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.

THE MEDICAL CENTER OF SOUTHEAST TEXAS 2555 JIMMY JOHNSON BLVD PORT ARTHUR, TX 77640 Feb. 22, 2019
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on review of records and interview, the facility failed to develop and enforce a process to ensure patients receiving psychoactive medications were provided the information necessary to make an informed decision to accept the treatment in 3 out 3 patients reviewed (Patient #62, #64, and #68) that received psychoactive medications.

Findings included:

On the morning of 2-13-2019, the chart for Patient #62 was reviewed at the nurse station on the Behavioral Health Unit, 5th floor. Staff #102 was interviewed during the chart review. Staff #102 confirmed that the patient had been discharged from the hospital that morning. The chart was reviewed for properly executed Consent to Treatment with Psychoactive Medication forms.

A Consent to Treatment with Psychoactive Medication form was found on the chart for the medication listed as Haldol. The dosage and route of medication was not listed. The form indicated that the patient was only given an oral explanation of the medication on 2-10-2019 at 1:00 AM. The record reflected that the patient was receiving Haldol orally and as a long-acting injection, requiring two separate consents.

A Consent to Treatment with Psychoactive Medication form was found on the chart for the medication listed as Cogentin. The dosage and route of medication was not listed. The form indicated that the patient was only given an oral explanation of the medication on 2-10-2019 at 7:46 PM.

A Consent to Treatment with Psychoactive Medication form was found on the chart for the medication listed as Depakote. The dosage and route of medication was not listed. The form indicated that the patient was only given an oral explanation of the medication on 2-10-2019 at 7:46 PM.

A Consent to Treatment with Psychoactive Medication form was found on the chart for the medication listed as Trazadone. The dosage and route of medication was not listed. The form indicated that the patient was only given an oral explanation of the medication on 2-10-2019 at 7:46 PM.

A Consent to Treatment with Psychoactive Medication form was found on the chart for the medication listed as Ativan. The dosage and route of medication was not listed. The form indicated that the patient was only given an oral explanation of the medication on 2-10-2019 at 1:00 AM.

The patient signed all of the consents. An illegible signature was present on all consents in the block labeled "Physician, P.A., R.Ph., RN or LVN Giving Explanation / Position / Date/Time". Staff #102 was asked whose signature was in the block on each of the forms. Staff #102 confirmed it was a nurse's signature. The block underneath the nurse's signature was a signature block for the physician to sign within two days of the consent being signed. The physician was required to sign stating that the explanation given by someone other than the physician had been verified. The physician's signature was not present on any of the forms. Since the physician did not confirm the explanations given to the patient, there was no written information provided to the patient, and the consent did not contain the dosage or route, there was no way to confirm that the patient had received the appropriate information necessary to make an informed decision to accept treatment with these psychoactive medications.

Review of Patient #68's medication consents showed that there were 5 consents. All consents had been provided by a nurse with oral explanation only. All were missing the physician signature verifying the patient had received the correct explanation.

Review of Patient #64's medication consents showed that there were 4 consents. All consents had been provided by a nurse with oral explanation only. The physician had signed, dated, and timed three of the consents within the 2-day time frame. The fourth consent was not dated or timed to ensure the patient was not given medications for a lengthy period of time without an appropriate explanation.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on interview and record review, the Governing body failed to ensure contracts/agreements dealing with patient care were provided in a safe manner. The facility failed to ensure contracts were renewed timely in 3 of 11 contracts/agreements that were reviewed.

This deficient practice had the likelihood to cause harm with all patients.


Findings include:


Review of a sample of contracted or arrangements listed revealed the following agreements were expired:

Garner Environment Services (emergency supplies)-08/16/2018
PalAmerican Security- 09/30/2018
Sysco Houston (disaster supplies) - 12/31/2018

During an interview on 02/14/2019 after 1:00 p.m., Staff #97 confirmed the expired contracts/agreements.
VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
Based on review and interview, the facility failed to follow its own policy and procedures in identifying, addressing, and resolving complaints and grievances.

This deficient practice had the likelihood to cause harm to all patients.



Findings include:

Review of the Complaint and Grievance log revealed complaints and grievances were logged with incident reports. There was no separate log for complaints and grievances. The log was 66 pages long for one year.

An interview with Staff #5 was conducted on the morning of 2/14/19. Staff #5 reported the list does not separate the incidents from the complaints and grievances. Staff#5 was calling corporate to determine how to separate the list with no avail. In the late afternoon hours, Staff #5 was able to compile a list of complaints and grievances. Staff #5 stated the facility is changing to another system and it has been difficult to navigate through the current system. Staff #5 confirmed that the facility was unable to generate a log for Sentinel Events or Root Cause Analysis.

Review of the facility's policy and procedure "Patient Complaints and Grievance Policy Guidelines" Stated, "PROCEDURE:
GRIEVANCE OR COMPLAINT
A. In the event a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, it is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution then the complaint is a grievance for the purposes of these requirements.
E. Complaint may become Grievance
1. Patient complaints that become grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding their patient care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more CoPs, or other CMS requirements.
2. Those post-hospital verbal communications regarding patient care that would routinely have been handled by staff present, if the communication had occurred during the stay/visit are not required to be defined as a grievance.
3. All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are to be considered a grievance for the purposes of these requirements."

Review of patient complaint 77 on 3/4/18 revealed the complaint was logged into the computer system by a RN House Supervisor. The complaint stated, "Pt called about his treatment in the ER. States that NP and nurse were rude was told that he had bone spurs but was not given any information about what to do for them while he waited for a podiatrist."(SIC) Staff #5 was asked why this was logged as a complaint and not a grievance. Staff #5 stated that it should have been but the house supervisors put in the information and log it as a complaint. Staff #5 stated, "They do that all the time and I have to go back in and change them. Staff #5 reported that this has been a continuing problem. Staff #5 was asked if that may be an education issue and Staff #5 stated, "Yes."

Review of patient complaint 79 10/18/2019 stated, "Patient stated that she had a $200 watch go missing. She said the night shift nurse had taken it off to start an IV. She is unsure where it was placed after the IV insertion. She said it was gold and she has had it for years." This complaint was not resolved in a timely manner and was never changed to a grievance process and addressed as such.

Review of patient complaint 1/11/19 stated, "Family unhappy with attending MD care of pt." This complaint was not resolved in a timely manner and was never changed to a grievance process and addressed as such.

Review of complaints and grievances from 3/18/18 to 1/11/19 revealed the process in determining what was a complaint vs a grievance was not identified and brought through the QAPI process to resolve.

An interview with Staff #5 was conducted in the afternoon of 2/14/19. Staff #5 stated the complaints and grievances were reported to Quality Assessment Process Improvement (QAPI). Review of the QAPI Meeting Minutes for September, October, November, and December of 2018 revealed there was no data or PI processes for September and October of 2018. Data was found reported in November and December but no PI processes or specific issues on lack of education of staff was identified or addressed. QAPI has not had any meetings for 2019.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on review of records and interview, the facility failed to ensure data was collected and monitored to assure the safety of services provided by 2 of 2 unit ( Behavioral Health Unit and Dialysis) reviewed for quality indicators.

On the afternoon of 2-14-2018, a review was made of quality data for the Quality Control Program. No quality tracking data was found concerning services provided by the Behavioral Health Unit.

On the morning of 2-15-2018, and interview was conducted with Staff #4. Staff #4 was advised that no tracking data was found. Staff #4 confirmed that the Behavioral Health Unit was not tracked for the measure of quality indicators.





A review of the QAPI meeting minutes for November and December 2018 did not address the issues with the disinfection logs, R/O machine logs, conductivity and PH discrepancies, staff not following the dialysis prescription, the numerous write overs and mark outs on the logs and treatment flow sheets during the investigation survey. The QAPI meeting minutes discussed treatment volume and statistics. There was no evidence that the dialysis staff were involved in the quality meeting.

An interview with Staff #40 and #118 on 02/14/2019 at 9:00 AM confirmed the QAPI meetings did not address the above findings.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on observation, record review, and interview the Hospital (off campus and main campus) failed to insure the department staff of the hospital were aware and and included in opportunities for improvement projects in 3 (Sleep lab, Wound Care, Dietary) of 7 (Housekeeping, Telemetry, Laboratory and Radiology) departments since April 2018, 10 months.

This deficient practice had the likelihood to effect all departments and patients of the hospital.


Findings included.


#1 Sleep lab on the off-site hospital campus.
On the morning of 2/12/2019, the tech, staff #35, who was available for interview, confirmed she was educated to her job duties and responsibilities toward the patients, but was unable to speak to what project improvement the sleep lab staff might be working on.

Interviews with wound care staff #119,on the afternoon of 2/13/2019 on the main campus, confirmed she thought the department director kept Quality data but she did not know for sure what it was.

Interview with the dietary director, staff #52, on the mornoiong of 2/14/2019 on the main campus, confirmed she was keeping data. She was checking food tray temps and refrigeration logs. Interview with kitchen staff revealed they did not know what quality indicators were or what they data collected for them was.

On the afternoon of 2/13/2019 in the board room of the main campus, an interview with the Director of Quality services confirmed she was aware that departments within the hospitals services were not educating their staff as to what a project improvement was or what their department was working to improve. She indicated it had been identified earlier. When asked if it had been long enough to expect that department staff would understand and be aware of their individual improvement projects she replied "yes". The Director further explained the department managers had been instructed to educate their staff regarding project improvement for each department.



Ten (10) months had passed since becoming aware of the failure of the department managers to educate their staff to the Quality program, indicators and improvements projects. The failure persisted. No documentation was provided to indicate staff education, awareness or accountability was being collected, tracked, and analyzed.