC ;:~.~~PROVED,...l::C:l=E~N.l.TEl;;,R~S~FO,.:,:R~M:,!:::E~D.:.lC::;;A::.,:R~E..!:& M:.:.:E-.lD:a:::.CA~~D;,.::S~Eo!.R:.:.V~C~E.:.S~--"""T" TO;:,.:;M=B. :!::~.!~! STATEMJONT OF DF.FCENCES (X PROVDERSUPPLERCJA (X2) MULTPLE CONSTRUCTON (X3J D' r; :3\J~vev AND PLAN OF CORRECTON DENTFCATON NUMBER: A. F.lULONG C: :,'U'ED ~-~ _! :454~0::;2~----J..:f.\::.:, W::.:N:G:;::========: -----_j--! t:!~~!!.-20.;..;...4::_.._-- NAMF. OF P'.OVOER OR SUPPLE:R STr:!EET ADDRESS, CTY, STATF., ZP CODF. MLL.NOOP 'OSPTAL 0 NORTH COOPER STRJ:ET ARL.!GTON, TX 780 (X~J 0 summary STATEMENT or. DEFCENCES PROVDEF!'S PLAN OF CORRF.CTON D PREFX {OACH DEFCENCY MUST BE PRECEDED BY FULL F'RF.=X (EACH CORRECTVO ACTON SHOULD BF. "... ~ (XS) :;omp~eton OATE TA~ FtEGULATORY OR.SC DE:NTFYNG NFORMATON) CROSS REFERF.~~;~~~~~6~E APPROPRATE ~---~---~--~ ! ~...) A 392 Contnued From page :j The unt had two dscharges and two admssons. Thrteen of the 9 patents were medcally compromsed, seven falls and four on aggresson precautons. On 0708/4 at 2225 Personnel #7 stated the staffng on the PCU Unt was not adequate for ' the acuty of tle patents and the number of nurses and techncans. Personnel #7 stated the j current unt census was 9 patents wth one LVN (Lcensed Vocatonal Nurse), one RN (Regstered Nurse) and one MHT (mental health techncan). On 07/08/4 at 2245 Personnel # was ntervewed. Personnel # stated he makes rounds on 9 patents. Personnel # stated the nursng staff are busy passng medcatons, chartng, answerng the phone, dschargng and admttng patents. Personnel # ndcated tle staffng on the PCU Unt was not adequate for / the acuty of the patents. Personnel # stated at tmes one techncan was responsble for 5 mnute rounds and LOS observaton at the same tme. On 07/09/4 at 330 (Patent #8) was ntervewed on the PlCU Unt (Patent #8) stated there wa:s not enough staff on the unt (Patent #8) stated patents have to wat for the staff and there are tm!!:s the staff do not check on the patents every ffteen mnutes. (Patent #8) stated the nurses are so busy n the offce dong paperwork and medcatons t~ey spend mnmal tme wth the (Pattent #8) stated there are tmes :she dd not feel safe. Tho """'"" Plan of Care for 204 "'fteoted, A392 "Schedulng and program assgnment ot nursng personnel s antcpated and based on the =~=-~--~---~----'---.L ~-- - form CMS.25B7(02 9).. r<lvloll' Vors0a 0Dsoleto;o Evont 0: EDU' l=~clllly D! ~0454 f eentlnust, '" ll'l~l)t Page 4 of 5

5 07/25/204 7: MLLWOOD Q PRN"" : > <:77204 DEPARTMENT 0~ HEALTH AND -luman SERVCES F(, ~ l,'proved,...:.c:,!!oe!.l'.l'.ft.:..::e..:.r~s:.:.f..;:;o:,:.;rw.m:.:.le-::d"-"c""'a~r.:.:e, :,&~M;.:.:E=.lDo!.!~CA..:.::::<D...::S:.:.E.:..::RV,:!.2~C~E;:;:.S~-~"P!"""------~--~---~-rO:.:.:M~B!! ;~:.Q~ SATEMENT OF DE~C!;!NOES ANO PLAN OF corrf.ctlon (X) PROVOF.RSU"P.ER/OLA DENTFCATON NUMBF.R: (X2) MULTPLE CONSTRUCTON A. BULDNG ()(3) D! r"!.'/ey C:,"L.l:'EO ~-~--L..::4~54:D~~2-~--_J_:B _:VV:N::G:;::::::::=::::=====------L-!J!~'!~[;;;;20;...:...;.4_,...oj NAME Of; PROVDER OR SUPPLER STR!!E ADDRESS, CTY, STATE, tp COD!: MLLWOOD -OSPJTA. 0 NO~lH COOPER ST'REET ARLNGTON, TX 760 (X\) D SUMMARY STATEMF.NT OF OF.FCENCr.s 0 :;>ROVDEF\'S PLAN OF correcton PREFX (EACH DEFCENCY MUST BE PRECEOEO BY FULl PREFX (EACH CORRECTVE ACTON SHDULO ElF.'.. r ()(5) ::ompleton 0\'T! ~EGULAORY OR LSC DENTFYNG NFORMATON) CF\OSS REFERr.NCED TO THE APPROPRATE DEFCF.NCY) ~---~~~ ~--~ ~---~ ! A 392 Contnued From page 4 A 392 dentfed n eds ofthe patent populaton... mal<.e approprate adjustment n the number and blend of nur!lng care personnel to ensure delvery of care... varables consdered n staffng.. level of patent assessment, level of assessment requred, census. nput from nursng staff members... patent responses to treatment.." The polcy and procedure enttled, "Level of Observaton/Hand"off Communcaton" wth a revson date of 05/3 reflected, "Any patent. placed on an advanced level of observaton... lne of sght... patent remans wthn vsual eyesght of staff... patent's bedroom door wll reman locked, when not n use, when patent changes, showers, uses bathroom, the staff wll keep the patent wthn lne of sght at all tmes... the safety of the patent must be the man consderaton...". '--~-..._-----~ ! FORM CMS-~567(02 M) Provlousl/ar.;)O~~ Dbeolat~ Event D: EDU FBclllty 0, 8Cl'54 f contlnu ';.,,!t~~et Page 5 ot 5