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Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Patient Rights. This failure had the potential to affect all patients receiving services in the hospital.

The facility failed to ensure:

1. Patients received care in a safe setting for 1 of 3 Emergency Department patients (ID#6) by:
a. Failing to identify and document behavioral health diagnosis;
b. Failing to perform suicide risk screening;
c. Failing to recognize and mitigate environmental risks;
[Refer to Tag A-0144]

2. the facility failed to follow its established grievance policy and process by:
a. Failing to document what steps were taken to investigate a grievance regarding clinical care and provider demeanor and failed to follow through on their recommendations/action for a grievance they substantiated. (Patient ID #5)
b. Failing to follow established process for addressing grievances regarding clinical care issues, initiate grievance process and investigation and provide a patient with written notice acknowledging grievance process initiation. (Patient ID # 7).
[refer to Tag A-0118]

Based on interview and record review, the facility failed to follow its established grievance policy and process. The facility:
a) failed to document what steps were taken to investigate a grievance regarding clinical care and provider demeanor and failed to follow through on their recommendations/action for a grievance they substantiated. (Patient ID #5)
b) failed to utilize its process for addressing grievances regarding clinical care issues, initiate grievance process and investigation and provide a patient with written notice acknowledging grievance process initiation. (Patient ID # 7).

Findings included:
Record review of facility policy, "Patient Grievance and Complaint Management," last approved 10/2021, stated "Purpose: to establish a process for timely referral, prompt review, investigation and resolution of patient grievances and complaints." It further defined "Patient Grievance is a written or verbal complaint by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to compliance with the CMS Conditions of Participation or a Medicare beneficiary billing complaint related to rights and limitations ..." The grievance resolution process stated "upone receipt of a grievance, the appropriate department director/manager will be contacted to review, investigate and resolve with the patient and/or patient representative. Medical staff leadership may be involved as needed to resolve physician delivery of care issues." The policy describes "Tracking, Trending and Analysis of Data." The policy stated the "documentation of the resolution process may include ..."pertinent investigational information, resolution and follow-up ..."

Patient ID #5:
Record review of HHSC Intake received via email on 6/1/2021. Complainant for Patient ID #5 stated "absolutely awful when it comes to discharging patient safely ... could barely see or walk .... was discharged. No tests were done. ...could not walk, gait was unsteady ..."Apparently (Staff ID #67) decided that (patient) was faking it, seeking drugs, and attention."

Record review of facility grievance log and records were reviewed on 5/3/2023 at 09:50 am with Risk Coordinator Staff ID #75. She reported that the facility became aware of a negative social media review placed online regarding Patient ID #5. This was entered into their tracking system and handled as a grievance. She stated the employee involved in this case investigation was no longer employed at the facility, so not available to interview. Grievance log showed grievance was logged as "received" on 06/04/2021. Staff ID #75 found hand-written notes which appeared to be related to the case however there was no date, time, source and method (phone or in person) that these issues were obtained. The grievance log stated closure letter was sent on 06/23/2021 and the grievance results log stated the grievance was "substantiated." She could not identify what steps were taken to investigate the grievance and what elements of the grievance were "substantiated." The grievance action stated "Coaching." It was not clear who was providing or receiving the coaching.

Interview 5/3/23 at 1:10 pm with Staff ID #83 Medical Staff Services personnel and electronic record review of Staff ID#67 credentialing file was performed. She stated there was no documentation of patient complaint, verbal counseling, performance issue or coaching for Staff ID #67. There was no record of this patient substantiated complaint, actions taken and it had not been a consideration for her re-appointment which occurred in July 2022.

Interview 5/3/23 at 2:00 pm with Quality staff #51. She stated that she checked with peer review coordinator. She stated they were unable to locate any coaching, remediation, notification or education regarding the substantiation of Patient ID #5 case.

Patient ID #7
HHSC Intake received via telephone, complainant stated that Patient ID #7 had presented to the ED for "laceration due to a bicycle accident." She alleged the patient underwent debridement and suturing procedure at the facility. She stated they were discharged home with no "prescription for antibiotics" and stated the patient returned for care the following day to another hospital for purulent drainage from wound with retained foreign bodies. She stated the patient required another "surgical procedure and IV antibitoics." She stated when she "followed up with the facility's emergency room staff ... the facility was unable to provide her with an explanation."

Telephone interview 5/1/23 at 2:55 with complainant for Patient ID #7. She validated concerns expressed in complaint. She questioned whether Nurse Practitioner Staff ID #69 had treated Patient ID #7 correctly. She stated she had been told by the terminal treating facility that patient should have been given anitbitoics. She stated when she called HCA Clear Lake and spoke with charge nurse, she was transferred to ED Provider (she could not recall the name) and did not obtain resolution.
Interview with Emergency Room charge nurse staff ID #79 on 5/3/23 at 11:15 am. He remembered receiving a call form an angry family member "yelling at him on the phone" about why patient ID #7 did not receive antibiotics. He stated he provided her the number to risk management department which is located on phone number list in charge nurse station. He stated he also transferred her phone call to the ED provider on service. He did not notify risk management or ED leadership and did not initiate the grievance process. He was unsure of the outcome.

Interview with Vice President of Quality 5/3/23 at 2 pm confirmed there was no evidence of a grievance logged for Patient ID #7 therefore no investigation, analysis or case review had been performed. She stated she would have expected that to be recognized as a grievance by facility staff.

Based on record review, and interview, the facility failed to provide care in a safe setting for 1 of 3 Emergency Department patients (ID#6) by:
a. Failing to identify and document behavioral health diagnosis;
b. Failing to perform suicide risk screening;
c. Failing to recognize and mitigate environmental risks;

Finding include:

Record review of facility policy titled "Patient Rights and Responsibilities," dated 12/2021 showed the following information:

12. The patient has the right to security and receive care in a safe setting.

b. Safety and security measures will be taken with respect to the patient's age, sex, physician and mental conditions.
c. The patient has the right to be placed in a protective privacy when considered necessary for personal safety.


Record review of facility policy titled "Suicide Risk Assessment Non-BH Settings Policy," dated 3/2023 showed the following information:

PRUPOSE:
To provide guidance to assist with the identification of patients in non-behavioral health (BH) settings who are at risk for suicide comma ensuring a safe environment for the provision of care.

POLICY:
It is the policy of to create an environment of care that will foster the assessment, identification, and management of patients who are at increased risk for suicide or self-harming behaviors. Patients who are at an increased risk for suicide or self-harming behaviors require intensive support, close observation, and frequent reassessment for their emotional and physical well-being. The scope of this plan begins at triage, prior to admission to the hospital, and continues until the patient is discharged.

Minimum requirement: patients and non-psychiatric areas (e.g., Emergency Room (ER), and non-BH inpatient units), ages 3 years and older, Who are being evaluated or treated for behavioral health conditions as their primary reason for care and all admitted patients, three years and older, should be screened using the C-SSRS. screening all patients were suicidal ideation who are being evaluated or treated for behavioral health conditions as their primary reason for care supports the Joint Commission's National Patient Safety Goal 15. 01. 01. The provider/practitioner We'll be notified have positive screens (i.e., at risk patients). The at-risk patients environment will be made safe by implementing the at risk safe environmental checklist and observation precautions ....

PROCEDURE
1. Nursing screening will include current, recent, and past thoughts of suicide, plans, means and/or intent, as well as recent or past history of suicide attempts within their lifetime, for patients ages 3 and above being admitted to the emergency rooms ...

10. The nurse will determine the appropriate interventions based on the C-SSRS. Once the subsequent suicide detailed risk assessment (DRA) is completed and overall risk level (ORL) will be used as the source of truth to determine the appropriate interventions:

Low risk- provider/practitioner notified
Moderate risk-provider/practitioner notified, line of sight/virtual patient safety attendant (PSA) , maintain suicide safe environment precaution, Document environmental precautions in EHR every shift and as needed with change of condition, suicide interventions implemented
High risk- Including those mentioned in low and moderate risk, physical patient safety attendant (PSA) in place 1:1.


Medical record review for patient (ID#6) for date of service 3/3/23 showed the following:


Nursing documentation:
Rapid initial Assessment performed by RN 3/3/23 at 1217 shows that patient arrived via ambulance.

Subjective assessment-"per EMS this call was for a possible fall, they said he was on the floor when they came into the room, He denies injury, complains of abdominal pain secondary to constipation.

Objective assessment-male patient from (behavioral health facility by name) where he is admitted for SI (Suicidal Ideation), does not remember falling, abd soft to palpation.

Nursing documentation showed no documentation of assessment of the patient's suicide risk or implementation of environmental interventions.

Departure information
Disposition HOME, Self-care, Departure date/time 3/3/23 1843

Patient Instructions: ED Constipation (Adult)

ER Provider documentation:
HPI Notes
36-year-old male in for evaluation of abdominal pain. Patient reports being constipated and not having bowel movement since the 28th. Patient denies any nausea, vomiting or fevers.

Basic Review of Symptoms: PSYCH: NL though content

Re-Eval & MDM (Medical Decision Making)
Plan: Plan to discharge patient home with magnesium citrate and have patient follow-up with primary care in 2 to 3 days.

Re-evaluation/Progress #1
Time of Re-eval 1545
Re-eval status- improved
Plan Post Re-eval- plan discharge

Patient Discharge and Departure:
Condition- Stable

Disposition Decision
Discharged to home 1733

Discharge Care Plan:
referrals

Physician documentation showed no mention of psychiatric history or concerns or patient stability.


Medical record review of patient (ID#6) from transferring behavioral health facility showed the following:

Executed order of protection dated 3/2/23 for patient (ID#6) stating the following:
The court finds that a physician has stated his opinion and the detailed basis for that opinion that proposed patient is mentally ill and the proposed patient presents a substantial risk of serious harm to himself or others if not immediately restrained pending the hearing. Such harm may be demonstrated either by the person's behavior or by evidence of severe emotional distress and deterioration in his mental condition to the extent that the person cannot remain at liberty.


Interview with ED medical director (ID# 84) on 5/3/23 at 8:00 AM, she confirmed that there was no documentation related to the patient's psychiatric condition. She went on to say that it appears from the documentation that the medical provider was unaware of the patient's behavioral health diagnosis which would have contributed to the patient being discharged to home instead of being transferred back to the behavioral health hospital. She stated that the medical provider doesn't always look at the nurse's rapid assessment, they gather information by speaking with the patient.

Interview with Emergency room charge Nurse (ID# 85) on 5/3/23 at 10:30 AM, he stated that when patients arrive via EMS from a psychiatric facility, the paperwork that accompanies the patient (i.e., history and physical, face sheet, warrant information) should be handed to the provider and communicated verbally. At times, it is left in the room for the provider or EMS make leave with it. He also stated that the only way to populate and document psychiatric related interventions is only if the chief complaint is a behavioral health diagnosis, not a medical issue.

Interview with Chief Nursing Officer (ID# 63) on 5/3/23 at 3:00 PM, she stated that the nurse receiving patient (ID#6) in the emergency department chose not to follow the facility's protocol with this patient.

Based upon record review and interview, the facility failed to ensure that an adverse event was adequately reported, tracked and analyzed (Patient ID # 6).

Findings included:

Record review of facility's "Risk Management - Notification of Occurrences" policy, effective 09/2021, stated "The Risk notification system provides a mechanism for reporting unusual occurrences and operational variances not consistent with normal hospital operations and patient treatment expectations as well as employee and visitor unusual occurrences and to identify events or occurrences which represent a risk of injury." It further stated "all incidents occurring at the hospital involving employees, patients, visitors or property, must be reported using the Meditech online notification report .... Additionally, all incidents will be investigated and appropriate follow-up corrective action will be documented."

HHSC Intake received on 3/14/23 by telephone for Patient ID #6 stating Patient ID #6 "was sent to the emergency room for stomach problems from a behavioral hospital. The patient was under a court order. Upon discharge from the emergency department, he was not sent back to the behavioral hospital but was discharged onto the street."

Medical Record review 5/2/23 at 2:30 pm with HIM Staff ID # 74 of Patient ID #6 medical record was performed. Medical record triage note stated 3/3/23 at 12:23 "Alert male patient from ...Behavioral Hospital where he is admitted for SI (suicidal ideation), does not remember falling, abd soft to palpation." Staff nurse documents 3/3/23 at 18:43 Staff "from behavioral hospital called to look for patient, patient not in ER at this time, looked in all 3 lobbys, talked to staff at desk and checked bathrooms."

Record review of facility's incident/variance logs with Risk Coordinator Staff ID #75 on 5/3/23 at 09:05 am. She confirmed there was no evidence of Patient ID #6 located on incident/variance logs.

Interview 5/3/23 at 09:10 am with Quality Staff ID #51. She confirmed that the listing of categories of occurrences or types of adverse events is included in the electronic reporting system and stated that the facility believed "over-reporting to be better than under-reporting." She confirmed that discharging a mental health patient with an order of protection in place or emergency detention warrant from the facility would qualify as a risk management occurrence which should be reported, analyzed and tracked.

Based on interviews and record review, the governing body failed to implement and enforce policies to address privileging for mid-level practitioners, by failing to verify and provide documented evidence that a mid-level practitioner (Staff ID #69) had competency or focused professional practice observations/evaluations, to perform wound closure and suturing procedures in the emergency department.

Findings included:

5/3/2023 1:10 pm - A request was made by the survey team for credentialing and privileging documentation demonstrating proof of competency for wound closure and suturing privileges for Staff ID #69 which was granted on 04/25/2022. Per Staff ID #83, Medical Staff Services employee, there was no competency verification or case logs found in Staff ID #69 credentialing file.

Record review of medical staff services electronic credentialing file with Medical Staff Services ID #83 on 5/3/2023 at 1:15 pm. Staff ID #69 file was reviewed. The application for privileges stated ..."local infiltrative anesthesia, suture lacerations, cleanse and debride wounds ...". "Start date 4/25/2022, End date 10/31/2023. Current status: Approved."

Record review of Patient ID #7 medical record was performed for date of service 4/10/23. It stated "Procedures - Laceration Management #1...R anterior knee, Wound 5 cm...Irrigation:1000ml Normal saline. Foreign body Explore/Removal: Explored for foreign body, none found. Repair skin Prolene 4-0, # sutures 6...". Procedure was performed and documented by Staff ID #69.

Record review of facility's "FPPE Policy to Confirm Practitioner Competence and Professionalism," October 26, 2020 stated "All practitioners who are granted clinical privileges ... are subject to focused professional practice evaluation (FPPE) to confirm their: clinical competence to exercise clinical privileges that have been granted to them." The policy stated "FPPE Clinical Activity Requirements. Each Department is responsible for recommending the following FPPE clinical activity requirements: 1) New practitioners: the number and types of procedures or cases that will be reviewed to confirm a new practitioner's competence to exercise the core and special privileges in his or her specialty."

Record review of the Texas Board of Nurse Examiners Rules and Regulations relating to Nurse Education, Licensure and Practice, Published February 2023, Chapter 221, Scope of Practice, stated 221.12(c, "In determining whether a particular action falls within an APRN's authorized professional and/or individual scope of practice, the following factors will be considered ... 3. Whether the APRN has demonstrable clinical competence and/or clinical experience in performing the action in the role of an APRN, obtained through supervision and/or training by a qualified practitioner." It further stated, "(d) it is the responsibility of the APRN to maintain records of completed training and competencies."

Interview 5/3/2023 at 1:30 pm with Medical Staff Services employee Staff ID #83, she stated that the emergency department nurse practitioners, including Nurse Practitioner Staff ID #69, were "granted privileges for core skills." She confirmed there were no case logs presented or utilized prior to credentialing and privileging them for these procedures. She confirmed there were no documented supervision/observations documented for any procedures that have privileges granted. She stated the process is for 5 "random chart audits" to be performed by the Emergency Department Medical Director Staff ID #82. She reviewed the 5 available random chart audits which were 5 patients with dates of service 4/27/2022 and 4/28/2022. She confirmed that none of the chart audits included patients with lacerations or wounds. She confirmed there were no case logs with observations by credentialed practitioners supervising Staff ID #69's procedures.

Based on record review and interview, the facility failed to implement a safe discharge plan for 1 of 3 mental health patients (ID#6).


Findings Included:

Record review of facility policy titled "Suicide Risk Assessment Non-BH Settings Policy," dated 3/2023 showed the following information:

PURPOSE:
To provide guidance to assist with the identification of patients in non-behavioral health (BH) settings who are at risk for suicide comma ensuring a safe environment for the provision of care.

16. Discharge Planning:
a. Pre-Discharge suicide Assessment:
Patients who were assessed LOW, MODERATE, HIGH upon admission will be reassessed for suicide prior to discharge. If the patient is LOW, MODERATE, or HIGH risk at this time, then patient will be evaluated for the appropriateness of discharge.
b. Suicide prevention/Discharge Patient Education will include the personal safety plan.


Record review of facility policy titled "Discharge Information," dated 12/2021 showed the following information:

PURPOSE: To establish guidelines for the discharge of patients from the Emergency Department.

PROCEDURE:
1. Prior to discharge each patient should meet the following criteria:
- Physician has ordered discharge
-Patient is responding and oriented at pre-treatment level...

a. Exceptions
-patients transferred to another facility

2. Upon discharge the nurse shall:
-Assure explanations of medications, treatments, self-care, referral and/or prevention.
-Provides and explains written instructions regarding after care, follow-up and/or referral through patient care instructions and discharge plan is individualized to meet patient's needs.
-Obtain a signature of patient or responsible party on the discharge instruction sheet. One copy is attached to the medical record and one copy is given to the patient or responsible party.
-Assist with any arrangements needed to facilitate discharge home. Social worker/interpreter intervention if needed.

Record review of facility policy titled "Care for the Behavioral Health Patient in the Emergency Department," dated 12/2021 showed the following information:

PURPOSE: To provide care coordination for patients with behavioral health needs within the Emergency Department.

POLICY: It is the policy of HCA Healthcare Houston Clear Lake to provide a safe and secure environment for all patients who access care. Patients with behavioral health needs who present to the ED (Emergency Department) will be assessed and receive treatment for any medical conditions. Assessment of the patient's mental status and observation of their behaviors will trigger the implementation of interventions designed to protect the patient and others in their environment. Assessment, monitoring, observations and education will be ongoing until the patient is transferred or discharged from the ED.

PROCESS:
Disposition of patients in the Emergency Department who have substance or acute psychosis, mental disorders:
8. The Emergency Room Physician is responsible for determining and documenting the plan of care.
10. The Emergency Room Physician is responsible for the documentation and demonstration of stability prior to admission, transfer, or discharge.
11. All patients requiring transfer to a behavioral health center will be transferred via EMS or Mental Health Deputy/Police Service. No patient will be transferred via personal vehicle.

Record review of medial record for patient (ID#6) for date of service 3/3/23 showed the following information:

Nursing documentation:
Rapid initial Assessment performed by RN 3/3/23 at 1217 shows that patient arrived via ambulance.

Subjective assessment-"per EMS this call was for a possible fall, they said he was on the floor when they came into the room, he denies injury, complains of abdominal pain secondary to constipation.

Objective assessment-male patient from (behavioral health facility by name) where he is admitted for SI(Suiciadal Ideation), does not remember falling, abd soft to palpation.

Nursing documentation showed no documentation of assessment of the patient's mental status or implementation of interventions

Emergency Notes
3/3/23 1843
Staff from Behavioral hospital called to look for patient, patient not in ER at this time, looked in all 3 lobby's and checked bathrooms

Departure information
Disposition HOME, Self-care, Departure date/time 3/3/23 1843

Patient Instructions: ED Constipation (Adult)

ER Provider documentation:
HPI Notes
36-year-old male in for evaluation of abdominal pain. Patient reports being constipated and not having bowel movement since the 28th. Patient denies any nausea, vomiting or fevers.

Basic Review of Symptoms: PSYCH: NL though content

Re-Eval & MDM
Plan: Plan to discharge patient home with magnesium citrate and have patient follow-up with primary care in 2 to 3 days.

Re-evaluation/Progress #1
Time of Re-eval 1545
Re-eval status- improved
Plan Post Re-eval- plan discharge

Patient Discharge and Departure:
Condition- Stable

Disposition Decision
Discharged to home 1733

Discharge Care Plan:
referrals

Physician documentation showed no mention of psychiatric history or concerns or patient stability.



Medical record review of patient (ID#6) from transferring behavioral health facility showed the following:

Executed order of protection dated 3/2/23 for patient (ID#6) stating the following:
The court finds that a physician has stated his opinion and the detailed basis for that opinion that proposed patient is mentally ill and the proposed patient presents a substantial risk of serious harm to himself or others if not immediately restrained pending the hearing. Such harm may be demonstrated either by the person's behavior or by evidence of severe emotional distress and deterioration in his mental condition to the extent that the person cannot remain at liberty.

Interview with interim ED director (ID# 66) on 5/2/23 at 1045 am, she stated that there is not a discharge planner for the emergency department. She stated that the discharge plan is made between the nurse and the provider. She went on to say that case management can be utilized if needed.

Interview with ED medical director (ID# 84) on 5/3/23 at 8:00 AM, she stated that patient (ID#6) should not have been discharged home but transferred back to the behavioral facility from which he came.