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HCA HOUSTON HEALTHCARE CLEAR LAKE 500 MEDICAL CENTER BLVD WEBSTER, TX 77598 Oct. 4, 2017
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on interviews and record review the facility failed to adhere to its grievance policy for 1 out of 1 patient #4 with documented grievances.


Findings: Facility failed to provide evidence of investigation and post investigation letter per policy to patient #4 who complained that a nurse had entered her room wearing a fragrance triggering a Trigeminal nueralgia event.

Tx 532

Interview on 10/4/2017 with Director of Quality, ID #57 at 1:00 PM was asked if certified letters are sent to patient's to follow up with complaints, she responded, "yes". Director ID #57 when asked to provide the letter for patient #4, was unable to locate the post-investigation written response to the above complainant's grievance.

Interview on 10/4/2017 with Risk Managemant Manager ID #58 at 1:30 PM reported that all grievance should be documented in the log, and a follow up letters should have been documented. Letters are sent certified requiring the recipeant did receive the letter. It is not acceptable that no documentation can be located on the compalint/grievance form for patient ID #4.

Interview on 10/4/17 with Nurse Manager #55 at 10:00 AM when asked if she was aware of the event on 1/30/17 involving patient ID #4 she said "yes". Asked if an incident report had been written and her complaint received? She said, "I did not write an incident report. As for the complaint, Risk Management #60 spoke with the patient #4".

Interview with RN, CNO, #61 at 2:30 PM reported that it is not acceptable that no documentation could be located involving the incident with patient #4. Yes, the expectation is all incidents and or complaints are communicated and report written.

Record review on 10/04/17 of facility policy titled: Risk Management-Notification of Occurrences reads:
1. It is the policy of the The Clear Lake Regional Medical Center that all incidents occurring at the hospital involving employees, patients, visitors, or property must be reported utilizing the Meditech online Notification Report.

2. While the responsibility for occurrence report and investigation exisits at all levels of hospital management, the primary burden of responsibilty is placed on the immediate supervisor in whose area an incident occurred.

Record review on 10/04/2017 of facility policy titled "Grievance and Complaint Management", dated 04/2016, read
"... 2. "...appropriate department director/manager will be contacted to review, investigate, and resolve with the patient and/or patient representative, with the goal of resolution to be wihtin seven (7) days of receipt of the grievance.
3. ...if the investigation is not or will not be compleed within seven days (7) days, the complaintant should be informed that the facility is still working to resolve the grievance and that the facility will folloe-up with a written response within twenty-one (21) days.
4. In resolution of the grievance a written notice of the decision MUST be provided to the complainant which should contain the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and records reviewed the facility failed to uphold 1 of 1 patient right to safe setting.

Facility failed to document and investigate a known environmental exposure that resulted in patient #4.

Findings include:
TX 532

Record review of complaint intake # TX 532 revealed patient #4 stated, "she requested staff not wear fragrance when providing care as this exacerbates her [DIAGNOSES REDACTED]. She went on to say staff wore fragrance ignoring her request and a [DIAGNOSES REDACTED] event occurred.

Interview on 10/4/17 with Nurse Manager ID# 55 at 10:00 when asked if she was aware of the event on 1/30/17 involving patient ID #4 she said "yes". As a Nurse Manager, is it expected that all incidents on your Unit are to be written up, "yes".

Interview on 10/4/2017 with RN, ID # 54 at 10:15 AM reported he remembered patient #4 and cared for her on day of the tirgrminal event. Nurse # 54 further reported he had called to Oncology Unit to have a nurse come to Unit 5 to address patient's Port-A-Cath. Asked, was a sign on the door stating " No fragrances", he said, "yes". Nurse #54 reported that night patient#4 could not speak and her lower chin was quivering and shaking after the nurse from Unit 6 had been in the room. She requested I call her Neurologist by sending me a text and I did.

Record review on 10/04/17 of faciulity policy titled: Patient Rights and Responsiblities, dated 04/2016 revealed the following:
12. ...The patient has the right to security and to receive care in a safe setting
a. The patient has the right to expect reasonable safety insofar as the Hospital practices and environment are concerned.

Record review on 10/4/17 of policy titled: Dress Code, dated 01/2016 revealed the following:
GUIDELINES FOR APPROPRIATE DRESS
(6) ... Colognes/Perfume: Employees should apply perfume and /or cologne lightly- if at all- to ensure co-workers and customers who have fragrance sensitivity are not affected. Employees in departments and/or areas of the hospital that are known to have co-workers with adverse reactions to fragrances are NOT ALLOWED to apply perfume and/or cologne before or during working hours this includes perfumed soaps and lotions.