HCA Houston Healthcare Pearland

Based on interview and record review the facility failed to uphold the rights of 1 of 4 patients to participate in the implementation of her plan of care to include disharge planning (Patient ID # 1).

Findingns include:

Patient ID#1/family had not participated in the discharge plan to hospice as evidenced by the facility not responding to the physicians order to set up hospice at discharge.

Observation of the Unit on 3/21/18 at 09:30 AM where Patient ID#1 was admitted was orderly, clean, and hall ways uncluttered. Charge Nurse ID#58 reported the Unit had 30 beds, and staffing ratio consisted of 1-5 ratio based on acuity.

In an interview on 3/21/18 with Director of Quality ID #54 stated, it is not acceptable that Hospice Care had not been shared with family or set up by case management. Is that the order for hospice to case management from doctor ID #59, yes it is.

Record review of Patient ID#1 Medical Record read: Order : discharge to Hospice Dr. ID #59 on 12/08/2017.

Record review of facility policy titled, Patient Discharge Policy, dated 01/2015, Revision, 01/2018 read:

PURPOSE: Pearland Medicacl Center will discharge patients with courtesy, consideration and safety while providing patient/family memmber with thorough and accurate instructions on disease process signs and symptoms, home care needs, equipment, home medications and follow up care.

RESPONSIBILITY; Staff nurse or Discharge Nurse will complete the discharge instructions, review discharge orders and instructions with patient/family member, confirm patienty/family member understanding of instructions and assist as needed

Based on interview and record review the facility failed in 1 of 4 patients discharge plan tohave an effective, ongoing discharge plan that facilitated the follow up hospice care ordered by a physician as evidenced by not transferrring or having hospice referral set up at discharge. (Patient ID #1)

Findings include:

Physician ID #59 wrote order on 12/08/2017 for Patient ID #1 to have Hospice Care per family wishes and Case Management did not follow up nor communicate that information to the receiving facility at time of Patient ID#1 discharge.

Interview on 3/21/2018 with Director of Cae Management ID #56 revealed that it is the responsibility of Caes Management to arrange for hospice care if a doctor orders the service. She further reported that , Yes, there was an order for Patient ID #1 too have hospice care at time of discharge and that no hospice arrangements had been made at discharge. She went onto say it is not acceptable practice to not complete physicians orders.

Record Review on 3/21/2018 of facility policy on patient discharge, titled Patient Discharge, dated 01/2025, review on 01/2018 reads:

POLICY:

1. A Physician's order for discharge will be obtained..

2. Discharge instructions will be completed in detaill in Meditech. One copy of the instructions will be provided and reviewed wiht the patient/family member abd a second copy will be placed in the chart...

PROCEDURE:

1. Purose: To provide general guidelines for assisting a patient upon discharge and to properlu complete the patient's medical record.

2. Equipment/Requisites: Patient's chart, physician's dischare orders and medicatin reconciliation orders...

Based on record review and interview, the facility failed to ensure the medical staff followed and were held accountable to the approved medical staff bylaws in the documentation of a patient's history and physical in 1 of 10 records reviewed (Patient ID #1).

Findings include:

Record review of patient's (ID#1) medical record for outpatient procedure performed by physician (ID#57), date of service 4/24/2017 contained a history and physical dated 2/17/2017 with a cover page dated 12/6/2017 stating the following: Please see the attached History & Physical that has been requested from your facility.

Interview with physician (ID# 57) on 12/6/2017 revealed that he makes sure there is a history and physical in each patient record before any procedure. If there is one in the chart that is within a certain time frame, I think ninety days or something, I will hand write whether or not there are any changes in the patient's condition.

Interview with Chief Nursing Officer (ID# 54) on 12/6/2017 at 12:49 PM revealed that the history and physical was not in the medical record. The copy provided was faxed over today from the referring physician.

Record review of facility Medical Staff Bylaws dated March 2016, revealed the following information:

Article 13: History and Physical

13.1 Timing of the History and Physical Examination

13.1.1 A complete medical history and physical examination must be performed and documented in the patient's medical record within 24 hours after admission or registration (but in cases prior to surgery or an invasive procedure requiring anesthesia services). The history and physical examination must be performed by a Practitioner who has been granted clinical privileges by the hospital to perform history and physicals.

13.1.2 If a medical history and physical examination has been completed within the thirty-day period prior to admission or registration, a durable, legible copy of this report may be used in the patient's medical record, if the history and physical examination was performed by a physician, oral maxillofacial surgeon, physician assistant, or advanced practice registered nurse. In such cases, within 24 hours after admission/ registration or prior to surgery or invasive procedure, whichever comes first, the patient must be reassessed by a Practitioner that has been granted clinical privileges by the hospital to perform history and physicals. The purpose of this assessment is to identify any changes subsequent to the original examination. The practitioner must update the history and physical examination to reflect any changes in the patient's condition since the date of the original history and physical or state that there have been no changes in the patient's condition.

Based on record review and interview the facility failed to respond in writing to a patient who complained to facility staff that an unqualified radiology technician made several attempts to insert an intravenous catheter in his arm and punctured his vein down to his elbow bone.

The facility failed to implement it's grievance policy which require an investigation and written response to patient complaints. The complainant alleged a manager from the radiology department called him and was extremely rude, no one else from the hospital contacted him.

Citing one (1) of three (3) staff in the interventional radiology department. Staff (# Q).

Findings:

Review of complaint narrative revealed the following information:

Patient (#2) complainant, alleged he went to the hospital for a CT(Computerized Tomography) Scan on 9/11/2015 and an ''individual'' in the Radiology Department attempted several times to insert an intravenous catheter to administer contrast dye and pierced through his vein down to his elbow bone which developed a bruise that lasted for 10 days after the incident.

The Complainant alleged the staff was not a ''Registered Radiology Tech'' his ID badge listed him as a 'Radiology Tech(Technician).

According to the complainant he reported the incident to the front desk staff and later that day an Administrator from the Radiology Department called him at home and was extremely rude, stating his staff was the ''best and was trained for the job''.

The Complainant stated no one else from the hospital contacted him.

Review of the facility's grievance logs dated August 1, 2015- November 30, 2015 for the Radiology Department and the hospital in general revealed no documentation of the patient's complaint and it's resolution.

During an interview on 1/5/2016 at 11:15 am with Staff (G) Medical Radiology Technologist he gave the following information:

Patient (#2) came to the department for a CT (Computerized Tomography) scan with contrast.

The patient was anxious, he explained the procedure to him and the patient signed all the required paperwork.

Staff (G) stated he inserted the catheter in the patient's vein and saw a 'flash' of blood, when he tried to advance the catheter he realized it was not working , there was some resistance, the vein might have been punctured.

According to Staff (G) he told the patient he had to ask someone else to try and access a vein. The Patient did not want anyone else to try and when he went to get the Nurse and returned the patient had left.

Staff (G) stated he reported the matter to the Director of Radiology Department and the Medical Director of Radiology. According to Mr. Harris he did not generate an incident report for the punctured vein nor did he document anything because the patient had left.

During an interview on 1/5/2015 AT 12:10 PM with Staff (Q), Director of the Radiology Department, he stated the patient did make a complaint regarding his staff qualification and that he was stuck several times when the staff tried to insert an intravenous catheter. He stated the patient refused to complete his treatment and left the hospital.

According to Staff (Q) he called the patient at home and the patient accused him of hiring unqualified persons. He told Patient (#2 ) that the Radiology Technician was qualified and was well trained.

Staff (Q) stated he did not report the complaint through the facility's grievance system because the patient had left the facility refusing to be treated.

During an interview on 1/5/2016 at 11:40 am with the Chief Nursing Officer she stated all complaints are tracked in the grievance system , investigated and a written notice send to to the complainant. She stated in this instance the process was not followed.

Review of the facility's grievance policy/procedure dated 1/14/201 revealed the following information:

Upon receipt of a grievance the appropriate department manager will be contacted. The grievance will need to be entered into the grievance log maintained by the Quality Department.

The Director will review and investigate the grievance within seven days of receipt of the grievance. A written response of the hospital's investigation and subsequent actions will be sent as soon as possible, in most cases within seven days.

Based on record review and interview the facility failed to document on a patient's medical record and develop an occurrence report when a patient's vein was pierced through, during attempts to insert an intravenous catheter in his arm.

This failed practice had the potential for faulty QA(Quality Assurance) reporting, analysis and inadequate corrective actions by the facility. Citing one (1) patient (#2) identified in a complaint.

Findings:

Patient (# 2).

Review of complaint narrative revealed the following information:

Patient (#2) alleged he went to the hospital for a CT(Computerized Tomography) Scan on 9/11/2015 and an ''individual'' in the Radiology

Department attempted several times to insert an intravenous catheter to administer contrast dye and pierced through his vein down to his elbow bone.This caused bruise that lasted for 10 days after the incident.

Review of medical record for patient (#2) dated 9/11/2015 revealed the patient arrived at the facility at 9:06 am with a physician ' s order dated 9/9/2015 for CT of abdomen and pelvis with Contrast dye.

There was documentation that Patient(#2) signed consents for care and all patient rights information.

Review of pharmacy records revealed the contrast dye was dispensed for administration but no documentation that it was administered.

There was no further documentation on the patient's medical record regarding his disposition and whether or not he received any treatment while he was in the hospital.

During an interview on 1/5/2016 at 11:15 am with Staff (G) Medical Radiology Technologist who treated Patient (# 2) he gave the following information:

Patient (#2) came to the department for a CT (Computerized Tomography) scan with contrast.

The patient was anxious, he explained the procedure to him and the patient signed all the required paperwork.

Staff (G) stated he inserted the intravenous catheter in the patient's vein and saw a 'flash' of blood, when he tried to advance the catheter he realized it was not working, there was some resistance ,the vein might have been punctured.

According to Staff (G) ordinarily an occurrence report would have been generated, however he did not generate an incident report for the punctured vein nor did he document anything in the patient's record because the patient had left without getting his treatment.

Review of occurrence reports for August 2015-October 2015 revealed no occurrence report regarding puncture of the patient's vein.

Review of the facility's Risk Notification Policy dated 1/14/2015 revealed the following information:

''Purpose: To provide a base for further investigation with a focus on patient safety and environmental safety processes and systems, and the corrective measures needed to prevent recurrence and sustain improvement

Adverse events, errors, unexpected events, variances and near miss involving patients will be promptly reported online in Meditech Risk Notification System even if the event seems insignificant at the time.

Objective facts of the occurrence of an adverse event involving a patient must be documented in the medical record to avoid possible allegations of 'willful concealment' or cover- up.

Document what was seen, record the patient's vital signs, and note the physical condition, and mental status, and the patient/family ' s subjective complaints.

Documentation should also include notification of the patient ' s physician.''