HospitalInspections.org

Based on interview and record review, the facility failed to fully uphold the patients' right to informed decision making regarding their care and treatment. Two (2) of five sampled patient records failed to contain completed consent for treatment (Patient ID #12) and procedural consent. (Patient ID # 1).

Findings included:

Record review of facility policy titled "Infromed Consents, General Guidelines", revised 01/2023, stated "It is the policy of OakBend Medical Center that each patient or legal representative be provided with information regarding tests, studies, operative and invasive procedures that allow the patient or representative to make an informed choice regarding his/her healthcare while maintaining optimum patient respect and dignity. It is the legal responsibility for the physician or licensed independent practitioner who will perform the surgical or diagnostic procedure or treatment to give information required to provide informed consent and to ensure signature is obtained from the patient. It is NOT the responsibility of hospital employees to provide this information, though they may be involved in obtaining signatures." It further stated "Procedure: B. The patient has the right to give or withhold consent before receiving medical treatment, and has the right prior to making this decision, to be fully advised of the risks and consequences for the treatment, alternatives to the treatment, risks and consequences of alternative treatments, and expected results of refusal. Refusal of care or participation in treatment will not put the patient at risk of retaliation or compromise their care or treatment. When a practitioner other than a physician performs the procedure,
he/she may obtain the informed consent. Example: a registered nurse
that inserts a PICC line may obtain the informed consent. 5. Hospital staff may prepare the informed consent form. Hospital staff may witness the patient or representative ' s signature after validation that the patient or representative has received and understands the information necessary to provide informed consent. Documentation of informed consent may also be found in other areas of the medical record, such as progress notes, history and physical, or other areas as appropriate."

Record review of two (2) sampled patient medical records who presented for treatment in December 2024 and January 2025. Patient ID #1 Disclosure and Consent - Medical and Surgical Procedures failed to have a date and time that the physician signed the consent form and the section for reason for patient incapacity is not completed. Patient ID #12 presented to the facility on 01/28/2025. His consent for treatment is dated 01/28/2025. The patient signature line stated "Inmate" and the witness area is signed. Medical records reflected the patient was awake, alert and oriented and had mental capacity to sign his consent for treatment.

The above findings were verified by Quality Director Staff ID #51 on 1/31/2025 at 2:30 pm. She confirmed that Patient ID #1 procedural consent should have date and time and reson for incapacity completed. She confirmed that Patient ID #12 should have signed his own consent for treatment, irrespective of his status as an inmate.

Based on interview, and record review, the facility failed to investigate an allegation of abuse per its policy (Patient ID #1).

Findings included:

HHSC Intake TX00526949 complainant stated "Staff RN (ID# 59) proceeded to pull on her arm, with he help of Staff RN ID #60, which resulted in a surprising sound that I later learned was associated with her shoulder."

Record review of Patient ID #1 medical record showed a PICC Insertion Record dated 12/13/2024 which stated "Pt notably contracted in both arms. RN Staff ID #60 assisted the patient in positioning the arm more appropriately. Notable pop heard and felt when moving arm into position." Record review of Patient ID #1 medical record showed a Shoulder Xray 12/13/2024 order at 21:46. The Xray result on 12/13/2024 at 22:50 stated "Findings: Osseous structures: Deformed appearance of the proximal right humerus. Radiographic appearance is suspicious for sequela of a remote injury. Cross-section imaging can be obtained to further evaluate if there is concern for an acute on chronic injury. Osteopenia. Degenerative change within the acromioclavicular and glenohumeral joint Joints: No glenohumeral dislocation. Soft tissues: Swelling throughout the right shoulder region. Right-sided PICC line. Distal tip projects over the cavoatrial region. Tracheostomy tube noted Recommendations: If the patient has persistent pain, a follow-up radiographic evaluation in 10-14 days, MRI, or three phase bone scan would be recommended to exclude an occult injury. IMPRESSION: 1. Deformed appearance to the proximal right humerus. Radiograph appearance is suspicious for sequela of remote injury."

Record review of facility policy titled "Patient Rights: Non-Abuse Policy", revised 01/2008, stated " GENERAL STATEMENT : It is the policy of OakBend Medical Center that no patient shall be subjected to negligence, verbal or physical abuse by any member of the staff. II. DEFINITIONS: A. Negligence Omission of any action that would have been taken by a reasonable person under the same circumstances or commission of something that a reasonable person would not have done under the same or similar circumstances. Physical Abuse Any willful, angry or violent touching of a patient that could or would produce bodily harm." The policy further stated " PROCEDURE A. Any suspected negligence or patient abuse shall be thoroughly investigated by the Chief Nursing Officer (CNO) and reported to the CEO. B. If a decision to terminate is rendered, the employee's director shall proceed with the policies relating to immediate termination of employment. C. The CNO will report any licensed or unlicensed staff to the appropriate authority as deemed by the State of Texas Nurse Practices Act."

Interview with Chief Nursing Officer Staff ID #53 on 01/31/2025 at 08:45 am. She confirmed that she was made aware of the incident concerning the humeral head fracture for Patient ID #1 which was acquired on 12/13/2024 evening with positioning for PICC line placement on 12/16/2024 morning as part of the facility safety huddle analysis with leadership. She confirmed that the facility failed to fully analyze all aspects of the case. She confirmed that the procedure nurse was a contracted service and she had not reported him to the Texas State Board of Nursing per policy. She reported he was no longer allowed to practice at their facility per agreement with contracted service.

Based on interview and record review, the facility failed to ensure nursing staff reported unusual events/assessments, which occurred during an invasive procedure and resulted in an injury to a patient, to a licensed provider (Patient ID #1).

Findings Included:

Record review of facility policy titled "Emergency Department Nursing Assessment and Reassessment Policy", last revised 05/2023, stated "
POLICY/PURPOSE (Facility) will provide patient care, treatments and services based on information collected from an interdisciplinary assessment of the patient's relevant physical, psychological, and social needs. There will be established guidelines for the triage, initial assessment and reassessment of patients presenting to (facility) emergency departments. Reassessments (system re-review) will be completed at regular intervals determined by the patient response and/or changes in condition or diagnosis ... D. Reassessment (system re-review) will be obtained every four hours from the initial assessment. If there is a change in patient's condition or diagnosis, a reassessment (system re-review) will be documented at that time."

Record review of contracted vascular access team policy titled "PICC Insertion Policy and Procedure," last revised 10/2023, stated "Complications: Insertion complications and other relevant clinical assessments should be reported to the licensed independent practitioner by the vascular access specialist and documented in the progress notes/nursing notes in the patient's medical record." It further stated "Procedure 36. The clinician verbalizes possible complications of the procedure related to the patient's condition."

Record review of Patient ID #1 electronic medical record showed a PICC Insertion Record dated 12/13/2024 which stated "Pt notably contracted in both arms. RN Staff ID #60 assisted the patient in positioning the arm more appropriately. Notable pop heard and felt when moving arm into position." Record review of Patient ID #1 medical record showed a Shoulder Xray 12/13/2024 order at 21:46. The Xray result on 12/13/2024 at 22:50 stated "Findings: Osseous structures: Deformed appearance of the proximal right humerus. Radiographic appearance is suspicious for sequela of a remote injury. Cross-section imaging can be obtained to further evaluate if there is concern for an acute on chronic injury. Osteopenia. Degenerative change within the acromioclavicular and glenohumeral joint Joints: No glenohumeral dislocation. Soft tissues: Swelling throughout the right shoulder region. Right-sided PICC line. Distal tip projects over the cavoatrial region. Tracheostomy tube noted Recommendations: If the patient has persistent pain, a follow-up radiographic evaluation in 10-14 days, MRI, or three phase bone scan would be recommended to exclude an occult injury. IMPRESSION: 1. Deformed appearance to the proximal right humerus. Radiograph appearance is suspicious for sequela of remote injury."

Telephone Interview with RN Staff ID #59 on 1/31/2025 at 09:35 am. He confirmed that he did not inform ED Physician Staff ID #61 about the "pop" heard and felt while manipulating flexion contractures to optimize positioning for PICC line placement.

Telephone Interview with Physician Staff ID #61 on 1/30/2025 at 4:15 pm. He reported he was not notified by Vascular Team Staff RN #59 that there were any possible complications related to PICC line placement. He stated he had no contact with Staff RN #59 that shift.

Based upon record review and interview, the facility failed to ensure that 1 of 1 contracted Registered Nurses (RN #59) reviewed had completed facility specific orientation and onboarding, according to facility policies and procedures.

Findings Included:

Record Review of Staff RN #59 employee file failed to reveal any facility specific education or orientation.

Record Review of facility policy titled "Agency and/or Contract Orientation, Competency and Evaluation of Staff", last revised 11/2020, stated,
"Policy statement: All agency and contracted staff will meet the same standard regarding staff qualifications, orientation, and competency assessment as any employee of (facility)."

Interview with Director of Nursing Staff ID #53 on 01/31/2025 at 09:05 am. She stated that nursing department has an onboarding period which includes classroom time and electronic modules. She confirmed that ongoing education included annual skills evaluations/validations. She confirmed the facility has a process for new staff hires, current staff and agency nurses for completing this onboarding process through HR Generalist Staff ID #66. However, she confirmed they have not included contracted nurses in this process up to this point.