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.

HCA HOUSTON HEALTHCARE CLEAR LAKE 500 MEDICAL CENTER BLVD WEBSTER, TX 77598 Feb. 13, 2019
VIOLATION: MEDICAL STAFF Tag No: A0044
Based on review of patient medical records, hospital documents and interviews with staff the governing body failed to ensure the medical staff requirements were met as evidenced by the physician's failure to perform a complete medication reconciliation within 24 hours of admission. This resulted in the patient not receiving the correct dosage and frequency of home medications on 12/06/18, 12/07/18 and 12/08/18 in 1 of 5 patients. This was in violation of hospital policy.

The findings included:

The medical record for Patient #11 reviewed on the morning of 02/13/19 in a conference room of the Mainland Medical Center campus revealed an H&P report dated 12/7/18 at 7:06am performed by Staff #34. The report stated the chief complaint was nausea and vomiting. The diagnosis, Assessment & Plan were UTI, Dehydration, nausea and vomiting, Bladder calculi with a Plan of Intravenous Fluids (IVF), antibiotics, urology evaluation if possible, no signs of obstructive uropathy, Physical Therapy (PT) /Occupational Therapy (OT), Resume home meds, anti-emetics, still nauseated.
The patient's IV fluids ordered in the ED dropped off after 24 hours of admission to the floor and were not reordered until 12/08/2018.
Note by Attending Physician, Staff #34 on 12/08/18 @ 2021 stated "home meds were entered wrong. So when Dr. Singh continued med wrong dosage and meds were continued."

A review of the hospital policy titled "Medication Reconciliation" with a last reviewed date of 12/2018 stated in part "The purpose of Medication Reconciliation is to accurately reconcile patient medications across the continuum of care ...Medication Reconciliation is completed to ensure that the patient is prescribed the appropriate medications upon admission to the facility, transfer between department, and discharge from the facility. B. Blanket orders such as "continue all medications" or "resume home medication" are not be accepted."

An interview was conducted on the morning of 02/13/2019 with Staff #26, Patient Safety Director. When Staff #26 was asked how are medications reconciled at the hospital. Staff #26 stated that Emergency Department nurses were to discuss all home medications with patients and family and they then enter the medications on the patient's record. She stated the ED physician can then either continue or discontinue the medications. She stated that all new nurses are getting medication reconciliation review training in their new hire orientation. Staff #26 stated she talked with Staff #35 who reported she reviewed Patient 11's chart and wrote orders prior to entering patient's room. Staff #26 stated Staff #35 restarted the patient's home medications with incorrect dosages of Prednisone. Staff #26 stated the intravenous fluids ordered by the ED physician were still on the medical record when Staff #35 first reviewed the chart on 12/06/18 but the ED order dropped off after 24 hours as per hospital policy. Staff #26 stated Staff #35 did not perform an assessment of the patient and did not write a progress note once she found out she was not a physician on the patient's insurance plan.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on review of patient medical records, hospital documents and interviews with staff the facility failed to ensure the patient and family rights to participate in her medical plan of care were enforced as evidenced by the lack of response of the physician and nurses to respond to patient's request to change medication from an evening to morning dosage due to increased pain in her arm noted on 12/07/18 @ 2001. The patient's daughter and other family members requested multiple times to have the attending physician phone them back to discuss the patient's plan of care, medications, and diet.

Findings were:

The medical record for Patient #11 reviewed on the morning of 02/13/19 in a conference room of the Mainland Medical Center campus revealed nurse's notes dated 12/06/18, 12/07/18, 12/08/18 that stated the complainant, patient's daughter had called with multiple requests to speak with the Attending Physician, Staff #34 with concerns about Patient #11's care plan, medications, diet, and IV fluids. Patient #11 was admitted with a diagnosis of Dehydration on 12/05/18. IV fluids ordered in the ED dropped off after 24 hours of admission to the floor and were not reordered until 12/08/2018.
A clear liquid diet was ordered in the ED on 12/05/18 due to patient's complaints of nausea and vomiting.

A nurse note dated 12/8/18 noted that Attending Physician, Staff #34 was called to address that the patient's daughter and daughter-in-law wanted to speak with him about the patient's plan of care. She addressed the medical record had been updated correctly and an order was given to restart the medications. She informed Staff #34 that Patient #11 had been on a clear liquid diet since admission (2 days) and received order for a cardiac diet. Informed MD of the complainant's concern the patient was not on IV fluids when her admitting diagnosis was dehydration. As of this time there were no orders in the record to restart IV fluids. The nurse obtained an order for normal saline IV fluids @ 75ml/hr. The family was very upset they had not talked with a doctor as of this time.
An interview with Staff #26, Patient Safety Director was conducted on the morning of 02/13/19 in a conference room of the Mainland Medical Center campus. Staff #26 acknowledged above documentation.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interviews, and review of the medical record, the facility violated the rights of patient #1. The facility failed to provide safety and dignity for patient #1. The surgeon staff #20 failed to document orders for abdominal midline wound care. "Use ostomy appliance" was documented on 7/25/18 in the progress note. The ostomy appliance was not applied to the abdominal wound of pt #1 until 7/28/2018. Three days after it was documented in the progress note and discuss with nursing. This caused potential for skin breakdown, infection, discomfort from foul smelling drainage, and mental anguish.

Findings included:
Review of progress notes per staff #20 surgeon reveal pt #1 was seen 7/25/18, 7/26/18, 7/28/18 by staff #20 the surgeon. Review of staff #20 progress note 7/25/18 1749, assessment/plan, advised nursing staff to place ostomy appliance over the site to record output and protect the skin. She continues to have foul-smelling drainage from her wound.

Review of staff #20 progress note 7/26/18 1839, Abdomen soft; purulent drainage from wound, less in volume, no odor today; pigtail drain from IR has SS fluid, no pus. Review of staff #20 progress note 7/28/18 0914, will consult ostomy nurse and plan to transfer to med/surg floor.

A telephone interview was conducted with staff #20 on 2/13/19 at 1:05 pm, staff #20 said he spoke to the nurses instructing them to obtain ostomy supplies for wound care.

Review of progress note, 7/28/18 at 1639 staff #21 NP ostomy. The midline abdomen incision dehiscence with large amount bilious drainage with fecal odor and slough at incision edges with wound penetrating into peritoneal cavity. Problem; 1. Abscess of abdominal cavity. 2. Open wound of abdominal wall with penetration into peritoneal cavity. 3. S/p right colectomy. 4. Colon cancer. 5. Anemia. "I personally cleaned the abdomen and applied one-piece colostomy appliance to manage drainage. Discussed with nursing on how to apply and maintain the ostomy appliance. I left some equipment in the room and showed the patient and family as well.

In a telephone interview conducted with staff #21 NP ostomy nurse on 2/13/19 at 10:15 am, staff #21 said she saw pt #1 on 7/28/18 for consult. She said the nurses were applying towels and abdomen pads to abdominal wound. Staff #21 said she obtained the supplies, instructed the nursing staff, patient, and family how to use the ostomy supplies, left some in the room for future use.
In an interview with staff #1 at the facility on 2/13/19 in the conference room staff#1 said it looks like a communication problem.

Review of staff #24 PA and staff #25 physician, 7/30/18 1903 progress note consult for second opinion. As the patient stood up there was copious drainage from the wound. The fluid appeared to be purulent. However, there is no evidence of bilious fluid.

Review of wound assessment policy ID 81, last approved 10/2018, stated the purpose of wound assessment form is to document and track the wound characteristics and measurements on an ongoing basis. The completion of ongoing assessments can assist wound care providers in predicting and subsequently evaluating the status and or measurement of wound healing.

Review of nursing progress notes revealed wounds were assessed but there were no wound assessment forms available for the surveyor to determine if the providers reviewed the forms.

In an interview with the complainant on 2/8/19 at 11:35 am daughter of pt #1 said she sent a letter to the hospital to look into the horrific way her mother was treated. They answered back saying they were sorry the wound care team was not notified and the supplies my mother needed were not available, but they now have trained staff to notify the wound care team. She said they were making changes in the environment, looking at wound care process and supplies. But it doesn't stop my mother from having months of IV antibiotics and a wound vac.
Review of facility documentation on 2/13/19 at the hospital confirmed the findings.
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records, hospital documents and interviews with staff the facility failed to ensure the medical staff requirements were met as evidenced by the physician's failure to complete and documents a medical history and physical (H&P) examination within 24 hours after admission in 1 of 5 medical records. This resulted in the patient admitted on [DATE] received the incorrect dosage and frequency of medications on 12/06/18, 12/07/18 and 12/08/18.

The findings included:

The medical record for Patient #11 reviewed on the morning of 02/13/19 in a conference room of the Mainland Medical Center campus revealed an H&P report dated 12/7/18 at 7:06am performed by Staff #34.

Review of the hospital "Rules and Regulations of the Medical Staff" dated 11/1/2018 stated in part "ADMISSION OF PATIENTS 1. A medical history and physical examination shall be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. A history and physical should include the following (age specific):
" Chief complaint
" History of present illness
" Clinically relevant past medical history
" Medications
" Allergies
" Psychosocial history
" Pertinent review of systems (may be included within the history of present illness)
" Physical examination, to include at a minimum examination of the affected body area(s) or organ system(s). Blank lines on any H&P form will indicate "not applicable" to this patient.

An interview was conducted on the morning of 02/13/2019 with Staff #26, Patient Safety Director. When Staff #26 was asked what the hospital policy was for the completion of a medical H&P. Staff #26 stated the hospital policy was that physicians were to complete a patient's history and physical within 24 hours of admission. Staff #26 stated Staff #35 did not perform an H&P on 12/26/18 due to the physician change. Staff #26 acknowledged the H&P for Patient #11 had not been completed within 24 hours of her admission.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of patient medical records, hospital documents and interviews with staff the facility failed to ensure registered nurses supervised and evaluated the nursing care for each patient as evidenced by inadequate evaluation of patient's medical needs such as medication reconciliation, continuation of ED ordered medical therapies, and diet.

Findings were:

The medical record for Patient #11 reviewed on the morning of 02/13/19 in a conference room of the Mainland Medical Center campus revealed nurse's notes dated 12/06/18, 12/07/18, 12/08/18 that stated the complainant, patient's daughter had called with multiple requests to speak with the Attending Physician Staff #34, with concerns about Patient #11's care plan, medications, diet, and IV fluids. IV fluids ordered in the ED dropped off after 24 hours of admission to the floor and were not reordered until 12/08/2018. A clear liquid diet was ordered in the ED on 12/05/18 due to patient's complaints of nausea and vomiting. 12/07/18 @ 0727 nurse note stated "Patient had no episodes of nausea or vomiting last night. No complaints of abdominal pain."

Review of an H&P report dated 12/7/18 at 7:06am performed by Attending Physician, Staff #34. The report stated the chief complaint was nausea and vomiting. The diagnosis, Assessment & Plan were UTI, Dehydration, nausea and vomiting, Bladder calculi with a Plan of Intravenous Fluids (IVF)

A review of the hospital policy titled "Medication Reconciliation" with a last reviewed date of 12/2018 stated in part "The purpose of Medication Reconciliation is to accurately reconcile patient medications across the continuum of care. Medication Reconciliation is an interdisciplinary process intended to enhance patient safety by reconciling current medications and decreasing the risk of adverse drug events. Medication reconciliation completed to ensure that the patient is prescribed the appropriate medications upon admission to the facility, transfer between department, and discharge from the facility. A. Medication Reconciliation is an interdisciplinary process between providers, nursing and pharmacy, of accurately collecting and reconciling a medication list for each patient. Medication Reconciliation will be completed to the best of one's ability within 24 hours of admission, 12 hours of transfer, and upon discharge.
Medication Verification: Process of confirming components of each medication the patient was taking prior to the time of admission. This includes the following elements: right drug, dose, route, frequency and date last taken. Performed by a nurse, pharmacist, or provider." The policy also noted "A. Admissions 7. The second tier validation will be completed at the second point of contact for the patient. This will be done as soon as possible and within the first 24 hours of patient arrival to the hospital ... The primary nurse for the admitted patient will go through each home medication with the patient (or other reliable source)."

An interview with Patient Safety Director, Staff #26 was conducted on the morning of 02/13/19 in a conference room of the Mainland Medical Center campus. When Staff #26 was asked if current staff had received additional training on medication reconciliation. Staff #26 stated the ED staff had been notified of the need for re-education related to medication reconciliation review but that there had not been any additional training of current nursing staff as of the date of the survey. She stated all new nurses are getting medication reconciliation review training in new hire orientation.

An interview with 4E Director,Staff #31 was conducted on the afternoon of 02/13/19 in a 4E unit office at the Mainland Medical Center campus. Staff#31 was asked how her RNs validate patient's home medication. She stated the nurses review home medications with the patient and/or family. The nurses also call patients' pharmacies and the pharmacist will update with the nurses. The pharmacies are the best resources. Staff #31 states the nurses perform the medication reconciliation and the physicians approve it. She stated if the physician does not return phone calls, she would call the physician and have a direct conversation with them. If she couldn't get in contact with the physician she would escalate the issue up through the chain of command.