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Based on observation, record review and interview, the facility failed to fully analyze adverse patient events & implement preventative actions following patient falls (Patient IDs #1 and #5).

Findings included:

Observation/interview on 4/4/2023 at 10:15 am in Patient ID #5's room, patient confirmed he sustained a fall "last week" during his current stay. He stated it was due to "placing his foot in the wrong place while standing up from wheelchair." He proceeded to demonstrate standing up from wheelchair unassisted. There was no chair alarm activated. There was no floor pads noted in room. Call bell was in reach. When the patient was asked if he had been instructed to call for help, he confirmed he had been instructed but stated "I am not that person." He went on to explain he did "not want to seem helpless" and he related calling for help with mobility as being helpless.

Record review of complaint intake # TX 00408472 read: "...On 01/09/22 the patient (patient ID #1) had a fall off her bed when she was reaching for her phone. The complainant stated ... "the facility has not taken any fall prevention measures to stop her falls."

Record review of medical record patient ID #1 - Medical record on 1/8/22 19:00 stated "respiratory found patient on floor on her stomach. VS. Mother and physician notified. House physician notified and examined. On exam, there was no evidence of injury. No new orders. 20:35 Reassessment performed. Physician Dr Asbury called back. 21:00 Mom at bedside. Patient explaining how she fell. 22:00 Reassessment done with VS. Every 2 hour reassessments performed throughout the night."

Record review of medical record for patient ID #5 with Charge RN Staff ID #54 on 4/4/2023 at 10:00 am revealed patient fall was documented on "03/27/2023 22:00" She was unable to articulate whether a fall assessment had been performed or what new fall prevention strategies were implemented as the result of the fall.

Review of facility policy "Falls Prevention", Policy # H-PC 03-008, "The policy... is to ensure the following...4. The facility quality program monitors patient outcomes related to the fall(s) and fall risks." "Documentation requirements: e. After a patient falls, it is investigated and entered into the ERS system. The nursing supervisor, or designee, will enter the data into the ERS system as soon as possible after the patient is stabilized."

Interview with Director of Quality Staff #52 on 04/04/2023 2:45 p.m., she confirmed Patient ID #5's medical record dated 03/27/2023 22:00. Entry was by Agency RN ID #70. Entry stated "Primary nurse entered pt's room to administer meds and complete assessment. Pt was observed sitting in his wheelchair at this time. When asked how he was doing, pt informed nurse that he had a fall prior to nurse coming into the room. Pt stated that he was attempting to put up the mask from the breathing treatment and cute the oxygen off because the noise was bothering him. Nurse asked pt if he called fro assistance and he stated that he did not because he is very proactive and used to doing things on his own. Nurse re-educated pt on fall prevention and safety. Pt verbalized understanding."

Interview with Director of Quality Staff #52 on 04/04/2023 1:50 p.m., she confirmed she was unable to locate evidence of event/incident of Patient ID #1 fall at any point during patient's stay from November 2021 - February 2022 in event/incident log. She confirmed she was unable to locate current inpatient, Patient ID #5, who sustained a fall on 3/27/2023 at the facility, on the variance or incident log. She confirmed that since these falls were not reported through incident tracking system, they were not fully investigated or analyzed and would therefore not be reflected in quality metrices. Staff ID #52 stated she would have expected nurse, respiratory therapist or nursing supervisor to fill out electronic variance report after each of the fall occurred.

Based on record review and interview, the facility failed to have documentation of an accurate history and physical (H & P), performed by a physician, in 1 medical record reviewed (Patient ID # 3).

Findings included:

Review of HHSC complaint intake for TX00382871 stated "patient was sent home with ileostomy with no supplies and no teaching."

Review of transferring facility medical records with Director of Quality Staff ID # 52 on 4/5/2023 at 10:00 am, revealed patient was s/p prostatectomy with ileal conduit (urostomy) placement.

Review of medical record on 4/5/2023 at 10:00 am for Patient ID# 3 with admission date of 11/30/20 showed "History of Present Illess: ... the patient is status post cystoprostatectomy." Past surgical history: Trach and trach." "Physical exam: ...Abd: Soft, Gtube in place." There was no mention of ostomy placement, type of ostomy and no physical exam noting an ostomy.

Review of Wound Care nurse initial assessment that was performed on 12/1/20 at 11:56 am, in medical record by Staff ID # 71 on 4/5/2022 at 9:30 am, with Wound Care Manager Staff ID # 63, showed that the initial nursing wound care assessment stated "ostomy pouch in place right lower quadrant abdomen."

Record review of facility's Medical Staff Rules and Regulations, revised January 19, 2023 stated "1 a. The medical record shall include ... medical or surgical treatment .... 2. A complete medical history and physical shall, in all cases, be dictated or documented in the medical record by the responsible practitioner no more than 24 hours after admission."

Interview with Wound Care Manager Staff ID # 63 on 4/5/2023 at 9:30 am, revealed he was unable to determine the type of ostomy that patient had based on physician documentation.

Interview with Quality nurse Staff ID #52 on 4/4/23 at 2:15 pm, she confirmed that the history and physical should reflect the patient's surgical history and the physical examination assessment should reflect an ostomy.

Based on record review and interview, the facility failed to ensure nursing provided wound care assessments in 1 of 3 records reviewed (ID #3).

Findings include:
Record review of facility policy titled "CORE Skin & Wound Care Program Overview," dated 6/2020, showed the following information:
POLICY
The policy of Kindred Hospital is to ensure the following:
3. Practice Standards/Procedures
One care approaches and product should be evidence based and consistent with... Wound Ostomy and Continence Nurses' Society (WOCN)
6. Documentation standards used to measure quality outcomes:
c. Assessment of wound characteristics via reassessment pathway completed with each routine dressing change.
d. Non-scheduled dressing changes will be assessed every shift for integrity and appearance.
e. Skin assessment slash inspection at time of admission and each shift.

Review of medical record for patient (ID#3) showed the following information:
Admission wound/skin assessment: two pressure related injuries found as documented. Braden score 12/moisture 1. ATMOS air reactive support surface with skin IQ for moisture management & Bilateral pressure offloading boots in place ... 2. Ostomy pouch in place right lower quadrant abdomen.
Subsequent wound care notes on the following dates have no mention of ostomy:
12/9/2020, 12/16/2020, 12/23/2020, 12/30/2020, 1/6/2021, 1/13/2021, 1/20/2021, 1/27/2021, 2/3/2021, 2/05/2021, 2/10/2021 and 2/11/2021.

The medical record also showed no nursing documentation of location of ostomy and/or assessments and care performed with shift assessments.

Interview with Wound Care Manager Staff (ID #63) on 4/5/2023 at 9:30 am, revealed he was unable to determine the type of ostomy that patient had based on documentation. He stated that wound care would only follow the ostomy care if it was considered difficult, if it was not deemed difficult the nursing staff would provide care.

Interview with Quality nurse Staff (ID #52) on 4/4/23 at 2:15 pm, she confirmed that there was no documentation of ostomy wound assessment and care reflected in the medical record.

Based on observation, interview, and record review, nursing staff failed to supervise and evaluate the oral feeding of Patient ID # 1 for 72 hours.

Findings included:

Complaint intake for Patient ID #1 received via HHSC hotline on 1/14/2022 and stated "The patient is not being helped with feedings and staff will not take time to feed the patient. The complainant has brought these concerns to the DON and administrator. The administrator tells the complainant they will work on improving but nothing happens."

Telephone interview with caregiver for Patient ID #1 on 3/30/2023 at 11:15 am. She clarified that Patient ID #1 patient was "essentially a quadriplegic patient" who required "total care" to meet ADLs. She stated that the patient reported not being fed during the period she complained to staff about. Caregiver verbalized that she addressed issue in person during visits with Staff ID #65 who she identified as "DON" and "charge nurse on the floor" but the "same issues kept on happening."

Record review of patient ID #1 record has the following entries:
11/9/21 - Diet changed to "Pureed" consistency
11/15/21 - "1:1 feeding" order entered
For nutrition:
11/16/21 10:33am "Nutrition: Breakfast: Refused." Entry by Certified Nursing Assistant Staff ID #68
11/17/21 There are no nutrition entries
11/18/21 There are no nutrition entries
11/19/21 There are no nutrition entries
11/20/21 05:14 am "Nutrition: Snack: Accepted. Snack eaten: All" Entry by Patient Care Assistant Staff ID #69

Record review of facility policy "CORE: Food and Fluid Intake", Policy H-PC-04-004, Released 06/2021 stated "4. Document the intake in meal intake record either on paper or electronic medical record. Document substitute offered/consumed, if applicable. Review documentation for trends of inadequate intake that has declined for the past three days, has exhibited complications while consuming food/fluids, has observable complications at meal service (refusal of meals/service ...."

Interview on 4/5/2023 at 09:50 a.m. with Charge Nurse Staff ID # 54. She stated that patient's who are total care and require assistance with feeding "should have a 1:1 feeding order placed in medical record by nursing, dietitian or physician." She stated this is how the medical record reflects 1:1 feeding assistance. She stated "1:1 feeding patients have a nursing assistant, therapist or nurse provide all meals". She confirmed that the oral intake should be documented in the medical record under nutrition.

Interview on 4/4/23 at 2:45 pm with Quality Director Staff ID #52, she confirmed there was no oral diet entries between 11/16/21 morning and 11/20/21 morning. There was no physician or dietitian notification of lack of oral intake.

Based on record review and interview, the facility failed to ensure that controlled substances were administered according to provider's orders, controlled substance waste was documented per facility policy, and that thorough audits and follow-up were completed for scheduled drug discrepancies.

Findings included:

Record review of HHSC Intake for TX 00408472 stated "the facility has been over-medicating the patient."

Telephone Interview on 3/30/2023 at 11:00 am with Patient #1 caregiver, she stated the nurses "commonly administered the wrong dose of medications, at the wrong times and did not provide assistance for patient to take oral medications."

Record review of facility's pharmacy services "Controlled Substance Audits" for the month of November/December 2021 with Director of Pharmacy Staff ID #64 on 4/5/2023 at 09:15 am, showed identified variances between controlled medication orders, medications administered and scheduled medication wastage which involved numerous staff nurses.

Record review of facility policy titled " Controlled Substance Management & Administration Outside the Pharmacy (Nursing Services)" dated 06/2020, stated the following information: "Discrepancy: failure of related controlled substance measures to be consistent." It also stated "the controlled substances inventory count will be considered inaccurate if any one of the following occur: c) Documentation on the CSAR is considered incomplete if any of the following are noted; lacks full names of patient or nurse signature; wastage lacks witnesses, signature and/or reason for wastage, errors are not marked out correctly with strike-through and re-entry of correct information." The policy stated "Removal from stock and documentation of administration and wastage: c) if the exact dose to be administered is not available, the nurse shall remove the closest dosage form available and waste the remainder with a witness. Dosage of partial doses, wasted doses and wastage of overfill, b) The excess amount of drug must be wasted prior to the actual dose being administered."

Interview with facility director of pharmacy, Staff ID # 64 on 4/5/23 at 09:30 am, he stated that he and the pharmacy staff run a report each morning of controlled medications which were administered. He stated this was rectified with each patient's orders. He stated that identified "improper wastage" or "failure to waste" were common issues identified. He stated, these were entered into the variance reporting system and then sent to the nursing director for follow-up. He confirmed that "improper wastage amount" could also mean that nurses were administering incorrect doses of medications. He confirmed that Staff Nurse ID #66 had 5 errors in administration of controlled substances to patients, including wrong medication dose wastage (which would mean wrong dose administered) during the period of 12/1/2021 to 12/7/2021. He confirmed that those had been variance through electronic reporting system and labeled "medication event." He stated that these discrepancies "were sent to the nursing director to follow-up."

Interview 4/5/23 at 12:00 with Director of Nursing Staff ID #65 was conducted. She stated that the variance report is routed to her. She goes to the nurse to identify the issue. She stated "they typically threw away the waste and failed to document." She provided verbal re-education of the policy verbally, followed by verbal and written counseling. She provided the written performance improvement form which was utilized for the process she described.

Interview 4/5/23 at 1:05 pm with Director of Quality Staff ID #52, she confirmed there was no evidence of re-education, verbal or written warning for any of the narcotic discrepancies with Staff ID # 66. She confirmed she would expect that information to be a component of the employee record.

Based on interview and record review, the facility failed to ensure the discharge planning process utilized full review of needs for 1 of 1 patient (ID #3 of). The discharge planner failed to assess the need for and ensure that ostomy teaching for the patient/caregiver, as well as ensure ostomy supplies were ordered for home health care.

Findings included:

Record review of facility policy titled "CORE Interdisciplinary Assessment and Reassessment," dated 6/2022, showed the following information:
POLICY
The policy of Kindred Hospitals are to ensure:
4. Assessments and data collection performed by licensed health care professionals will include and address:
a. patient specific needs
e. discharge planning needs
PROCEDURE
Licensed, qualified staff assess each patient's care needs throughout the patient's hospital stay and provide specific care at the time based on assessment data ...
11. Case Management/Social Service Department
e. Discharge planning begins upon the patient's admission to the hospital. As the initial assessment focuses upon goals of the patient, the goals include the discharge plan. Case management, in collaboration with the interdisciplinary team, is also responsible for assessing the dish charge needs of the patient in relation to living arrangements, equipment, home care needs, transportation, etc. Reassessment is done at minimum every seven days in collaboration with the interdisciplinary team.

Review of medical record for patient (ID#3) showed teaching on the following:
Respiratory Home training - trach tube suctioning, trach care,
Counting respiratory rate, taking radial and carotid pulse, use of ambu bag to ventilate ...
Wound Management Home training-instructed on offloading, relieving pressure to wound to help give time to heal

Projected home DME needs:
Trach
Suction
Home Nebulizer
Humidity
Trach supplies

Interview with Wound Care Manager Staff ID # 63 on 4/5/2023 at 9:30 am, revealed that patient's and/or caregivers are to receive ostomy teaching prior to discharge. He confirmed that there was no documentation of patient/ caregiver teaching in the medical record for patient (ID#3).
Interview with Quality nurse Staff ID #52 on 4/4/23 at 2:15 pm, she confirmed that there was no documentation of ostomy teaching or home ostomy supplies order located in the medical record for patient (ID#3). She stated that the facility received notification of a patient complaint regarding the lack of teaching.

Record review of facility letter to caregiver for patient (ID#3) dated 4/28/2021 showed the following information:
Providing quality care is the ultimate goal of the staff at kindred hospital Houston Medical Center. The concerns identified have been investigated and we provided our feedback below in any appropriate actions necessary to improve our process.
o We apologize that you did not receive education on the ileostomy.