The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST JOSEPH MEDICAL CENTER 1401 ST. JOSEPH PARKWAY HOUSTON, TX 77002 Sept. 7, 2018
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on a review of facility documentation and staff interview, the facility failed to provide documented evidence to 1 of 9 patients (Patient #1), or their legally authorized representatives, to properly document and explain their patient rights prior to discharge.

Findings were:

Record review of current facility policy titled Patient Choice," effective date 08/21/2017, revealed the following:

"The patient representative may authorize signature by phone or fax if the patient is not able to sign and the patient 's representative cannot travel to the hospital."

Record review of Medicare Letter dated 10/9/2017 at 1400 revealed a telephone consent to move patient (ID #1) to Ashford Garden was obtained from the guardian. The documentation was incomplete. No name was written on the consent to indicate who obtained the consent from the guardian.

Record review of the case manager notes dated 10/9/2017 at 2:36 p.m. indicate the legal guardian was notified of the transfer of Patient (ID #1) to Ashford Gardens via voicemail by the Case Manager (ID #65).

Telephone interview with the Chief Nurse (ID #51) on 9/18/2018 at 1100, she stated "the nurse should have signed her name as the person obtaining the consent
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review on 9/5/2018 and 9/6/2018 the facility failed to ensure nursing care plans were kept current by ongoing assessments of the patients' needs and the patient's response to interventions in 9 of 18 patients (4,5, 6,7,9,10,11,15,18).

The hospital must ensure that the nursing staff develops and keeps current, a nursing care plan for each patient. The nursing plan may be part of an interdisciplinary care plan.

Findings include:

Patient (ID #3) a [AGE] year old male was admitted [DATE] for chest pain he transferred from intensive care unit after a cardiac catheterization, with a diagnosis of [DIAGNOSES REDACTED]

Patient (ID # 4) a [AGE]-year-old female, admitted [DATE] with L4 Compression Fracture, s/p Motor Vehicle Accident. The patient did not have a current care plan that address her diagnosis.

Patient (ID # 5) a 80-year female patient admitted for belly pain on 8/22/2018 had surgery for diverticulosis. Patient received an ileostomy, the care plan did not address the patient's intake and output related to her surgical diagnosis.

Patient (ID #6) a 86-year male patient admitted for right knee pain on 9/5/2018, did not a care plan related to his current diagnosis and upcoming surgery.

Patient (ID # 7) a [AGE] year old female was admitted on [DATE] for urinary incontinence she had a vaginopexy performed on 9/4/2018. The care plan did not address her potential urinary issue, related to her diagnosis.

Patient (ID #9) admitted [DATE] for angina and shortness of breath had coronary artery bypass on 9/4/2018. He was extubated on 9/5/2018 and was sitting up in the chair. The care plan did not address his pain or mobility issues.

Patient (ID #10) admitted [DATE], with a diagnosis of [DIAGNOSES REDACTED]' medical issue of UTI.

Patient (ID #11) admitted [DATE], with a diagnosis of [DIAGNOSES REDACTED].

Patient (ID # 15) admitted [DATE] with a diagnosis of [DIAGNOSES REDACTED]'s medical issues.

Patient (ID # 18) admitted [DATE] with a diagnosis of [DIAGNOSES REDACTED].

Record review of the current facility policy titled Assessment, Reassessment and Care Planning Policy & Guidelines (IPOC's) dated 11/15/2016:

VI. Content/Focus
a. The nursing assessment in short term and high risk locations (e.g. emergency department, procedural areas) should be focused on the presenting complaints or anticipated procedures.

b. Inpatient nursing assessments and reassessment should be comprehensive and based on the domains reflected in the current nursing documentation system.

Interview with RN (staff ID #51) on 9/7/2018 at 1230 stated the care plans (IPOC's) should reflect the patients care and updated as needed.