The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TMC- BONHAM HOSPITAL 504 LIPSCOMB STREET BONHAM, TX 75418 Feb. 23, 2018
VIOLATION: COMPLIANCE WITH STATE AND LOCAL LAWS Tag No: C0152
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and interview, the facility failed to ensure State hospital licensing regulations were followed in 3 (Patient #3, #4 and #5) out of 3 patients reviewed, requiring the facility to ensure:

"the right of the patient to receive, at the time of admission, information about the hospital's patient rights policy(ies) and mechanism for the initiation, review, and when possible, resolution of patient complaints concerning quality of care."

Findings were as follows:

Review of Patient #3's admission paperwork, including the Patient Rights notice, found that they were not signed by the patient or patient representative. The forms had "Pt unable / overdose" or "Pt unable" written in the patient signature block. The forms were dated on 2-15-2018 but not timed. Records showed that the patient's daughter was available on 2-15-2018, as she had signed the "Request for No Life Support Administration" form on her mother's behalf on that date at 5:50 PM.

Review of Patient #4 and #5's (admitted to swing beds and also referred to as Resident #4 and Resident #5) admission paperwork showed that neither resident had signed the Swing-Bed admission document containing an acknowledgement of receipt of the "Patient Bill of Rights / Advance Directive / Ethics Committee". Patient #4 had been admitted on [DATE]. Patient #5 had been admitted on [DATE].

Interview was conducted with Staff #11 on 2-22-2018 at 11:12 AM. Staff #11 stated that it was the admission clerk's responsibility to have admission paperwork signed by the patient. Staff #11 was asked about the process for obtaining signatures in cases where the admission clerk was unable to obtain signature and the patient was on the Medical / Surgical Unit. Staff #11 stated it was the Unit Clerk's responsibility. Staff #13 was interviewed at that time about the process. Staff #13 stated she was unsure of the process. Staff #13 stated the Unit Clerk is also the Telemetry Monitor and would have to find someone else to obtain the signatures or someone else to watch the telemetry monitors. Staff #2 confirmed that there was no formal process.
VIOLATION: CLEAN FACILITY Tag No: C0225
Based on observation and interview, the facility failed to ensure the medication room on the Medical / Surgical Unit was clean and orderly.

Findings includeed:

A tour of the Medical/Surgical Unit medication room was made on the morning of 2-23-2018 with Staff #2, Staff #4 and Staff #19 present. Staff #3 joined the tour as it was in progress.

Laminate was observed to be missing from the edge of the sink countertop. The exposed edges were unfinished and had remnants of glue and exposed wood. This created a surface that could not be properly sanitized.

Two boxes of syringes were found stored in a drawer by the sink. One box (100 count) was full and had expired 2017-06. The other box (100 count) was approximately half-full and expired 2017-07.

Syringes for drawing up medication and administering medications were stored in cardboard boxes on the floor in a corner. The corner was found to have a heavy build-up of dirt and debris on the flooring and baseboards.

A cabinet by the sink and the corner of the wall by the cabinet were soiled with drops of an unknown reddish substance.

The corner of the wall by the cabinet had exposed wall board where the corner was splitting and not sealed.

The medication refrigerator was observed on a metal table that had dried substances on it.

The wall beside and behind the medication dispense cabinet had multiple holes in the wall that left the wall board exposed and open access for insects or rodents into the medication room.

Staff #2 was interviewed during the tour on the morning of 2-23-2018. Staff #2 stated that they had just inspected the medication room the previous week. Staff #2 confirmed the findings.

Staff #19 was asked if there were any work orders for the laminate or for any items in the medication room. Staff #19 stated she would check to see if work orders had been place. No work orders were provided to the surveyor.
VIOLATION: STAFF TREATMENT OF RESIDENTS (483.13(C)) Tag No: C0384
Based on review of records and interview, the facility failed to document a thorough investigation of alleged neglect in 1 (Resident #1) out of 1 allegations reviewed.

On the afternoon of 2-22-2018, the complaints and grievance logs were reviewed with Staff #2 and Staff #4. There was no record of Resident #1 ever making a complaint or grievance. When asked about Resident #1, Staff #2 and Staff #4 both stated they remembered her. Staff #2 stated that on a Monday, the Resident told her the weekend staff was slow to take care of her on Saturday, 10-28-2017. Staff #2 confirmed that Resident #1 had alleged the staff neglected her toileting needs. Staff #2 stated that the hospital took extra steps to try to please this resident, as she had numerous complaints. Staff #2 stated Staff #18 visited the patient daily during the week to identify any areas of concern for the patient.

Staff #2 stated she had not logged any complaints or grievances because she thought they had all been addressed. Staff #2 stated she had investigated the resident's allegations and did not find any evidence to support the allegations. However, no records of the investigation were made.

An interview was conducted with Staff #18. Staff #18 stated she was assigned to round on Resident #1's room on a daily basis during the week. When asked if she entered complaints and grievances in the computer when the patient reported problems, Staff #18 stated that she did not. She stated she reported problems to the responsible staff or departments to be addressed. Staff #18 did not investigate complaints and did not know the outcome of any investigations or meetings the patient had with nursing.

On 2-22-2018 a request was made for the hospital policies relating to Abuse and Neglect. Two policies were provided:

Policy #: HR-318; Policy Name: Reporting, Neglect and Exploitation; Section: Employee Standards of Conduct

Policy Number: (blank); Policy Title: Reporting Suspected Abuse, Neglect, and Exploitation of Children, the Elderly and/or Disabled Person; Department: Facility Wide

Neither policy addressed the process for documenting, investigating, and protecting the patients during the investigation process when allegations are made against facility staff of abuse, neglect, or exploitation of patients.
VIOLATION: PATIENT ACTIVITIES (483.15(F)) Tag No: C0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and interview, the facility failed to ensure that an ongoing program of activities based upon patient needs identified as the results of the completed SNF/Swing Activity Assessment was effective. Goals were not identified based off of the assessment and incorporated into the plan of care, and goals were not evaluated to ensure resident needs were met by the activity opportunities provided in 3 (Resident #4, #5, and #7) out of 3 residents reviewed.

Findings were as follows:

Review of Resident #4's chart revealed the resident had been admitted to a swing bed on 2-17-2018 at 6:00 AM. The SNF/Swing Activity Assessment was completed on 2-17-2018 at 7:32 PM. The assessment consisted of a list of the resident's "Preferred, social, and daily activities". The assessment form did not have a designated entry place for identified activity goals designed to meet the patients identified needs and interests.

One entry on SNF/Swing Activity Flow Sheet was dated 2-29-2018 at 12:37 PM. The entry stated that the resident participated in arm exercises and television. The comments documented were, "Pt was assisted up in recliner w/ her watching TV and doing arm ex."

No ongoing plan of activities for the resident had been identified. No goal of the activities had been identified. No resident response to activities had been identified. Activities were not incorporated into a plan of care.

Review of Resident #5's chart revealed the resident had been admitted to a swing bed on 1-29-2018 at 7:08 PM. The SNF/Swing Activity Assessment was completed on 1/30/2018 at 4:36 PM. One entry for SNF/Swing Activity Flow Sheet was found. It was dated 2-13-2018 at 6:39. The note charted that activated participated in was "Skilled swingbed conferences". No other description of activity or resident's involvement was found.

No ongoing plan of activities for the resident had been identified. No goal of the activities had been identified. No resident response to activities had been identified. Activities were not incorporated into a plan of care.

Staff #15 was interviewed on 2-22-2018 at 11:47 AM. Staff #15 confirmed that no other activity notes were entered on Resident #4 and Resident #5. Staff #15 was asked about a schedule of activities or an activity program. Staff #15 confirmed that there was not a schedule of activities that residents could participate in. Activities were normally one-on-one. When asked how often residents participate in activities, Staff #15 stated, "I was told 1 to 5 times per week." When asked why there weren't more notes, Staff 15 stated that was all that was done. Staff #15 stated residents participate based on their tolerance or if they are in the mood for it. When asked if he charts when residents are unable to or refuse to participate, Staff #15 stated, "No, I come back later. I chart if they continue to refuse."

An interview was conducted with Staff #18 on 2-22-2018 at 4:00 PM in the CEO conference room. Staff #18 confirmed that there was not a written activities program for residents to participate in. Staff #18 stated that the resident census varied and resident abilities prevented them from having scheduled group activities.

On 2-23-2018 at 9:25 AM, Resident #7 was interviewed in her room with Staff #2 present. Resident #7 was admitted on [DATE] at 4:36 PM. Resident #7 stated her interests were watching TV, working on Word Search puzzles, and she liked to walk in the hallway. She stated it was hard to walk in the hallways because she had her right knee replaced for the third time. She used a walker.

The electronic chart was reviewed at the nursing station with Staff #4 and Staff #20. Review of the SNF/Swing Activity Assessment matched the activities reported during Resident #7's interview. Staff #4 and Staff #20 were asked to find the goals of the activities and evaluation of resident's response to the activities she had participated in. Staff #4 and Staff #20 confirmed that there were none. Activities were not incorporated into a plan of care.

Review of policy number P.MS.0001, titled Swing Bed Activities, was as follows:

"Procedures and Guidelines

1. All patients admitted to Swing Unit will be assessed by the Occupational Therapy service.
2. The Social/Activity Assessment will be completed and the results placed in the patient's chart within seven days of admission (unless pt DC before 7 days).
3. The individual activity goals will be incorporated into each patient's health care plan.
4. Activities can be provided by an activities aid with documentation in the chart of the activities performed with the patient or by OT/PT/COTA/PTA/ST/Tech.
5. If dramatic changes in a patient's performance ability is observed, a notation will be entered in the chart that day with a verbal report of the observations made to the attending Charge Nurse.

Reassessment:

1. The Social/Activity Assessment will be completed on each patient every seven days with program modifications made as appropriate.

2. If a dramatic change is noted in the patient's performance, a reassessment will be completed immediately with goals and treatment modified accordingly."