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.

UNIVERSITY OF TEXAS M D ANDERSON CANCER CENTER,THE 1515 HOLCOMBE BLVD HOUSTON, TX Oct. 28, 2019
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of records and interview, the facility failed to ensure that the Registered Nurse (RN) took appropriate actions on 30 days out of 82 days when an assessment of patient care needs showed that care could not be provided as ordered by the physician for Patient #33. The physician had placed an order twice for the patient to have a sitter at the beside during 82 days of her stay. The facility did not provide a sitter on 30 of 82 days. RN staff, after assessing patient care needs and identifying that care needs could not be met, failed to contact the physician for changes in orders or the physician's plan of care to have a sitter at the bedside.

Findings included:

Cross Refer to Tag A0119 for detailed findings.

Review of Patient #33's chart showed that the physician ordered a sitter to be at the patient bedside on 6-22-2019. This was after the patient had sustained a fall on 6-13-2019. The sitter order was valid throughout the stay until the patient discharged on [DATE]. Between 6-22-2019 and 8-31-2019, records showed that there were 24 occasions that a sitter had not been available. The facility did not make alternate arrangements for a sitter and a sitter was not provided. Records showed that the patient and family had expressed concerns on 4 separate occasions about sitters not being provided to ensure patient safety. The final documented occurrence of family complaint about no sitter was on 8-31-2019. This complaint resulted in a safety intelligence report being filed and the physician placing a duplicate order for a sitter at the patient's bedside. Despite the physician re-ordering the sitter at beside, and even though the original order had never been discontinued, 6 more occasions were documented where a sitter was not available and not provided through alternate arrangement.

RN Staff #22 and #42 were interviewed on 10-30-2019 and 10-31-2019. During the interview process, Staff #22 stated that the patient didn't really need a sitter at all times due to her limited mobility. Staff #22 and Staff #42 were asked if the physician had been notified of this assessment so that the order along with the physician's plan of care could be changed as a result of this assessment. RN #22 and #42 both confirmed that the physician had not been contacted for new orders. When patient care needs identified and ordered by the physician were not going to be met by the facility, the RN staff supervising and evaluating the nursing care for Patient #33 took it upon themselves to disregard the physician order and modify the physician's plan of care for a sitter at the beside without obtaining new physician orders.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of records and interview, the facility failed to ensure there was an effective process for grievances to be initiated, reviewed, and resolved in 2 of 2 Safety Intelligence: Q/R Manager Review Forms (Incidents on 6-13-2019 and 8-31-2019) in which allegations were made concerning the facility neglecting to provide care for the patient. Patient #33's family member made allegations on 6-13-2019 and 8-31-2019 to the hospital staff that the hospital had neglected to provide Patient #33 with safe care.

Findings included:

Review of Patient #33's chart showed that the patient was admitted on [DATE] and discharged on [DATE]. The patient was an [AGE]-year-old with a history of multiple cancers. As a result, she had chronic pain in the lower back area. She was admitted for treatment with steroid injections. She was scheduled to be discharged on [DATE]. Patient #33 fell out of the bed on 6-13-2019 prior to being discharged to a rehabilitation facility. While imaging scans showed no new fractures, documents reviewed showed Patient #33 experienced increased pain and decreased mobility that prolonged her stay.

Review of physician orders showed that Patient #33 had been placed on fall precautions. On 6-22-2019 the physician had placed an order for a sitter to be at the bedside. This order was found to be in effect until 9-13-2019, when the patient discharged . A duplicate order was made by the physician on 8-31-2019 after Patient #33's family member complained to staff about the patient being left without a sitter.

Registered Nurse (RN) Managers, RN Staff #22 and #42, were interviewed on 10-30-2019 and again on 10-31-2019 at 1:00 PM. During the interview process, RN Staff #42 confirmed that she was not aware of how many days that sitters had not been provided during the patient stay. RN Staff #42 confirmed that she was not aware that there had been a physician order placed on 6-22-2019 and valid through discharge. RN Staff #22 and RN Staff #42, were asked to provide the dates that a sitter was not available. A handwritten list of 22 dates was provided. Review of the Nursing Plan of Care notes in the patient record showed that there were 8 additional days that a sitter had not been available during a shift. Additional dates included:
6-27-2019
6-28-2019
6-30-2019
7-14-2019
7-16-2019
8-31-2019
9-4-2019
9-5-2019


The Safety Intelligence: Q/R Manager Review Form was reviewed with RN Staff #22 and RN Staff #42. The Event Detail block contained the following, "The patient's daughter was very angry that a sitter had not been provided for the patient and verbalized her issues and complaints at length, first with the charge nurse then with me, during my call-back response to her page. A consistent message was provided that a sitter was not available, but that the patient was being monitored closely by staff and receiving appropriate care as needed. A supplement report has been submitted to unit leadership and Patient Advocacy."

RN Staff #22 and RN Staff #42 confirmed that during Patient #33's stay, while she was being "monitored closely by staff and receiving appropriate care as needed", that six (6) Safety Intelligence reports had been made for the following reasons:
The patient fell on one occasion.
The patient's Fentanyl patch was found to be missing on one occasion.
The patient's scheduled medication was found in her bed on two occasions after it was documented to be given.
The patient was not being provided sitters as the physician ordered.
The patient had new abrasions to her skin.

On 10-31-2019, RN Staff #22 and RN Staff #42 provided documentation from 6-23-2019 that the patient's daughter had refused a sitter for her mother. When asked if there was evidence that the daughter refused a sitter on the other days a sitter was not provided as ordered (30 in total), RN Staff #22 and RN Staff #42 confirmed there was not. The patient chart review revealed that the patient and family expressed concern on at least 4 occasions about the lack of sitters. A Nursing Plan of Care note from 7-10-2019 stated that the patient was very upset about not having a sitter. A note from 7-19-2019 stated the patient's daughter was unhappy and voiced her concerns about not having a sitter. A note from 7-26-2019 stated the patient's daughter called twice to request that the sitter be provided for the night and one was not provided. On 8-31-2019, the patient's daughter became upset, a safety intelligence report was filed, and the physician wrote a duplicate order for a sitter to be at the bedside. Despite actions taken on 8-31-2019, records showed the facility neglected to provide a sitter on 6 more days (September 1, 2, 4, 5, 7, and 8) prior to patient discharge on 9-13-2019.

On 10-31-2019 at 1:59 PM, Patient Advocate Staff #37 was interviewed. Staff #37 confirmed that he had processed a grievance concerning Patient #33. The grievance was concerning several allegations from the patient's fall on 6-13-2019. When asked the specific allegations or complaints, Staff #37 identified the following issues that had been expressed by Patient #33's family member:
The patient fell because her bed rails were down.
The patient fell because the bed alarm was not on.
The patient's daughter was having to incur additional out-of-pocket expenses due to the delay in discharge after the fall.
The patient was experiencing more pain after the fall.
The patient's lifetime Medicare days were going to be used up due to the delay in discharge after the fall.

Staff #37 was asked what the resolution to the allegations in the grievance were. Staff #37 stated the nurse manager had investigated the fall and pain management. He stated the nurse manager had indicated there was not a problem, but was unsure of her final determination on whether or not the rails were in the proper positions or if the bed alarm had been appropriately set.

Review of the safety intelligence report indicated under the heading, "Identify any contributing factors at the time of the fall. Select all the apply.", that factors included, "Grab bar or hand rail placement, Patient did not call for help, Side rails found down." Under Manager/Consultation Notes, RN Staff #42 documented, "re-education of bed alarm activation discussed."

Staff #37 stated that the patient family member's request to have her parking expenses reimbursed had been approved and processed. However, Staff #37 confirmed that he had never contacted the patient or family member to notify them that the parking fees would be reimbursed and were ready to be picked up. The resolution letter sent to Patient #33's family member on 8-13-2019 indicated the resolution process had been completed, but did not include information about reimbursement of expenses. He stated he was waiting for the patient's daughter to contact him.

Staff #37 stated he was unsure of the resolution regarding the complaint that the patient's lifetime Medicare days were going to be used up because of the extended stay. He stated he had spoken with the Risk Manager about the use of Medicare days, but did not know what the final outcome regarding billing had been.

Staff #37 confirmed that he had sent a final grievance letter on 8-13-2019 stating that the review and resolution process had been completed, but did not know what the final resolution was regarding specific allegations.

The Patient Review form provided by the Patient Advocate was reviewed. The form identified the Grievance Specifics as "Alleged poor quality of care, re: bed rail/alarm." The form did not contain specific information of what information had been found in the patient's chart concerning bed rails/alarms or any specific actions to be taken after the fall to protect the patient, such as physician orders for a sitter at bedside. The form did include that parking would be reimbursed, but did not include the final resolution concerning the approval of out-of-pocket expenses to be reimbursed. The form did not include the final decisions on the use of lifetime Medicare days or how the patient stay would finally be billed.

Staff #37 confirmed that the grievance from 6-13-2019 did not include any issues concerning the use of sitters and had been closed on 8-8-2019. A safety intelligence report from 8-31-2019 was reviewed with Staff #37. Staff #37 confirmed that he had looked at the report, but did not initiate a grievance process or ensure that the allegations of the potential neglect in patient care were investigated. Staff #37 confirmed that the concerns of potential neglect expressed by Patient #33's daughter on 8-31-2019 regarding not providing a sitter should have been processed as a grievance.

Review of MD Anderson Institutional Policy #CLN0467, Patient Complaints and Grievance Policy, defined a grievance as, "A formal or informal written or verbal Complaint that is made to MD Anderson by a Patient or Patient Representative regarding the Patient's care (when the Complaint is not resolved at the time of the Complaint by staff present), abuse, neglect; ...." Neglect was defined as, "For the purpose of this policy, Neglect is considered a form of Abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." The physician had ordered sitters twice to prevent physical harm after the patient had sustained a previous fall. The patient was noted to be upset on one occasion due to not having a sitter. The patient's family had expressed concern over the patient's safety on three occasions. A grievance was never initiated or investigated.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of records and interview, the facility failed to ensure 1 patient (Patient #33) out of 5 patient grievances reviewed were provided a written notice of decision that included the determination or action taken regarding the grievance.

Findings included:

Cross Refer to Tag A0119 for detailed findings.

Review of patient records showed that Patient #33 fell on [DATE]. Patient Advocate Staff #37 opened a Patient Review form on 6-13-2019 and closed it on 8-8-2018. Review of the form showed the patient's family member made a grievance in which she alleged "poor quality of care re: bed rail/alarm", expressed the following concerns during the course of the grievance and requested a resolution:
The patient was in excruciating pain.
The family wanted a change in physicians.
The patient's family member incurred additional out-of-pocket expenses due to the delayed discharge after the fall and was requesting reimbursement of expenses.
The patient's Lifetime Medicare days would be used up due to the delay in discharge after the fall.

The grievance resolutions letter was reviewed. Staff #37 confirmed that he had prepared and sent the letter dated 8-13-2019. The letter contained the following information:

"On August 08, 2019, our review and resolution process was completed. The following steps were taken to address your concerns: Leadership and the appropriate staff were notified about the concerns brought to our attention. After a review, a conference was held on June 27, 2019 and again on August 8, 2019. It was noted that testing was completed and results were provided to you and your mother. A plan of care to include skilled nursing facility following discharge from the hospital was discussed. We apologize for this unfortunate experience. If you need further assistance, please contact us at the number listed below."

The letter contained the contact name and number for Patient Advocate Staff #37.

When the grievance resolution letter was compared to the Patient Review form that included allegations/concerns along with notes of meetings and actions taken. Notes from the June 27, 2019 meeting referenced showed that the daughter was still upset with the pain control and Occupational Therapy/Physical Therapy "post injection procedures." Notes from the August 8, 2019 meeting showed that the daughter was "still going back to the fall" but the physician explained "that testing had been completed and there weren't any fractures nor extra injuries." The daughter agreed to the patient going to a skilled nursing facility when accepted.


The grievance resolution letter did not address the family's concerns about the physician and request for change in physicians. The grievance resolution letter did not address the determination made for the request to be reimbursed out-of-pocket expenses incurred as a result of the delay in discharge or action to be taken to resolve the grievance. The grievance resolution letter did not address the concern that the patient's Lifetime Medicare days should not be used up as a result of her delay in discharge due to the fall or actions taken to resolve the grievance.

Review of MD Anderson Institutional Policy #CLN0467, Patient Complaints and Grievance Policy, stated that the Resolution Letter would include, "A statement of the results of the investigation and actions taken to resolve the Grievance".