HospitalInspections.org

Based on document review and interviews, the facility failed to:

1. have a policy or process to administer Midazolam (Versed-a benzodiazepine medication commonly used for sedation and anesthesia) off label (using a drug for a purpose not specifically approved by the FDA) for the use of a psychiatric behavioral medication emergency in 2 of 2(#7 and #17) patient charts reviewed.

2. ensure a physician assessed and reassessed patients before and after the administration of a chemical restraint.

3. ensure a physician performed a face-to-face evaluation within 1 hour of the administration of the chemical restraint in 2 of 2 (#7 and #17) patient charts reviewed.

4. ensure nursing deescalated, assessed, and reassessed 2 of 2 (#7 and #17) patient charts reviewed after the administration of a chemical restraint.

Refer to Tag A0160

Based on review, observation, and interviews, the facility failed to;
A. ensure nursing was assessing and reassessing patients for skin breakdown, potential for breakdown, and pain control in 1 of 1 (#9) patient charts reviewed.

B. provide nursing documentation for patient assessments, incontinent care provided, turning and repositioning schedules for the patient, and assistance for ADLs (Activities of Daily Living such as Bathing, Dressing, Toileting, and Eating) to prevent further skin breakdown in 1 of 1 (#9) patient chart reviewed.

Refer to A395


10135

The facility failed to ensure there were sufficient numbers of nurses and personal care attendants on 2 of 2 units reviewed for staffing (Hospital B 6th floor Medical Surgical unit and Hospital A 3 South Tower Surgical unit).

Hospital B 6th floor Medical Surgical unit was either short a Registered nurse (RN) or a Patient care technician (PCT) 10 out of 15 days during the timeframe of 03/04-18/2025.

Hospital A 3 South Tower Surgical unit was either short Registered nurses (RNs), Licensed vocational nurses (LVNs) or Patient care technicians (PCTs) 15 out of 15 days during the timeframe from 03/06-20/2025.


Refer to A0392 for additional information.



The facility failed ensure nursing kept current care plans that met the patients' needs in 3 of 23 sampled patients (Patient #'s 9, 10 and 12). The facility failed to ensure:

Patient #10 was started on a feeding timely after the family changed their mind about Hospice services 11/29/2024. Patient #10 was started on a tube feeding 6 days later on 12/05/2024.

Patient #12 received daily weights and accurate intake and outputs as ordered by the physician. Staff failed to ensure
Patient #12 received follow-up pain assessments after administration or pain medication. Facility staff failed to ensure there was treatment orders for Patient #12's peritoneal dialysis (PD)port site.

Patient #9 had care plan addressing skin breakdown. The skin breakdown included a surgical site to and an unstageable pressure sore.

Refer to A0396 for additional information.

Based on observation and interviews the facility failed to ensure that the infection control program maintained a clean and sanitary environment to avoid the transmission of infection in 2 of 2 (Hospital A-ER and Hospital B ER-Pharmacy) departments.

Refer to Tag A0750

Based on document review and interviews, the facility failed to:

1. have a policy or process to administer Midazolam (Versed-a benzodiazepine medication commonly used for sedation and anesthesia) off label (using a drug for a purpose not specifically approved by the FDA) for the use of a psychiatric behavioral medication emergency in 2 of 2(#7 and #17) patient charts reviewed.

2. ensure a physician assessed and reassessed patients before and after the administration of a chemical restraint.

3. ensure a physician performed a face-to-face evaluation within 1 hour of the administration of the chemical restraint in 2 of 2 (#7 and #17) patient charts reviewed.

4. ensure nursing deescalated, assessed, and reassessed 2 of 2 (#7 and #17) patient charts reviewed after the administration of a chemical restraint.


The facility had one provider number and one license number but had two hospitals on different campuses. Hospital- A was in Kingwood, and Hospital- B was in Cypress. The facilities had shared Governing Board meetings and Medical Staff meetings but two different CEOs.



Patient #7

A review of patient # 7's medical chart revealed he was a 24-year-old male who arrived at Hospital B's Emergency Room (ER) on 8/30/24 at 1605. A review of the physician notes on 8/30/24 at 1511 stated, "24-yo male with past medical Struve anxiety, MDD, presents with complaints of suicidal ideation that has been going on since last month. Patient states that he wants to run across the freeway. Patient stated that he started taking his Lexapro and hydroxyzine a month ago. Patient reports he previously has been on it but has been off for some time. Patient also reports that he wants to beat up his male ex best friend. Patient is on EDO. Patient has previously been admitted to an inpatient psychiatric facility. Patient denies any other symptoms". Also, the physician documented that the patient was "alert and oriented, suicidal, and homicidal ideation."

A review of the medical record revealed that the physician ordered a case manager referral. The case manager interviewed patient #7 on 8/30/24 and recommended inpatient care along with the Mental Health Authority. The Case manager proceeded to send admission criteria forms to multiple facilities to find inpatient psychiatric care for the patient.

On 9/3/24, patient #7 was administered a Broset test. According to Nih.gov, the Broset Violence Checklist (BVC) is a tool used to assess the potential for violence in patients, especially within healthcare settings. It's a 6-item checklist that helps predict imminent violent behavior by identifying specific behaviors like confusion, irritability, and threats. The BVC is used to help healthcare professionals take preventative measures and develop management plans.

Scoring:
Each behavior is scored as 0 (absent) or 1 (present). The scores are then totaled, and the total score indicates the level of risk: 0 = low risk, 1-2 = moderate risk, and 3+ = high risk. Patient #7 had been administered the test each shift with a score of 0.

A review of the nurse's notes dated 9/1/24 at 0724 revealed the test was given to patient #7. The findings revealed;
- - BROSET - -
Able to complete the Broset: Yes
Confused: No
Irritable: No
Boisterous: No
Verbal threats: No
Physical threats: No
Attacking objects: No
Broset score total: 0
Broset risk type: Small"

A review of the nurse's notes dated 09/01/24 was as follows:

"1650- "PT REFUSING TO TAKE SHOWER, PT STATES, "I DON'T CARE ANYMORE AND I'M FINE". THE PT STATES "IF I HAD KNOWN I WAS GOING, TO HAVE TO WAIT THIS LONG TO GO TO A PLACE I WOULD NOT HAVE CALLED 911 TO COME GET ME". "I AM READY TO LEAVE THIS PLACE". PT DECLINES ANY FURTHER INTERVENTIONS. PT WILL NOT ALLOW VITALS TO BE OBTAINED AND ATTEMPTED TO REMOVE THE IV.

Patient #7 was on every (q) 15-minute checks from the sitter.

1657- PT IS DEMONSTRATING WITHDRAWN BEHAVIOR. HE HAD A VISIT TODAY FROM HIS WIFE/GIRLFRIEND. SINCE THE VISIT, HE HAS BECOME DESPONDENT AND ASKING TO BE LEFT ALONE. PT STATES, "I AM USED TO BEING IGNORED".

1705- PT REFUSED TO REMOVE THE SHEET FROM HIS HEAD WHEN ASKED BY THE STAFF. SECURITY ATTEMPTED TO REMOVE THE SHEET. THE PATIENT BECAME COMBATIVE AND HOSTILE. CHARGE NURSE ______, TWO SECURITY OFFICERS, AND A SITTER IN THE ROOM. DR. WU NOTIFIED OF THE PATIENT'S BEHAVIOR. MEDICATION ORDERED."

Further review of the medical record revealed there was no documentation of any de-escalation attempts, no documented evidence on how the patient was combative or hostile (such as verbal, physical, or both). The nurse documented that the patient had a sheet over his head. There was no documentation on why this was a problem. There was no documentation that the patient was attempting to harm himself with the sheet.

A review of the physician orders revealed that patient #7 was ordered;

Droperidol 2 mg intramuscular (IM) x1 (primarily used as an antiemetic and can be used as a sedative and tranquilizer for managing agitation). The Medication Administration Record (MAR) stated the medication was administered by the nurse at 1715 in the left buttock.

Versed 5mg IM x1 (sedative primarily used as a moderate sedation before surgery or during a procedure) This drug may cause amnesia and requires monitoring. (Adverse effects: variations in blood pressure and heart rate, impaired balance and gait, sedation, respiratory depression, and retrograde amnesia. Adverse effects may be potentiated by other medications (like analgesics). The MAR stated the nurse administered the medication at 1708 in the left arm.

Benadryl 50mg IM x1 (Antihistamine) The MAR stated the nurse administered the medication at 1708 in rt buttocks. There was no documentation that the patient was held to administer these medications.

The nurse documented on 9/1/24 at 1807 that "Pt declined the dinner tray. Will hold at nurses' station until he decides when he wants to eat" 1938 Pt in room eating dinner tray. Patient calm and cooperative at this time. When asked how he's feeling replies, "I'm OK." I'll continue to assess behavior."

A review of the nurse's notes revealed there were no vital signs taken until 9/1/24 at 1957, 3 hours post medication administration. There was no documentation that Patient #7 refused a vital signs assessment before 1957 (7:57 PM).

A review of the policy and procedure titled, "Patient Restraint Policy," failed to address the use and monitoring of chemical restraints/ emergency behavioral medications.

A review "Addendum 2: 09/01/24 1709 ______(by ER physician)Patient Addendum -1708: patient agitated, aggressive, yelling, trying to leave, requiring chemical restraint with droperidol, versed, benadryl IM." There was no face-to-face performed or documented. There was no physician assessment documented from a physician on 9/2/24. The next documentation by a physician was on 9/3/24 at 0630.




Patient #17

A review of Patient #17's medical record revealed he was a 15 y/o male brought to hospital A's ER on 3/6/25 at 1239 for suicidal ideations. A review of the physician notes dated 3/6/25 at 1250 stated, " 15-year-old male brought in by parents for concerns of aggressive behavior. According to mom and dad patient has had aggressive behavior. Does have a past medical history significant for aggressive behavior and depression for which he is on Risperidone, Abilify and Prozac. According to mom she states that he is a pathological liar and likes to skip school. He is made multiple accusations of sexual misconduct against teachers and principals at school and parents have had to change multiple schools because of his accusations and his behaviors and his refusal to go to school. Mom also suspects that he uses hard drugs to which the patient attests. He states he uses alcohol and marijuana almost daily. He also does methylphenidate, heroin and fentanyl injectables almost on a daily basis. Has multiple different drug dealers that come and go into the house. He has threatened to kill mom and dad and his siblings. Today got into an altercation at this time which is what prompted parents to call the cops and patient was placed in an EDO and brought to the emergency department. Attested to suicidal ideation to the nursing, staff, to me and to the psych assessor ...Acute Problem list: SI, Aggressive Behavior ...Psych assessor was able to evaluate the patient and recommended inpatient treatment. Patient has had a total of 3 rounds of conversation with the psych assessor and parents are on board with inpatient placement. Will initiate inpatient placement. Is requesting a fourth round of conversation with the psych assessor. Signed out to incoming physician awaiting transfer to a psych facility once accepted."

A review of the nurses notes dated 3/6/25 at 1250 stated, "- - SUBJECTIVE ASSESSMENT - -
Patients description of reason for visit:
PATIENT IS HERE FOR EVALUATION FOR VOMITING BLOOD OVER THE LAST SEVERAL DAYS /W ABDOMINAL PAIN. HISTORY OF GERD, EOE, POTS. SAYS HIS STOMACH HURTS AND HE CANNOT EAT. PATIENT ALSO DESTROYED PARENTS HOUSE EARLIER AND HE WAS ANGRY AND UPSET. PATIENT HAS BEEN SKIPPING SCHOOL AND WALKING HOME, WHICH UPSETS MOM. PATIENT REPORTS HE LEAVES SCHOOL BECAUSE THE ASSISTANT PRINCIPAL AT KINGWOOD HIGH SCHOOL IS FLIRTING WITH HIM AND ASKING FOR SEXUAL FAVORS. SAYS HE HAS NOT REFORTED IT BECAUSE NOBODY WILL BELIEVE HIM. PARENTS REPORT HE TOOK SOMETHING AND PATIENT ADMITS TO DRUG USE BEFORE ARRIVAL. PATIENT ADMITS TO SMOKING MARIJUANA, USING METH, INJECTING "DIRTY 30" WICH IS FENTYNAL AND PERCOCET TOGETHER. SAYS HE HALLUCINATES WHEN HE IS WITHRAWLING FROM DRUGS. SAYS HE GETS MAD AND HEARS THINGS. PAST TRAUMA OF SEXUAL ABUSE. STARTED USING DRUGS AT AGE 12. PATIENT SAYS HE HAS BEEN SUICIDAL AND HOMICIDAL IN THE PAST. SAYS HE DOES NOT WANT TO GO BACK TO A PSYCH FACILITY. SAYS HE WILL "SLIT HIS THROAT" IN FRONT OF EVERYONE IF HE HAS TO GO BACK. SAYS HE WANTS TO IMPROVE HIS RELATIONSHIP WITH HIS MOTHER. SAYS IF IT DOES NOT IMPROVE IN 1 MONTH HE WILL "BLOW HIS BRAINS OUT".

A review of the nursing notes revealed the patient had vital signs taken at 1250.

On 3/6/25, at 1430, the nurse documented, "Virtual sitter in place waiting for pts physical sitter. Patient remains calm and cooperative." 1530 sitter in place patient calm and cooperative ...1735- Pt agitated, does not want to stay as inpatient per teledoc recommendation Charge ERN spoke with pt and with mom. Mom agrees pt needs to stay for inpatient therapy. 1745 Pt loud voice, screaming obscenities "Fuck You" at mom and stepdad. Security called. 1804 Pt stated to the RN administering the meds, "tell my mom bye." Security officers x2 with RNs adm meds IM. Pt cooperative with med administration."

A review of the MAR revealed the physician ordered Haldol 5 mg slow IV push x1 and Versed 2mg IV x1. on 3/6/25 at 1759. The nurse was unable to give IV due to pt removed IV and medication was given IM, but there was no order to change route for Haldol or Versed. The nurse documented, "ED MD aware and ok with adm route." There was no documentation of de-escalation techniques used, there was no other behaviors documented other than screaming obscenities. There was no documentation of nurse observation during and after the administration of a moderate sedation drug, there were no vital signs taken until the patient was discharged at 2200.

A review of the MD notes for 3/6/25 revealed a note on 03/06/25 at 1830: that stated, "I assumed care of this patient from the previous physician. Briefly, this is a 50-year-old (sic) male with an extensive psychiatric history with multiple psychiatric hospitalizations who came in after an altercation with his stepfather. Reportedly has been skipping school and being generally disruptive. In the Emergency Department, he became agitated, which warranted treatment with haloperidol and midazolam."

There was no documentation from the current or previous physician about the patient's behaviors, if the patient was assessed before administering chemical restraints, or if the physician was aware of the medication administered by IM route. There was no documentation of a 1-hour face-to-face evaluation.

An interview was conducted with staff #15 on 3/18/25 from hospital A. Staff #15 was asked for a restraint log. Staff #15 was able to produce a mechanical restraint log but not for chemical restraints. Staff #15 confirmed there was no restraint log for chemical restraints. She stated the logs could be pulled for violent and nonviolent restraints, but the facility was unable to provide one to the surveyor upon multiple requests.

An interview was conducted with Staff # 67, the Director of QAPI, and the Chief Nursing Officer (CNO) for Hospital B on 3/19/25. The CNO stated that she was not aware of the physician administering Versed to patients for a psychiatric emergency. The CNO stated the facility did not have any policy or process for medical staff to use Versed off label for psychiatric emergencies. Staff # 67 stated that she was also unaware of the ER physicians ordering Versed as medication in a psychiatric emergency. Staff #67 stated that chemical restraints were not being monitored for restraint use in QAPI.

An interview was conducted with the CEO of hospital B on 3/19/25. The CEO stated that the physicians have been notified and a memo was sent out to ED providers, Medical Director, Regional Medical Director, and Chief of Staff. The memo stated, "Use of Versed and Other Moderate Sedation Drugs on Behavioral Health Patients. Effective immediately, please cease the use of Versed and other off-label prescribing of moderate sedation drugs for behavioral health patients. In the coming days, we will convene the Pharmacy and Therapeutics Committee of the Medical Staff and Medical Executive Committee to revisit and revise our hospital policy to comply with state regulation. Please note that the utilization of anti-psychotic drugs for this patient population is acceptable. We wish to prevent off-label uses of moderate sedation drugs that do not comply with our current policy or that are not accompanied by appropriate patient safety monitoring and safeguards. Once Pharmacy and Therapeutics, Medical Executive Committee, and Board of Trustees have approved revised policy, we will communicate what is acceptable under such policy. In the interim, we will share a list of those medications on formulary that are acceptable to prescribe in these circumstances. Please note that this direction comes in follow-up to a recent survey by Texas Department of Health." The CEO of Hospital A also provided the same letter to the physicians of the ER at Hospital A.

An interview was conducted with Staff #52 and #6 on 3/20/25 at hospital A concerning the use of Versed. Staff #52 confirmed that patients from hospital A's ER had also received Versed for behavioral health emergencies. Staff #6 stated that she was addressing restraints in QAPI but did not have any data or information to provide on chemical restraints for violent patients.


47892


An interview was conducted on April 3, 2025, after 3:30 PM with Staff #14. Staff #14 was asked if Patient #17 was continuously monitored by an RN trained in moderate sedation after he received an injection of Versed. Staff #14 stated that Patient #17 "had a patient sitter with a direct line of sight to Patient # 17 located outside his doorway." Staff #14 was asked was the patient sitter an RN with moderate sedation training. Staff #14 stated, "Patient sitters are not RNs."

Based on interview and record review, the facility failed to ensure there were sufficient numbers of nurses and personal care attendants on 2 of 2 units reviewed for staffing (Hospital B 6th floor Medical Surgical unit and Hospital A 3 South Tower Surgical unit).

Hospital B 6th floor Medical Surgical unit was either short a Registered nurse (RN) or a Patient care technician (PCT) 10 out of 15 days during the timeframe of 03/04-18/2025.

Hospital A 3 South Tower Surgical unit was either short Registered nurses (RNs), Licensed vocational nurses (LVNs) or Patient care technicians (PCTs) 15 out of 15 days during the timeframe from 03/06-20/2025.


This deficient practice had the likelihood to cause harm to all patients on the units.


Findings include:


Hospital B 6th floor Medical Surgical unit



During confidential interviews the following was stated about staffing:

"Lately staffing is kind of short. We are supposed to have 4 nurses and 1 charge nurse. When there's not enough the charge nurse has to take patients. Sometimes we do not have techs. If respiratory is short staffed, we have to do the breathing treatments. The most patients we take is 6, but if there is no tech, one tech or no charge nurse that is too much. You can't do the nursing part of the job. Somethings are passed on to the night shift."

When it comes to staffing" some days are better than others. Somedays there is not enough, and the charge nurse has to take a full load. The techs are 1:12 patients when there are 2 techs here. If there are not enough techs the nurses take on some of their assignments. When there is no free charge nurse there is no resource person for the floor."

"It would help to have an acuity tool. An acuity tool is in the making."


Review of "MS6 ASSIGNMENT SHEETS" and Staffing Grid Department Data Report revealed the following:

On 03/16/2025 there was a census of 23 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was no charge nurse (CN), 4 registered nurses (RN) and 2 personal care technicians (PCT) working. The staffing matrix called for 1 CN, 4 RNs and 2PCTs. The floor was short a free-floating charge nurse.

On 03/16/2025 there was a census of 24 on the 7:00 pm - 7:00 am shift. According to assignment sheets there was 1 CN, 4 RNs and 1 PCT working. The staffing matrix called for 1 CN, 4 RNs and 2 PCTs. The floor was short a PCT.

On 03/15/2025 there was a census of 22 on the 7:00 pm - 7:00 am shift. According to assignment sheets there was 1 CN, 4 RNs and 1 PCT working. The staffing matrix called for 1 CN, 3 RNs and 2 PCTs. The floor was short a PCT.

On 03/14/2025 there was a census of 21 on the 7:00 am - 7:00 pm shift. According to assignment sheets there was no CN, 4 RNs and 2 PCTs working. The staffing matrix called for 1 CN, 4 RNs and 2 PCTs. The floor was short a free-floating charge nurse.

On 03/14/2025 there was a census of 21 on the 7:00 pm - 7:00 am shift. According to assignment sheets there was 1 CN, 4 RNs and 1 PCT working. The staffing matrix called for 1 CN, 3RNs and 2 PCTs. The floor was short a PCT.

During an interview on 03/19/2025 after 1:25 p.m., Staff #35 said the extra RN did on-line education during the shift.

On 03/13/2025 there was a census of 21 on the 7:00 am - 7:00 pm shift. According to assignment sheets there was no CN, 4 RNs and 1 PCTs working. The staffing matrix called for 1 CN, 4 RNs and 2 PCTs. The floor was short a free-floating charge nurse and a PCT.

On 03/13/2025 there was a census of 24 on the 7:00 pm - 7:00 am shift. According to assignment sheets there was no CN, 4 RNs and 2 PCTs working. The staffing matrix called for 1 CN, 4RNs and 2 PCTs. The floor was short a free-floating charge nurse.

On 03/12/2025 there was a census of 24 on the 7:00 pm - 7:00 am shift. According to assignment sheets there was no CN, 4 RNs and 2 PCTs working. The staffing matrix called for 1 CN, 4RNs and 2 PCTs. The floor was short a free-floating charge nurse.

On 03/07/2025 there was a census of 21 on the 7:00 am - 7:00 pm shift. According to assignment sheets there was 1CN, 4 RNs and 1 PCT working. The staffing matrix called for 1 CN, 4 RNs and 2 PCTs. The floor was short a PCT.

On 03/06/2025 there was a census of 22 on the 7:00 am - 7:00 pm shift. According to assignment sheets there was 1CN, 4 RNs and 1 PCT working. The staffing matrix called for 1 CN, 4 RNs and 2 PCTs. The floor was short a PCT.

On 03/04/2025 there was a census of 24 on the 7:00 pm - 7:00 am shift. According to assignment sheets there was 1CN, 4 RNs and 1 PCT working. The staffing matrix called for 1 CN, 4 RNs and 2PCTs. The floor was short a PCT.

During an interview on 03/19/2025 after 1:25 p.m., Staff #35 confirmed the shortages in staff.



Hospital A 3 South Tower Surgical unit

During confidential interviews the following was stated about staffing:

"The unit has 36 beds. The staffing ratio is 6:1 for nurses and 12:1 for PCT's. Because of high volumes I would like to see 1:5. This unit is medical, surgical, orthopedics, telemetry and trauma."

PCT's "get 12 patients regularly, but occasionally more. We are able to get the work done it just takes longer."

"Sometimes there are not enough PCT's. If we have 3 techs we have 12 patients. Can't get all our task done if we are taking more patients. Examples given were Chlorhexidine baths not done and turning and repositioning are done every 2-4 hours."

The patient to nurse ratio is "6:1 and this is a trauma unit and it's difficult at times. There are high turnover for admissions and discharges, acuity of patients high and were getting a little bit of everything." As far as PCT's "sometimes there are enough and the nurses pitch in with care when there's not enough."

"Charge nurse takes patients if there are not enough nurses. When we are lucky, we have 3 PCT's, but were averaging two. Day shift nurses have to help with cleaning patients, baths and vital signs. The night shift has to get their own vitals. With a 6: 1 ratio it is hectic. Patients have chest tubes, high acuity and total bedbound. One time I had a patient that was having seizures every 1-3 minutes and also had 5 other patients to take care of. 5:1 is an ideal ratio."


"We have been trying to get something done. It is almost impossible to take care of patients. Nurses go home crying."


"Not enough and were not supposed to talk about it. The ratio is 6:1 and it's too many. We have a high rate of admissions and discharges. About 10-11 patients per shift, people coming and going for procedures, and assessments of patients in the AM. It's hard to feel like we are spending quality time with patients. We have surgical patients who are non-ambulatory and can't turn themselves. Somedays there are not enough techs to keep the butts dry. Three techs are not enough, we need 4. They pull our staff to other floors. We should not be running without a charge nurse because we have a lot of LVN's. That responsibility falls on the RN's. We are getting IMC and IMU stepdown patients. When Rapid response comes and assesses a patient, that patient is left here and unstable until moved. The nurse also has 5 other patients with that unstable patient. Patients are inappropriate for this floor. They can't turn these people every two hours. I think pressure sores are directly related to the staffing. We get violent patients who are pending charges."

"We have high acuity patients, complex, a lot need close monitoring, have tubes, drains, foley catheters, and nasogastric tubes. We are a medical surgical unit on paper, but we are orthopedic, trauma, bariatric, general surgery, and snake bites. Everybody is so tired (physically) and tired of the ratio. A while ago there was no free charge nurse and last night there was only one tech for the entire floor. We are supposed to have 3 techs. It is too many people to change and turn and it I not done as often as it should. I don't feel like I can care for the people like I should because I don't have time. It's not in the budget to have the staffing we need. I get anxiety when I come to work."

Staffing "is dangerous. We have 1:6 patient ratio and the acuity are so high. I don't feel we give the patient care we should give because we don't have the time. When a Rapid response is called on a patient your other 5 patients may suffer.The emergency department does not call report sometimes. You get a text from the unit secretary saying the new patient is in the room. The techs are burnt out. Two techs with this acuity, they barely have time to care for the patients."


Review of the facility's Daily Rosters and Staffing Grid Department Data Report revealed the following:

On 03/20/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 charge nurse (CN), 4 registered nurses (RN), 2 licensed vocational nurses (LVN) and 3 personal care technicians (PCT) working. The staffing matrix called for 1 CN, 4 RNs, 3LVNs and 3 PCTs. The floor was short an LVN.

On 03/19/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was no CN, 3 RNs, 2 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1CN, 1 RN and 1LVN.

On 03/19/2025 there was a census of 34 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was 1CN, 4 RNs, 2 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 PCT.

On 03/18/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1CN, 3 RNs, 2 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN and 1LVN.

On 03/18/2025 there was a census of 36 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was 1CN, 4 RNs, 2 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN.

On 03/17/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 4 RNs, 2 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1CN, 1 LVN and 1 PCT.

On 03/16/2025 there was a census of 35 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was no CN, 4 RNs, 2 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 CN and 1LVN.

On 03/16/2025 there was a census of 36 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was no CN, 4 RNs, 2 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 CN and 1 PCT.


On 03/15/2025 there was a census of 32 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was no CN, 5 RNs, 1 LVN and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 CN and 1 PCT.

On 03/14/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 3 RNs, 3 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN.

On 03/14/2025 there was a census of 32 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was no CN, 4 RNs, 2 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 CN.

On 03/13/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 3 RNs, 3 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN.

On 03/13/2025 there was a census of 35 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was no CN, 6 RNs, and 3 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 CN.

On 03/12/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1CN, 3 RNs, 3 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN and 1 PCT.


On 03/11/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1CN, 3 RNs, 3 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN.

On 03/10/2025 there was a census of 34 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 3 RNs, 3 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 PCT.

On 03/10/2025 there was a census of 36 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was 1 CN, 4 RNs, 2 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 PCT.

On 03/09/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 2 RNs, 4 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 2 RNs and 1PCT.

On 03/09/2025 there was a census of 36 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was 1CN, 4 RNs, 2 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 PCT.

On 03/08/2025 there was a census of 35 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 4 RNs, 2 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 LVN and 1 PCT.


On 03/08/2025 there was a census of 36 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was 1 CN, 4 RNs, 2 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 PCT.

On 03/07/2025 there was a census of 35 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 3 RNs, 3 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN.

On 03/06/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 3 RNs, 3 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN.

On 03/06/2025 there was a census of 36 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was no CN, 5 RNs, 1 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 CN.

During an interview on 03/20/2025 after 11:05 a.m., Staff #47 confirmed the shortages and stated they were not using to the current staffing matrix. They were told by their division about 3 weeks ago that they have to staff 1 CN, 3 RNs, 3 LVNs and 3 PCTs.


Review of the facility's policy named "Nursing Master Staffing Plan with Guidelines for Staffing and Assignments" effective 04/2023 revealed the following:
"Purpose:

To ensure that a written facility plan for nurse staffing that ensures an adequate number and skill mix of nurses is developed, communicated, and adapted as necessary.

Policy:
...2. Each patient care unit will be staffed in accordance with established guidelines that consider the following:
a. Acuity of patients,
b. Scope of services provided,
c. Levels of intensity of the patients for whom care is being provided,
d. Contextual issue (architecture, geography, availability of technology) and,
e. Level of preparation and experience of those providing care (number, competency, and skill mix) ...."

Based on review, observation, and interviews, the facility failed to;
A. ensure nursing was assessing and reassessing patients for skin breakdown, potential for breakdown, and pain control in 1 of 1 (#9) patient charts reviewed.

B. provide nursing documentation for patient assessments, incontinent care provided, turning and repositioning schedules for the patient, and assistance for ADLs (Activities of Daily Living such as Bathing, Dressing, Toileting, and Eating) to prevent further skin breakdown in 1 of 1 (#9) patient chart reviewed.

The facility had one provider number and one license number but had two hospitals on different campuses. Hospital- A was in Kingwood, and Hospital- B was in Cypress. The facilities had shared Governing Board meetings and Medical Staff meetings but two different CEOs.

A review of patient # 9's medical chart revealed she was admitted to hospital A on 2/17/25 at 15:09. Patient #9 was living in a skilled nursing facility after she had a right above the knee amputation and had developed a wound to her upper rt groin. The rt above the knee amputation surgical site had dehisced (gape or burst opened), causing gangrene of the wound.

A review of the physician notes dated 2/17/25 stated, "HISTORY OF PRESENT ILLNESS: A 64-year-old female who is known to have diabetes hypertension, stroke, right-sided weakness had a right BKA because of the peripheral vascular disease and diabetic leg. She presented to the hospital with a nonhealing wound. She has a wound VAC dressing on the right BKA recently done. Deny any fever or chills, not healing. She has been touching the wound for a long time now. She has a midline. She was getting antibiotics through the midline.

ASSESSMENT AND PLAN: The patient was seen by ____ (physician), status post above-knee amputation, worsening right-sided wound, diabetes, hypertension, right groin wound with serous discharge, purulent s panning from the right groin. Blood cultures were negative. The patient requires wound VAC, which has been placed, but the whole healing area on the distal aspect of the stump has become gangrenous with a smell. I think it is more of a surgical case and therefore, I am going to consult the surgical team and to refashion the stump, I explained to the family at the bedside and they show full understanding and we have to refashion the wound, we have to give antibiotic judiciously and continue with penem (antibiotic) and Zyvox (antibiotic) ..."

A review of the medical chart revealed that patient #9 was admitted to the 4ST medical floor on 2/17/25. There were no pictures taken of the patient's buttocks or sacrum.

A review of wound care notes dated 2/18/25 at 2025 revealed the wound care specialist (WCS) documented they were consulted to address the rt above the knee amputation (AKA) and rt groin wound. There was no documentation that the WCS documented any other wounds nor if the WCS did a skin assessment to look for any further wounds on the following assessments documented for 2/18/25, 2/20/25, and 2/22/25.

A review of patient 9's chart revealed she was moved to unit 3300. Nursing notes and photographs were found documented on 2/25/24 at 10:00 am. The unit nurse documented that the wound to the buttocks was a Maceration (softening and breakdown of skin due to prolonged moisture exposure) Posterior buttocks bilateral (both sides). There were pictures taken but no documented measurements or staging. The wound was described as "beefy red" with bloody drainage. A dressing was placed on the wound. The unit nurse also documented, "Peri area noted maceration, transferred from other unit. Some open areas noted, skin cleansed and Triad applied, pt placed on air mattress." There was no documented staging or written measurements. The nursing note was provided by the wound care nurse during the patient chart review on 3/20/25.

A review of the nurse's notes dated 2/25/25 at 0830 stated the patient was non-ambulatory and required a 2-person assist. The patient was weak in all extremities. An "adult skin risk" assessment stated the patient was bedfast, mobility very limited, probably inadequate nutrition and potential problem for friction and shear. "Risk for pressure injury." PT documented that the patient was in too much pain to participate in PT at 1320. There was no documentation that the nurse was aware that the patient's pain had been addressed or treated. There was no nursing documentation of turning the patient or incontinent care until 2/26/25 at 0024. The nurse documented, Hygiene care provided: Extensive 2-person assist, 2-person assist with perineal care provided, and oral care provided. There was no documentation that the patient had received any other incontinent care or was being turned to prevent skin breakdown.

There were no further nurses' notes provided from 2/27/24 until 3/7/25. The surveyor was unable to determine if the patient was being turned, given ADLs, or addressing pain during this time period.

On 2/27/25, the WCS documented wound care to the right groin and right AKA, but there was no documentation of the maceration to the buttocks or peri area, and no photos were found.

On 2/28/25, patient #9 was transferred from unit 3300 to 3N per the notes provided by the WCS. No pictures were taken of the wound on her buttocks at the time when she arrived to 3N.

A review of the Medication Administration Record (MAR) dated 3/1/25 at 1514 revealed the patient had a pain level of 10 on a pain scale of 1-10 being the worst. Patient #9 was administered Hydromorphone (narcotic) 0.25mg was administered IV. The nurse documented again at 1613 that a reassessment of the pain medication was done, but there was no documentation that the patient had any pain relief or what the patient's pain level was.

On 3/1/25 at 1649, the WCS documented that the patient had a surgical revision to the AKA on 2/28/24. The WCS documented, "Patient had a right revision on 2/28/25. Wound vac in place with adequate seal. Attempted dressing change to right groin wound, and patient started slapping wound care nurse and yelling, 'No, No. Will attempt dressing change at a later date." There was no further documentation that the nurse attempted at a later time that the patient's pain was assessed or any attempt to find out why the patient did not want the dressing changed.
On 3/3/25 at 1025 a.m., the WCS documented wound care to the right leg and groin, but there was no documentation that the patient was assessed for any further wounds, and there were no pictures or treatments to the buttocks area.

On 3/4/25, patient # 9 was transferred back to 3300 per the notes provided by the WCS. Patient #9's buttocks and sacrum had gone from a small wound to an unstageable wound, which was a reportable pressure injury. A review of the information provided by WCS revealed a picture of the buttocks and the left heel. There were no notes on the sizes or stage.

On 3/5/25 at 1427, the WCS documented, "Left Buttock: Unstageable pressure injury (HAPI- Hospital Acquired Pressure Injury); 9.5x9.2 x UTD. ("UTD" stands for "Unstageable Full Thickness Skin or Tissue Loss - Depth Unknown) 90% black stable Eschar with edges shown pink and off-white discoloration, no drainage noted at this time, no odor detected ..."

On 3/7/25 at 1729, the WCS documented, "Sacrum/Left buttock -Pressure injury, unstageable-Wound 100% covered with non-viable black soft eschar and dark tanned slough, boggy to touch. No exudate noted, malodorous. Edges irregular and undefined. Slough and eschar are firmly adherent to wound base. Cross-hatched with scalpel ..."
A review of the nurse's note dated 3/7/25 1400 shows that the patient had a urinary catheter placed at 1400. The patient was given Hygiene care at 1558, and it was stated the patient had already bathed today. "Hygiene care provided: Extensive. 1 person asst Perineal care provided: Extensive. 1 person assist." There was no evidence that the patient was on a turning schedule.

The patient chart revealed a dietary consult was done on March 7th, 2025. The dietician documented the initial visit at 1532. There were no nursing notes provided after 3/9/25. The notes for wound care were provided by the wound care specialist, staff #71 and #72.

On 3/10/25 at 2025, the WCS documented, "WOUND TO LT BUTTOCK HAS SPREAD TO SACRAL AREA, OVER TO RT BUTTOCK AND DOWN TO LT UPPER LEG. WOUND HAS NOW BECOME A STAGE 4 AS BONE IS PALPABLE. SLOUGH AND LOOSE ESCHAR COVERING MOST OF WOUND BED. DEBRIDMENT RECOMMENDED AT THIS TIME FOLLOWED BY NPWT." (NPWT- Negative Pressure Wound Therapy- is a type of therapy to help wounds heal.)

On 3/12/25 at 1617, the WCN documented, "WOUND TO BUTTOCKS/SACRUM/PERINEUM STILL REQUIRES SURGICAL DEBRIDEMENT. IT WAS CLEANSED WITH VASHE AND PATTED DRY. URGOCLEAN TO WOUND BED AND COVERED WITH URGOCLEAN. MEPILEX COVERING URGOCLEAN. TRIAD TO PERIAREA. PT HAD MUCH AGITATION TODAY THAT SHE REQUIRE IM GEODON." A review of the MAR revealed that the patient was not administered Geodon.

On 3/14/25, the patient had a surgical debridement of the sacral ulcer and a diverting ostomy on 3/14/25. No wound care was provided.

On 3/15/25 at 2025 the WCN documented, "Multiple sites of wound care provided. The right groin left buttocks/sacrum, right above the knee amputation surgical wound, left groin, and scattered open wounds to posterior thighs."

An interview was conducted with staff # 47, RN on the afternoon of 3/18/25. Staff #47 stated the patient was in contact isolation in room 353. Staff #9 stated the patient had been transferred to several floors during her hospital visit and stated the family had been with the patient and very attentive. Staff #47 stated she was aware of the patient's wounds and the extensive care needed for the wounds. Staff #47 stated the patient had come to her floor on 3/10/25 and that the family had voiced their concerns to the staff and administration about the poor nursing care provided. Staff #47 stated that they had been short PCTs (patient care technicians or aides). Staff #47 stated that she had talked to the PCT caring for patient #9 concerning a turn schedule when the patient came to the floor, and the PCT stated they were unaware that patient #47 needed to be turned every 2 hours. Staff #47 stated that she felt that the issue was resolved, but there was no documentation to show the turning schedule or incontinent care provided. Staff #47 stated that Staff # 42 had been talking with the family about their concerns and grievances. Staff #47 stated Staff #42 had been writing the issues down and talking with administrative staff. Staff #42 was unavailable for interview due to being out of state at the time. Staff #47 did not have access to the notes but stated that Staff #42 had discussed it with RISK on 3/13/25.

An interview was conducted with staff # 8, Director of Risk, and staff # 6 QAPI on the morning of 3/13/25. Staff #8 and #9 denied any complaints, grievances, or incident reports for patient #9. A review of the grievance log from 9/1/24 to 3/17/25 revealed that patient #9 was not on the log.

An interview was conducted with patient #9's sister and niece on 3/13/25 at 5:00 PM. Patient #9's sister stated that she had been with the patient during her amputation and cared for her there and followed her to the skilled nursing facility where she was receiving rehabilitation services. The sister stated that patient #9 was going to the gym and was up to the wheelchair, alert, and oriented. The sister stated that she became more confused and became ill. The patient was sent to the hospital where she was diagnosed with gangrene of the newly amputated leg and had a wound on her right groin. She stated the patient was so confused and unable to turn, get up to the bathroom, or answer simple questions. The sister stated that she stayed with the patient as much as she could because the hospital was short-handed and no one to help turn her sister. The sister began to cry and stated that she would push the call light and the nurse would come in, turn off the call light, and walk back out. She stated that the nurse would not return, and she was not strong enough to turn the patient by herself. Patient #9 had chronic diarrhea and was laying in feces for a long time. The patient had pads underneath and diapers between her legs that were soaked in urine.

The niece stated that the patient was very weak and unable to turn herself. On 2/28/25, the aide on unit 3300 found a small broken-down area on the patient's sacrum and showed it to the niece and the nurse on duty. The niece took pictures of the patient's bottom. The niece stated that the wound care nurses had been treating the patient's wounds but had not looked at the patient's bottom. The niece stated that by 3/4/25, the wound to her bottom was very large and deep, with black dead tissue in the middle. The niece stated that the nurses would just put a clear dressing over the wound, and there would still be feces in the wound. The niece stated that the nurse came in one time and put a dressing on the patient's bottom, but it didn't completely cover the wound, leaving it draining and exposed to the constant flow of loose stool. The niece stated that they were so upset and had multiple complaints to the staff, and staff #42 was the only person who had tried to help them.

An interview was conducted on the morning of 3/20/25 with staff # 71 RN and #72 RN WCS. Staff #71 and #72 had brought all their wound care notes, photos, timelines, and incident reports to the interview. Staff #71 stated that patient #9 had developed hospital-acquired wounds since admission and that they had written and reported an incident report on 3/5/25 as the date the buttocks wound was discovered. Staff #71 confirmed the wound was found previously by a PCT and shown to the RN on 2/28/25, but the unit nurse failed to put in an incident report or a consult to wound care for the wound. Staff #71 and &72 confirmed they were unaware of the wound to the buttocks until 3/5/25. The incident report dated 3/5/25 stated the root cause of the wound was "Deep tissue injury (DTI) later opened to unstageable." The patient was ordered an air mattress, moisture control, q2hr turns, no diapers, layers on top of (illegible) mattress to 1, Monitor nutrition, consult dietician, consult PT/OT to assist with mobility." The nurse had documented on 2/25/25 that the patient had been placed on an air mattress. Staff #71 and #72 confirmed that she was not on an air mattress. Staff #71 provided an incident report dated 3/19/25 (while the surveyor was in the hospital). The incident stated that the patient was on a regular bed. Poor nutrition with delayed nutrition consult. Actions implemented, "utilization of wound care Webex for tracking air mattress orders/delivery. Partnering with dieticians to help educate nursing for indications for nutrition consult."

Staff #71 and #72 confirmed that these basic requests for patients with wounds were not ordered or initiated until 16 days after the patient was admitted with a wet gangrenous surgical wound to the right below the knee amputation and an open wound to the right groin. The patient was identified upon admission as bed-bound, required assistance to reposition, and was incontinent of bowel and bladder. Staff #72 stated the patient had developed wounds to her inner thighs and buttocks since her hospital admission and felt, in her professional opinion, that this occurred from shearing and excoriation from lying in urine too long.

According to nih.gov, "Shear occurs when tissue layers move over the top of each other, causing blood vessels to stretch and break as they pass through the subcutaneous tissue. For example, when a client slides down in bed, the outer layer of skin remains immobile because it remains attached to the sheets due to friction." This can be caused by pulling the patient up in the bed without using the proper technique.

According to nih.gov, "Excoriation, or skin breakdown, from urine occurs due to prolonged skin exposure to urine, leading to moisture-related irritation and damage, often seen in individuals with incontinence ... The presence of urine, especially with its ammonia content, and bacteria in urine can break down the skin's outer layer and impair its barrier function, leading to inflammation and further skin breakdown."

Based on interview and record review, the facility failed ensure nursing kept current care plans that met the patients' needs in 3 of 24 sampled patients (Patient #'s 9, 10, and 12). The facility failed to ensure:

Patient #10 was started on a feeding timely after the family changed their mind about Hospice services 11/29/2024. Patient #10 was started on a tube feeding 6 days later on 12/05/2024.

Patient #12 received daily weights and accurate intake and outputs as ordered by the physician. Staff failed to ensure
Patient #12 received follow-up pain assessments after administration or pain medication. Facility staff failed to ensure there was treatment orders for Patient #12's peritoneal dialysis (PD)port site.

Patient #9 had care plan addressing skin breakdown. The skin breakdown included a surgical site to and an unstageable pressure sore.


This deficient practice had the likelihood to cause harm to all patients.

Findings include:

Patient #10

Review of the Emergency department (ED) record on Patient #10 was an 86 year old female who presented to the ED on 11/26/2024 at 11:57 p.m. with complaints of a change in mental status. Patient #10 had a history which included cerebral vascular accident, gastroesophageal reflux disease, and congestive heart failure. The ED assessment showed Patient #10 had a weight of 64 kilograms (140.8 pounds).

A computed tomography scan dated 11/26/2024 revealed Patient #10 had scattered subarachnoid hemorrhage and a fracture of the skull.

A physician's order dated 11/27/2024 revealed Patient #10 was on strict intake and outputs.

A physician's order dated 11/28/2024 revealed Patient #10 was on support care, intravenous feedings and a naso gastric tube feeding starting on the 3rd day.

Hospitalist notes dated 11/28/2024 revealed documentation that Patient #10's the son refused the tube feeding at this time.

During a confidential interview it was revealed that the nurses were asked daily when the tube feeding would be started and that the family did not refuse the tube feeding.

Review of the intake and output record from 11/28/2024-12/04/2024 revealed Patient #10 was NPO (nothing by mouth) and had intravenous fluids infusing.

Physician's notes dated 11/29/2024 revealed they would clarify with the son about hospice and that a tube feeding was to be started on 11/30/2024.

Review of case management notes dated 11/29/2024 revealed the Patient #10's son decided he did not want hospice There was documentation that the physician was notified.

A dietitian assessment dated 11/30/2024 revealed Patient #10 had a weight of 59.7 kilograms (131.34 pounds). The recommendation was to change the ADAT (advance diet as tolerated) to a regular diet. If unable to advance diet due to medical condition the recommendation was for nutritional support. There was documentation that the dietitian wanted Patient #10 started on PPN (peripheral parenteral nutrition) and the physician stated that the family wanted no intervention at this time.
This was a significant weight loss of 9.46 pounds since presenting to the ED 4 days ago.

Physician notes dated 12/02/2024 revealed the son and daughter wanted more care than just hospice done for Patient #10.

Review of a swallow study dated 12/04/2024 revealed recommendations to keep the patient NPO and that she would benefit from alternate means of nutrition due to severity of deficits.

Physician notes dated 12/05/2024 revealed there was a consult with nutrition, nasogastric tube inserted, and a trickle feeding was started.

On 12/05/2024 a nasogastric tube was inserted, but no consent could be found.

During an interview on 03/18/2025 after 2:01 p.m., Staff #34 confirmed the information in the chart. Staff #34 confirmed Patient #10 was not started on a feeding until 12/05/2024.


Patient #12

Review of the ED record on Patient #12 revealed that she was a 68-year-old female who presented on 12/05/2024 with complaints of chest pain and bilateral leg swelling. Patient #12 had diagnoses which included coronary artery disease, hypertension and acute or chronic kidney failure. Patient #12 had a weight of 58.6 kilograms (128.92 pounds).

Lab results dated 12/05/2024 revealed Patient #12 had the following:
Low sodium 132
Low chloride 94
Elevated blood urea nitrogen 27.0
Low calcium 6.6
Low albumin 2.4
Low red blood cell counts 3.35.

According to physician orders dated 12/06/2024 Patient #12 was to continue nightly peritoneal dialysis and was on a fluid restriction of 1.5 liters per day.

Review of physician orders dated 12/06/2024 revealed orders for intake and outputs, daily weights and a renal diet.

Review in take and outputs revealed from 12/06 to 12/09/2024 there was no intake and output documented. On 12/11, 13 and 14 there was no intake documented. The only documentation for meal intakes was poor, fair or good. There was no indication as to the percent of intake.

There was no documentation of the physician ordered daily weights on the chart at all. The only weight on the chart was the admission weight of 58.6 kilograms (128.92 pounds).


Pain
There was a physician's order for the pain medication Morphine sulfate 2 milligrams (mgs) intravenous (IV) every 4 hours prn pain 7-10.

Review of pain assessment notes and medication administration records revealed that Patient #12 had a pain level of 6 for abdomen and bilateral leg pain on 12/06/2024 at 1223 midnight. There was documentation that medication was administered, but there was no documentation of what medication. At 3:13 a.m., Patient #12's pain level of 9 for leg pain and a dose of morphine was administered. There was no documentation of a follow-up assessment. The next documentation of an assessment on the notes was at 9:00 a.m. and the pain level was a 6 for abdomen and bilateral leg pain.

On 12/12/2024 at 4:11 p.m. Patient #12 had a pain level of 10 at 4:11 p.m. for left pain. Staff administered one tablet of the pain medication Norco. There was no follow-up assessment.


Dressing changes on Peritoneal dialysis (PD)

There was documentation in nurses' notes and flow sheets that the PD site was cleaned on 12/07/2024, 12/08/2024, and 12/11/2024. There was no documentation of what was being used to clean the site. There was no documentation of a physician's order on how to clean the PD site.

During an interview on 03/19/2025 after 11:24 a.m., Staff #36 said that treatments to the port sites were done every other day with dialysis treatments. When the site needed to be cleaned any other time, he would stabilize it and call a dialysis nurse.

During an interview on 03/19/2025 after 1:00 p.m., Staff #80 said the dressing on the port sites were changed on Monday nights.

During an interview on 03/19/2025 after 2:14 p.m., Staff #13 confirmed not being able to find a treatment order for the nurses on the floor to use. Staff #13 had a call placed to the dialysis staff for treatment orders and none was provided as of 03/20/2025 at 5:25 p.m.

According to the Nations Institute on Health website www.niddk.nih.gov revealed some of the following:

" Peritoneal dialysis is a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body ...
Take care of your exit site, supplies, and catheter to prevent infections ...
Clean your skin where your catheter enters your body every day, as instructed by your health care team ...
...Infection

One of the most serious problems related to peritoneal dialysis is infection. You can get an infection of the skin around your catheter exit site or you can develop peritonitis, an infection in the fluid in your belly. Bacteria can enter your body though your catheter as you connect or disconnect it from the bags..."

During an interview on 03/19/2025 after 2:14 p.m., Staff #13 confirmed there were no daily weight, intake and outputs were incomplete and there was no follow up pain assessment documented. Staff #13 confirmed they did not have a scale or policy to determine what poor, fair and good meant for the percent of meal intakes.







32143

Patient #9

The facility failed to provide a nursing care plan to the surveyor upon multiple request for patient #9. A review of patient # 9's medical chart revealed she was admitted to the hospital on 2/17/25 at 15:09. Patient #9 was living in a skilled nursing facility after she had a right above the knee amputation and had developed a wound to her upper rt groin. The rt above the knee amputation surgical site had dehisced (gape or burst opened), causing gangrene of the wound. The patient received blood, multiple wounds were treated. The patient developed hospital acquired wounds that were treated and required surgical interventions.

There was no nursing care plan in the patients chart upon review. The facility was asked multiple times for a completed medical record. Medical records were provided three times with no nursing care plans.

Based on review and interview the facility failed to provide patient medical records upon request on 2 of 2(#9 and #12) patients.

The facility had one provider number and one license number but had two hospitals on different campuses. Hospital- A was in Kingwood, and Hospital- B was in Cypress. The facilities had shared Governing Board meetings and Medical Staff meetings.

The complaint survey for hospital A and B was conducted 3/18/25 through 3/20/25. The surveyors started requesting medical charts to be copied for the survey team on 3/18/25 from hospital A. Staff #6 and #8 stated they would be working on these requested charts.

On 3/19/25 The survey team was at the hospital B campus and requested patient charts. Patient Charts were sent via email and complete. Patient # 12 was the only medical record that was not provided.

On 3/20/25 after asking about the requested charts multiple times staff #6 and #8 had sent emails of different pieces of a chart but were not complete charts. Staff #8 stated the charts were too big to be sent and needed to put it on the drive. Staff #8 stated that the patient #9 was not complete because she was still inpatient. The surveyor explained that was ok, but the surveyor needed all of the chart up to 3/20/25. Staff #8 stated that was not a problem. In the afternoon of 3/20/25 staff #12 brought in a flash drive with patient charts. He stated that IT would come and watch the chart transference. The following charts were transferred from the drive to the surveyor's computer for patient #16, #10, #3, #2, #1, #17, #23, #11, #22, #18, #9 and #21. The surveyor opened up the charts to make sure they downloaded and were able to be opened. The survey team exited.

Upon review of the charts the next day the surveyor realized patient #9 and #21's chart was missing multiple items, nurses notes, flow sheets, PT/OT notes, surgical notes, wound care notes and pictures. The drive also failed to have patient #12's chart loaded. After multiple phone calls and emails to staff #6 she explained that she was trying to down load the information and was sending things in bits and pieces through email. On 3/26/25 staff #6 was asked to overnight the patient files if they were to big for email and the Tyler office address was given to her.

On 3/26/25 staff #81 emailed and called the surveyor. Staff #81 stated she was with a contracted service to supply medical records for the facility and would assist in getting the medical records to the surveyor. Information was provided on what the surveyor needed. Some of the patient files came through to the Tyler office fax and was placed in the shared drive however, patient #9's medical records faxes were blank. The information provided was the same information originally given on the drive and was still incomplete for patients #9 and #12. Staff #81 was able to send nursing notes through email on patient #9.

Staff #81 requested that I send a chart request form for each chart requested to be sent along with a signed disclosure of protected health information form for each requested chart.

The surveyor began to receive calls from Staff #82 concerning the medical records. Staff #82 stated that she worked at another contracted service different from staff #81 and she would be assisting me in getting the requested charts. Staff #82 stated that patient #9 was discharged from the facility and she would be able to send a closed completed chart. After multiple emails and phone calls staff #82 sent a disk of the patient charts overnight. The charts were not sent to the address requested but to the central office of CMS (Centers for Medicare and Medicaid Services) in Dallas, Texas on 4/1/25. The surveyor contacted CMS and they were unable to forward the information due to no CD drives available.

The surveyor spoke with staff #81 and #82 and explained that I had not gotten the files and they were sent to the wrong address. The surveyor requested the charts be resent. The surveyor also stated that patient #12's chart was never sent. The surveyor did not receive any further disk or patient medical record information requested. The CEOs of both hospital A and B was emailed and informed of the situation.

Based on observation and interviews the facility failed to ensure that the infection control program maintained a clean and sanitary environment to avoid the transmission of infection in 2 of 2 (Hospital A-ER and Hospital B ER-Pharmacy) departments.

The facility had one provider number and one license number but had two hospitals on different campuses. Hospital- A was in Kingwood, and Hospital- B was in Cypress. The facilities had shared Governing Board meetings and Medical Staff meetings but two different CEOs.

Findings;

A tour of hospital A's emergency Room (ER) was conducted on 3/18/2025 at 11:05 am with staff # 9 ER director and staff #62 RN scribe. Findings in the ER were as follows;

ER holding area had missing tiles on the floor. The floor was heavily soiled with dirt, dust, and hair. The room had 5 IV stands that were found heavily soiled on the bottom with dust, dirt, and hair.

A wound care metal supply cart was heavily soiled with dirt, dust, and hair. The top of the cart was soiled with dust, old pieces of tape, and tape residue. In the medical holding area (after the patient had been through triage) had a leather recliner and a blood pressure monitor on wheels. The leather chair had multiple rips and tears, leaving the chair vulnerable to spilled liquids, bodily fluids, and infected wounds that would not be able to be cleaned appropriately. The wall behind the chair was missing sheet rock.

Lab supplies were found in a white plastic container used to carry from patient to patient to draw blood samples. The carrier was soiled with dust and old tape residue. Next to the white plastic container were swabs lying in a cardboard box.

A Sono site ultrasound machine was found in the patient minor holding area. The machine was in the hallway, uncovered, and was soiled with dust, tape residue, and hair. Patient medical supplies were lying in open containers on the bottom of the machine next to the floor. The medical supplies were lying in dusty containers.

1 workstation computer on wheels was found to be open to a patient's medical records in the hallway. The top workstations were soiled with dried liquids, dust, and hair. The patient's plastic drinking cups were stacked on top of the soiled cart. The bottom of the cart was heavily soiled with dirt and dust.

An EKG machine was found soiled with dust and dirt. On the side of the cart was an old (Coban) dressing tied to the machine holding leads. The old dressing was heavily soiled with dust.

A patient bedside table was in the hallway holding cleaning wipes. The bottom of the table was heavily soiled with dust and dirt. Paint was missing from the bottom leg, exposing rusted metal.

In a room marked "supply room" was the nutrition room. Inside the room was a coffee maker, Ice, refrigerator with juice, sandwiches, Jello, and applesauce. Inside the drawers and cabinets were spilled dried goods and liquids. The refrigerator was soiled with dust, hair, and spilled liquids.

At the main nurse's station were 3 rolling plastic carts with three-tiered drawers holding multiple lines, leads, and cords for telemetry and other equipment. The lines were shoved in the box and tangled. Some of the drawers had broken equipment in them with notes on top. The drawers were dusty and had unknown dried particles in the bottom of the bin.

The nurses' workstation and desk area were heavily soiled and dusty. Cabinets were opened in the nurse's station area. Respiratory supplies were found shoved in a dirty and soiled cabinet. There was an unidentifiable plastic bag with a spilled brown liquid mixed with the patient's supplies. A cardboard box was found in the cabinet with an outdated call system with lines wrapped up. On top of the equipment was an IV bag of normal saline. The area was not clean or monitored for medication storage. The flooring around the base of the nurse's station was missing and had collected dirt, dust, and hair. The veneer on the side of the nurse's station desk was missing, exposing bare wood.

The clean supply room had shipping boxes on the floor; the floor was soiled with dust and dirt, and the counters were dusty and had old tape and tape residue. In an upper cabinet, two narcotic lock boxes were found to be empty but heavily soiled with a sticky brown substance, dust, and hair.

Two patient stretchers, clean and ready for patients, had rips in the mattress, exposing materials that are unable to be cleaned properly. The beds were soiled with dirt, spilled dried liquid, and tape residue.

In the behavioral health area of the ER, the nurse's station was dirty with dust and clutter. The surveyor opened a drawer behind the nurse's station. It was filled with patient medical supplies, batteries, and a flashlight. There was a metal box that stated, "toilet key." The box was opened, and different medications (pills) were found loose in the box. Staff #9 stated, "I don't know what to say." He began to look at the pills to try to identify what the pills were and how they got there.

Two nurses' chairs were ripped and had the raw cushion exposed.

The facility had two trauma rooms. One of the trauma rooms was occupied with a patient. Staff # 9 confirmed that the unoccupied trauma room was ready for a patient. The following issues were found;

The stretcher had a clean sheet on top. The surveyor raised the mattress and had blood on her hands from the mattress, along with dried blood all over the bottom. Paper and trash were found under the mattress. The handle to raise the head of the stretcher was heavily covered in old tape. Old, used gloves were found under the bed.
Opened and packaged patient medical supplies were found lying on the nurses' work station. The station was soiled with dust and hair.

The curtain in the room was heavily soiled with dirt and dried spilled liquids.

Sterile patient supplies were found stored on the floor in containers, and some supplies were found on the floor exposed to dirt, hair, and dust.

The baby bassinet and warmer were uncovered. The sheet and blanket on the bassinet were soiled with dust and littered with papers.

All the glass doors to the patient supply cabinets were left open, exposing the sterile and clean medical supplies to the dirty environment. Staff #9 confirmed the finding and called in housekeeping and staff to properly clean the room before it was needed for an emergent trauma.

An interview was conducted with staff #65, the ER housekeeper, on 3/18/25 at 12:30 pm. Staff #65 stated she and two other housekeepers were responsible for 18 rooms, bathrooms, and nurses' stations of the ER, and she had only worked there for a few months. Staff #65 stated that she mops and does the trash in most rooms at least once a day. She stated that the nurses usually clean the rooms between patients. Staff #65 stated that she does not get paged or notified of any rooms to be cleaned. She stated that the nurses will ask her to clean if needed.


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Hospital B (Emergency department pharmacy)

During an observation on 03/19/2025 at 5:31 p.m. the following was found:

Nursing staff were observed coming in and out of the pharmacy room.

Three walls inside the pharmacy room had bins of medical supplies, wound care dressings, respiratory supplies, intravenous supplies and bags of intravenous fluids. There were sterile supplies also in the bins. The bins were not covered to prevent cross contamination.The inside and outside of the bins were soiled with dust.

Two unopened sterile thoracic catheters were laying on the floor underneath a shelf.

The floor underneath the supply bins were littered with unopened medical supplies such as needles, syringes of saline flush, intravenous catheter and specimen cups.

Open bins of sterile thoracostomy trays were stored next to the open trash can which was full of trash.

Three bags of 5% Dextose IV fluids were stored in an uncovered bin on a table. The bin was soiled with dust and white debris.

Thoracic catheters which expired on 9/11/ 2023 and 03/09/2025 were found stored in the room.

Labels on some of the supplies revealed the following:

Thoracostomy trays label read that they should be stored at a room temperature of 59-68 degrees.
Lumbar puncture trays label read that they should be stored at a room temperature of 68-77 degrees.
Dry suction water seal chest drain label read that they should be stored at a room temperature of 59-77 degrees.
Bags on of intravenous solutions packaging read that they were to be stored at a room temperature of 77 degrees.

There was no temperature and humidity gauges in the room.

During and interview on 03/19/2025 after 5:31 p.m., Staff #76 confirmed the observations and that there was not a gauge in the room to monitor the temperature and humidity. Pharmacist #76 said she thought environmental services was monitoring it.

On 03/19/2025 a request was made to see the monitoring logs. As of 03/20/2025 at 5:25 p.m. no logs were provided.