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.

KINGWOOD MEDICAL CENTER 22999 US HWY 59 KINGWOOD, TX 77325 April 18, 2018
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to complete an accurate discharge planning evaluation on admission for 1 of 5 sampled discharged patients (Patient # 6 ).

Findings include:

TX 399

Record review of Patient # 6's admission "History & Physical Exam, dated 08-06-17 ,read: " ...This is a case of a [AGE]-year-old male who presented to the emergency room (ER) after a fall. This patient has multiple medical problems ... Per patient, he fell 2 days prior to admission and had been on the floor for that duration and was brought to the ER by emergency medical services (EMS) with the patient covered in feces and urine. The patient has a bilateral below the knee amputation (BKA), wheelchair bound. The patient lives with the ex-wife and per EMS, the family notified EMS only today and the patient has been on the floor for 2 days. The patient has multiple wounds to both lower extremity stumps...Assessment & Plan: 1 .... Case Management consultation for home situation and possibly discharge planning ... (8-06-17) ".

Record review of Patient # 6's admission "Discharge Planning Evaluation", dated 8/7/2017 included the following screening question: " ... Based on information gathered is it likely that the person's care needs can be met in the environment from which he/she entered the hospital ? The documented answer was "Yes."

Interview on 04-18-18 at 1:45 p.m. with Case Manager#9 , she said based on the information provided in the admission H & P [that this patient had been left on the floor for 2 days and brought in covered with urine & feces] this question should have been answered "No".

Case Manager # 9 went on to say the person completing this discharge planning evaluation had access to the H & P and would have known that information.

Record review of facility policy titled "Discharge Planning", dated 02/2016, revealed a description of the facility wide discharge planning process. The policy stated within 24 hours of admission to the facility, the patient's primary nurse, and case manager/social worker (CM/SW) complete an initial screening evaluation of patient's discharge needs. "Working with the patient/family and members of the interdisciplinary health care team, the CM/SW identifies and develops a preliminary discharge plan and goals..."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to ensure 1 of 5 sampled patients was protected from possible abuse and neglect upon discharge (Patient # 6.).

The facility failed to make a timely referral to Adult Protective Services (APS) per policy.

Findings include:

TX 399

Record review of Patient # 6's admission "History & Physical Exam", dated 08-06-17 , read: " ...This is a case of a [AGE]-year-old male who presented to the emergency room (ER) after a fall. This patient has multiple medical problems ... Per patient, he fell 2 days prior to admission and had been on the floor for that duration and was brought to the ER by emergency medical services (EMS)with the patient covered in feces and urine. The patient has a bilateral below the knee amputation (BKA), wheelchair bound. The patient lives with the ex-wife and per EMS, the family notified EMS only today and the patient has been on the floor for 2 days. The patient has multiple wounds to both lower extremity stumps...Assessment & Plan: 1 .... Case management consultation for home situation and possibly discharge planning ... (8-06-17)".

Interview on 04-18-18 at 1:45 p.m., with Case Manager # 9 she stated Patient # 6 had 2 sons. They wanted nothing to do with their father because he kept going back to his ex-wife. The sons were not able to help him because of this ex-wife. The sons told Case Manager # 9 they felt the ex-wife supplied their father illegal drugs. The ex-wife was the provider of services for Patient # 6. This information was not documented in the case management notes.

Review of Patient # 6's clinical record revealed he was admitted on [DATE] . Record review of case management notes revealed a referral to Adult Protective Services (APS) was not made until the day of discharge on 08-25-17:

"8/25/17 (11:44 a.m. by Case Manager # 9) spoke with ( ) at APS due to concern for safe discharge plan to home. He said they will follow pt upon discharge ..."

Patient # 6 was transported from the facility on that same day (8/25/17) at 2:46 p.m. to his ex-wife's home.

Interview on 04-18-18 at 1:45 p.m. with Case Manager # 9 she stated an APS referral was the responsibility of nursing, case management; whomever comes in contact with the patient. They make the referral to APS and document it in their notes. She was unsure of the timeframe.

Review of facility policy titled" Adult Protective Services Referral," dated 4/2012, read:

" ...Purpose: To initiate an investigation of possible abuse/neglect of an adult. To protect the rights of an adult who is unwilling/unable to protect himself/herself from a potentially dangerous environment ...

Policy: The ( facility) Case Management Department or other healthcare provider with knowledge of (sic) will initiate Adult Protective Services investigation whenever information regarding possible abuse/neglect is given to individuals of that department by family, co-workers, patients and/or any other source.

Procedure: When the information of alleged abuse/neglect is received by Case Manager ...that person will immediately contact APS with a report ..."

Interview on 04-18-18 at 3:15 p.m. with Vice President of Quality # 1, she stated the APS referral should have made shortly after the information about the home situation was obtained in the ER.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the medical staff failed to ensure 5 of 5 discharged patients had timely History & Physical (H & P) examinations or Discharge Summaries (DC) documented per Medical Staff Bylaws and Rules/Regulations (Patient # 6, 7, 8, 9,10):

Findings include:

TX 399

Record review on 4/18/18 of five (5) closed records revealed the following:

Three (3) closed records lacked timely admission H & P Examinations:

Patient # 7 was admitted [DATE]: H & P was dictated 8/24/17; signed 9/17/17

Patient # 10 was admitted [DATE]: H &P exam signed on 7/24/17

Patient # 8 was admitted [DATE]; H & P exam was dictated 8/22/17; signed 8/24/17


Three (3) closed records lacked timely Discharge (DC) Summaries:

Patient # 6 had no discharge summary (Vice President of Quality #1 unable to locate)

Patient # 9 was discharged [DATE]; DC Summary signed on 10/26/17

Patient #8 was discharged [DATE]; DC Summary signed on 10/26/17

Interview on 04-18-18 at 3:30 p.m. with Vice President of Quality # 1 she stated H & Ps must be completed within 24 hours of admission and Discharge Summaries within 30 days following patient discharge.

Record review of facility's "Medical Staff Bylaws:, dated 2017, read:" ...

12. ARTICLE TWELVE: HISTORY AND PHYSICAL EXAMINATION: A complete admission history and comprehensive physical examination shall be the responsibility of the attending Practitioner and shall be recorded in the chart or available within twenty-four (24) hours of admission as an inpatient/observation patient and prior to undergoing any invasive or operative procedures, even on weekends and holidays. This report should include all pertinent findings resulting from assessment of all the systems of the body...:

Record review of facility "Medical Staff Rules & Regulations" , dated 2-22-17, read: ...7.6.1 Discharge Summary : (a) in General: A discharge summary must be recorded for all patients. The summary must concisely recapitulate the reason for hospitalization , the significant findings...the procedures performed and treatment rendered....7.9 Completion of The Medical Record...If the record still remains incomplete thirty(30) days following discharge, it shall be considered a delinquent record.."
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to conduct a secondary discharge assessment within 48 hours of admission per facility policy for 1 of 5 sampled discharged patients ( Patient # 6).

Findings include:

TX 399

Record review of facility policy titled "Discharge Planning", dated 02/2016, read:"1. Within 24 hours of admission to the facility, the patient's primary nurse, and case manager/social worker (CM/SW) complete an initial screening evaluation of patient's discharge needs. 2. During initial screening, if certain "high risk" triggers are noted ( indicating complex discharge needs), a secondary discharge assessment will be completed by the CM/SW within 48 hours of admission. (See Appendix 1: High Risk Triggers)... Review of Appendix 1 revealed the following listed as high risk triggers: " ...suspected neglect...lack of support system... high risk /post hospital..functional status..."

Record review of Patient # 6's admission "History & Physical Exam", dated 08-06-17 , read: " ...This is a case of a [AGE]-year-old male who presented to the ER after a fall. This patient has multiple medical problems ... Per patient, he fell 2 days prior to admission and had been on the floor for that duration and was brought to the ER by EMS with the patient covered in feces and urine. The patient has a bilateral below the knee amputation (BKA), wheelchair bound. The patient lives with the ex-wife and per EMS, the family notified EMS only today and the patient has been on the floor for 2 days. The patient has multiple wounds to both lower extremity stumps...Assessment & Plan: 1 .... Case management consultation for home situation and possibly discharge planning ... (8-06-17)".

Further review of Patient # 6's record revealed he was admitted on [DATE] and discharged on [DATE]. An initial "Discharge Planning Evaluation ", dated 8-07-17 at 11:10 a.m. was completed. There was no secondary Discharge Planning Evaluation completed for Patient # 6.

Interview on 04-18-18 at 1:45 p.m. with Case Manager#9 , she said suspected neglect and lack of support system were considered high-risk triggers and a secondary Discharge Planning Assessment should have been completed.