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Based on record review and interview, the facility failed to follow established Grievance Management Process in 1 of 3 grievances reviewed. (ID # 1)

Findings include:

Review of facility policy titled "Patient Grievance" dated 06/13/23 showed the following information:
I.POLICY/GENERAL STATEMENT
Houston Methodist is committed to creating an open environment of communication in which patients, patients' LAR (legally authorized representative)/ companions, family members and visitors feel comfortable relaying comments regarding care received and services delivered. Each hospital has established a process for prompt resolution of a patient's grievance or concerns and informs each patient who to contact to file a grievance. Each hospital encourages employees to resolve and report patient concerns to hospital management. Each hospital has established A measurement process for documenting and continuously improving the service and satisfaction of patients, families, and visitors.
II. DEFINITIONS
Grievance: a patient grievance is a written or verbal complaint (with the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient or the LAR/companion regarding the patient's care, discrimination, abuse or neglect issues related to the hospital's compliance with the Centers for Medicare and Medicaid services (CMS) hospital conditions of participation or certain billing complaints.


Review of facility policy titled "Grievance Management Process" dated 06/2018 showed the following:

Quality Statement:

To ensure proper handling of all complaints and grievances and notification to our risk and quality departments. Proper implementation of the procedure contributes to compliance with the CMS conditions of participation; patient rights; DNV/NIAHO standards, and TDH.

IMPLEMENTATION
1. A patient or their LAR reaches out to the hospital through various means of communication, which includes but is not limited to, written and verbal communication.
2. The grievance is received by the patient liaison, guest relations management, resolution specialist, or quality and risk management from the department receiving the information from the patient and/4 the patient's LAR directly.
3. The guest relations management, resolution specialist and patient liaisons work as a team to process the grievance.

Interview with physician (ID# 59) on 11/7/23 at 1115 stated that he received communication he thinks via email from the unit manager (ID # 65) and liaison regarding the medical decision making for patient (ID#1). He stated that he has at least two calls to the family regarding the care provided to their family member that passed away.

Review of email thread beginning 4/27/22 sent to physician (ID# 59) on 5/1/22 included communication from guest relations, unit leadership and risk management regarding the medical care and documentation for patient (ID#1).

Interview with guest relations staff (ID# 55) on 11/7/23 at 1355 stated that there was no documented grievance for patient (ID#1). He also stated that communication in email thread provided by (ID# 59) would meet the definition of a grievance.

Based on record review and interview, the facility failed to ensure medications were administered as physician order in 3 of 6 patient medical records reviewed (ID#s 1, 2, and 7).

Findings include:

Record review of facility policy titled "Medication Administration" dated 01/31/2023 showed the following information:
III. Procedure
A. Administering Medications
1. Verify physician/ APP order
2. Check medication stop date as ordered, as applicable
5. The nurse administering the medication should ascertain the following:
a. Right medication
b. Right patient
c. Right dosage
d. Right route
e. Right time
f. Right reason for which the medication is being administered


Review of medical record for patient (ID #1) showed order for propofol (DIPRIVAN) continuous infusion 10mg/mL dated 10/7/22 at 1445. D/C (discharge) order was written on 10/8/22 at 1129. The continuous infusion was stopped 10/7/22 by RN (ID# 68) at 1604.
The medical record showed no documented reason for infusion to be stopped prior to D/C order.


Review of medical record for patient (ID# 2) showed order for Acetaminophen (TYLENOL) 650 mg tablet, oral, every six hours PRN (as needed) for fever, Fever GREATER than 100.5 F. Medication Administration record for patient (ID# 2) showed medication administration 9/17/22 at 0132. Documented temperature for patient (ID #2) closest prior to administration was 97.8 F on 9/16/23 at 1900.

Review of medical record for patient (ID# 7) showed order for Acetaminophen (TYLENOL) 650 mg tablet, oral, every six hours PRN (as needed) for mild pain (score 1-3). Medication administration record for patient (ID#7) showed administration of Acetaminophen 650mg oral on 10/31/23 at 1538. Pain documented for patient (ID# 7) prior closest to administration was documented at "0" at 1500 on 10/31/23.

Review of medial record for patient (ID# 7) also showed order for fentanyl (SUBLIMAZE) injection 25 mcg, IV (Intravenous), every 2 hours PRN for severe pain (score 7-10). Medication Administration Record for patient (ID#7) shows administration of fentanyl 25mcg by RN (ID# 70) on 11/4/23 at 0533, with pain documented at 0533 of "0".

Interview with RN staff (ID# 65) on 11/8/23 at 1005 confirmed the above findings.

Based record review and interview, the facility failed to follow established process for requesting to amend protected health information (PHI) in 1 of 1 patient (ID#1).

Findings include:

Record review of facility policy titled "Patient's Right to Request an Amendment of Protected Health Information" dated 11/21/2022 showed the following information:

I. POLICY AND GENERAL STATEMENT

Houston Methodist respects the patient's right to request an amendment protected health information. Exceptions to information that may be amended, and the circumstances in which Houston Methodist may deny a patient's request for amendment, are provided by law.

III. PROCEDURE
A. Patient's Request for Amendment of PHI
1. Is that if a patient disagrees or believes his/her Phi is incomplete or incorrect, the patient has the right to request an amendment of this information.
2. All requests will be directed to the health information management (HIM) department for handling. The HIM department will provide a patient with the request for amendment form to complete.
4. If the patient does not submit the amendment request form but does provide a written request, the request must contain the following elements:

a. patient's name;
b. patient state of birth, Social Security number, or medical record number
c. patients mailing address
d. date and description of information to be amended
e. reason for amendment
f. dated signature of patient or QPR (and legal authority of such individual, if the request is not signed by the patient).

F. Denying a Request for Amendment

1. A request for amendment will be denied if:

a. Houston Methodist did not create the PHI, unless the originator of the information is no longer available to act upon the requested amendment;
b. Houston Methodist designated record set does not contain the PHI in the request;
c. information is not available for patient access and addressed in Houston Methodist policy, IM08 ...
d. PHI Is accurate and complete

2. If the amendment is not accepted, based upon the review and determination of the author of the entry, the HIM department will provide the patient with a timely written denial.

3. The denial will be written in plain language and contain:

a. the basis for the denial;
b. The patient's right to submit a written statement disagreeing with the denial and how the patient may file such a statement. The patient will be directed to send the statement of disagreement to Houston Methodist
c. a statement that, if the patient does not submit a statement of disagreement, the patient may request that Houston Methodist provide the patients request for amendment and the denial with any future disclosures of the Phi that is subject of the amendment; and
d. a description of how the patient may complain to Houston Methodist or the secretary of the Department of Health and Human Services. Since Houston Methodist's Entity Business Practices Officer provides oversight for the complaints process, the description will provide this individual's name or the title and telephone number as contact person, or the name or title and telephone number of a designee assigned by the Houston Methodists entity business practices officer ...

Interview with pathologist (ID# 58) on 11/7/23 at 1330 she stated that she received a call from family member of patient (ID#1) stating that she disagreed with the clinical history in the autopsy report and requested that it be amended. She stated that she did not know how the call was routed directly to her. She stated that she discussed the request Director of Autopsy (ID# 64) and it was decided that change would not be pertinent to her report.

Interview with Medical Director of Pathology (ID# 63) on 11/7/23 at 1335 she stated that she also was included in a discussion to amend the autopsy report. She stated that she advised pathologist (ID# 58) not to make the change as clinical history is not a requirement and it was already incredibly comprehensive. When asked if the family member was referred to medical records with their request, she stated "No, the report is not part of the medical record."

Interview with HIM Director (ID# 56) on 11/7/23 at 1343 she stated that the autopsy is part of the medical record when performed at the facility. She confirmed that there was no documented request for the amendment of autopsy report for patient (ID#1).