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Based on interview and record review, the facility failed to ensure the right to receive care in a safe setting. The facility failed to effectively communicate and document that a patient's family member had assaulted staff members in the facility, failed to investigate the assault and allowed the family member to return to the facility without security communication or involvement. This caused potential harm to other patients, families and staff.

Findings Included:
Record review of facility PBX Operator Log with Staff ID #77 showed that on 4/20/22 at 5:22 pm a "Code Grey" incident page had been paged out in the facility.

Record review of Patient ID #21 medical record physician dated 4/21/2023 stated "on the evening of 4/20/23", Patient ID #21 family member "became frustrated with the care that the patient was receiving ..." "Per staff, the (patient's family member) started yelling, threatening staff, and physically hitting staff prompting her removal from the building by security." She was reported to be "emotionally unstable" in the note.

Record review of Social Work staff ID #78 note entered 4/21/23 at 4:30 pm stated "Social worker was present for family meeting with the patient's (family member) along with members of the medical team." She "was very upset throughout the meeting ..." There was no documentation of leadership team or security involvement. There was no documentation of behavioral expectations for safe visitation parameters.

Record review of facility's "Patient Rights and Responsibilities", last reviewed December 2020, "Privacy and safety: b. The patient has a right to receive care in a safe setting. i. Follow current standards of practice for environmental safety, infection control and security."

Record review of facility's policy "Code Gray: Management of Disruptive or Violent Patient - Patient Care", effective April 2023, stated the facility "is committed to providing workplace safety; which prohibits threats and violence of any kind, requires immediate reporting of any incident that causes a concern for safety, and requires discipline of offenders....c. Telecommunication will in turn page the Code Gray overhead or it will be directly paged overhead by the security team at the McNair Campus. d. The Code Gray Emergency Response Team is a pre-designated, response team consisting of staff trained in the management of aggressive behavior.
i. The Hospital security department will be used as the incident's management structure for security incidents.
ii. Emergency Response Team members include representatives from nursing, security, mission, respiratory, the house supervisor and other staff as directed by the team leader.
iii. If patients are involved, the Emergency Response Team Leader shall be the assigned patient care nurse or designated charge nurse, and if no patients are involved, the team leader will be the ranking security representative.
iv. The Emergency Response Team shall perform as instructed by the Emergency Response Team Leader in support of the incident objectives.
v. The incident report objectives may include:
1. Identify potentially violent persons
2. Separate potential violent persons to protect visitors, staff, and patients
3. De-escalate potential violent behavior
4. Coordinate response with law enforcement if appropriate
3. Documentation of the incident should occur in the patient's medical record and the incident reporting management system."

Interview 4/28/2023 at 10:40 am with Staff RN # 64 confirmed that Patient ID #21 family member "pushed the nurse practitioner and attempted to punch the new graduate nurse." She stated the alleged perpetrator proceeded to "go up and down hallway cursing and pacing in the unit." She stated a "Code Gray" was called and security arrived on the unit. She stated "security removed her."

Interview on 4/28/2023 at 12:15 pm with Director of Patient Safety, Staff ID #74. She stated there was no variance/incident report located in the electronic variance reporting system "IRIS" for Patient ID #21 family member allegedly assaulting staff and being escorted from the facility by security. She stated she would expect there to be an incident report related to that incident.

Interview 4/28/2023 at 2:30 pm with Security Director Staff ID # 77. He stated he could not locate an incident report in the electronic variance system called IRIS related to the Code Grey paged out on 4/20/22 at 5:22pm. He stated there was no report filed in the security "SCORES" reporting system pertaining to a Code Grey on 4/20/22. He was unaware that Patient ID #21 family member had allegedly assaulted 2 staff members and was escorted from the facility. He was unaware that the same alleged perpetrator had been asked to come back to the hospital the following day to participate in a family meeting. He stated he would have expected to find documentation of the event and he believed security personnel should have been made aware of the alleged perpetrator's return to campus.

Based upon record review and interview, the facility failed to ensure that adverse events were adequately reported, tracked and analyzed (Patient ID #1 and Patient ID #21).

Findings included:
Record review for both events:
Record review of facililty's Quality Assessment and Performance Improvement (QAPI) Plan, effective July 2021, stated "Program Scope and Objectives: The program objective includes measurement, monitoring, and analysis of quality and safety indicators, including adverse events, and other aspects of performance to assess process of care, treatment, services, and operations provided."

Patient ID #1
HHSC Intake received on 11/12/2020 for Patient ID #1 stated Patient ID #1 "was admitted to the facility on 10/5/2020. He was going to get a procedure while at the facility for his back pain. The patient "had to be asleep to make sure he wouldn't move." Once he woke up from the anesthesia, he "screamed due to pain." The patient "could not move his right arm. His right arm was swollen, bright red." The patient "found out it was a burn." It was not described "where he obtained it or how he obtained it. The patient was told it was a second degree burn." While at the facility they applied "an ointment and bandage" which "continued when he the was discharged from the facility."

Record review with Staff ID #68 on 4/26/2023 at 12:45 pm revealed a nursing progress note written by Staff ID #76 on 10/10/2020 at 2:21 pm which stated "patient returned from MRI and pacu on right arm was noted to be swelling and is tender to the touch. Pt did not have this before he was taken to MRI margins marked and (staff physician ID #75) aware."

Record review with Staff ID #68 on 4/26/2023 at 12:50 pm revealed a physician progress note by Staff ID #75 on 10/11/2020 stated "R arm swelling: with oozing: radiation burn vs trauma? - us, pain, ng, wound care, add oral AB."

Interview on 4/26/2023 at 1:35 pm with Patient Safety Manager Staff ID #77. He stated that adverse events, variances and incidents should be entered by staff into the electronic incident tracking system called "IRIS." He stated there was no facility policy and procedure which stipulated what sorts of events should be entered. He stated, "clinical staff should enter any deviation from the standard of care." He confirmed that a new untoward physical exam finding immediately following a procedure in a department would qualify for entry. He confirmed that an incident report had been entered into the IRIS system on 10/10/20 at 11:30 am by MRI staff and verified that the incident had been routed to MRI leadership Staff ID #78. She responded by saying the technician "had padded the elbows," acknowledged that an xray and ultrasound of the extremity had been ordered and the incident was closed. He confirmed the incident failed to identify that the patient's exam changed/morphed over the following days, including requiring treatment for burns. He verified that the investigation failed to identify that issue. He confirmed that the radiology department provider leadership was not involved in case analysis or discussion of possible identification of sources for the injury. He stated that he would have expected the floor nurses receiving the patient with a new physical exam finding to have re-entered a variance in the system.

B. Patient ID #21
Record review of facility PBX Operator Log with Staff ID #77 showed that on 4/20/22 at 5:22 pm a "Code Grey" incident page had been paged out in the facility.

Record review of facility's policy "Code Gray: Management of Disruptive or Violent Patient - Patient Care", effective April 2023, stated the facility "is committed to providing workplace safety; which prohibits threats and violence of any kind, requires immediate reporting of any incident that causes a concern for safety, and requires discipline of offenders....c. Telecommunication will in turn page the Code Gray overhead or it will be directly paged overhead by the security team at the McNair Campus. d. The Code Gray Emergency Response Team is a pre-designated, response team consisting of staff trained in the management of aggressive behavior.
i. The Hospital security department will be used as the incident's management structure for security incidents.
ii. Emergency Response Team members include representatives from nursing, security, mission, respiratory, the house supervisor and other staff as directed by the team leader....
3. Documentation of the incident should occur in the patient's medical record and the incident reporting management system."

Record review of Patient ID #21's medical record physician progress note dated 4/21/2023 stated "on the evening of 4/20/23", Patient ID #21 family member "became frustrated with the care that the patient was receiving ..." "Per staff, the (patient's family member) started yelling, threatening staff, and physically hitting staff prompting her removal from the building by security." She was reported to be "emotionally unstable" in the note.

Record review of Social Work staff ID #78 note entered 4/21/23 at 4:30 pm stated "Social worker was present for family meeting with the patient's (family member) along with members of the medical team." She "was very upset throughout the meeting ..." There was no documentation of leadership team or security involvement. There was no documentation of behavioral expectations for safe visitation parameters.

Record review of facility's "Patient Rights and Responsibilities", last reviewed December 2020, "Privacy and safety: b. The patient has a right to receive care in a safe setting. i. Follow current standards of practice for environmental safety, infection control and security."

Interview 4/28/2023 at 10:40 am with Staff RN # 64 confirmed that Patient ID #21 family member "pushed the nurse practitioner and attempted to punch the new graduate nurse." She stated the alleged perpetrator proceeded to "go up and down hallway cursing and pacing in the unit." She stated a "Code Gray" was called and security arrived on the unit. She stated "security removed her."

Interview on 4/28/2023 at 12:15 pm with Director of Patient Safety, Staff ID #74. She stated there was no variance/incident report located in the electronic variance reporting system "IRIS" for Patient ID #21 family member allegedly assaulting staff and being escorted from the facility by security. She stated she would expect there to be an incident report related to that incident.

Interview 4/28/2023 at 2:30 pm with Security Director Staff ID # 77. He stated he could not locate an incident report in the electronic variance system called IRIS related to the Code Grey paged out on 4/20/22 at 5:22pm. He stated there was no report filed in the security "SCORES" reporting system pertaining to a Code Grey on 4/20/22. He was unaware that Patient ID #21 family member had allegedly assaulted 2 staff members and was escorted from the facility. He was unaware that the same alleged perpetrator had been asked to come back the following day to participate in a family meeting. He stated he would have expected to find documentation of the event and he believed security personnel should have been made aware of the alleged perpetrators return to campus.

Based on record review and interview, the medical staff failed to ensure 1 of 3 discharged patients had accurate Discharge Summaries (DC) documented per Medical Staff Bylaws and Rules/Regulations (Patient # 1).

Findings Included:
Record Review of facility policy "Rules and Regulations of the Clinical Staff", reviewed December 10, 2020, stated "2.9 Discharge Summary. Discharge Summary shall include: diet, diagnosis, activity on discharge, medication reconciliation and follow-up care. 2.9.3.3 State the final diagnosis. 2.9.3.6. Address the medical and/or surgical treatment, to include the patient's response, complications and consultations."

Record Review of Patient ID #1 medical record noted a physician progress note by Staff physician ID #75 dated 10/11/2020 12:19 pm which stated "10/11 ... pending arm US., 10/10 MRI under anesthesia, still cervical spine pending, post MRI pt right forearm swell lump and erythema oozing."

Record Review of Patient ID #1 medical record noted a physician discharge summary by Staff physician ID #75 stated "Discharge date 10/14/2020. Discharge Diagnoses Low back pain, Acute right sided low back pain with sciatica." The discharge physical exam stated "Extremities: extremities normal, atraumatic, no cyanosis or edema." There was no mention of diagnosis including right upper extremity injury and no physical exam finding reflective of abnormal exam findings which existed.

Interview with 4/26/2023 12:50 pm with quality staff ID #68 confirmed that Patient ID #1's nursing assessment on day of discharge described right arm with swelling, erythema and blisters. He confirmed that the inpatient medication list reflected silver sulfadiazine (Silvadene) with "apply 1 application topically daily." He confirmed the discharge medication reconciliation included continuing Silvadene. He confirmed there was no diagnosis which included any abnormal finding on the extremity or justification for this addition. He confirmed the physician discharge physical exam was inconsistent with other provider and nursing documentation related to the extremity. He confirmed that there were no discharge instructions reflecting care or follow-up for right arm care, complications acquired during hospital stay or instructions such as wound care or wound dressing changes.