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Based on record review and interview, the facility failed to thoroughly and effectively identify, address and resolve a complaint for 1 of 1 patient (Patient #8), as shown by evidence of incomplete investigation process.

Findings included:

Review of facility policy #RTS04 titled "PATIENT GRIEVANCE PROCEDURE', last revised 2/123 showed an investigation to determine the validity of a grievance would be performed and appropriate state mandatory reporting guidelines would be followed. In addition, the patient advocate would issue a final written response to the grievance to include the steps taken to investigate the grievance.

Record review at the time of survey of facility's Grievance Log showed a report from Patient #8's family member (the report did not specify which family member filed the complaint). The report simply stated the following:

-3/17/23 notification of complaint concerning Patient #8. "Around 1:30 pm patient called his family and told them he hit his head against the wall and bleeding profoundly. Family became very worried, requested for a FaceTime."

-Date resolved: 3/17/24 (no letter sent). "..staff arranged the FaceTime call with the patient and family. But then patient told his family that he lied because he wants family to come pick him up. Complaint resolved at 3:30 pm same day". Person doing investigation-Patient Advocate-Staff #G.

Record review on 6/21/24 at 10:00 of Patient #8's clinical chart showed the following: On 3/16/24, there were two incident reports generated for an event occurring at 9:51 pm. One was for an emergency medication given due to physical aggression and the other was for an injury sustained by the patient; 'skin tear to head with bleeding, left leg abrasion'. Nursing progress notes date 3/17/24 showed "Wounds ....Scalp with abrasion type wounds to dermal layer at top of head ...".

In an interview on 6/21/24 at 12:00 pm, Staff #G stated that he received notice that the patient called his family and told them his head was bleeding. However, Staff #G stated he was not aware the patient sustained any injuries and was also unaware patient was restrained and given emergency medications at the same time. Staff #G also added that the investigation and response to family would have been different and more comprehensive had he known about all of the facts surrounding the restraint and concurrent injury. Staff #G also stated that there was no further investigation regarding the incident and believed it to be resolved at the time, not realizing the patient was actually reporting the truth to his family.

Based on record review and interview, the facility failed to ensure an effective abuse protection program related to the investigation of abuse allegations.

The facility's policy failed to require the availability of all portions of facility investigations of abuse for regulatory review and verification.

Surveyor was unable to view video footage related to facility investigation of family allegations of abuse of Patient ID # 10, as it was not retained.

Findings included:

TX00496850

Record review of facility policy titled "Assessment and Reporting of Abuse, Neglect," last revised date 5/30/2024 , section # 7. "If reporting is not mandatory...": policy does not address retention of all documentation of facility investigation, including video footage for regulatory verification of a thorough investigation.

Review of the clinical record of Patient ID # 10 showed she was an 83 year old female admitted to the facility on 3/15/2024 for increased agitation and physical aggression with a history of schizoaffectve disorder; bipolar type. Patient # 10 was discharged on 4/01/2024.

Review of photos supplied to facility by family of Patient # 10 on 4/02/2024 showed: a large area of bruising on right shoulder blade extending over to right shoulder: color: green, yellow, and purple; and bruising to left shoulder. "Family expressed concern that patient was physically harmed on the weekend of 3/29 to 04/01/2024."

Record review of facility "Summary Report of Investigation," dated 04/05/2024 showed the facility took the following actions (not all inclusive):

-- reviewed medical record for nursing skin assessments

-- interviews with staff : patient refused to lay down in bed in her room-"went to sleep on the hard chairs in day room."

- staff observed patient "on several occasions tossing, turning, and sliding back and forth on her back, on the hard chairs and all attempts to stop her failed..."

Facility investigation showed details of camera review footage on 4/5/2024: "camera 17 & camera 19 (3/29/24 -1200 through 4/01/2024 at 0600 ) reviewed : pt sleeping on hard chairs in the group area. -staff are observed encouraging her to go to room- pt observed to be "wiggling" on the hard chairs, including appearing to rub her shoulder blades on the harder non-padded part of the chair. Pt observed laying on her back with her knees bent over the hard plastic arm of the chair. "

Surveyor was unable to view the video to validate the above information.

During an interview with Staff A, Administrator, on 6/21/2024 at 10:30 AM, she stated the video was not kept, as the allegations were unsubstantiated.

Facility documentation showed the allegations were unsubstantiated. The facility sent a letter to the family, dated 4/08/2024 that contained the details and findings of their investigation, per policy.

Based on record review and interview, the facility failed to ensure there was documentation of a restraint in 1 of 1 patient medical record (Patient #8), including no face-to-face 1 hour post restraint evaluation.

Findings included:

Review of facility policy#NSG-02 titled "Documentation", Section: Nursing, last revised 1/1/23, showed that patient treatments and observations which reflect the care and progress a of the patient would be documented in the patient's medical records. Also, that the RN would document pertinent and factual information, including assessments, interventions and outcomes related to the patient's treatment.

Review of another facility policy, #NSG-76 titled "SECLUSION AND RESTRAINT-TEXAS", last revised 2/1/24 showed that as part of the facility's procedure for restraints, the nurse would document contact with physician and also document that a one hour face-to-face post restraint evaluation form was completed. The form documented the date & time of restraint, patient behaviors, alternative interventions to prevent restraints and medical review of patient's status post restraint.

Record review at time of survey of Patient #8's medical records showed the following: On 3/13/24 at 3:41 pm, the patient was restrained with the emergency behavioral medications Haldol 2.5 intramuscular injection (IM) and Benadryl 50 mg IM, due to aggression.

Further record review of patient's medical chart showed the patient was ordered and then given these emergency restraint drugs per the Medication Administration Record (MAR). However, the patient's chart failed to show evidence of the required one-hour post restraint face-to-face evaluation being performed, any other assessments and evaluations, or patient monitoring.

In addition, there was no other documentation in the patient's records indicating a restraint had occurred: there was no incident report generated for the event, no nursing notes and no physician notes present in the chart addressing and explaining this restraint.

In an interview on 6/20/24 at 1:30 pm while reviewing the patient's records together, QD-Staff #H acknowledged the absence of the necessary documentation which should have been present in the chart.

Based on observation, interview, and record review, the facility failed to ensure a registered nurse supervised and evaluated the care of patients per professional nursing standards of practice [citing Patient IDs # 1, 10].

a.) Observation of Patient # 1 showed her sitting at bedside. An extremely strong odor of urine was noted upon entry to room. Adult brief found soaked and full of urine and feces. Facility policy does not require specific frequency of checking patients who are incontinent ; or require documentation that this nursing intervention is carried out.

b) Review of medical record of Patient ID # 10 showed multiple inaccurate nursing skin assessments.

Findings included :

a) Nursing care of patients with incontinence:

Review of facility policy titled "Activities of Daily Living (ADL),"dated 03/01/2023 showed : "...nursing personnel will clean and /or bathe incontinent pts. immediately upon voiding or soiling...nursing personnel will assess all incontinent (patients)..."

The policy did not detail the specific frequency of assessing patients with incontinence ; or require documentation of this nursing intervention per professional nursing standards.

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Record review of Texas Administrative Code (TAC) Title 22; PART 11 Texas Board of Nursing ; CHAPTER 217 ; RULE §217.11 "Standards of Nursing Practice" showed:

(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:

(B) Implement measures to promote a safe environment for clients and others;
(D) Accurately and completely report and document: (ii) nursing care rendered;
(U) Supervise nursing care provided by others for whom the nurse is professionally responsible.

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Observation during initial tour of the facility on 6/20/2024 at 9:25 AM showed Patient # 1 sitting at bedside of bed B. Surveyor was accompanied by Staff-C, mental health tech (MHT). Immediately upon entering the room, an extremely strong smell of urine was noted. Surveyor asked the MHT to request the Chief Nursing Officer (CNO), to come to the room. The CNO was in the hallway a couple of doors down.

Both Staff- C, MHT and Staff -B, CNO acknowledged a strong odor of urine in the room. They were both asked how long ago this patient was checked and changed? Neither could answer this; CNO said he would find out.

Patient # 1 was observed pulling at her pants, trying to stand and grasp her walker. Staff-B went to assist her to the bathroom, saying she was at risk for falls. The patient, MHT, & CNO went into the bathroom. Surveyor observed from the door as Patient # 1's adult brief was removed. it was bulging and filled with urine and feces.

Interviews after the observation between 9:30 and 9:50 AM were conducted:

-Staff-C, MHT said: the process was that showers were started down at the end of all hall and patients were taken to toilet before shower. When asked how often patients with incontinence were were checked? he said "as frequently as we can." He said there was no documentation.

-Staff -D, MHT said "we should check for incontinence every 2 hours. We don't document the checking; just if we change them."'

-Staff- B, CNO said" incontinent patients are checked every 2 hours"; he later stated they were checked "periodically" and this was not documented.

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b: Nursing skin assessments :

Record review of facility policy titled " Skin/Wound Care," dated 10/01/2023, showed:

- Nursing, in collaboration with the healthcare team , will assess and manage skin integrity for all patients upon admission and throughout their stay.

- A skin assessment is completed by the registered nurse on all patients at admission, weekly, after a fall/injury, upon new skin findings and at discharge.

During an interview with Staff-B, CNO, on 6/21/2024 at 10:20 AM he said: skin assessments were done every shift; full wound assessments were done on admission , weekly, on Saturdays, and at discharge.

Review of Patents #10's electronic medical record with the CNO showed :

Daily shift RN assessment March 15- 24, 2024 (both day and night shifts): documentation showed "normal ; skin intact; no bruises"

"3/24/2024 0200 AM: "weekly skin assessment : bruise noted to left forearm: picture taken." Review of the photograph showed a large green, light purple, yellow bruise located in the inner aspect of the left forearm from the cubital fossa ( inner elbow crease) reaching almost to the wrist.

RN assessments from March 25 to April 1, 2024 -after the picture taken -(both day and night shifts): showed "normal ; skin intact; no bruises."

CNO said the nursing skin assessments after March 24, 2024 were not accurate for Patient # 10 . Although she sometimes refused medications and assessments, this bruise to the left forearm was easily seen.