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Based upon record review and interview, the facility failed to ensure 11 of 21 (#1-#11) patients and/or the patient's representative were informed of patient rights or explained to them in a language the patient could understand.

Review of Policy #RI.1400 CDHS titled "Patient Rights and Responsibilities" revealed the following: "Based on the philosophy of Catholic health care, each individual is a child of God, created in His image and likeness, who possesses a dignity which is worthy of reverence, protection, and preservation from the moment of conception until death, each patient at the hospital is provided with a copy of his/her rights and responsibilities." The policy did not contain a process or procedure for how each patient was to receive a copy of patient rights and responsibilities or how the facility was to inform or explain to the patient the patient's rights and responsibilities.

Review of 11 of 21 (#1- #11) patient records revealed no documentation that patient had been given a copy of their patient rights or that patient rights had been explained to the patient.

An interview with the Nurse Manager at the Port Arthur satellite facility was conducted on 2/29/11 at 3:00 pm. The Nurse Manager reported the facility had used a duplicate copy of the patient's rights that the patient signed at the bottom of the page and the patient was given a copy and a copy was kept in the medical record. The Nurse Manager further reported that now when a patient is admitted, the patient's demographic information was put in the computer and the computer printed the initial paperwork which included the patient rights and responsibility but it does not contain a signature line. The Nurse Manager confirmed that the medical records did not have documentation of the patient receiving a copy or an explanation of the patient rights.

Based upon observation, record review and interview, the facility failed to inform patients of the grievance process and failed to follow facility policy to prominently and publicly display the Patient Grievance information.

Observational tour on 2/27/2012 at 1:30 pm. of the Beaumont facility revealed no postings on the Patient Grievance Process. Observational tour of the Port Arthur facility on 2/28/2012 at 10:00 am revealed no postings on the Patient Grievance Proces

Review of the facility policy # RI.1340 CDHS titled "Grievance" revealed the following section titled "Patient Notification":

1. Upon admission to the hospital, patients or their representatives are informed of the right to file a grievance agaist the hospital.

2. Upon admission to the hospital, patients or their representatives are informed of the name and telephone number of the hospital staff member to be contacted by patients or their representatives in order to file a grievance.

3. Upon admission to the hospital, patients or their representatives are provided with a copy of the "Patient Grievance" form.

4. The "Patient Grievance" form is prominently displayed as a public posting.

Review of the Patient Rights and Responsibilities revealed the following "Right": "CONFLICT MANAGEMENT - THE RIGHT TO VOICE CONCERNS REGARDING ISSUES RELATING TO CARE AND TO KNOW THAT VERBALIZING THE CONCERN WILL NOT AFFECT THE PATIENT'S CARE IN A NEGATIVE MANNER AND THAT CONFLICTS WILL BE RESOLVED FAIRLY AND OBJECTIVELY."

This statement does not inform or explain the grievance process if received by the patient.

Review of the Patient Handbook reportedly given to the patient on admission contained the following information regarding Grievances and Complaints:

"You have the right to file a formal grievance against the hospital if you feel that you are being treated unfairly or inappropriately. You have the right to prompt resolution of a grievance against the hospital. The hospital does not allow any type of retribution or retaliation against patients who file grievances against the hospital.

To file a formal grievance against the hospital, patients should call or see the person listed as the 'Grievance Contact' on the insert in this booklet.

Regardless of whether or not you have used the hospital's grievance process, you have the right to lodge a grievance with the state hospital licensing agency by calling the phone number listed on the insert in this booklet."

Further review of the Patient Handbook revealed NO insert with a Grievance Contact and NO insert for the phone number of the state hospital licensing agency.

Review of 21 of 21 medical records revealed no documentation of explanation of the grievance process. The patient rights and the patient handbook did not provide the steps to be taken in the grievance process.

An interview was conducted with the Nurse Manager of the Port Arthur facility on 2/29/2012 at 3:00 pm. The Nurse Manager confirmed the patient rights did not explain the grievance process, the patient handbook did not contain the inserts regarding reporting a grievance, and the facility did not have a public posting of the grievance process.

Based on record review and interview, the facility failed to follow its policy regarding the processing of patient grievances. 6 of 6 patient grievances were not reviewed by the grievance committee, per facility policy. Also, these two grievances were not reported to the Medical Executive Committee.

Findings include:

Review of policy RI.1340 CDHS, " GRIEVANCE, " revealed the following:
" Grievance Process
1. A patient or a patient ' s representative files a grievance by contacting the appointed hospital staff member and presenting the grievance in either written or oral form.
2. When a grievance is presented orally, the appointed hospital staff member will request that the complainant express the grievance in writing by completing the " Patient Grievance " form. If the complainant is unwilling or unable to complete the written form, the appointed hospital staff member will complete the complainant section of the " Patient Grievance " form based on the information provided.
3. Within three (3) days of the appointed hospital staff member ' s receipt of the grievance, the Patient Grievance Committee reviews the written grievance.
4. Within three (3) days of the initial Grievance Committee meeting, the committee completes an investigation of the grievance, which may include document review, personal interview, policy and procedure review and/or physical inspection.
5. Upon completion of its investigation, the Patient Grievance Committee draws a conclusion as to the validity of the grievance and, if indicated, recommends and implements a course of action to resolve the grievance.
6. Within two (2) days of the completion of its investigation, the Patient Grievance
Committee provides the complainant with a written notice of the steps taken to investigate the grievance, the results of the grievance process and the date (or expected date) of resolution.
7. Grievances alleging inadequate quality of care by hospital staff, medical staff or contract services are reported to the Medical Executive Committee, Grievances alleging premature discharge are reported to the Utilization Management Committee and/or the Medical Executive Committee. "

Review of the grievance/complaint log of the Beaumont facility from September 2011-February 2012 revealed 10 complaints/grievances. 2 of the 10 were considered grievances. Neither grievance was referred to the Patient Grievance Committee. Review of the documents titled "Customer Concerns" at the Port Arthur facility from June 2011-February 2012 revealed 10 "Customer Concerns". 4 of the 10 were considered grievances. Neither grievance was referred to the Patient Grievance Committee.

Review of the Medical Executive Committee (MEC) Minutes for 2011 revealed no grievances were discussed.

During an interview on 2/29/12 at 9:30am in the administration offices, staff #1 and staff #3 confirmed that neither grievance was referred to the Patient Grievance Committee or the MEC.

Based on record review and interview, the facility failed to provide a written reply to 6 of 6 grievances.


Findings include:

Review of policy RI.1340 CDHS, " GRIEVANCE, " revealed the following:
" Grievance Process
6. Within two (2) days of the completion of its investigation, the Patient Grievance
Committee provides the complainant with a written notice of the steps taken to investigate the grievance, the results of the grievance process and the date (or expected date) of resolution. "

Review of the grievance/complaint log for the Beaumont facility from September 2011-February 2012 revealed 10 complaints/grievances. 2 of the 10 were considered grievances. 1 of the 2 grievances was addressed via phone call only. No letter was written. Review of the grievance/complaint log for the Port Arthur facility from June 2011-February revealed 10 complaints grievances. 4 of the 10 were considered grievances. No written notice of the results of the investigation were done.;

During an interview on 2/29/12 at 9:30am in the administration offices, staff #1 and staff #3 confirmed that one grievance was addressed via phone call only and no letters written.

Based upon record review and interview, the facility failed to honor the advance directives for 1 of 21(#9) patients reviewed.

Review of patient #9's medical record revealed patient was an 85 year old male admitted to the facility on 2/16/2012. Patient was diagnosed with Acute Respiratory Failure, Bilateral pnuemonia, New onset Atrial Fibrillation. Physician's admit orders indicated patient's Code Status as FULL CODE. There was also a seperate physician's orders for Code Instructions that indicated FULL CARDIOPULMONARY RESUSCITATION. Review of a document in the medical record that was titled "DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES" revealed the following directive: "If in the judgement of my physician, I am suffering with an irreversible condition so that I cannot care for myself or make decisions for myself and am expected to die without life-sustaining treatmkent provided in accordance with prevailing standards of care: I request that all treatments other than those needed to keep my comfortable be discontinued or withheld and my physician allow me to die as gently as possible." This document was signed by patient #9 on 2/19/2011, witnessed by two individuals and notarized on the same date.

Review of the facility's policy #RI.1240CDHS titled "Advance Directives" revealed the following:
"Documenting Advance Directives Status: 3. If the patient or responsible representative acknowledges that the patient has an advance directive, a copy of such directive will be requested and made part of the permanent record. GUIDELINES: 1. A competent patient who is an adult may issue a directive. 2. A declarant msut issue the written directive in the presence of two witnesses who qualify under "INFORMATION CONCERNING THE DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES". 3. The physician shall make the fact of the existence of the directive part of the declarant's medical record.

Further review of patient #9's medical record revealed no documentation in physician's notes or nurse's notes of any discussion about patient's FULL CODE orders and the Advanced Directive on the chart to only provide comfort measures.

Nurse's notes revealed on 2/27/2012 at 3:11 am: "Patient moaning, became unresponsive. Sinus rhythm per monitor. Code blue called. See Code Sheet. Review of form titled "CardioPulmonary Resuscitation Worksheet" revealed the following: Type of Emergency-Respiratory Arrest, Initial EKG-Bradycardia, Method of Ventilation-Bag/Mask, Intubation performed at 3:35 am. Worksheet revealed attempts to resuscitate were to no avail and patient was pronounced at 3:51 am.

An interview was conducted on 2/29/2012 with the Nurse Manager at 3:00 pm. in the family conference room. The Nurse Manager reported he was not aware of this situation but that sometimes honoring advance directives become a "gray area" when patient's family wants facility to take measures other than what is on the advanced directives.

Based on observation and interviews, the facility failed to provide preventive maintenance for two Data Scope Monitors (portable machines used to monitor a patient ' s blood pressure, oxygen saturations and heart rate and rhythm).

While touring the facility with Staff #13 on 02/28/2012 at approximately 10:00AM, the inspection of room #457 (Respiratory Storage Room) revealed two Data Scope Monitors that had not been inspected by the Bio Medical Department nor had the two monitors been entered into the facility ' s inventory. These two Data Scope Monitors were available for patient use.

Interview with Staff #13 on 02/28/2012 at approximately 10:00AM in room #457 (Respiratory Storage Room) confirmed the two Data Scope Monitors had not been inspected by the Bio Medical Department nor had the two monitors been entered into the facility ' s inventory.

Based on record review and interview, the facility failed to provide specialized training for its Infection Control Professional (ICP).


Findings include:

The Centers for Disease Control and prevention defines Infection Control Professional as follows: " Infection prevention and control professional (ICP). A person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control. " (Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006)

Review of staff #7 ' s (ICP) personnel and education file revealed no specialized training in infection control from any recognized professional society, such as Association for Professionals in Infection Control and Epidemiology (APIC) or Society for Healthcare Epidemiology of America (SHEA).

During an interview on 2/29/12 at 2:15pm in the patient gym, staff #7 confirmed that she had no specialized training in infection control from any recognized professional society, such as Association for Professionals in Infection Control and Epidemiology (APIC) or Society for Healthcare Epidemiology of America (SHEA).

Based on record review and interview, the facility failed to measure the quality of three hospital services. Linen and laundry, housekeeping, and radiology were not reporting quality measures to the Quality Committee.

Findings include:

A review of the meetings of the Quality Committee from January through December 2011 revealed no data/reporting from linen and laundry, housekeeping, and radiology.

During an interview on 2/29/12 at 2:15pm in the patient gym, staff #7 confirmed that linen and laundry, housekeeping, and radiology were not reporting quality data to the Quality Committee.