2567 UMMC 12-17 Through 12-21-21

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
510 W TIDWELL
UNITED MEMORIAL MEDICAL CENTER
HOUSTON, TX 77091
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG
DEFICIENCY)
A 000 INITIAL COMMENTS A 000
An unannounced full federal survey was

conducted by Centers for Medicare and Medicaid
Services Dallas from 12/17/21-12/21/21 to
determine compliance with 42 CFR 482
Conditions of Participation (CoP) for Hospitals.
An entrance conference was held on the morning
of 12/17/2021 with key administrative personnel.
The purpose, scope, and process of the full

survey was explained and an opportunity for
questions and discussion was provided. An exit
conference was held 12/21/2021 with key
administrative personnel. Preliminary findings of
the survey were discussed, next steps in the
survey process were explained, and again, an
opportunity for questions and discussion was
provided.
United Memorial Medical Center (UMMC) has

three locations:
Tidwell (main)-census was 12 at time of entrance
Sugar Land-census was 2 at time of entrance
North-census was 5 at time of entrance
All three locations were visited during this survey.
In addition, three (3) complaints intakes were

investigated.
TX00394177-unsubstantiated
TX00396742-unsubstantiated
TX00396743-substantiated
Deficient practices of the following Conditions of

Participation 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 possibly
death:
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9RS11 Facility ID: 810305 If continuation sheet Page 1 of 97
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A 000 Continued From page 1 A 000

§482.55 Condition of Participation: Emergency
Services (North location): The Emergency
Department (ED) at UMMC North exterior doors
were locked when surveyors attempted to enter
on Friday 12/17/21 5:30AM. There was a sign at
the door instructing to call for assistance. The
surveyors called multiple times and left
voicemails but no response was received and
were unable to have access to the ER. The
surveyors gained access to the ER 42 min later
after a surveyor was able to catch a staff member
within sight of the window and queued for entry.
The facility was previously cited 01/08/21 for

locked exterior entrance door to the emergency
department when the Tidwell location had an 8.5
x 11 sign posted in English instructing persons
needing assistance to call the ED by phone, but
the phone was not working.
On 12/19/21 at 11:09AM the interim CEO was

informed of the findings of the Immediate
Jeopardy and was offered the opportunity to
provide a plan of removal that would abate the
likelihood of harm identified. On 12/20/21 4:57PM
the plan of removal to abate the IJ was accepted.
The plan included:
1. ED door to remain open at all times and
monitored
2. Education and training provided to nursing
staff, ancillary and security staff regarding access
to the Emergency Department
3. Security officer always posted at the ED
entrance 24/7.
4. Minimum staffing for the ED will include one
Registered Nurse (RN) and one unlicensed
personnel at all times
The Interim CEO was responsible for the plan of
removal interventions.
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The following Conditions of Participation were

found to be out of compliance:
42 CFR 482.12 Governing Body

42 CFR 482.21 Quality Assurance and
Performance Improvement (QAPI)
42 CFR 482.25 Pharmaceutical Services
42 CFR 482.42 Infection Control
42 CFR 482.51 Surgical Services
42 CFR 482.55 Emergency Services
The following Emergency Medical Treatment And

Labor Act (EMTALA) requirements were not met:
42 CFR 489.20 (r)(3) Emergency Room Log
42 CFR 489.24(a) Medical Screening Exam
42 CFR 489.24(e) Appropriate Transfer
A 043 GOVERNING BODY A 043
CFR(s): 482.12
There must be an effective governing body that is

legally responsible for the conduct of the hospital.
If a hospital does not have an organized
governing body, the persons legally responsible
for the conduct of the hospital must carry out the
functions specified in this part that pertain to the
governing body ...
This CONDITION is not met as evidenced by:

Based on observation, document review, and
interviews, it was determined the Governing Body
failed to effectively provide oversight in the total
operation of the hospital.
Findings include:
1. Emergency Services: Based on observation,
interviews and records review the facility failed to
provide entrance into the Emergency Room
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department in a timely manner (North location).
This failed practice could likely result in serious
harm or death to a patient needing access to
emergency services.
See findings in Tag A1101
2. Quality Assessment and Performance

Improvement Program (QAPI): Based on
document review, policy review, and staff
interview, it was determined that the hospital's
QAPI program failed to meet the Condition of
Participation of QAPI due to not implementing a
system-wide performance improvement across all
hospital departments and services. The QAPI
program at the hospital did not apply performance
improvement in that the program:
A) Failed to ensure that policies and a plan of
correction that were put into place based on
previous survey findings at the Tidwell location
and related to Emergency Department (ED)
access were also followed system-wide (see
A1100).
B) Did not ensure that Pharmaceutical services
were reviewed for quality of services and actions
were taken to implement corrective actions for
the pharmacy quality improvement indicators
system-wide; (see A0489, A0502).
C) Did not ensure that performance improvement
plans implemented for one location in the hospital
were also implemented system-wide.
D) Did not ensure that competency and clinical
performance of all clinical staff were evaluated
consistently.
E) Did not ensure that the hospital's review of
patient's clinical records were maintained in a
manner that provided accuracy of information and
patient informed consent for care.
F) Failed to implement system-wide pharmacy
policies and failed to implement performance
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improvements for deficient practices found in
pharmacy services.
G) Failed to implement performance
improvement for infection control deficiencies
cited on previous surveys (see A749).
3. Pharmaceutical Services: Based on

observations, record reviews, and interviews, the
hospital failed to meet Pharmaceutical Services
Condition of Participation. The facility's
pharmaceutical services failed to:
A) Ensure expired medications were stored
separately from non-expired medications (see
findings in tag A0491).
B) Ensure non-narcotic drugs were properly
disposed of to prevent drug diversion (see
C) Ensure drugs listed in schedules II, III, IV, and
V of the Comprehensive Drug Abuse Prevention
and Control Act were destroyed and appropriately
discarded to prevent diversion (see findings in tag
A0491).
D) Ensure integration of pharmaceutical services
system-wide for oversight (see findings in tag
A0491).
E) Ensure the hospital followed its policy
/procedures for wasting and disposing its
controlled substance (see findings in tag A0491).
F) The facility failed to ensure the Director of
Pharmacy maintained oversight of training and
competency evaluation of staff mixing
intravenous medications (See findings at A0501).
G) The facility failed to ensure medications were
secured in a location accessible only to
authorized personnel. (See findings at A0502).
These failures placed the facility at an increased
risk of drug diversion and adverse patient
outcome.
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4. Infection Prevention and Control and Antibiotic
Stewardship Programs- Based on policy review,
document review, observation, and interview, the
facility failed to meet Infection Control and
Prevention and Antibiotic Stewardship Program
Condition of Participation. The facilities failed to:
A) Implement their COVID-19 (Coronavirus
Disease 2019) Pandemic Plan related to
screening visitors for signs/symptoms of
COVID-19 upon entry to the facility.
B) Implement their policy related to cohorting
(rooming together) and separation of patients
who present with symptoms of COVID-19 from
patients who are asymptomatic for symptoms of
COVID-19.
C) Implement their policy and ensure regular
screening of hospital staff before reporting to
work and entering the hospital.
D) Implement their infection control policy related
to hospital construction to prevent and/or
decrease the risk of hospital acquired infections
in patients, visitors, and healthcare workers.
(Refer to A0749).
E) Provide a sanitary environment to avoid
sources and transmission of infections.
These failures placed staff, visitors, patients, and
future patients at risk for exposure and/or
acquisition of hospital acquired infections.
5. Surgical Services- Based on observation,

policy review, medical record review, document
review, and interview the hospital failed to meet
the requirements of the Condition of Participation
of Surgical Services.
A) The hospital failed to ensure six (Staff (S)114,
S115, S116, S117, S118, S119) of six
practitioners' credentialing files reviewed for
privileges were granted specific clinical privileges
and procedures authorized by the governing
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board and signed by the department chairman
based on the practitioner's license, education,
training, experience, current competence, health
status, and judgement prior to performing
surgery. This deficient practice had the potential
to affect all patients receiving surgical services at
any of the three hospital campuses (see findings
in tag A0945).
B) The hospital failed to ensure an updated
examination of the patient, including any changes
in the patient's condition, was documented and in
the medical record prior to the surgery when the
medical history and physical examination (H&P)
was completed within 30 days before admission
or registration for six (P29, P32, P33, P35, P37,
P38) of eleven patient records reviewed for a
documented updated H&P prior to surgery from a
sample of 58 patients. This deficient practice had
the potential to miss current diagnoses/conditions
for patients receiving surgical services (see
C) The hospital failed to ensure there was a
properly executed informed consent that
contained the date, time, and signature of the
person witnessing the patient or the patient's
legal representative signing the consent form
and/or the provider for eight patients (P32, P33,
P34, P35, P36, P38, P40, and P41) of twelve
patient records reviewed for a properly executed
informed consent from a total sample of 58
patients. This deficient practice had the potential
to affect all patients receiving services at any of
the three hospital campuses (See findings in tag
A0955).
D) The hospital failed to ensure an operative
report was written or dictated immediately
following surgery and signed by the surgeon that
described techniques, findings, and tissues
removed or altered for two (P40, P41) of two
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patients observed in Pre-op prior to surgery.
There was no operative note
documented/dictated/completed in two (P03,
P32) of 12 (P03, P22, P29, P31, P32, P33, P34,
P35, P36, P37, P38, P39) patient records
reviewed for a completed operative note from a
the potential to affect all patients having a surgical
procedure at the three hospital campuses (see
E) The hospital failed to: a) ensure a competency
evaluation on performing sterile processing duties
was completed for one (S113) of one sterile
processing technician's personnel file reviewed
and b) ensure one of one sterile processing
technician (S53) performed manual washing of
surgical instruments in accordance with the
manufacturer's instructions for use. These
deficient practices had the potential to affect all
patients receiving surgical services at any of the
three hospital campuses (see findings in tag
A0951).
A 263 QAPI A 263
CFR(s): 482.21
The hospital must develop, implement and

maintain an effective, ongoing, hospital-wide,
data-driven quality assessment and performance
improvement program.
The hospital's governing body must ensure that

the program reflects the complexity of the
hospital's organization and services; involves all
hospital departments and services (including
those services furnished under contract or
arrangement); and focuses on indicators related
to improved health outcomes and the prevention
and reduction of medical errors.
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The hospital must maintain and demonstrate

evidence of its QAPI program for review by CMS.

Based on document review, policy review, and
staff interview, the hospital failed to implement a
system-wide performance improvement across all
hospital departments and services. The QAPI
program at the hospital did not apply performance
improvement in that the program:
1. Failed to ensure that policies and a plan of

correction related to Emergency Department
access based on previous survey findings at the
Tidwell location were put into place and followed
system-wide; (see A1100)
2. Did not ensure that pharmaceutical services

were reviewed for quality of services and actions
were taken to implement corrective actions for
the pharmacy quality improvement indicators
system-wide; (see A0489, A0502)
3. Did not ensure that performance improvement

plans implemented for one location in the hospital
were also implemented system-wide;
4. Did not ensure that competency and clinical

performance of all clinical staff were evaluated
consistently;
5. Did not ensure that the hospital's review of

patient's clinical records ensured records
maintained in a manner that provided accuracy of
information and patient informed consent for
care;
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6. Failed to implement system-wide pharmacy
policies and failed to implement performance
improvements for deficient practices found in
pharmacy services;
7. Failed to implement performance improvement

for infection control deficiencies cited on previous
surveys (see A749).
A 283 QUALITY IMPROVEMENT ACTIVITIES A 283
CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3)
(b) Program Data

(2) [The hospital must use the data collected to -
.....]
(ii) Identify opportunities for improvement and
changes that will lead to improvement.
(c) Program Activities

(1) The hospital must set priorities for its
performance improvement activities that--
(i) Focus on high-risk, high-volume, or
problem-prone areas;
(ii) Consider the incidence, prevalence, and
severity of problems in those areas; and
(iii) Affect health outcomes, patient safety, and
quality of care.
(3) The hospital must take actions aimed at

performance improvement and, after
implementing those actions, the hospital must
measure its success, and track performance to
ensure that improvements are sustained.
This STANDARD is not met as evidenced by:

Based on document review, policy review, and
staff interview, the hospital failed to use data
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collected for QAPI review to ensure performance
improvement across the hospital system. The
failed practice had the potential to affect all
patients receiving care in the hospital and clinics.
Findings:
1. A review of the 2021 Quality Assessment and
Performance Improvement (QAPI) Plan Policy #
ADM.01.1 44 .0 for UMMC revealed the scope of
the QAPI program for the Emergency Department
(ED) would include: "an organization-wide
program that reflects the full scope and
complexity of services provided by the
organization, identifies opportunities for
improvement, and works to address those
opportunities."
2. A federal survey conducted by the state survey

agency completed on 01/08/2021 cited findings
for a patient unable to access the Emergency
Department (ED) at the Tidwell location of the
hospital on 01/05/2021. The facility plan of
correction for this deficient practice included a
plan to redirect incoming calls placed from
outside the hospital into the ED to other staff if
the ED desk phone was not answered. The
hospital's plan to correct the deficient practice
also included a plan to provide a door bell in
addition to the phone service redirects.
3. The hospital failed to ensure this plan was

implemented system-wide which resulted in
findings of immediate threat of harm for patients
who might present at the North location when the
survey team at the North location could not
access the ED for a period of 42 minutes upon
entrance on 12/17/2021. Surveyors attempted to
call ED staff via phone number posted on the ED
door and left messages on the ED phone number
but were not able to gain immediate access. The
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phones at the North location did not redirect calls
to other staff when the ED desk phone was not
answered. The corrective action plan for
responding to ED access was not carried out
across the hospital system.
4. Interview with S103 and S102 on 12/19/2021 at

3:00 PM confirmed the QAPI program minutes
did not address carrying out program
improvements to other hospitals in the system for
the plan of correction dated 1/8/2021. S103
stated the QAPI action plan did not include the
clinics and a system-wide plan to implement
corrections, "but that is planned for the future".
5. The hospital QAPI priority grid included a

performance improvement project for Medical
Staff Credentialing. A review of the QAPI policy
revealed the scope of the QAPI program would
include monitoring/tracking of all physician
privileges.
6. The hospital failed to ensure six of six (S114,

S115, S116, S117, S118, S119) practitioners'
credentialing files reviewed for privileges were
granted specific clinical privileges and procedures
authorized by the governing board and signed by
the department chairman based on the
practitioner's license, education, training,
experience, current competence, health status,
and judgement prior to performing surgery. This
deficient practice had the potential to affect all
three hospital campuses.
A 297 QAPI PERFORMANCE IMPROVEMENT A 297
PROJECTS
CFR(s): 482.21(d)
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As part of its quality assessment and
performance improvement program, the hospital
must conduct performance improvement projects.
(1) The number and scope of distinct

improvement projects conducted annually must
be proportional to the scope and complexity of the
hospital's services and operations.
(2) A hospital may, as one of its projects, develop
and implement an information technology system
explicitly designed to improve patient safety and
quality of care. This project, in its initial stage of
development, does not need to demonstrate
measurable improvement in indicators related to
health outcomes.
(3) The hospital must document what quality
improvement projects are being conducted, the
reasons for conducting these projects, and the
measurable progress achieved on these projects.
(4) A hospital is not required to participate in a
QIO cooperative project, but its own projects are
required to be of comparable effort.

Based on record review, policy review and
interview the hospital failed to ensure that there
was measurable progress achieved for quality
improvement projects. Medical Staff
Credentialing was listed as a QAPI project for the
hospital system and QAPI meetings failed to
address Medical Staff in six of six QAPI meeting
minutes. This failure to document measurable
progress to monitor and track credentialing has
the potential for adverse patient outcomes when
surgical staff credentials are not verified.
Findings:
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1. The hospital QAPI priority grid included a
performance improvement project for Medical
Staff Credentialing. A review of the QAPI policy
revealed the scope of the QAPI would include
monitoring/tracking of all physician privileges.
2. The hospital failed to ensure six of six (S114,

S115, S116, S117, S118, S119) practitioners'
credentialing files reviewed for privileges were
granted specific clinical privileges and procedures
and judgement prior to performing surgery. This
deficient practice had the potential to affect all
3. Review of Practitioner S114's delineation of

privileges application for spine surgery dated
08/26/2021 showed a list of privileges requested
but failed to show if the privileges were approved
or denied. The application was signed by S120 on
09/18/2021.
Review of Practitioner S115's delineation of

privileges application for orthopedic surgery dated
with a Governing Board member's signature but
failed to show the date the privileges were
granted.

granted.
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including total shoulder replacement but failed to
show if the procedure was granted or denied. The
application also failed to show what facility the
privileges requested were for. Review of a
second application for Practitioner S117's
delineation of privileges for general surgery dated
03/28/21 showed a list of privileges requested but
failed to show which privileges were granted and
also failed to show the required signature of
S120. Review of a third application for
Practitioner S117's delineation of privileges for
plastic surgery dated 03/28/2021 showed a list of
privileges requested and signed by S120 on
06/29/21 but failed to show which privileges were
granted.

privileges application for podiatry surgery dated
and signed by S120 on 03/01/2021 but failed to
show what facility the requested privileges were
granted for.

04/13/21 showed a list of privileges but failed to
show what privileges were requested. The
application was signed by S120 on 10/30/2021.
During an interview on 12/21/21 at 4:30 PM, S93
confirmed the above Practitioner credential file
findings and that the applications were not in
compliance with the facility Medical Staff Bylaws.
4. Review of Quality/Patient Safety Committee

Meeting Minutes dated 2/23/2021, 4/13/2021,
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6/16/2021, 8/18/2021, 10/19/2021, and
12/13/2021 revealed:
(A) no mention of medical staff/credentialing
reported for 10/19/21, and 12/13/2021, and
(B) medical staff report deferred for 8/18/21,
6/16/2021, 4/13/2021, and 2/23/21.
Failure to ensure credentialing files and

practitioner applications were in compliance
demonstrated that the facility failed to monitor
and track all physician credentials as
recommended in the hospital's performance
improvement project. There was no
documentation the hospital QAPI program
addressed this in QAPI meeting minutes.
Interview with S103 on 12/20/21 at 4:30 PM
confirmed that the QAPI minutes did not include
discussion of the credentialing files and any
performance improvement for monitoring the
files.
A 395 RN SUPERVISION OF NURSING CARE A 395
CFR(s): 482.23(b)(3)
A registered nurse must supervise and evaluate

the nursing care for each patient.

Based on medical record review and interview,
the hospital failed to ensure that the registered
nurse (RN) clarified a physician's order for
cardiovascular medication for 2 patients (P31,
P37) of 11 patient records reviewed for physician
orders from a total sample of 58 patients. This
deficient practice had the potential to affect any
patient with physician orders for cardiovascular
medication at any of the three hospital campuses.
Findings include:
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Review of the policy titled, "Medication Use

Process: Administration Transcription,
Administration, Discharge/Transfer," reviewed
April 2019, indicated ". . . Medications which have
more than one indication for use will be clarified
before that medication will be dispensed by
Pharmacy unless patient safety may be
compromised as determined in collaboration with
Nursing, Pharmacy, and other health care
providers. . ."
1. Review of P31's "Anesthesia Orders" signed by

the anesthesiologist on 11/30/21 at 9:15AM
indicated the "Medication Orders for PACU" [Post
Anesthesia Care Unit] included "Cardiovascular
(Choose 1 med [medication] only) 1. Labetolol
[sic] [used to treat high blood pressure] 10mg IVP
[milligrams intravenous push] q [every] 5 min
[minutes] PRN [as needed] up to max [maximum]
20mg for SBP > 180mmHg [systolic blood
pressure greater than 180 millimeters mercury]
(Hold if HR < 60 bpm [heart rate is less than 60
beats per minute] and Notify Anesthesiologist) 2.
Hydralazine [used to treat high blood pressure]
10mg IVP q 10 min PRN up to max 20mg for
SBP > 180mmHg."
Review indicated two cardiovascular medications

were checked rather than only one as the
direction was written. There was no
documentation that the RN clarified the order with
the anesthesiologist. No cardiovascular
medication was administered in PACU.
2. Review of P37's "Anesthesia Orders" signed by

the anesthesiologist on 11/05/21 with no time
documented indicated the "Medication Orders for
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PACU" included "Cardiovascular (Choose 1 med
[medication] only) 1. Labetolol [sic] 10mg IVP q 5
min PRN up to max 20mg for SBP > 180mmHg
(Hold if HR < 60 bpm and Notify Anesthesiologist)
2. Hydralazine 10mg IVP q 10 min PRN up to
max 20mg for SBP > 180mmHg."
Review indicated two cardiovascular medications

were checked rather than only one as the
direction was written. There was no
documentation that the RN clarified the order with
the anesthesiologist. No cardiovascular
medication was administered in PACU.
In an interview on 12/19/21 at 12:45 PM, S40 at

Sugar Land stated the anesthesiologist's order for
cardiovascular medication should have been
clarified by the RN.
A 398 SUPERVISION OF CONTRACT STAFF A 398
CFR(s): 482.23(b)(6)
All licensed nurses who provide services in the

hospital must adhere to the policies and
procedures of the hospital. The director of
nursing service must provide for the adequate
supervision and evaluation of all nursing
personnel which occur within the responsibility of
the nursing service, regardless of the mechanism
through which those personnel are providing
services (that is, hospital employee, contract,
lease, other agreement, or volunteer).
Based on observation, document review, staff
interview, and policy review, the facility failed to
maintain responsibility for the competency and
clinical activities of all nursing personnel for
seven of seven nursing personnel files reviewed,
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(S41, S42, S43, S44A, S44B, S46, and S47).
This failure had the potential to allow unqualified
staff members to provide direct patient care, with
possible negative outcomes for all patients
receiving services from this facility.
Findings include:
Review of the facility policy titled, "Staff

Competency," last revised 12/16, revealed, "It is
the responsibility of the Department Director to
identify and maintain competencies based on the
specific needs of the patient population served
...Competence assessment for staff and
contracted staff who work in the same capacity as
staff providing care, treatment and services is
based on the following: Direct observation by
qualified supervisor or preceptor. Successful
completion of general and unit specific checklist.
Successful performance of identified procedure
...Annual Competencies (performance
evaluations): Performance evaluation of identified
annual competencies will be documented on
Skills/Competency checklists.
During a tour of the facility with S40 on 12/18/21

at 10:00 AM, S40 stated that there is no
pharmacy in the facility other than the automated
dispensing system. S40 stated, nursing staff is
responsible for compounding (mixing) some
antibiotic powders with normal saline solution to
reconstitute the medication prior to intravenous
(IV) administration. When asked who provides
the training and checks the competency of the the
nurses to complete this task, S40 stated, "The
pharmacist and myself." S40 stated, he/she
"signs off" the compounding of medications and
ensures the nurses use aseptic (free from
contamination from disease-causing
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microorganisms) technique.
During an interview with S46, Registered Nurse

(RN) on 12/18/21 at 2:20 PM, S46 was unable to
recall any annual skills check related to mixing IV
medications. S46 stated that he/she trained for
clinical skills required by learning from other
nurses. Review of the personnel file of S46
revealed no documented orientation or
competency evaluation of skill for mixing IV
medications.
During an interview with S47, RN, on 12/18/21 at

2:51 PM, S47 stated, he/she was oriented to
clinical skills by a "preceptor," an experienced
RN. S47 was unable to recall any annual skills
check related to mixing IV medications. Review of
the personnel file of S47 revealed no documented
orientation or competency evaluation of skill for
mixing IV medications.
Review of the personnel file of S41, RN, revealed

no training or competency check specific to
mixing IV medications. The document titled,
"(Facility Name) Competency Checklist," dated
08/10/21, showed multiple skills checked and the
document signed only by S41 him/herself.

a document titled, "IV Admixture (adding a
substance to another substance) Competency
Checklist," dated 08/05/21 with the competencies
checked and signed only by S43, him/herself.

a document titled, "IV Admixture Competency
Checklist," dated 08/06/21, with the
competencies checked and signed only by S43,
the RN who completed a self-assessment on the
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competencies the previous day.
Review of the personnel file of S44A, RN,

revealed a document titled, "IV Admixture
Competency Checklist," was dated 08/21/21,
initialed by S40, but had no competency skills
checked off.
Review of the personnel file of S44B revealed a

document titled, "NurseDash Candidate Profile,"
dated 12/07/20 and consisting of a skills
checklist. No training or competency check by the
facility was found in the file.
During a follow-up interview with S40, on

12/19/21 at 1:15 PM, the staff reviewed the
personnel file of S44B. S40, stated that the facility
does not have any documentation of S44B's
training and/or competency check conducted by
the facility itself, only those checks provided by
the agency providing this staff for employment.
During the interview, S40, also confirmed that the
facility would not consider it appropriate for a
nurse to self-assess for skills competency
evaluations and stated it was inappropriate for
one nurse to sign off another nurse's competency
evaluation. S40, stated that the Director of
Nurses (DON) was responsible for the training
and skills of all nursing staff, whether employed
directly by the facility or employed through a
contract.
A 405 ADMINISTRATION OF DRUGS A 405
CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2)
(1) Drugs and biologicals must be prepared and

administered in accordance with Federal and
State laws, the orders of the practitioner or
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practitioners responsible for the patient's care as
specified under §482.12(c), and accepted
standards of practice.
(i) Drugs and biologicals may be prepared and

administered on the orders of other practitioners
not specified under §482.12(c) only if such
practitioners are acting in accordance with State
law, including scope of practice laws, hospital
policies, and medical staff bylaws, rules, and
regulations.
(2) All drugs and biologicals must be

administered by, or under supervision of, nursing
or other personnel in accordance with Federal
and State laws and regulations, including
applicable licensing requirements, and in
accordance with the approved medical staff
policies and procedures.
Based on policy review, medical record review,
and interview, the hospital failed to ensure
medications were administered as ordered by the
physician for one patient (P36) of eleven patient
records reviewed for medication administration
from a sample of 58 patients. This deficient
practice had the potential to affect any patient
receiving pain medication at the three hospital
campuses.
Findings include:
Review of the policy titled "Medication Use

Process: Administration Transcription,
Administration, Discharge/Transfer," reviewed
April 2019, indicated ". . . 4) Medications are
checked from the medication record against the
label on the bottle or unit dose package. The
following shall be confirmed prior to each
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administration: . . . e) The appropriate time, to
ensure adherence to the prescribed frequency
and time of administration. . ."
Review of P36's "Cervical Post-Operative Order

Set" indicated a verbal order from Staff (S58) on
11/01/21 at 11:30 AM, to give "Norco
(hydrocodone/APAP) [hydrocodone with
acetaminophen, an analgesic preparation used to
treat moderate to severe pain] 10/325mg
[milligrams] . . . two tablets every 4 hours po PRN
[orally as needed] for severe pain (pain rating
7-10)" and "Norco (hydrocodone/APAP)
10/325mg . . . one tablet every 4 hours po PRN
for moderate pain (pain rating 4-6)."
Review of P36's "Nurses Notes" indicated on

11/01/21 at 6:40 PM, the nurse documented P36
"complaining of 8 of 10 pain - incision, provided
pain medication." Review of the "Medication
Administration Record (MAR)" indicated P36
received Norco 10/325 mg, two tablets, on
11/01/21 at 6:40 PM.
Review of P36's "Nurses Notes" indicated on

11/01/21 at 9:20 PM, the nurse documented P36
". . . complaint of pain post op site cervical area . .
. pain 6/10 [six on a pain scale of 10], pain
medicine given." Review of the MAR indicated
P36 received Norco 10/325 mg, two tablets, on
11/01/21 at 9:20 PM.
Review of P36's medical record indicated P36

received Norco 10/325 mg, two tablets, on
11/01/21 at 9:20 PM for pain at a level of six of
10, when the physician order was to give one
tablet for moderate pain at a rate of four to six on
a scale of 10. The nurse also administered the
second dose of Norco two hours and 40 minutes
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after the first dose was given rather than four
hours between doses as ordered.
In an interview on 12/19/21 at 12:45 PM, S40

confirmed P36 should have received one tablet of
Norco for the second administration, and the time
between the two administrations was not four
hours. S40 stated the physician's order was not
followed by the nurse.
A 410 BLOOD TRANSFUSIONS AND IV A 410
MEDICATIONS
CFR(s): 482.23(c)(4)
Blood transfusions and intravenous medications

must be administered in accordance with State
law and approved medical staff policies and
procedures.
Based on medical record review, staff interview,
and policy review, the facility failed to ensure staff
appropriately monitored patients for blood
transfusion reactions for one of one transfusion
record reviewed (Patient (P)43). Failure to
monitor patient reactions to transfusions could
lead to undetected adverse reactions and
negative outcomes for all patients receiving blood
products at this facility.
Findings include:
Review of the facility's policy titled, "Blood

Administration Guidelines," last revised 10/2020,
revealed, "Monitoring: The following vital signs
are the minimum required and should be
performed with the administration of each new
unit of blood: A. Monitor and record vital signs
(temperature, pulse, respiration, and blood
pressure): Pre vital signs 15 minutes prior to
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transfusion initiation, 15 minutes from initiation X1
(one time), 30 minutes from initiation X1 and then
every 1 hours from the initiation with the post vital
signs and 1 hour from the completion of
transfusion. B. Assess signs and symptoms every
15 minutes twice, then every hour until
transfusion is completed. 6. Observe for signs of
reaction at the end of 15 minutes, 30 minutes,
and then every hour until the transfusion is
complete. Observe for: Urticaria (rash), chills
...fever ...facial flushing, edema (swelling),
bronchial spasm (narrowing of airway, causing
shortness of breath), elevated pulse, decreased
blood pressure, abdominal cramping, throbbing
headache, backache, hemoglobinuria (blood in
urine), feeling of anxiety or 'impending doom',
untoward oozing of a wound in anesthetized
patient."
Review of P43's medical record, "Physician

Orders," revealed orders for transfusion of two
units of packed red blood cells (PRBCs), the first
unit on 05/28/21 and the second unit on 05/29/21.
Review of the "Blood Administration Record"

dated 05/28/21 revealed that the first unit of
PRBCs was initiated at 1:00 PM. No
documentation was found of vital signs 15
minutes prior to initiation of the transfusion.
The set of vital signs timed for "30 minutes post

initiation" were documented at 1:45 PM or 45
minutes after initiation.
The set of vital signs timed for "1 hour post

initiation" were documented at 2:45 PM or one
hour and 45 minutes after initiation.
The set of vital signs timed for "2 hours post

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initiation" were documented at 4:00 PM, or three
hours after initiation.
The transfusion ended at 5:00 PM. The only

documentation found of assessments of signs of
reaction were on the "Nurses Notes" on 05/28/21
at 3:00 PM, during the transfusion, in which the
nurse documented, "First unit of blood transfusion
in progress. No adverse reaction noted," and on
05/28/21 at 9:45 PM, in which the nursed
documented, "Blood transfusion complete.
Patient denies chest pain, SOB (shortness of
breath), nausea/vomiting or dizziness." The only
assessment of P43 noted one hour post
transfusion was a documented set of vital signs,
with no assessment of other signs of reaction.
Review of P43's "Blood Administration Record"

dated 05/29/21 revealed the second unit of
PRBCs was initiated at 1:20 PM. No
documentation was found of vital signs 15
minutes prior to initiation of the transfusion.
The set of vital signs timed for "30 minutes post

initiation" were documented at 1:55 PM, or 35
minutes after initiation.
The set of vital signs timed for "2 hours post

initiation" were documented at 3:25 PM or two
hours and five minutes after initiation.
The transfusion ended at 5:00 PM. The only

assessment of P43 noted one hour post
transfusion was a documented set of vital signs,
with no assessment of other signs of reaction.
The only documentation found of assessments of

signs of reaction during and after the transfusion
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were noted on the "Nurses Notes" on 05/29/21 at
3:40 PM, immediately after the transfusion ended,
in which the nurse documented, "Patient tolerated
blood transfusion very well, no reaction or
adverse reaction observed."
During an interview with S40 on 12/20/21 at 12:40

PM, S40 reviewed the above medical record and
agreed the nursing staff had not followed facility
policy and expectation for monitoring patients
during a blood transfusion for timing of vital signs
and assessments of sign and symptoms of
transfusion reaction. S40 agreed the facility policy
for monitoring a patient before, during, and after a
blood transfusion included not only vital signs but
the other signs of reaction as delineated in the
policy.
A 432 ORGANIZATION AND STAFFING A 432
CFR(s): 482.24(a)
The organization of the medical record service

must be appropriate to the scope and complexity
of the services performed. The hospital must
employ adequate personnel to ensure prompt
completion, filing, and retrieval of records.

Based on medical record review, document
review, staff interview, and policy review, the
facility failed to ensure qualified and trained staff
were in a position to oversee the quality of
medical records. Failure to maintain accurate and
complete medical records could interfere with the
care and follow-up care of all patients receiving
services at this facility.
Findings include:
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Review of a sample of the facility's all-paper

medical records during the survey revealed
multiple variances for completion and accuracy
(See specific findings Tag A0450).
During an interview with S40 on 12/17/21 at

11:20, the all-paper medical records were
reviewed. S40 agreed the records were
incomplete and/or inaccurate. S40 stated, he/she
was responsible for auditing all Emergency
Department (ED) records. The S40 stated,
his/her training for medical record audits was
from S39.

PM, the variances noted in the record reviews
were reviewed. S72 stated, he/she had been
employed in the Medical Services department for
three months and was responsible for auditing
inpatient and surgery medical records. S72
stated, he/she was not certified as a medical
services technician and had received training at
this facility only from S39. When asked, S72
stated that he/she was unfamiliar with the facility's
policy on medical records and required
documentation and stated that he/she had
received no job-specific training other than
practice audits conducted with S39. When asked
if he/she had resources for questions and/or
concerns about medical record/documentation
requirements, S72 stated, "Sometimes I'm not
sure who is the author to talk to, I can't read it,"
and "I'm not sure who to ask questions.
Sometimes I 'google' things."
During an interview with S39, on 12/20/21 at 3:15

PM, S39 stated that he/she is the direct
supervisor of S72 and stated he/she provided
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orientation and training for S72, "hands on, we
went through the charts and showed (him/her)
how we want it done." When asked if S39
provided any oversight or review of S72's work,
S39 stated, "I do it about once a month but not at
a regular date and not a certain number of charts
per month." After reviewing the variances in the
medical records, S39 stated, "(S72) does have a
certified person to go to with problems at (another
facility location). I'll give her the name and contact
information."
Review of the personnel file of S72 revealed only

basic facility orientation and no documented
job-specific training or competency checks
pertaining to audits of medical records.
Review of the facility's policy titled,

"Documentation of Medical Records," last revised
10/07, revealed, "All documentation is to be
completed in ink in clearly legible writing or by
mechanical processes that result in clear, durable
copies. All documentation entries are to be dated
and time [sic] as required by law. All
documentation entries are to be initialed or
signed with the indication of the individual's
credentials where indicated."
A 489 Condition of Participation: Pharmaceutical Se A 489
CFR(s): 482.25
§482.25 Condition of Participation:

Pharmaceutical Services.
The hospital must have pharmaceutical services

that meet the needs of the patients.
The institution must have a pharmacy directed by
a registered pharmacist or a drug
storage area under competent supervision. The
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medical staff is responsible for
developing policies and procedures that minimize
drug errors. This function may
be delegated to the hospital's organized
pharmaceutical service.
Based on observation, interview, document
review, and policy review, the acute care hospital
failed to meet the requirements of the Condition
of Participation for Pharmaceutical Services. This
failure had the potential to affect all patients
receiving services in the hospital.
The facility failed to ensure:
1. The Director of Pharmacy maintained oversight

of training and competency evaluation of staff
mixing intravenous medications. (See findings at
A0501).
2. Medications were secured in a location

accessible only to authorized personnel (see
findings at A0502);
3. Expired medications were stored separately

from non-expired medications (see findings at
A0491);
4. Non-narcotic drugs were properly disposed of

to prevent drug diversion (see findings at A0491);
5. Drugs listed in schedules II, III, IV, and V of the

Comprehensive Drug Abuse Prevention and
Control Act were destroyed and appropriately
discarded to prevent diversion (see findings at
A0491);
6. Integration of pharmaceutical services in all the

hospital and satellite clinics for oversight (see
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findings at A-0491);
7. The hospital followed its policy /procedures for

wasting and disposing its controlled substance
(see findings at A-0491).
A 491 PHARMACY ADMINISTRATION A 491
CFR(s): 482.25(a)
[§482.25 Condition of Participation:

Pharmaceutical Services
.....The medical staff is responsible for developing
policies and procedures that
minimize drug errors. This function may be
delegated to the hospital's organized
pharmaceutical service.]
§482.25(a) Standard: Pharmacy Management

and Administration
The pharmacy or drug storage area must be
administered in accordance with
accepted professional principles.
Based on observations, record reviews, and
interviews, the facility's pharmaceutical services
failed to:
1). Ensure expired medications were stored
separately from non-expired medications.
2). Ensure non-narcotic drugs were properly
disposed of to prevent drug diversion.
3). Ensure drugs listed in schedules II, III, IV, and
V of the Comprehensive Drug Abuse Prevention
and Control Act were destroyed and appropriately
discarded to prevent diversion.
4). Ensure integration of pharmaceutical services
in all the hospital and satellite clinics for oversight.
5). Ensure the hospital followed its policy
/procedures for wasting and disposing its
controlled substance.
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These failures placed the facility at an increased
risk for drug diversions and adverse patient
outcomes.
Findings included:
On 12/17/21, at 9:30AM, while conducting an
observation tour at the Specialty Outpatient Clinic
at UMMC North, the following medications in the
clinic medication cabinet were found expired:
1. Three (3) Humulin N-Kwik-Pen U-100 unit/ml
Pre-filled insulin. Expired November 2021;
2. One (1) Libre 2- Flash Glucose Monitor System
Sensor. Expired October 31, 2021;
3. One (1) Synjardy XR 12.5 mg/1000mgs.
Expired November 2021;
4. One (1) Victoza Injectable 1.2mg/18mg.
Expired October 2021.
Further observation, revealed the following

medications were found in the clinic room trashed
in an open trash container:
1. Three (3) packets of Xigduo XR (dapagliflozin /
metformin) 5/500 mg. Expired October 2021;
2. One (1) packet of Synjardy XR (empagliflozin/
metformin) 10mg/1000mg. Expired November
2021.
These findings were confirmed by S28, who was

assigned to work in the clinic.
Interview with S28 on 12/17/21 at 9:55AM

revealed it was the staff's responsibility to remove
expired medications for disposal. S28 reported
she disposed of expired medications by throwing
medications in the trash, which is to be taken out
by housekeeping staff. S28 said that the
Pharmacist never came to check on the clinic
medications.
On 1217/21 at 10:35AM, the following
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medications were observed in a patient
examination room at the Specialty Outpatient
clinic in an open trash container:
1. Three (3) bottles: Xarelto 20 mg tablet. Expired
November 2021
2. One (1) 1% Xylocaine 10 ml/injectable
Interview with S20 on 12/17/21 at 2:40 PM,

revealed he was not aware of any approved
procedures to destroy or dispose of expired
medications in the clinic. S20 reported he was not
in-serviced or trained on medication disposal.
Interview with S22 on 12/17/21, at 2:50 PM,
revealed a lack of hospital pharmacist or
pharmacy staff coordination and integration of the
Outpatient Clinic pharmacy services with the
hospital. S22 further stated there were no
licensed clinical staff members other than the
specialty doctors at the clinic and not being aware
that expired medications were all discarded in
open trash by the housekeeping staff and later
dumped outside in a non-covered dumpster. S22
reported a lack of hospital policy and procedures
in the disposal of medications in the clinic and no
pharmacist involvement in the clinic medications
oversight.
Observation tour of UMMC North medication

room, emergency department (ED) medication
room, and the main hospital pharmacy on
1218/21, revealed the hospital had not set up
process in place for wasting (disposal) of used
(partial) bulky narcotics.
Interview with S15 on 12/18/21, at 9:44 AM

revealed all narcotics were disposed of in the sink
and flushed down the drain. S15 stated, "I
normally pour it in the sink, to tell you the truth."
S15 reported she was not aware of the hospital's
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procedure for disposal of narcotics. She stated in
the past she would dispose in sharps containers,
but "another older nurse told me I can waste it in
the sink." When asked about how she would
dispose of used bulky narcotics, S15 reported
she would return them to the pharmacy for
destruction. S15 reported she had not engaged
with the pharmacist on narcotic waste and
disposal. S15 further clarified that they were not
documenting how and where the controlled drug
was wasted, as required per the hospital policy.
Interview with S31 12/18/2121 at 10:08AM

revealed all narcotics were disposed in the
sharps container. S31 reported she was a new
employee and had not wasted any used bulky
narcotics. S31 further stated, "I used to waste
narcotics in the cactus (a controlled substance
waste management system), but here they don't
have one."
Interview with S14 on 12/18/21 at 10:30AM,

revealed she was not aware nurses were wasting
controlled substances in the sink. S14 reported
that it was her expectation for the medication to
be wasted in the sharp container. When asked
how they wasted bulky, unused controlled
substances that would not fit in the sharp's
container, she reported it was taken back to the
pharmacy.
Interview with S27 on 12/18/21, at 11:00AM at

revealed he was not aware nurses were wasting
and disposing of narcotics in the sink. S27 also
reported the nurses did not bring "partial narcotics
to the pharmacy for disposal." When asked about
the proper wasting and disposal of narcotics, S27
replied, "we're in the process of looking at buying
cactus for our pharmacy and med rooms.
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Narcotics shouldn't be wasted in the sink". When
asked about supervision of the medications in the
Specialty Outpatient Clinic, S27 replied, "I don't
handle medications at the Specialty Outpatient
clinic." S27 reported he was not aware
medications were disposed of in open trash and
expired medications being stored with unexpired
medications. S27 confirmed there was a lack of
oversight by his department on medications used
by the Specialty Outpatient Clinic. S27 further
clarified the lack of hospital policies and
procedures in regards to how and where the drug
was physically wasted.
The hospital policy and procedures Titled"

Medication use process: Automated dispensing
cabinet system, policy # PHA.TX 097", with an
effective date of May 12, 2021, provided by S27
on December 18, 2021, stated, "All controlled
Substances require a witness to waste and a
waste comment to be entered, which includes
how and where the drug was physically wasted."
A 501 PHARMACIST SUPERVISION OF SERVICES A 501
CFR(s): 482.25(b)(1)
§482.25(b)(1) - All compounding, packaging, and

dispensing of drugs and
biologicals must be under the supervision of a
pharmacist and performed
consistent with State and Federal laws.
Based on document review, staff interview, and
policy review, the facility failed to ensure that
nursing staff training and competencies for mixing
of intravenous (IV) medication were supervised
by a pharmacist for seven of seven nursing
personnel files reviewed (S41, S42, S43, S44A,
S44B, S46, and S47). Failure to ensure staff is
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trained to maintain sterility of the IV end product
had the potential to cause negative outcomes for
patients receiving these medications.
Findings include:
During a tour of the facility with S40 on 12/18/21

at 10:00AM, S40 stated that there is no pharmacy
in the facility other than the automated dispensing
system. S40 stated that nursing staff is
responsible for mixing some antibiotic powders
with normal saline (NS) solution to reconstitute
the medication prior to IV administration. S40
stated, "it is mostly the preop nurses who
prepared the IV meds." When asked who
provides the training and checks the competency
of the the nurses to complete this task, S40
stated, "the pharmacist and myself." S40 stated
that he/she "signs off" the training and
competency checks for compounding of
medications and aseptic (free from contamination
from disease-causing microorganisms)
technique. When asked to provide documentation
of Pharmacist and DON involvement in the
training and competency program, the S40 was
unable to provide such evidence.
Review of the list of IV medications routinely

prepared and administered in the facility, titled,
"IV Infusion Rx (prescription) Reference Chart,"
listed the following medications and the diluent
(solution mixed with the powdered medication):
Ceftriaxone 500 mg (milligrams) - NS 50 ml

(milliliters)
Ceftriaxone 1 gram - NS 50 ml
Cefepime 1000 mg - NS 50 ml
Doxycycline 100 mg - NS 100 ml
Vancomycin 500 mg - NS 100 ml
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Vancomycin 1000 mg - NS 250 ml
Zosyn 3.75 gram - NS 100 ml
During an interview with S46, Registered Nurse

(RN) on 12/18/21 at 2:20 PM, S46 was unable to
recall any annual skills check related to mixing IV
medications. S46 stated that he/she trained for
clinical skills required by learning from other
nurses, not from the DON or pharmacist. Review
of the personnel file of S46 revealed no
documented orientation or competency
evaluation of skill for mixing IV medications.
During an interview with S47, RN, on 12/18/21 at

2:51 PM, S47 stated that he/she was oriented to
clinical skills by a "preceptor," another
experienced RN, and not from the DON or
pharmacist. S47 was unable to recall any annual
skills check related to mixing IV medications.
Review of the personnel file of S47 revealed no
documented orientation or competency
evaluation of skill for mixing IV medications.

documented training or competency check
specific to mixing IV medications.

specific to mixing IV medications.

specific to mixing IV medications. The document
titled, "(Facility Name) Competency Checklist,"
dated 08/10/21, showed multiple skills checked
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and the document signed only by S41
him/herself, and not by the DON or pharmacist.
Review of the personnel file of S43 revealed a

document titled, "IV Admixture (adding a
substance to another substance) Competency
Checklist," dated 08/05/21 with the competencies
checked and signed only by S43 him/herself, not
by the DON or pharmacist.
Review of the personnel file of S42 revealed a

document titled, "IV Admixture Competency
Checklist," dated 08/06/21, with the
competencies checked and signed only by S43
noted above who completed a self-assessment
on the competencies, and not by the DON or
pharmacist.
Review of the personnel file of S44A, RN,

revealed a document titled, "IV Admixture
Competency Checklist," dated 08/21/21, was
initialed by S40, DON, but had no competency
skills checked off as completed.
Review of the personnel file of S44B revealed a

document titled, "NurseDash Candidate Profile,"
dated 12/07/2020, including a skills checklist. No
training or competency check by the facility was
found in the file. No training or competency check
specific to IV mixing was found in the file.
Review of the facility's policy titled, "Medication

Use Process: Dispensing-Obtaining Medication
After Hours-Preparation of IV Admixtures,"
approved by S27, effective date 08/98, revealed,
"The Director of Pharmacy, in collaboration with
Nursing and Nursing Education, assures that all
nurses who may be called upon to make an IV
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Admixture during non-Pharmacy hours are
appropriately and adequately oriented and trained
in this Pharmacy function. This will be
accomplished by means of orientation and annual
inservice updates (Nursing Skills Workshops).
A 502 SECURE STORAGE A 502
CFR(s): 482.25(b)(2)(i)
§482.25(b)(2)(i) - All drugs and biologicals must

be kept in a secure area,
and locked when appropriate.
Based on observation, staff interview, and policy
review, the facility failed to secure medications in
the nursing unit and surgical unit on one of two
observation days. Failure to maintain the security
of medications could lead to access by
unauthorized personnel, with possible negative
outcomes for all patients receiving care at this
facility.
Findings include:
1.During an observation on the inpatient nursing

unit on 12/17/21 from 5:30 AM to 5:50 am, a
cabinet in the nurses' station was unlocked with
the key in the lock. No personnel were visible in
the unit at the time of the observation. Upon
examination of the contents of the cabinet, two
boxes were noted to contain medications.
The first box, labeled, "Med. Counter box,"

contained vials of the following medications:
diazepam (a controlled substance) 10 milligrams
(mg) and gabapentin (an anticonvulsant). These
medications were labeled with the name of a
current inpatient.
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The second box, labeled, "Room 3 Home Meds,"
contained vials of the following medications:
esomeprazole (decreases stomach acid) 40 mg,
celecoxib (used for arthritis pain), metaxalone
(muscle relaxant) 800mg, gabapentin 300 mg,
tizanidine Hcl (hydrochloride/short-acting muscle
relaxant) mg., clonidine HCl (treats high blood
pressure) 0.1mg, buspirone HCl (treats anxiety)
15 mg, nebivolol HCl (treats elevated blood
pressure) 10 mg.
During an interview on 12/17/21 at 5:50 AM,

S44B stated that the medication cabinet should
be locked, and the key should be kept in the
nurse's pocket, not in the cabinet. S44B stated
that the medications found unlocked in the
cabinet belonged to the two current inpatients.

AM, the above observations were reviewed. S40
stated, "all medications should be locked."
Review of the facility policy titled, "Medication Use

Process: Administration - Management of
Bedside Medications," last revised 04/00,
revealed, "Medications stored at patient's bedside
must be secured and accessible by only
authorized personnel and the patient
themselves."
2.Observation on 12/17/21 at 7:27 AM, in

Operating Room (OR) 2 at the Sugar Land site
revealed a full 250 milliliter bottle (not opened)
and an opened, half-full bottle of Sevoflurane
Inhalation Anesthetic (a volatile anesthetic that
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provides hypnosis, amnesia, analgesia, akinesia,
and autonomic blockade during surgical and
procedural interventions) in the unlocked second
drawer of the anesthesia cart. Further
observation revealed the first, locked drawer of
the anesthesia cart was labeled as having
medications in the drawer.
In an interview on 12/20/21 at 9:55 AM, S73,

when asked by the surveyor if Sevoflurane
Inhalation Anesthetic should be locked/secured,
S73 stated "it's not a narcotic, but I'm guessing it
should be locked."
A 747 INFECTION PREVENTION CONTROL ABX A 747
STEWARDSHIP
CFR(s): 482.42
The hospital must have active hospital-wide

programs for the surveillance, prevention, and
control of HAIs and other infectious diseases, and
for the optimization of antibiotic use through
stewardship. The programs must demonstrate
adherence to nationally recognized infection
prevention and control guidelines, as well as to
best practices for improving antibiotic use where
applicable, and for reducing the development and
transmission of HAIs and antibiotic resistant
organisms. Infection prevention and control
problems and antibiotic use issues identified in
the programs must be addressed in collaboration
with the hospital-wide quality assessment and
performance improvement (QAPI) program.
Based on policy review, document review,
observation, and interview, the facility failed to (1)
implement their COVID-19 (Coronavirus Disease
2019) Pandemic Plan related to screening visitors
for signs/symptoms of COVID-19 upon entry to
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the facility, (2) implement their policy related to
cohorting (rooming together) and separation of
patients who present with symptoms of
COVID-19 from patients who are asymptomatic
for symptoms of COVID-19, (3) implement their
policy and ensure regular screening of hospital
staff before reporting to work and entering the
hospital, (4) implement their infection control
policy related to hospital construction to prevent
and/or decrease the risk of hospital acquired
infections in patients, visitors, and healthcare
workers. (Refer to A0749).
Findings include:
1. The facility failed to implement their policy and

ensure that visitors were screened during working
hours at the entrance and at the emergency
department (ED) doors after hours. The facility
failed to ensure visitors were checked and
screened for fever, signs and symptoms of
COVID-19, or known or suspected contact with
an individual diagnosed with COVID-19.
2. The facility failed to implement their policy

related to cohorting patients who present with
similar syndromes of COVID-19, grouping
affected patients into a designated section of a
clinic or emergency department, designated ward
or floor of a facility, or a response center in a
separate building to minimize the possibility for
transmission to other patients at the facility and to
staff members.
3. The facility failed to implement their policy

related to regular screening of hospital staff
before reporting to work using CDC screening
instructions to include the presence of fever
greater than 100.4 F one hour before reporting to
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work and associated COVID-19 signs and
symptoms. Staff failed to sign daily log whenever
reporting to work acknowledging the absence of
fever and associated COVID-19 symptoms.
4. The facility failed to implement their infection

control policy to prevent and/or decrease the risk
of nosocomial (hospital acquired) infections in
patients, visitors, and healthcare workers during
hospital construction.
A 749 INFECTION CONTROL PROGRAM A 749
CFR(s): 482.42(a)(2)
The hospital infection prevention and control

program, as documented in its policies and
procedures, employs methods for preventing and
controlling the transmission of infections within
the hospital and between the hospital and other
institutions and settings;
Based on policy review, document review,
observation, and interview, the facility failed to (1)
implement their COVID-19 (Coronavirus Disease
-2019)Pandemic Plan related to screening visitors
for signs/symptoms of COVID-19 upon entry to
the facility, (2) implement their policy related to
cohorting and separation of patients who present
with symptoms of COVID-19 from patients who
are asymptomatic for symptoms of COVID-19, (3)
implement their policy related to regular
screening of hospital staff before reporting to
work and entering the hospital, (4) implement
their infection control policy related to hospital
construction to prevent and/or decrease the risk
of hospital acquired infections in patients, visitors,
and healthcare workers.
Failure of the facility to ensure infection control
policies were followed and implemented placed
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staff, visitors, patients, and future patients at risk
for exposure and acquisition of hospital acquired
infections.
Review of the policy entitled, "Visitation -

COVID-19," #INF.0.25.0, revised 06/21, showed
... "policy it applies to visitors of ICU (Intensive
Care Unit) and all care settings and services
where a presumptive (likely but not confirmed) or
confirmed case of COVID-19 is being treated,
and to screening of the hospital staff ...1) ...visitor
access to the facility shall be limited to the
following points of entry: during working hours:
main entrance of the hospital only. After hours:
through ED (Emergency Department) door for
visitors who are permitted to visit the vulnerable
patients only, of ICU or of the COVID unit ...2)
process of screening during visitation: during
working hours: when the visitor is entering
through the main door/lobby; screening will be
performed ...after hours: visitors will enter the
hospital through the ED door. The ED personnel
at the front desk will be responsible to screen the
visitor by checking the temperature and asking
for screening questions ...6) Screening of regular
staff of the hospital before reporting to work: all
staff members should be actively screened using
the CDC (Centers for Disease Control and
Prevention) screening instructions, for the
following signs and symptoms: Presence of fever
(i.e., temperature above 100.4 F) which should be
checked by the staff themselves an hour before
reporting to work and if negative report to work or
if positive, inform their manager and stay back.
Staff should also check themselves for possible
COVID-19 symptoms. Staff is expected to sign
the log for screening provided at their workstation
and should acknowledge the absence of fever
and the associated symptoms of COVID
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whenever they report to work, and for any history
of exposure to a known or suspected contact
diagnosed with COVID-19."
Review of the policy entitled, "Hospital Planning

and Response To Pandemic COVID-19,
#INF.036.0, revised 11/18/21, showed ..."Key
Concepts in this Policy/Plan ...1) limit points of
entry and manage visitors, screen patient for
respiratory symptoms ...2) Isolate symptomatic
patients as soon as possible. Set up separate
well ventilated triage areas, place patients with
suspected or confirmed COVID-19 in private
rooms with door closed ...prioritizing AIIR's
(Airborne Infection Isolation Rooms) for
undergoing aerosol generating procedures ...3)
Protected healthcare personnel ...prioritize
respirators and AIIRs for aerosol generating
procedures ...B. Upon arrival and during the visit
...UMMC ensure rapid safe triage and isolation of
patients with symptoms of suspected COVID-19
or other respiratory infection (e.g., fever, cough)
...all patients are asked about the presence of
symptoms of respiratory infection and history of
travel to areas experiencing transmission of
COVID-19 or contact with possible COVID-19
patients. All COVID positive patients are isolated
in an examination room with the door closed. If an
examination room is not readily available, it is
ensured that the patient is not allowed to wait
among other patients seeking care ...3. Adhere to
Standard and Transmission-Based Precautions
...4. Patient Placement ...cohorting patients who
present with similar syndromes, i.e., grouping
affected patients into a designated section of a
clinic or emergency department, or a designated
ward or floor of a facility, or even setting up a
response center in a separate building
...designated cohorting sites should be chosen in
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consultation with infection control, and hospital
epidemiologist, and facility engineering staff,
based on patterns of airflow and ventilation ...and
capacity to safely hold potentially large numbers
of patients ...the cohort site has a controlled entry
to minimize the possibility for transmission to
other patients at the facility and to staff members
not directly involved in managing the outbreak
...d) Screening of Visitors ...each visitor should be
actively screened for the following: presence of
fever ( ...above 100.4F) and/or possible
COVID-19 symptoms, known or suspected
history of COVID-19, known or suspected contact
with an individual diagnosed with COVID
individual who do not pass this screening are not
permitted to enter the facility ...design and install
engineering control to reduce or eliminate
exposure by shielding healthcare personnel
(HCP) and other patients from infected individual.
Example of engineering controls include; physical
barriers or partitions to guide patients through
triage areas ...air-handling systems (with
appropriate directionality, filtration, exchange rate
etc.) that are installed and properly maintained."
Review of the policy entitled, "Infection Control

Construction/Renovation Policy (Risk
Assessment & Permit), #INF.012.2, revised
04/19, showed "Purpose "To prevent and
decrease the risk of the acquisition of nosocomial
(hospital acquired) infection in
patients/visitors/healthcare workers during
hospital construction and renovation ...an
essential first step in a comprehensive
Construction and Renovation Plan is an Infection
Control Risk Assessment (ICRA)."
Review of the "Infection Control Construction

Permit," dated 12/18/21 for the project posted on
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the barrier outside the cafeteria/dining room
showed a duration of four days for the
construction project. The permit was listed as a
Class II but failed to show the infection control
risk group as required. The permit showed a
Class II permit required the following:
- Provide active means to prevent air-borne
dust from dispersing into the atmosphere.
- Water mist work surfaces to control dust
while cutting.
- Seal unused door with duct tape and black?
[sic]
- Block off and seal air vents.
- Wipe surface with cleaner/disinfectant.
- Contain construction waste before transport
in tightly covered containers.
- Wet mop and/or vacuum with HEPA filtered
vacuum before leaving work area.
- Place dust mat at entrance and exit of work
area.
- Isolate HVAC systems in area where work is
being performed; restore when work completed.
- Additional requirements to include; use hard
barrier / sheet rock and seal door towards
hallway.
1. On 12/17/21 at 5:30 AM, four surveyors

entered the facility during after-hours visitation
through emergency department (ED) entrance
doors. The surveyors were greeted by staff at the
ED nursing station located at the entrance of the
ED. None of the four surveyors were screened for
fever, signs and symptoms of COVID-19, or
known or suspected contact with an individual
diagnosed with COVID-19 prior to touring the ED
and facility nursing units.

AM, S102 confirmed visitors that enter during
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after-hours visitation from 9:00 PM to 6:00 AM
enter through the ED entrance door. A request for
the after-hours visitation log was requested and
S102 was unable to produce a visitors log for
after-hours visitation reflecting visitors were
screened for COVID-19 as required per facility
policy.
During an interview on 12/17/21 at 2:50 PM, S99

confirmed the facility policy for visitor screening
was not being followed.
On 12/18/21 at 8:30 AM, four surveyors entered

the facility and none of the surveyors were
screened for signs and symptoms of COVID-19
or known or suspected contact with an individual
diagnosed with COVID-19. A review of the
"Security Visitor/Patient Sign-In Log" and the
"COVID-19 Daily Visitors' Screening" main
entrance patient screening log dated 12/17/21
and 12/19/21 revealed no evidence of visitor
screening for signs and symptoms of COVID-19
or known or suspected contact with an individual
diagnosed with COVID. The logs showed the
facility had a total of 224 individuals enter the
facility without being screened for signs and
symptoms of COVID-19 or known or suspected
contact with an individual diagnosed with
COVID-19.
During an interview on 12/18/21 at 9:00 AM, S99

confirmed the facility failed to appropriately
screen visitors entering the main entrance during
visitor hours. S99 confirmed visitors entering the
ED during after-hours visitation and visitors
entering the facility through the main entrance
during visiting hours should have been screened
for signs and symptoms of COVID-19 or known
or suspected contact with an individual diagnosed
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with COVID-19 per facility policy. S99 confirmed
the findings on the main entrance security patient
visitor screening log entries for 12/17/21 through
12/19/21.
2. During a tour conducted at the facility main

entrance on 12/17/21 at 7:00 AM, two waiting
rooms were observed. While facing the main
entrance greeting desk where a security guard
was sitting, one waiting room was located on the
left and a secondary waiting room was located to
the right. Observation of the waiting room on the
right showed a patient registration window located
inside the waiting room with approximately ten
seats along the wall and directly in front of the
patient registration window.
During an interview on 12/17/21 at 7:00AM, S97

stated that COVID-19 symptomatic patients are
placed in waiting room located on the right, which
was also where all ED patients and patients being
admitted to inpatient register. S97 confirmed
patients that are asymptomatic for COVID-19
must enter the waiting room along with
symptomatic COVID-19 patients to register.

confirmed all patients, including ED patient, as
well as patients being admitted to inpatient,
register at the window located in the COVID-19
symptomatic waiting room.

confirmed the "Hospital Planning and Response
To Pandemic COVID-19" policy was not being
followed. S99 confirmed COVID positive patients
were not being isolated in an examination room
with the door closed and COVID-19 symptomatic
patients were being allowed to wait among
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asymptomatic patients seeking care.
3. During a tour of the ED on 12/17/21 at 6:40AM,

accompanied by S102, a review of the "Individual
Employee Log For COVID-19 Screening,"
showed the staff currently on duty S104, S105,
S106 had no entries for the month of December
2021 and S106 had no entries from August 2021
through December 2021. The employee
COVID-19 screening log findings were confirmed
with the S102 at the time of the ED tour.
During a tour of the ICU on 12/19/21 at 11:00 AM,

accompanied by S91, a random review of 20
"Individual Employee Log For COVID-19
Screening," showed 12 employees with no entries
in December 2021 and eight employees with no
entries from July 2021 through December 2021.
These findings were confirmed with S91 at the
time of the tour.
4. A tour of the cafeteria, kitchen, and dining

room on 12/18/21 at 10:08AM, accompanied by
S111, revealed contractors actively tearing up
vinyl flooring causing large amounts of dirt, dust,
and debris to be dispersed into the atmosphere.
The area under construction failed to have an
Infection Control Construction Permit or any
barriers or active means to prevent air-borne dust
from dispersing into the atmosphere. Staff
member S111 asked the contractor to stop all
construction until appropriate barriers could be
put into place. The tour findings were confirmed
by staff member S111 at the time of the tour.
During an interview on 12/18/21 at 11:45AM with

S111, S99, S112, and S103 regarding the
Cafeteria Construction Project, all members
confirmed the facility was removing vinyl floor
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using a machine to scrape up the old floor. S111
stated the construction project started on
12/17/21 around 3:00 PM. All staff confirmed the
construction did not have a completed Infection
Control Construction Permit per facility policy or
required barriers to control dirt, dust and debris
from being dispersed into the air.
During a tour of the cafeteria/dining room

construction area on 12/18/21 at 12:00 PM team
members S111, S112, S113, S103, and S99
confirmed the presence of dust, dirt and debris
being generated and floating in the air without the
presence of required containment barriers. The
team members confirmed there should have
been a Class II Infection Control Construction
Permit barrier and stated they would immediately
complete the Infection Control Construction
Permit for the project and post it on the
construction site, as well as complete the
required barriers for a Class II construction
project. The team members confirmed the
following were required, but not present for a
Class II Infection Control Construction Permit:
- Active means to prevent air-borne dust from
dispersing into the atmosphere
- Water mist work surfaces to control dust while
cutting.
- Sealed unused door with duct tape and black
plastic.
- Blocked off and seal air vents.
- Surface being wiped with cleaner/disinfectant.
- Workers perform wet mopping and/or vacuum
with HEPA filtered vacuum before leaving
work area.
- The presence of a dust mat at entrance and
exit of work area.
A 940 SURGICAL SERVICES A 940
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CFR(s): 482.51
If the hospital provides surgical services, the

services must be well organized and provided in
accordance with acceptable standards of
practice. If outpatient surgical services are
offered the services must be consistent in quality
with inpatient care in accordance with the
complexity of services offered.

Based on observation, policy review, medical
record review, document review, and interview,
the hospital failed to meet the requirements of the
Condition of Participation of Surgical Services.
1. The hospital failed to ensure six (Staff (S)114,

S115, S116, S117, S118, S119) of six
practitioners' credentialing files reviewed for
privileges were granted specific clinical privileges
and procedures authorized by the governing
board and signed by the department chairman
based on the practitioner's license, education,
training, experience, current competence, health
status, and judgement prior to performing
surgery. This deficient practice had the potential
to affect all patients receiving surgical services at
any of the three hospital campuses. (see findings
in tag A0945)
2. The hospital failed to ensure an updated

examination of the patient, including any changes
in the patient's condition, was documented and in
the medical record prior to the surgery when the
or registration for six (Patient (P) 29, P32, P33,
P35, P37, P38 of eleven patient records reviewed
for a documented updated H&P prior to surgery
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from a sample of 58 patients. This deficient
practice had the potential to miss current
diagnoses/conditions for patients receiving
surgical services (see findings in tag A0953).
3. The hospital failed to ensure an operative

report was written or dictated immediately
following surgery and signed by the surgeon that
described techniques, findings, and tissues
removed or altered. Observation on 12/20/21 at
9:25AM in the pre-operative (Pre-op) area at the
Sugar Land site revealed the operative note was
written, signed, dated, and timed by S58 for two
(P40, P41) of two patients observed in Pre-op
prior to surgery. There was no operative note
documented/dictated/completed in two (P03,
P32) of twelve (P03, P22, P29, P31, P32, P33,
P34, P35, P36, P37, P38, P39) patient records
reviewed for a completed operative note from a
the potential to affect all patients having a surgical
procedure at the three hospital campuses (see
4. The hospital failed to: ensure a competency

evaluation on performing sterile processing duties
was completed for one of one sterile processing
technician's personnel file reviewed and ensure
one of one sterile processing technician
performed manual washing of surgical
instruments in accordance with the
manufacturer's instructions for use when
observed on 12/20/21 at 11:08 AM. These
three hospital campuses (see findings in tag
A0951).
A 945 SURGICAL PRIVILEGES A 945
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CFR(s): 482.51(a)(4)
Surgical privileges must be delineated for all

practitioners performing surgery in accordance
with the competencies of each practitioner. The
surgical service must maintain a roster of
practitioners specifying the surgical privileges of
each practitioner.

Based on medical staff bylaws review,
credentialing files review, and interview, the
facility failed to ensure six practitioners (S114,
S115, S116, S117, S118, S119) were granted
specific clinical privileges and procedures
and judgement prior to performing surgery. The
failure to ensure surgeons are qualified prior to
performing a surgical procedure places all
surgical patients at risk for a negative outcome.
Findings include:
Review of the document titled, "United Memorial

Medical Center Medical Staff Bylaws," last
reviewed April 19, 2019, showed, " ...3. Applicant:
Any Practitioner who is qualified to and does
submit a complete application for appointment to
the Medical Staff of the Hospital. 4. Bylaws: The
Medical Staff Bylaws of United Memorial Medical
Center ...7. Clinical Privileges The authorization
granted by the Governing Board to a Member of
the Medical Staff based on a Practitioner's
license, education and training, experience,
current competence, health status, and judgment
to provide specific care services with well defined
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limits. The delineation of a Practitioner's clinical
privileges included limitations, if any, on the
individual's privileges to admit and treat patients
or direct the course of treatment for the
conditions for which the patients were admitted.
8. Credentialing: The process of granting
authorization to members of the Medical Staff by
the Governing Board to provide specific patient
care and treatment services in the hospital within
defined limits based upon a Practitioner's license,
education and training, experience, current
competence, health status, and judgment. 9.
Delineation of Clinical Privileges: The process of
listing the specific clinical privileges a Medical
Staff Member may be granted ...11. Department
Chairman: The Medical Staff Member appointed
or elected in accordance with the Bylaws to serve
as the head of a Medical Staff department ...A.
Credentials Committee 1. The Medical Executive
Committee serves as the Medical Staff
Credentialing Committee. 2. Duties: ...c. Review
the medical staff application forms and the clinical
privileges cards ...g. Review all Department
Chairman recommendations for medical staff
appointment applications, progression from
provisional status and reappointment applications
and requested clinical privileges ...Section 1
Clinical Privileges, Appointment / Reappointment
A. Every Practitioner with Medical Staff
membership and clinical privileges shall be
entitled to exercise only those clinical privileges
specifically granted to him by the Governing
Board ...D. The initial application for medical staff
appointment must indicate the specific clinical
privileges requested by the applicant ...including
consideration as to whether the facility is capable
of providing the required equipment, personnel
and supportive services within a specified time
frame."
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but failed to show if the privileges were approved
or denied. The application was signed by the
S120 on 09/18/2021.

granted.

granted.

including total shoulder replacement but failed to
show if the procedure was granted or denied. The
application also failed to show what facility the
privileges requested were for. Review of a
second application for Practitioner S117's
delineation of privileges for general surgery dated
03/28/21 showed a list of privileges requested but
failed to show which privileges were granted and
also failed to show the required signature the
S120. Review of a third application for
Practitioner S117's delineation of privileges for
plastic surgery dated 03/28/2021 showed a list of
privileges requested and signed by the S120 on
06/29/21 but failed to show which privileges were
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granted.

privileges application for podiatry surgery dated
and signed by S120 on 03/01/2021 but failed to
show what facility the requested privileges were
granted for.

04/13/21 showed a list of privileges but failed to
show what privileges were requested. The
application was signed by S120 on 10/30/2021.
During an interview on 12/20/21 at 4:30PM, S93

confirmed the above Practitioner credential file
findings and that the applications were not in
compliance with the facility Medical Staff Bylaws.
A 951 OPERATING ROOM POLICIES A 951
CFR(s): 482.51(b)
Surgical services must be consistent with needs

and resources. Policies governing surgical care
must be designed to assure the achievement and
maintenance of high standards of medical
practice and patient care.

Based on observation, policy review, document
reviews, personnel file review, and interviews, the
hospital failed to:
1. Ensure a competency evaluation on performing
sterile processing duties was completed for one
of one sterile processing technician's personnel
file reviewed (S113).
2. Ensure one of one sterile processing
technicians (S53) performed manual washing of
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surgical instruments in accordance with the
manufacturer's instructions for use.These
Findings include:
1. Review of the policy titled, "Staff Competency,"

#HRD.019.042.3, last reviewed 04/19 showed,
"Purpose: To describe the hospital's program for
ensuring that patient care and services are
provided by individuals competent to perform
their assigned duties. Scope: This policy applies
to all individuals providing patient care and
services at United Memorial Medical Center ...It is
the policy of the hospital to maintain a
comprehensive program for ensuring that
employees possess the skills and competencies
required to safely and effectively provide patient
care and services. It is also the policy of the
hospital to demonstrate, assess, maintain and
improve staff competence on an on-gong basis
...It is the responsibility of the Department
Director to identify and maintain competencies
based on the specific needs of the patient
population served ...Competence assessment for
staff and contracted staff who work in the same
capacity as staff providing care, treatment, and
services is based on the following: ...Direct
observation by qualified supervisor or preceptor.
Successful completion of general and unit
specific skills checklist. Successful performance
of identified procedure ...Competency of skill
inventory is updated when any of the following
occur: New technology is introduced,
performance of skill is limited and competency
needs to verified ...2. Orientation Period ...c)
Competency assessment: The employee will
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complete skills/competency self-assessment. The
department director or designee will verify
verification of the employee's initial competency
level through the first 90-120 days of
employment."
Review of S113's personnel file showed a

consultant agreement dated 11/16/21 for the
position of sterilization technician in the sterile
processing department. Continued review of
S113's personnel file failed to show the presence
of a resume, skills/competency self-assessment,
or verification by the director or designee of the
employee's initial competency level through the
first 90-120 days of employment.
In an interview on 12/20/21 at 4:00 PM, the S122

confirmed the above findings in the personnel file
of staff member S113.
2. Review of the Center for Disease Control and

Prevention's (CDC) "Guideline for Disinfection
and Sterilization in Healthcare Facilities, 2008
Update: May 2019" indicated ". . . Duration of
Exposure Items must be exposed to the
germicide for the appropriate minimum contact
time . . . all applicable label instructions on EPA
[environmental protection agency]-registered
products must be followed . . . in general, longer
contact times are more effective than shorter
contact times. . . . Cleaning is the removal of
foreign material (e.g, [for example] soil and
organic material) from objects and is normally
accomplished using water with detergents or
enzymatic products. Thorough cleaning is
required before high-level disinfection and
sterilization because inorganic and organic
materials that remain on the surfaces of
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instruments interfere with the effectiveness of
these processes. Also, if soiled materials dry or
bake onto the instruments, the removal process
becomes more difficult and the disinfection or
sterilization process becomes more difficult and
the disinfection or sterilization process less
effective or ineffective. . . . With manual cleaning,
the two essential components are friction and
fluidics. Friction (e.g., rubbing/scrubbing the
soiled area with a brush) is an old and
dependable method. Fluidics (i.e., [that is] fluids
under pressure) is used to remove soil and debris
from internal channels after brushing and when
the design does not allow passage of a brush
through a channel . . . For instrument cleaning . . .
Enzymatic solutions should be used in
accordance with manufacturer's instructions,
which include proper dilution of the enzymatic
detergent and contact with equipment for the
amount of time specified on the label. . ."
Review of the "Renuzyme Plus Product

Specification," the enzymatic cleanser used by
S53 to manually wash surgical instruments,
indicated "Renuzyme Plus is a dual-enzyme
formula providing extra cleaning at lower
temperatures. Application Designed for severe
soils, cold-water applications, and when shorter
contact/soak times are required. Items placed in
soak tanks, ultrasounds, or manually cleaned
benefit from the dual-enzyme formula. . . Manual
Cleaning Immerse soiled instruments in a basin
containing a solution of 1 oz [ounce] to 2 oz per
gallon (8-16ml/L) [milliliters per liter] of water.
Amount of product used will vary depending on
severity of soil conditions. Renuzyme Plus can be
used in both cold and warm water. For best
results, Renuzyme Plus should be used in warm
water 27[degrees symbol]-65[degrees symbol]C
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[Centigrade] (81[degrees
symbol]F[Fahrenheit]-149[degrees symbol]F).
Soak for 1-10 minutes. Do not exceed
65[degrees symbol]C (149[degrees symbol]F)
temperature. Lower water temperatures will
require longer soak times. After soaking,
thoroughly rinse and transfer to manual,
ultrasonic or washer/disinfector cleaning
operation. Discard used solutions daily or when
visibly soiled."
Review of CDC's "Guideline for Hand Hygiene in

Health-Care Settings," dated 10/25/02, indicated,
". . . Recommendations 1. Indications for
handwashing and hand antisepsis A. When
hands are visibly dirty or contaminated with
proteinaceous material or are visibly soiled with
blood or other body fluids, wash hands with either
a non-antimicrobial soap and water or an
antimicrobial soap and water . . . B. If hands are
not visibly soiled, use an alcohol-based hand rub
for routinely decontaminating hands in all other
clinical situations . . . H. Decontaminate hands if
moving from a contaminated-body site to a
clean-body site during patient care. . . . J.
Decontaminate hands after removing gloves . . ."
Review of the hospital policy titled, "Infection

Control Decontamination Flow," last reviewed
April 2019, indicated, ". . . There will be
established guidelines for the flow of
contaminated equipment and supplies in the
Operating Room to minimize the potential for
cross-contamination. II. Process Standards To
facilitate the attainment of Outcome Standards A.
Instrument washed between cases for
re-sterilization will be cleaned in designated
cleaning areas and NOT in scrub sinks or other
areas of the Operating Room Suite. B.
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Instruments being washed between cases must
be cleaned in the Decontamination Room with
designated disinfectant. C. Instrument are
transported on carts and covered while in
transport. Carts will be cleaned with disinfectant
after use." There was no documentation of the
process to be followed for disinfection and
sterilization of surgical instruments.
Review of the undated printed list titled, "UMMC

[United Memorial Medical Center] - Sugarland
Endoscopy," contained in a plastic sleeve above
the work area in the decontamination room,
indicated, "Sterile Processing Detergent - Getinge
Clean [name of washer used for washing surgical
instruments] - Renuzyme [name of disinfectant] . .
. Man [manual] = [equals] 1-2 oz [ounce] per Gal.
[gallon] = We use 6 Gal. [referring to amount of
water] = 6-12 oz per wash [referring to Enuzyme
Plus] = 9 oz [amount of Enuzyme Plus dispensed
automatically from wall-mounted dispenser] =
266.14 ML [milliliter]"
Observation in the Decontamination Room at the

Sugar Land location on 12/20/21 at 11:08AM
revealed S53 donned a plastic apron over S53's
scrubs, gloves, mask, and face shield. S53 was
observed to not tie the apron which resulted in the
apron flapping and exposing the back of S53's
scrubs when S53 turned S53's back to the cart
with contaminated surgical instruments to place
the first washed tray of instruments into the
washer. S53 filled the sink that had a marked line
for six gallons with water from the tap. S53 then
dispensed Renuzyme Plus from the wall-mounted
dispenser. S53 stated the dispenser dispensed
nine ounces of Renuzyme Plus and the water
from the tap was filtered. There was no
observation of a thermometer and timing device
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in the room. Observation revealed S53 did not
check the temperature of the water and Enuzyme
solution before placing surgical instruments to
soak and throughout the cleaning of three
separate sets of instruments. Observation
revealed once S53 added the last surgical
instrument to the solution, S53 began to remove
instruments and rinsed the instruments under the
running tap water in the next sink compartment
from the one used to soak instruments. There
was no timing done by S53 to assure that the last
instruments placed to soak had soaked for at
least one minute before removing the instruments
and rinsing them. After each tray of instruments
had been manually washed, S53 placed one tray
in the washer at 11:35AM and a second tray in
the washer at 11:52AM. S53 removed the rubber
mat from the tray that contained the
contaminated surgical instruments at 11:53AM,
rinsed the mat under running filtered tap water,
dipped the rinsed mat in the enzymatic solution,
immediately removed the mat from the enzymatic
solution, and placed the mat in the empty third
compartment sink (not used for soaking or rinsing
instruments). At 11:58AM S53 removed the
rubber mat from the third compartment sink and
placed the mat in the wire basket that had
contained the contaminated surgical instruments
(had not been washed and soaked with
enzymatic solution). S53 then placed the
instruments that had been soaked and rinsed on
the rubber mat. S53 was observed to remove
gelpi retractor (a self-retaining surgical instrument
used to hold back organs and tissues to increase
access in deep incisions) from the enzymatic
solution and placed the retractor in the tray to be
placed in the washer without first rinsing the
retractor. Observation revealed once the washer
was filled, S53 started the washer at 12:25PM. At
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12:30PM, while wearing the same gloves used to
clean contaminated surgical instruments, S53
used CaviWipes (disposable towelettes
pre-saturated with CaviCide Surface Disinfectant
Cleaner) to wipe the counter and sinks.
Observation revealed S53 touched and opened
the CaviWipe container with contaminated gloves
to place a wipe through the opening used to
remove wipes without opening the entire
container.
In an interview on 12/20/21 at 1:50PM, S53

confirmed S53 did not check the temperature of
the water and enzymatic solution. S53 stated
he/she is supposed to check the temperature.
S53 confirmed S53 did not tie his/her apron. S53
stated S53 does not have a means of measuring
the time that instruments are soaked. S53 stated
S53 has no procedure for decontamination and
sterilization of instruments other than the
one-page policy S53 presented. S53 confirmed
the above observations when the observations
were reviewed with S53.
A 953 UPDATED EXAM A 953
CFR(s): 482.51(b)(1)(ii)
Prior to surgery or a procedure requiring

anesthesia services and except in the case of
emergencies:
(ii) An updated examination of the patient,

including any changes in the patient's condition,
must be completed and documented within 24
hours after admission or registration when the
medical history and physical examination are
completed within 30 days before admission or
registration and except as provided under
paragraph (b)(1)(iii) of this section.
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Based on medical staff rules and regulations
review, medical record review, and interview, the
hospital failed to ensure an updated examination
of the patient, including any changes in the
patient's condition, was documented and in the
medical record prior to the surgery when the
or registration for six of 11 patient surgical
records reviewed (P29, P32, P33, P35, P37,
P38). This deficient practice had the potential to
affect all patients receiving surgical services at
any of the three hospital campuses.
Findings include:
Review of the "United Memorial Medical Center

Medical Staff Rules & [and] Regulations," last
reviewed 04/19/19, indicated ". . . B. History and
Physical Examination for Inpatient Admissions,
Observation Status and Day Surgery Procedures.
1. Complete History & Physical A complete
admission history and comprehensive physical
examination, dictated or hand written shall be
completed by an admitting physician or the
admitting physician's AHP [allied health
professional] authorized to perform a history and
physical examination and shall be recorded and
in the medical record within twenty-four (24)
hours after admission including weekends and
holidays. The history & physical shall include the
following: . . . Signature/date/time . . . 2. If the
H&P was performed within thirty (30) days by the
MD/DO [medical doctor/doctor of osteopathic
medicine] a. An appropriate assessment must be
performed by the MD/DO. The assessment must
include: A physical assessment of the patient to
update any components of the patient's current
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medical status that may have changed since the
H&P or to address any areas where more current
data is needed. Confirmation that the necessity
for the surgical procedure or care is still present
based on the assessment of the patient's
condition, and any comorbidities, in relation to the
reason the patient was admitted or surgery is to
be performed. B. An updated entry must be
documented within twenty-four (24) hours after
admission but prior to surgery, for any procedure
requiring consent or anesthesia services,
documenting the patient's current status and/or
any changes in the patient's condition when the
medical history and physical examination are
completed within 30 days prior to admission. The
updated note must be attached on the H&P. c.
The H&P, including all updates and assessment
for the admission must be on the patient's chart
within twenty-four (24) hours, but prior to surgery.
3. An H&P that has been documented more than
30 days prior to admission does not meet the
requirements for a current H&P and cannot be
updated with an interval note. A new H&P is
required. 4. When the history and physical
examination are not recorded before an
operation, or any potentially hazardous diagnostic
or invasive procedure, the procedure shall be
canceled, unless the Physician states in writing
that delay would be detrimental to the patient. . .
."
1. Review of P29's H&P indicated S58 performed

the H&P on 12/11/21. Further review indicated
there was no documentation of an update
documented on 12/14/21 prior to P29's surgical
procedure.
2. Review of P32's medical record indicated P32

had a surgical procedure on 11/18/21. Review of
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P32's "Intraoperative Record" indicated the
surgery began at 12:30 PM on 11/18/21. Further
review indicated P32's H&P was performed on
10/27/21 and updated on 11/18/21 at 1:00 PM
after the surgery had begun and not prior to
surgery.

had two endoscopy procedures (examination of
the gastrointestinal tract using a camera held on
to a flexible tube called an endoscope) on
11/01/21 performed by S59. Further review
indicated an H&P was documented on 10/27/21.
There was no documentation of an updated H&P
by S59 prior to P33's surgery.

had a surgical procedure on 11/01/21 performed
by S58. Further review indicated S35's H&P was
performed by S58 on 10/21/21. There was no
documentation of an updated H&P by S58 prior to
P35's surgery.

had a surgical procedure performed on 11/05/21
by S62. Further review indicated S62 performed a
H&P on 10/21/21. There was no documentation
of an updated H&P by S62 prior to P37's surgery.

had an injection procedure in the operating room
on 11/11/21 performed by S64. Further review
indicated S64 documented a H&P on 10/18/21.
S64 documented an update on 11/11/21 at 6:51
AM, and the surgery began at 6:48 AM. The
updated H&P was not documented prior to the
start of the surgery.
In an interview on 12/19/21 at 11:26 AM, S40

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stated an updated H&P should be in the patient's
medical record before the procedure if the H&P
was performed within 30 days of the procedure.
S40 stated a new H&P is needed if the H&P was
done more than 30 days before the procedure.

stated if an H&P update is not timed, one cannot
assure it was done prior to surgery.
A 955 INFORMED CONSENT A 955
CFR(s): 482.51(b)(2)
A properly executed informed consent form for

the operation must be in the patient's chart before
surgery, except in emergencies.

Based on medical staff rules and regulations
review, medical record review, and interview, the
hospital failed to ensure that there was a properly
executed informed consent for eight (P32, P33,
P34, P35, P36, P38, P40, and P41) of twelve
surgical patient records reviewed . This deficient
practice had the potential to affect all patients
receiving services at any of the three hospital
campuses.
Findings include:

reviewed 04/19/19, indicated ". . . 7. Informed
Consent All inpatient and outpatient medical
records must contain a properly executed and
completed written informed consent form. . . . 9.
Clinical entries 1. The author of each entry shall
be identified and shall authenticate his entry. All
clinical entries in the patient's medical record
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shall be accurately dated, timed and
authenticated by written signature, identifiable
initials or computer key. . . ."
1. Review of P32's "Anesthesia

/Perioperative/Pain Management" consent for a
procedure performed on 11/18/21 indicated no
date and time when the anesthesiologist and the
witness signed the consent.

date and time when the witness signed the
consent and no signature, date, and time of the
anesthesiologist providing the anesthesia.

4. Review of P35's "Disclosure and Consent" for

a surgical procedure performed on 11/01/21
indicated no time when the surgeon signed the
consent, and no date and time when the witness
signed the form.


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consent and no date and time when the witness
signed the form.

consent and no date and time when the witness
signed the form.

stated, "everything should be dated and timed,"
when shown patient consents that had no
signature, date, and/or time when signed by the
physician and witness.
A 959 OPERATIVE REPORT A 959
CFR(s): 482.51(b)(6)
An operative report describing techniques,

findings, and tissues removed or altered must be
written or dictated immediately following surgery
and signed by the surgeon.

Based on observation, medical staff rules and
regulations review, medical record review, and
interview, the hospital failed to ensure an
operative report was written or dictated
immediately following surgery and appropriately
dated, timed, and signed by the surgeon for two
of two patients observed (P40, P41) and for two
of twelve patient surgical records reviewed (P03,
P32) . This deficient practice had the potential to
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affect all patients having a surgical procedure at
the three hospital campuses.
Findings include:

reviewed 04/19/19, indicated ". . . A medical
record must be maintained for each inpatient and
outpatient evaluated or treated in any part or
location of the hospital. 9. Clinical entries 1. The
author of each entry shall be identified and shall
authenticate his entry. All clinical entries in the
patient's medical record shall be accurately
dated, timed and authenticated by written
signature, identifiable initials or computer key. . . .
11. Operative Reports . . . b. Operative or other
high-risk procedure reports shall include a
detailed account of the findings of surgery, details
of the surgical technique, specimens removed,
post-operative diagnosis, and name of primary
surgeon and any assistants. c. Operative or other
high-risk procedure reports shall be written or
dictated immediately following surgery for
inpatients as well as outpatients. d. The
completed operative report is authenticated by
the surgeon and filed in the medical record as
soon as possible after surgery. e. An operative or
other high-risk procedure progress note is
entered in the medical record immediately after
the procedure, if the full operative report cannot
be entered into the record upon completion of the
operation or procedure before the patient is
transferred to the next level of care."
Observation on 12/20/21 at 9:25 AM in the Pre-op

area at the Sugar Land site revealed P40's
"Immediate Post-Op Note / Orders" was signed
by S58 on 12/20/21 at "12P" (12:00 PM) and
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included the preoperative diagnosis,
postoperative diagnosis, procedure performed,
no complications, no estimated blood loss, and
no specimen. The operative note was observed
by the surveyor on 12/20/21 at 9:30 AM while P40
was in Pre-op waiting to be taken to surgery.
Observation on 12/20/21 at 9:25 AM in the Pre-op

area at the Sugar Land site revealed P41's
"Immediate Post-Op Note / Orders" was signed
by S58 on 12/20/21 at "11 A" (11:00 AM) and
included the preoperative diagnosis,
postoperative diagnosis, procedure performed,
no complications, no estimated blood loss, and
no specimen. The operative note was observed
by the surveyor on 12/20/21 at 9:30 AM while P41
was in Pre-op waiting to be taken to surgery.
1. Review of P03's "Physician History and

Physical" (H&P) dated 12/06/21 at 11:10 PM
showed P03 was admitted for complaints of
shortness of breath (SOB), cough, headache and
body aches. P03 was diagnosed with COVID-19
(Coronavirus Disease-2019) and admitted to the
hospital COVID-19 nursing unit. Review of P03's
"Physician Postoperative Note" dated 12/15/21 at
9:05 AM showed a diagnosis of COVID-19
pneumonia and respiratory failure. The
postoperative note showed the surgical
procedure was a placement of a tracheostomy (a
hole surgically placed in the throat for an airway).
The postoperative note failed to show the
following:
-Date and times of the surgery.
-Name(s) of the surgeon(s) and assistants or
other practitioners who performed surgical tasks
(even when performing those tasks under
supervision).
-Post-operative diagnosis.
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-Complications, if any.
-A description of techniques, findings, and tissues
removed or altered.
-Surgeons or practitioners name(s) and a
description of the specific significant surgical
tasks that were conducted by practitioners other
than the primary surgeon/practitioner (significant
surgical procedures include: opening and closing,
harvesting grafts, dissecting tissue, removing
tissue, implanting devices, altering tissues).
-Prosthetic (an artificial device that replaces a
missing body part) devices, grafts, tissues,
transplants, or devices implanted, if any,
During an interview on 12/20/21 at 3:10 PM, the

S102 confirmed the postoperative note findings in
the medical record of P03.

had an excision of a recurrent pilonidal cyst on
11/18/21. Review of the entire medical record
indicated there was no operative note
documented or dictated by S65.

stated the operative note is supposed to be
completed after surgery. S43 stated the operative
note is checked by the post-anesthesia nurse
after surgery.

stated the operative note shouldn't be
documented until after the procedure. S58 gave
no explanation for S58 documenting the operative
note before the surgical procedure began.

confirmed the finding of no operative note in
P32's medical record, but S40 "would not confirm
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they're [the findings] against the federal
regulations, because I'm not familiar with the
regulation."
A1100 EMERGENCY SERVICES A1100
CFR(s): 482.55
The hospital must meet the emergency needs of

patients in accordance with acceptable standards
of practice.

Based on observation, interviews and records
review the facility failed to provide entrance into
the Emergency Department (ED)/Emergency
Room (ER) in a timely manner (North location).
This failed practice could result in serious harm or
death to a patient needing access to emergency
services.
Refer to tag 1101.
A1101 ORGANIZATION AND DIRECTION A1101
CFR(s): 482.55(a)
Organization and Direction. If emergency

services are provided at the hospital --

Based on observation, interviews and records
review the facility failed to provide entrance into
the Emergency Department (ED)/Emergency
Room (ER) in a timely manner (North location).
This failed practice could result in serious harm or
death to a patient needing access to emergency
services.
On 12/17/21 at 5:30AM surveyors attempted to
enter the main entrance of the ED at UMMC
North. A security services car was parked in the
front of the ED, with a security guard inside. The
security guard had a direct vision of the ED main
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A1101 Continued From page 74 A1101

entrance. The warning lights in the car were on.
When the survey team attempted to open the ED
main door, the door was locked. There was a
sign at the door with instructions in english and
spanish that stated "Please call ER staff and
explain symptoms". There was also a printed
phone number to call.
At 5:38 AM a call was placed to the number
posted on the ED main entrance door. The call
went to voicemail. A voicemail was left
requesting entrance. There was no a return call.
At 5:51 AM a second call was placed to the
number posted on the ER main entrance door
requesting entrance for medical assistance. The
call went to voicemail. There was no return call.
At 5:54 AM surveyors observed two hospital staff
entering from the right side entrance door of the
ED. The surveyors were within visibility of the two
staff members.
At 5:59 AM a third call was placed to the number
posted on the ED main entrance door. There was
no answer.
At 6:12 AM a staff member in the ED was looking
out through a small glass window inside the ER
when the surveyors waved in an attempt to catch
her attention.
At 6:13 AM the staff member came to the ED
main entrance and opened the door.
S11 unlocked the ED main entrance door
indicating she was the only staff in the ED and
was also the House Supervisor. S11 stated she
was taking care of one patient and the Doctor and
X-Ray Technician were also responsible to
answer the telephone however, neither was
present. The staff indicated the security guard
could unlock the door for patients to enter.
According to S11, the ED main entrance door
was locked from 7:00 PM to 6:00 AM due to high
crime in the area.
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When asked what would happen if a patient
comes with a serious emergency and the door
was locked, S11 stated "The patient will have to
wait outside until the ED staff or the security
guard can open the door".
On 12/17/21 6:20 AM S25 was interviewed. The
staff stated she entered the ED from the side
door at 5:54 AM. She indicated the side door is
for hospital employees to be screened for COVID
symptoms before entering the work area. When
asked if she saw two people in front of the ED
door waiting to enter earlier in the morning , the
staff member stated, "Yes I did, but it is not my
job to unlock the door". When asked if she
mentioned to anyone there were people at the ER
main entrance waiting to come inside, she
responded, "No, there was nobody at the ED
desk".
On 12/17/21 at 6:24 AM an interview was

conducted with S12. During the interview the
staff member stated she does not work in the ED,
however, she knows the ED main entrance door
is locked from 7:00 PM to 6:00 AM because of
uncertainty at night.
On 12/17/21 at 6:40 AM an interview with S13
was conducted. The staff member stated the ED
main door is locked from 7:00 PM to 6:00 AM.
On 12/17/21 at 6:47 AM S14 was interviewed.
The staff member indicated the hospital ED main
entrance door is locked from 7: 00 PM to 6:00 AM
due to security issues. S14 stated the ED nurse is
usually the night shift house supervisor, and the
only nurse from 7:00 PM to 7:00 AM. S14 stated
the ED Doctor and the X-Ray Technician should
be at the ED front desk to open the door or
answer the telephone.
On 12/17/21 at 12:15 PM S14 provided the
hospital policy and procedure titled "Assessment
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and Reassessment of the ED Patient." The policy
reflects: "To efficiently assess and prioritize
patient according to acuity of patient's condition,
and to provide timely medical screening
examination and treatments to patients who
present to the Emergency Department requesting
examination or treatment of an emergency
medical condition".
On 12/17/21 at 12:20 PM an interview with S14
was conducted. During the interview the staff
member stated she did not know the Doctor or
X-Ray Technician location from 5:00 AM to 6:00
AM or why they did not respond to the telephone
call or voicemail. The staff member also admitted
to not having a hospital policy and procedure in
writing that addressed the locking of the ER door
from 7:00 PM to 6:00 AM. The hospital
administration agreed to lock the ER doors from
7:00 PM to 6:00 AM during the COVID-19
pandemic due to security issues at the location.
When asked what process the hospital has in
place to answer the telephone in the ED during
the time the doors are locked, the staff member
replied, "I thought we had a process but I see the
process failed".
On December 17, 2021 approximately 3:30 PM
security guard company owners S18 and S19
were interviewed. During the interview, it was
revealed the security guard did not have keys to
the ED main door entrance but can call the ED
staff and inform them of a patient outside their
doors. The security guard company owners did
not know why the security guard on post did not
call the ED staff.
A2405 EMERGENCY ROOM LOG A2405
CFR(s): 489.20(r)(3)
[The provider agrees,] in the case of a hospital as
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defined in §489.24(b) (including both the
transferring and receiving hospitals), to maintain a
central log on each individual who comes to the
emergency department, as defined in §489.24(b),
seeking assistance and whether he or she
refused treatment, was refused treatment, or
whether he or she was transferred, admitted and
treated, stabilized and transferred, or discharged.
§489.24 The provisions of this regulation apply to

all hospitals that participate in Medicare and
provide emergency services.

Based on interview and record review, the facility
failed to maintain an accurate ED Central Log.
P15 was transported via ambulance on 8/22/2021
and was not recorded in the ED Central Log.
Findings included:
TX00394743
Record review of a facility policy titled

"Emergency Medical Treatment & Labor Act, last
reviewed date 04/2019, stated "Record-keeping:
The hospital must maintain the following ...-a
central log on each individual who comes to the
emergency department seeking assistance and
whether ...transferred, admitted, stabilized,
discharged etc ...for five(5) years.
During a telephone interview on 12/20/2021 at

11:42 AM with Houston Fire Department (HFD)
Emergency Medical Services (EMS) Supervisor
(FD80), he stated he was called out to United
Memorial Medical Center (UMMC) to assist his
EMS crew. His crew arrived on scene to United
Memorial Medical Center on 8/22/2021 at
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12:08PM with a patient to present to UMMC
emergency room. The EMS crew on scene was
told by UMMC ER staff that the facility was not
accepting patients at that time and that the EMS
crew and patient should go elsewhere or wait with
the patient for unknown amount of hours. Upon
arrival to the scene, FD80 stated he observed
patient (P15) in a wheelchair along with his crew
outside of the emergency room in between the
first and second set of double doors, "in a
breezeway area." FD80 stated "the patient had
not been triaged or registered" and "I asked to
speak to the supervisor". The nursing supervisor
(S121) at the time, came to speak with FD80 and
stated they are not refusing the patient, but the
HFD crew will have to wait with the patient for
about "7 hours". FD80 stated he then called the
HFD medical director and was given the directive
to transport the patient to a different hospital.
During a telephone Interview on 12/19/21 at

12:10PM with FD79, Houston Fire Department
(HFD), supervisor, FD79 stated his crew arrived
at UMMC Tidwell location on 08/16/2021 at
approximately 11:00 pm. HFD crews, per their
policies, had called ahead to the emergency
medical services base station and inquired as to
the "status" of UMMC. According to the base
station, UMMC was on "Drive By" status,
indicating that EMS units "should pass if
possible". The patient was then informed of
UMMC's status as busy, but the patient insisted
on going to UMMC for personal reasons. The
HFD crew was not able to enter the emergency
room, as the doors would not open. The HFD
crew and the patient waited in the parking lot for
several minutes attempting to gain access. FD79
stated he eventually was able to speak to the
house supervisor (S121). The house supervisor
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(S121) stated the crew would have to wait two to
three hours due to the emergency room being
busy. FD79 stated he then called the HFD
Medical Director and got approval for transport to
a different hospital.
Record review on 12/19/2021 at 11:50AM of the

UMMC ED Central log for August 22 & 23, 2021,
failed to reveal documentation of registration of
P15.
Record review on 12/20/2021 at 09:45AM of the

UMMC facility ED Central log for August 15, 16,
&17, failed to reveal documentation of registration
of P59
Record review of UMMC policy titled "Emergency

Medical Treatment & Active Labor Act
(EMTALA)", last reviewed 04/19, showed:
-the hospital shall provide a medical screening

exam (MSE) by qualified medical personnel for
every patient who comes to the emergency
department and makes a request for examination
or treatment of a medical condition;
-an MSE shall also be conducted when a request
is made on behalf of an individual, even if the
person requesting the exam is not the individual's
legally authorized representative.
Record review of UMMC policy titled "Diversion

Policy" last reviewed 04/19 showed:
-All patients presenting to the Emergency
Department will be medically screened and
evaluated regardless of the hospital's drive-by
status.
A2406 MEDICAL SCREENING EXAM A2406
CFR(s): 489.24(a) & 489.24(c)
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(a) Applicability of provisions of this section.

(1) In the case of a hospital that has an
emergency department, if an individual (whether
or not eligible for Medicare benefits and
regardless of ability to pay) "comes to the
emergency department", as defined in paragraph
(b) of this section, the hospital must-
(i) Provide an appropriate medical screening
examination within the capability of the hospital's
emergency department, including ancillary
services routinely available to the emergency
department, to determine whether or not an
emergency medical condition exists. The
examination must be conducted by an
individual(s) who is determined qualified by
hospital bylaws or rules and regulations and who
meets the requirements of §482.55 of this chapter
concerning emergency services personnel and
direction; and
(ii) If an emergency medical condition is
determined to exist, provide any necessary
stabilizing treatment, as defined in paragraph (d)
of this section, or an appropriate transfer as
defined in paragraph (e) of this section. If the
hospital admits the individual as an inpatient for
further treatment, the hospital's obligation under
this section ends, as specified in paragraph (d)(2)
of this section.
(2)(i) When a waiver has been issued in

accordance with section 1135 of the Act that
includes a waiver under section 1135(b)(3) of the
Act, sanctions under this section for an
inappropriate transfer or for the direction or
relocation of an individual to receive medical
screening at an alternate location do not apply to
a hospital with a dedicated emergency
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department if the following conditions are met:
(A) The transfer is necessitated by the
circumstances of the declared emergency in the
emergency area during the emergency period.
(B) The direction or relocation of an individual to
receive medical screening at an alternate location
is pursuant to an appropriate State emergency
preparedness plan or, in the case of a public
health emergency that involves a pandemic
infectious disease, pursuant to a State pandemic
preparedness plan.
(C) The hospital does not discriminate on the
basis of an individual's source of payment or
ability to pay.
(D) The hospital is located in an emergency area
during an emergency period, as those terms are
defined in section 1135(g)(1) of the Act.
(E) There has been a determination that a waiver
of sanctions is necessary.
(ii) A waiver of these sanctions is limited to a
72-hour period beginning upon the
implementation of a hospital disaster protocol,
except that, if a public health emergency involves
a pandemic infectious disease (such as pandemic
influenza), the waiver will continue in effect until
the termination of the applicable declaration of a
public health emergency, as provided under
section 1135(e)(1)(B) of the Act.
(c) Use of dedicated emergency department for

nonemergency services. If an individual comes to
a hospital's dedicated emergency department and
a request is made on his or her behalf for
examination or treatment for a medical condition,
but the nature of the request makes it clear that
the medical condition is not of an emergency
nature, the hospital is required only to perform
such screening as would be appropriate for any
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individual presenting in that manner, to determine
that the individual does not have an emergency
medical condition.
Based on interview and record review, UMMC
Tidwell location failed to provide a medical
screening exam (MSE) to patients transported to
the facility by ambulance on 8/16/2021 &
8/22/2021 (P59 & P15). Both patients were
subsequently transported to Hospital A
Emergency Department (ED).
Findings include:
During a telephone Interview on 12/19/21 at

12:10PM with the Houston Fire Department
(HFD), supervisor (FD79), FD79 stated his crew
arrived at UMMC Tidwell location on 08/16/2021
at approximately 11:00PM. HFD crews, per their
policies, had called ahead to the emergency
medical services base station and inquired as to
the "status" of UMMC. According to the base
station, UMMC was on "Drive By" status,
indicating that EMS units "should pass if
possible". The patient was then informed of
UMMC's status as busy, but the patient insisted
on going to UMMC for personal reasons. The
HFD crew was not able to enter the emergency
room, as the sliding glass doors were locked.
FD79 stated his crew was met by a UMMC staff
member. The UMMC staff member told the HFD
crew that UMMC was on divert and had no staff
and no beds. The UMMC supervisor also came
out to the ambulance and told the HFD crew that
they would not be allowed in and must wait in the
parking lot. The UMMC supervisor then closed
the emergency room doors and walked away.
The HFD crew and the patient waited in the
parking lot for several minutes while they
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continued their attempts to gain entry to the ED.
The sliding glass automatic door remained
locked.
FD79 stated his crew called him to the scene for
assistance. Upon arrival to UMMC, FD79
attempted to enter the emergency room
department doors, which were locked. FD79
stated UMMC staff would not allow him to enter
the UMMC ED either. After a period of time, FD79
stated that someone who appeared to be a
UMMC staff member entered the facility via a
door, and he stated "I was able to sneak in
behind that person in order to get into the facility."
FD79 said he then walked into the emergency
room, to the front desk. There was no one at the
front desk. He also observed the waiting room
was empty. He proceeded further down the hall
and encountered a staff member. FD79 inquired
as to who was the charge nurse on duty. FD79
stated the staff member replied "They are
working." "I thought we were on saturation."
"There are only two nurses." FD79 stated, he
eventually was able to speak to the house
supervisor S121. The house supervisor S121
stated the crew would have to wait two to three
hours due to the emergency room being busy.
FD79 stated he then called the HFD medical
director and got approval for transport to a
different hospital. Over 30 minutes of time had
elapsed during the crew's attempts to gain
access to UMMC's emergency department.
Record review of the Patient Care Report (PCR)

from Houston Fire-EMS (an official report and
transcript of a patient encounter) dated August
16, 2021 for P59 showed:
"Telemetry contacted for transport to United
Memorial Medical Center with a 3 min eta.
Telemetry responded with ER sat [sic] and
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diversion, as with every other local hospital.
Situation was explained to patient and patient
stated she still wanted to go because she has no
transport, and it is within walking distance."
"Patient was assisted to front entrance ....where
crew was met by nurse. Nurse stated to crew and
patient that UMMC was on divert and also had no
beds and no staff. Crew asked nurse if they are
denying care to which she replied she is getting
her supervisor."
HFD Supervisor was then contacted.
"Dr. approached at ambulance and stated the

same as nurse and told crew he can't allow us to
come in, but wait outside and cannot guarantee a
bed for patient, and would not let anyone in to
triage pt. Dr. was asked if he is refusing care,
which he closed doors and walked away"
HFD supervisor spoke to UMMC then to HFD

medical director.
"Crew was advised to transport patient to Hospital

A being next closest ER. Patient was secured
again on bench and transported to Hospital A.
Patient was triaged in ER and taken to waiting
room."
FD79 provided an audio recording of the

emergency room encounter on 8/16/2021.
Recording summary:
FD79 heard saying "Hey! You work here? They

wouldn't let them in. So I was in the area and they
called me." "Hi sir are you the charge nurse?"
An unknown male voice responded with "No".
FD79 then asks "Where is the charge nurse?"
The unknown male voice responded with "They
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are all working."
FD79 responds with, "We have an ambulance
outside and they just called me to see if ...they
are outside and they weren't being let in. They
just told me to see if I can find out what was.."
The unknown male voice responds, "We are
short of staff. We have only two nurses and then
we are swamped with patients from the day shift
and then at this time also. I thought we are on
saturation .....we are two nurses so I don't know
who see the patient."
FD79 is heard saying, "We just need to know if
you are going to accept the patient or not accept
the patient."
The unknown male voice responds, "We are not
refusing ...."
FD79 asks "Who is in charge then? You are."
Male voice: [inaudible words] " We or us"
FD79: "So whoever the charge nurse is, we need
to know if you are accepting the patient or not
accepting the patient."
Male voice: "We need time!" [inaudible words]
FD79: "No sir, but we can't sit in your parking lot."
Male voice: "I know, so who is going to take care
of that there?" ..... "You can talk to the
supervisor."
FD79: "That's who I want to speak to. The
supervisor. Who is that?"
Male voice: "I don't know. He's now in Covid. But I
cannot make the decision."
FD79: "You don't know who the supervisor is?"
Male voice: "No, I know who the supervisor is."
FD79: "I'm just trying to find out if we need to go
to a different hospital. Is someone getting the
supervisor?"
[inaudible words]
Different Male voice responds: "I already talked to
them."
FD79: "But that was them. They called me, which
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I'm their supervisor because they didn't get an
answer apparently. So now they called me out
and I want to talk to the supervisor, if that is
possible."
FD79: "Ok but who is the supervisor? Can you
get them, please?"
[several inaudible words]
FD79: "You have a waiting room for patients?"
[several inaudible words]
FD79: "Hi How are you doing? I'm the supervisor
for the area and they tell me you are the
supervisor."
Different male voice: "Yes"
FD79: "I'm just a messenger, I know you guys are
super busy. My ambulance called me out. I was in
the area because they said they weren't allowed
to come inside and they have a patient in the
parking lot. So we just want to know if you are
gonna accept the patient or not accept the
patient."
UMMC supervisor male voice: "We are saturate.
We not saying yes or no. If the ambulance can
wait two or three hours until we get chance. They
are all busy. Saturated by now. If the ambulance
gonna wait ....if they gonna wait 2 or 3 hours ....."
Unknown female voice: "They have to wait! We're
not denying nobody.."
UMMC male supervisor: "We are super busy!"
FD79: "At hospitals we don't sit in the parking lot.
They let us come inside."
Unknown female voice: "Then they start to be our
responsibility!"
FD79: "Are you the supervisor?"
Unknown female voice: "No!" [inaudible words]
FD79: "Well thank you. I tried to talk to you
earlier." [inaudible words]
Unknown female voice: "Cause what I said is
true?"
FD79: "Cause you didn't want to talk to me
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earlier!"
Unknown female voice: "I'm not the supervisor!
Like you're just mad."
UMMC male supervisor: "If they gonna wait ...in
the next 2, 3 hours, nobody. They're super busy."
FD79: "I understand sir, but we deal with 15
different hospitals and no hospital makes our
units wait outside. They have waiting rooms. And
I saw your waiting room had one person in it! So
either you accept or you don't accept and we
leave and go to a different hospital and I'll have
my medical director call you guys again."
UMMC male supervisor: "We not say we don't
wanna accept now, except the ambulance is
gonna wait at least 2 hours."
FD79: "If they are gonna get a bed, I'll have them
wait a little bit."
UMMC male supervisor: "I can't guarantee you
that now. This is a Covid hospital. We are super
busy. You see us on tv all the time."
FD79: "I just want to know what y'alls policy is on
waiting because is there a way they could wait
inside? Do y'all have a lobby for someone like
that?"
UMMC male supervisor: "If they are gonna stay
here for 2-3 hours. [inaudible words] No one will
see this patient."
FD79: "The problems we keep having I'll be
honest with you, is my guys call me, like cause
they felt they are locked out cause they are out in
the parking lot .... So they feel like they are
locking the doors and not letting us in, so that's
the cause of the conflict."
UMMC male supervisor: "If they wanna come in
stay here ...in the next 3 hours the way it look like,
nobody gonna take report ...."
During an interview on 12/20/2021 at 10:00AM

with S71, Patient Care Technician, who was on
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staff during the patient encounter, S71 was asked
if he had any knowledge of an issue where a
patient presented to the ER on 8/16/2021 via
HFD and they were asked to wait, the HFD
supervisor came on scene, and the patient was
transported elsewhere due to not being seen by
UMMC staff. S71 said, "I don't remember that
situation at all." When asked if he or someone on
staff spoke to a HFD supervisor, he stated "I don't
remember anyone speaking to a supervisor." "We
see everyone that comes here."
During a telephone interview on 12/20/2021 at

11:42AM with the Houston Fire Department
(HFD) Emergency Medical Services (EMS)
Supervisor (FD80), he stated he was called out to
UMMC to assist his EMS crew. His crew arrived
on scene to United Memorial Medical Center on
8/22/2021 at 12:08pm with a patient to present to
UMMC emergency room. The EMS crew on
scene was told by UMMC ER staff that the facility
was not accepting patients at that time and that
the EMS crew and patient should elsewhere or
wait with the patient for unknown amount of
hours. Upon arrival to the scene, FD80 stated he
observed patient P15 in a wheelchair along with
his crew outside of the emergency room in
between the first and second set of double doors,
"in a breezeway area." FD80 stated "the patient
had not been triaged or registered" and "I asked
to speak to the supervisor." The nursing
supervisor (S121) at the time, came to speak with
FD80 and stated they are not refusing the patient,
but the HFD crew will have to wait with the patient
for about "7 hours". FD80 stated he then called
the HFD medical director and was given the
directive to transport the patient to a different
hospital.
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Record review of the Patient Care Report (PCR)
from Houston Fire-EMS (an official report and
transcript of a patient encounter) dated
08/22/2021 for P15 showed:
"In efforts for continuity of care, M031 (EMS unit)
asked for hospital status and was told "saturation"
by telemetry. M031 transported pt (patient)
non-emergent to UMMC. UMMC refused to
register pt, refused to triage pt, and MD (medical
doctor) states the only option due to ''no beds'',
was for M031 to wait with pt until one became
available. Wait time quoted by MD is 7 hours
approx. M031 called for AS030 (HFD supervisor)
to make location. AS030 made location and was
told the same verbiage [sic] from MD as M031
was. AS030 then called for MD (HFD medical
officer) on call through telemetry for recorded line
purposes. MD at UMMC refused to speak with
any HFD personel [sic] after that and was not
present for remainder of time throughout UMMC.
AS030 was then told by HFD MD on call that it
was in the pts best interest to be transported to a
different hospital."
Record review of PCR from Houston Fire-EMS

Supervisor encounter, dated 8/22/2021 for P15
showed:
"AS030 asked about moving patient the waiting

room. S121 again stated he cannot wait inside
and needs to wait with HFD crew. When M31 first
arrived, M31 stated they were not allowed to
enter the second entry way door. AS030 advised
S121 that M31 will not be waiting for hours with
the patient. S121 turned and walked away.
AS030 asked the staff in the ER if S121 was a
doctor or the charge nurse. Staff stated S121 is
the nurse supervisor and is in charge. There was
absolutely no persons waiting in either waiting
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rooms. AS030 took pictures of the empty waiting
rooms. There were also three rooms with beds
available behind the nurses area down the hall.
AS030 contacted telemetry to be patched through
to online doctor, who was an HFD physician, who
stated he will reach out to the HFD Medical
Director about the incident. The HFD Medical
Director advised AS030 to have another
conversation with the Nurse Supervisor S121.
AS030 talked with the nurse at the nurse's station
and requested to speak with S121. The nurse
called S121 on the phone but stated he was not
answering at the moment and must be on the
other phone line. AS030 waited approximately
another 10 minutes and asked if S121 was
available again. Nurse called a second time and
stated he did not answered (sic), he must be on
the other phone line. AS030 waited another 10
minutes and asked again, if S121 was available.
The nurse called and somebody answered the
phone, however the person on the other line
stated S121was unavailable at the moment.
AS030 asked if there was anybody else in charge
or above S121, ER staff stated he is the only one.
AS030 has been on location for over one hour
dealing with the ER staff while the patient is
sitting in a wheelchair in the entry way. AS030
contacted the HFD physician about waiting 25
minutes with no contact with S121. AS030, M31,
and the patient discussed options about alternate
destinations and/or staying at UMMC."
During an interview on 12/19/2021 at 02:00PM,

with S36, the charge nurse that was on duty on
day shift 08/22/2021, she was asked if she
recalled the situation involving HFD attempting to
present a patient to UMMC emergency room that
day. She stated she did not recall the situation,
and stated "we will never turn anyone away here.
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That is a violation on EMTALA." When asked if
every patient that comes to the ER is medically
screened for an emergency medical condition,
S36 responded, "Yes".
When asked, when a patient arrives to the ED at
a time when the ER is "saturated" meaning it is
extremely busy or if all of the beds are full, what is
done with the patient, S36 explained, "The staff
will ask EMS to stay with the patient, but UMMC
ED staff will immediately start the triage and
registration process at the ambulance. The
patient will go on the ED log and process of
starting a medical screening exam begins. Even
sometimes the physician will go out to the
ambulance to see the patient."
When asked if during a time when the ED is on
divert, and a patient still arrives at the emergency
room for screening, S36 stated they will see the
patient anyway and evaluate for an emergency
medical condition.
During an interview on 12/19/2021 at 02:10PM,

with S70, a staff nurse that was on duty on day
shift 08/22/2021, S70 was asked if she recalled
the situation involving HFD attempting to present
a patient to UMMC emergency room that day.
She stated she did not recall the situation, and
stated "we welcome everyone at any time to our
emergency room."
During an interview on 12/19/2021 at 02:05 pm,

with S78, emergency room physician, he was
asked if at any time would he turn away a patient
presenting to the emergency room to receive a
medical screening exam. He stated at no time
would he turn away a patient. They would all be
seen. When asked what he would do if a patient
presented to the emergency room at a time the
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facility was on saturation or divert or drive by
status, S78 stated "If the emergency room is full
we would try to discharge a patient in order to
make bed space." We will not turn anyone away."
Record review of UMMC policy titled "Emergency

(EMTALA)", last reviewed 04/19, showed:
-the hospital shall provide a medical screening

exam (MSE) by qualified medical personnel for
every patient who comes to the emergency
department and makes a request for examination
or treatment of a medical condition;
-an MSE shall also be conducted when a request
is made on behalf of an individual, even if the
person requesting the exam is not the individual's
legally authorized representative.
Record review of UMMC policy titled "Diversion

Policy" last reviewed 04/19 showed:
-All patients presenting to the Emergency
Department will be medically screened and
evaluated regardless of the hospital's drive-by
status.
A2409 APPROPRIATE TRANSFER A2409
CFR(s): 489.24(e)(1)-(2)
(1) General
If an individual at a hospital has an emergency
medical condition that has not been stabilized (as
defined in paragraph (b) of this section), the
hospital may not transfer the individual unless -
(i) The transfer is an appropriate transfer (within
the meaning of paragraph (e)(2) of this section);
and
(ii)(A) The individual (or a legally responsible
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person acting on the individual's behalf) requests
the transfer, after being informed of the hospital's
obligations under this section and of the risk of
transfer.
The request must be in writing and indicate the
reasons for the request as well as indicate that he
or she is aware of the risks and benefits of the
transfer.
(B) A physician (within the meaning of section

1861(r)(1) of the Act) has signed a certification
that, based upon the information available at the
time of transfer, the medical benefits reasonably
expected from the provision of appropriate
medical treatment at another medical facility
outweigh the increased risks to the individual or,
in the case of a woman in labor, to the woman or
the unborn child, from being transferred. The
certification must contain a summary of the risks
and benefits upon which it is based; or
(C) If a physician is not physically present in the

emergency department at the time an individual is
transferred, a qualified medical person (as
determined by the hospital in its bylaws or rules
and regulations) has signed a certification
described in paragraph (e)(1)(ii)(B) of this section
after a physician (as defined in section 1861(r)(1)
of the Act) in consultation with the qualified
medical person, agrees with the certification and
subsequently countersigns the certification. The
certification must contain a summary of the risks
and benefits upon which it is based.
(2) A transfer to another medical facility will be

appropriate only in those cases in which -
(i) The transferring hospital provides medical
treatment within its capacity that minimizes the
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risks to the individual's health and, in the case of
a woman in labor, the health of the unborn child;
(ii) The receiving facility
(A) Has available space and qualified personnel
for the treatment of the individual; and
(B) Has agreed to accept transfer of the individual
and to provide appropriate medical treatment.
(iii) The transferring hospital sends to the

receiving facility all medical records (or copies
thereof) related to the emergency condition which
the individual has presented that are available at
the time of the transfer, including available
history, records related to the individual's
emergency medical condition, observations of
signs or symptoms, preliminary diagnosis, results
of diagnostic studies or telephone reports of the
studies, treatment provided, results of any tests
and the informed written consent or certification
(or copy thereof) required under paragraph (e)(1)
(ii) of this section, and the name and address of
any on-call physician (described in paragraph (g)
of this section) who has refused or failed to
appear within a reasonable time to provide
necessary stabilizing treatment. Other records
(e.g., test results not yet available or historical
records not readily available from the hospital's
files) must be sent as soon as practicable after
transfer; and
(iv) The transfer is effected through qualified

personnel and transportation equipment, as
required, including the use of necessary and
medically appropriate life support measures
during the transfer.

Based on medical record review, interview, and
review of the facility's policy, the facility failed to
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ensure the Emergency Department (ED) provided
an appropriate transfer to two of two ED patients
requiring transfer to a higher level of care (P23
and P24), by providing written risks and benefits
and patient signature related to the transfer.
Failure to provide an appropriate transfer to a
higher level of care as needed could lead to
negative patient outcomes for all patients
presenting to the ED.
Findings include:
Review of the facility's policy titled, "Emergency

(EMTALA)," last revised 06/17, revealed, "The
individual may be transferred ...with physician
certification if a physician ...has documented in
the 'Physician Certification' section of the
Memorandum of Transfer, Part 2 for that based
upon the information available at the time of the
transfer, the expected medical benefits from
transfer outweigh the risks and include a
summary of the risks and benefits on which it is
based ...The hospital shall notify the individual
...both orally and in writing, of the transfer and the
reasons therefore. An acknowledgement of such
notification shall be obtained by asking the
individual ...to sign the appropriate section of the
'Addendum to Memorandum of Transfer" form."
Review of P23's medical record "Emergency

Physician Record," revealed P23 presented to the
facility ED on 11/01/21 with "Difficulty Breathing."
Following a medical screening exam (MSE), the
physician made the decision for transfer of P23 to
a higher level of care. Review of the "Physician
Certification" revealed, "The following risks and
benefits of being transferred have been explained
to the individual:" was blank. No document titled,
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"Addendum to Memorandum of Transfer"
containing P23's signature was found in the
record.
Review of P24's medical record "Emergency

Physician Record," revealed Patient 24 presented
to the facility ED on 09/08/21 with "Shortness of
Breath." Following a medical screening exam
(MSE), the physician made the decision for
transfer of P24 to a higher level of care. Review
of the "Physician Certification" revealed, "The
following risks and benefits of being transferred
have been explained to the individual:" was blank.
No document titled, "Addendum to Memorandum
of Transfer" containing P24's signature was found
in the record.

AM, the above medical records were reviewed.
S40 confirmed the physician failed to document
the risks and benefits of the transfer and failed to
obtain signatures of P23 and P24 acknowledging
understanding of those risks and benefits on the
Physician Certification.

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PRINTED: 01/07/2022

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

A 000 INITIAL COMMENTS A 000

An unannounced full federal survey was

The purpose, scope, and process of the full

United Memorial Medical Center (UMMC) has

In addition, three (3) complaints intakes were

Deficient practices of the following Conditions of

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

A 000 Continued From page 1 A 000

The facility was previously cited 01/08/21 for

On 12/19/21 at 11:09AM the interim CEO was

A 000 Continued From page 2 A 000

The following Conditions of Participation were

42 CFR 482.12 Governing Body

The following Emergency Medical Treatment And

There must be an effective governing body that is

This CONDITION is not met as evidenced by:

A 043 Continued From page 3 A 043

2. Quality Assessment and Performance

A 043 Continued From page 4 A 043

3. Pharmaceutical Services: Based on

A 043 Continued From page 5 A 043

5. Surgical Services- Based on observation,

A 043 Continued From page 6 A 043

A 043 Continued From page 7 A 043

The hospital must develop, implement and

The hospital's governing body must ensure that

A 263 Continued From page 8 A 263

The hospital must maintain and demonstrate

This CONDITION is not met as evidenced by:

1. Failed to ensure that policies and a plan of

2. Did not ensure that pharmaceutical services

3. Did not ensure that performance improvement

4. Did not ensure that competency and clinical

5. Did not ensure that the hospital's review of

A 263 Continued From page 9 A 263

7. Failed to implement performance improvement

(b) Program Data

(c) Program Activities

(3) The hospital must take actions aimed at

This STANDARD is not met as evidenced by:

A 283 Continued From page 10 A 283

2. A federal survey conducted by the state survey

3. The hospital failed to ensure this plan was

A 283 Continued From page 11 A 283

4. Interview with S103 and S102 on 12/19/2021 at

5. The hospital QAPI priority grid included a

6. The hospital failed to ensure six of six (S114,

A 297 Continued From page 12 A 297

(1) The number and scope of distinct

This STANDARD is not met as evidenced by:

A 297 Continued From page 13 A 297

2. The hospital failed to ensure six of six (S114,

3. Review of Practitioner S114's delineation of

Review of Practitioner S115's delineation of

Review of Practitioner S116's delineation of

A 297 Continued From page 14 A 297

Review of Practitioner S117's delineation of