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Based on interview and record review, the facility failed to ensure prompt resolution of patient grievances. This failure resulted in no documentation of complaint investigation or resolution for 3 of 3 patients (Patients 12, 13, and 14).

Findings included:

In an interview with Staff B (PI director) on 11/18/2020 at 9:30am, the surveyor requested the complaint log for October 2020. Staff B stated there was no log to provide. He did provide three (3) loose complaints for Patients 12, 13, and 14.

Review of the Customer Care / Concern Form for Patient #12 dated 10/5/2020 showed a complaint of inability to make a phone call. There was no documentation of response or resolution by a staff member.

Review of the Customer Care / Concern Form for Patient #13 dated 10/23/2020 showed a complaint of inability to get a PRN (as needed) medication. Much of the patient's writing was very difficult to read. There was no documentation of response or resolution by a staff member.

Review of a written complaint for Patient #14 dated 10/18/2020 showed a complaint of inability to get routine medications. There was no documentation of response or resolution by a staff member.

In an interview with Staff B on 11/19/2020 at 10:00am, he stated he had investigated the complaint by Patient #12 but failed to document his conversation with the patient. He also stated that the Patient Advocate position had been vacated and he was responsible for that position until it could be filled.

Review of the policy, "Patient & Family Complaints & Grievances," revised 3/1/2019, showed: "Behavioral Hospital of Bellaire will provide an effective mechanism for handling patient ...complaints and grievances as an important part of providing quality care and service to our patients ....
Grievance Process ....
4. The staff member receiving a verbal or written grievance shall insure that a Patient Customer Care / Concern Form is completed and notify the Patient Advocate or Shift Supervisor.
5. The patient Advocate or, in his/her absence, the Shift Supervisor shall investigate and address the grievance within 24 hours of the time the grievance is received if possible.
6. If the concern cannot be resolved at this level, the Patient Advocate will facilitate the investigation and resolution of the grievance through a complete investigation by the appropriate department head."

Based on interview and record review, the facility failed to ensure that informed medication consent (as allowed under State law) was obtained for the administration of a psychiatric medication. This failure resulted in 1 of 6 patients (Patient #1) receiving a psychiatric medication without informed medication consent.

Findings included:

Review of the Medication Administration Record for Patient #1 showed he received Cymbalta 30mg daily (used in the treatment of depression) beginning 10/30/2020 at 9:00am.

Review of the Coding Summary Report in the medical record for Patient #1 showed he was admitted 10/27/2020 under the care of Staff F (MD) and discharged on 11/2/2020. Further review of the medical record failed to produce a consent form for the administration of Cymbalta.

In an interview with Staff C (CNO) on 11/19/2020 at 11:00am, she stated that a signed consent form was not found in the medical record of Patient #1.

Review of the policy, "Informed Consent for Medication Administration," last reviewed 12/17/2018, showed: "DOCUMENTATION OF INFORMED CONSENT: Informed consent for the administration of psychoactive medication will be evidenced by a copy of the Consent for Treatment with Psychoactive Medication form executed by the patient admitted under the voluntary, emergency, or Order of Protective Custody (OPC) provisions of Texas statues or his legal authorized representative. This executed form will ...be retained in the medical record."

Based on observation and interview, the facility failed to develop methods for preventing transmission of infections in the lobby. This failure resulted in 1 of 1 staff members (Staff H) did not provide proper cleaning and disinfection of ink pens (used for signing the visitor log) on 11/18/2020.

Findings included:

Observation of the hospital lobby on 11/18/2020 at 9:00am showed Staff H sitting behind the receptionist desk. On the desk was a box with two ink pens in it.

In an interview with Staff H during this observation, she instructed the surveyor to sign the visitor's log. The surveyor asked Staff H if the pens had been cleaned and disinfected. She stated the pens had not been cleaned, adding she had supplies to clean the pens. She went to the cabinet drawers behind her and pulled out a container of Disinfectant Super Sani-Cloth Wipes and wiped down the ink pens. She was asked if there was a process for the cleaning and disinfecting of the ink pens. She stated she would speak with her supervisor.

Review of the Prevention 2020 Plan showed: The Infection Prevention department will identify risks for the acquisition and transmission of infection agents on an ongoing basis and update the Risk Assessment as needed ...goals ...4. To prevent the transmission of infectious disease among patients, licensed independent practitioners, and staff.