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Based on Record review and interview, the facility failed to provide patient's family with a written notice of the steps taken on behalf of patient to investigate a grievance, the results of the investigation, and the date of completion for 1 of 2 patients (Patient #1) in the patient sample who had filed a grievance.

Findings included:

Record review of facility's grievance policy titled "Patient and Family Complaints & Grievances", last reviewed 12/14/20 (no policy number) states that a grievance is defined as a formal or informal written or verbal complaint to the hospital by a patient, or the patient's representative regarding the patient's care. It also states any complaint is considered a grievance if it can not be resolved by staff at the time of the complaint.

In addition, the policy states that staff receiving the complaint shall insure that a Patient Customer Care/Concern Form is completed and the grievance shall be investigated within 24 hours. Also, the patient Advocate responding to the grievance shall follow up with the family within 7 days of the grievance.

Record review on 1/7/22 at 12:30 pm of facility's Complaint Log showed an entry in December, 2021 for Patient #1, written by Staff #S. It stated that the patient's daughter had called on 11/19/21 upset about the outcome of the treatment for her father and how bad he looked when he was transferred to the emergency room on his last day at the facility. The daughter complained about the multiple bruises all over her father's body and how he did not respond to any conversation. The daughter informed Staff #S that she and her family filed a police report. The log showed that the complaint was resolved, however, there were no notes explaining how the grievance was resolved, no notes on any investigation into the complaint, and no documentation of any written correspondence to the family.

In an interview on 1/7/22 at 1:10 pm with Staff #S, she stated that Patient #1's daughter had called her and was extremely upset and the complaint was sent to a supervisor. Staff #S stated the patient was transferred to the Emergency Room because he needed a higher level of care and he was constantly sleeping and not arousable. She added that Dr.-Staff #O had spoken to the daughter and she was not happy with him.

In an interview with PI Director-Staff #C during the same time of interview with Staff #S, he stated that the phone call was transferred to himself from Staff #S and he spoke with the daughter. He added she was very upset and cursing and the conversation did not progress very far. Staff #C stated that the daughter said she needed answers as to why her father was all bruised up and had an infection on his leg, as well as the father not being able to communicate as he had been able to at the time of admission to facility. Staff #C also stated that the daughter came to the facility because she was very upset and had to be escorted off the property because there were no visitors allowed due to Covid 19.

When asked if there was any investigation and/or any written response to the patient's family regarding the grievance, Staff #C stated there was not.

In an interview on 1/10/22 at 11:55 am with Dr.-Staff #O, he stated he was the one who took care of the patient's medical issues. He stated that Patient #1 needed a 1:1 sitter most of the time he was in the facility due to his confusion, aggression and risk to himself walking or running into things. He was also aggressive with other patients. Staff #O stated the patient had 2 falls while in facility that he knew of. He also stated he had to transfer the patient out to an Emergency Room (ER) due to a cut on the leg that became infected. He was unsure how the cut was sustained on his left leg, shin area, which was infected. He also stated that the patient's Altered Mental Status (AMS) had worsened, which was another reason he was sent out to the ER.

Based on Record Review and Interview, the facility failed to allow the patient or offer the patient's guardian the opportunity to participate in the development and implementation of the plan of care in 1 of 1 patients sampled for this (Patient #1).

Findings included;

Record review of facility policy titled "Master Treatment Planning", last revised 12/14/20 (no policy ID#) states that following the nursing assessment, the RN will add any medical problems to be addressed to the treatment plans and discuss this with the patient.

In addition, it also states that the Master Treatment Plans will be reviewed and shared with legal guardians.

Record review at time of survey of Patient #1's medical chart failed to reveal any evidence that family members were invited to participate in the patient's plan of care.

Record review of Patient #1's medical chart showed he had the diagnosis of Dementia and was extremely confused per medical and nursing assessment and progress notes during his entire hospital stay, and was unable to effectively participate in his plan of care. There was no evidence that the patient was offered to participate.

In an interview on 1/10/22 at 11:55 am with Dr.-Staff #O, he stated he did not know if the family was ever asked to participate in the patients plan of care. He also stated the patient was extremely confused, one of the main reasons the patient had been admitted for treatment. He also stated Patient #1 had a 1:1 close observation sitter watching him because of this. In addition, Staff #O stated that it was psychiatry that would usually have a meeting with families to discuss plans of care.

In an interview on 1/13/21 at 11:00 am with Staff #C, he stated that the he had received a phone call from the patient's daughter complaining about the care of her father. Staff #O presented the patient's therapist's progress notes, which failed to show any family members were invited to participate in the patient's plan of care. All other licensed staff's progress notes were reviewed at the time of survey and they all failed to show that any family members were asked to participate in the plan of care for Patient #1.

Based on Record Review and Interview, the facility failed to provide a safe environment for 5 out of 15 sampled patients (Patient #'s 1, 5, 10 and #12) as shown by the failure of nursing to provide accurate and consistent daily Nursing Skin Assessments.

Findings included:

Record review of facility policy titled "Patient Assessment Daily Nursing Flowsheet", last reviewed 12/14/20 (no policy ID#) stated that this assessment flowsheet will be completed by nursing every 12 hours, making it every nursing shift, which currently is from 7:00 am to 7:00 pm and from 7:00 pm to 7:00 am. The purpose of this policy is to ensure an accurate assessment of the patients' needs every shift. Any positive findings require documentation. This four-page form is the primary nursing documentation per the policy.

Record review during time of survey of Patient #1's chart showed the following: The patient, a 73-year-old male, was admitted voluntarily to the facility on 10/31/21 under the care of Dr.-Staff #R because of worsening confusion and aggression. The patient's diagnoses were Major Depressive disorder, recurrent, severe, with psychotic features, Schizoaffective disorder, Acute onset of psychosis and agitation, and Dementia. The patient had first gone to the Emergency Room at HCA Houston in Kingwood for aggression, dementia and hallucinations and was subsequently transferred to Behavioral Hospital of Bellaire on 10/31/21 (admit date) for treatment of these conditions. The patient was then transferred to Memorial Hermann Southwest for treatment of left lower leg cellulitis and chest congestion on 11/18/21 and never returned to facility.

The patient's initial skin assessment on 11/1/21 upon admission was unremarkable with the exception of dry feet and old scar, left side, back of thigh, and varicose veins.

The Nurse Shift Progress & Assessment Note-Daily nursing Flow Sheet (to be completed each nursing shift-from 7:00am-7pm and 7:00 pm to 7:00 am) showed the following for Skin Assessments:

-11/2/21 Skin-no issues;
-11/3/21 Skin-No issues;
-11/4/21 Skin-No issues;
-11/5/21 Skin-no issues;
-11/6/21 Skin-no issues;
-11/7/21 Skin-no issues (7a-7p shift), -11/7/21 Skin-Left leg bandages (skin
wounds) (7p-7a shift). Written nurse progress notes do not describe it;
-11/8/21 Skin-no issues;
-11/9/21 Skin-Skin-Left leg laceration (but written notes do not describe it) (7a-7p
shift). 11/9/21 Skin-no issues (7p-7a shift);
-11/10/21 Skin-no issues (7a-7p shift), 11/10/21 Skin-old bruises (no written
description) (7p-7a shift);
-11/11/21 Skin-wound. Bruises, knots, patient has bruises all over body;
-11/12/21 Skin-wound, bruises (no written description) (7a-7p shift), 11/12/21 Skin
Bruise (no written description) (7p-7a shift);
-11/13/21 Skin-Bruises (no written description) (7a-7p);
-11/14/21 Skin-no issues (7a-7p);
-11/15/21 Skin-no issues (7a-7p shift), 11/15/21 Skin-no issues (7p-7a);
-11/16/21 Skin-bruises (7a-7p shift), written progress notes from RN-Staff #AA
stated ... ...noticed a lot of bruises on patent's bilateral legs, bilateral buttocks and
anterior bilateral legs has cuts .....put patient down for medical consult ...;
-11/17/21 Skin-bruises. Progress notes stated there were unexplained bruises on
patient's body-backside, buttocks, left front leg, scratches on left anterior cubital
of arm ....cleaned bruises and scratches and applied triple antibiotic ....reported to
supervisor (7a-7p shift). 11/17/21 Skin-left lower leg wound, large bruising on both
buttocks, lower left leg warm to touch, swollen, red, medical consult requested
(7p-7a shift);
-11/18/21 Skin-leg wound, 9:00 am progress notes stated left leg wound, chest
congestion, patient in wheelchair, 11:00 am progress notes stated Patient being
transferred to Memorial Hermann Southwest to rule-out cellulitis of left leg, also
chest congestion .....1:1 tech accompanying.

Record review of patient #1's progress notes made by MHT-Staff #Z, who was a 1:1 sitter, written 11/5/21 at 8:30 am, showed: ...showered patient ....noticed a bleeding bruise on his left shin (leg) and scar on upper lip

Record review of progress notes written 11/5/21 (time unclear) by 1:1 sitter MHT-Staff #T showed "Pt was seen by Medical Doctor ....His bleeding wounds was treated and wrapped".

Record review at the time of survey of Dr.-Staff #O's progress notes on 11/5/21 at 12:19 am for Patient #1 showed the following: Patient fell yesterday and hit nightstand ....patient with laceration in mouth but difficult to assess ...patient with superficial laceration to left shin.

Record review of progress notes dated 11/9/21 at 10:35 am by FNP-Staff #V showed: ...Fall..staff stated patient bumped his head.

Record review of progress notes from Dr.-Staff #W dated 11/17/21 at 12:05 pm showed: non-infected abrasion of arms ... ... Neosporin BID x 7days.

Record review of progress notes dated 11/18/21 (time?) from Dr.-Staff #O showed: Patient with continued but worsening altered mental status ...patient also physically deconditioning, now in wheelchair ...+Left Lower Extremity Rash/swelling, buttock/leg bruise, +Cellulitis left lower leg approximately 8 cm with swelling, erythema and tenderness, + bruise left eye, lip, right thigh and knee ...A/P-Cellulitis ...refer to ER for evaluation, respiratory congestion-ER evaluation.

In an interview on 1/10/21 at 11:55 am with Dr. Staff #O, he stated, concerning Patient #1, that most of the time, the patient was on 1:1 close observation with a MHT (Mental Health Technician), who was constantly watching him. Staff #O stated that he had transferred the patient out because a day or two prior, he had a cut that became infected on his left shin and did not recall how or when the laceration to left shin occurred. He also stated that he noticed bruises on the patient.

Record review of progress notes from Sothwest Memorial Hospital, where Patient #1 was transferred from Behavioral Hospital of Bellaire showed the following:

Record review obtained from Southwest Memorial Hermann Hospital by Dr. Staff #HH, dated 11/18/21, where patient was transferred to from Behavioral Hospital of Bellaire and never returned showed from initial encounter with ER doctor #HH. It stated in part: "Chief Complaint pt coming from Bellaire Behavioral for cellulitis of the left leg ...

Record review of Southwest Memorial Herman Hospital Southwest from Staff-Dr. #GG showed the following in the Discharge note; History of Present Illness.. Pt is a 73 year old male with hx of schizophrenia and bipolar disorder sent from Bellaire Behavioral hospital for redness and swelling to the left lower leg. Pt has been at Bellaire behavioral for several weeks and has had wound to the lower leg that is having increasing redness and signs of cellulitis .....Patient was noted to have worsening redness and concerns of cellulitis in his left leg and hence was sent to the emergency room for further evaluation ...antibiotics were started. ID was consulted, neurology and psychiatry were consulted as well, CT and Ultrasound of left thigh suggestive of cellulitis with abscess, surgery was also consulted, recommended no indication for surgery ...patient was started on BiPAP and was transferred to IMCU. Patient also had fever of 102.9 this morning ...After discussion, family decided on hospice ... +BS Extremities: has erythema and edema of left lower extremity with some purulent discharge ....Fever Acute hypoxemic respiratory failure Dysphagia Cellulitis of left lower leg ...Pneumonia Toxic metabolic encephalopathy Lewy body dementia with behavioral disturbance Diabetes mellitus, type 2 Hypernatremia Cephalic vein thrombosis, left Sepsis Sepsis ....unspecified Delirium due to known physiological condition ...."



Record review at time of survey of Patient #9 showed the following: The patient was admitted to facility on 11/30/21 under the care of Dr.-Staff #BB and discharged on 12/6/21 AMA (Against Medical Advice). The patient, a 15 year old female, was admitted for a failed suicide attempt by swallowing the contents of her antidepressant medication and overdosed (30 Trazadone 100 mg pills). The patient's diagnosis was Major Depressive disorder, recurrent, severe. The patient had a self-induced laceration to her left wrist which needed staples from the emergency room due to the cut being deep. The patient's History and Physical exam showed Laceration to the left wrist ...wound 1.5 cm, and stated "Patient is a cutter". While the patient was in her room in the facility, she used a bottle cap to remove the sutures in her wrist and cut herself more. She was subsequently sent to the emergency room on 12/1/21, then returned to the facility.

The Nursing Shift Progress & Assessment Notes showed the following:

12/1/21 Skin -Fresh SH (self harm) cut to wrist (7p-7a shift). There was no page
three written nurse progress note in the chart;
12/2/21 Skin-Left Cut (7a-7p shift) Page 3, written description showed ...left wrist
cut intact and covered. 12/2/21 Skin-No issues (7p-7a shift);
12/3/21 Skin-Sutures L f/a (left forearm) (7a-7p shift). 12/3/21 Skin-no issues
(nothing written on page 3 progress notes regarding cut);
12/4/21 Skin-no issues (7a-7p shift)(nothing on page 3). 12/4/21 Skin-no issues
(7p-7a shift)(nothing written on page 3 regarding cut);
12/5/21 Skin-no issues (7a-7p shift). 12/5/21 Skin-no issues (7p-7a shift) (nothing
written on page 3 for both shift regarding cut);
12/6/21 Skin-Other (7a-7p shift)(nothing written on page 3 describing 'other'), 12/6/21 Skin-no issues.

Record review at time of survey of Patient #10's clinical records showed he was a 30 year old male admitted to facility on 11/25/21 under the care of Dr. Staff-#CC and was discharged on 12/9/21. His diagnoses were Schizophrenia and Schizoaffective disorder, Diabetes, Asthma. Further review of records showed a form called Patient Infection Report, filled-in by a skin wound specialist RN Staff-#EE on 12/3/21. It stated: Skin wound-Right 2nd digit (finger) ... Cellulitis of right ring finger. No symptoms on admission ...patient has Diabetes.

Nursing Shift Progress & Assessment Notes showed the following:

11/30/21 Skin-no issues (7p-7a shift);
12/1/21 Skin-no issues (7a-7p shift). 12/1/21 Skin-no issues (7p-7a shift);
12/2/21 Skin-no issues (7a-7p shift). 12/2/21 Skin-"Laceration" (7p-7a shift);
12/3/21 Skin-Right finger wound, infected. 12/3/21 Skin-"Laceration";
12/4/21 Skin-No skin issues (7a-7p shift). 12/4/21 Skin-no issues (7p-7a shift);
12/5/21 Assessment not found in chart (7a-7p shift) 12/5/21 Skin (no entry-not
addressed) (7p-7a shift);
12/6/21 Skin-no issues (7a-7p shift). 12/6/21 Skin-(no entry-not addressed)(7p-7a
shift);
12/7/21 No assessment found in chart for 7a-7p shift. 12/7/21 Skin-no issues (7p-7a
shift);
12/8/21 No assessments found in chart for either shifts;
12/9/21 Skin-no skin issues (7p-7a shift). Morning shift not found in chart.

Record review at time of survey of Patient #12's medical chart showed she was a 50-year-old female admitted to facility on 12/1/21 under the care of Dr.-Staff #FF and discharged on 12/9/21. Her diagnoses were Major Depressive disorder, recurrent, unspecified, Suicidal Ideation, Acute Embolism and thrombus, Deep Vein Thrombosis, Hypertension, Hyperlipidemia, Gingivitis, History of Malignant Neoplasm of Cervix.

Initial Admission Skin Assessment during intake showed Bruise to Right Upper Forearm-front and back, Bruising on Abdomen, Left great Toenail and 2nd Toenail black.

Nursing Shift Progress & Assessment Notes showed the following:

12/1/21 Skin-bruising (7p-7a shift). There was no description of the bruising;
12/2/21 Skin-no issues (7a-7p shift). 12/2/21 Skin-no issues (7p-7a shift);
12/3/21 Skin-no issues (7a-7p shift). 12/3/21 Skin-not addressed-blank entry (7p-7a
shift);
12/4/21 Skin-not addressed-blank entry (7a-7p shift). Skin-no issues (7p-7a shift);
12/5/21 Skin-no issues (7a-7p shift). 12/5/21 Skin-no issues (7p-7a shift);
12/6/21 Skin-no assessment-no entry (7a-7p shift). 12/6/21-no assessment found in
chart;
12/7/21 Skin-no assessment done-no entry (7a-7p shift). 12/7/21 Skin-no issues
(7p-7a shift);
12/8/21 Skin-no issues (patient was taken to ER for abdominal pain and returned
same day). 12/8/21 Skin-no issues (7p-7a shift);
12/9/21 Skin-no issues (7a-7p shift).

In several interviews with Staff #C and interview on 1/12/22 at 1:10 pm with Staff #G at the time of the findings of the nursing skin assessment, both acknowledged they were inconsistent.

Record review at time of survey of Patient #5's medical chart:

Psychological Evaluation: of Patient #5, 1/2/22 reviled the following: The patient, a 61-year-old male, was admitted to the facility from a group home on 1/1/22 under the care of Dr. Raichman #CC because of suicidal ideation with depression. He arrived in his personal wheelchair. The patient's diagnoses were Major Depressive disorder, Anemia, Obesity, Esophageal reflux disease.

History and Physical: Physician dated 1/2/22 indicated Major Depressive disorder, chronic venous stasis and leg ulcers. Morbid obesity. Untreated Hepatitis C, Nicotine abuse. Chronic obstructive pulmonary disease (COPD), Hyperlipidemia. Chronic Pain. Skin assessment read: EXTREMITIES: "Remarkable for an expensive venous stasis and increased pulses bilateral lower extremities. He has multiple partially healed and _____ spaces ulcers on his legs. Currently no cellulite as is noted." SKIN:" see nursing notes again for complete skin survey."

The patient's initial admission assessment - skin, 1/1/22, at 1620 read: patient has the bilateral chronic wounds covered with Kerlix (gauze dressing). Patient stated he had these wounds for over three years. Patient has chronic back pain. Body diagram documented "scar" on back of right hand and right and left shins circled with "Wounds." "bilat LE wounds." No measurements or further descriptions were documented.

Pain assessment: "Skip to next section."

Physician order 1/2/22 at 1700 Medical consult>Wound care.

Physician Progress Note 01/05/22 he is receiving wound care from the wound care nurse. We talked to him about the group home and how to take care of his wounds. Plan: Control Depression.

The Nurse Shift Progress & Assessment Note-Daily nursing Flow Sheets (to be completed each nursing shift-from 7:00am-7pm and 7:00 pm to 7:00 am showed the following for Skin Assessments:

-1/1/22 at 1900, Patient has bilateral or extremities ulcer wounds covered with dressing.
-1/2/22 Bilat leg wounds
Physician Order 1-3-22 at 1700, Medical Consult> Wound care
Physician Order -1/4/22 at 1100 Wound Care, Transfer to MD Order Noted by RN 1/5/22 at 0320 (16 hours 20 minutes later).
1-3-22 No notes on skin
1/4/22 Wound nurse note. Dressing change done stage IV wounds bilateral lower legs.
-1/4/22 at 1430 by wound care nurse; dressing change. Plan to change in 24 hours or PRN (as needed), leaking erythema (redness)
-1/4/22 at 1500 seen and evaluated by wound care nurse. Medicated for pain twice with good result. Staff will continue to monitor his progress.
-1/5/22 at 1503, Had a wound on his leg, since medical supply not available the wound care nurse didn't come to do the wound care cleaning. And for nursing supervisor and she will do we get tomorrow.
-1/5/22 at 1826, Staff provided wound care. HCP (Hepatitis C) wound infection. Neomycin (over the counter topical antibiotic). Wound drainage, pain and itching boxes on form checked. No measurements or further descriptions were documented.
- 1/6/22 1400, by Staff #D ADON. Chronic Stage IV wound on both lower extremity. Patient requires pain medication prior to wound care.
No undermining noted. Depth of 0.3 cm. Wound 1 RLE bed measures 30.5 x 13.5 x 10 x 0.3 cm. Wound 2 (LLE) measures at 10 x 8 x 0.1.
Large amount of yellow drainage with odor noted from all wounds. Observable necrotic tissue also noted. Surrounding tissue with erythema. Large amount of serous drainage noted.
Wounds were irrigated with normal saline, xerofoam applied to surrounding tissue to prevent further breakdown from maceration. Collagen gel and xerofoam applied to wounds. Covered with a hydrocolloid dressing. Plan to change dressing in 24 hours or PRN, leaking.
Patient instructed in importance in staying off wound areas and limit sitting in wheelchair to one hour. Verbalizes understanding.
WBC within normal limits and patient afebrile. Will monitor.
- 1/7/22 Skin: Bilat leg wound. No measurements or further descriptions were documented.
-1/8/22 Wound on bilat lower legs wrapped. Visible on the unit. Restless sleep through the shift. Will continue to monitor the patient's progress and safety.
-1/09/22 Skin-no issues No mention in narrative note.
-1/10/22 7am - 7pm SKIN: Bilat leg wound. No measurements or further descriptions were documented.
-1/10/22 7am - 7pm Skin-no issues No mention in narrative note.
-1/11/22 Test results: Covid Positive.
-1/12/22 Wound nurse note. Dressing change done stage IV wounds bilateral lower legs.
-1/12/22 at 2100 Will continue to monitor the patient's progress and safety. Wound dressing intact.

The record did not contain a physician wound consult, nor specific wound care orders. The record did not address the Hepatitis C.

Facility policy: "Patient Assessment Daily Nursing Flowsheet", last reviewed 12/14/20 (no policy ID#) stated that this assessment flowsheet will be completed by nursing every 12 hours, making it every nursing shift, which currently is from 7:00 am-7:00 pm and from 7:00 pm to 7:00 am. The purpose of this policy is to ensure an accurate assessment of the patients' needs every shift. Any positive findings require documentation. This four-page form is the primary nursing documentation per the policy.

Interviews:
In an interview 1/11/21 at 1515 RN Staff # V, stated, she had never seen patient # 5's wounds twice for dressing changes or dressing change. "The wound care nurse does that. When asked if a wound care doctor had evaluated the patient, she responded "I don't think so."

In an interview 1/11/21 at 1500 patient #5 stated no one had discussed treatment of his Hepatitis C. He stated he did not receive daily dressing changes and was not sure what the plan for his wounds was. He stated he was usually medicated before a dressing change, but his pain was a 12 on a scale of 1-10 with 10 high pain. He stated he had told staff his pain was horrible but got the same pills (medication).
In an interview 1/14/21 at 11:55 am with RN Staff #, D stated, she had done wound assessments and dressing changes on patient #5 twice. She stated she dressed the wounds per her previous wound care experience because she did not find specific orders. She stated she wasn't sure if patient #5 had been seen by a wound physician and more intensive wound care had not been discussed.


43549


Based on observation Record Review and Interview, the facility failed to provide a safe environment for 2 of 7 patients (#'s 14, and 20) on Unit 9, the Covid - 19 unit, as evidenced by the failure of nursing to ensure toxic substances avail to patients only with supervision.

Observation:

During a visit to unit 9, the Covid-19 unit on 1/13/22 at 1230 MHT II was interviewed about the process to clean patient rooms when patients transfer rooms in the evenings. She reported that after housekeeping leaves at 1830 must clean the room for a discharged patient. She stated, "let me show you." MHT II asked patient #14 if she could show and this surveyor her room and patient #14 agreed. MHT #II and this surveyor entered room 901, the patient's room, shared with patient # 20, where she explained her cleaning process. Patient #14 entered her room and began to speak to this surveyor about her life and discharge plans. Patient #14 beckoned this surveyor to her clothing shelves to show a paper. On the eye level shelf there was an approximately 2 in long (partially smoked) cigarette butt. She stated it was hers and she had saved it from the previous smoke break with staff and patients. She stated cigarettes are expensive "They're like $10 a pack!" She said she needed to save butts because she "can't afford to buy a lot of cigarettes."

Staff #C, Performance Improvement Director, was on the unit and was summoned to view the cigarette butt and confirmed its presence.
Floor nurse #JJ entered the room ad took the cigarette butt. Patient #14 became angry "You Bitch! I need that. I keep those for the next smoke."

Record Review:

Admission Psychiatric Evaluation: Patient #14, 1/2/22 reviled the following:
Patient #14 was a 55-year-old female admitted 01/01/22 for suicidal ideation. Homeless.

Diagnosis: Major depressive disorder, recurrent, severe, without psychotic features.
" Alcohol Use disorder
" Cocaine use disorder
" Post-traumatic stress disorder
" Epilepsy

Mental Status Exam:

History of Present illness:

Patient reports that she has been drinking one leader of alcohol a day, smoking 2 to 3 g of cocaine a day, and has been feeling more depressed recently. She is homeless and does not have a good support system due to her substance abuse. Patient endorses depressed mood currently. Has a history of mania only when taking cocaine and psychosis when taking cocaine, but otherwise no history of mania for psychosis. Does have PTSD symptoms, nightmares, flashbacks, the physical abuse from her difficult life on the streets.
General appearance: Poorly groomed, poorly kempt, appears older than stated age. Attitude in behaviors are guarded, evasive, manipulative. Patient as symptoms consistent with being drug seeking. Denies auditory or visual hallucinations. Oriented to person placed time and situation. Inside and judgment are poor. Intelligence is average.

Facility policy:

1. Contraband/Valuables Search and Storage Reviewed 12/14/20.

Policy: Behavioral Hospital of Bellaire will provide safe keeping of contraband and valuables for patients that cannot have these taken home. The hospital will not be liable for valuables that are not stored in the hospital's contraband/valuables storage room or safe.

Procedure: When the patient arrives on the unit, the skin assessment and contraband search will be conducted in a private location without video recording capability on the unit by the unit nurse and mental health technician of the same gender. Search will protect patient privacy, and dignity, and safety. ...
No more than three (3) changes of clothing will be placed in a paper bag and given to the patient to take with them to the Unit. All other items will be stored in a contraband/valuables storage room. These items will be returned to the patient at the time of discharge by the Unit staff.
Contraband Unapproved Items:
This list includes but is not limited to:
Cigarette lighters and matches
" (The policy does not mention tobacco products, drugs or medications.)

References:

Illinois Poison Center Cigarettes | Illinois Poison Center

Toxicity Level -Toxic
Possible Symptoms
Ingesting cigarettes can cause vomiting, sweating, drowsiness / tiredness, shaking, confusion, seizures, and even death.

Article:

Tobacco and Cigarette Butt Consumption in Humans and Animals
Nicotine found in cigarette butts may cause vomiting and neurological toxicity; leachates of cigarette butts in aquatic environments may cause exposure to additional toxic chemicals including heavy metals, ethyl phenol and pesticide residues.

This review suggests that cigarette butt consumption by small children and animals is a frequent source of concern and attention for poison control centers, parents and pet owners. The ubiquity of this waste should thus be a concern for policymakers who would seek to reduce the costs of dealing with tobacco ingestions for both parents and providers

Article Information: (PMC - US National Library of Medicine, National Institutes of Health)
Tob Control, 2011 May 20(Suppl_1):i17-i20, doi:10.1136/tc.2011.043498
PMCID:PMC:3088460
PMID: 21504918
Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088460/#__ffn_sectitle

Interviews:
In an interview on 1/13/22 at 1235 MHT II was interviewed about the process to clean patient rooms when with Staff #C, Performance Improvement Director he stated the cigarette butt was contraband and that no patients are allowed to keep tobacco products in their rooms.

When interviewed on 1/13/22 at 1240 RN #JJ stated cigarettes are to be smoked outside and disposed of if not completely smoked. He stated cigarettes are kept in the nursing station, not patient rooms. He stated staff are to observe smoke breaks for patient smoking safety.

On 1/13/22 at 1245 MHT II was interviewed about patient smoke breaks. She stated patients have smoke breaks before breakfast at about 0730, at lunch time about 1230 and again after dinner at about 1730. She stated cigarettes are stored at the nursing station and patients go outside to smoke. She stated she took patients out for their smoke breaks that day and patient #14 must have kept her cigarette after smoking and put it in her room. She stated she did not observe patient #14 finish smoking.

Unit 9 RN #KK was interviewed 1/13/22 at 1248 about patient's having cigarettes in their rooms. She stated that should not happen.


Based on observation, record review and interview the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases for 8 of 8 Covid -19 unit patients (#'s 4, 6, 15, 16, 19, 21, 22 and 23) as evidenced by the Registered Nurse and Mental Health Technician failing to cleanse their hands between glove changes on Unit 9, the Covid - 19 unit.

Policy: Infection Control COVID -19/ Coronavirus In-patient; Reviewed 12/21

Purpose: To eliminate or reduce to the lowest possible number, incidents of contracting blood borne infections by providing direction to employees who may, by the nature of their work, be exposed to blood, blood products, body fluids, secretions or excretions.

Procedure:
A. Staff must wash hands before and after contact with each patient, after contact with blood or potentially contaminated articles or infectious products, and prior to donning gloves and immediately after removing gloves.

Observation:
During a tour of Unit 9, Covid -19 unit 1/10/22 at 1300 with staff #C, Performance Improvement (PI) Director, a patient was noted on a mattress on the floor of a small unit dining room. Patient personal items were in a paper bag on the floor of that room. Registered Nurse (RN) #M and Mental Health Technician (MHT) #K were asked about the mattress on the floor. RN #M stated there was not an available male bed, so the male patient was being housed in the dining room on the floor. They were asked about infection control practices on the unit and who is responsible for the. They stated bed in the dining room (DR). MHT #K stated housekeeping cleans but when they are not available the MHTs do spot cleaning and change beds.

This surveyor requested they explain this Covid unit bed change process. Both RN #M and MHT #K donned purple gloves and explained they often work together to complete the task. MHT #K began to demonstrate cleaning and making an empty bed 901A. Both employees stripped linen off the bed and placed it in a covered hamper. MHT #K and RN #M demonstrated cleaning surfaces with disinfectant wipes. They then then removed their gloves and donned new gloves without using hand sanitizer or washing hands prior to donning the new gloves. MHT #K retrieved clean linen and he and RN #M picked up separate linen pieces (sheet/pillowcase) to make the bed. This surveyor stopped the process and jointly asked them what they would do after making the bed. Both walked to the nurses' station and removed their gloves. RN#M placed a clean pair of gloves on his hands without using hand sanitizer or washing hands prior to donning the new gloves. He then picked up a pen and stated, "We'd be all done." MHT #K cleansed his hands at the nursing station before donning new gloves.

When interviewed 1/10/22 at 1325 RN#M stated he knew he should cleanse hands between any glove change. He stated he "Just forgot" to cleanse his hands between glove changes.

When interviewed 1/10/22 at 1325 MHT#K stated he knew he should have cleansed his hands between glove changes but missed that step one time while demonstrating.

When interviewed 1/10/22 at 1340 staff #C, Performance Improvement (PI) Director confirmed observing RN#M and MHT #K change gloves after handling contaminated linens without cleansing hands prior to donning clean gloves.

Based on Record Review and Interview, the facility failed to insure that 3 out 15 patients (Patients #1, #2, & #5) had complete Care Plans that nursing staff developed to meet the patients' needs.

Findings included:

Record review of facility policy titled "Master Treatment Planning", last revised 12/14/20 (no policy ID#) states that following the nursing assessment, the RN will add any medical problems to be addressed to the treatment plans and discuss this with the patient.

It also states that the treatment plan will be reviewed and/or updated weekly and will reflect changes in the patient's course of treatment.

In addition, it also states that the Master Treatment Plans will be reviewed and shared with legal guardians.

Record review on 1/10/21 during time of survey of Patient #1's medical chart showed it failed to address the patient's left leg shin laceration which occurred on 11/5/21, nor did it address the multiple bruises sustained by the patient over the course of his hospital stay which is documented in the daily nursing assessment. This left shin wound was present up until the day the patient was discharged on 11/18/21 after it had turned into cellulitis, as shown by Dr.-Staff #O's progress notes.

In an interview on 1/10/21 at 4:30 pm with both Staff #C and Staff #H, they both acknowledged that the Care Plans were missing this information.

Based on Record Review and Interview, the facility failed to insure that all medical records had documented Discharge Summaries with outcome of hospitalization, disposition of care, and provisions for follow-up care for 2 of 15 patients sampled (Patients #1 & #12).

Findings included:

Record review at time of survey of Patient #1 and #12's medical charts showed the Discharged Summary documents were blank and not filled-out. It was past 30 days since both patients had been discharged from the facility.

In an interview on 1/12/22 at 1:10 pm with Staff #C, he was presented with the blank discharge summaries, acknowleged they were not done, and stated that sometimes the doctor's Discharge Summaries where in the computer, using the Midas software. However, after checking, Staff #O confirmed they were not done in the computer either.