07/25/2014

17:04

8174042252

MILLWOOD QI

PRII· T: . 1:1: 07/17/2014
DEPARTMENT OF HEALTH AND HUMAN SERVICES
F ·: ~".I\!1\PPROVEO
~C:.sE~NT
E::!R~SwF:.::O:!.!:R~M!!!E;;.!;D!.!.:IC~A;l!R.!!!E~&i!!..,;M~ED!:!.!l~Co:AI~D~S~E..wR~V.!..!!!lC~E~S---""T""-----~------~--;OFMJi
J: !];,.,Q_938-0391
11
STAT~MENT OF DcFICIE~ICir.s
ANO Pt.AN OF CORRECTION

(X3) I lii'E 131JRVEY

(X2) MULTIPLF. CONSTRUCTION

(X1) PROVIDF.R/SUPPLIER/CI.IA

IDENTIFICATION NUMBER:

: .),,I'I'L.I!T!::O

A. aUILDING_~------

,,

( ,,

l---:-~~:-"""":"':'~::::-:::::--L---_:4~S~40~1~2----..J..::_:·wt=NG;::=::~:::;:::;~~====-==-::::~--..L-.•. ~::::!~!!l/2014
8

STRE.~T AQPRESS,

NAME OF PROVIDER OR SUPPI,IER

CITY, STATE, ZIP CODE

1011 NORTH COOPeR STREET

MILI..WOOO HOSPITAl.
(X4) 10

PREFIX
fAG

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ARLINGTON, T:X 7G011
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SUMMARY ST/\Tr.MENT OF DF.FICIENCIES
(EACH O~FICIENCY MUST BE PRF.CEDEO BY FUI,L
REGULATORY Ort LSC IDENTIFYING INFORM/\TION)

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A 000 INITIAL COMMENTS

I Note: The CMS-2567 (Statement of Deficiencies)
is an official, legal document All information must
remain unchanged except for entering the plan of
correction, correction dates, and the signature
space. Any discrepancy in the original deficiency
I citation (s) will be reported to the Dallas Regional
. Office (RO) for referral to the Office of the
Inspector General (010) for possible fraud. If
information
Is inadvertently changed by the
1
provider/supplier, the State Survey Agency (SA)
should be notified Immediately.

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PREFIX
TAG

PROVIDF.R'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SI·IOULO BE
CROSS-Rer-ERENCED TO TI-lE APPROPRIATE
OEFICIENCY)

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COMPLETION

DATE

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SIJbmisslon of this plan of correction
is not an admi~!;lion by the hospital
that the citation~ are correct or that
tM hospital violated the rules.That
said, a special meeting was held with
members of Administration and
Leadership upon receipt of the Centers
for Medicare and Medicaid Statement of
Oefic:iencles. The report was
discM~sed and a course of action was
developed.

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An unannounced investigation of complaint TX
· 00199217 was conducted onsita. An entrance
I c:onfert~nce was held on the evening of 07/06/14
. with the House Supervisor. The hospital
representative was Informed that this
investigation would be conducted according to the
survey protocol in the State Operations Manual,
Chapter 5, section 5100 and Appendix A, and
Olccording to 42 CFR 482 the Conditions of
Participation for Hospitals. The applicable survey
report form was applied.
Survey findings were presented at an exit
conference on the evening of 07/09/14 with the
Chief Executive Officer and ather designated staff
members. The hospital representatives were
informed Complaint TX 00199217 was
substantiated and deficiencies were cited. An
opportunity was provided for the facility to provide
evidence of compliance with those reCjuirements
for which non"compliance was found. None was
provided to the surveyors
A 3921482.23(b) STAFFING AND DELIVERY OF CARE

I The n1~rsing service must have ade(luate

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LABORI\TORY DIRECTOR'S OR PROVIDER/SUPPLIER RF.PRESENTATIVE'S SIGNATURF-

3921
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A392

The DON reviewed the current pi'Oeesses for
determinil1g and assigning of staff to Psychiatric
Intensive Cata Unit along with the 4 other units .....,_, - .......- - - '
TlflE

j.>lG) OATil

---1-~~'..11!~~=---~--~--=C:.!...F0~-~--··. 2::2~-H

Any deflcir,.ney !It em nt end " with an ~~teJ'IBk (") denotes " dNiclency which the institution m;;~y be excused from corroellng providing It Ia dotf,)rmlned that
other Gafe!~Uiilrda provide suflielent protection to the patients, (See Instructions.) c:xeapt for nursing homes. tho flndlngs stated above are dl~closable 90 dayl
followinQ tho dll1e of survey whether or not a plan of c~m·e<;tlon I~ provided. For nur~ing home~, the above flMinQ$ and plans of c:orreetion are dlscloseble 14
days fOifowlnQ ttle date these doeumont!:l are made eve1il!\blo to tl1e facility. If defieienciC$ are cited, an approv{d plan of correction is requisite to continued
program pertJc.lpatlon.
FORM CMS-2557t02-99)

PIOVIOU8

Versions ObooiAln

Evon! ID; EOIU11

 07/25/2014

17:04

8174042262

MILLWOOD

J,:.,.:c 08/11

QI

PRIN' 1; r:) •)7/1712014
DEPARTMENT 01~ HEALTH AND HUMAN SERVICES
!=•: ~! 11,1 1!•,PPROVED
~C~E.JNT.!..!E;;~.R~Su.F~O:.~.;RuMu.!E:.!!D!.!:IC~A;I.l.R.:,:,E....::&~M~E!!olD~I.:::.CA:;.::Iu.::D~S~E!l..:R~VI:.:=C~E~S---.,...---------------iO:.!..!M.!!':E,~. ::JG:~.•9936-0391
STATEMENT OF OEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDE:A/SUPPLIERICLIA
IDENTIFICI\TION NUMBF.R.

(X2) MULTIPLE CONSTRUCTION
/1, BUILOING _ _ _ _ _ _ __

(X3)

[1 •

:rr• !i•liRVEV

CI·I~I'Lii'reo

~----~..,....---~~=--L____:4:6:40::,:1~2----_J_:B.:_:·WI=NG:..r:~~:::::::::;;;:::::::::=::;:~------~--.J_-· ;!: :'.:9:~~1.-12...01...4..._-;
NAMF. OF PROVIDER OR SUPPLIER

STREET ADOAESS, CITY, STATE, ZIP CODIO
1011 NORTH COOPER STREET

MILLWOOD HOSPITAL

A~LINGTON,

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A 3921 Continued From page 1
numbers of licensed registered nurses, licensed
practical (vocational) nurses, and other personnel
to provide nursing care to all patients as needed.
There must be supervisory end staff personnel for
each department or nursing unit to ensure, when
: needed, the immediate availability of a registered
nurse for bedside care of any patient.
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A3921

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' This STANDARD is not met as evidenced by:
Based on interview and record review the
I hospital failed to ensure 1 of 5 units PICU

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(Psychiatric Intensive Care Unit) was adequately
staffed based on patient needs from 07/03/14
. throug11 07/07/14.

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I Findings Included:

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(Patient #4's) pre-admission exam dated
06/22/14 timed at 2145 reflected, "Fiatient has
been previously diagnosed with bipolar disorder
and is currently In a manic episode ... auditory
hallucinations and is fixated on Voodo ... homicidal
ideations towards mother, paranoid and has not
slept lr, three days ... "

TX 76011

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A392

including
• high ri&l< needs
• level$ of observations
-on going patient care as$(!$&ments.
·"Supervi~;~ory Report" Policy# 1200.117
·Patient Care Assignment" ; Polley ff. 1200.112
·"Nursing Assignments" ; Polley# 1200.211
-''P~;~tient Reassessment";
-"The Nursing Plan of Care for -2014";
-Texas Saf-e Staffing Act 2009;
·Policy# 1200.111 " Methods oF Determining
Education Needs";
- Polley # 1200.130 "Chain of Command"
The DON will be revising the l.eval of Observ<l , lll
Polley to Incorporate higher levels of observati• 1
for patient safety oversight.
i[18/15f2014
This revised policy will be presented to the Me.••: t:J·I
Staff Committee for approval at the next meetl11 ·I
08/15/2014
The DON determined that dally oenaus and b;;1: ''' irlt.!
acuity necessitated adjustment of the staff to
patient ratios to accommodate the increasing I,
higher acuity in the patients requiring admisslo1 1'·'
the Intensive care unit and acute care psyclll 1 r
inpatient admissions.
l'il7/17/2014
The DON Is developing an acuity toot to furth•~ ~
augment stafflng based on teeommendations ·1 ·:, n

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the Nursing Advisory Committ~:~e and the new·
amended Level of Observation ~ollcy.
·
~18/10{2014
The DON/Designee will educate the direct
c:are RN nursing staff on the use of the new ac li
tool and revised "L.evel of ObsetVation " polic\
via nurses In-service$, validated by sign in ah~ 1 •U . 08{15/2014

The physician's orders dat@d 07/01/14 through
07/07/14 reflected, "Line of sight while awake."

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The nursing progress note dated 07103114 timed
at 1600 reflected, "Patient anxious and pacing the
hallways ... "

The DON/Designee will monitor variances
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daily, adjust levels where needed, and report I :1 1 ''tl
Senior Management Team and PI Committee
08/15/2014
monthly.
Variances will be reported Nurae Starr Advise·•!
Committee end Governing Board Quarterly s . 11' :in•11
with the next scheduled meeting.

The nrJrsing progress note dated 07/04/14 timed
0700 to 11 00 reflected "Patient exhibiting
increased anger... at 1800 remains on LOS (Line
of Sight) while awake ... patient changes clothes
. multiple times during the shift wee ring
inappropriate clothing.,, she is oppositional and
defiant..."
~------~----------------------~------··.
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FORM CMS.;1,5B7(02·99) l"revlous V;>r~IQnr. Ob&OI&le

F.v~'>~IID:

EOIU11

l'~clllly

ID: S1 0454

l
···-··--..__..
of

11 continu~: :ll', c;l'11let F'age 2

5

 07/25/2014

17:04

8174042252

MILLWOOD QI
PRINi [I); 1)7117/2014
FC 1';1/II~,PPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES

~C~E;L,:N.,.wTE!::.!R~S~F!..lO.:.:R..l..l.t:M:.!!!E~D!.:::IC:.:;,A~R:.=E~&4M::!!E::.tD~IC:::::A~I~D;..:,S::::E:.:.:R~V.:.:;IC:,::E.:.1::S:........_ _-r_--~-----------~O~M~B. ~j;;~"J;1938-0391
STATEM!ONT OF DEFICII!NCIES
AND PLAN OF CORRIOCTION

(X1) PROVIDERISUPPI.IER/CLIA
IDI>.NTIF'ICATION NUMeER:

(X2) MUI.TIPLE CONSTRUCTION
A, F.!UILDING _ _ _ _ _ _ __

(X3)

c, ,r ' £.1.1RVIOY
c: M~ll_5;!-eo

1-------------'----~_:46::,:4::0_::12:______J..:e::.:,IM:.:::.:NG:;:::=======::..------.L-•. ~;~~!~l!!r.;;;.20.:...1._4_--4
NAMF. OF PROVIDF.R OR SUPPLIF.R

STREET ADDRI!SS, CITY, STATE, ZIF' COOl:

1011 NORTH COOPI!R STREET

MILL.WOOD HOSPITAL
(X4) 10

!"REFIX
TAG

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ARLINGTON, TX 76011

SUMMARY STATEMENT 01' DEFICIF.NCI!!S
lEACH DIOFICIENCY MUST BE PAECF.OEO BY F'ULL
REGUI./\TOAY OR LSC IDENTIFYING INFORMATION)

10
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A 3921 Continued From page 2

PREFIX
TAG

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A3921

I 0915 reflected, "Pressured speech, disorganized

The 07/05/14 nursing progress note timed at

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PR0VID5R'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SI;OULO ElF.
CROSS-ReFERENCED TO TI1E APPROPRIATE
OEFICIF.NCY)

The PICU staffing records for 07/03/14 through
07/08/14 reflected the following:

IX&)
1:0M~L~TION

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11) The staffing for 7 AM to 3 PM on 07/03/14
reflectad, 1 RN and 1 MHT for 12 patients and

I one LOS (line of sight) for (Patient #4).

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12) The staffing for 7 AM to 3 PM on 07/04/14

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reflect1;1d, 1 RN and 1 MHT for 14 patients, and
one LOS for (Patient #4).

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I5) The staffing for 7 AM to 3 PM on 07/07/14

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3) The staffing for 7 AM to 7 PM on 07/05/14
reflected, 1 RN and 1 MHTfor 13 patients, end
, one 1.0$ for (Patient #4 ). Eight of the 13 patients
were an suicide precautions, 6 of the 13 were on
fall precautions and three patients were on
aggression precautions.

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4) The staffing for 7 AM to 7 PM on 07/06/14
I reflected, 2 nurses and 1 MHT for 17 patients and
one LOS for (Patient #4). Nine ofthe 17 patients
were on suicide precautions, 6 on fall
precautions, 3 on aggression precautions and
three admissions.

reflected, 2 nurses, 2 MHT's for 20 patients and
LOS for (Patient #4). Nine of the 20 patients
Ione
were on suicide precautions, seven on
I aggression precautions and two on fall
precautions.

16) The staffing for 3 PM to 11 PM on 07108114
1

reflected, 1 RN. 1 L.VN and 1 MHT for 19 patients.

FORM CM$-2557(0~-99) PreviOliS Vlor>ion~ Ob&olet"

F.v~~~

ID; EDIU11

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~acllity

I
ID; 6H)454

If continue! •:• 1 :~i'l•l!el l"age 3 Of S

 07/25/2014

17:04

8174042252

MILLWOOD QI
PRII\I, 1;;:1: 1.17/17/2014
FCI ·;:1~1 .~II~PROVED

DEPARTMENT OF 1-IEALTH AND HUMAN SERVICES

,......l::C:l=E~Ni.l.TEl;;,IR~S~FO,.:,:R~M:,!:::E~D.:.liiC::;;A::.,:R~E..!:&1M:.:.:E-.lD:ai:::.CA~I~D;,.::S~Eo!.R:.:.V~IC~E.:.S~--"""T"----------------TO;:,.:;M=B.I :!::~•.!~!938-0391
STATEMJONT OF DF.FICIENCIES
AND PLAN OF CORRECTION

(X11 PROVIDERISUPPLIERICIJA

(X2) MULTIPLE CONSTRUCTION
A. F.lUILOING _ _ _ _ _ _ __

IDENTIFICATION NUMBER:

r; :3\JI~vev
C:•:•,I'Ui'IED

(X3J D'

..."•
~

~-~--------_!
NAMF. OF PI'I.OVIOER OR SUPPLIE:R

_____:454~0::;12~----J..:f.\::.:,WI::.:N:G:;::========:__-----_j--! t:i!~~!!.-20.;..1;...4::_.._--1
STr:!EET ADDRESS, CITY, STATF., ZIP CODF.

1011 NORTH COOPER STRJ:ET

MILL.INOOP I'IOSPITAL
(X~J 10
PREFIX
TA~

ARL.I!IIGTON, TX 78011

suMMARY STATEMENT or. DEFICIENCIES
{IOACH DEFICIENCY MUST BE PRECEDED BY FULL
FtEGULATORY OR I.SC IDE:NTIFYING INFORMATION)

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F'RF.i=IX
TAG

PROVIDEF!'S PLAN OF CORRF.CTION
(EACH CORRECTIVIO ACTION SHOULD BF.
CROSS·REFERF.~~;~~~~~6~E APPROPRIATE

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(XS)
:;oMP~eTION

OATE

~---~---~--~-----+---!-------~ . . )..- - - - 1
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A 3921 Continued From page :j

I The unit had two discharges and two admissions.
Thirteen of the 19 patients were medically

I compromised, seven falls and four on aggression
I precautions.
On 07108/14 at 2225 Personnel #7 stated the
staffing on the PICU Unit was not adequate for
' the acuity of tl1e patients and the number of
nurses and technicians. Personnel #7 stated the
current unit census was 19 patients with one LVN
(Licensed Vocational Nurse), one RN (Registered
• Nurse) and one MHT (mental health technician).

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IOn 07/08/14 at 2245 Personnel #11 was

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· interviewed. Personnel #11 stated he makes
rounds on 19 patients. Personnel #11 stated the
nursing staff are busy passing medications,
charting, answering the phone, discharging and
admitting patients. Personnel #11 indicated tile
staffing on the PICU Unit was not adequate for
the acuity of the patients. Personnel #11 stated at
times one technician was responsible for 15
minute rounds and LOS observation at the same
time.

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On 07/09/14 at 1330 (Patient #8) was interviewed
on the PlCU Unit (Patient #8) stated there wa:s
not enough staff on the unit (Patient #8) stated
patients have to wait for the staff and there are
tim!!:S the staff do not check on the patients every
fifteen minutes. (Patient #8) stated the nurses are
so busy in the office doing paperwork and
medications t~ey spend minimal time with the
patients. (Pattent #8) stated there are times :she
did not feel safe.

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A392i

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Tho """'"" Plan of Care for 2014 "'fteoted,
"Scheduling and program assignment ot nursing
1 personnel is anticipated and based on the
=~=-~--~---~----'---.L.....------~--·-·
fORM CMS.25B7(02·911) .. r<lvloll' Vors1011a 0Dsoleto;o

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Evont 10: EDIU1'1

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ID!

~10454

If eentlnust, '" ll'l~l)t Page 4 of 5

 07/25/2014

17:04

8174042252

MILLWOOD QI
PRIN"" : > <:711712014
F(, ~ 111l,ii'PROVED

DEPARTMENT 01~ HEALTH AND I-lUMAN SERVICES

,.......:.C:,!!oE!.l'.l'.fT.:..::E..:.R~S:.:.F..;:;O:,:.;Rw.M:.:.lE-::D"-"IC""'A~R.:.:E,__:,&~M;.:.:E=.lDo!.!I~CA..:.:I:::<D...::S:.:.E.:..::RV,:!.21~C~E;:;:.S~-~"P!"""------~--~---~-rO:.:.:M~B ! i! ;~:.Qi~38-0391
SIATEMENT OF DE~ICI!;!NOIES
ANO PLAN OF cORRF.CTlON

(X1) PROVIOF.RISUI"PI.IER/OLIA

(X2) MULTIPLE CONSTRUCTiON
A. BUILDING _ _ _ _ _ _ __

IDENTIFICATION NUMBF.R:

r" i! .1'111/EY
CI:,II"L.l:1'EO

()(3) D!

1------~-~--L_____..::4~54:D~1~2-~--_J_:B·_:VVI:N::G:;::::::::=::::=====------L-I !JI!~'!~[;;;;20;...:1...;.4_,.....oj
STRI!!EI ADDRESS, CITY, STATE, tiP COD!:

NAME Of; PROVIDER OR SUPPLIER

1011

MILLWOOD I-IOSPJTAI.
(XI\) ID
PREFIX
TAG

1

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NO~lH

COOPER ST'REET

ARLINGTON, TX 76011

SUMMARY STATEMF.NT OF OF.FICIENCir.s
(EACH DEFICIENCY MUST BE PRECEOEO BY FULl
I~EGULAIORY OR LSC IDENTIFYING INFORMATION)

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TAG

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· · . r···

:;>ROVIDEF\'S PLAN OF cORRECTION
(EACH CORRECTIVE ACTION SHDULO ElF.'
CF\OSS·REFERr.NCED TO THE APPROPRIATE
DEFICIF.NCY)

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~---~~~~--~----------1-i----~---~---------A 3921 Continued From page 4
I identified n®eds ofthe patient population ... mal<.e
appropriate adjustment in the number and blend
of nur!ling care personnel to ensure delivery of
care ... variables considered in staffing .. level of
patient assessment, level of assessment
1 required, census. input from nursing staff
members ... patient responses to treatment.."

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'--~-......._-----~--------------!..------------···
FORM

CMS-~567(02·M) Provlousl/ar.;)O~~ Dbeolat~

....!-···----1

A 3921

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Communication" with a
revision date of 05/13 reflected, "Any patient
I placed on an advanced level of observation ... line
of sight... patient remains within visual eyesight of
staff... patient's bedroom door will remain locked,
I when not in use, when patient changes, showers,
I uses bathroom, the staff will keep the patient
within line of sight at all times ... the safety of the
I patient must be the main consideration ... "

()(5)

·::oMPLETION
01\'TI!

Event ID: EDIU11

FBclllty 10, 81Cl'154

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!iti~1~et

Page 5 ot 5