CMS-HCA-Houston-Healthcare-Southeast

Based on interview and record review, the facility failed to provide effective restraint training to nursing staff. Four (4) of 6 nursing staff interviewed in the ED and SAHA areas failed to verbalize understanding of IM medication related to managing/controlling patient behaviors and chemical/drug restraint [RN/IDs : J, K, I, and G ] .

Findings:

Record review of facility policy titled Patient Restraint Policy, revised date 01/2018, showed : Drugs as restraints: a drug or medication when it is used to manage the patient's behavior or to restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition is considered a restraint...

Nursing staff interviews:

Several nursing staff interviews were conducted in the SAHA unit and the main ED on 12-16-2020 between 10 A.M and 11 A.M. All of the nursing staff was asked this same question ( among others) : If IM meds are given to control/manage patient's behaviors--is this a drug/ chemical restraint'?

The following are excerpts of the nursing staff comments:

RN/ Staff J : ...I don't consider (IM meds to manage behaviors) a restraint. I consider it 'helping them [patients] feel better. Staff J was asked this follow-up question: When would you consider a drug a restraint? RN/Staff J answered: never.

RN/ Staff K: ....Any drug that is not already listed on the EMAR used for this reason would be considered a restraint. We'd have to call the ER physician.

RN/Staff I: it depends on the drug and the patient's response...--if it puts the person completely out or not...

RN/ Staff G: An IM drug is a restraint/chemical restraint if you want to sedate someone. Most of the time is is a STAT order and not PRN....

RN/ Staff H: If an IM drug is used when a patient is combative and a danger to hurt themselves or staff--this is a restraint...

RN/Staff L : We do not do chemical restraints here in SAHA. If a patient needed that--they would have to go to the main ER-they have monitoring capabilities we don't have here. Chemical restraint is the last resort for uncontrolled behaviors. I know they cant be ordered PRN.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure that 4 of 9 sampled patients were not administered a drug restraint using a PRN restraint order (Patient ID# 1, 2, 5, and 6).

These four patients were administered Haldol IM using a PRN order to manage their behaviors, which is considered a drug restraint.

Findings:

Review of facility policy titled Patient Restraint Policy, revised date 01/2018, showed: An order for restraint or seclusion may not be written as a standing order, protocol or as a PRN or as needed order.

Review of a facility document titled Management of the Agitated Psychiatric Patient Protocol,revised date 07/2016, showed the following:

* a single medication or combination of of the following medications should be chosen based in the patient's degree of psychosis, profile and comorbidities. Caution and medical monitoring should occur after these acute injections particularly when an antipsychotic agent is given with a benzodiazipine, as respiratory depression can occur..

* Listing of antipsychotic medication choices in this protocol included: Haldol IM 5-10 mg dosages, Zyprexa 10-20 mg dose, and Geodon 10-20 mg dose;

* Restraint and/or seclusion should be employed only when absolutely necessary to prevent the patient from severely harming him/herself or others. If the patient begins to self-harm and cannot be stopped with deescalation and psychiatric medication, then seclusion and/or restraint may be needed.

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Review of the of the computerized ED SAHA Safe Order Set showed the following antipsychotic medication choices ( by physicians) :

a. Haldoperidol (Haldol) Lactate 5mg syringe 2 mg IM/Q 4 hours PRN psychosis;

b. Haldoperidol Lactate 5mg syringe 5 mg IM/Q 4 hours PRN psychosis;

c. Haldoperidol Lactate 5mg syringe 10 mg IM/Q 4 hours PRN psychosis;

d. Ziprasidone (Geodon) IM 10 mg in (sterile water injection 10ml) 1.2 ml Q 6 hours PRN psychosis;

e. Ziprasidone IM 20 mg in (sterile water injection 10ml) 1.2 ml Q 12 hours PRN psychosis;

f. OLANZapine (Zyprexa) 10 mg in (sterile water injection 10ml) 2.1 ml Q 8 hours PRN psychosis;

PRN Anxiolytics included : Lorazepam IM and PO (by mouth) dosages for physician choice.

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Review of the Code of Federal Regulation (CFR 482.13 (e)(1)(i)(H) read : A restraint is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

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Medical Record Review :

Review on 12/11/20 and 12/16/20 of the electronic medical records of 9 sampled patients with Staff C, Vice President of Quality and Staff D, Manager of SAHA, showed the following:

Patient ID # 1:

Psychiatric Evaluation: 12/05/20 (1342) : [AGE] year old female patient brought in by police; found laying in middle of the road. Not slept in 3 days; PMH: bipolar; depression, anxiety, medication noncompliant -pt evaluated via telehealth. pt alert /oriented; manic mood; anxious affect. Thought processes illogical, tangential, flight of ideas and disorganized. Inpatient admission was recommended for safety & stabilization. Pt will be an involuntary admission.

Physician orders: Haldol & Ativan , dated 12/04/20:

Haldol 5 mg IM every 4 hours as needed/PRN Reason: Psychosis

Ativan 2mg/ml: 2 mg every 6 hours as needed/PRN: Reason: anxiety/sedation

Medication Administration Record (MAR) showed: 12/06/20 (0234) Haldol 5 mg and Ativan 2 mg given IM left deltoid

Nurses Notes prior to med. administration (not all inclusive ) showed:

12/05/2020 ( 2000) rec'd pt standing upright by nurses station very manic and asked ques. after ques.. Thoughts disorganized and very labile. Appears very anxious of so many issues...redirected...

12/05/20 (2200) refused scheduled meds; very labile, delusional, disorganized thoughts..

12/06/20 (0230); patient at first pacing back and forth, appeared paranoid. Patient always watching the nurses in the station and this time very paranoid and without a warning the patient suddenly step(sic) inside the nurses' station and grabbed the phone from the writer's hand and tried to break the telephone and detach the wire and throw it away. Next thing, the patient turned to the other nurse who tried to call a code gray and attacked her and tried to bite the writer and the other nurse inside the nurses' station. Code was called and still the patient very combative and aggressive and wants to bite the writer and the other nurse. Writer somehow was able to the pt and brought the patient outside the nurses' station and tried to put the patient in seclusion room. This time code gray team came and helped put the patient into the seclusion room. IM Ativan 2 mg given and Haldol 5 mg administered to the gluteal area of the patient...

Patient ID # 2

ED Admit 11/27/20 (0043) PD says she was found wandering streets and neighborhood since yesterday. pt disoriented and does not know where she was. Stated complaint: disoriented found walking in traffic. behavioral health hold.

Psychiatric eval: 11/28/20 (1232): chief complaint she was found wandering in the street. Pt is a [AGE] year old female...psych consulted for mood/psychosis. As per record: pt presented for evaluation after found in street. An EDO filed by police due to concern for self-harm. history is limited due to patients condition because she will not answer questions appropriately, Upon eval....pt found to be covering under the blanket, She moves her extremities but refused to wake up or answer questions..pt was seen by me a few months and was agitated and combative at the time with mood swings. Pt received PRN IM meds last night...Unable to assess thought processes; thought content: bizarre; limited and poor judgment and insight... Assessment: unspecified psychosis.

Physician orders: Haldol & Ativan:

Haldol 5 mg IM every 4 hours PRN; PRN Reason: Psychosis, dated 11/27/20 ( 2112)

Ativan 2 mg/ml ; 2 mg IM every 4 hours as needed PRN; PRN reason: Anxiety/Sedation

Medication Administration Record ( MAR) : showed: 11/27/20 ( 2128): Haldol 5 mg & Ativan 2 mg given IM left upper arm

Nurses notes pror to med. adminstration 🙁 not all inclusive) prior to PRN Haldol/Ativan given 11/27/20 at 2128:

11/27/20 ( 1934): patient awoke and became upset asking what was going on. Pt updated regarding plan of care. EDO and behavioral health process explained. Patient continued to whine and tell this RN that she is not a child. Attempted to reorient patient but patient returned to laying in bed and covered self with blanket. Patient allowed vital signs to be taken.

11/27/20 (2155) : pt is a [AGE] year old female brought to SAHA 2122 due to psychotic behavior. Pt is alert and oriented x 2. pt appears unkempt with disorganized thought process. Pt was uncooperative during transfer from ER to SAHA. Pt was yelling and cursing...saying 'y'all want to rape me', She was threatening to hit this RN when asked to remove her clothes. Pt states she is here because she has bad breath. Pt was not answering questions appropriately. She was loud with rapid speech and flight of ideas, Pt was not following commands. She was given Ativan 2 mg and Haldol 5 mg, IM for her safety and the safety of others. Pt agreed to the medication...Staff will monitor closely for safety and behavioral changes.

Patient ID # 5

11/27/20 : ER notes: [AGE] year old male pt via EMS c/o SA via hallucinations, pt was at a gas station complaining of pain in testicles. He said spirits were pulling them. per chart: pt had extensive history of drug abuse ;chart also lists possible diagnosis of schizophrenia .

Psych eval.: Pt presented with confused mood; incongruent affect. Speech: normal rate, rhythm and tone. During the evaluation , patient appeared internally preoccupied by looking around the room and suddenly speaking to inanimate objects. Evaluation was unable to be completed due to pt not being able to answer the questions form clinician. Client reported in ER chart: reason for visit was due to pain in testicles; his family is after him. Unable to assess for SI or HI. Inpatient admission recommended for safety and stabilization. Hallucinations and odd behaviors may be due to drug usage. For now, pt will be involuntary admission.

Physician orders: Haldol & Ativan, dated 11/27/20 :

Haldol 5 mg IM every 4 hours PRN; PRN Reason: Psychosis

Ativan 2 mg/ml ; 2 mg IM every 4 hours as needed PRN; PRN reason: Anxiety/Sedation

Medication Administration Record ( MAR) :

11/28/20 ( 0929) : Haldol 5 mg given IM left deltoid; Ativan 2 mg given IM left arm

12/01/20 (1010) : Haldol 5 mg given IM left deltoid; Ativan 2 mg given IM left deltoid

Nurses Notes prior to med administration (not all inclusive ) showed:

11/28/20 adminstration:

11/28/20 (0801): pt awake automatically begins pacing in circles repetitively,, Pt is also notes to be conversing with internal factors. Pt served breakfast...will monitor.

11/28/2020 (0907) : pt engaging with internal stimuli and made the following statements below: Are you blowing up the earth that's how you looking at me dude? And stated what if there was a gun to blow up his testicles. Patient is actively hallucinating. Haldol and Ativan will be administered.

11/28/20 ( 0929) : Haldol & Ativan administered d/t drug induced psychosis and hallucinations. Will continue to monitor pt for safety.

12/01/20 administration :

12/01/20 ( 0926) : pt spinning around, reports there are sprints. Pt agreed to take Ativan 2 mg and Haldol 5 mg IM...

Patient ID #6

11//11/202: ER rapid initial assessment (2043) arrived via police pt was found waking on the street of Holland Avenue walking in front of vehicles being a danger to herself. Pt was found walking in the lane of traffic as vehicles were trying to avoid hitting her. Refusing to answer questions, mumbling to self. Unable to hear words being said.

Psych eval:11/12/20: pt is uncooperative with treatment. Recently discharged from an inpatient psych facility. Patient denies admission and then recants and admits admission but unable to discuss diagnosis: Mood & behavior: depressed, guarded, irritable, anxious; thought process: paranoid : pt presented paranoid; delusional people are messing with my brain. Recommend transfer to inpatient psych facility. Diagnosis: unspecified Psychosis, severe stimulant use disorder.

Physician orders: Haldol & Ativan, dated 11/11/2020:

Haldol 5 mg IM every 4 hours PRN; PRN Reason: Psychosis

Ativan 2 mg/ml ; 2 mg IM every 4 hours as needed PRN; PRN reason: Anxiety/Sedation

Medication Administration Record ( MAR) :

11/11/ 2020 (2229) Haldol 5 mg given IM left deltoid

11/11/ 2020 (2229) Ativan 2 mg given IM right deltoid

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Nurses Notes prior to med administration (not all inclusive ) showed:

11/11/20 (2111): pt siting up in bed awake, blinking rapidly and shaking legs. When attempting to obtain blood, pt continues to mumble.

11/11/20 ( 2203); pt got out of bed an standing at side of bed mumbling. Pt able to be redirected back to bed. Continues to be uncooperative with questions.

11/11/20 ( 2224) : attempted to draw labs again, pt became increasingly anxious and aggressive pulling her arms away. Pt continued to mumble, blinking rapidly and shaking her legs then stating : I need to get out of here. Pt. then quickly got out of the bed and was unable to be redirected. Code Gray called

11/11/20 ( 2229) :Ativan and Haldol administered, Pt agreed with medication administration.

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During an interview on 12/16/2020 at 2:45 PM an extensive discussion was held among Staff A, CEO; Staff C, Vice President of Quality ; and Staff D, Manager of SAHA. Staff C and Staff D explained the Management of the Agitated Psychiatric Patient Protocol, was developed following a 2016 survey when all drug protocols were reviewed and revised. The facility did not consider Haldol IM or other anti-psychotics administered IM as a drug restraint but as part of the standard treatment for psychosis.

Surveyor discussed the findings of the medical record review that showed IM Haldol was given in response to documented behaviors. The IM acute injection, given in response to behaviors that were a danger to the patient and/or staff, demonstrated immediacy and was used to manage behaviors. This was considered a restraint.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to inform a patient of their rights upon admission. [citing Patient # 8 ]

Findings included:

TX 637

Review of facility's policy titled Patient's Rights and Responsibilities, dated 02/2018, showed the facility staff must provide all patients a written statement of their rights at time of registration. This statement must be acknowledged by the patient.

Record review of Patient # 8's medical record showed she was a [AGE] year old female who arrived at the emergency department (ED) via ambulance on 10-06-18 at 1452. Per ambulance staff patient was sent from another hospital due to stating she was having vaginal bleeding. Nursing assessment showed Patient # 8 was oriented to person, time, place and situation. Her mood and affect were assessed as congruent. It was documented this was a voluntary admission.

Interview on 04-18-19 at 11: 15 AM with the Health Information Management (HIM) Director, she verified the record provided was the complete medical record for the 10-06-18 admission for Patient # 8.

Continued review of Patient #8's medical record failed to show a signed and dated acknowledgement of receipt of patient rights.

Review of ED physician progress note, dated 10-06-18, showed Patient # 8 was medically cleared for a psychiatric evaluation. HCAT (Health Crisis Assessment Team) evaluated the patient and recommend inpatient care. This will be voluntary.

Patient # 8 requested placement in a traditional adult bed hospital and not a geri-psych bed. For this reason, her admission was made involuntary for a transfer to a psychiatric facility. Record review showed forms were initiated for involuntary commitment on 10-07-18 at 0522; however an Emergency Apprehension & Detention Warrant (EDW) was not issued and signed until 10-09-18.

During an interview on 04-18-19 at 1:30 PM with Staff F , ED Registered Nurse, he stated all admitted patients should have a signed & dated acknowledgement of receipt of patient rights, unless they were unable to sign or refused. In any case, the exception should be documented.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to uphold a patient's right to informed consent. Facility failed to obtain a consent for treatment from Patient # 8 upon admission per hospital policy.

Findings included:

TX 637

Record review of facility's policy titled Procedure for Registration Forms & Signatures, 05/01/15 showed standard form required at registration included 'Conditions of Admission' (COA), which included a general consent to treat.

Record review of Patient # 8's medical record showed she was a [AGE] year old female who arrived at the emergency department (ED) via ambulance on 10-06-18 at 1452. Per ambulance staff patient was sent from another hospital due to stating she was having vaginal bleeding. Nursing assessment showed Patient # 8 was oriented to person, time, place and situation. Her mood and affect were assessed as congruent. It was documented this was a voluntary admission.

Interview on 04-18-19 at 11: 15 AM with the Health Information Management (HIM) Director, she verified the record provided was the complete medical record for the 10-06-18 admission for Patient # 8.

Continued review of Patient #8's medical record failed to show a signed and dated general consent to treat during the time she was under a voluntary admission status.

Review of ED physician progress note, dated 10-06-18, showed Patient # 8 was medically cleared for a psychiatric evaluation. HCAT (Health Crisis Assessment Team) evaluated the patient and recommend inpatient care. This will be voluntary.

Patient # 8 requested placement in a traditional adult bed hospital and not a geri-psych bed. For this reason, her admission was made involuntary for a transfer to a psychiatric facility. Record review showed forms were initiated for involuntary commitment on 10-07-18 at 0522; however an Emergency Apprehension & Detention Warrant (EDW) was not issued and signed until 10-09-18.

During an interview on 04-18-19 at 1:30 PM with Staff F , ED Registered Nurse, he stated all admitted patients should have a signed & dated general consent to treat, unless they were unable to sign or refused. In any case, the exception should be documented.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to provide care in a safe setting for Patient # 1.

a. The facility failed to ensure staff utilized appropriate de-escalation techniques during an episode of aggressive, combative, elopement behaviors exhibited by Patient # 1.

b. The facility failed to ensure Patient # 1 did not have access to hazardous items that could be used for self-harm while she was on suicide precautions.

Findings included:

Staff Management of Patient Behaviors:

Record review of facility policy titled Annual Mandatory Education,revised date 06/2018, showed it was facility policy to ensure that all employees including contracted individuals complete annual mandatory education based upon job training needs and safety concerns.

Observation on 04-18-19 at 9:25 AM in the facility emergency department (ED) showed Patient # 1 walking toward the automatic double-doors that led to the lobby. The patient was agitated, swearing, and telling staff she wanted to leave. Several staff members were following this patient.

Further observation showed Staff J, head of security, was standing immediately next to Patient # 1 . Staff J grasped Patient # 1 by by her right arm. She yelled Do not touch me ! as she pulled her arm away and swung it in the air. Patient # 1 was observed more agitated after she had been grasped by Staff J.

As staff attempted to guide Patient # 1 back into the ED nursing station area, Patient # 1 said loudly Don't (curse word) walk behind me... get out of my face! Staff J, head of security said No, you are in my face.

Further observation showed Patient # 1 was walking around the ED nursing station area, followed by 5 staff members. Patient # 1 remained agitated, restless and said loudly y'all get back to work and leave me alone!

During an interview on 04-18-19 at 1:45 PM with Staff J, head of security, he denied grasping Patient # 1 by the arm. He stated that he had received TEAM training from his company on management of aggressive behaviors.

Record review on 04-18-19 of computer screen shot of contract company training for security Staff J showed he received TEAM training on 12-13-18.

Record review of the TEAM [Techniques For Effective Aggression Management]training handbook provided by Staff J showed ...verbal de-escalation techniques included:... respect their personal space...try and maintain at least 2 arm lengths, or 6 feet of distance.. avoid making it a 'me' versus 'you' confrontation...during the aggression cycle:... avoid physically touching person...

During an interview on 04-18-19 at 11:00 AM with Staff E, ED director, he said all ED staff were required to be trained in Crisis Prevention Institute (CPI) crisis intervention training and Trauma Informed Care (TCI) to utilize when caring for behavioral health patients. He said the security staff was contracted and he did not know if they had CPI and TCI training.

Accessibility of Hazardous Items:

Record review of the facility's policy titled Suicide Prevention, revised on 01/2016, showed a suicide risk screening was performed in the ED. Patients identified as at risk for suicide were placed on suicide precautions immediately. Safe environment & patient safety guidelines were implemented.

Record review of the medical record of Patient # 1 showed she was a [AGE] year old female admitted involuntarily to the ED on 04-17-19 under an Emergency Detention Order. Diagnoses of drug abuse; psychotic disorder. Further record review showed the following:

* 04-17-19 : (1809) physician order for suicide precautions / Level 2: Line of Sight at all times.

*04-17-19 (2002): Registered Nurse (RN) progress note read pt has multiple sharp objects in hand and on person.

* Suicide Prevention/Safe Environment Checklist, dated 04-17-19, showed documentation of dangerous items removed from patient was verified every 15 minutes from 1715 on 4-17-19 until 0700 on 04-18-19.

During an interview on 04-18-19 at 11:20 AM with Staff E, ED director, he said the ED had only one room ( #8) considered psych safe. Most all patients who were on suicide precautions (SP) were placed in the areas visible to the nurses's station for safety purposes. Most of the patients were on 1:1 monitoring with a sitter, depending on the Level of SP ordered.

ED Director reviewed Patient # 1's record and said he was unaware how the patient had obtained sharp objects on 04-17-19 at 2002. The safe environment checklist had been completed for the timeframe in question.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure that a registered nurse (RN) supervised and evaluated the care for Patient # 8.

Nursing failed to accurately assess and reassess skin integrity for Patient # 8.

Findings included:

TX 637

Record review of facility's policy titled, Plan for Assessment / Reassessment, dated 08/2016, showed each department where nursing care is provided uses an assessment format that is individualized to the patient population served...a head to toe systems review and all other clinical documentation will indicate only items that fall outside defined parameters.

Review of facility Appendix A referenced in the above cited assessment policy , [specific to the Emergency Department (ED)] showed the scope of the RN admission assessment included skin and wound assessments.

Patient # 8 :

Review of Patient #8s medical record showed :

Physician ED documentation:

10-06-18 (1508) : [AGE] year old female presents to ED with complaint of chronic sores to her bilateral legs....stage 3 pressure ulcer to posterior left thigh; stage 1 pressure ulcer to posterior right thigh...

Nursing ED documentation:

10-06-18 (1455): arrived via EMS ...told them she had sores on the back of her leg-assessment said skin warm & dry

10-06-18 (1532):Integumentary: WDP [Within Defined Parameters]: YES

10-06-18 (2202):skin warm & dry: YES, color within expectations for ethnicity: YES

10-07-18 (0522):skin warm & dry: YES; color within expectations for ethnicity: YES

10-07-18 (0522):TRIAGE REASSESSMENT:subjective assessment: ...pt told EMS she had sores on the back of her leg.

10-07-18 (1945):PHYSICAL FINDINGS: Musculoskeletal: WDP; Integumentary WDP

Further review of this same medical record showed that Assessment Parameters were defined as 'Within Defined Parameters' when : skin, warm dry and intact; No complaints of lesions, rash, wounds, bruises, petechiae , or abrasions.

A completed Body wound diagram completed by nursing staff, dated 10-08-18 (0445), showed three (3) circles drawn on posterior body diagram : two(2) Bs (bruises) and one (1)wound. There was no description of the bruises or wound.

On 05-02-19 , comment via email by Staff B, Chief Nursing Officer (CNO), she stated she reviewed Patient # 8's medical record with the ED leadership. Their review showed the patient's skin assessment was not accurately reflected in the assessment area of her medical record.

Show Text of Violation

Based on review of documentation, and interviews with facility staff, the facility failed to ensure that a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.

The findings were:

The facility policy title, Falls Precaution and Management, states, Standard fall precaution will be implemented on all patients. All patient will be evaluated to identify 'standard risk' or 'high risk' for fall during the admission assessment process; at minimum of once every shift; following a change in medical condition and/or level of care; and post fall ... Standard Fall Risk Interventions: properly fitting non-skid footwear; bed placed in lowest position only 3 max side rails up; secure all locks on bed, stretcher, and wheelchair when in patient use; discuss importance of calling for assistance; patients will be rounded on to address the four P's - pain, positioning, potty, and placement of personal items ... High Fall Risk Interventions: Apply all standard fall risk precautions and the addition of the following: place a yellow arm band on patient; place yellow non-skid socks on patient; place fall risk signage on patient's door; apply bed alarm ...

The facility policy titled, Transportation of Patients Within the Facility, states, Notification to Nursing Staff: Nurse must receive patient at bedside - do not leave patient without hand off occurring at bedside.

The following documents and select medical records of Patient #1 for dates of service 3/4/18 - 3/22/18 were reviewed:

1. The ED provider documentation on 3/4/18 revealed:

a. Pt is 66 y/o female w/ hx of DM and ESRD who presents to ED via EMS s/p pt pulled out dialysis cath. EMS adds that pt fell at NH a few days ago. Pt has been recently altered and combative for several days. Pt last had full session of dialysis x2 days ago and is regularly scheduled for dialysis M/W/F. Pt from Baywood health rehab, hx limited due to pt condition. She states she feels like vomiting. Pt denies pain ... Unable to Obtain ROS Altered mental status ... Re-Evaluation & MDM: Unknown who primary renal team is after discussion with NH. Pt with anemia in setting of ESRD and recent bleeding from catheter. Pt consented for transfusion from child/NOK. Special procedure ordered but pt does not need immediate dialysis. She is altered. Ammonia pending. Son states pt has been altered recently but this is not very clear at this time. Will admit for further evaluation.

2.The nursing clinical note documentation on 3/22/18 revealed:

a. At 1509, a RN note stated, Pt transferred to room 2083 in stable condition. Son informed of transfer. Pt alert and oriented on room air at time of transfer denies pain/discomfort all orders reviewed and verified ...

b. At 2117, a RN note stated, This nurse found patient on the floor with blood coming from the left side of her head. This nurse applied pressure and called for help. tech came into the room and also called for help. Once the patient was stabilized patient taken down for CT of the head, xray of left hip, shoulder, knee, hand and elbow. [physician] was notified at 1615. AOS notified at 1550 fall occurred at 1540. Patient has remained alert and oriented x4 since the fall. [physician] sutured the left ear. Patient is now resting in the bed.

3. The patient's Post Fall Huddle Form from 3/22/18 revealed:

a. Patient a fall risk? Yes

b. History of falls prior to admission? Yes

c. What interventions were done for fall risk? Yellow Sox

d. Fall risk factors prior to fall: Impaired mobility, Impaired mentation

e. What was the patient doing at the time of the fall? Patient was found on the floor sitting on her buttocks - she stated she was trying to use the restroom

f. New interventions documented after the fall? Red socks, bed alarm, move closer, bed alarming working

g. Where did the fall occur? Patient room

h. Was the fall witnessed? No

i. Injury: abrasion, bruise/hematoma, fracture/dislocation, laceration, pain whole left side

j. What could we have done differently? Bedside report, placed eyes on patient when patient brought to unit, tell buddy to put eyes on patient, inform tech patient was here

k. Preventable? ICU staff to do bedside report/handoff; do not leave pt bed in high position, no bed alarm

Other documents regarding the patient's fall was reviewed and noted, ICU staff did not communicate to transporting staff the fall risk of the pt. ICU transporting staff left the bed in a high position with her personal items out of reach. ICU transporting staff did not wait for IMCU receiving staff and did not escalate transfer of care to the charge nurse. This leaving the pt unassessed with no bed alarm in place.

Staff #3 was interviewed on 9/25/18. Staff #3 was asked what they recalled about the patient's fall and findings of the facility's investigation. Staff #3 stated, Two of the ICU nurses transferred the patient to the IMCU. They didn't wait for the receiving IMCU nurse because they had to get back quickly to the ICU. The receiving IMCU nurse was busy at the time trying to d/c a central line from another patient and it took longer than anticipated to complete. The patient was left in the room by herself, the bed was left in a high position and the call light was not within reach. When the IMCU nurse came into the patient's room, they found the patient on the floor with injuries to the left side of the body. The patient ended up with a laceration to her left ear and an elbow injury.

In an interview with Staff #1 on the afternoon of 9/25/18 Staff #1 acknowledged the finding above.

Show Text of Violation

Based on observation, interview and record review the facility failed to ensure full and equal visitation privileges for 5 of 5 patients on Geri-Pysch Unit (Patient ID, #1, 2, 3,5, 6).

Findings include:

TX 434

Observation on 4/ 26/17 at 10:00 am at the facility on the Geri-Psych Unit entrance revealed signage that read: ...No Visitation on Tuesdays and Thursdays...

Record review of complaint narrative TX 434 read: ... Tuesdays and Thursdays you can't visit the Geri-Psych Unit...

Interviews on 4/26/17 between 10:00 - 11:00 am with four (4) current Patients ID # 2, #3, #5, #6 revealed understanding that there was no visiting hours on Tuesdays & Thursdays.

In an interview on 4/26/17 with Charge Nurse, RN ID # 52 at 9:15 am she reported visiting hours were from 2:30-4:00pm, except on Tuesdays and Thursdays. She said, I'm not sure why, has been that way since I have been here for four (4) years.

In an interview on 4/26/17 at 10:15 am with Social Worker, ID # 51 on Geri-Psych Unit, he stated he was aware there was no visiting on Tuesdays & Thursdays. He did not verbalize the reason for this.

Interviews on 4/26/17 between 10:30-12:00 with four (4) staff members, Nurse Manager, RN, ID # 60, RNs , ID # 54 & 55, PCA (Patient Care Assistant) ID # 53, revealed consistent understanding of visiting policy. All stated there was no visitation on Tuesdays & Thursdays.

In an interview on 4/26/17 at 12:00 pm with Director, ID # 59, he reported that management was aware that they needed to be more family friendly, especially with visiting.

In an interview with Security Guard, ID # 61 at front desk on 4/27/17 at 2:00 pm she stated; there were no visiting hours on the Geri-Psych Unit on Tuesdays & Thursdays. ( Question was asked on Thursday ).

Record review of facility Patient Handbook revealed the following schedule for visiting on the Geri-Psych Unit:

Mondays: 2:30 - 4:00 pm

No visitation on Tuesdays

Wednesdays: 2:30 - 4:00 pm

Thursday: No visitation

Friday: 2:30 - 4:00 pm

Saturday: 2;30 - 4:00 pm

Sunday: 2:30 - 4:00 pm

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review a Registered Nurse (RN) failed to supervise and evaluate the care for 1 of 3 patients needs, based on her assessed needs (Patient ID# 1).

Findings include:

TX 434

Record review of the clinical record of Patient ID # 1 revealed a [AGE] year old African American female. She was admitted for aggressive behaviors, hypertension, and with a past medical history of dementia.

Record review of progress notes by PA (Physician Assistant), ID #63 from 12/30/16 to 1/26/17 revealed documentation of Patient ID # 1 with failure to eat, poor appetite, and loss of weight requiring daily weights by nursing, additional supplements, i.e. Ensure, an enriched protein drink, and finger foods.

Record review of Patient # 1's medical record on 4/27/17 with Clinical Educator, ID # 58 revealed that there were no documentation of daily weights. Five (5) weights were documented in the medical record as follows:

* 12/28/17 = Wt: 175

* 12/29/17 = Wt: 185, re-weighed 12/29/17 = Wt: 185

* 1/16/17 = Wt: 109

* 1/17/17 = Wt: 160

In an interview with Charge Nurse, RN ID # 52 on 4/26/17 at 10:00 reported that there was no policy about weighing the patients. The patients were weighed on admission and then only if there was an order for daily weights, or specific to time and date.

In an interview on 4/26/17 with PCA, (Patient Care Assistant) ID #53 at 10:45 am she reported that the staff only weigh patients when they first come to the Unit. Also she reported that if a patient was not eating she reported to the nurse and if she is told to weigh them again she would.

Record review of policy titled: Food and Nutrition Services Management, last revised 09/2016 read as follows:

PROCEDURE

1. Nutritional care monitioring:

Physician: Assumes the responsibility for the overall nutritional management of the patient

Registered Dietitian: Assesses patient's needs, evaluates...

Nursing Services: Meal rounds conducted to determine if patients are having any difficulty with meal service that might impact their nutritional status.

The following triggers are utilized to identify patients by ongoing monitoring who have been identified to be at nutritional risk on admission...Changes in PO (orally) intake, Weight loss....

Show Text of Violation

Based on record review and interview the facility failed to implement its infection control policies to ensure staff handle, store and use linen in a safe manner to prevent the spread of infection.

The facility failed to ensure staff:

--Clean used equipment and floors;

--Change gloves and wash hands after patient contact to prevent cross contamination and the spread of infection; and

--Wear personal protective equipment (PPE) when entering rooms of patients on isolation precautions.

This failed practice had the potential for the spread of infection to staff and patients.

Citing random observations on two (2) of four (4) medical/surgical units; two (2) of two(2) operating Room suites.

Findings included:

Observation on 9/20/2016 on Medical/Telemetry Unit (Unit 4) at 10:45am revealed Patient #30 was lying in bed with a Foley Catheter attached to a urine drain bag. The bag was on the floor atop a patient bath towel.

Observation at 11:25am on (Unit 4) revealed Staff #131, a Licensed Vocational Nurse, was providing care that included suctioning for Patient #32 who was on contact isolation for MRSA (Methicillin-resistant Staphylococcus Aureus) of the nares.

Staff #131 rolled her work station on wheels (WOW) containing paper work, a phone, computer and other supplies into the patient's room.

After completing Patient #32's care, Staff #131 left the patient's room with the WOW and failed to clean all the attachments on the cart, including the scanner, post and base of the cart.

During an interview on 9/20/2016 at 11:30am with Staff #132 (the RN Manager), she stated staff should not use patient towels on the floor and that the urine bags should be placed in a container. Staff #132 further stated the WOWs were used in all patient rooms and should be cleaned from top to bottom after each use.

Review of the facility's infection control infection control policy and procedure dated July 2016, revealed the following information: Reusable equipment will be cleaned and reprocessed appropriately before use in the care of another patient. Do not place soiled linen on the floor

Clean utility room.

Observation of the north medical/surgical unit at East Houston Regional on 9/22/2016 at 0945 revealed a dust ball on the floor in the clean utility room.

In an interview with RN #201 on 9/22/2016 at 0945, she stated that the dust ball should not be there.

Record review of the facility's policy, Cleaning Procedure-Utility Rooms dated 8/2008 stated: #11 ... Dust mop floor, starting in the far corner of the room and working back toward entrance ... #17 ... Inspect the room.

Cross contamination.

Observation on south medical/surgical unit on 9/22/2016 at 1045 revealed RN #166 performing pericare on Patient #82. After removing the patient's diaper, the nurse went to the patient's storage area without removing her gloves. She then changed gloves without sanitizing her hands. She provided the pericare and retaped the diaper. She then picked up the periwipe container with contaminated gloves and replaced the container in the storage area. She removed her gloves and, only with the prompting by RN Manager #182, washed her hands.

In an interview with RN #182 on 9/22/2016 at 1045, she stated that RN #166 contaminated the peri-wipes container when she did not wash her hands.

Record review of the facility's policy, Isolation, Standard Precautions/Transmission Based Precautions dated 01/2015 stated: All healthcare workers will practice proper hand hygiene and adhere to the 'Hand Hygiene and Artificial Nails' policy [and] wear disposable medical examination gloves for providing direct patient care ... remove gloves after contact with a patient and/or surrounding environment (including medical equipment), using proper technique to prevent hand contamination ... Change gloves during patient care if the hands will move from contaminated body site to a clean body site.

Soiled linen supply room.

Observation on south medical/surgical unit on 9/22/16 at 1100 revealed a bag of soiled linens on the floor.

In an interview with RN #182 on 9/22/16 at 1100, she stated that the bag of soiled linens should not have been on the floor.

Record review of facility's policy, Isolation Standard Precautions/Transmission Based Precautions dated 01/2015 stated: Soiled linen including towels, wash cloths, and patient clothing may be contaminated with pathogenic organisms ... Do not place soiled linen on the floor.

Bayshore Medical Center.

Observation one (1) of one (1) surgical skin preparation for surgery at Bayshore Medical Center on 9/20/2016 at 11:45am revealed the following:

Registered Nurse circulator #137 performed skin asepsis for patient #13 while wearing a short-sleeved scrub top.

Interview with Perioperative Services Educator #199 on 9/21/2016 at 9:27am revealed that facility policies are based on recommended practices of the Association of Perioperative Registered Nurses (AORN). Facility policies are updated every three (3) years. When new recommendations are presented by AORN policies are looked at and are updated if needed. Educator #199 acknowledge having knowledge of recommendation by AORN for nurses performing skin asepsis is to wear a long-sleeved jacket to avoid skin squames from the nurses bare arm to drop onto the the area being prepped, increasing the risk of surgical site infection.

Record review of the facility policy titled, Attire for Restricted and Semi-Restricted Areas, dated 8/2016, revealed the following: Non scrubbed personnel are encouraged to wear long-sleeve jackets in the operating room during the procedure.

East Houston Regional Hospial.

Observation at East Houston Regional Hospital in the Surgical Services department on 9/22/2016 at 10:32am revealed the following:

Physician #179 entered the Surgical Services area wearing his white lab coat. He proceeded to the operating room where surgery was in progress for patient #74. Physician #179 did not have a surgical mask on. He stuck his head and shoulder into the room to speak to surgeon #193 and then left the Surgical Services area.

Interview with Director of Perioperative Services #171 on 9/22/2016 at 10:32am revealed that physicians were not allowed to wear lab coats into the restricted area and that there was a designated area for lab coats to be placed.

Interview with Physician #179 revealed that he was aware of the proper attire required in the restricted area and acknowledge that he broke protocol.

Record review of facility policy titled, Attire for Restricted and Semi-restricted Areas, dated 8/2016 revealed the following: Appropriate surgical attire will be worn to promote high-level cleanliness and hygiene and to reduce microbial contamination in the environments where sterile procedures are performed.

Bayshore Medical Center.

Observation on 09/20/2016 at 11:40am outside Patient #23's room on the Intermediate Care Unit (IMCU) at Bayshore Medical Center revealed lab technician #157 donned a gown, gloves and mask. Further observation revealed a sign on the patient's door that read: STRICT CONTACT Precautions.

In an interview at the time of observation with lab technician #157, she said the difference between strict contact and contact isolation was that strict contact meant more PPE (personal protective equipment) was worn; a mask was needed because of airborne issues.

Further observation revealed lab technician #157 entered Patient #23's room and performed venipuncture to obtain blood samples for lab tests. Prior to exiting the room, she removed the PPE and sanitized her hands with hand gel. She failed to wash her hands with soap and water.

In an interview with IMCU Manager #119 at the time of observation, she stated, STRICT contact precautions meant the patient had a C. Diff (Clostridium difficile) infection. Staff were required to wear gown and gloves and wash their hands prior to entering and prior exiting the room with soap and water. In addition, all hard surfaces and equipment within the patient's room must be cleaned with bleach wipes.

Record review of lab results for Patient #23, dated 09/16/2016 read: ...positive antigen and toxin: indicates POSITIVE for presence of C. Difficle.

East Houston Regional.

Observation on 09/22/2016 at 11:10am outside room #2907 revealed a sign on the door that read STRICT Contact Isolation. Room #2909 (adjacent to #2907) had a sign that read CONTACT Isolation.

In an interview at the time of observation with Housekeeper #164, she stated the difference between strict contact and contact precautions was for STRICT we are more careful, more strict. We cover up more because it is airborne. When asked if the patient room was cleaned differently for strict contact precautions, Housekeeper #164 stated, No, we clean the same for all rooms.

Record review of facility policy titled, Isolation, Standard Precautions/Transmission Based Precautions, dated 07/2016, read: Strict Isolation - use Strict Contact Precautions for specified patient known or suspected to be infected or colonized ... with important organisms that require the use of hand hygiene and/or the use of bleach products as a disinfectant, such as Clostridium difficle and Norovirus ... 1. Gowns, gloves and Handwashing. A. Perform hand hygiene before entering room. B. Wear gown and gloves when entering room ... E. wash hands with soap and water before leaving room ... 1. Environmental Disinfection: a. All common equipment and environmental surfaces should be disinfected with a bleach product. b. EVS (Environmental Services) to clean room daily with bleach.

Bayshore emergency room (ER).

Observation on 09/20/2016 at 10:30am revealed a locked room with a sign, Soiled Utility on the door. Further observation revealed several areas of dark red smears on the floor.

In an interview with Charge nurse / Registered Nurse #116, she stated, That looks like blood; it should have been cleaned up. Another staff member provided RN #116 with gloves and bleach wipes. She cleaned the floor and the bottom of her shoes before exiting the room.

East Houston Regional ER.

Observation on 09/22/2016 at 9:30am in Exam Room #5 revealed an open alcove-type storage area. The floor inside this alcove had a thick layer of dirt and grime. In an interview at the time of observation with ER Director #181, she stated this was the space in which the industrial blood alcohol level screening machine was stored. She went on to say someone had removed the machine to use it and the floor should be cleaned.

Further observation in Exam Room #5 revealed a crumpled absorbent pad and a stained adult brief in a storage cabinet. ER Director #181 confirmed the contaminated pad and brief should have been properly discarded and not returned to the cabinet.

Continued observation revealed multiple (5 +) wall-mounted hand sanitizers in the ER had a thick layer of dust on the top of them and also on the drip tray at the bottom of the dispenser.

Review of facility policy titled, Cleaning of Utility Rooms, dated 01/2012, read: ...11. Dust mop floor ... 13. Place a Wet Floor sign at door ... 14. Wring out mop in a bucket of germicidal solution. 15. Damp mop the room, starting at the far corner of the room.

East Houston Regional ER.

Sterile Patient Supplies.

Observation on 09/22/2016 between 0900 and 1000am in the ER revealed the following unwrapped, single-use sterile patient supplies:

--Exam Room # 5: oxygen mask (non-rebreather) and tubing; and

--Respiratory therapy supply area: BiPAP (bi-level positive airway pressure) mask and tubing.

In an interview with ER Director #181 at the time of observation, she stated that, once opened, single use patient supplies should be discarded if not used.

Bayshore Cardiovascular Intensive Care Unit (CVICU).

Linen Transport.

Observation on 09/20/2016 at 11:15am in the CVICU revealed Housekeeper #158 entered the unit through double doors from an outside corridor. She obtained several clean bedsheets and a blanket from the linen cart. Further observation revealed Housekeeper #158 exited the CVICU through the double doors holding the clean linen immediately next to, and touching, her uniform. She continued walking down the hallway.

In an interview with Housekeeper #158 at the time of observation, she started she was taking the linen to a room being prepared for a new patient. CVICU Manager #205 explained to Housekeeper #158 that she had contaminated the linen by holding it next to her dirty uniform. The CVICU Manager also informed the housekeeper that clean linen should be transported by a linen cart or held away from your body. Housekeeper #158 said, No one has ever told me this before.

Review of facility policy titled, Guidelines for Handling of Linen, dated 01/2012, revealed details for the process for staff handling of soiled linen only; not clean.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure 2 (Patient #1 and Patient #2) of 10 patients (Patient #1, #2, #3, #4, $5, #6, #7, #8. #9 and Patient #10) or family were provided the opportunity to make an informed decision and provide consent regarding the use of chemical restraint. This failed practice resulted in the patient being chemically restrained, temporarily paralyzed and placed on life support without consent.

Findings included:

In a phone interview with MD #69 on 06/09/2016 at 0955, he stated, Patient #1, a psychiatric patient, was given general anesthesia and placed on life support because of his behavior. He also stated Patient #1 was upset about being put on a ventilator and Patient #2, a developmentally delayed patient, was given general anesthesia and placed on life support in order to control him.

Patient #1.

Record review of Emergency Notes by RN #58 dated 11/02/2015 at 1625 (the first of three admissions) revealed Patient #1 was discharged into the care of his sister. His mother's phone number was documented in the record.

Record review of Emergency Provider Report by MD # 57 dated 11/03/2015 at 1623 revealed the second of three admissions for Patient #1. He left prior to receiving his discharge paperwork.

Record review of Emergency Provider Report by MD #56 on 11/04/2015 (1139-1706) revealed the third of three admissions for Patient #1.

Record review of Emergency Notes by RN #63 on 11/05/2015 at 0117 revealed that Patient #1 was put into the seclusion room due to increased agitation. While in seclusion, he punched the walls and door resulting in left hand lacerations. MD # 60 ordered the patient be moved from the psychiatric annex back to the emergency department.

Record review of Emergency Provider Report by MD #60 dated 11/05/2015 at 0235 revealed Patient #1 was intubated. At 0358, the lumbar puncture was done emergently ... given patient not consentable [sic] as he is agitated, confused, no family contact.

Record review of Patient #1's chart November 4-12, 2015 did not reveal a consent for sedation.

Record review of the Medication Administration Record for Patient #1 on 11/05/2015 (0220-0304) revealed the following medications administered: Rocuronium [muscle relaxant], Etomidate [anesthetic], Propofol [muscle relaxant], Vecuronium [muscle relaxant], Versed [sedative] and Fentanyl [analgesic].

Record review of the History & Physical by MD #68 dated 11/05/2015 at 1525 revealed Patient #1 became very agitated and was intubated for further protection.

Record review of Psychiatric Evaluation Note by MD #70 dated 11/09/2015 at 1536 revealed Patient #1 had a history of schizoaffective disorder.

Patient #2.

Record review of Emergency Provider Report by MD #76 dated 03/17/2016 at 0945 revealed, Patient #2 was a 24 year old, aggressive, combative male brought in by the police in cuffs. Primary Impression: Agitation. Secondary Impression: Psychosis.

Record review of Patient Notes by RN #78 dated 03/17/2016 at 1337 revealed Patient #2 stated he had used kush [synthetic cannabinoids] the previous day, but difficult to tell how accurate patient is related to being medicated.

Record review of Patient Notes by RN #80 dated 03/18/2016 at 0920 revealed, Patient #2 stated he had been doing Sonic Boom which is a synthetic marijuana. At 1120: Management problem ... multiple intramuscular medications for agitation, threatening and combative behavior ... actively hallucinating. At 1333 - Patient was put into seclusion ... Extremely poor boundaries. At 1437 - While in seclusion patient began banging on the door so hard he broke the door ... code gray called. MD #76 notified and ordered that patient be transferred to ER to be intubated at 1437.

Record review of Patient Notes by RN #81 on 03/18/2016 (1442-1443) revealed, Patient #2 was given ketamine and intubated by MD #76.

Record review of Patient #2's chart did not reveal a consent for sedation.

Record review of History & Physical by MD #82 dated 03/18/2016 at 1658 revealed Patient #2 was a [AGE] year old African American male. He was placed in seclusion and broke the door. The patient was taken to the emergency room , sedated, paralyzed and intubated due to severe aggression. He is now on the ventilator ... sedated with diprivan. Impression: Acute respiratory failure secondary to severe agitation.

Record review of Policy, Sedation Analgesia, dated 03/2015 revealed: Statement of Purpose ... To ensure the following established goals are met: ... Assure the patient ' s safety and welfare ... The licensed independent practitioner or advanced practice professional is responsible for obtaining informed consent for the procedure ... Relative to the planned procedure and sedation analgesia, information is provided to the patient and family prior to administration regarding the following: ... Risk ... Potential benefits/drawbacks ... Any significant alternatives ... Potential problems related to recuperation ...

Record review of Policy, Patient Rights and Responsibilities, dated 01/2012 revealed: All patients are to be treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights and involvement in their own care.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure the right for 2 (Patient #1 and Patient #2) of 10 patients (Patient #1, #2, #3, #4, $5, #6, #7, #8. #9 and Patient #10) to receive care in a safe setting as evidenced by the use of the most restrictive measures of restraint prior to the use of less restrictive measures such as physical restraints. This failed practice resulted in both patients being chemically restrained, temporarily paralyzed and placed on life support.

Findings included:

In a phone interview with MD #69 on 06/09/2016 at 0955, he stated:

+ General anesthesia and life support is being used at this hospital to control the behavior of psychiatric patients.

+ There is controversy about the use of anesthesia and ventilators to control behavior but some emergency room physicians feel it is appropriate.

+ Patient #1 was upset about being put on a ventilator.

+ Patient #2, a developmentally delayed patient, was given general anesthesia and placed on life support in order to control him.

In an interview with Chief Medical Officer (CMO) #72 on 06/08/2016 at 1045, he stated:

+ MD #69 was very upset because Patient #1 and Patient #2 were intubated.

+ MD #69 was concerned over patient rights and wrote a letter about his concerns.

+ MD #69 brought up his concern about the use of ketamine on psychiatric patients in the emergency department in a meeting on May 31, 2016 with CMO #72, ER Director MD #76 and MD #91. The issue of patient rights was again discussed, along with airway safety and the need for better documentation.

+ The use of restraints would have been a less restrictive measure to control Patient #1.

+ The use of intubation should be a last resort.

In an interview with Behavioral Health Director MD #70 on 06/09/2016 at 1050, he stated:

+ Intubation of psychiatric patients for control of their behavior was not common practice in emergency departments.

+ He had seen psychiatric patients intubated in this facility's emergency department.

+ The first line of treatment for agitated patients was psychiatric medications, maybe 3-4 doses.

+ The use of restraints should have been a step between medications and intubation in the treatment of Patient #1 and Patient #2.

Patient #1.

Record review of Emergency Notes by RN #58 dated 11/02/2015 at 1625 revealed the first of three admissions for Patient #1.

Record review of Emergency Provider Report by MD # 57 dated 11/03/2015 at 1623 revealed the second of three admissions for Patient #1.

Record review of Emergency Provider Report by MD #56 on 11/04/2015 (1139-1706) revealed the third of three admissions for Patient #1. He reported seizure, joint pain, depression, anxiety, auditory hallucinations and marijuana use. Inpatient treatment was recommended due to bothersome hallucinations and acting odd.

Record review of Emergency Notes by RN #63 on 11/05/2015 at 0117 revealed that Patient #1 was put into the seclusion room due to increased agitation where he punched the walls and door resulting in left hand lacerations. MD # 60 ordered the patient be moved from the psychiatric annex back to the emergency department.

Record review of Emergency Provider Report by MD #60 dated 11/05/2015 at 0235 revealed Patient #1 was intubated.

Record review of the Medication Administration Record for Patient #1 on 11/05/2015 (0220-0304) revealed the following medications administered: Rocuronium [muscle relaxant], Etomidate [anesthetic], Propofol [muscle relaxant], Vecuronium [muscle relaxant], Versed [sedative] and Fentanyl [analgesic].

Record review of the History & Physical by MD #68 dated 11/05/2015 at 1525 revealed Patient #1 became very agitated and was intubated for further protection. Assessment included: altered mental status, acute respiratory failure, history of substance abuse, depression and acute psychosis.

Record review of Pulmonary Consultation Note by MD #69 dated 11/05/2015 at 1904 revealed that Patient #1 was intubated after ketamine. Diagnosis: manic depressive disorder. MD #69 extubated the patient and recommended soft restraints if needed and psychiatric consult.

Record review of Psychiatric Evaluation Note by MD #70 dated 11/09/2015 at 1536 revealed Patient #1 had a history of schizoaffective disorder.

In an interview with Behavioral Health Educator RN #75 on 06/09/2016 at 0920, she stated that the facility intubated for behavioral problems as a last resort. She also stated that she had never seen soft restraints at the facility.

In an interview with ED Director MD #76 on 06/09/2016 at 1245, he stated:

+ Restraints were not used for behavioral problems.

+ The use of ketamine, intubation, and general anesthesia is a chemical restraint. That's our goal.

In an interview with Behavioral Health Manager #77 on 06/09/2016 at 0920, he stated, that Corporate MD #89, was looking into how to handle behavioral problems of patients on kush [synthetic cannabinoids] that present to the ED.

Patient #2.

Record review of Emergency Provider Report by MD #76 dated 03/17/2016 at 0945 revealed, Patient #2 was a [AGE] year old aggressive, combative male brought in by the police in cuffs. Primary Impression: Agitation. Secondary Impression: Psychosis.

Record review of Patient Notes by RN #78 dated 03/17/2016 at 1337 revealed Patient #2 stated he had used kush [synthetic cannabinoids] the previous day, but difficult to tell how accurate patient is related to being medicated.

Record review of Patient Notes by RN #80 dated 03/18/2016 at 0920 revealed Patient #2 stated he had been doing Sonic Boom which is a synthetic marijuana. At 1120: Management problem ... multiple intramuscular medications for agitation, threatening and combative behavior ... actively hallucinating. At 1333 - Patient was put into seclusion ... Extremely poor boundaries. At 1437 - While in seclusion patient began banging on the door so hard he broke the door ... code gray called. MD #76 notified and ordered that patient be transferred to ER to be intubated at 1437.

Record review of Patient Notes by RN #81 on 03/18/2016 (1442-1443) revealed Patient #2 was given ketamine and intubated by MD #76.

Record review of History & Physical by MD #82 dated 03/18/2016 at 1658 revealed Patient #2 was a [AGE] year old African American male. He was placed in seclusion and broke the door. The patient was taken to the emergency room , sedated, paralyzed and intubated due to severe aggression. He is now on the ventilator ... sedated with diprivan. Impression: Acute respiratory failure secondary to severe agitation.

Record review of Intubation Note for Patient #2 by MD #83 dated 03/21/2016 at 0042 revealed: Indications: respiratory failure at request of MD #90, uncontrolled psychosis.

Record review of Policy, Sedation Analgesia, dated 03/2015 revealed: Statement of Purpose ... To ensure the following established goals are met: ... Assure the patient ' s safety and welfare ... The licensed independent practitioner or advanced practice professional is responsible for obtaining informed consent for the procedure ... Relative to the planned procedure and sedation analgesia, information is provided to the patient and family prior to administration regarding the following: ... Risk ... Potential benefits/drawbacks ... Any significant alternatives ... Potential problems related to recuperation ...

Record review of Policy, Patient Rights and Responsibilities, dated 01/2012 revealed: All patients are to be treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights and involvement in their own care.

Show Text of Violation

Based on interview and record review, the facility failed to ensure the Emergency Department developed policies and procedures for the use of less restrictive measures in the medical care of patients. This failed practice resulted in patients being chemically restrained, temporarily paralyzed and placed on life support in the Emergency Department; 2 (Patient #1 and Patient #2) of 10 patients (Patient #1, #2, #3, #4, $5, #6, #7, #8. #9 and Patient #10) were intubated to control their behavior.

Findings included:

In a phone interview with MD #69 on 06/09/2016 at 0955, he stated, General anesthesia and life support is being used at this hospital to control the behavior of psychiatric patients. He also stated, Patient #1 and Patient #2 had been intubated and placed on life support to control their behaviors.

In an interview with Chief Medical Officer (CMO) #72 on 06/08/2016 at 1045, he stated that MD #69 was very upset because Patient #1 and Patient #2 were intubated. He also stated that there was no protocol for the use of ketamine with psychiatric patients, restraints would have been a less restrictive measure to control behavior and the use of intubation should be a last resort.

In an interview with Behavioral Health Director MD #70 on 06/09/2016 at 1050, he stated:

+ Intubation of psychiatric patients for control of their behavior was not common practice in emergency departments.

+ He had seen psychiatric patients intubated in this facility ' s emergency department.

+ The first line of treatment for agitated patients was psychiatric medications, maybe 3-4 doses.

+ The use of restraints should have been a step between medications and intubation in the treatment of Patient #1 and Patient #2.

In an interview with Behavioral Health Educator RN #75 on 06/09/2016 at 0920, she stated that the facility intubated patients for behavioral problems as a last resort. She also stated that she had never seen soft restraints at the facility.

In an interview with ED Director MD #76 on 06/09/2016 at 1245, he stated:

+ Restraints were not used for behavioral problems.

+ There was no protocol for the use of ketamine, intubation and ventilation for patients with behavior problems. People are different.

+ The use of ketamine, intubation, and general anesthesia is a chemical restraint. That's our goal.

In an interview with MD #56 on 06/09/2016 at 1300, he stated he was not aware of a set protocol for the use of ketamine, intubation and ventilation for the control of a psychiatric patient's behavior.

Show Text of Violation

Based on observation, interview, and record review June 8-10, 2016, the governing body failed to ensure that:

1. The patient ' s right to receive care in a safe setting was upheld,

2. Protocols were developed in the Emergency Department for the progressive use of restraints, and

3. Pharmacy provided oversight for the use of chemical restraints in the Emergency Department.

The identified practices resulted in actual harm to 2 patients and presents a likelihood of harm to all current and potential patients with behavioral problems in the Emergency Department.

Based on interview and record review, the facility failed to ensure the patient's right to receive care in a safe setting as evidenced by the use of the most restrictive measures of restraint .prior to the use of less restrictive measures. This failed practice resulted in patients being chemically restrained, temporarily paralyzed, and placed on life support. This poses a risk for current and potential patients with behavioral problems in the Emergency Department. Refer to 482.13(c)(2) - [A-0144].

Based on interview and record review, the facility failed to ensure the patient or family was provided the opportunity to make an informed decision and provide consent regarding the use of chemical restraint. This failed practice resulted in the patient being chemically restrained, temporarily paralyzed and placed on life support without consent. This poses a risk for current and potential patients with behavioral problems in the Emergency Department. Refer to 482.13(b)(2) - [A-0131].

Based on interview and record review, the facility failed to ensure the pharmacist provided oversight in the developing, supervising and coordinating protocols for and the use of medications. This failed practice resulted in two patients being chemically restrained, temporarily paralyzed and placed on life support in the Emergency Department. This poses a risk for current and potential patients with behavioral problems in the Emergency Department. Refer to 482.25(a)(1) - [A-0492].

Based on interview and record review, the facility failed to ensure the Emergency Department developed policies and procedures in the medical care provided to behavioral patients. This failed practice resulted in two patients being chemically restrained, temporarily paralyzed and placed on life support in the Emergency Department. This poses a risk for current and potential patients with behavioral problems in the Emergency Department. Refer to 482.55(a)(3) - [A-1104].

Show Text of Violation

Based on record review and interview the facility failed to assess and document a patient's pain level and provide appropriate pain management intervention when the patient complains of pain prior to being transferred from the hospital;

The facility failed to evaluate and document the patient's response to pain medication that was administered prior to her discharge from the hospital. Citing Patient (# 2) named in a complaint.

Findings:

Review of complaint narrative revealed allegations that Patient # 2 arrived at Q Nursing Home screaming from pain because Hospital (P) where she was a patient did not give her the pain medication she requested for her pain prior to sending her to a Nursing Home.

Review of history and physical dated 6/13/2015 revealed information the patient was admitted to the hospital with complaints she fell while getting in a truck and is having pain in her back and both knees.

Subsequent radiology examination revealed the patient had a right knee fracture. She was admitted to the post surgical unit for pain management and knee immobilization.

Review of nurses notes dated 7/8/2015 at 6:51 pm revealed information Patient # 2 complained of pain.

There was documentation the Tramadol was not due until 6:00 pm.

The Physician was informed and a one (1) time order of Tylenol 650 mg was administered to the patient at 4:52 pm.

There was no documentation the patient was assessed for severity of pain or evaluated for the patient's response to the medication that was administered.

Review of discharge records revealed the patient was discharged from the facility at 4:57 pm (two minutes after she received the Tylenol).

Review of medication administration records dated 6/13/2015 through 7/8/2015 9 revealed the patient was being treated with pain medication as follows:

Hydro/codone/APAP 10/325 one (1) tablet every four (4) hours as needed.(order discontinue 7/9/2015 due to discharge)

Tramadol 50 mg tablet every 6 hours as needed.

Duragesic Patch 50 microgram/Hr (fentanyl) as needed every three (3) days.

Flexeril 10 mg orally every eight (8) hours last given 7/4/2015 at 0626 am.

Review of discharge summary dated 7/8/2015 revealed the discharge plan for Patient (# 2) was to discharge the patient to a nursing home to continue pain management until the pain was sufficiently controlled for her to tolerate therapy.

During a telephone interview on 10/23/2015 at 9:15 am with Physician (#MJ ) he stated Tylenol was not sufficient pain medication for the patient because she had severe fracture pain.

He further stated there were standing orders that could have been given because the medications would not be discontinued until after the patient left the hospital.

During a interview on 10/23/2015 at 12:20 pm with the Chief Medical Officer he stated the patient's pain would not have been adequately managed with Tylenol.

He stated he would review the medical record and address the matter with Staff.

Review of the facility's Pain Management Guidelines dated March, 2015 revealed the following information:

An appropriate pain scale rating will be utilized in conjunction with psychological data to guide pharmacological management of pain.

Effectiveness of pharmacological and non-pharmacological intervention will be evaluated within the appropriate time frames.

Pain should be reassessed after each pain medication administered. Pain assessment and reassessment must be documented.

Show Text of Violation

Based on record review and interview the facility failed to develop a plan of care for a patient when the patient had a positive urine culture for E.Coli bacteria to ensure appropriate treatment intervention was implemented.

This failed practice resulted in the patient being discharged from the facility with an undiagnosed , untreated treated urinary tract infection(UTI). Citing Patient # 2 named in a complaint.

Findings:

Review of complaint narrative revealed allegations that Patient # 2 was transferred from Hospital P on 7/8/2015 to Q Nursing Home with an untreated urinary tract infection (UTI).

Review of history and physical dated 6/13/2015 revealed information the patient was admitted to the hospital with complaints she fell while getting in a truck and is having pain in her back and both knees.

Subsequent radiology examination revealed the patient had a right knee fracture. She was admitted to the post surgical unit for pain management and knee immobilization.

There was no history of fever or chills. Urinalysis revealed dark yellow urine clear in color. Genitourinary: No urinary symptoms. The patient was alert and oriented x 3.

Review of nurses notes dated 6/14/2015 revealed documentation that a Foley catheter was inserted,indication urinary retention and immobilization.

Nurses notes dated 6/28/2015 revealed documentation the patient's urine was cloudy and foul smelling.

Urine was sent to the laboratory for culture on 6/29/2015 and the Foley catheter was removed, (after being inplace for 15 days).

Review of the culture results revealed the urine was positive for E.Coli with a colony count greater that 100,000 colony forming units (cfu).

Review of Nurses notes dated 7/6/2015 revealed documentation A urine culture was done again on 7/6/2015 .

Review of the culture results revealed the urine was positive for E.Coli with colony count greater that 100,000 cfu.The Foley catheter was reinserted.

Review of physician's orders and progress notes dated 6/29/2015 through 7/8/2015 when the patient was discharged from the hospital revealed no documentation addressing the positive urine cultures.

Review of nursing care plans revealed a nursing care plan was not developed to address the positive urine cultures.

There was no documentation that the physician was informed of the first urine culture report.

Review of discharge plan and instructions dated 7/8/2015 revealed the positive urine cultures were not addressed.

Review of medication Administration record and treatment orders dated 6/13/2015-7/8/2015 revealed the patient was never given antibiotics or any other treatment for UTI.

During a telephone interview on 10/23/2015 at 9:25 am with Physician (#MJ) who attended Patient # 2 while she was in hospital, he stated the

chief focus of care for Patient # 2 was pain management for the multiple fractures she had.

He stated he coluld not recall what the colony count was for the urine but treatment would be considered for a colony count greater than 100,000.

During an interview on 10/23/2015 at 12: 25 pm with the Chief Medical Officer he stated the patient had a urine culture with a colony count greater

than 100,000 she should haven been treated for the Urinary Tract Infection (UTI).

During an interview on 10/23/2015 at 8:45 am with the Nurse Manager on the unit where Patient #2 was a patient she stated a nursing care plan

should have been developed to indicate the culture findings and the physician informed.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility's nursing staff failed to apply label while administering Intravenous medication in 2 of 5 sampled patients

Findings:

Patient #2

On 03/18/2015 at 01:05 p.m. patient # 2 was in room #3042, pt. was coherent with a companion at the bedside. The companion introduced herself as the daughter. The Surveyor noted a left hand Peripheral Intravenous running with 75 mls/min of Lactated Ringer ' s Solution. The Surveyor asked the patient since when it was inserted; he answered I can ' t recall what I only know is they put this on me yesterday.

Reviewed patient #2 medical records on 03/18/2015 revealed that patient #2 admitted to the facility on [DATE] due to Right Hip dislocation.

Interview with the Nurse Manager (1) on 03/18/2015 at 01:25 p.m., the Surveyor notified her that the PIV label for patient #2 is not identified; she said Okay, I will make sure we will have it labeled.

On 03/19/2015 at 10:30 a.m. the Surveyor checked patient # 2 that was in room #3042. He was awake, coherent with the same companion on 03/18/2015 companion at the bedside. The Surveyor noted a Right hand Peripheral Intravenous running with 75 mls/min of 0.45% Saline Solution. The Surveyor asked the patient since when it was inserted, he answered I messed up with my IV last night, I guess when I was sleeping, and the night nurse inserted it here in my right hand that time.

Patient #3

On 03/19/2015 at 09:45 a.m. patient # 3 was in room #3046, pt. was coherent with a companion at the bedside. The companion introduced herself as the daughter. The Surveyor noted a right forearm Peripheral Intravenous running with Magnesium and Sodium Chloride Solution. The Surveyor asked the patient since when it was inserted; he answered They poked me like 3 times, but was it was placed when I came in.

Reviewed patient #2 medical records on 03/19/2015 revealed that patient #3 admitted to the facility on [DATE] due to Lombago, and Acute Otitis Media.

Interview with the Staff Nurse (3) on 03/19/2015 at 10:40 a.m., the Surveyor notified her that the PIV labels for patient #2 & 3 are not identified; she said Yes, I am going to put a label now for each of them.

Facility Policy reviewed about Medication Administration: Intravenous Administration Guidelines Approved on 02/2015 page 1.C. When a peripheral cannula is being used for continuous or intermittent IV infusion, it will be changed every 72 hours provided that no IV-related complications are encountered before this time. Page 2.E.1 All IV tubing will be labeled with a ' Day of the Week ' sticker when initiated. The ' Day of the Week ' sticker will denote the date that the tubing is to be changed.

Show Text of Violation

Based on observation, interview and record review, the facility's nursing staff failed to monitor and evaluate the nursing care for each patient in 2 of 3 sampled patients.

Findings:

Patient #2

On 01/13/2015 at 10:00 a.m. patient # 2 was lying slightly elevated with 1 pillow on his bed, coherent with a companion at the bedside. The companion introduced herself as a mother.

Patient #3

On 01/13/2015 at 10:15 a.m. patient # 3 was lying slightly elevated with 1 pillow on his bed, coherent with a companion at the bedside. The companion introduced herself as a wife, and said I never saw anyone turning my patient or changing his position to prevent bedsore since we came here since Saturday last week, I am the only one doing that. He developed bed sore here since when he came last year. The Surveyor verified this to the patient, and he nodded saying No, I was not turned since this morning.

During an interview on 01/13/2015 at 10:25 a.m. with assigned Nurse (3) for patient # (3), the Surveyor asked the Registered Nurse for a copy of her monitoring to prevent pressure sore, and she said I have this record. She presented to the Surveyor that the patient was turned at 7am,9am, 12 pm, and 3pm on 01/13/2015. Record review of patient #3 revealed patient has Sacral and Heel Ulcers, with a documentation showing an advanced positioning of patient.

During an interview on 01/13/2015 at 10:30 a.m. with assigned Nurse (3) for patient # (3), the Surveyor asked the Registered Nurse for the process of repositioning the patient and she said We are supposed to turn our patients every 2 hours or frequently to prevent bedsore.

Record review of patient #1 revealed patient has unstageable Pressure Ulcers on the Sacrum with a documentation showing a blank positioning of patient.

The Director of Nursing (5) said We have a Rounding Report we can show you. She presented to the Surveyor and the patient ' s Rounding Report with turning position was empty every hour for patient #3. The Surveyor asked her how to ensure that patients are monitored regularly to prevent bed sore, and she said That is the hard part to prove since our nurses discard this record as this is not part of the chart. We do not have in our computer system that will show a patient was turned in a particular hour to a certain position.

The Interim Risk Manager (2) stated The nurses have to follow the care guidelines when they chart, and turning the patient every 2 hours is part of that. So, before the end of the shift they need to check if it was done. We are following the Lippincott Procedure for our policy about Repositioning the patient. The Surveyor notified her that the patients are not monitored to be positioned, as there was no documentation that will support that it was performed regularly.

Lippincott Procedures about Pressure Ulcer Prevention with Revision on January 09, 2015 stated on page 1 Turn and reposition the patient every 1 to 2 hours or more frequently as required. Page 2 stated Document procedure.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to fully analyze an adverse event in a timely manner.

The facility failed to ensure that a variance report was completed per policy guidelines following the discovery of an injury to Patient # 6 ' s leg.

Findings include:

TX # 669

Review of complaint intake TX # 669 revealed Patient ID # 6 was admitted to facility on 04-02-14 for poor circulation of the right leg and gangrene of the second toe in her right foot. According to the complaint intake documentation, Patient ID #6 left the room to have an angiogram on 04-04-14. Upon the Patient ' s return to the room, a family member discovered blood on the bed sheet and a gash on Patient # 6 ' s right leg, just above the ankle. There had been no mention of the injury provided to the family; the gash was just covered by tape.

Review of Patient ID # 6 ' s clinical record revealed she was a [AGE] year old female admitted to the facility on on [DATE] for poor circulation and non-healing gangrenous right toes.

Record review on 07-23-14 of facility Risk Occurrence Report, dated 04-08-14 (0754) completed by RN # 62 read: Patient and daughter stated that patient had a skin tear to rt. Lower extremity when she went down for angiogram. Daughter stated that her mother ' s skin was intact before leaving the floor and came back with skin tear ...

Interview on 07-23-14 at 1:10 PM with RN # 63 she stated she was the nurse assigned to the angiogram case on 04-04-14 with Patient ID # 6. She said she remembered the patient was moved from the stretcher to the x-ray table with a slider board. There were staff at the patient ' s head and feet; Patient ID # 6 ' s legs were picked up during the transfer.

RN # 63 said after the transfer, she saw blood on the sheet and noticed the laceration to Patient ID # 6 ' s right lower leg. She said I had no idea how it got there. It looked as if it had just happened; it was bleeding. She went on to say she cleaned the wound with normal saline and covered it with a tegaderm dressing. The angiogram was done and report was given to the recovery room (RR) nurse. RN # 63 said she informed the RR room nurse of the wound to the patient ' s leg.

RN # 63 said she did not complete a variance report; stated I should have. Review of RN # 63 ' s nursing note on 04-04-14 read: right lower extremity laceration; covered with tegaderm.

Interview on 07-23-14 at 12:30 p.m. with facility Risk Manager ID # 52 she stated that when the facility met with the patient ' s daughter she seemed most upset that no staff informed her about the injury. Risk Manager ID # 52 acknowledged the variance report was completed 4 days after the injury was discovered and it should have been completed the same day.

Interview on 07-23-14 at 12:45 p.m. with facility Director of Risk Management ID # 56 she stated the expectation was that staff complete variance reports immediately or at least by the end of the shift the occurrence happened. She acknowledged that had a variance report been completed timely for Patient ID # 6 ' s injury, the communication process with the family would have begun sooner.

Review of facility policy titled: Variance Reporting Patient and Non-Patient, revised date 12/11, read:

Definition of ' event ' , variance, ' occurrence ' : any happening out of the ordinary that results in a potential for or actual injury to a patient visitor ...any event that is not consistent with or reasonably expected as a consequence of medical care and treatment. ...Policy adverse events ...unexpected events ...will be promptly reported inline in the Meditech System even if the event seems insignificant at the time ...Event reports should be completed during the shift the event occurs or is discovered to have occurred...the individual most directly involved or who discovers the event is responsible for entering the event into the system ...

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure patient made informed decisions regarding their treatment. Facility failed to instruct the patients about psychoactive medications administered prior to giving the medications for 7 of 12 sampled patients (ID #s 1, 4, 6, 8, 9, 10 & 11). This deficient practice has the potential to affect all patients preventing them from making informed decisions about their care and exercising their right to request or refuse treatment.

Findings:

Review of medical records for patients (ID #s 1, 4, 6, 8, 9, 10 & 11) revealed that the following psychoactive medications were ordered and administered. Informed consent forms for the medications required prior to the administration of these medications were not completed as required under state law (25 TAC 405.804(a)), and the facility ' s policy and procedure.

Review of Physician Orders and Medication Administration Record (MAR) for the following patients revealed:

Patient ID#1 admitted on [DATE] and discharged on [DATE] received Lamictal 25mg by mouth (PO) at bedtime. Medication was ordered and started 5/30/13 at 9:00pm. No informed consent for medication in patient ' s medical record.

Patient ID# 4 admitted on [DATE] received the following medications without informed consent:

Geodon 80mg PO twice daily was ordered 8/10/13 and started same day.

Abilify 5mg PO daily was ordered 8/8/13 and started 8/9/13

Ambien 5mg PO at bedtime was ordered 8/4/13 and given from 8/4/13

Patient ID# 6 admitted on [DATE] received the following medications:

Seroquel 800mg PO at bedtime was ordered and started on 8/9/13.

Effexor 225mg PO daily was ordered and administered on 8/10/13.

Paxil 25mg PO daily was ordered and started 8/10/13.

Consents for the medications were completed on 8/13/13.

Patient ID# 8 admitted on [DATE]: Trazodone 50mg PO at bedtime was ordered 8/2/13 and given from 8/2/13, consent was signed 8/4/13.

Patient ID# 9 admitted on [DATE]:

Zyprexa 10mg PO three times a day was ordered on [DATE] and started same day.

Xanax 0.25mg PO twice daily was ordered 8/8/13 and initiated 8/8/13.

Consents for medications were signed on 8/13/13.

Patient ID#10 admitted on [DATE] and discharged on [DATE]: Lithium carbonate 300mg PO every eight hours and Risperdal 3mg PO at bedtime were ordered on [DATE] and started same day, Informed Consent forms were signed 7/9/13.

Patient ID# 11 admitted on [DATE] and discharged on [DATE] received the following medications without informed consent:

Librium 25mg PO four times a day was ordered on [DATE] and started 7/23/13.

Risperdal 1mg PO twice daily ordered on [DATE] and initiated same day.

Medical Records reviewed with Staff ID# 58. Interview with Staff ID# 58 and Chief Nursing Officer in conference room on 8/24/13, they acknowledged that informed consents should be signed prior to administration of psychoactive medications.

Review of facility ' s policy titled Informed Consent Medications/Psychoactive dated April 2011, section Procedure read:

(C) Informed consent is received for each newly ordered medication ... ...

(F) The informed consent for medication is documented on the Informed Consent for Medication form.

(H) Only those medications that the patient has consented to may be administered.

Show Text of Violation

Based on record review and interview the facility failed to conduct an appropriate medical screening examination by ensuring a pregnant woman in labor with history of a previous cesarean delivery was seen and examined by a physician according to hospital protocol for high risk pregnancies. Citing one Patient named in a complaint.

Findings:

Patient #1

Complaint Narrative

Review of complaint narrative revealed documentation that Patient #1 arrived at Hospital SJ on 3/5/11 shortly after midnight via private automobile. Patient #1 told the ER Physician at Hospital SJ that the Nurse Midwife at Hospital EH sent her over so that she could have a vaginal delivery.

Further review of the narrative revealed information that Patient #1 was examined and was 5-6 cm dilated. A plan was developed to do a repeat cesarean delivery. Patient #1 was counseled on the risks of vaginal birth and informed her that because Hospital SJ did not have an operative report from her last delivery they were uncomfortable with allowing her a trial of labor. The patient understood and agreed to a repeat cesarean.

Hospital EH

Review of record titled patient activity record documented that the patient arrived on the Labor and Delivery unit on 3/5/11 at 22:20 hours.

Flow sheet documented the patient's vital signs were done at 22:30. Blood Pressure (B/P) 108/61, pulse 77, respirations 16 and temperature 97.7 degrees. She was having uterine contractions at a frequency of every 6-7 minutes lasting for 60-70 seconds. The quality of contraction was mild. She was dilated 4cm with 80% effacement. Membranes were intact.

Further review of the flow sheets dated 3/5/11 revealed documentation that at 23:00 Staff #51, Certified Nurse Midwife (CNM), was at the bedside to evaluate her. There was documentation at 23:04 that Patient #1 states she wants to go back to Hospital SJ, she states she was there till 20:00 today and wants to have her baby there.

Review of Obstetrical History and Physical dated 3/5/11 revealed Patient #1 was examined at 23:05 by Staff #51. Patient gave history of having a cesarean section (C/S) 2/15/2006 for fetal distress. She had limited prenatal care with current pregnancy. She was recently seen at two hospitals and her plan for delivery a repeat C/S by 3/8/11 if she did not go into labor.

Impression after examination was IUP (Intra Uterine Pregnancy).

Plan was to discuss options for repeat C/S at Hospital EH - offer transfer to Hospital SJ if patient desires VBAC (vaginal birth after cesarean) states my husband can drive me. Hospital SJ called - spoke with Labor and Delivery about patient at 23:08. (no information of what was said)

Further review of flow sheet dated 3/5/11 at 23:11 revealed documentation that patient dressed and discharge instruction given to go straight to Hospital SJ now, patient verbalized understanding. Patient escorted to family car in stable condition. Patient given choice to go via ambulance or personal car, patient and spouse state prefers own car.

Review of physician's order record, dated 3/5/11 at 23:30 revealed the following information:

Diagnosis: IUP (Intra Uterine Pregnancy) at 40 weeks and one day, previous C/S in labor. Discharge from triage to go directly to Hospital SJ per patient request signed by Staff #51.

Review of progress notes dated 3/5/11 23:30 documented the following information: Spoke with Resident at Hospital SJ, Attending on call will not do vaginal birth after cesarean section (VBAC). Patient will need repeat C/S even if in labor and desires VBAC.

Staff #51 documented that she spoke to the Obstetrician on call at Hospital EH regarding the patient and the physician said he would offer a repeat C/S to the patient since VBAC is not available at Hospital EH. She went to discuss with patient, patient and spouse had already left Labor and Delivery unit.

Discharge instructions were given to the patient to go directly to Hospital SJ Labor and Delivery by the Triage Nurse. Called Hospital SJ Labor and Delivery to let them know that the patient was enroute.

Review of Discharge Summary dated 3/5/11 at 23:10 documented that Discharge provider was Staff #51. Patient's condition was stable, she was discharged to: Other

Teaching instruction given to patient and spouse, instructions understood. Patient was to go directly to Hospital SJ is per patient request.

There was no documentation that a Physician saw and examined the patient prior to discharge or that a physician ordered a discharge for the patient.

The patient did not leave against medical advice she was discharged by facility staff and given discharge instructions.

Review of the facility's Hospital Clinical Guidelines for Midwifery service dated 12/1/2010 documented the following information:

If a condition is identified in a patient receiving care from the CNM (Certified Nurse Midwife), which requires evaluation or management by a physician, the patient will be referred to the appropriate consultant.

Further review of the policy section titled Known Conditions Requiring Referral To Physician Care:

Obstetrical complications such as prior cesarean sections in labor (unless delivery is imminent).

There was no evidence that Patient #1 was placed in the care of a physician. There was no physician's evaluation. The patient was discharged from the facility less than two hours after arrival on the Obstetric Unit.

Review of the facility's policy # LL.EM.005 dated 3/2008 described as EMTALA documented the following information:

Purpose: To establish guidelines for providing appropriate medical screening examinations and, if the individual is determined to have an emergency medical condition, any necessary stabilizing treatment or an appropriate transfer for the individual as required by Emergency Medical Treatment and Active Labor Act (EMTALA).

Section IV documented that the evaluation of the patient is an on-going process. The record must reflect continued monitoring according to the individual's needs and must continue until the individual is stabilized or appropriately transferred. This evaluation must be documented in the individual's medical records prior to discharge or transfer. When stabilizing treatment is rendered for an EMC, medical records should indicate the treatment necessary, medications, treatment, surgeries and services provided, and their effect on the EMC, including screenings, tests, evaluations, impressions and diagnoses.

The facility did not follow their policy to provide an appropriate medical screening examination.

During an interview on 3/18/11 at the facility with Staff #51, she stated she did not discharge the patient, it was another nurse. According to Staff #51, she had a discussion with the hospital physician regarding the patient's desire for a vaginal birth, the Physician said he would offer a repeat C/S only. Spoke to staff at Hospital SJ and they also would only do a repeat C/S. Staff #51 said she went to speak to the patient and was informed by the triage nurse that the patient was discharged and instructed to go to Hospital SJ.

According to Staff #51 when she found out the patient was gone she was angry. She called Hospital SJ to alert them that the patient was enroute to their facility.

The Surveyor asked Staff #51 how the discharge situation was handled she stated she informed the Unit Director the following morning. Staff #51 did say the narrative notes she wrote, were written after the patient left.

During a telephone interview on 3/29/11 at 2:00 pm with Patient #1, she stated she was discharged and instructed to go directly to Hospital SJ. She went to Hospital SJ where they delivered her by cesarean section.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to provide stabilizing treatment for a patient in labor who went to the Labor and Delivery suite for her delivery. The patient was examined by Labor unit staff and diagnosed as being in labor. The facility staff discharged the patient from the facility without delivering the baby and placenta. Citing one Patient named in a complaint.

Findings:

Patient #1

Complaint Narrative

Review of complaint narrative revealed documentation that Patient #1 arrived at Hospital SJ on 3/5/11 shortly after midnight via private automobile. Patient #1 told the ER Physician at Hospital SJ that the Nurse Midwife at Hospital EH sent her over so that she could have a vaginal delivery.

Further review of the narrative revealed information that Patient #1 was examined and was 5-6 cm dilated. A plan was developed to do a repeat cesarean delivery. Patient #1 was counseled on the risks of vaginal birth and informed her that because Hospital SJ did not have an operative report from her last delivery they were uncomfortable with allowing her a trial of labor. The patient understood and agreed to a repeat cesarean.

Record at Hospital EH

Review of record titled patient activity record documented that the patient arrived on the Labor and Delivery unit on 3/5/11 at 22:20 hours.

Flow sheet documented the patient's vital signs were done at 22:30. Blood Pressure (B/P) 108/61, pulse 77, respirations 16 and temperature 97.7 degrees. She was having uterine contractions at a frequency of 6-7 minutes lasting for 60-70 seconds. The quality of contraction was mild. She was dilated 4cm with 80% effacement. Membranes were intact.

Further review of the flow sheets dated 3/5/11 revealed documentation that at 23:00 Staff #51, Certified Nurse Midwife (CNM), was at the bedside to evaluate her. There was documentation at 23:04 that Patient #1 states she wants to go back to Hospital SJ, she states she was there till 20:00 today and wants to have her baby there.

Review of Obstetrical History and Physical dated 3/5/11 revealed Patient #1 was examined at 23:05 by Staff #51. Patient gave history of having a cesarean section (C/S) 2/15/2006 for fetal distress. She had limited prenatal care with current pregnancy. She was recently seen at two hospitals and her plan for delivery a repeat C/S by 3/8/11 if she did not go into labor.

Impression after examination was IUP (Intra Uterine Pregnancy).

Plan was to discuss options for repeat C/S at Hospital EH - offer transfer to Hospital SJ if patient desires VBAC (vaginal birth after cesarean) states my husband can drive me. St. Joseph's called - spoke with Labor and Delivery about patient at 23:08. (no information of what was said)

Further review of flow sheet dated 3/5/11 at 23:11 revealed documentation that patient dressed and discharge instruction given to go straight to Hospital SJ now, patient verbalized understanding. Patient escorted to family car in stable condition. Patient given choice to go via ambulance or personal car, patient and spouse state prefers own car.

Review of physician's order record, dated 3/5/11 at 23:30 revealed the following information:

Diagnosis: IUP (Intra Uterine Pregnancy) at 40 weeks and one day, previous C/S in labor. Discharge from triage to go directly to Hospital SJ per patient request signed by Staff #51.

Review of progress notes dated 3/5/11 23:30 documented the following information: Spoke with Resident at Hospital SJ, Attending on call will not do vaginal birth after cesarean section (VBAC). Patient will need repeat C/S even if in labor and desires VBAC.

Staff #51 documented that she spoke to the Obstetrician on call at Hospital EH regarding the patient and the physician said he would offer a repeat C/S to the patient since VBAC is not available at Hospital EH. She went to discuss with patient, patient and spouse had already left Labor and Delivery unit.

Discharge instructions were given to the patient to go directly to Hospital SJ Labor and Delivery by the Triage Nurse. Called Hospital SJ Labor and Delivery to let them know that the patient was enroute.

Review of Discharge Summary dated 3/5/11 at 23:10 documented that Discharge provider was Staff #51. Patient's condition was stable, she was discharged to: Other

Teaching instruction given to patient and spouse, instructions understood. Patient was to go directly to Hospital SJ, is per patient request.

Review of the facility 's policy # LL.EM.005 dated 3/2008 described as EMTALA documented the following information:

Purpose: To establish guidelines for providing appropriate medical screening examinations and, if the individual is determined to have an emergency medical condition, any necessary stabilizing treatment or an appropriate transfer for the individual as required by Emergency Medical Treatment and Active Labor Act (EMTALA).

Section IV documented that the evaluation of the patient is an on-going process. The record must reflect continued monitoring according to the individual's needs and must continue until the individual is stabilized or appropriately transferred. This evaluation must be documented in the individual's medical records prior to discharge or transfer. When stabilizing treatment is rendered for an EMC, medical records should indicate the treatment necessary, medications, treatment, surgeries and services provided, and their effect on the EMC, including screenings, tests, evaluations, impressions and diagnoses.

The facility failed to provide evidence that the patient had continued monitoring, no tests or continued assessment was documented

the facility discharged the patient approximately an hour after she arrived at the facility without delivering the patient and the placenta.

Patient #1 returned a phone call to the Surveyor on 3/29/11 at 2:00 pm.

During the interview the patient stated she went to Hospital EH because she had gone earlier to Hospital SJ was told she was half a centimeter dilated, her contractions were irregular she was not in labor and was sent home.

According to Patient #1 her pain was getting very bad so she went to Hospital EH. At Hospital EH the Doctor examined her and said she was 4cm dilated and was in labor. She told the Doctor that she was at Hospital SJ earlier and was sent home. The Doctor told her she would call Hospital SJ, afterwards she was told four times that if she went back to Hospital SJ, they would do a vaginal delivery there because Hospital EH will only do a repeat C/S.

Patient #1 stated she was surprised at the information because Hospital SJ had told her they would only do a repeat C/S because they did not have any information regarding her previous delivery and the risk of a ruptured uterus.

Patient #1 stated she was discharged and instructed to go directly to Hospital SJ. She was given instructions and the Nurse walked her to the waiting room where her husband was waiting. She walked to her car which was parked outside.

When asked by the Surveyor if she was offered an ambulance, Patient #1 stated the Nurse told her she could go in an ambulance or her car and since her car was there she decided to go by car. No one told her it was a risk to go by private car.

Hospital SJ

Review of Obstetric Triage Record at Hospital SJ revealed Patient #1 was admitted on [DATE] at eight (8) minutes after midnight. Reason for admission was documented as labor with contractions at a pain scale of 7/10 (10 being the most severe pain). She was examined and there was documentation that the Impression was: Active labor, with plan for a repeat cesarean section.

Examination: Temperature 98.0 degrees, pulse 70, respiration 108. Gestation was 40 weeks and 2 days with an expected delivery date of 3/4/11.

Vaginal examination: She was 5-6 centimeters dilated 80% effaced at station (-2). Irregular contractions every three (3) minutes. The patient gave medical history of having Diabetes.

Review of Labor and Delivery record revealed a male infant weighing six (6) pounds, four (4) ounces was delivered by C/S at 3:20 am on 3/6/11. The patient had Meconium stained liquor. (Approximately three and a half hours after arriving at the hospital from Hospital EH.)

During a telephone interview on 3/17/11 at 8:15 am with the Quality Director at Hospital SJ, she stated the Nurse Midwife at Hospital EH called Hospital SJ on 3/5/11 at about 11:30 pm requesting to transfer Patient #1 for a vaginal delivery after C/S. The physician informed the Nurse Midwife that Hospital SJ would only do a repeat C/S for the patient and since Hospital EH offers the same service and the patient is already there and in labor they should keep and treat the patient.

During a telephone interview on 3/31/11 with Physician T from Hospital SJ he stated it was a complete surprise to him when the patient showed up in her own private vehicle, in labor, from Hospital EH. According to Physician T, Hospital EH did not call them to say the patient was on her way.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to ensure an appropriate transfer was in place for a patient in active labor that was discharged from the Labor and Delivery suite with instructions to go in her private car directly to Hospital SJ (12.6 miles away). The patient had a history of previous cesarean section. Citing one Patient named in a complaint.

Findings:

Patient #1

Complaint Narrative

Review of complaint narrative revealed documentation that Patient #1 arrived at Hospital SJ on 3/5/11 shortly after midnight via private automobile. Patient #1 told the ER Physician at Hospital SJ that the Nurse Midwife at Hospital EH sent her over so that she could have a vaginal delivery.

Further review of the narrative revealed information that Patient #1 was examined and was 5-6 cm dilated. A plan was developed to do a repeat cesarean delivery. Patient #1 was counseled on the risks of vaginal birth and informed her that because Hospital SJ did not have an operative report from her last delivery they were uncomfortable with allowing her a trial of labor. The patient understood and agreed to a repeat cesarean.

Record at Hospital EH

Review of record titled patient activity record documented that the patient arrived on the Labor and Delivery unit on 3/5/11 at 22:20 hours.

Flow sheet documented the patient's vital signs were done at 22:30. Blood Pressure (B/P) 108/61, pulse 77, respirations 16 and temperature 97.7 degrees. She was having uterine contractions at a frequency of 6-7 minutes lasting for 60-70 seconds. The quality of contraction was mild. She was dilated 4cm with 80% effacement. Membranes were intact.

Further review of the flow sheets dated 3/5/11 revealed documentation that at 23:00 Staff #51, Certified Nurse Midwife (CNM), was at the bedside to evaluate her. There was documentation at 23:04 that Patient #1 states she wants to go back to Hospital SJ, she states she was there till 20:00 today and wants to have her baby there.

Review of Obstetrical History and Physical dated 3/5/11 revealed Patient #1 was examined at 23:05 by Staff #51. Patient gave history of having a cesarean section (C/S) 2/15/2006 for fetal distress. She had limited prenatal care with current pregnancy. She was recently seen at two hospitals and her plan for delivery a repeat C/S section by 3/8/11 if she did not go into labor.

Impression after examination was IUP (Intra Uterine Pregnancy).

Plan was to discuss options for repeat C/S at Hospital EH - offer transfer to Hospital SJ if patient desires VBAC (vaginal birth after cesarean) states my husband can drive me. Hospital SJ called - spoke with Labor and Delivery about patient at 2308. (no information of what was said)

Further review of flow sheet dated 3/5/11 at 23:11 revealed documentation that patient dressed and discharge instruction given to go straight to Hospital SJ now, patient verbalized understanding. Patient escorted to family car in stable condition. Patient given choice to go via ambulance or personal car, patient and spouse state prefers own car.

Review of physician's order record, dated 3/5/11 at 23:30 revealed the following information:

Diagnosis: IUP(Intra Uterine Pregnancy) at 40 weeks and one day, previous C/S in labor. Discharge from triage to go directly to Hospital SJ per patient request signed by Staff #51.

Review of progress notes dated 3/5/11 23:30 documented the following information: Spoke with Resident at Hospital SJ, Attending on call will not do vaginal birth after cesarean section (VBAC). Patient will need repeat C/S even if in labor and desires VBAC.

Staff #51 documented that she spoke to the Obstetrician on call at Hospital EH regarding the patient and the physician said he would offer a repeat C/S to the patient since VBAC is not available at Hospital EH. She went to discuss with patient, patient and spouse had already left Labor and Delivery unit.

Discharge instructions were given to the patient to go directly to Hospital SJ Labor and Delivery by the Triage Nurse. Called Hospital SJ Labor and Delivery to let them know that the patient was enroute.

Review of Discharge Summary dated 3/5/11 at 23:10 documented that Discharge provider was Staff #51. Patient's condition was stable, she was discharged to: Other

Teaching instruction given to patient and spouse, instructions understood. Patient was to go directly to Hospital SJ, is per patient request.

There was no documentation that the facility staff obtained an acceptance from Hospital SJ. There was no documentation of risk or benefit of patient going to SJ Hospital. Staff did not document that patient was informed of the potential risk of leaving the hospital by personal vehicle.

Review of the facility 's policy # LL.EM.005 dated 3/2008 described as EMTALA documented the following information:

Purpose: To establish guidelines for providing appropriate medical screening examinations and, if the individual is determined to have an emergency medical condition, any necessary stabilizing treatment or an appropriate transfer for the individual as required by Emergency Medical Treatment and Active Labor Act (EMTALA).

Section IV documented that the evaluation of the patient is an on-going process. The record must reflect continued monitoring according to the individual's needs and must continue until the individual is stabilized or appropriately transferred.

Further review of the facility policy revealed policy titled Transfer of OB Patients to Other Facilities # 707- 060 presented at the time of the investigation documents the following information at section A, B, C, E and H:

High-risk patients will be transferred to a facility providing a higher level of care.

Purpose: to provide patients with appropriate level of care.

Procedure sections A, B, C, E and H gave the following information:

(A) Attending physician must make arrangement for transfer of patients and write an order.

(B) Nursing is to arrange with admitting office of the receiving facility.

(C) Nursing will contact receiving unit and give verbal report.

(E) Nursing will arrange transport by ambulance or helicopter

(H) Complete a Memorandum of transfer to go with the patient.

There was no indication that these protocols were followed.

During a telephone interview on 3/29/11 at 2:00 pm with Patient #1, she stated she was discharged and instructed to go directly to Hospital SJ. She was given instructions and the Nurse walked her to the waiting room where her husband was waiting. She walked to her car which was parked outside.

When asked by the Surveyor if she was offered an ambulance Patient #1 stated the Nurse told her she could go in an ambulance or in her personal car and since her car was there she decided to go by car. No one told her there was a risk to go by private car.

Hospital SJ

Review of Obstetric Triage Record at Hospital SJ revealed Patient #1 was admitted on [DATE] at eight (8) minutes after midnight. Reason for admission was documented as labor with contractions at a pain scale of 7/10 (10 being the most severe pain). She was examined and there was documentation that the Impression was: Active labor, with plan for a repeat cesarean section.

Interview on 3/17/11 at 8:15 am with the Quality Director at Hospital SJ, she stated the Nurse Midwife at Hospital EH called Hospital SJ on 3/5/11 at 11:30 pm, requesting to transfer Patient #1 for a vaginal delivery after cesarean section. The physician informed the Nurse Midwife that Hospital SJ would only do a repeat C/S for the patient and since Hospital EH offers the same service and the patient is already there and in labor they should keep and treat the patient.

During a telephone interview on 3/31/11 with Physician T from Hospital SJ, he stated it was a complete surprise to him when the patient showed up in her own private vehicle in labor from Hospital EH. According to Physician T, Hospital EH did not call them and said the patient was on her way.

Respect us. Protect us. Pay us!

HCA Houston Healthcare Southeast

33 CMS Violations since 2011-03-18

Immediate Jeopardy Violations

Violation Name: PATIENT RIGHTS(A-0115)

Violation Name: PATIENT RIGHTS(A-0115)

Non Immediate Jeopardy Violations

Violation Name: PATIENT RIGHTS: RESTRAINT OR SECLUSION(A-0160)

Violation Name: PATIENT RIGHTS: RESTRAINT OR SECLUSION(A-0169)

Violation Name: PATIENT RIGHTS: NOTICE OF RIGHTS(A-0117)

Violation Name: PATIENT RIGHTS: INFORMED CONSENT(A-0131)

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: PATIENT CARE ASSIGNMENTS(A-0397)

Violation Name: PATIENT VISITATION RIGHTS(A-0217)

Violation Name: NURSING CARE PLAN(A-0396)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: Health Care Facilities Code - Other(K-0900)

Violation Name: Electrical Systems - Maintenance and Testing(K-0914)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: NURSING CARE PLAN(A-0396)

Violation Name: CONTENT OF RECORD: ORDERS DATED & SIGNED(A-0454)

Violation Name: INFECTION CONTROL PROFESSIONAL(A-0748)

Violation Name: OPERATING ROOM POLICIES(A-0951)

Violation Name: PATIENT RIGHTS: INFORMED CONSENT(A-0131)

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

Violation Name: PHARMACIST RESPONSIBILITIES(A-0492)

Violation Name: EMERGENCY SERVICES POLICIES(A-1104)

Violation Name: GOVERNING BODY(A-0043)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: NURSING CARE PLAN(A-0396)

Violation Name: ORDERS FOR DRUGS AND BIOLOGICALS(A-0409)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: PATIENT SAFETY(A-0286)

Violation Name: PATIENT RIGHTS: INFORMED CONSENT(A-0131)

Violation Name: MEDICAL SCREENING EXAM(A-2406)

Violation Name: STABILIZING TREATMENT(A-2407)

Violation Name: APPROPRIATE TRANSFER(A-2409)

Respect us. Protect us. Pay us!

HCA Houston Healthcare Southeast

33 CMS Violations since 2011-03-18

Violation Name: PATIENT RIGHTS(A-0115) toolTips('.tooltip_post_id_custom_df8d39ab451fe31f5459edfcbb343e92','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A hospital must protect and promote each patients rights\.');

Violation Name: PATIENT RIGHTS(A-0115) toolTips('.tooltip_post_id_custom_032ce197d0f9646ac4b478abfa0e89ec','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A hospital must protect and promote each patients rights\.');

Non Immediate Jeopardy Violations

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144) toolTips('.tooltip_post_id_custom_81cf32be2826f01eca43260d131963b2','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>The patient has the right to receive care in a safe setting\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_110ba38702fb558a5cef7dd0ef52b8a1','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_656d2557d438df6fc4e34efc1bae4916','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_bb7b4d8c5cbefdf7af2e4d82e6998367','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144) toolTips('.tooltip_post_id_custom_f75189c202bc8e4445c346596749a61d','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>The patient has the right to receive care in a safe setting\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_25bc9f829af28a7bfb1d98a6a56eaaec','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_e06fdea33a3cd1bb0e931ea921fa66d5','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: PATIENT RIGHTS(A-0115)

Violation Name: PATIENT RIGHTS(A-0115)

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)