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Based on interview and record review, the facility failed to :

1. document and investigate a significant patient / family grievance per its established policy. [Citing Patient # 13];

2. provide clear information to patients on admission that they may file a grievance with the State agency, regardless if they have first followed the hospital's grievance process;

3. supply accurate contact information in patient admission handout regarding facility Complaint/Grievance Procedures.

Findings include:

TX 00632631

1.

Record review of the facility's policy titled "Complaint/Grievance,"revised date 09/2018, showed the following:

*"CMS definition of a grievance:... a written (formal or informal, including emails and faxes), or verbal complaint by a patient or their representative, regarding the patient's care, abuse and/neglect.."

* If a complaint is not resolved immediately it becomes a grievance; the DQS directs the investigation, which begins immediately.
* The resolution must respond to the substance of each grievance, while identifying and investigating any deeper systemic problems identified by the grievance;
*The grievant should be notified within seven (7) days that the grievance has been received and the investigation is in progress. A certified letter will be sent.
* A written outcome letter should be sent to the grievant no later than thirty (30) days after the complaint is received.

Record review of facility document titled "Patient Bill of Rights," dated 11/03/2014, showed patients have the right to be informed of the procedure for making complaints about care and know the resolution of complaints.

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Record review of complaint intake # TX00362631 showed Patient # 13 was a 16 year- old- male admitted to the facility on 06/26/2020. Patient # 13 had sustained multiple traumatic injuries following a fall through a skylight from 2 stories above. After undergoing multiple surgeries at a different hospital, Patient # 13 was transferred to Nexus for continued management of on-going pulmonary and nephrology issues, as well as pain management & rehabilitation. Documented allegations in the complaint intake included: multiple issues related to patient rights; nursing care; infection prevention & control; sanitary environment, and HIPAA concerns.

During a telephone interview on 10/27/2020 at 2:20 PM with the Complainant, she reviewed the concerns that were documented in the complaint intake. Complainant stated she had completed a written hospital "satisfaction survey" on July 9, 2020 and given it to a facility staff person (whom she named). In addition, she attached several pages of notes to the survey that provided details of her concerns.

Complainant alleged the care continued to worsen, as did Patient # 13's condition. She requested Patient # 13 be transferred back to the medical center hospital where he originally had multiple surgeries immediately after the accident. Complainant said prior to the transfer on 08/17/2020, Staff B- Quality Director, and Staff H- Case Manager, came to the room to discuss her care concerns. Complainant reported that Quality Director told her he was unaware of the written concerns she had submitted over a month prior. Complainant said she emailed a copy of the satisfaction survey and the attached notes to the Quality Director on 08/26/2020.

Quality Director responded to the Complainant on 8/28/2020 and said in an email, the notes "would help with my investigation." Complainant supplied surveyor copies of the "satisfaction survey" , dated 7/9/2020; attached notes; and email correspondence. In addition, she provided written consent to disclose herself as the complainant and source of the documentation. She reported she had received no feedback from the facility after the 8/28/2020 email from the Quality Director.

On 10/28/2020 during the facility entrance conference, surveyor requested the facility "Complaint/Grievance Log for 2020." Staff B, Quality Director said the facility did not currently maintain a complaint or grievance log. He went on to say he had not been in the Quality position long. He said he had a few folders that contained notes on a few complaints. In addition, he maintained an Excel spreadsheet to track major on-going issues. Surveyor requested all information related to complaints / grievances.

Record review on 10/29/2020 of approximately six (6) folders that contained complaint notes & letters showed a folder with Patient # 13 's name. Inside the folder was a physician progress note , dated 8/14/2020, from the patient's general surgeon in the medical center. Quality Director said the document may have come from the case manager after the patient had a follow-up visit with the physician. There was no documentation other than this progress note in the folder.

During an interview on 10/29/2020 at 1: 45 PM with Staff B, Quality Director, surveyor asked if he had knowledge of a completed facility "satisfaction survey" or detailed notes, emails from the mother of Patient # 13. Staff B said he he had that documentation on his computer and was working in it. Surveyor asked to review these documents.

Record review of the copies of the electronic documents provided by the Quality Director showed an email from the Complainant, dated 8/26/2020 , a satisfaction survey; and handwritten notes from the complainant. These were the same documents provided to the surveyor by the complainant.

Continued review showed an untitled, undated page that had a heading: "Bath"--with several dates & times listed under this heading. A second heading titled "WC" with one date listed. The Quality Director said he was working on the investigation.

He went on to say the mother wanted the son transferred back to the medical center. At first the transfer was denied ; he helped facilitate the transfer.


2.

Record review on 10/28/2020 of the facility patient admission packet showed a form titled " Complaint/Grievance Procedures." This document listed four (4) steps a patient /representative may take to file a complaint or grievance internally, including a Nexus Compliance Hotline telephone number.

Further review of this same document showed the following: " If you are not satisfied with the decisions made by the hospital, you may request an appeal.... You have the right to further appeals , if needed..."

During an interview with RN #F , she stated this information packet was given to all patients upon admission.


3.

Record review on 10/28/2020 of the facility admission packet showed a form titled " Complaint/Grievance Procedures." This document listed the following potentially misleading and / or erroneous contact information for "further appeals":

*"Assisted Living Facility ": (listed an address and telephone number). This facility is a hospital.

* "Centers for Medicare & Medicaid / Department of State Health Services" were listed together. These are two (2) separate agencies: one is federal; one is state.

The telephone number provided on this form for the state agency (Texas) to contact was incorrect.

Based on interview and record review, the facility failed to uphold the right of six (6) of nine (9) sampled patients to make informed decisions about their care ( Patient ID : # 2, # 4 # 5, # 6, #7, and # 8) .

Record review showed multiple incomplete "Physician Orders Life Sustaining Intervention". This is the form used to officially document patient / decision-maker wishes and doctor orders regarding end-of-life medical interventions.

Findings included:

Review of facility form titled "Patient Bill of Rights," revised 11/03/2014, showed under section "Decision Making": Patients have the right to make decisions regarding withholding or foregoing life-sustaining measures including CPR, nutrition, and additional therapies.

Record review of facility "Life Sustaining Intervention" form showed sections for delineating: CPR; Comfort measures; Limited Interventions; Full treatment ; Artificial Nutrition ; Discussion and signatures.

Record review of facility directions for completing form titled " Physician Orders Life Sustaining Intervention" ("POLSI" form) showed:

*must be completed by health care professional based on patient preferences and medical indications.

*Form must be signed by the physician and the patient / decision-maker to be valid.
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Record review on 10/28/20 with Staff G of nine (9) current patient medical records showed the following:

* Patient # 2: "Life Sustaining Intervention" order form was completely blank. His date of admission was 09/28/2020.

* Patient # 6: "Life Sustaining Intervention" order form was completely blank. Her date of admission was 10/14/2020.

* Patient 4; Patient # 5, and Patient # 8: no physician signatures on the "Life Sustaining Intervention" order form.

* Patient # 7: no patient or decision-maker signature on the "Life Sustaining Intervention" order form.

During an interview on 10/28/2020 at 11: 25 AM with Staff G she stated the "Life Sustaining Intervention" order form should be completed on admission and for sure within 24 hours. Staff G verified the 6 forms were blank or not signed.

Based on observation, interview, and record review, the facility failed to ensure patients received care in a safe setting.

The facility stored multiple cardboard boxes in an crowded and unsafe manner. The boxes included: 70% ethyl alcohol hand-sanitizing gel and PPE to include "cover gowns," face masks, face shields, bleach-disinfecting wipes, and coveralls.

Surveyor was unable to view the fire sprinkler heads during observation of this storage area on 10/28/20.

Findings included:

Record review of "Safety Data Sheet" for "70% Alcohol Hand Sanitizer Gel " showed an NFPA Flammability Rating of 3. Review of NFPA 704 rating system showed "Level 3 : materials that are easily capable of explosive decomposition, but require an ignition source or will react explosively with water. "

Review of facility policy titled "General Stores Physical Organization," revised date 03/02/2020, showed:

* supplies will be stored no higher that eighteen (18) inches below the fire sprinkler heads and no lower than six ( 6) inches from the floor;
* no supplies will be stored directly in the floor,

As part of the CMS COVID-19 focused survey, surveyor asked to observe the bulk storage of PPE supplies. Observation on 10/28/20 at 10:25 A.M. in Materials Management showed a small main area. The Materials manager said the bulk PPE was kept in a room adjacent to the main area.

Materials Manager unlocked a room that had a padlock closure; she used a key. Facility Staff C, CCO, accompanied the surveyor & materials manager

Observation on 10/28/20 10:30 A.M. showed a typical "patient sized" room. Observation inside the room showed the following:

*Immediately inside the door to the left was a covered supply cart; several boxes of PPE gowns were stacked on top of the cart within about 4 inches of the ceiling. A ceiling tile was missing, exposing the boxes to the open space above the ceiling; several pipes were visible.

*At least 150 plus cardboard boxes stacked all along the walls ; and stacks of boxes covered almost the entire floor space;

*There was a very narrow path ( approx. 24 inches) that led into the room; high stacks of boxes on both sides of the path;

*All of the boxes were stored directly on the floor; multiple stacks of the boxes reached to the ceiling; the room was extremely crowded.

* The boxes contained "cover gowns," face masks, face shields, bleach-disinfecting wipes, coveralls, and large containers of 70% ethyl alcohol hand-sanitizing gel.

*An open box that contained a gallon of 70% ethyl alcohol hand sanitizing gel;

*Two (2) additional gallons of this gel were located directly on the floor next to the door.

Material manager said this PPE had been stored this way for at least 3 to 4 weeks; there had been some new flooring put in. When the floor had been completed; the supplies were brought in.

During an interview at the time of observation with Staff , CCO, he said he was unaware of this storage situation . He acknowledged it was a potential fire hazard and infection control issue. He stated it would be corrected immediately.


Observation on 10/29/2020 at 10 A.M. showed this room had been cleared of all supplies.

Based on record review and interview, the facility failed to ensure that one (1) of 3 sampled patients who had been placed in restraints had physician orders for restraint per facility policy. (citing Patient # 1 )

Findings included:

Record review of facility policy titled "Restraints,"dated 4/2018, showed:

* Use of restraint must be with an order of a physician or physician designee, who is authorized to order restraint;

* An order for restraint or seclusion must be obtained prior to the application of restraints, except in an emergency situation;

* The physician or physician-designee shall make a face-to-face assessment at least every 24 hours at which time the restraints shall be reordered or discontinued as indicated.

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Record review on 10/29/2020 with Staff E, Director of Nurses, of three (3) medical records of current patients who had been restrained showed:

Patient # 1 was admitted on 10/09/2020. Review of Patient # 1's restraint orders showed the following:

*Four (4) days that showed he was restrained with bilateral wrist restraints and mittens without a physician order : October 13, 26, 27, 28, 2020.

*Six (6) days that showed physician orders that were not timed- for bilateral wrist restraint and mittens: October 10, 12, 16, 21, 24, 25, 2020.

During an interview on 10/29/2020 at 2:45 PM with facility DON , she stated an order for restraint must be obtained prior to application, unless it was an emergency. In addition, the DON said it was required that the restraint orders be signed, dated, and timed by the physician.

Based on record review and interview, the facility failed to implement a process for timely follow-up by Nursing for laboratory results for 5 of 5 sampled patients (Patient #5, 6, 7, 9, 10) . The facility failed to :

a. Develop a written policy that addressed laboratory processes, to include follow-up receipt of lab results;

b. Monitor compliance with documentation in "Laboratory Log" binder.

Findings included:

Observation on 10/28/2020 on 2-South showed a binder titled "Laboratory Log." The binder held a "Lab Log" form for each patient, with copies of actual lab order forms.

Record review of the "Lab Log" showed the form had 6 columns with headers labeled as follows: "Date; Test Ordered; Collected By; Date & Time; Initials; Final Results." Further review of the "Lab Log" binder showed incomplete documentation for five (5) sampled patients (Patient #5, 6, 7, 9, 10):

Patient # 5:

"Lab Log" was totally blank for this patient;
10/23/20: review of lab slip orders showed a CBC was drawn; no documentation results received.

Patient # 6:

10/16/20: C diff collected; no documentation result received;
10/18/20: CBC, BMP; Mg; P04-listed; no documentation these were collected or results received

Patient # 7:

10/17/20: CMP; BMP; P04:-documented as collected-no documentation results received.
10/18/20: CBC; BMP; Mag; Phos; PT/INR listed; no documentation these were collected or results received.
10/19/20: BMP;CBC listed; no documentation these were collected or results received.
10/20/20: CBC; CMP; PT- listed; no documentation these were collected or results received.
10/20/20:PT @ 9 PM- listed; no documentation these were collected or results received.
10/22/20:PT/ INR- listed; no documentation these were collected or results received.
10/25/20:BMP;CBC;PT/INR listed; no documentation these were collected or results received.
10/27/20:HiT panel-documented as collected-no documentation results received.
10/28/20:HiT Antibody-STAT-documented as collected-no documentation results received.

Patient # 9:

10/20/20: CBC; CMP; Mag; Phos; PT/INR; Prealbumin listed; no documentation these were collected or results received.
10/21/20: CMP; CBC; Mg; Phos listed; no documentation these were collected or results received.

Patient # 10:

10/16/20: CBC; Pt/INR; CMP listed: no documentation these were collected or results received.
10-19-20: BMP; CBC listed: no documentation these were collected or results received.
10-22-20: BMP;CBC w. diff listed: no documentation these were collected or results received.
10-23-20: CBC, BMP listed: no documentation these were collected or results received.

Interviews conducted on 10/28/2020 between at 9:45 A.M. and 11: 00 A.M. with 2 South nursing staff showed :

* Staff I, RN, described the process following a physician order for laboratory work. Staff I was unsure if it was nursing or unit secretary's responsibility to document the final results were received on the "Laboratory Log." Staff I said it might be a shared responsibility. She was not aware of a facility lab follow-up policy

*Staff J, RN, described the process following a physician order for laboratory work. Staff J said it was nursing staff responsibility to complete the "Laboratory Log", including receipt of the final results. Staff J said she did not think there was a policy that detailed the lab work process.

During an interview on 10/29/2020 at 3:15 PM with Staff E, DON, she reviewed the "Laboratory Log" binder with surveyor. She stated it was a nursing responsibility to document the lab results were received. The DON said that although the hospital was soon changing to an electronic laboratory process; the paper documentation process would remain as an option, in the case of computer downtime. The DON went on to say the hospital did not have a policy that addressed laboratory processes.

Based on observation, interview, and record review, the facility failed to implement an effective program to prevent and control the transmission of infections within the hospital. The facility failed to:

1. develop & implement a policy consistent with CDC guidelines regarding placement / discontinuation of transmission-based precautions for patients positive for COVID-19;

2. store PPE and hand sanitizing supplies in a manner that prevented contamination;

3. ensure that staff utilized hand hygiene appropriately;

4. make certain staff wore masks per CDC guidelines;

5. ensure a housekeeping cart was not stored immediately adjacent to "clean" linen, causing direct contamination of the linen.

6. properly store patient care equipment per facility process.

7. complete an Infection Control Risk Assessment (ICRA) prior to renovation/ construction work on an in-house lab -2nd floor.

Findings included:

1. Transmission-based Precautions : COVID-19

Review of facility policy titled "Isolation Plan," revised date 04/18, showed:

*Droplet precautions: used for patients with suspected or known pathogens transmitted by respiratory droplets;
*when transport is necessary, patient will wear a surgical mask;
*the appropriate isolation sign will be placed on the patient's door.

Record review on 10/28/2020 of the current patient census showed Patient# 11 was on "CD" precautions in room 220 . During an interview with Staff F, Corporate Director of Patient Safety, she said "CD" was "contact / droplet" precautions and Patient # 11 was likely a post-COVID-19 patient.

On 10/28/20 at 10:45 A.M. during a tour of 2-South Unit, observation of Room 220 failed to show any signage to indicate Patient # 11 was currently on "Contact / Droplet" precautions. In addition, Patient # 11 was not in the room. Continued observation showed Patient # 11 coming down the hallway seated in a wheelchair, being pushed by PT staff. Patient # 11 was not wearing a mask.

During an interview on 10/28/20 at 10:55 A.M. with Staff J, RN, she looked at the census report and verified it said Patient # 11 was on Contact/Droplet precautions. Staff J said a physician order must be obtained to discontinue the precautions. Staff J and Staff G, unit secretary reviewed the electronic record, they were unable to locate an order to discontinue "contact/droplet" precautions.

During an interview on 10/28/20 at 11: 15 A.M, with Staff K, charge RN, she said that recently the Infectious disease physician had discussed discontinuing transmission-based precautions post-COVID patients after two (2) negative COVID tests. Staff K began reviewing Patient # 11's electronic record to locate two(2) negative COVID tests. Staff K was unable to locate negative COVID tests or a physician order to discontinue transmission based precautions.

Review of patient # 11's admission orders, dated 10/16/20 showed he was admitted on 10-16-20 with a diagnosis of "COVID-19 pneumonia." Patient # 11 was placed on droplet precautions upon admission. There was no physician order to discontinue these droplet precautions.

2. Storage of PPE & hand sanitizing supplies-:

Review of facility policy titled "General Stores Physical Organization," revised date 03/02/2020, showed:

* supplies will be stored no higher that eighteen (18) inches below the fire sprinkler heads and no lower than six ( 6) inches from the floor;
* no supplies will be stored directly in the floor.
~~~~

As part of the CMS COVID-19 focused survey, surveyor asked to observe the bulk storage of PPE supplies. Observation on 10/28/20 at 10:25 A.M. in Materials Management showed a central main storage area with metal shelving. The Materials manager said the bulk PPE was kept in a room adjacent to the main area.

Materials Manager unlocked a room that opened to the main hallway, It had a padlock closure; she used a key. Facility Staff C, CCO, accompanied the surveyor & materials manager.

Observation on 10/28/20 10:30 A.M. showed a typical "patient sized" room. Observation inside the room showed the following:

*A covered supply cart immediately inside the door to the left; located next to the wall. Several boxes of PPE gowns were stacked on top of the cart within about four inches of the ceiling. A ceiling tile was missing, exposing the boxes to the open space above the ceiling; several pipes were visible.

*At least 150 plus cardboard boxes stacked all along the walls ; and stacks of boxes covered almost the entire floor space;

*There was a very narrow path ( approx. 24 inches) that led into the room; with high stacks of boxes located on both sides of the path;

*All of the boxes were stored directly on the floor; multiple stacks of the boxes reached to the ceiling; the room was very crowded.

*The boxes contained "cover gowns;" face masks; face shields; bleach-disinfecting wipes; coveralls, and large containers of 70% ethyl alcohol hand-sanitizing gel.

*An open box that contained a gallon of 70% ethyl alcohol hand sanitizing gel;

*Two (2) additional gallons of this gel were located directly on the floor next to the door.

Surveyor was unable to visualize any sprinkler heads in the room at the time of observation.

Material manager said this PPE had been stored this way for at least 3 to 4 weeks; there had been some new flooring put in. When the floor had been completed; the supplies were brought in.

During an interview at the time of observation with Staff , CCO, he said he was unaware of this storage situation . He acknowledged it was a potential fire hazard and infection control issue. He stated it would be corrected immediately.

Observation on 10/29/2020 at 10 A.M. showed this room had been cleared of all supplies.

3. Hand hygiene:

Review of facility policy titled "Hand Hygiene," dated 09/2020, showed that facility staff should perform hand hygiene:

*before having direct contact with patients;

*before donning and after removing gloves.

Observation on 10/28/20 at 11: 25 A.M showed Staff K, RN charge nurse , reviewing an electronic medical record at a computer station. Observation on either side of this computer desk alcove showed two (2) patient rooms: 205 and 206.

Continued observation at this same time showed Staff AM, RN, entered room 205 (Patient #12). Signaled outside the room showed this patient was on "Contact" transmission-based precautions. Staff AM failed to sanitize her hands prior entering the room and donning a pair of exam gloves. Staff AM suctioned Patient # 12; she washed her hands after removing her contaminated gloves.

During the same time period, observation showed Staff MN, PT staff , entered room # 206 (Patient # 1). Signaled outside the room showed this patient was on ""Contact/ Droplet" transmission-based precautions. Staff MN failed to sanitize her hands prior to entering the room and donning a pair of exam gloves.

4. Mask wearing:

Record review of CC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronaries Disease 2019 (OVID-19) Pandemic," June 19, 2020, recommended "Implement Universal Source Control Measures: DHCP should wear a facemask at all times while they are in the healthcare facility, including in bedrooms or other spaces where they might encounter co-workers."

CC guidelines for wearing face masks correctly include :
·wearing the mask over nose and mouth and secure mask under chin;
·Fit mask snugly against the sides of face.

Observation on 10/28/2020 at 9:15 A.M. showed staff person at front desk wearing a face mask pulled under her nose.

Observation on 10/28/2020 at 10:15 A.M. showed OVID screener at front entrance with her face mask pulled under chin.

Observation on 10/28/2020 at 10:40 A.M. on the 2nd floor hallway showed construction staff wearing a mask pulled under his chin.

Observation on 10/28/2020 at 11:45 A.M. showed Staff HO, case manager, wearing her mask below her nose.

All persons improperly wearing masks corrected them when surveyor asked them to do so.

5. Storage of Housekeeping cart:

Observation on 10/28/20 at 10:50 A.M. on 2-South Unit showed an unattended housekeeping cart in the hallway. An "over the bed" table was located immediately next to the cart. There was a stack of "clean" linen covered with a sheet on top of the table . A mop was left leaning directly onto the table, touching the linen.

Continued observation showed an additional housekeeping cart located down the hall nearby. This cart was attended by Staff O, housekeeper. She was asked what staff member was assigned to the unattended cart. Staff O stated the staff member assigned to the cart had to go downstairs for something. Staff O said that when housekeeping carts are not in use, they are supposed to be stored in the housekeeping storage closet.

During an interview at the time of observation with Staff F, Patient Safety Director, she stated the housekeeping cart should have been placed in the closet when not in use. Staff F directed staff to remove the contaminated linen from the table.

6. Proper storage of patient care equipment :

Observation on 10/28/20 at 11:27 A.M. showed an equipment storage room in the ICU area showed several multi-patient use equipment. Some were covered in plastic; some were not.

Uncovered equipment included: Philips ventilator, Dynascope machine, enteral feeding pumps, IV infusion pumps. There were at least 6 to 8 pieces of patient care equipment that were covered with clear plastic.

Interview at the time of observation with Staff K, charge nurse, she stated clean equipment should be covered with plastic.


7. ICRA:

Review of facility policy titled" Construction," revised date 11/18, showed:

*Purpose: to provide safe environment for patients, employees, and visitors during construction and renovation.
*Facility will contact infection control before renovation project begins.
* A Pre-Construction Risk Assessment will be completed - a copy will be given to Facilities and Infection Control.
* Facility policy included a framework with criteria for "Type of Construction ": Type A, B, C, D ; as well as "Patient Risk Group": Low, Medium, High, Highest.
*Infection Control Matrix: showed method to identify the Class of Precautions :Construction Project by Patient Risk .
~~~
Observation on 10/28/20 at approximately 10:30 A.M. showed construction being done in a hallway on the 2nd floor; close to the elevator exit Interview with Facility Plant Operations manager he said it was a minor renovation project. They were remodeling a room to covert it to an in-house lab. Project included : adding counter tops and painting. Further observation showed He also said they had been replacing wall coverings and molding in the hallways. This in-house lab was located in fairly close proximity to medical-surgical patient rooms. These patients were considered as a "High Risk Group" according to the facility's ICRA policy.

Surveyor asked about the completion of an ICRA; there was none posted.

Record review on 10/28/20 of facility Infection Control Meeting minutes failed to show a completed ICRA for this renovation project. Staff F, Patient Safety Director, confirmed an ICRA had not been completed.