**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview the facility failed to ensure patients in the emergency room received a complete nursing assessment and reassessment per facility policy in 2 of 11 patients seen in the emergency room [DATE]. (Patient ID#s 15 an 21 ) Findings include: Record review of facility policy titled ER Triage/Assessment/Reassessment, dated 2/2022 showed the following: POLICY All patients presenting to the emergency room will be assessed using a triage methodology to determine the severity of the presenting chief complaint. The triage acuity level is assigned to each patient using a 5- Level Triage Acuity Scale (ESI) during the initial assessment. The triage acuity level determines time the patient can safely wait to be seen by a primary nurse and physician when no beds or caregivers are immediately available, anticipated treatment and resources are required. Patients awaiting an initial medical screening exam (MSE), regardless of where the patient is waiting , should be reassessed hourly. DEFINITIONS 1. Rapid Initial Assessment- Triage is a dynamic process of sorting, prioritizing, and assessing the patient and is performed by a qualified RN at the time of presentation and before registration. The triage Rapid Initial Assessment should be initiated within ten minutes of arrival to the emergency department. This assessment consists of information, which is obtained, the would enable the triage RN to determine a minimal acuity. This assessment is composed of a chief complaint, subjective, objective neurovascular, cardiovascular, respiratory status, first point of contact, mode of arrival, pain assessment, allergies, vital signs (if needed). PROCEDURE All patients presenting to the emergency department shall receive a Initial Rapid Assessment (Triage) by a Registered Nurse based on the severity of presenting symptoms. Assessments in the ED should be completed and documented as follows: 1. Rapid Initial Assessment (Triage) may include, but is not limited to: ... 2. Triage Reassessment Prior to the Medical Screening Exam (MSE), the patient should be reassessed on an hourly basis at a minimum. 3. Detailed Assessment... 4. Reassessment Guidelines Reassessment guidelines are provided as follows. The rapid initial assessment should be performed within 10 minutes of arrival. Reassessments should be performed at a minimum of hourly until the medical screening exam is initiated. Following the MSE, reassessments should be completed based on the acuity and/or status of the patient, regardless of the patient's location. A. Level 2/ Emergent Conditions that are a potential life threat... 2. Reassessments- Hourly C. Level 3 / Urgent Conditions that could potentially progress to a serious problem requiring emergent interventions 2. Reassessments- Every 2 hours or as patient condition requires. Medical record review on 2/16/2022 at 1217 PM for patient (ID 15 ) showed the patient arrived in the emergency department (ED) on 2/16/2022 at 0207. The patient received a Rapid Initial Assessment at 0209. No other nursing assessments were documented. The patient was discharged from the facility 02 2/16/2022 at 0246. ED manager (ID 53) at this time confirmed the above findings and stated that all patients should receive a full nursing assessment and it should be documented. Medical record review for patient (ID 21 ) on 2/16/2022 at 12:51 showed that patients arrived at 0822. The patient was assigned acuity level of 3 (urgent) and rapid initial assessment was completed at 0821. There was no other nursing assessments documented for the patient at this time. ED manager (ID 53 ) confirmed the above findings and stated that the arrival time may be documented after the initial rapid assessment due to the registration process. She went on to say that the patient should have had a complete assessment and reassessment performed and documented.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview the facility failed to offer other alternatives to reduce the need for restraints for two patients (ID#2,4) of four patients. Finding Included: The facility policy dated 2/2016 Patient Restraint/Seclusion stated: Restraint or seclusion use will be limited to clinically justified situations, and the least restrictive restrain will used with the goal of reducing and ultimatley eliminating, the use of restraints. Record review of the nurses noted documented on 08/25/2019 revealed Patient, (ID#2) was admitted for altered mental status and had a nasogastric tube inserted. It is also documented that the patient was stretching, moving and thrashing the arms around, and was high risk of pulling the tube. Patient (ID#2) was observed to be restrained on 08/27/2019 at 10:35 a.m. Record review of the census dated 08/27/2019 revealed Patient, (ID #4) was admitted on [DATE] for altered mental status. Interview with the staff (ID #57) on 08/27/2019 at 10:30 a.m. revealed Patient (ID#4) had [DIAGNOSES REDACTED] with metastasis to the brain and had been combative. Observation on 08/27/2019 at 10:30 a.m. noted Patient (ID#4) trying to get out of bed, while her wrist were restrained bilaterally and her feet and body were hanging out of the bed. Interview 08/27/2019 at 11:00 a.m. with the nurse manager, (ID#56) stated they had not considered other alternatives.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview the facility did not ensure nursing care plans hospital were kept current, for two (ID#2, 8) out of five patients did not reflect the patient's current needs. Findings Included: Record review of facility policy, dated 5/2019, Clinical Documentation Charting Guidelines within the Electronic Health Record, stated: CAREPLAN DOCUMENTATION Select the Care Plan based on information collected during the Admission History, initial assessment, and diagnoses. Your patient might also have suggested care plans based on documentation, problems, and diagnoses 1. Care plans should be related to the patient's current diagnosis and the interventions and outcomes. Record review of Patient (ID#2) a [AGE]-year-old female was in the admitted for hypoxia, sepsis, and pneumonia. The care plan did not address potential for skin breakdown Record review revealed Patient (ID#8) a 22-year old-female was admitted for shortness of breath, worsening leg edema, and was six days post cesarean section. The care plan did not address the physical or the emotional care of a patient post cesarean section. Interview on 08/27/2019 with the charge nurse (ID #58) stated yes, something should be documented.
Based on review of hospital documents and interviews with staff the facility failed to ensure patient rights were exercised and met as evidenced by the failure to ensure all sexual assault survivors that presented to the ED were provided with transportation to a designated Forensic Examination facility for a sexual assault exam performed by a Sexual Assault Nurse Examiner (SANE). Findings were: A review of the hospital policy titled Sexual Assault, ER 1.29, Policy Stat ID: 35; Last Revised:01/2018 stated in part PROCEDURE 4. ED RN will perform primary basic assessment and explain procedure for evidence collection and patient options regarding forensic exam and use of Certified Sexual Assault Nurse Examiner (SANE). If patient would like the evidence collection to be performed by a Sexual Assault Nurse Examiner (SANE), the patient will be referred to a designated Forensic Examination hospital and the ED RN will document in the EHR utilizing the Release of Sexual Assault to an Alternate Facility form. Designated Forensic Examination Facilities 1. Adult and Pediatric a. Ben Taub Hospital: 713.873.8601 A review of the hospital policy titled Complimentary Local Transportation, L-7, Policy Stat ID: 35; Last Revised:01/2003, stated in part PURPOSE: The purpose of this policy is to ensure, through the implementation of prudent and reasonable controls, that Tenet Facilities provide complimentary local transportation in a manner that: A. Promotes greater access to medical care for patients living in a Tenet Facility's Service Area; B. Promotes patient safety and ease of care; The policy also stated C. Payment for complimentary local transportation shall be made with vouchers provided by a Tenet Facility. An interview was conducted with day shift ED Charge RN, Staff #10 on 2/26/19 at approximately 1:50 pm in a hospital conference room. Staff #10 stated that During the day shift we contact case management for cab vouchers. Overnight I know they have had difficulty with getting cab vouchers. At night it's a little more problematic for them. It was probably a case of not knowing who to go up the chain to. We need to figure out who will hold a few cab vouchers at night but the process has not yet been approved.
Based on review of documentation and interviews with the facility staff, and patient #1's daughter; the facility failed to protect the safety and rights of patient #1 causing mental anguish for the patient and his family. Patient #1 was transferred to the wrong SNF (skilled nursing facility). Findings were: Review of Patient's Rights and Responsibilities, 1.73, last revised 4/2017, 3. stated, Rights and responsibilities are noted with the expectation that observation of these will contribute to more effective patient care and greater patient satisfaction. Policy ID 01, Patient Care Discharge Planning stated, identifying the patient/family needs and resources required for an effective and safe transition from the hospital to his/her discharge destination. Physician Certification Form Statement for Ambulance Transport, 9/5/2018. Destination: Park Manor Cy Fair, Cypress Station. A line was drawn through Cy Fair. Review of the MOT reveal patient #1 was to be transferred to Park Manor of Cypress Station. Report was given to staff nurse at Cypress Station per staff #14. An interview was conducted with staff #14 RN, 2/26/19 1130 at the facility. Staff #14 said when she discharged patient#1 to SNF she reviewed the MOT form, called the receiving nurse listed gave report. Gave EMS the name, address and room number the patient was going to. At the time of the interview staff #14 reviewed copy of the MOT for patient #1, verified what was written. MOT stated transfer patient to Cypress Station Park Manor. The form was completed by case management. An interview was conducted at ll05 2/26/19 at the facility with staff #6 CM. Staff #6 said they receive a call from patient #1 daughter asking where is my father, he is not here at Park Manor Cypress Station. After making calls, patient #1 was found at Park Manor Cy Fair, the wrong SNF. Staff #6 said she investigated but didn't know if EMS drivers got the addresses mixed up or the staff. Cypress Station Park Manor is where patient #1 should have been taken. Park Manor Cy Fair is where the patient was taken. The surveyor asked staff #6 what is the policy for transferring patients to SNF? Staff #6 said they do not have a policy for discharges to SNF. The process is for case managers to complete an MOT form, place in the medical record so the nurse completing the discharge can give report to the receiving facility, give the room number to EMS. During the interview the finding were confirmed by staff #6.
Based on review of hospital documents and staff interviews the facility failed to ensure registered nurses supervised and evaluated the nursing care for each sexual assault survivor that presented to the ED as evidenced that 1 of 5 ED RNs did not follow hospital policies and hospital training related to nursing care to sexual assault survivors that presented to the ED. Findings were: A review of the hospital policy titled Sexual Assault, ER 1.29, Policy Stat ID: 35; Last Revised:01/2018 stated in part POLICY 1. The ED will provide care for the sexual assault patient. 3. The ED Provider is responsible for an evaluation of all bodily injuries associated with the assault and the ED RN will be responsible for evidence collected and documentation of same. The policy also stated PROCEDURE ...4. ED RN will perform primary basic assessment and explain procedure for evidence collection and patient options regarding forensic exam and use of Certified Sexual Assault Nurse Examiner (SANE). 5. If the patient chooses not to receive evidence collection from a SANE RN, the designated ED nurse will collect basic evidence utilizing the sexual assault evidence collection kit. The designated ED nurse is one who has completed the Forensic Evidence Collection EDU which satisfies the Texas Board of Nursing requirements in Board Rule 216.3(d)(1). A review of the hospital document titled Evidence Collection and Preservation in Sexual Assault Exam Performance Checklist performed on the afternoon of 2/26/19 revealed a signed Sexual Assault Exam Competency Validation for ED RN Staff #8 dated 2/24/17. An interview was conducted with ED RN Manager, Staff #4 on 02/25/19 at approximately 3:35pm in his office. He was asked if the hospital ED had a designated RN that performed basic forensic evidence collection on sexual assault survivors. He stated that the ED charge nurses would be the staff that performed the collection. A telephonic interview was conducted with Night Shift ED RN Staff #8 on 2/26/19 9:34 am. Staff #8 was asked if she remembered a sexual assault patient she was assigned to that needed transportation to Ben Taub forensic clinic for an evidence collection exam. Staff #8 stated she did not remember the specific case. Staff #8 was asked if there was a designated ED RN to collect basic forensic evidence if a sexual assault survivor chooses to have the forensic evidence collected in the hospital ED. She stated that Houston Northwest Hospital did not have a designated nurse to collect basic forensic evidence. She stated she had never performed a basic forensic evidence collection on a sexual assault survivor. An interview was conducted with ED RN Charge Staff #10 on 2/26/19 at 1:50 pm in a hospital conference room. Staff #10 stated I let them know that we can perform the evidence collection but there is more to the test than just evidence collection. It was probably a case of not knowing who to go up the chain to.
Based on review of documentation and interviews with the staff, the facility failed to provide an effective and safe transition from the hospital to the SNF for patient #1. Patient #1 was transferred to the wrong SNF. Findings were: Review of Discharge planning and information form 9/5/2018, 1912 stated, receiving facility accepting transfer Park Manor of Cy Fair. Review of discharge Summary 9/5/18 1739, disposition: case management made referral to SNF. Patient accepted by Park Manor Cy Fair. Transfer to Park Manor of Cy Fair SNF. Discharge document/instructions 9/5/18, transfer to another facility. Receiving Facility Accepting transfer: Park Manor Cy Fair. Policy ID 01, Patient Care Discharge Planning stated, identifying the patient/family needs and resources required for an effective and safe transition from the hospital to his/her discharge destination. An interview was conducted at ll05 2/26/19 at the facility with staff #6 CM. Staff #6 said they receive a call from patient #1 daughter asking where is my father he is not here at Park Manor Cypress Station. After making calls, patient #1 was found at Park Manor Cy Fair, the wrong SNF. Staff #6 said she investigated but didn't know if EMS drivers got the addresses mixed up or the staff. Cypress Station Park Manor is where patient #1 should have been taken. Park Manor Cy Fair is where the patient was taken. The surveyor asked staff #6 what is the policy for transferring patients to SNF? Staff #6 said they do not have a policy for discharges to SNF. The process is for case managers to complete an MOT form, place in the medical record so the nurse completing the discharge can give report to the receiving facility, give the room number to EMS. During the interview the finding were confirmed by staff #6.
Based on record review and interview, the facility failed to enforce its grievance policy # PCS 11.02 and respond in writing when a patient made a complaint to facility staff expressing dissatisfaction with the care and services she received during her hospital admission. Citing one (1) patient named in a complaint.( Patient # 1). Findings: Review of complaint narrative revealed allegations the Patient # 1 was admitted to the facility's emergency room (ER) and was assigned a male nurse. The patient asked the male nurse to leave her room because she was uncomfortable with males. The male nurse refused to leave the room and told her to get out of the bed because it was needed for another patient. Patient #1 refused to get out of the bed and security was called. The Security Officer told her to ''get out of the bed or he would drag her out, hog tie her, and drag her off to jail. The patient stated she was discharged from the hospital and she was still sedated from her medication and had her I. V (intravenous) in. The patient asked to speak to a ''Hospital person'' to make a complaint against the staff and no one came to speak to her. Review of emergency room triage notes for Patient #1 dated 5/18/2017 revealed the patient arrived in the ER via EMS (Emergency Medical Services) at 20:46 with complaints of chest pain, shortness of breath and having anxiety for the past 3 days. Patient #1 was placed in a room and was triaged by Staff G 57 (a male Registered Nurse). Review of emergency room Nurses notes dated 5/19/2017 at 3:30 am revealed documentation the patient was told she was discharged for home but was refusing to leave. She did not want the Charge nurse(Staff # H58) to take her IV out and requested to speak with a supervisor. House Supervisor at bedside, Patient requested (Staff H58) leave the room so she could speak with the supervisor. During an interview on 7/28/2017 at the facility at 11:40 am with Staff C53 (Risk Manager) she stated after the patient was discharged from the hospital the patient called and left a message on her voice mail that she wanted to speak to her, but did not say what her concerns were. According to the staff she called the patient back a few times but did not get a response. Staff C53 stated she was informed on 5/26/2017 that Patient #1 called the Chief Operating Officer (COO) and made a complaint. Staff C53 stated she did not respond in writing to the patient since the COO had already talked to her. During an interview at the facility on 7/28/2017 at 12:45 pm with Staff E 55 Registered Nurse Manager for the emergency room she stated Patient # 1 came to the hospital to speak to her after she was discharged . The patient discussed her concerns about the care and services she received at the hospital. Staff E 55 stated she spoke to the patient at length but did not respond in writing. During an interview on 7/28/2017 at 11:55 am with Staff D 54 Registered Nurse Director for the emergency room , she stated the facility tried to accommodate patients within reason. She stated the Supervisor that spoke to the patient during her ER visit should have forwarded the patient's concerns through the grievance system but that was not done. Review of the facility's Grievance Policy/Protocol # PCS 11.02 dated 8/20/14 revealed the following information: Whether a patient/family grievance is received by hospital staff in person, by telephone or in writing, a Patient and Family Complaint/Grievance report shall be originated by staff receiving the grievance. The staff shall forward the Patient and Family Complaint/Grievance report to the manager/director of the affected department for investigation and resolution. Each issue defined as a grievance will be followed up with a written notice of decision from the manager/director.
Based on interview and record review, the facility's nursing staff failed to identify the site location of blood collection in 1 of 2 sampled patients. Patient #1 Findings: Patient #1 Reviewed laboratory orders for Patient #1 on 05/06/2015 including CBC (Complete Blood Count). Order details stated Blood, Stat Collect, Collection Date 05/06/2015 13:10 CDT, Nurse Collect. No further information about the location of blood collection. Interview with the Assistant Chief Nursing Officer (2) on 09/10/2015 at 09:35 a.m., the Surveyor notified her that blood collection for Patient #1 has no specific location in the documentation; she said We do not have it here, but the name of the nurse and time of collection is shown. Interview with the Director of Nurse Informatics (4) on 09/10/2015 at 09:45 a.m., the Surveyor notified her that blood collection for Patient #1 has no specific location in the documentation; she said Our records cannot identify exactly how it was collected. Facility Policy reviewed about Facility Policy was reviewed about Phlebotomy # 15.01 Page 1 Objective: To safely obtain appropriate blood samples from a properly identified patient. Page 5 Documentation: On documentation tool, note specimen collection, date, time and date and time of collection. Note any specifics as to how and where the specimen was obtained.
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