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Based on observation and interview on 08/10/2023 at 1055 one oxygen tank was found lying on the floor and unsecured in the extra room of the continuing care unit.

Findings Include:

Oxygen Safety (Kingwood Campus Only) last revised 12/2020, stated:
C. Handling, Storage and Transport of Cylinders:
All freestanding cylinders shall be stored in a rack, on a cart, in a portable cylinder holder, in a gas cylinder storage cabinet, or secured with a chain to protect them.

Interview and observation of all staff in the area (ID #58, 63, 71) verified the findings and stated the oxygen tank should be secured.

Based on observation record review and interview, the facility failed to protect the rights to a safe environment for 7 of 7 patients in their Behavioral Health unit, as shown by the facility not identifying and addressing a safety hazard in a common patient bathroom.

Findings included:

Review of facility policy titled "Safety Management Plan", ID# 13252774, revised 3/2023 showed that the hospital will identify risks associated with the environment of care.

Observation on 8/10/23 at 11:50 am of facility's Emergency Department's Behavioral Health unit, accompanied by Director of Med Surge-Staff #69, showed the following:

There were nine private patient rooms with a current census of seven. There were two common patient bathrooms adjacent to each other. In one of the bathrooms, there was a drain located on the floor, approximately six inches in diameter. The drain did not have a mesh grate cover in place and was open, exposing a circular hole approximately two feet deep. This posed a safety hazard for patients walking into and out of the bathroom, including those not wearing shoes.

Review of patient census as well as direct observation on 8/10/23 showed there were seven patients present in the facility's nine-bed Behavioral Unit-a part of the facility's Emergency Department.

In an interview at the time of findings, Staff #69 acknowledged this was a safety hazard, took a picture, and said it would be reported and fixed.

The facility failed to ensure nursing staff adequately evaluated patient's per the facility's current policy and procedure as shown by:

a. 3 if 12 patient records reviewed did not contain the necessary blood pressure measurements.

b. 2 of 12 records reviewed show no initial registered nurse assessment of pain assessment.


Policies Reviewed:


Reviewed on 08/11/2023 of the facility's current policy titled, Assessment/Reassessment of the ED Patient", Policy ID# 10840058, Last Revised 03/2022. Policy: All patients presenting to the emergency room are assessed using a triage methodology to determine the severity off the presenting chief complaint. A triage acuity level is assigned to each patient using the Emergency Severity Index Triage Tool for Emergency Department Care (ESI). I. Procedure: Triage assessment includes but is not limited to: B. Subjective/Objective Assessment, C. Chief Complaint, I. Pain Assessment. Triage Reassessment: A. The triage nurse, or designee will conduct re-assessments at least every two hours of patients who have yet to be moved to the appropriate treatment area. C. Re-Assessment includes a full set of vital signs and status related to patient's chief complaint. III. Primary Assessment: The primary assessment includes, but not limited to: A. Detail Assessment: 1. Vital signs, 2. Pain scale, B. Chief complaint related assessment, Medication Reconciliation, D. Physical Findings, E. Chief complaint related plan of care. IV. Reassessments: A. Reassessments performed after the medical screening exam (MSE) is completed are performed by RNs according to acuity: 2. Level (2) Emergent should be documented at a minimum of hourly and more frequently if conditions warrant. 3. Level (3) Urgent should be performed prior to disposition or every 4 hours. My be performed more frequently if conditions warrants.


Reviewed on 08/11/2023 of the facility's current policy titled, "Routine Nursing Care Standards", Policy Id # 8459766, Last Revised 01/2017. Purpose: To outline general patient care guidelines to ensure patient-centered care: Procedure: Medical/Telemetry/Surgical Care Specific Guidelines: Vital Signs (included, but not limited to BP, Heart Rate, Oxygen saturation, Respiratory Rate). At least every 4 hours and PRN for change in condition, temperature every 4 hours and PRN for change in condition.


Reviewed on 08/11/2023 of the facility's current policy titled, "Assessment/Reassessment: Pain Management Guidelines", Policy State ID 8147044; Last Revised 03/2022. Purpose: To provide the patient with appropriate pain management and to respect and foster the patient's sense of dignity and involvement in their own care. Policy: 2. The health care team shall institute a plan of care with the goal of the facilitating patient comfort, speedy recover, decreasing complications and disability, and improving quality of life. A. Patients shall be assessed for pain upon admission and reassessed according to specific unit policy regarding vital signs and shift assessment frequency, or as necessary.


Record Review:

Pain Assessment

Review on 08/11/2023 at 14:30 PM of patient ID # 10's medical record along with Vice President of Quality, staff ID #54 revealed the following:

Presented to the facility on 08/10/2023 at 09:18 AM, Medical Screening Exam 09:20 AM, Triage 09:23 AM, Room 09:28 AM, Priority 3. Review of initial nursing assessment by registered nurse, staff ID # 71 patient's description of reason for visit: "I was outside in the heat working and was smoking a vape when I started to have SOB (shortness of breath) and chest pain." Chief Complaint Cardiac related. There was no documentation found of a pain assessment by the registered nurse during the initial nursing assessment. Patient discharged at 11:10 AM, Primary Impression: Chest Pain, Secondary Impression: Marijuana use, Anxiety, Dehydration. Disposition: Home, self-care, stable.

Review on 08/11/2023 at 14:45 PM of patient ID # 9's medical record along with Vice President of Quality, staff ID #54 revealed the following:

Presented to the facility on 08/10/2023 at 11:23 AM, Medical Screening Exam 11:24 AM, Triage 11:30 AM, Room 11:32 AM, Priority 3. Review of initial nursing assessment by registered nurse, staff ID # 61 patient's description of reason for visit: "I have been having RLQ (right lower quadrant) pain since my drain fell out after having my appendix removed". Chief complaint: GI/Abdominal pain. There was no documentation found of a pain assessment by the registered nurse during the initial nursing assessment.


Vital Signs

Review on 08/11/2023 at 15:00 PM of patient ID # 26 along with Vice President of Quality, staff ID #54 revealed the following:

Presented to the facility on 07/23/2023 at 22:32 PM, Medical Screening Exam 22:36 PM, Triaged 22:42 PM, Room 22:43 PM, Priority: 2. Patient presented via EMS from regent care with repot of AMS (altered mental status onset this evening around 1800. Staff states patient has a foot amputation that has chronic infections and osteomyelitis; Patient currently being treated for a foot infection. On 07/24/2023 at 0035. Patient status changed to Admission withhold, medical telemetry with admission set orders which stipulates VS every 4 hours. Review of patient's medical records failed to document vital signs every 4 hours. Vital signs were documented on 07/24/2023 at 05:42 AM, no vital signs at 09:42 AM found.

Review on 08/11/2023 at 13:30 PM of patient ID #11 along with Vice President of Quality, staff ID #54 revealed the following:

Presented to the facility on 08/09/2023 at 19:14 PM, Medical Screening Exam at 19:20 PM, Triaged 19:19 PM, Admit at 02:48 AM. ESI level 3. Records documented 2 vital signs done BP at 19:19 PM and again at change of shift at 07:00 AM.

Review on 08/11/2023 at 13:45 PM of patient ID #12 along with Vice President of Quality, staff ID #54 revealed the following:

Presented to the facility on 08/08/2023 at 00:18, Medical Screening Exam at 00:25 AM, Triaged at 00:21 AM, ESI level 3. Admitted at 06:15 AM. Vital signs dome at midnight and 07:15 AM. Missed vital signs at 03:00 AM.

The above findings were reviewed on 08/11/2023 with Staff ID #54 who confirmed the findings.

Based on observation and interview, the facility failed to post the required signage in the adult waiting areas, and patient bathrooms.

Finding Included:

Based on observation and interview on 08/10/2023 between 1000-1200 while in the ED revealed the facility had:
Missing patient rights and federal signage outside both entrances of the ED
ambulance entrance and two waiting rooms, where patient congregate, and missing
required sexual trafficking signage was not posted in 4/6 bathrooms.

Interview with the staff (ID#63) during the observation verified the finding.