HospitalInspections.org

Based on document review and interview the facility failed to follow its policy titled, "Patient Grievance Process" to ensure a patient's allegations of abuse or neglect were documented, investigated, and processed promptly in 1 of 1 (Patient #2) medical records reviewed.

Findings:

A review of the Complaint and Grievance Logs for August and September 2024 was conducted with Staff #5 on 9/24/2024 at 10:30 AM. Staff #4 confirmed Patient #2 was not listed on the log.

An interview was conducted with Staff #5 on 9/24/2024 at 10:30 AM. Staff #4 was asked if Patient #2 or a representative had filed a grievance with the facility. Staff #5 stated. "She is not on the log, so I do not think so." Staff #4 was asked how she processes the complaints and grievances. Staff #5 stated, "I will document the investigation for our records, and I will keep it in a folder". Staff #5 was asked if she had sent anyone a letter to inform them an ongoing investigation was being conducted. Staff #5 confirmed she had only been in the position since October 2023 and had never processed a grievance or mailed a letter to a complainant.

An interview was conducted with the Administrator, Staff #1, and the Director of Nurses (DON) Staff #2 on 9/24/2024 at 1:30 PM. Staff #1 was asked if he was contacted by Patient #2's family regarding the care she received at the facility. Staff #1 stated, "Yes, I was, and I looked into the complaint at the time. Staff #2 was on vacation but when she returned, I turned the investigation over to her for completion". Staff #2 was asked if the investigation was completed. Staff #2 stated, "The family had concerns regarding a bruise on Patient #2's side and complained about the staff being rough with her during her incontinent care. The complaint that the patient fell was not true". Staff #2 was asked if there was any documentation regarding the internal investigation and if the Patient Advocate was notified of the grievance the family had filed. Staff #2 confirmed Patient #2 was not placed on the Complaint/Grievance Log and that Staff #5, the Patient Advocate was not informed of the investigation.

A review of the facility policy titled, "Patient Grievance Process", Policy Number RTS-04, with a revised date of 9/01/2024, was as follows:

PURPOSE:
To provide an internal process that establishes guidelines for:
* Submission of a patient and/or family's grievance allegation to the facility
* Timely review and investigation of the allegation
* Provision of a response
* Timely referral to the appropriate external agency as deemed necessary

POLICY:
The Governing Body is responsible for the effective operation of the complaint/grievance resolution process. Each facility has identified an individual to serve as the facility' Patient Advocate who is responsible for the follow-up and response to grievances submitted by a patient or caregiver...

DEFINITIONS...
Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not
resolved at the time of the complaint by staff present), abuse or neglect, and/or patient's rights ...

PROCEDURE:
Grievance Submission
...3. If no resolution is made by staff present at the time of the complaint, the Patient Advocate is notified, and the grievance process is initiated. If the patient and/or family file a grievance allegation as defined above, the grievance process is initiated immediately ...

Grievance Procedures
1. The Patient Advocate logs the grievance allegation onto the "Complaint/Grievance Log" and contacts the patient, or patient representative, and opens an investigation to determine the validity of the grievance allegation within 48 hours of notification or receipt of the grievance allegation. If the grievance is regarding an allegation of abuse or neglect, the appropriate state mandatory guidelines for reporting will be followed.
2. The Patient Advocate completes the investigation using the "Grievance Report" within 7 calendar days of the date of the notification or receipt of the grievance allegation.
3. If the investigation is ongoing on the 7th day, an extension letter should be sent to the grievant with documentation confirming date of issuance. The extension letter should include the date the expected resolution will be completed and sent.
4. The Patient Advocate issues a final written response to the grievant by the 7th day, or no later than the date referenced on the extension letter, from the date of the grievance allegation, and will include:
a. The name of the facility contact person
b. The steps taken on behalf of the person reporting to investigate the grievance
c. The results of the grievance process
d. The facility's decision
e. The date of completion.
f. The contact information to appeal the offered resolution ...

Role of the Patient Advocate:
1. Maintains a complete "Complaint/Grievance log" along with files and results of all grievances including a signed copy of the letter sent to the grievant and dated documentation of the method of delivery.
2. Complete a thorough investigation of all grievances representing the expressed desires of the individuals served and advocating for the resolution of their grievances.
3. Responsible for reporting all grievance investigation findings and resolutions to QAPI committee hierarchy.

Role of the Administrator
1. Ensure appropriate policies and procedures are followed for grievances alleging abuse and neglect of patients ..."


During an interview on 9/24/2024 after 1:30 PM, Staff #1 and Staff #2 confirmed the facility policy was not followed for the grievance process, and Patient #2 was not listed on the Complaint/Grievance Log. Staff #2 confirmed there was no documentation of the investigation or the outcome of the investigation by the facility staff. Also, Staff #2 confirmed Patient #2's family was not notified by mail of the outcome of the investigation.

Based on document review and interview the facility failed to:

a. ensure chemical restraints/emergency behavioral medications (EBM) administered intramuscularly (IM) for behavioral emergencies were identified and monitored as a chemical restraint in 2 of 2 (Patient #7 and Patient #3) medical records reviewed.

b. ensure chemical restraints/EBMs were added to the restraint log in 1 of 1 (Patient #3) medical record reviewed.

c. follow its policy titled, "Seclusion and Restraint".


Medical records were reviewed in the administration conference room on 9/24/2024 after 1:30 PM with Staff #5 and Director of Nurses (DON) Staff #2.


Findings:

Patient #3
Patient #3 was a 71-year-old male who was admitted to the facility on 8/09/2024. A review of the medical record revealed Patient #3 received an EBM/Chemical restraint on 8/16/2024. A review of the restraint and seclusion packet revealed the following:


8/16/2024

A review of the restraint packet dated 8/16/2024 was as follows:

Patient #3 was placed in a physical restraint/therapeutic hold on 8/16/2024 from 5:31 PM-5:34 PM. Registered Nurse (RN) Staff #17 documented that the patient was held in a therapeutic hold for approximately 3 minutes. He was able to redirect his thoughts enough for him to stop resisting and the hold was released.

Physician #15 gave a verbal order for Haldol (antipsychotic) 5 milligrams (mg) intramuscular (IM) and Ativan (anti-anxiety medication) 2mg IM now x 1 dose on 8/16/2024 at 5:39 PM. The medication was administered by RN Staff #4 on 8/16/2024 at 5:45 PM.

Further review of the restraint packet revealed RN Staff #17 failed to monitor Patient #3s vital signs every 15 minutes for one hour after the Emergency Behavioral Medication (EBM) was administered. The patient's vital signs (blood pressure, te,perature, heart rate and respiratory rate) should have been assessed and documented at 6:00 PM, 6:15 PM, 6:30 PM, and 6:45 PM.

RN Staff #17 documented that Patient #3 refused the assessment of vital signs at 5:54 PM. RN Staff #17 documented vital signs at 6:25 PM. No further documentation of Patient #3s vital signs was found in the medical record.

In an interview on 9/24/2024 with Staff #2 and Staff #5 it was confirmed Patient #3 was not monitored or assessed after the EBM was administered according to the facility restraint policy.

A review of the document titled, "Seclusion/Restraint Log" dated 5/4/2024-9/24/2024 did not reveal that Patient #3 was placed on the log or the EBM/chemical restraint administered on 8/10/2024 and 8/16/2024.

An interview was conducted on 9/24/2024 after 1:30 PM, DON Staff #2 confirmed Patient #3 was not listed on the restraint log.



Patient #7
Patient #7 was a 71-year-old female who was admitted to the facility on 9/23/2024. A review of the restraint and seclusion packet revealed the following:

Patient #7 received an EBM/chemical restraint on 9/24/2024 at 4:20 AM. A verbal order was given by Physician #15 on 9/24/2024 at 4:04 AM that read; Haldol (an antipsychotic medication) 5 milligrams (mg) intramuscular (IM) one time only and Ativan (anti-anxiety medication with a sedating effect) 2 mg IM one time only. The medication was administered by Licensed Vocational Nurse (LVN) Staff #12 on 9/24/2024 at 4:20 AM.

A review of the restraint packet did not reveal what staff participated in the behavior emergency. Registered Nurse (RN) Staff #10 completed the restraint documentation. RN Staff #10 documented the precipitating event that read,
"Continuously screaming out loud, broke emergency toilet call light, tore down shower curtain".

A review of the monitoring documented by RN Staff #10 revealed vital signs were not documented every 15 minutes for 1 hour. RN Staff #10 documented Patient #7 refused vital signs at 4:35 AM (no respirations were documented) and vital signs were attempted again at 4:50 AM but Patient #7 refused (no respirations were documented). RN Staff #10 documented blood pressure, temperature, pulse, and respirations at 7:00 AM and wrote, "patient refused vital signs until 7:00 AM".

The one-hour face-to-face was documented by RN Staff #10 on 9/24/2024 at 5:20 AM. This is the same nurse who participated in the initiation of the EBM/Chemical restraint for a behavioral emergency.

An interview was conducted with Director of Nurses (DON) Staff #2 on 9/24/2024 after 3:00 PM. DON Staff #2 confirmed RN Staff #10 did not follow the facility policy and monitor the patient's vital signs every 15 minutes for 1 hour as evidenced by only 2 attempts of assessing the vital signs were documented. DON Staff #2 confirmed there was no respiration count until 7:00 AM.


A review of the facility policy titled, "Seclusion and Restraint-Texas" Policy Number NSG-76, with a review date of 7/01/2024 was as follows:

" ...POLICY:
The facility's functional program is designed to ensure and respect the patient's right to be free
from seclusion and/or restraints in any form. Seclusion and/or restraint would only be used if
patient presented a behavioral emergency of eminent danger to self or others. A patient will be
released from seclusion and/or restraint as soon as the risk of harm to self or others no longer
exists. Seclusion and/or restraint is not used as means of coercion, discipline, convenience, or
retaliation by staff ...

Definitions;

Physical Restraint: A physical restraint is any manual method, physical or
mechanical device, material, or equipment that immobilizes or reduces the ability of a
patient to move his or her arms, legs, body, or head freely.

Chemical Restraint: A chemical restraint is a drug or medication when it is used as a
restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition." Per
State Regulation set Y.4.00 requirement 415.254 (a)(2), no intervention voluntary or
involuntary shall be used for the purpose of convenience of staff members ....

PROCEDURE: (These procedures apply only to the inpatient setting)
Registered Nurse (RN):
1. Initiation:
*Initiate emergency restraint and/or seclusion in absence of physician post determination
that alternative interventions were not effective or would not deter harm to self/others.
*Notify physician as soon as possible and no greater than one hour.
*Document contact and obtain a physician order from the Seclusion and/or Restraint order set or an Emergency Psychotropic Medication administration on the Emergency Psychotropic IM Medication order set ...

4. Face-to-Face Evaluation
Conduct one hour face-to-face (if trained to do so) even if patient is no longer in restraint/seclusion and physician is not present.

*Document on Face-to -Face Evaluation Form:
a. date/time
b. Behaviors
c. Alternative interventions to prevent restraint/seclusion
d. Medical review of patient's status post-intervention

*Consult post face-to-face evaluation, review findings with physician. Document
contact/review ...

RN/MHT:
1. Monitoring:
*Provide monitoring as indicated on Seclusion/Restraint Flow sheet every 1 minutes.
*Provide care for patient as indicated in Seclusion/Restraint Flow sheet in time(s) indicated.
*Psychoactive medication follows the same protocol and procedure: every 15 minutes an assessment and vital signs must be conducted, and the one-hour RN assessment is performed. All patients receiving intramuscular psychoactive medication will be assessed at a minimum of every 15 minutes for one 1 hour for vital signs, nutritional needs, and safety. A complete RN assessment will be performed at one hour and documented on the flow sheet.
*Current physical, emotional, and behavioral condition status
*Medication(s) administered
*Type of care needed ..."

An interview was conducted in the afternoon on 9/24/2024 with Administrator Staff #1 and DON Staff #2. DON Staff #2 confirmed the nursing staff failed to follow the facility policy and monitor Patients #3 and #7 after the IM administration of a psychoactive medication for a behavioral emergency.

Based on observations, document review, and interviews, the facility did not maintain an adequate number of staff on the Geriatric Unit to ensure the safety of both patients and staff. Specifically, the facility was understaffed on 8 out of 19 reviewed shifts, posing risks of falls, injuries, and potential fatalities among patients. Additionally, the facility did not adhere to its policy titled "STAFFING PLAN."

Refer to Tag A1704

Based on observations, document review, and interviews, the facility did not maintain an adequate number of staff on the Geriatric Unit to ensure the safety of both patients and staff. Specifically, the facility was understaffed on 8 out of 19 reviewed shifts, posing risks of falls, injuries, and potential fatalities among patients. Additionally, the facility did not adhere to its policy titled "STAFFING PLAN."

Findings:

An observation tour was conducted on 9/24/2024 at 10:00 AM with Registered Nurse (RN) #4. The hospital has one Geriatric Unit and one common area for patients to gather. As the surveyor was walking down the only hallway with patient rooms, it was noted that Patient #7 was in her assigned room, 9A, and yelling at the staff incoherently.

An interview was conducted with RN Staff #9 on 9/24/2024 at 10:15 AM in the nursing station on the geriatric unit and during the interview with RN Staff #9, RN Staff #9 confirmed that Patient #7 had received an emergency behavioral medication/chemical restraint early that morning and was still requiring de-escalation and redirection by the Mental Health Technician (MHT) due to her verbal outbursts. RN Staff #9 confirmed she was the only RN on the unit to manage the care of 22 patients.

A review of the medical record for Patient #7 revealed Patient #7 received an emergency behavioral medical (EBM)/chemical restraint at 4:20 AM BY Licensed Vocational Nurse (LVN) Staff #12. RN Staff #10 was the only RN on the geriatric unit at the time the EBM was administered. Patient #7 received Haldol (an antipsychotic) 5 mg (milligrams) intramuscular (IM) and Lorazepam (an anti-anxiety medication that causes sedation) 2mg IM.


According to the manufacturer insert Haldol (Haloperidol) is an antipsychotic medicine that is used to treat schizophrenia and psychosis. It can also be used for psychiatric emergency behavioral situations. Any patient receiving these medications should be monitored by a trained medical professional due to the side effects of Anemia, Headache, Increased or Decreased respiratory rate, Orthostatic hypotension, Prolonged QT interval, and Visual disturbances.

A review of the restraint and seclusion packet dated 9/24/2024 at 6:32 AM revealed RN Staff #10 monitored the patient during the restraint episode leaving no other RN available to monitor or manage the care for the other 23 patients on the unit.


The Staffing Matrix revealed the following staffing pattern for each 12-hour shift:

Patient Census of 1-6; 1 Registered Nurse (RN), 1 Licensed Vocation Nurse (LVN), and 1 Mental Health Technician (MHT)
Patient Census of 7-12; 1 RN, 1 LVN, and 2 MHTs
Patient Census of 13-18; 1 RN, 1 LVN, 3 MHTs; after 14 patients a House Supervisor or Bridge Nurse will be scheduled.
Patient Census of 14-18; 1 RN, 1 LVN, 3 MHTs, and 1 House Supervisor (HS) or Bridge Nurse;
Patient Census of 19-24 patients; 1 RN, 1 House Supervisor or Bridge Nurse, 1 LVN, and 4 MHTs.

*When the patient census rises to 14 and above the staffing matrix will include an additional RN (House Supervisor or Bridge Nurse). The HS is scheduled to work from 10:00 AM-10:00 PM and the Bridge Nurse is scheduled to work from 2:00 PM-10:00 PM.

A review of the staffing schedules and assignment sheets dated 9/15/2024-9/24/2024 was conducted with Staff #2 Director of Nurses (DON). The review covered a total of 19, 12-hour shifts and revealed:

9/15/2024-23 patients, short 1 RN on days and 1 RN and 1 MHT nights. No HS or Bridge Nurse was scheduled.
Further review for this day (9/15/2024) revealed RN Staff #9 was clocked out for lunch from 12:00-12:30 PM leaving LVN Staff #13 unsupervised by a RN and managing the care of 23 patients. A review of the staffing and assignment sheets dated 9/15/2024 did not reveal a RN relieved RN Staff #9 for a 30-minute lunch break.

9/16/2024-22 patients, short 1 RN until 10:00 AM (HS) and 1 MHT on days.

9/17/2024-22 patients, short 1 RN until 10:00 AM (HS) short 1 MHT on days.

9/18/2024-22 patients, short 1 RN until 10:00 AM (HS) on days and short 1 MHT on nights.

9/21/2024-21 patients, short 1 MHT and short 1 RN until 10:00 AM (HS) on days and 1 MHT on nights.

9/22/2024-24 patients, short 1 RN until 10:00 AM (HS) on days.

9/23/2024-24 patients, short 1 RN until 10:00 AM (HS) on days.

9/24/2024-22 patients, short 1 RN until 2:00 PM (bridge nurse) on days.


Out of 19 shifts reviewed the facility was short 1 RN for 8 of 19 shifts and short 1 MHT for 6 of 19 shifts reviewed.

An interview was conducted with DON Staff #2 on 9/24/2024 after 11:30 AM. Staff #2 was asked about the House Supervisors and the Bridge Nurse Staffing. Staff #2 stated, "The HS or the Bridge Nurses are scheduled anytime the census reaches 14 and above. The HS is scheduled from 10:00 AM- 10:00 PM and the Bridge Nurse is scheduled from 2:00 PM-10:00 PM. We will usually schedule an HS but if one is not available then the Bridge Nurse will be scheduled, and they work 8-hour shifts". Staff #2 was asked who relieves the RN and the LVN for lunch breaks. Staff #2 replied, "The HS or the bridge nurse cover all the lunch breaks". Staff #2 was asked who would help the RN who is scheduled for the shift until the HS arrives at 10:00 AM or the Bridge Nurse arrives at 2:00 PM. Staff #2 stated, "The staff calls us if they need assistance. There are 2 RNs in the front that can assist and there is an LVN scheduled with the RN every day."

Staff #2 was asked when the patient census was above 14, were there two RNs scheduled for each 12-hour shift. Staff #2 stated, "No, the HS will come in at 10:00 AM and leave at 10:00 PM or the bridge nurse will come in at 2:00 PM and leave at 10: PM". Staff #2 confirmed that before and after the hours of the scheduled HS or bridge nurse there would only be one RN per 12-hour shift in the building on the weekends.

An interview was conducted with Registered Nurse (RN) Staff #9 on 9/24/2024 at 1:26 PM. RN Staff #9 was asked if she was the only RN on the unit for the day. RN Staff #9 replied, "The bridge nurse comes in at 3:00 PM". RN Staff #9 was asked who would be assigned to give her a lunch break. Staff #9 replied she would wait until after 3:00 PM to go to lunch because there was no one else available to relieve her. RN Staff #9 was asked if she completed the 12-hour nursing assessments on all 22 patients. RN Staff #9 stated, "No, they are not finished but the bridge nurse will help when she gets here". RN Staff #9 stated, "On Sunday, the 15th I was the only RN the entire shift and we had 23 patients. I had to complete 23 shift assessments and manage the care of the patients. We didn't have a HS or a bridge nurse that day".

An interview was conducted with DON Staff #2 on 9/24/2024 after 2:00 PM. Staff #2 confirmed the following:

On Friday 9/13/2024 after 10:00 PM until Saturday 9/14/2024 at 10:00 AM there was only one RN in the building to manage the care of 21 patients.

On Saturday 9/14/2024 after 10:00 PM until Monday 9/16/2024 at 8:00 AM there was only one RN in the building to manage the care of 23 patients.

On Friday 9/20/2024 after 10:00 PM until Saturday 9/21/2024 at 10:00 AM there was only 1 RN in the building to manage the care of 18 patients.

On Saturday 9/21/2024 after 10:00 PM until Sunday 9/22/2024 at 10:00 AM there was only 1 RN in the building to manage the care of 24 patients.

On Sunday 9/22/2024 after 10:00 PM until Monday 9/23/2024 at 8:00 AM there was only 1 RN in the building to manage the care of 24 patients.


An interview was conducted with Staff #14 on 9/27/2024 at 12:35 PM. Staff #14 was asked what employees do if they do not take lunch. Staff #14 stated, "The lunch breaks are automatically deducted, and the staff has to fill out a sheet stating they did not take a lunch and turn it into me so that they can get paid for their missed lunch". Staff #14 confirmed RN Staff #9 was clocked out for lunch and there was no sheet turned in for a missed lunch period.


A review of the Texas Board of Nurse Practice was as follows:
" ...Licensed Vocational Nurse Scope of Practice
The Texas Nursing Practice Act (NPA) and the Board's Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVNs). The LVN scope of practice is a directed scope of practice and requires appropriate supervision of a registered nurse, advanced practice registered nurse, physician assistant, physician, dentist, or podiatrist ..."

An interview was conducted with DON Staff #2 and Administrator Staff #1 on 9/24/2024 after 3:00 PM. Staff #1 and #2 confirmed the above days of being short-staffed with either an MHT or an RN.

A review of the facility policy titled, "STAFFING PLAN" Policy Number NSG-06 with a revised date of 9/01/2022 was as follows:

" ...PURPOSE:
To establish criteria that provides guidelines for meeting anticipated needs of the nursing staff and to provide for safe delivery of care to the patients in a fiscally responsible manner.

POLICY:
The Governing Body has adopted, implemented and enforces a written Nurse Staffing policy to ensure that an adequate number and skill mix of nurses are available to meet the level of patient care needed. The Director of Nursing, or designee plans a master schedule for each discipline within the nursing department. The master schedule is adjusted as needed to provide for patient needs and ensure positive patient outcomes. The charge nurse or nursing supervisor, in the absence of the DON, makes necessary changes to staffing units to meet unit needs. The facility is staffed by a prescribed matrix with nursing staff allocated based on patient population needs to accommodate increased census and special needs of the patient ....

PROCEDURE:
Inpatient:
Factors considered in determining staffing needs: ...
*A registered nurse is physically present and immediately available at all times when a patient is present on the unit. As used in this policy, "immediately available" requires the registered nurse to be physically present in the patient common area, nursing station, lounge area adjacent to the nursing station, or in other areas in which the overhead paging system is audible. This policy does not require the registered nurse to be regularly interrupted during a meal period. Instead, the registered nurse can and should schedule a 30-minute uninterrupted meal period and request coverage from the LPN/LVN on duty to ensure that the meal period is not interrupted. If a registered nurse is unable to take a meal period, then s/he shall report the missed meal period to her/his supervisor or HR, who will override the meal period deduction. Registered nurses are required to certify that their time records are accurate and complete prior to the end of each pay period ...

*A registered nurse is responsible for supervising all License Practical/Vocational Nurses (LPN/LVN), Mental Health Techs (MHT) and Certified Nursing Assistants (CNA) ..."

In an interview on 9/24/2024 after 3:00 PM, DON Staff #2 confirmed the LVN was not allowed to relieve the RN for a 30-minute lunch break.