PRINTED: 10/25/2018
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
450193

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

6720 BERTNER

CHI ST LUKE'S HEALTH BAYLOR COLLEGE OF MEDICINE ME
(X4) ID
PREFIX
TAG

10/03/2018

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

A 000 INITIAL COMMENTS

HOUSTON, TX 77030
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

A 000

An unannounced onsite complaint investigation
was initiated in response to a complaint filed and
authorized by the Dallas Regional Office (RO) for
The Centers for Medicare and Medicaid Services
(CMS), on 10/02/2018 at 9:35 am. The purpose
and process for the survey was discuss with the
administrative staff, all questions were answered.
TX00297369 Substantiate. Deficiencies were
cited.
An exit conference was conducted with the
administrative staff on 10/03/2018 at 11:50 am.
The preliminary findings were discuss, all
questions were answered. During the exit
conference the administrative staff were vocal in
stating the defibrillator was available. It was the
surgeon's choice to use the external defibrillators.
A 724 FACILITIES, SUPPLIES, EQUIPMENT
MAINTENANCE
CFR(s): 482.41(d)(2)

A 724

Facilities, supplies, and equipment must be
maintained to ensure an acceptable level of
safety and quality.
This STANDARD is not met as evidenced by:
Based on review of documentation it was
determined that the hospital failed to ensure that
there were sufficient quantities of emergency
equipment (internal defibrillator paddles)
immediately available during cardiac (open chest)
surgery.
Findings were:
There were not sufficient quantities of emergency
equipment (internal defibrillator paddles)
immediately available during cardiac (open chest)
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

(X6) DATE

TITLE

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: 8QVZ11

Facility ID: 810100

If continuation sheet Page 1 of 2

 PRINTED: 10/25/2018
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
450193

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

6720 BERTNER

CHI ST LUKE'S HEALTH BAYLOR COLLEGE OF MEDICINE ME
(X4) ID
PREFIX
TAG

10/03/2018

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

A 724 Continued From page 1

HOUSTON, TX 77030
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

A 724

surgery. Patient #1 had cardiac surgery on
January 2, 2018. During the surgery the surgeon
utilized a defibrillator and internal defibrillator
paddles. Problems with the defibrillator resulted
in staff members replacing the defibrillator with a
second defibrillator. Staff later went to the cardio
vascular operating room sterile core area to
obtain a replacement set of internal defibrillator
paddles and none were immediately available.
Review of facility documents provided to the
survey team for review revealed that on January
2, 2018 revealed the comments:
"Pt begin to fibrillate, multiple attempts made to
defibrillate but defibrillator failed to discharge.
Paddles disassembled and reassembled by OR
staff resulting in successful charge and
defibrillation of pt. Pt begin to fibrillate later during
the case; original paddles failed to discharge
again and original paddles did not discharge;
second set of paddles were then opened to sterile
field. Plugged in, and used to successfully
defibrillate the patient. During instance of no
discharge, it was discovered that there were no
sterile internal paddles on the shelf in the CV0R
core; sterile paddles were obtained from SPD."

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 8QVZ11

Facility ID: 810100

If continuation sheet Page 2 of 2