january 10 health inspection of renaissance hospital terrell

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A. BUILDING (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: STATEMENT OF DEFICIENCIES AND PLAN OF C ORRECTION (X3) DATE SURVEY COMPLETED PRINTED: 01/28/2013 FORM APPROVED (X2) MULTIPLE CONSTRUCTION B. WING _____________________________ ___________ ___________ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 450683 01/10/2013 R-C TERRELL, TX 75160 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER RENAISSANCE HOSPITAL TERRELL 1551 HWY 34 S PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE ID PREFIX TAG (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {A 000} INITIAL COMMENTS {A 000} 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 citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately. An unannounced complaint survey was conducted on si te. An entrance confere nce was held in the Physcian' s lounge on 1 1/13/1012 at 10:00 AM with the Assistant Administrator, Chief Nursing Officer, and Medical Record Director. The purpose and process of the survey was explained and an opportunity was given for questions and discussion. COMPLAINT: TX 00167549 -SUBSTANTIATED. The condition and deficient practices were identified on 11/15/2012 under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient's health and safety and placed patients at risk of potential harm, serious injury, and possibly subsequent death. 42 CFR 482.13 Patient Rights 42 CFR 482.23 Nursing Servicies 42 CFR 482.42 Infection Control 42 CFR 482.51 Surgical Servicies LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficie ncy stateme nt ending with an asterisk (*) denotes a de ficiency w hich the in stitution may be excused from corre cting prov iding it is d etermined 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 695E12 Event ID: Facility ID: 810260 If continuation sheet Page 1 of 219

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