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Based on review and interview the facility failed to ensure the patient or patient representative was clear on how to submit a grievance and failed to ensure that all verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements, are considered a grievance in 2 of 2 (#1 and #3 )patient charts reviewed.

A review of patient #3's medical record revealed he was a 28-year-old male admitted to the hospital on 10/11/23 for periorbital cellulitis of the right eye (primary). Patient #3 also had a diagnosis of autism(non-verbal), Severe intellectual disability, cerebral palsy, and seizure disorders. Patient #3's mother was the primary caregiver and advocate.

Patient #3's mother made a complaint with the HHSC-SO Consumer Rights & Services on 10/9/23. The mother stated that she had asked staff # 21 RN for "briefs". The mother stated that staff #21 stated, "We don't supply them ...we don't stock them here, guess I will have to go to central supply." She asked for the briefs around 3:00 PM and did not receive them until after midnight. The house supervisor brought the briefs after the mother complained multiple times. The mother continued to have the following issues that she brought forward to the nursing staff and administrative staff, Patient #3 was given ketamine before a procedure. Staff # 22 RN left the room and the unused medication in a syringe within reach of her son. The mother put the syringe in her pocket and forgot it was there. Later when the patient was moved from the ER to the floor, staff #21 asked the mother if she had picked up the syringe and she stated she did that she had forgotten. (Ketamine is a dissociative anesthetic used medically for induction and maintenance of anesthesia.)

Patient #3's mother had multiple complaints about seizure medications ordered at the wrong dosages, staff not maintaining his airway properly after a sedated procedure, multiple requests for wrist restraints to prevent the patient from hitting his face after facial surgery, staff refusing to assist with the patients ADL's, and a documentation error on the MRI results.

The mother stated that on 11/15/2023 Staff # 10 (program manager for patient experience) arrived in the room around 9:00 AM and the floor RN (nursing director). The mother explained to them the complaints she had of general nursing care, medication issues, the ketamine syringe being left in the room, and the overall experience. The mother stated that staff # 10 was talking over her and dismissing her issues.

The mother stated she was taken to a board room on 11/16/23 by staff #10. The mother stated it lasted 37 minutes. The mother stated that there were 9 people in the room, and she had to stop the meeting and insist they introduce themselves, so she knew who was attending this meeting. She stated that staff #10 began to ask her about her experiences. The mother stated after the meeting she shared with staff #10 that she was not satisfied and felt staff #10 was intimidating and " she focused on putting a Band-Aid on the situation prevented me from getting my thoughts across." The mother stated, "I felt she was trained on intimidation tactics to bully me into silence, and I was not ok with this."

The mother stated that she had also spoken with Staff # 2 (Regional Director over Quality and Risk) on 11/20/23. The mother stated she felt she was being run over by yet another verbal train of gaslighting."

A review of the policy and procedure "Patient Grievances and Complaint Resolution" stated,
DEFINITIONS:
A. Complaint: An issue considered resolved by staff present when the patient is satisfied with actions taken on their behalf, or the nature of the complaint does not meet the definition of a grievance.
l. Post-discharge verbal communication regarding patient care that would routinely have been handled by staff present if the communication had occurred during the stay, are not required to be defined as a grievance.

B. Grievance: A formal or informal written (written communication is always considered a grievance) or verbal complaint (when a verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient or patient's representative, regarding any of the following:
1. The patient's care
2. Abuse of neglect
a. If there is an immediate patient safety concern suspected, procedures will be followed as outlined in the "Suspected Abuse or Neglect While Under the Care of the Hospital" policy.
3. Issues relating to the organization's compliance with the CMS Hospital Conditions of Participation {COP}, or
4. A Medicare beneficiary billing complaint related to rights and limitations provided 42 CFR 489 ...

C. Processing a Complaint
1. Complaints given to staff members by patients, or their representatives should be addressed in a timely manner and an attempt to resolve the issue should be made. If resolution is achieved, then no further action is required. However, if resolution is not achieved after attempts have been made to resolve the complaint it should be forwarded to Patient Advocate Office. Unresolved complaints or those requiring additional investigation or intervention should be listed on the Patient Grievance Tracking Log as a complaint for reporting purposes."

A review of the grievance log for October, November, and December 2023 revealed there was no grievance logged for patient #3.

An interview was conducted with staff # 21 RN on 1-9-24 at 3:50 PM. Staff # 21 stated that she remembered patient #3 and his mother. Staff #21 confirmed that the patient's mother did ask for diapers (briefs) several times and staff # 21 stated she told the mother they had blue pads but no diapers for the patient. Staff #21 confirmed he did not know they could get diapers till later on and that they were kept in central supply. Staff #21 stated that she received a call from the ER on 11/13/23 to go into patient #3's room and ask if the mother had picked up a syringe of ketamine. Staff #21 stated the mother pulled the syringe out of her pocket and handed it over to staff #21 RN. Staff #21 stated that Staff #22 RN came to the floor and retrieved the syringe for waste. Staff #21 stated that she did not fill out an incident report or document the incident in the chart.

An interview was conducted with Staff #22 on 1-9-24 at 4:08 PM. Staff # 22 confirmed she administered ketamine to patient #3 and had medication left over that had to be wasted with a witness. Staff #22 stated that she thought she put the syringe in her pocket and got busy with the patient. Staff #22 stated she did not realize the syringe was not in her pocket and was missing. Staff #22 stated that the patient's mother had put it in her pocket and had moved to the floor. Staff #22 stated she retrieved the medication and wasted it with a witness. Staff #22 confirmed this was not protocol and she should have wasted the unused medications immediately. Staff #22 stated that she did not do an incident report nor was the incident reported.

An interview was conducted with Staff # 2 REG. DIR. Quality/Risk and Staff #10 on 1-9-24. Staff #10 was asked if there were any grievances or written information on patient #3's mother's complaints or allegations. Staff #10 stated, "No. we were able to address her complaints." Staff #10 stated the facility did not log a complaint as a grievance unless it was in writing. Staff #10 was asked if she had multiple meetings with the mother and a meeting on the 16th in the conference room meeting with multiple staff. Staff #10 confirmed that there were multiple meetings. Staff #10 stated that she had talked to the mother, but she kept bringing up the same things and complaints that they had discussed previously. Staff #10 stated she was never satisfied. Staff #10 was asked why a grievance was not started on this patient's complaints. Staff #10 stated that a grievance was not done unless it was in writing. Staff # 2 was holding the grievance policy and procedure and read from the policy. Staff #2 stated that a grievance should have been started and processed when the complaint was not immediately resolved. Staff #2 stated that they just received a written complaint from the mother today and they would be working it up as a grievance and responding to each of the allegations.




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Findings;

A review of patient #1 electronic health record (EHR) reveals the patient arrived by Emergency Medical Services (EMS) at the facility's emergency room (ER) on 06/05/2023 with a complaint of unresponsiveness and intubation (a process where a tube is inserted through a person's mouth, down their trachea. The tube keeps the airway open so that air can get through). Patient #1 was admitted to the Neuro ICU (an intensive care unit devoted to the care of patients with life-threatening neurological problems) with a diagnosis of Acute Encephalopathy (an acute functional alteration of mental status due to systemic factors), Respiratory Failure (a serious condition that makes it difficult for a person to breathe on their own) and Leukocytosis (a high level of white blood cells in the blood).

Further review of patient # 1's EHR revealed the patient was seen by case management staff regularly during admission. On 06/12/2023 case management staff documented the patient's family was unwilling to discuss discharge planning, the family requesting to discharge the patient home and verbalizing complaints about the care received. It was documented that the charge nurse was notified of the family's concerns. On 06/13/2023, case management staff documented in the patient's EHR that the family voiced concerns that the patient was not ready for discharge. The family was unwilling to discuss any options. Steps to an appeal were discussed and the charge nurse and nursing director were notified. On 06/19/2023 case management documented that the family reported they would take the patient to another hospital. Adult Protective Services (APS) were notified over concerns about the patient's care at home.

A review of the June, July, and August 2023 grievance logs revealed no grievance logged for patient #1. The facility failed to proceed with the grievance process to address the patients' complaints that could not be immediately resolved.

An interview was conducted with Staff #12 on 01/09/2024 at 2:30 PM. Staff #12 reported "There are no complaint logs kept on the floor and complaints are not tracked. If I am told about an issue, we try to resolve it here."

An interview was conducted with Staff #11 on 01/09/2024 at 2:40 PM. Staff #11 reported "We do not keep any logs or track complaints. The patient advocate is contacted by the nursing director if an issue is reported."

An interview was conducted with Staff #10 on 01/09/2024 at 3:20 PM. Staff #10 reported "Any nursing Director can fill out a complaint form if they feel like the issue can't be resolved. Most complaints are resolved on the floor, I only track them if they are reported to me. I was not notified of any incidents."

Based on review and interview nursing failed to ensure that Ketamine, a controlled substance, was safely secured by the RN, and excess medication was promptly wasted after use in 1 of 1 (#3) patient charts reviewed.

A review of patient #3's medical record revealed he was a 28-year-old male admitted to the hospital on 10/11/23 for periorbital cellulitis of the right eye (primary). Patient #3 also had a diagnosis of autism(non-verbal), Severe intellectual disability, cerebral palsy, and seizure disorders. Patient #3's mother was the primary caregiver and advocate.

Patient #3's mother made a complaint with the HHSC-SO Consumer Rights & Services on 10/9/23. The mother stated patient #3 was given Ketamine (a dissociative anesthetic) before the procedure. The mother stated staff # 22 RN left the room and the unused medication syringe within reach of her son. The mother stated that she put the syringe in her pocket and forgot it was there. Later when the patient was moved from the ER to the floor, staff #21 RN asked the mother if she had picked up the syringe and she stated she had that she had forgotten to turn it in.
A review of patient #3's chart revealed a physician order dated 11/13/23 at 11:13 AM. The order stated, " Ketamine in 0.9% sodium Chloride (Ketalar) 50 mg/5 mL NS injection 59 mg, once, intravenously."

A review of the medication removal log revealed staff #22 ER RN removed 2-50mg/5ml syringes from the medication cabinet on 11/13/23 at 11:30 AM. Staff #22 documented in the nursing notes that patient #3 was administered 59 mg IV on 11/13/23 at 11:32 AM. The medication log revealed the remaining 4.1mls not used were not wasted with a witness until 3:16 PM, 4.25 hours later.

According to https://www.fda.gov/drugs/ketamine, "Ketamine is a controlled substance. Specifically, it is a Schedule III substance under the Controlled Substances Act. Schedule III drugs, which include codeine and anabolic steroids, have less potential for abuse than Schedule I (heroin) or Schedule II (cocaine) drugs. However, abuse of Schedule III substances may lead to physical or psychological dependence on the drug."

An interview was conducted with staff # 21 RN on 1-9-24 at 3:50 PM. Staff #21 stated that she received a call from the ER on 11/13/23 to go into patient #3's room and ask if the mother had picked up a syringe of Ketamine. Staff #21 stated the mother pulled the syringe out of her pocket and handed it over to staff #21 RN. Staff #21 stated that Staff #22 RN came to the floor and retrieved the syringe for waste. Staff #21 stated that she did not fill out an incident report or document the incident in the chart.

An interview was conducted with Staff #22 on 1-9-24 at 4:08 PM. Staff # 22 confirmed she administered Ketamine to patient #3 and had medication left over that had to be wasted with a witness. Staff #22 stated that she thought she put the syringe in her pocket and got busy with the patient. Staff #22 stated she did not realize the syringe was not in her pocket and was missing. Staff #22 stated that the patient's mother had put it in her pocket and had moved to the floor. Staff #22 stated she retrieved the medication and wasted it with a witness. Staff #22 confirmed this was not protocol and she should have wasted the unused medications immediately. Staff #22 stated that she did not do an incident report nor was the incident reported.