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.

CHRISTUS SOUTHEAST TEXAS- ST ELIZABETH 2830 CALDER AVENUE BEAUMONT, TX 77702 July 8, 2015
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on interview and record review the facility failed to ensure a timely response to a grievance on 1 of 1 sampled patients (a confidential patient).
This deficient practice had the likelihood to cause harm in all patients presenting to the surgical recovery room.
Findings include:

Review of a complaint and grievance report with a receipt date of 05/07/2015 revealed an allegation of patient privacy rules being violated (confidential patient). According to the allegation a patient's HIV (human immunodeficiency virus) status was discovered by a visiting family member. The allegation was that patient information was left out at the bedside in the recovery unit and a family member read the chart. Review of a written response letter revealed documentation the first notification was made to the complainant about receipt and investigation results of the allegation was on 6/12/2015 (over 35 days after receipt of the grievance).
During an interview on 07/08/2015 after 1:13 p.m., Staff #5 confirmed the allegation was true and did occur. Staff #5 confirmed she was the nurse who left the information at the bedside. A family came into PACU without her knowledge and read the information. Staff #5 confirmed the patient was upset after the incident occurred and she had apologized to the patient.
During an interview on 07/08/2015 after 5:00 p.m., Staff #3 confirmed not knowing the date the letter was sent and that the information would be faxed to the surveyor. The response letter was faxed and revealed a response date of 06/12/2015.

Review of a facility policy named "COMPLAINT/GRIEVANCE RESOLUTION PROCESS FOR PATIENTS" dated 01/2015 revealed the following:
12. Department Managers/Directors shall participate in the appropriate and thorough investigation. The results and actions taken are documented in writing and returned to Guest Services and /or Administrative designee within three (3) business days.
13. Guest services and/or Administrative designee will ensure that a verbal and/or written acknowledgement of the grievance is sent to the appropriate party within seven (7) business days of receipt.
14. When the investigation is completed, a written response containing the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, the date of the completion and the name and phone number of a contact person and will be sent to the complainant within thirty days.
c. If the investigation is incomplete at thirty(30) days an acknowledgement is sent to the complainant indicating when a formal response can be expected.
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
Based on observation, interview and record review the facility failed to ensure information in medical records was kept private in 2 of 2 patients (Patient #s' 1 and a confidential patient).

This deficient practice had the likelihood to cause harm in all patients presenting to surgery recovery room.
Findings include:

Review of a complaint and grievance report with a receipt date of 05/07/2015 revealed an allegation of patient privacy rules being violated. According to the allegation a patient's HIV (human immunodeficiency virus) status was discovered by a visiting family member. The allegation was that patient information was left out at the bedside in the recovery unit and a family member read the chart.
During an interview on 07/08/2015 after 1:13 p.m., Staff #5 confirmed the allegation was true and did occur. Staff#5 confirmed she was the nurse who left the information at the bedside. A family came into PACU without her knowledge and read the information. Staff #5 confirmed the patient was upset after the incident occurred and she had apologized to the patient.


During an observation on 07/08/2015 after 1:13 p.m., three patients were in beds in PACU (post anesthesia care unit). A family member was brought to bed #4 to visit Patient #1. The privacy curtains were pulled leaving Patient #1 and the family member alone in the bay area. Patient #1s' medical record and test results were on a computer at the bedside and test results were on the foot of the bed. The patient information was not covered or contained and was in plain view of the family member.
Staff #4 confirmed the observation. Staff #4 confirmed they had problems in the past with privacy of records. Their new system now was to provide a privacy card to the family member, minimize the computer screen and remove the jot sheet (which contained patient information) away from the bedside.
The facility failed to ensure this new system was followed.

Review of a facility policy named "PATIENT RIGHTS AND RESPONSIBILITIES" dated 02/2013 revealed the following:
Privacy and Confidentiality: The patient has the right, within the law, to personal and informational privacy as manifested by the following rights:
e. To have his /her medical record read only by individuals directly involved in his/her treatment or those monitoring its quality, and, by other individuals upon written authorization of the patient of his/her legal representative or by individuals authorized by law or regulation.
f. To expect all communications and other records pertaining to his/her care, including the source of payment for treatment to be treated as confidential.