HospitalInspections.org

Based on review of records and interview, the facility failed to ensure a complaint received after the discharge of a patient was processed as a grievance. This presents a risk that the facility may not identify or respond to a quality of care issue or adverse outcome experienced by a patient. This was not in compliance with facility policy or federal regulation.

Findings included:

A call was placed by the surveyor at 1116 on 4/12/2021 to the father of Patient #2. The father stated that Patient #2 was a patient at HBHH. The father stated that he had contacted the facility and made a verbal complaint that Patient #2 was administered medication that the parents had not consented to; that Patient #2 had an injury while a patient at the facility on 3/1/2021; the parents were not notified of the injury; and proper assessment and care was not provided. The father of Patient #2 stated he requested an investigation of the incident and the above allegations by the facility several times and never received a response. The father of Patient #2 stated, "there is supposed to be a video and they were going to watch it and contact me back ...I have not heard from them, I have called them and I have been dealing with this over a month and they have avoided me." The father of Patient #2 stated that he did not received a written response from the facility in answer to his complaint.

An interview was conducted in the facility conference room on 4/12/2021 at approximately 1400 with Staff #4, Nurse Manager and Staff #5, Patient Advocate.

Staff #5 stated that she recalled [the father of Patient #2] contacting the facility with a complaint about the care of his daughter at the facility after Patient #2 was discharged on 3/4/2021. Staff #5, stated, "the dad called me and said, ' I want more info about her chart and medication. ' I turned the call over to the nurse manager, because I ' m not a nurse."

Staff #4 stated, "I remember [Staff #5] gave me the chart for [Patient #2]. I gave the dad a call, he told me the story, I told him to let me look through the chart and see what was documented." Staff #4 stated that she reviewed the documentation in the chart with the father of Patient #2.

Staff #4 stated, "I explained to him (the father), there was not a wrongful medication, two nurses signed off that you gave consent. Then she didn ' t get the med anymore, and it was discontinued."

The surveyor inquired about video or camera surveillance, mentioned by the father of Patient #2. Staff #4 stated there are cameras in the area of the alleged event. The surveyor requested to view the video for the morning of 3/1/2021, beginning at 7 am. Staff #4 stated that the videos are only maintained for 30 days (the surveyor request was made on April 12, 2021). The surveyor asked if either Staff #4 or Staff #5 viewed the videos after the allegation was made. Staff #4 and Staff #5 each stated they did not review the video and further stated that no one had reviewed the video.

Staff #4 stated, "when I talked to him [the father of Patient #2], I thought that was the end, I gave him the information - I had the record open in front of me and answered his question." Staff #4 stated she had no documentation of her communication with [the father of Patient #2].

Staff #5 said she had no contact with the father after the initial call, "when I handed him over to [Staff #4]." Staff #5 stated "I felt that the concern would be handled by her [Staff #5]."

In an interview with Staff #2 in the facility conference room at 1410 on 4/12/2021, he stated that there was no grievance filed or grievance investigation conducted by the facility on behalf of Patient #2.

After conducting interviews and reviewing the medical records, an interview was conducted with Staff #1 and Staff #2 on 4/13/2021 at 1125 in the facility conference room. After reviewing the facility policy entitled, "Patient Complaint and Grievance Process", Staff #1 and Staff #2 confirmed that the complaint filed by the father of Patient #2 should have been handled as a grievance, as the father requested a response from the hospital. The complaints made by the father of Patient #2 after the discharge of Patient #2 were confirmed by Staff #4 and Staff #5. There was no investigation conducted of the grievance and the concerns of the father of Patient #2 were not addressed.

Facility policy, Patient Complaint and Grievance Process, policy #1000.09, last reviewed 2/25/2021, stated, in part, "DEFINITIONS A. A patient grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient ' s representative, regarding the patient ' s care, abuse or neglect ...
F. Patient complaints that become grievances also include situations where a patient or a patient ' s representative telephones the hospital with a complaint regarding his/her patient care or with an allegation of abuse or neglect, or failure of the hospital to comply with one of more CoPs or other CMS requirements ...
G. Whenever the patient or the patient ' s representative requests his/her complaint be handled as a formal complaint or grievance, or when the patient requests a response from the hospital, then the complaint is a grievance and all the requirements apply ...
III. PROCEDURE D. All grievances are to be submitted verbally or in writing to the Patient Advocate, either by the patient, the patient ' s representative or a staff member to whom the grievance was reported ...
F. The Patient Advocate will conduct an investigation of the grievance, reviewing the patient ' s medical record, to obtain information regarding the patient ' s clinical condition.
G. All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered a grievance that requires immediate attention. The Patient Advocate will interview the patient and/or patient ' s representative for additional information as needed. The Patient Advocate will also query other members of the healthcare team that have been involved in the care of the patient.
H. After thorough research has been conducted, the Patient Advocate will work in tandem with staff identified as key individuals critical to problem resolution for the specific identified concern ...
I. All grievances receive immediate priority and must be investigated with efforts made toward resolution within 24 hours. If a grievance cannot be resolved within 24 hours, the grievance will be referred as described below. This organization will make every attempt to provide a response within seven (7) days of receiving a grievance.
1. If a grievance is not resolved, the investigation is not complete, or if the corrective action is still being evaluated within the seven (7) day timeframe, the hospital shall send a response to the patient stating that the hospital continues to work to resolve the complaint and the hospital will follow-up with another response within 30 days of the original grievance ...
J. The patient will be provided with written notice of:
1. The name of the Patient Advocate
2. The steps taken to investigate and resolve the grievance
3. The final result of the complaint and grievance process
4. The date of completion of the complaint and grievance process.
K. Written notice will be provided to the patient ..."

The above findings were confirmed in an interview at approximately 3:30 pm on 4/13/2021 with Staff #1 and Staff #2 in the facility conference room.

Based on review of clinical records, hospital policies, and staff interviews, the hospital failed to ensure that meal consumption was documented by nursing staff for each patient, as the meal consumption was not documented for 24 hours by mental health technicians for a patient that had been identified as not eating or drinking at admission. This presents a risk that a patient with an identified nutritional risk may not be properly monitored or treated.

Findings included:

The medical record for Patient #1 was reviewed in the facility conference room the afternoon of 4/13/2021.
Admission documentation revealed that "patient has decreased oral intake...Pt has hx of inpatient admissions at [other facility] not eating/drinking for a few days..." Patient #1 was ultimately transferred from this facility to a medical hospital on 3/16/2021, in part, due to his decreased nutritional intake.

Initial Nursing Assessment conducted at 0237 on 3/12/21, stated, " ...Pt was encourage (sic) to drink fluids and eat due to report saying he has not ate or drank, but pt shook his head no and refused. Dietary Communication Slip completed, ordered Regular diet.

Psychiatric Evaluation was completed on 3/12/2021 at 1155, which stated, "Chief complaint was not provided by the patient, as he was not speaking. [Patient #1] was admitted due to decompensation, not eating or taking care of himself ..."

3/12/21
15 Minute Patient Observation Record: [Meal consumption left blank on this date, without documentation reflecting the percent of meals consumed or refused for the 24 hour period.]

3/13/21
Physician Note at 1124 stated, "Nurses report patient has not eaten ..."
Nursing Note at 1700 stated, "Several attempts were made by staff offer pt foods/water/ensure but pt kept turning face to the opposite direction ..."

3/14/21
Nursing Note at 0915 stated, "flat affect, staring into blank space, not responding to questions refusing meds/ meals/drink ..."
1130 Pt still appears fatigued and dehydrated. Ordered that pt be sent out to ER for further evaluation.
1250 Pt transferred to [medical hospital] via ambulance.
1900 Pt returned to facility/unit via EMS.
Records from [medical hospital] on 3/14/2021 at 1636 revealed that [Patient #1] received 1000 mL of Lactated Ringers IV and 1000 mL of Sodium Chloride 0.9% IV.
 
3/15/21 Physician Order at 0455 stated, "Transfer [medical hospital] or [medical hospital] for medical management & catatonic" and an order at 1233 stated, "Boost po TID (three times a day) x 3 days (supplement)."
Nursing Note at 0915 stated, " ...Pt is refusing to eat, ensure was ordered pt was able to drink 1 ensure. Dr order transfer order to [medical hospital]" and at 2043, nursing note stated, "Patient has not been eating ..."
 
3/16/21 Physician Note at 1019 stated, "Nurses report patient has started ... taking Boost but will still not talk."
Nurses note at 1400 stated, " ...pt is refusing to eat refusing to take a shower refusing meds and refusing to drink water. Order is received to send pt to the emergency room of [name] hospital for further evaluation and to discharge him from Houston Behavioral Health Care Hospital."

A face to face interview was conducted with Staff #4, Nurse Manager on 4/12/2021 at approximately 1400 in the facility conference room. Staff #4 stated, "When we get a patient not eating or drinking, we monitor vital signs and labs. If they are out of the norm or they are deteriorating, we immediately send him out to a medical facility ...We don ' t do IVs or tube feedings at this hospital."
 
When asked if intake or output is monitored, Staff #4 replied, "We don ' t monitor output unless ordered by the doctor, and it ' s not usually ordered, though. The MHT ' s (mental health techs) monitor intake, how much percentage of the meal they eat."

Facility policy, "Management of Medically Compromised Patients, policy #200.54, last reviewed 4/6/2020, stated, in part, " ...decrease in nutritional intake (solids/liquids) over a period of several days ... are to be reported to the attending physician/designee by a member of the nursing staff as soon as possible ..."

The above findings, that the percentage or amount of the meal consumed was not documented on the 15 Minute Patient Observation Record on 3/12/21 for Patient #1 on 3/12/21, were confirmed in an interview with Staff #1 and Staff #2 at approximately 3:30 pm on 4/13/2021 in the facility conference room.

Based on a review of documentation and interviews, the facility failed to ensure that a treatment plan was developed based on the findings of the psychiatric evaluation, initial nursing assessment, daily physician and nursing notes. These findings could result in inadequate care of the patient's physical needs and psychiatric needs if all identified problems are not included in the treatment plan. 

Findings included:

Facility policy, Multidisciplinary Treatment Planning Meeting, policy #1200.9, last reviewed 2/25/2021, stated, in part, "C. The treatment plan will be updated weekly or sooner if clinically indicated. The review will be documented on the Treatment Plan Review For. The treatment plan review may include: ...4. Problems identified for treatment/new problems ..."

Review of the medical record for patient #1 was reviewed in the facility conference room the afternoon of 4/13/2021. Admission documentation revealed that "patient has decreased oral intake...Pt has hx of inpatient admissions at [other facility], not eating/drinking for a few days..." Patient #1 was ultimately transferred to a medical hospital on 3/16/2021, in part, due to his decreased nutritional intake.

Initial Nursing Assessment conducted at 0237 on 3/12/21, stated, " ...Pt was encourage (sic) to drink fluids and eat due to report saying he has not ate or drank, but pt shook his head no and refused. Dietary Communication Slip completed, ordered Regular diet.

Psychiatric Evaluation was completed on 3/12/2021 at 1155, which stated, "Chief complaint was not provided by the patient, as he was not speaking. Patient #1 was admitted due to decompensation, not eating or taking care of himself ..."

3/13/21
Physician Note at 1124 stated, "Nurses report patient has not eaten ..."
Nursing Note at 1700 stated, "Several attempts were made by staff offer pt foods/water/ensure but pt kept turning face to the opposite direction ..."

3/14/21
Nursing Note at 0915 stated, "flat affect, staring into blank space, not responding to questions refusing meds/ meals/drink ..."
1130 Pt still appears fatigued and dehydrated. Ordered that pt be sent out to ER for further evaluation.
1250 Pt transferred to [medical hospital] via ambulance.
1900 Pt returned to facility/unit via EMS.
Records from [medical hospital] on 3/14/2021 at 1636 revealed that [Patient #1] received 1000 mL of Lactated Ringers IV and 1000 mL of Sodium Chloride 0.9% IV.
 
3/15/21 Physician Order at 0455 stated, "Transfer [medical hospital] or [medical hospital] for medical management & catatonic" and an order at 1233 stated, "Boost po TID (three times a day) x 3 days (supplement)."
Nursing Note at 0915 stated, " ...Pt is refusing to eat, ensure was ordered pt was able to drink 1 ensure. Dr order transfer order to [medical hospital]" and at 2043, nursing note stated, "Patient has not been eating ..."
 
3/16/21 Physician Note at 1019 stated, "Nurses report patient has started ... taking Boost but will still not talk.
Nurses note at 1400 stated, " ...pt is refusing to eat refusing to take a shower refusing meds and refusing to drink water. Order is received to send pt to the emergency room of [name] hospital for further evaluation and to discharge him from Houston Behavioral Health Care Hospital."

The Master Treatment Plan for Patient #1 was initiated on 3/12/21 and updated through his brief stay. The problems listed were:
Alteration in reality testing
BPH
Risk for COVID-19.

A face to face interview was conducted with Staff #1 on 4/13/2021 at 1125 in the facility conference room to review the treatment plan for Patient #1. Staff #1 stated that there was no problem specifically identified on the treatment plan related to alteration or reduction in nutrition intake. The problem statement on the treatment plan stated that alteration in reality testing was related to Schizophrenia "as evidenced by catatonia ..." Staff #1 confirmed that the treatment plan should have been more specific about the patient ' s dietary concerns, even if the lack of eating and drinking was part of his catatonia.

The above findings were confirmed in an interview at approximately 3:30 pm on 4/13/2021 with Staff #1 and Staff #2 in the facility conference room.