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400 ROSALIND REDFERN GROVER PARKWAY

MIDLAND, TX 79701

PATIENT RIGHTS

Tag No.: A0115

Based on review of documentation and interviews, the facility failed to protect and promote each patient's rights. As evidenced by:

1. The facility failed to appropriately report complaints and allegations (of physical and verbal abuse) made by the patient per facility grievance policy. At the time the complaints/allegations were made, the faclity was unable to resolve the issues to the patient's satisfaction, thus they did not ensure the patient's right to an effective grievance resolution. Please cross refer to A0118.


2. The facility utilized a video monitoring system that was still present in the room upon the surveyors' visit with the patient on 02/11/21, the need for continuous video monitoring was not documented every 4 hours per policy. Without the necessary documentation of continued necessity outlined in facility policy, the video monitoring system violated the patient's right to privacy. Please cross refer to A0143.


3. The facility failed to ensure the safety of patients from abuse and harassment as evidenced by not having a policy in place to address how to report/investigate patient allegations of staff abuse. The facility also continued to have the staff involved in the alleged abuse continue to work on the same floor, 1 of the 2 staff members provided direct care to Patient #1 on 02/07/21. The first known allegation of abuse occurred on 02/08/21 evening, both staff members remained on the schedule after that evening. Based on interview and documentation, at least 3 staff members were aware of the abuse allegation on 02/08/21, only one documented the allegations. There was no follow up to these initial allegations, administration was only made aware of the allegation separately through social media video the patient posted. Cross refer to A0145.


Due to the above facts, the facility was informed on 02/11/21 that an immediate jeopardy existed related to the failure to report and address the initial abuse allegations. The facility was not ensuring the safety of all other patients from potential abuse, due to the fact the staff members involved in the alleged incident (#4 and 5) remained on the schedule and continued to work after the outcry of abuse was made. It could not be determined that patient safety from abuse and neglect was effectively being ensured by the facility.


The facility was able to abate the IJ while the surveyors were on site on the evening of 02/11/21 by updating policies, staff members involved were placed on paid administrative leave until an investigation of abuse concludes, and training was immediately provided to staff on site regarding reporting and handling abuse allegations.

PATIENT RIGHTS: GRIEVANCES

Tag No.: A0118

Based on a review of documentation and interviews, the facility failed to ensure that the established process for prompt resolution of patient grievances was implemented.

Findings:

Facility based policy entitled, "Your Rights" stated in part,

"Patient Complaints and Grievances

Complaints that are received are viewed as opportunities to improve patient care, communication and the services rendered. All patients, families and representatives have a right to present complaints and receive a response, without compromising the individual's access to care.

For timely resolution while still present in the hospital, those with complaints are encouraged to follow this recommended complaint procedure:

o Ask to speak to a supervisor.

o If unresolved, contact the Patient Advocate by dialing ext. 1567 internally or by dialing 432 221-2273 from outside the hospital, or

o Contact the Administrative Offices of Midland Memorial Hospital by dialing 432 221-1111"


Facility policy entitled, "Patient/Family/Visitor Grievance Policy" stated in part,
"Definitions:

Staff present at time of complaint is defined as primary nurse, shift supervisor, clinical manager or team leader.

Hospital management is defined as house supervisor, director, department head or vice president.

Patient Advocate is defined as any individual whose primary responsibility is to address patient satisfaction issues.

A patient complaint is a formal or informal verbal or written complaint that is made to the staff/hospital by a currently hospitalized patient (or the patient's representative), that can be handled promptly by staff present (primary nurse, shift supervisor, team leader or clinical manager).

A patient grievance is a formal or informal written, emailed, faxed, or verbal complaint that is made to the staff/hospital by a patient ( or the patient's representative) that could not be resolved promptly by staff present. If a complaint cannot be resolved promptly by the staff present or is referred to a complaint coordinator, patient advocate, or hospital management (house supervisor, director/department head) it is considered a grievance. A formal or informal written, emailed, faxed, or verbal complaint initiated by the patient (or the patient's representative) received after discharge is also considered a patient grievance

Patient/Family Visitor Issues

Patient/family/visitor complaints will be immediately reported to the following individuals in descending order until the complaint is resolved to the patient/family/visitor's satisfaction:

Primary Nurse/Shift Supervisor Clinical Manager/Nursing

Supervisor Director/Department Head

Patient Advocate

It should be noted that if a complaint cannot be resolved to the patient's/patient representative's/family's/visitor's satisfaction utilizing the staff present at the time of the complaint or is referred to a patient advocate or hospital management, the complaint then becomes a patient grievance and the following procedure should be followed:
Patient/Family Visitor Grievances Process

All grievances will be promptly referred to the Quality Management Department. The yellow Patient Complaint or Resolv [sic] form can be used for this purpose."


Facility policy entitled "Code of Conduct" stated in part,

"MMH's Commitment to Legal and Ethical Behavior

Conducting all Activities with the Utmost Respect and Dignity Toward Others - MMH Representatives are required to treat each other and MMH patients with the utmost dignity and respect, and MMH has a zero tolerance policy towards the display of disruptive and inappropriate behavior ...

(b) Disruptive or Inappropriate Behavior - is defined as behavior which interferes with others' ability to perform their duties and responsibilities effectively, undermines a person's confidence in an individual healthcare worker or the organization, and/or interferes with the orderly conduct of the organization. Examples of disruptive or inappropriate behavior include, but are not necessarily limited to:

o Lack of timely and appropriate response to requests and concerns ..."


Patient #1 made allegations of physical abuse against staff members at the facility in social media videos that were posted early Tuesday morning 02/09/21. Facility administration became aware of these allegations Tuesday morning after watching these videos.


Review of Patient #1's medical record revealed the following:

* Staff member #15 documented the patient making verbal allegations of abuse against staff on the evening on 02/08/21. A progress note stated in part, "...Patient is hysterical on rounds this evening. I have spent 45 minutes talking to her and her aunt.
She asserts that she has undergone abuse by the nursing staff. She states that they repeatedly banged her head on the rails of her bed, that they dropped her on her face in her own urine, and that they tried multiple times to pull out her feeding jejunostomy tube. She states that this all happened on Friday night. She is inconsolable and has inferred that she wants to seek legal counsel. She is upset with me as well saying that I abandoned her ...I have told her that I will talk with administration to make certain that these allegations are investigated. I have advised the patient that if she thinks legal counsel is appropriate she should proceed with what she thinks is right."


In telephone interview on 02/11/21 at 02:40 PM, staff member #15 verified they were notified of these allegations Monday night 02/08/21. Staff #15 was asked what they did after these allegations were made. They replied, "I spoke with the nursing supervisor that assured me that the issues had been kick up the chain to be resolved." Staff member #15 also stated, "I know [staff member #7] was already doing an investigation into it. I spoke with the nursing staff that was there Monday evening. I'm 100 % certain it was [staff member #7]."


In telephone interview on 02/11/21 at 03:00 PM with staff member #7, they verified that they and staff member #10 were called to patient #1's room Monday evening 02/08/21. They were asked if patient #1 alleged any physical abuse on Monday 02/08/21. They replied, "Other than her saying she [staff member] was rough with her maybe getting her cleaned up or get her up, rough enough to cause her drain to pull and cause it to bleed. Most of her complaints were verbal, condescending poor attitude from the staff ...We said we'll address these immediately, if you have any issues give me a call, that way we can address it immediately. All we can assure you, you know if anything else happened to call immediately, but the other complaints are going to take time get more than one side to the story. She said we have that day to do it. She wanted leave AMA, she gave us through that Monday to get something in place ...She was really really upset."


In an interview on 02/11/21 at 3:22 PM, staff member #10 verified responding to Patient #1's room with staff member #7 on Monday evening 02/08/21. Staff member #10 stated "[staff #5] made some comments the patient didn't like, apparently the aunt said, 'Please take care her, she's a sick young lady.'


The patient said, she [staff member #5] said, 'She talks to me like that again, I'll slap her mouth.' Told us she had thrown her in the bed, I assumed she turned her. There's no way [staff member #5] would have done anything like that. She said she had thrown her in the bed and she hit the bedrail, had urinated on herself. She 'bust out some stitches.'" Staff member #10 stated their intention was to follow up and interview the staff involved in the alleged allegations on Tuesday morning.


Neither staff member #7 or #10 documented the above conversations or allegations of abuse in the medical record for Patient #1.
Per facility policy, Patient #1's complaints/allegations should have been reported to the Patient Advocate, there is no documentation that occurred. It appeared the patient's complaints were not resolved to the patient's "satisfaction utilizing the staff present at the time of the complaint." Per policy, at that point the complaint becomes a patient grievance "all grievances will be promptly referred to the Quality Management Department".


In interview on 02/11/21, staff members #2 and 3 verified that administration and quality were not made aware of the patient's allegations of physical abuse until notified of the social media videos on Tuesday morning 02/09/21.


The three staff members (#7, 10, and 15) were notified of the various versions of the patient's complaints/abuse allegations on 02/08/21 and did not notify administration or the patient advocate per policy. Only one of the three staff members (#15) documented the allegations in the medical record for Patient #1.


By failing to report these complaints and allegations (of physical and verbal abuse) made by the patient, and being unable to resolve the issues to the patient satisfaction, the facility did not ensure the patient's right to an effective grievance resolution. The patient subsequently recorded the social media videos which brought these serious allegations to the attention of administration and quality to address on 02/09/21.

PATIENT RIGHTS: PERSONAL PRIVACY

Tag No.: A0143

Based on a review of documentation, interview, and observation, the facility failed to ensure the patient right to personal privacy.

Findings:

Facility policy titled "Patient Fall Prevention Program" stated, in part:

"Procedure: Adult

1. Inpatient Areas: Assessment

A. All adult patients should be considered at risk for a fall and should have the universal fall precautions instituted (see 2.A.)

B. All adult inpatients will be assessed with the Hendrich II Fall Risk Assessment, Mobility Assessment and High-Rick Fall Qualifiers on admission, each change of shift, transfer to another unit, any significant change in condition and if a fall occurs.

C. Adult patients considered at increased risk for fall will be categorized as an Impending Fall Risk:

The adult patient is a(sic) Impending Fall Risk if they meet any of the following Criteria

1. Hendrich II Risk score is five (5) or greater

2. Mobility Assessment is four (4) or greater

3. Any high-risk fall qualifier

a) Lower extremity amputation (including any part of the foot)

b) History of falls within the last 6 months"


Facility policy titled "Continuous Video Monitoring Policy and Procedures" stated, in part:
" ...c. Primary Care Giver Responsibility:
...
xi. Reassess patient at least every four (4) hours for the need to continue monitoring with continuous video monitoring."


In an interview on 02/11/21 at 5:34 PM with Patient #1 regarding the telesitter in their room, they stated, "I don't want it in here. I told them I don't. I don't know why it's here."


Review of Medical Record for Patient #1 included the following:

Nursing progress notes stated the following:

* 2-11-21 at 1:08 am - "patient stated she did not feel comfortable with telesitter monitor in room due to lack of privacy when ambulating to bathroom in backless gown. Informed patient that the camera can be turned off at request so that her privacy could be maintained while ambulating, etc. She asked why it was in the room, and asked who authorized its use. Informed patient that I was unsure of who put monitor in room, but that the telesitters are used to help maintain patient safety. Jennifer, House Supervisor, informed of situation and in patient's room at 0057 [1:57 am] to speak with patient."

* 2-11-21 at 1:55 am - "Per [staff member #6], patient agrees to keep telesitter in room and will request privacy as needed."

* A nursing note written on 2-9-21 at midnight stated , "Pt [patient] was educated about the bed alarm having to be on because she is a fall risk. Tele sitter was placed in the room."


Review of the clinical record on the evening of 02/11/21 revealed the Hendrich II Fall Risk Scale was performed at the following times:

* 02-8-21 at 7:53 am

* 02-8-21 at 7:00 pm

* 02-9-21 at 10:46 am

* 02-9-21 at 1:26 pm

* 02-9-21 at 7:29 pm

* 02-10-21 at 7:35 am

* 02-10-21 at 7:10 pm

* 02-11-21 at 7:41 am

* 02-11-21 at 7:20 pm


Although the video monitoring system was still present in the room upon the surveyors' visit with the patient on 2-11-21, the need for continuous video monitoring was not documented every 4 hours. Without the necessary documentation of continued necessity outlined in facility policy, the video monitoring system violated the patient's right to privacy.

PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT

Tag No.: A0145

Based on a review of documentation and interview, the facility failed to ensure each patient had the right to be free from all forms of abuse or harassment.

Findings:

Facility based policy entitled, "Your Rights" stated in part,

"You have the right to Care Delivery.

o Receive care in a safe setting free from any form of abuse, harassment, and neglect ..."


Facility policy entitled, "Abuse/Neglect Adult" stated in part,

"Purpose: Nursing staff will notify social services and law enforcement personnel, who will assist in the provision of appropriate supportive and legal services for adult victims of sexual abuse or assault.

If any member of the staff has reason to suspect that the patient is or has been the victim of sexual abuse, he/she must immediately notify the patient's nurse, physician and/or social services for appropriate follow-up and reporting.

1. Staff will notify Clinical Manager, Social Services, and/or Law Enforcement immediately when sexual abuse or assault is suspected or alleged.

2. Upon referral, Social Services and/or Law Enforcement will provide supportive counseling and crisis intervention as needed.
Screening Criteria...

A. Any reported abuse by the patient or caregiver should be reported immediately ..."


Facility policy entitled "Code of Conduct" stated in part,

"MMH's Commitment to Legal and Ethical Behavior

Conducting all Activities with the Utmost Respect and Dignity Toward Others - MMH Representatives are required to treat each other and MMH patients with the utmost dignity and respect, and MMH has a zero tolerance policy towards the display of disruptive and inappropriate behavior ...

(b) Disruptive or Inappropriate Behavior - is defined as behavior which interferes with others' ability to perform their duties and responsibilities effectively, undermines a person's confidence in an individual healthcare worker or the organization, and/or interferes with the orderly conduct of the organization. Examples of disruptive or inappropriate behavior include, but are not necessarily limited to:

o Use of profanity and vulgar expressions or gestures ...

o Intimidating behaviors such as slamming or throwing of objects, verbal abuse (yelling, shouting, etc.), physical aggressiveness, and sexual harassment."


At the time of the sutrvey, the existing policy and procedure in place at the facility did not address how to report or investigate allegations of verbal or physical abuse against staff. This was verified with staff member #2 on 02/11/21. In an interview with staff member #2 on 02/11/21 at 12:40, they were asked what the facility process for investigating abuse and neglect was and what they did with staff members involved. They replied, "I can check with HR I'm not familiar with a specific policy for that." The staff member added, "In practice, if a nurse or clinical staff suspect abuse, they would report to the clinical manager and the police."


Patient #1 made allegations of physical abuse against 2 staff members (#4 and 5) verbally to staff members (#7, 10, and 15) on 02/08/21 and via a video released on social media on 02/09/21.


Review of Patient #1's medical record revealed the following:

* Staff member #15 documented the patient making verbal allegations of abuse against staff on the evening on 02/08/21. A progress note stated in part, "...Patient is hysterical on rounds this evening. I have spent 45 minutes talking to her and her aunt.
She asserts that she has undergone abuse by the nursing staff. She states that they repeatedly banged her head on the rails of her bed, that they dropped her on her face in her own urine, and that they tried multiple times to pull out her feeding jejunostomy tube. She states that this all happened on Friday night. She is inconsolable and has inferred that she wants to seek legal counsel. She is upset with me as well saying that I abandoned her ...I have told her that I will talk with administration to make certain that these allegations are investigated. I have advised the patient that if she thinks legal counsel is appropriate she should proceed with what she thinks is right."


In telephone interview on 02/11/21 at 02:40 PM, staff member #15 verified they were notified of these allegations Monday night 02/08/21. Staff #15 was asked what they did after these allegations were made. They replied, "I spoke with the nursing supervisor that assured me that the issues had been kick up the chain to be resolved." Staff member #15 also stated, "I know [staff member #7] was already doing an investigation into it. I spoke with the nursing staff that was there Monday evening. I'm 100 % certain it was [staff member #7]."


In telephone interview on 02/11/21 at 03:00 PM with staff member #7, they verified that they and staff member #10 were called to patient #1's room Monday evening 02/08/21. They were asked if patient #1 alleged any physical abuse on Monday 02/08/21. They replied, "Other than her saying she [staff member] was rough with her maybe getting her cleaned up or get her up, rough enough to cause her drain to pull and cause it to bleed. Most of her complaints were verbal, condescending poor attitude from the staff ...We said we'll address these immediately, if you have any issues give me a call, that way we can address it immediately.


All we can assure you, you know if anything else happened to call immediately, but the other complaints are going to take time get more than one side to the story. She said we have that day to do it. She wanted leave AMA, she gave us through that Monday to get something in place ...She was really really upset."


In an interview on 02/11/21 at 3:22 PM, staff member #10 verified responding to Patient #1's room with staff member #7 on Monday evening 02/08/21. Staff member #10 stated "[staff #5] made some comments the patient didn't like, apparently the aunt said, 'Please take care her, she's a sick young lady.'


The patient said she [staff member #5] said, 'she talks to me like that again I'll slap her mouth.' Told us she had thrown her in the bed I assumed she turned her. There's no way [staff member #5] would have done anything like that. She said she had thrown her in the bed and she hit the bedrail, had urinated on herself. She 'bust out some stitches.'" Staff member #10 stated their intention was to follow up and interview the staff involved in the alleged allegations on Tuesday morning.


Neither staff member #7 or #10 documented the above conversations or allegations of abuse in the medical record for Patient #1.


Patient #1's allegations of abuse should have been reported immediately to administration and/or quality so the allegations could be addressed and investigated effectively.


In interview on 02/11/21, staff members #2 and 3 verified that administration and quality were not made aware of the patient's allegations of physical abuse until notified of the social media videos on Tuesday morning 02/09/21, at that point an investigation was initiated and on-going at the time of the survey.


The three staff members (#7, 10, and 15) were notified of the various versions of the patient's abuse allegations on 02/08/21 and did not notify administration or follow up regarding these allegations. Only one of the three staff members (#15) documented the allegations in the medical record for Patient #1. The failure to report or address the patient's abuse allegations delayed investigation into the allegation by the facility.


The staff members involved with the alleged abuse (staff member #4 and 5) continued to work on the unit and were still scheduled to continue working at the time of the survey investigation.


In an interview with staff member #2 on 02/11/21 at 12:40, they were asked when the 2 staff involved in the alleged allegations were scheduled to work. They replied, "[Staff member 4] worked last night and is scheduled for tomorrow. [Staff member #5] was supposed to work last night, but called in, she is scheduled for February 15th next Monday."


Review of the staff schedule for February 2021 revealed the following:

* After the alleged incident on 02/05/21 staff #5 was scheduled to work on 02/10/21 and 02/15/21. According to staff #2 they called in on 02/10/21 and did not work.

* After the alleged incident on 02/05/21 staff #4, worked on 02/06, 02/07, and 02/10. She was next scheduled to work on 02/12. In a telephone interview on 02/11/21 staff #4 verified they worked directly with Patient #1 on 02/07/21.


Based on the above findings, the facility failed to ensure the safety of patients from abuse and harassment as evidenced by not having a policy in place to address how to report/investigate patient allegations of staff abuse. The facility also continued to have the staff involved in the alleged abuse continue to work on same floor, one of the 2 staff members provided direct care to Patient #1 on 02/07/21. The first known allegation of abuse occurred on 02/08/21 evening, both staff members remained on the schedule.


Based on interview and documentation, on 02/08/21 at least 3 staff members were aware of the abuse allegation. On 02/08/21, only one documented the allegations. There was not follow up to these initial allegations, administration was only made aware of the allegation separately through social media video the patient later posted.


Due to the above facts, the facility was informed on 02/11/21 that an immediate jeopardy (IJ) existed related to the failure to report and address the initial abuse allegations. The facility was not ensuring the safety of all other patients from potential abuse, due to the fact the staff members involved in the alleged incident (#4 and 5) remained on the schedule and continued to work after the outcry of abuse was made.


Due to the above findings, it could not be determined that patient safety from abuse and neglect was effectively being ensured by the facility.


The facility was able to abate the IJ while the surveyors were on site on the evening of 02/11/21 by updating policies, staff members involved were placed on paid administrative leave until investigation of abuse concludes, and training was immediately provided to staff on site regarding reporting and handling abuse allegations.

MEDICAL RECORD SERVICES

Tag No.: A0450

Based on a review of documentation and interview, the facility failed to ensure that all patient medical record entries were complete.

Findings:

Facility policy titled "Enteral Tube Feeding" contained no instructions regarding removal (or subsequent documentation of the removal) of a nasal/oral gastric tube. According to professional reference https://nurseslabs.com/nasogastric-intubation/#charting-2, "Record removal of nasogastric tube, client's response, and measurement of drainage. Facilitates documentation and provides for comprehensive care."


Patient #1 made allegations that a nurse at the facility forcefully pulled out their nasogastric tube (NG) on 02/05/21.


In telephone interview on 02/11/21, staff member #5 who cared for the patient on 02/05/21 reported the NG tube was removed in the Post Anesthesia Care Unit (PACU) before returning to the floor that evening. This staff member denied removing the patient's NG tube.


Review of the medical record for Patient #1 revealed the following:

* Intake and Output Record: Output: Nasogastric tube Nare, left

Output was documented from 02/04/21 through 02/05/21 from 0600 to 1800: 350 ml was documented. No output was documented from 1800-0600 on 02/05/21-02/06/21.

* Anesthesia Record on 02/05/21

"15:11: Pre-Existing Lines/Tubes
NG/OG Tube: Present on Arrival
NG,/OG Tube: Verification by Aspiration of Gastric Fluids Note: Free Text - J tube to gravity, intact"

There was no documentation in the patient record of the NG tube being removed. This was verified on 02/12/21 in an interview with staff member #8. Due to the lack of documenting the removal of the NG tube, it cannot be established when it was removed and by which staff member. There is no clear documentation to support staff member #4's statement that it was removed before they took over care of the patient.