HospitalInspections.org

Based on record review and interview, the facility failed to ensure the grievance resolution process was completed and documented in 1 of 3 patient related grievances (ID# 8).

Findings include:

Review of facility policy titled "Grievance Resolution Process," last revised October 21, 2024 showed the following information:

PURPOSE
To protect and promote the rights of each patient, a patient has been established to promptly resolve patient grievances. This process is delegated to a grievance committee.

POLICY
All patients have the right to initiate the grievance resolution process...If the patient care complaint cannot be resolved at the time of complaint by the staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or require further actions for resolution, then the complaint is a grievance.


The surveyor asked to review all documentation regarding grievance for patient (ID#8). Two letters were provided.
Review of letter of acknowledgement to patient (ID# 8) dated 6/11/2025 stated the following:
We want to thank you for bringing your concerns to us regarding the care we provided you while you were a patient at PAM Health Rehabilitation of Humble. As a follow-up, I would like to share the process that we will initiate to investigate your concerns. We will review your medical record and speak to staff involved to have a better understanding of the issues you have outlined....We will follow-up with you when the investigation is complete.

Review of response letter to patient (ID#8) dated 6/17/2025 showed the following:
The hospital was advised of a concern regarding inconsistent timely response to requests. As a result of the investigation, we have reeducated the staff...


Interview with Interim Director of Quality Management (ID# 52) on 8/13/2025 at 3:00 pm she confirmed there was no documentation of investigation steps taken in the resolution process.

Based on interview and record review, the facility failed to ensure nursing provided intervention/ timely intervention on needs of a patient in pain in 1 of 4 patients (ID# 6).


Findings Include

Record review of facility policy "Guidelines for Nursing Care" last revised March 20, 2024, revealed "Pain: Assessment and Documentation - Upon Admission, Pain reassessed within 4 hours after PRN pain intervention."

Medical record review for patient (ID#6) showed the following:
Admission assessment on 02/12/2025 1953 showed pain scale documented "10" with no documented intervention.
Nursing assessment on 2/14/2025 at 1456 showed pain scale "4".
Physician order for Tramadol 50 mg by mouth every six hours PRN for pain scale 4-6. Indication: Pain
Medication administration record showed Tramadol 50 mg was given 2/14/2025 at 22:23.

Interview with Nurse Manager (ID 54) on 8/13/2025 at 11:00 am confirmed the above findings, Patient (ID#6) had no ordered intervention for a pain level of 10 and the physician should have been contacted. She also stated that the Tramadol administered on 2/14/2025 was not a "timely" intervention.

The hospital failed to ensure that an RN supervised and evaluated the care of 2 of 4 patients (ID#s 3 and 8).

Findings include:

Record review of facility policy "Guidelines for Nursing Care" last revised March 20, 2024, revealed "Hygiene - if no contraindication, bath/shower - Three times/week/and PRN."

Medical record review of Patient ID #3 showed physician order to start 7/30/2025 0900 for Bathing three times a week, Monday, Wednesday, Friday. Review of multidisciplinary notes showed hygiene care for patient (ID# 3) was not provided per physician order.

Medical record review of Patient ID #8 showed physician order to start 12/04/2024 08900 for Bathing daily. Review of multidisciplinary notes showed hygiene care for patient (ID# 3) was not provided per physician order.


Interview with Nurse Manager ID #54 on 08/13/2025 at 11:25 am, she confirmed the above findings.