HospitalInspections.org

TX 00411544

Based on interview and record review, the facility failed to enforce policy and procedures to ensure patient rights in 1 of 13 (Patient ID #1) patient records reviewed. The facility failed to follow their own policy for patient rights that states patients will receive considerate and respectful care:

a) In an environment that is safe and free of falls.
b) That is respectful and meets hygiene/bathing needs.

This deficient practice had the likelihood to cause harm in all of the 31 patients admitted to the facility for care and treatment.

Findings include:

a) Record review 6/8/2020 12:45 p.m. of facility fall log dated December 1, 2020 through December 31, 2020 with Staff ID #2, Director of Quality, revealed that Patient #1 sustained two falls while in the facility. Fall #1 occurred on 12/16/20. The log stated "patient fell while trying to get out of wheelchair and walk to bathroom." The patient sustained no apparent injuries and plans were put in place to move patient to a new room, closer to the nurses' station. Fall #2 occurred on 12/28/20 and stated that patient "patient was found sitting on floor in room." He complained of R (right) knee pain. Medical record revealed patient had a R right knee xray on 12/28/20. There was no acute fracture noted.

Record review 6/8/22 1:20 p.m. of PAM Health Patient Rights and
Responsibilities with Staff ID #3, CNO. She confirmed the admission packet is provided in a navy blue folder to all new patients and/or their primary caregiver. She confirmed that patients rights and responsibilities are a part of the packet. She agreed that item #1 stated "you have the to considerate and respectful care." In addition, right #5 stated "you or your legal representative have the right to: receive information about your health status, course of treatment prospects for recovery and outcomes of care (including unanticipated outcomes). You have the right to effective communication and to participate in the development and implementation of your plan of care ...." In addition, patient right #15 stated patient has the right to "receive care in a safe setting, free of mental, physical, sexual or verbal abuse or neglect, exploitation or harassment."

Review of facility policy 6/8/22 4:15 p.m. titled "Nursing: Fall Prevention," revised March 28, 2022, with Staff ID #2, Director of Quality, validated the facility uses a Morse Fall Scale for fall risk prevention. The patient who has previously fallen is given a "high risk" score. It stated that "The healthcare team should tailor the interventions to be patient-specific." Strategies such as "... Remain with patient while toileting. Assist and monitor patient in bathroom. Family member with patient. Increased observation level" are all components of the policy.

Interview 6/8/22 1:55 p.m. Staff ID #3, CNO, confirmed that Patient ID #1 sustained 2 falls while in the facility. She confirmed he was relocated to a room near the nurses' station from Room 2001 to Room 2008.

b) Based on interview and record review, the facility failed to uphold the rights of Patient ID # 1 by not providing considerate and respectful care in a safe environment. The facility failed to perform a bath or shower every other day per facility policy. This deficient practice had the likelihood to cause harm in all patients admitted to the facility for care and treatment.

Record review of complainant intake provided 2/22/2022 noted that on December 15, 2021 Patient ID #1: "he was dirty and had not been cleaned up." On December 21, patient ID #1 "finger nails were long and had poop under them."

Record review 6/8/2020 1:55 p.m. with Staff ID #3, CNO, revealed patient #1 was admitted 12/11/2020 and discharged 12/31/2020. Patient ID 1 had a "shower/shampoo" documented on 12/14/21, 12/15/21, 12/17/21, 12/29/21. There were other forms of hygiene documented during lapses that included "personal care that includes warm washcloth, oral care, combing hair or shaving."

Record review 6/8/22 1:15 p.m. of PAM Health, Nursing Policy Nsg 24, "Guidelines for Nursing Care" (Reviewed March 29, 2017, Revised Last March 28, 2022) with Staff ID # 3, CNO. Policy stated "Hygeine: If no contraindication, bath/shower every other day and as per patient request."

Interview 6/8/22 2:15 p.m., Staff ID # 3, CNO, confirmed that bathing is supposed to be "performed weekly by occupational therapy" as part of activities of daily living functional therapy evaluation and by nursing and/or nursing assistants at other times, at a minimum of "every other day." She confirmed that the medical record did not reflect this occurring for Patient ID #1.

Based on record review and interview, the facility did not have qualified personnel to develop discharge planning evaluations in that 1 of 3 Case Managers Staff #13 assigned to develop discharge planning evaluations was licensed as an Occupational Therapist. The facility's position description for case managers required at a minimum a nursing or social work degree required. The facility currently has a census of 31 patients that could be affected by unqualified discharge planner.

Policy Reviewed:

Review 06/08/2022 at 5:15 p.m. along with Staff #12, Director of Human Resources of the facility's current job description titled "Case Manager Position Description", Case Manager Job Code 6010, Job Description, Rev. 3/22 reads: The Case Manager is responsible for the interdisciplinary coordination of care for a designated patient population. The Case Manager performs reviews of all inpatient admission records to ensure proper utilization of hospital resources and determination of admission for appropriate level of care. Assesses and identifies discharge needs and coordinates appropriate discharge plan. Works collaboratively with the interdisciplinary team to facilitate achievement of desired financial and quality outcomes. The Case Manager will also maintain and enhance payor relationships. Performs other related duties as assigned or requested."

Education and Training: RN licensure in state where the hospital resides is preferred. Nursing or social work degree required. Current BLS certification required.
Records Reviewed:

Recordssd Reviewed:

Review on 06/08/2022 at 5:00 p.m. along with Human Resource Director Staff #12 of Staff #13 job description signed 06/03/16 for Case Manager/60100, Job Description 5/10. Position Qualifications: Education and training: Professional licensure (RN, MSW, Therapist) or related experience to assess clinical and psychological needs and interface with provisional staff, both external and internal.

Interview on 06/08/2022 with CNO #3 stated that each of the three Case Managers was assigned to one of the three Physical Medicine and Rehabilitation doctors. Case Manager, Staff ID #13 is assigned to physician IDs #15 and #23 who are partners.

Review of current patient census list six patients for the attending physicians Staff #15 and #23 that Staff #13 is assigned to.

Review of current hospital census on 06/08/2022 Case Manager, Staff #13 was responsible for discharge planning evaluations of the following


Patient ID Admit Date Physician

#1 06/05/2022 Clarke
#3 05/16/2022 Clarke
#10 06/03/2022 Lee
#11 06/02/2022 Clarke
#13 05/23/2022 Clarke
#11 06/01/2022 Clarke

Interview 06/08/2022 at 6:15 p.m. with CEO, Staff #1 and Director of Human Resources, Staff #12 confirmed the signed job description dated 06/03/2016 does not match the current job description revised 03/2022 for the educational requirements for a Case Manager.

Staff #1 confirmed that Staff #13 is an Occupational Therapist and is not licensed as a nurse or social worker as required in the current Case Manager description and thought she may have been grandfathered in. No additional documentation was received concerning if Staff #13 was grandfathered in prior to exiting of the survey.