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.

BAYSHORE MEDICAL CENTER 4000 SPENCER HWY PASADENA, TX 77504 April 27, 2017
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0217
Based on observation, interview and record review the facility failed to ensure full and equal visitation privileges for 5 of 5 patients on Geri-Pysch Unit (Patient ID, #1, 2, 3,5, 6).

Findings include:

TX 434

Observation on 4/ 26/17 at 10:00 am at the facility on the Geri-Psych Unit entrance revealed signage that read: "...No Visitation on Tuesdays and Thursdays..."

Record review of complaint narrative TX 434 read: "... Tuesdays and Thursdays you can't visit the Geri-Psych Unit..."

Interviews on 4/26/17 between 10:00 - 11:00 am with four (4) current Patients ID # 2, #3, #5, #6 revealed understanding that there was no visiting hours on Tuesdays & Thursdays.

In an interview on 4/26/17 with Charge Nurse, RN ID # 52 at 9:15 am she reported visiting hours were from 2:30-4:00pm, except on Tuesdays and Thursdays. She said, " I'm not sure why, has been that way since I have been here for four (4) years".

In an interview on 4/26/17 at 10:15 am with Social Worker, ID # 51 on Geri-Psych Unit, he stated he was aware there was no visiting on Tuesdays & Thursdays. He did not verbalize the reason for this.

Interviews on 4/26/17 between 10:30-12:00 with four (4) staff members, Nurse Manager, RN, ID # 60, RNs , ID # 54 & 55, PCA (Patient Care Assistant) ID # 53, revealed consistent understanding of visiting policy. All stated there was no visitation on Tuesdays & Thursdays.

In an interview on 4/26/17 at 12:00 pm with Director, ID # 59, he reported that management was aware that they needed to be more family friendly, especially with visiting.

In an interview with Security Guard, ID # 61 at front desk on 4/27/17 at 2:00 pm she stated; there were no visiting hours on the Geri-Psych Unit on Tuesdays & Thursdays. ( Question was asked on Thursday ).

Record review of facility Patient Handbook revealed the following schedule for visiting on the Geri-Psych Unit:

Mondays: 2:30 - 4:00 pm
No visitation on Tuesdays
Wednesdays: 2:30 - 4:00 pm
Thursday: No visitation
Friday: 2:30 - 4:00 pm
Saturday: 2;30 - 4:00 pm
Sunday: 2:30 - 4:00 pm
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review a Registered Nurse (RN) failed to supervise and evaluate the care for 1 of 3 patients needs, based on her assessed needs (Patient ID# 1).

Findings include:

TX 434

Record review of the clinical record of Patient ID # 1 revealed a [AGE] year old African American female. She was admitted for aggressive behaviors, hypertension, and with a past medical history of dementia.

Record review of progress notes by PA (Physician Assistant), ID #63 from 12/30/16 to 1/26/17 revealed documentation of Patient ID # 1 with failure to eat, poor appetite, and loss of weight requiring daily weights by nursing, additional supplements, i.e. Ensure, an enriched protein drink, and finger foods.

Record review of Patient # 1's medical record on 4/27/17 with Clinical Educator, ID # 58 revealed that there were no documentation of daily weights. Five (5) weights were documented in the medical record as follows:

* 12/28/17 = Wt: 175
* 12/29/17 = Wt: 185, re-weighed 12/29/17 = Wt: 185
* 1/16/17 = Wt: 109
* 1/17/17 = Wt: 160

In an interview with Charge Nurse, RN ID # 52 on 4/26/17 at 10:00 reported that there was no policy about weighing the patients. The patients were weighed on admission and then only if there was an order for daily weights, or specific to time and date.

In an interview on 4/26/17 with PCA, (Patient Care Assistant) ID #53 at 10:45 am she reported that the staff only weigh patients when they first come to the Unit. Also she reported that if a patient was not eating she reported to the nurse and if she is told to weigh them again she would.

Record review of policy titled: " Food and Nutrition Services Management", last revised 09/2016 read as follows:

" PROCEDURE
1. Nutritional care monitioring:
Physician: Assumes the responsibility for the overall nutritional management of the patient
Registered Dietitian: Assesses patient's needs, evaluates...
Nursing Services: Meal rounds conducted to determine if patients are having any difficulty with meal service that might impact their nutritional status.

The following triggers are utilized to identify patients by ongoing monitoring who have been identified to be at nutritional risk on admission...Changes in PO (orally) intake, Weight loss...".
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure nursing staff developed and kept current, a nursing care plan for Patient ID # 1.

Findings include:

TX 434

Record review of Patient # 1's History & Physical (H & P) exam, dated 12-28-16 revealed a [AGE] year old African American female admitted for aggressive and bizarrre behaviors, with a past medical history of dementia.

Record review of progress notes from Physician Assitant (PA) ID # 63 indicated patient not eating, weight loss, and need for daily weights to be done.

* 12/30/16 - Pt. (patient) seen in her room confused, nonverbal, not eating".
* 1/12/17 - Not eating very well, added ensure with each meal.
* 1/14/17 - Vital signs stable, pt. is confused and is eating less, will add finger foods and ensure.
* 1/16/17 - Pt. needs assistance in feeding. No new issues. Continue care per psych team. Wt: 109
* 1/17/17 - She is also not eating well. Pt is getting daily weights. Weight dated 1/17/17 "160".

Record Review of Nursing documentation on 1/23/17 at 2005 by Nurse ID # 62 revealed the following: "No aggressive behavior, poor appetitie, spits food out when she does not want it."

Record review and interview on 4/26/17 at 9:30 am of Patient # 1's nursing care plan with Clinical Educator ID # 58 revealed no documentation of daily weights, addition of "finger foods", and Ensure having been added to the nursing care plan. Further review of the nursing care plan failed to reveal nursing interventions related to weight loss, loss of appetitie, or change in Patient # 1's medical status while reviewing the nursing care plan.

In an interview on 4/27/17 at 3:00 pm with Clinical Nurse Educator, RN, ID # 58 revealed that RN's(Registered Nurse) were responsible for updating patient care plans immediately when there was a change in status and when completed it would be visible in the care plan.