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 May 2, 2019
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to inform a patient of their rights upon admission. [citing Patient # 8 ]

Findings included:

TX 637

Review of facility's policy titled " Patient's Rights and Responsibilities," dated 02/2018, showed the facility staff must provide all patients a written statement of their rights at time of registration. This statement must be acknowledged by the patient.

Record review of Patient # 8's medical record showed she was a [AGE] year old female who arrived at the emergency department (ED) via ambulance on 10-06-18 at 1452. Per ambulance staff patient was sent from another hospital due to stating she was having vaginal bleeding. Nursing assessment showed Patient # 8 was oriented to person, time, place and situation. Her mood and affect were assessed as congruent. It was documented this was a voluntary admission.

Interview on 04-18-19 at 11: 15 AM with the Health Information Management (HIM) Director, she verified the record provided was the complete medical record for the 10-06-18 admission for Patient # 8.

Continued review of Patient #8's medical record failed to show a signed and dated acknowledgement of receipt of patient rights.

Review of ED physician progress note, dated 10-06-18, showed Patient # 8 was medically cleared for a psychiatric evaluation. "HCAT (Health Crisis Assessment Team) evaluated the patient and recommend inpatient care. This will be voluntary."

Patient # 8 requested placement in a traditional adult bed hospital and not a "geri-psych" bed. For this reason, her admission was made involuntary for a transfer to a psychiatric facility. Record review showed forms were initiated for involuntary commitment on 10-07-18 at 0522; however an Emergency Apprehension & Detention Warrant (EDW) was not issued and signed until 10-09-18.

During an interview on 04-18-19 at 1:30 PM with Staff F , ED Registered Nurse, he stated all admitted patients should have a signed & dated acknowledgement of receipt of patient rights, unless they were unable to sign or refused. In any case, the exception should be documented.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to uphold a patient's right to informed consent. Facility failed to obtain a consent for treatment from Patient # 8 upon admission per hospital policy.

Findings included:

TX 637

Record review of facility's policy titled "Procedure for Registration Forms & Signatures, " 05/01/15 showed standard form required at registration included 'Conditions of Admission' (COA), which included a general consent to treat.

Record review of Patient # 8's medical record showed she was a [AGE] year old female who arrived at the emergency department (ED) via ambulance on 10-06-18 at 1452. Per ambulance staff patient was sent from another hospital due to stating she was having vaginal bleeding. Nursing assessment showed Patient # 8 was oriented to person, time, place and situation. Her mood and affect were assessed as congruent. It was documented this was a voluntary admission.

Interview on 04-18-19 at 11: 15 AM with the Health Information Management (HIM) Director, she verified the record provided was the complete medical record for the 10-06-18 admission for Patient # 8.

Continued review of Patient #8's medical record failed to show a signed and dated general consent to treat during the time she was under a voluntary admission status.

Review of ED physician progress note, dated 10-06-18, showed Patient # 8 was medically cleared for a psychiatric evaluation. "HCAT (Health Crisis Assessment Team) evaluated the patient and recommend inpatient care. This will be voluntary."

Patient # 8 requested placement in a traditional adult bed hospital and not a "geri-psych" bed. For this reason, her admission was made involuntary for a transfer to a psychiatric facility. Record review showed forms were initiated for involuntary commitment on 10-07-18 at 0522; however an Emergency Apprehension & Detention Warrant (EDW) was not issued and signed until 10-09-18.

During an interview on 04-18-19 at 1:30 PM with Staff F , ED Registered Nurse, he stated all admitted patients should have a signed & dated general consent to treat, unless they were unable to sign or refused. In any case, the exception should be documented.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to provide care in a safe setting for Patient # 1.

a. The facility failed to ensure staff utilized appropriate de-escalation techniques during an episode of aggressive, combative, elopement behaviors exhibited by Patient # 1.

b. The facility failed to ensure Patient # 1 did not have access to hazardous items that could be used for self-harm while she was on suicide precautions.

Findings included:

Staff Management of Patient Behaviors:

Record review of facility policy titled "Annual Mandatory Education,"revised date 06/2018, showed it was facility policy to ensure that all employees including contracted individuals complete annual mandatory education based upon job training needs and safety concerns.

Observation on 04-18-19 at 9:25 AM in the facility emergency department (ED) showed Patient # 1 walking toward the automatic double-doors that led to the lobby. The patient was agitated, swearing, and telling staff she wanted to leave. Several staff members were following this patient.

Further observation showed Staff J, head of security, was standing immediately next to Patient # 1 . Staff J grasped Patient # 1 by by her right arm. She yelled "Do not touch me !" as she pulled her arm away and swung it in the air. Patient # 1 was observed more agitated after she had been grasped by Staff J.

As staff attempted to guide Patient # 1 back into the ED nursing station area, Patient # 1 said loudly "Don't (curse word) walk behind me... get out of my face! " Staff J, head of security said "No, you are in my face."

Further observation showed Patient # 1 was walking around the ED nursing station area, followed by 5 staff members. Patient # 1 remained agitated, restless and said loudly "y'all get back to work and leave me alone!"

During an interview on 04-18-19 at 1:45 PM with Staff J, head of security, he denied grasping Patient # 1 by the arm. He stated that he had received "TEAM" training from his company on management of aggressive behaviors.

Record review on 04-18-19 of computer "screen shot" of contract company training for security Staff J showed he received "TEAM training" on 12-13-18.

Record review of the TEAM [Techniques For Effective Aggression Management]training handbook provided by Staff J showed "...verbal de-escalation techniques included:... respect their personal space...try and maintain at least 2 arm lengths, or 6 feet of distance.. avoid making it a 'me' versus 'you' confrontation...during the aggression cycle:... avoid physically touching person..."

During an interview on 04-18-19 at 11:00 AM with Staff E, ED director, he said all ED staff were required to be trained in Crisis Prevention Institute (CPI) crisis intervention training and Trauma Informed Care (TCI) to utilize when caring for behavioral health patients. He said the security staff was contracted and he did not know if they had CPI and TCI training.

Accessibility of Hazardous Items:

Record review of the facility's policy titled "Suicide Prevention," revised on 01/2016, showed a suicide risk screening was performed in the ED. Patients identified as at risk for suicide were placed on suicide precautions immediately. Safe environment & patient safety guidelines were implemented.

Record review of the medical record of Patient # 1 showed she was a [AGE] year old female admitted involuntarily to the ED on 04-17-19 under an Emergency Detention Order. Diagnoses of drug abuse; psychotic disorder. Further record review showed the following:

* 04-17-19 : (1809) physician order for suicide precautions / Level 2: Line of Sight at all times.

*04-17-19 (2002): Registered Nurse (RN) progress note read "pt has multiple sharp objects in hand and on person."

* Suicide Prevention/Safe Environment Checklist," dated 04-17-19, showed documentation of "dangerous items removed from patient "was verified every 15 minutes from 1715 on 4-17-19 until 0700 on 04-18-19.

During an interview on 04-18-19 at 11:20 AM with Staff E, ED director, he said the ED had only one room ( #8) considered "psych safe." Most all patients who were on suicide precautions (SP) were placed in the areas visible to the nurses's station for safety purposes. Most of the patients were on 1:1 monitoring with a sitter, depending on the Level of SP ordered.

ED Director reviewed Patient # 1's record and said he was unaware how the patient had obtained sharp objects on 04-17-19 at 2002. The safe environment checklist had been completed for the timeframe in question.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure that a registered nurse (RN) supervised and evaluated the care for Patient # 8.

Nursing failed to accurately assess and reassess skin integrity for Patient # 8.

Findings included:

TX 637

Record review of facility's policy titled, "Plan for Assessment / Reassessment," dated 08/2016, showed each department where nursing care is provided uses an assessment format that is individualized to the patient population served...a head to toe systems review and all other clinical documentation will indicate only items that fall outside defined parameters.

Review of facility "Appendix A" referenced in the above cited assessment policy , [specific to the Emergency Department (ED)] showed the scope of the RN admission assessment included skin and wound assessments.

Patient # 8 :

Review of Patient #8s medical record showed :

Physician ED documentation:

10-06-18 (1508) :" [AGE] year old female presents to ED with complaint of chronic sores to her bilateral legs....stage 3 pressure ulcer to posterior left thigh; stage 1 pressure ulcer to posterior right thigh..."

Nursing ED documentation:

10-06-18 (1455): arrived via EMS ...told them "she had sores on the back of her leg"-assessment said "skin warm & dry"
10-06-18 (1532):Integumentary: WDP [Within Defined Parameters]: YES
10-06-18 (2202):skin warm & dry: YES, color within expectations for ethnicity: YES
10-07-18 (0522):skin warm & dry: YES; color within expectations for ethnicity: YES
10-07-18 (0522):TRIAGE REASSESSMENT:subjective assessment: ..."pt told EMS she had sores on the back of her leg."
10-07-18 (1945):PHYSICAL FINDINGS: Musculoskeletal: WDP; Integumentary WDP

Further review of this same medical record showed that "Assessment Parameters" were defined as 'Within Defined Parameters' when : skin, warm dry and intact; No complaints of lesions, rash, wounds, bruises, petechiae , or abrasions."

A completed "Body" wound diagram completed by nursing staff, dated 10-08-18 (0445), showed three (3) circles drawn on posterior body diagram : two(2) "B"s (bruises) and one (1)"wound". There was no description of the bruises or wound.

On 05-02-19 , comment via email by Staff B, Chief Nursing Officer (CNO), she stated she reviewed Patient # 8's medical record with the ED leadership. Their review showed the patient's skin assessment was not accurately reflected in the assessment area of her medical record.