DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 04/02/2012 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X2) MULTIPLE CONSTRUCTION (X3) DATE SUR AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETE A. BUILDING Ms B. WING NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE VDEY 2000 OLD HICKORY TRAIL DESOTO, TX 75115 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE 000 INITIAL COMMENTS 000 An entrance conference was conducted at approximately 11 AM the morning of Tuesday, March 6, 2012 in the conference room of the administration area of the facility. In attendance with the addition of the four surveyors were the Chief Executive Of?cer for the facility and the Risk Manager. It was explained to them that this was a validation survey following their accreditation survey by the Joint Commission that was conducted In January of this year. The approximnate length and the extent of the survey were explained. An exit conference was conducted at 1:30 PM on March the 8th 2012 in the conference room of the adminsitrative area of the facility. 146 482.62(d) NURSING SERVICES 146 ?46 _Se"??es Correctlve Actlon: The hospital or unit must have a quali?ed director 4/13/2012 of nurSIng serVIceS. In addItIon to the nursing staff, met with the ON, ADON, dIrector of nurSIng, there must be adequate . . . . and Manager. The Nurse Staf?ng numbers of registered nurses, iIcensed practical . . Committee prepared recommendations to nurses, and mental health workers to prOVIde . adopt an Aculty tool to augment the nurSIng care necessary under each patIent staf?n Ian that will aid in deteminin active treatment program and to maintain . . Fess notes on each atient the staf?ng mm for each unlt. The acuity tool is unit-speci?c for geriatric, adult adolescent and pediatrics. The acuity tool was presented to the Governing This STANDARD is not met as eVIdenced by: Board for approval on April 13, 2011 Based on review of documentation. observation and interview. it was determined that the facility House supervisors will be trained to failed to provide adequate nursing staff to ensure use the acuity tool by April 20, 2012 4/20/2012 the safety of the facility 8 patients and staff. Training inctudes consensus on acuity Findings were: Facility policy entitled Master Staf?ng Plan LABORATORY OR SIGNATURE TITLE (X6) DATE Any de?ciency 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 Previous Versions Obsolete Event Facilitle: 510465 If continuation sheet Page 1 of6 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 04/02/2012 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING 454065 NAME OF PROVIDER OR SUPPLIER HICKORY TRAIL HOSPITAL STREET ADDRESS, CITY, STATE. ZIP CODE 2000 OLD HICKORY TRAIL DESOTO, TX 75115 Meeting Minutes from the Nursing Staf?ng Committee dated July 2011 stated in part, Round Robin Issues With Staff: DS?Expressed concern about not having a 2nd nurse on A5 children 5 unit when there are more than 14 patients. The ADON stated when there is no nurse available the supervisor will staff with an extra MHT to support the RN. Ultimately there will and should be 2 RNs and 2 MHTs. Also. she had concerns about the lack of ?exibility of the grid to provide adequate staf?ng when aquity changes from unit to unit. CB-Concerned about the visitation policy. Not enough staff to accommodate visitation every day especially now since there needs to be an RN on the unit at all times. Meeting Minutes from the Nursing Staffing Committee dated January 2012 stated in part, (X4) in SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) pREFix (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 146 Continued From page 1 146 (active Fluid? 3,65?? stated in part Staf?ng is based on normal staff 3 3:21:11}: 23:33:; nursing m'x rat'os Of the fonow'f?g: supervision). The tool requires assessments RN House_supemsor eaCh Sh'? (mayor for census and acuity on each unit every shift may "Qt be ass'gned to a um? I to determine staf?ng needs effective April 20, At leaSt 1 RN for every _12 Cl'erfts 2012. Staf?ng needs will be assessed on a LVN be added for h'gh acu'ty 0" shift by Shift basis by theNursing Supervisor increased census to medications or Interim DON and will be adjusted based MHT (Marital Health TeChnICIan) for 9390 upon census and acuity of the unit. If census Program If census arid warrant 0" or acuity increase during a shift, the House according to unit need and patient observation supervisor will can in additiona1 staff to levels meet staf?ng needs from the Pool? Adult Services ratio will be maintained at 1:4 of available staff. Several new staff have for the day and evening shift. A 1:6 ratio will be been hired to augment this pool. maintained for the night shift. This number will vary according to acuity needs and number of Monitoring: 4/20/2012 high risk clients as determined by the Charge The Interim DON and Nursing Supervisors and Nurse and House Supervisor. will monitor every shift each unit census and ongoineg acuity to determine the staf?ng needs. Each shift staf?ng will be reported to the CEO daily in the morning leadership meeting. The Interim DON will review acuity calculations and staf?ng sheets daily to ensure accuracy for three months to ensure that staf?ng needs are being met and to hire new staff as needed to meet staf?ng needs. A quarterly ?Nursing Report? is submitted to the Governing Board by the Interim DON and includes all Staf?ng Committee variances, concerns, nursing staff feedback re staf?ng adequacy and any recommendations to improve staf?ng. FORM Previous Versions Obsolete Event Faci'i?V'D: ?"465 If continuation sheet Page 2 of 6 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 04/02/2012 FORM APPROVED OMB NO. 0938-0391 Round Robin Issues With Staff: We currently do not have an acuity tool. We are at this time staffing based on numbers. At times the acuity on the units make it necessary to increase tech support. Supervisors consider reviewing the acuity of the patients on each unit from shift to shift and make appropriate adjustments. Current issues have been on Adult 1 where 1 nurse and 1 tech are not safely able to meet the needs of the patients. Reconsider adding a second tech to unit 1 when patient numbers are 9 or more. The following dates and shifts did not meet patient to staff ratios according to facility policy: 2/22/12, 3?11 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio) 2/22/12, 3-11 shift, Unit 5 had 18 patients and 1 RN, 1 LVN and 2 MHTs (1:4.5 ratio) 2/22/12, 11-7 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio) 2/23/12, 7-3 shift, Unit 1 had 19 patients and 1 1:1 Close Observation. The unit had 1 RN, 1 LVN and 3 MHTs (134.75 ratio) 2/23/12, 7-3 shift, Unit 4 had 10 patients and 1 RN and 1 MHT (1:5 ratio) 2/23/12, 3-11 shift, Unit 1 had 19 patients and 1 1:1 Close Observation. The unit had 1 RN, 1 LVN and 3 MHTs (1:4.75 ratio) 2/23/12, 3-11 shift, Unit 4 had 9 patients (124.5 ratio) 2/23/12, 11-7 shift, Unit 5 had 14 patients and 1 RN and 1 MHT (1:7 ratio) 2/24/12, 7-3 shift, Unit 1 had 18 patients and 1 1:1 Close Observation. The unit had 1 RN, 1 LVN, and 3 MHTs (1:4.5 ratio) STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING 454065 03/03/2012 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 2000 OLD HICKORY TRAIL HICKORY TRAIL HOSPITAL DESOTO, Tx 75115 W) ?3 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLEFION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) 146 Continued From page 2 146 FORM Previous Versions Obsolete Facilitle; 810465 If continuation sheet Page 3 of 6 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 04/02/2012 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 454065 (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY COMPLETED A. BUILDING a. WING 03/08/2012 NAME OF PROVIDER OR SUPPLIER HICKORY TRAIL HOSPITAL STREET ADDRESS, CITY, STATE, ZIP CODE 2000 OLD HICKORY TRAIL DESOTO, TX 751 1 5 2124/12, 7-3 shift, Unit 4 had 11 patients and 1 RN and 1 MHT (1:5.5 ratio) 2/24/12, 3?11 shift, Unit 1 had 17 patientsMHTs (1:4.25 ratio) 2/24/12, 3-11 shift, Unit 4 had 11 patients and 1 RN and 1 MHT (1:5.5 ratio) 2/25/12, 7-7 shift, Unit 1 had 22 patients and MHTs (125.5 ratio) 2/25/12, 7-7 shift, Unit 3 had 13 patients and 1 RN and 2 MHTs (124.3 ratio) 2/25/12, 7-7 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio) 2/26/12, 7-7 shift, Unit 1 had 27 patients and MHTs (1 :6.75 ratio) 2/26/12, 7-7 shift, Unit 4 had 13 patients and 1 RN and 1 MHT (1:6.5 ratio) 2/27/12, 7-3 shift, Unit 1 had 27 patientsMHTs (1:6.75 ratio) 2/27/12, 7?3 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio) 2/27/12, 3-11 shift, Unit 1 had 25 patients and MHTs (1:6.25 ratio) 2/27/12, 311 shift Unit4 had 14 patients and 1 RN and 1 MHT (1:7 ratio) 2/27/12, 3-11 shift, Unit 5 had 15 patients and 1 RN and 2 MHTs (1:5 ratio) 2/28/12, 7-3 shift, Unit 1 had 27 patients and 2 RNs and 2 MHTs (1:6.75 ratio) 2/28/12, 3-11 shift, Unit 1 had 24 patients and 2 RNs and 2 MHTs (1:6 ratio) 2/28/12, 3u11 shift, Unit 4 had 13 patients and 1 RN and 1 MHT (1:6.5 ratio) 2/29/12, 7-3 shift, Unit 1 had 25 patients and 2 RNs and 2 MHTs (126.25 ratio) 2/29/12, 3-11 shift, Unit 1 had 23 patients and 2 RNs and 2 MHTs (1:5.75 ratio) 3/1/12, 7-3 shift, Unit 1 had 24 patients and 2 RNs and 2 MHTs (1:6 ratio) (x4, ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTNE ACTION SHOULD BE COMPLETION TAG REGULATORY 0R LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) 146 Continued From page 3 146 FORM Previous Versions Obsolete Event Facility/ID: 810465 If continuation sheet Page 4 of 6 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 04/02/2012 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 454065 (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING S. WING 03/08/2012 NAME OF PROVIDER OR SUPPLIER HICKORY TRAIL HOSPITAL STREET ADDRESS, CITY. STATE, ZIP CODE 2000 OLD HICKORY TRAIL 3/1/12, 3-11 shift, Unit 1 had 24 patients and 2 RNs and 2 MHTs (1:6 ratio) 3/2/ 12, 7-3 shift, Unit 1 had 20 patients and 2 RNS and 2 MHTs (1 :5 ratio) 3/2/12, 7-3 shift, Unit 4 had 9 patients and 1 RN and 1 MHT (1:4.5 ratio) 3/2/12, 7-3 shift, Unit 5 had 14 patients and 1 RN and 2 MHTs (1:4.6 ratio) 3/2/12, 3-11 shift, Unit 1 had 20 patients and 2 RNs and 2 MHTs (1:5 ratio) 3/2/12, 3-11 shift, Unit 4 had 9 patients and 1 RN and 1 MHT (1:4.5 ratio) 3/2/12, 3-11 shift, Unit 5 had 1 RN and 2 MHTS (1 :5 ratio) 3/4/12, 7-7 day shift, Unit 1 had 26 patients and 2 RNs and 2 MHTs (1 :6.5 ratio) 3/4/12, 7-7 day shift, Unit 3 had 13 patients and 1 RN and 2 MHTs (1:4.6 ratio) 3/4/12, day shift, Unit 4 had 14 patients and 1 RN and MHT (1:7 ratio) 3/4/12, 7-7 day shift, Unit 5 had 15 patients and 1 RN and 2 MHTS (1 :5 ratio) 3/4/12, 7?7 night shift, Unit 1 had 26 patients with 1 1:1, 2 RNs and 3 MHTS (1 :6.25 ratio) 3/5/12, 7-3 shift, Unit 1 had 26 patients with 1 1:1, 2 RNs and 2 MHTs (1 :6.25 ratio) 3/5/12, 7-3 shift, Unit 4 had 13 patients and 1 RN and 1 MHT (126.5 ratio) 3/5/12, 3-11 shift, Unit 1 had 27 patients with 1 1:MHTs (1:6.75 ratio) 3/5/12, 3-11 shift, Unit 3 had 13 patients with MHT (1:4.3 ratio) 3/5/12, 3-11 shift, Unit 4 had 14 patients with 1 RN and 1 MHT (1:7 ratio) 3/5/12, 11-? shift, Unit 1 had 26 patients with 1 1:MHTs (116.5 ratio) In an interview with the Director of Nurses on Tx 75115 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X5) pame (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 146 Continued From page4 146 FORM Previous Versions Obsolete 810465 If continuation sheet Page 5 Of6 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 04/02/2012 FORM APPROVED OMB NO. 0938-0391 DEFICIENCY) STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING 03I08I2012 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE 2000 OLD HICKORY TRAIL HICKORYTRAIL HOSPITAL DESOTO, TX 75115 W) In SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE 146 Continued From page 5 company policy. 3/6/12, it was acknowledged that the facility did not aiways meet staf?ng needs according to 146 FORM Previous Versions Obsolete Event FacililyID: 810465 If continuation sheet Page 6 Of 6 Texas Department of State Health Services PRINTED: 04/16/2012 STATEMENT OF DEFICIENCIES (x1) AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 81 0465 FORM APPROVED (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING B. 03/08/2012 NAME OF PROVIDER OR SUPPLIER HICKORY TRAIL HOSPITAL STREET ADDRESS. CITY, STATE, ZIP CODE 2000 OLD HICKORY TRAIL DESOTO, TX 75115 (X4) ID PREHX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 000 25 TAC 134 INITIAL COMMENTS Note: The State Form 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 de?ciency citation(s) will be referred to the Of?ce of the Texas Attorney General (OAG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately. Note: The State Form 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 de?ciency citation(s) will be referred to the Of?ce ofthe Texas Attorney General (OAG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) shouId be notified immediately. An unannounced recertification survey was conducted on site. An entrance conference was held with the Chief Executive Of?cer and Risk Manager on the morning of 03/06/12 to explain the purpose and process of the survey. The hospital representative was informed that this investigation would be conducted according to the Texas Administrative Code. Chapter 133. The applicable survey report form was applied. Survey findings were presented at an exit conference on the afternoon of 03/08/12 with the Chief Executive Of?cer and administrative representatives. The hospital representatives were given to opportunities to provide evidence of compliance where no compliance was found. No evidence was provided to the surveyor. . 000 By submitting this Plan of Correction, the Facility does not admit that it violated the regulations. The Facility also reserves the right to amend the Plan of Correction as necessary and to contest the de?ciencies, ?ndings, conclusions, and actions of the agency. NR 5? SOD - State Form LABORATORY OR REPRESE STATE FORM /14 (feared mg @513 (X6) TE wk If continuati sheet 1 of 29