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MEMORIAL HERMANN HOSPITAL SYSTEM 1635 NORTH LOOP WEST HOUSTON, TX 77008 Sept. 1, 2020
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interview and record review, the facility failed to fully investigate a family's expressed complaint regarding the transfer of Patient # 11 to an outside facility.

Findings included:

TX 699

Record review of facility policy titled "Patient Complaints and Grievances Policy," dated 12/31/2018 showed :

* a "patient grievance" is a formal or informal written or verbal complaint that is made by a patient or patient's representative regarding the patient's care;

*when the patient requests a response from the health care system, the complaint is considered a grievance and all the requirements apply.

*grievance issues are incorporated into performance improvement and patient safety activities.
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During a telephone interview on 8-19-2020 at 2:30 PM. with the step daughter of Patient # 11 she stated there had been a lot of difficulty in communication with the facility staff during Patient # 11's admission to the facility. A lot of conflicting information about her condition had been provided by staff or no information at all.

She went on to say on the evening of 8/18/2020 (last night) at 6:57 PM; her father called the hospital to check on Patient #11. He was told "we transferred her to Park Manor." The daughter said she got on the telephone and asked to speak with someone in charge. She spoke with Staff J , Operations Administrator. She informed him the family was very upset; they were not informed the patient was being transferred. The step daughter said her father wanted Patient # 11 returned to the hospital. She requested the names of the CMO, CNO and Risk Manager. The family requested to speak to the CMO, CNO, and risk manager about this incident.

Patient # 11 was transferred back to the hospital this morning (8/19/2020) at 7 AM. Per the family request, a telephone conference was conducted with hospital leadership this morning. The step daughter said her father, herself and sister were on the call and expressed many of their issues and concerns. The hospital said "they messed up communication; we will do better." The step daughter said she hoped "the hospital would improve the processes for informing families in many different areas. It was very stressful for the family...this type of occurrence happened 3 to 4 times during her stay..." [ Please see federal tag A- 0395 for related information].

During a telephone interview conducted on 08/31/2020 at 9: 00 AM with Staff J, Operations Administrator, he confirmed he took the call from Patient # 11's spouse and step daughter on the evening of 08/18/2020. They were very upset the patient was transferred without them being informed. They were concerned about Patient # 11's decision-making ability due to her present health condition. Staff J said he called the charge nurse, risk manager, and later spoke to Staff K, the CMO. The CMO told him to have the patient brought back to the facility. They would meet the family to "see what went wrong and how we can make it better."

Record review of Patient # 11's clinical record showed a case management progress note entry dated 08/19/2020 that stated a conference call was held that day at 12:20 PM with Patient# 11's husband and two (2) daughters. Hospital representatives included the CMO, risk manager, and case management representatives. It was documented the family expressed their concerns about communication and updates on patient's medical condition. It was explained by the facility the patient needed skilled nursing to gain strength prior to acute inpatient rehabilitation. The facility arranged for the spouse of Patient # 11 to visit his wife that day. It was also documented that the attending physician would be asked to call and speak with the patient's husband.

Record review on 08/21/2020 of a facility document titled "Customer Experience Tracking-All Grievances,"dated July-August (to date), 2020 showed five (5) complaints documented as received on 08/18/2020 that were "resolved/closed." There were two (2) grievances received on 08/18/2020 that were "open." There were no documented complaints or grievances that involved Patient # 11.

During an interview on 08/21/2020 at 2:45 PM with Staff M, Director of Patient Relations , he stated he had been notified that Patient # 11's husband and daughters were very unhappy with the transfer and the location. He was told the patient was brought back to the facility the next day at 7 AM. He could not explain the reason for the lack of a documented investigation.

During a telephone interview conducted on 08/31/2020 in the afternoon with Staff B, Quality Director, he confirmed there was no documentation of an investigation regarding Patient # 11's family's concerns. He acknowledged there was no in-depth review of specific communication failures to identify opportunities for improvement.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interviews and record review, a registered nurse failed to effectively supervise the care of Patient #11. Nursing staff failed to inform the spouse or family of three (3) transfers of Patient # 11: two (2) outside the hospital; one (1) within the hospital.

Findings included:

TX 699

During a telephone interview on 8-19-2020 at 2:30 PM. with Family member ID #M, step-daughter of Patient # 11, stated there had been a lot of difficulty in communication with the facility staff during Patient # 11's admission to the facility. A lot of conflicting information about her condition had been provided by staff or no information at al.

Outside transfers:

1. Family M went on to say on the evening of 8/18/2020 (last night) at 6:57 PM; her father called the hospital to check on Patient #11. He was told "we transferred her to Park Manor." Family TD X said she got on the telephone and asked to speak with someone in charge. She spoke with Staff J , Operations Administrator. She informed him the family was very upset. They were not informed the patient was being transferred;she had already left the facility.

2. On a different day, the family received a telephone call from the facility ER requesting permission to give Patient # 11 a blood transfusion. The ER staff informed the family, Patient # 11 had been transferred back to the hospital from TIRR due to her condition. Family M said "the family had not been notified she had even been transferred to TIRR in the first place."

Intra-hospital transfer:

Family M said her father called on "I think on 8/15/2020" to check on her mother and was told by the staff she was no longer in the ICU but had been transferred to a medical-surgical floor.

Interviews were conducted on 08//21/2020 between 10 and 10:45 A.M., with four (4) RNs ( Staff E, F, G, H ) on Unit 5 West. All four (4) RNs stated the spouse or family member of a patient would be informed of any transfer -both within the hospital and outside. All four RNs ( Staff E, F, G, H) stated this transfer communication was the responsibility of the nursing staff; and should be documented in the medical record.

Record review on 08/20/2020 of the clinical record of Patient # 11 with Staff C, Quality Manager, failed to show documentation the spouse or family of Patient # 11 had been notified prior to the 3 transfers.







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