HCA Houston Healthcare Conroe

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 23032 Based on record review and interview the hospital failed to follow its policy and procedures related to patient grievances The hospital failed to fully investigate a grievance made by the spouse of Patient # 2. Findings included : Review of facility policy titled “ Complaint/Grievance Process,”approved 01/2026, showed : C. Grievance Resolution Process: 2. Upon receipt of a grievance , the Patient Advocate ( or designee) shall confer with the appropriate department manager to review, investigate and resolve with the patient ...A representative of the administrative staff will oversee and assist with the resolution process as needed, Medical staff leadership may be involved as needed fro resolve physician delivery of care issues. 4. Regardless of the nature of the grievance , the substance of each grievance must be addressed while identifying, investigating, and resolving any systemic problems indicated by the grievance. ~~~~~~~~ During a telephone interview on 6/8/2026 at 8:15 AM with the spouse of Patient # 2, she stated : “I clearly asked for a second opinion. It was in between the 2 tests they were doing. I asked for a transfer.” Review of a facility grievance , dated 5/29/2025 showed complaints expressed by the spouse of Patient # 2. Two of her main concerns were as follows: -The physician did not communicate about “brain death scan results.” -The physician did not offer to transfer the patient for a second opinion. During an interview on 6/10/26 at 1:15 PM, with Staff-ID-P, Patient Safety Manager, she said she was involved with this investigation. The documentation of the investigation was reviewed. The hospital documented the following steps to investigate 5/29/2025: ICU Director documented a statement that said no investigation was needed; she witnessed that clear communication was made with the wife. 5/30/2026- “case management to review if wife ever wanted to transfer out.” [no follow-up to this was documented by case management.] The facility failed to : a) conduct a review of the record to assess for any requests for a transfer or second opinion by the spouse. b) review physician progress notes ; speak with the hospitalist who managed this patient’s care and had multiple interactions with this patent’s spouse. Staff ID-P said she thought the case was reviewed by the Chief Medical officer (CMO) at the time; however, this was not documented.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 23032 Based on record review and interview , the hospital failed to ensure that nursing care interventions were appropriately documented based on patient needs [citing Patient # 1 ]. Findings included: Record review of Texas Administrative Code (TAC) Title 22; PART 11 Texas Board of Nursing; CHAPTER 217 ; RULE §217.11 “Standards of Nursing Practice” showed: (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (D) Accurately and completely report and document: (ii) nursing care rendered; ~~~~~~~~~~ Review of the electronic health record of Patient ID-1 with Staff-A, Patient Safety Manager, showed; Patent # 1 was a 80 year old female patient admitted on 4/17/2026 for generalized weakness and increased confusion. She had past medical history of hypertension, stroke, and diabetes mellitus. Review of the record showed physician order, dated 4//17/2026 (2037) for sequential compression devices (SCD). Review of nursing documentation showed : -The SCDs were documented as “on” the patient only twice in 6 days: 4/17/26 at 2027; and 4/22/26 at 2114. Review of nursing documentation between 4/17/2026 and 4/4/22/2026 showed there were 11 times the word “none” was written or area was left blank. Interview with Staff -A, she stated there should be nursing documentation at least once per shift that the SCDs were “on” or that the “patient refused.””

“TISSUE AND EYE BANK AGREEMENTS CFR(s): 482.45(a)(2) Incorporate an agreement with at least one tissue bank and at least one eye bank to cooperate in the retrieval, processing, preservation, storage and distribution of tissues and eyes, as may be appropriate to assure that all usable tissues and eyes are obtained from potential donors, insofar as such an agreement does not interfere with organ procurement; This Standard is not met as evidenced by: 23032 Based on interview and record review, the facility’s agreement with its organ procurement organization (OPO), LifeGift, failed to specify the tissue bank and eye banks to which referrals will be made. Findings included: During an interview on 6/9/2026 at 10 AM with Staff -D, Quality Director, she verified that the hospital had an agreement with Life Gift for organ procurement. Review of the document titled “LifeGift Organ Donation Center Donor Institution Agreement,” signed 11/19/2019, failed to to specify the tissue bank and eye bank to which referrals will be made. The Quality Director was unable to locate this information in the LifeGift OPO agreement. She verified the hospital had no separate agreements with tissue or eye banks. It was agreed the hospital will follow up with LifeGift regarding this matter.”

“STAFF EDUCATION CFR(s): 482.45(a)(5) Ensure that the hospital works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues; This Standard is not met as evidenced by: 23032 Based on record review and interview, the hospital failed to ensure that all required regulatory components were included in staff education for organ donation issues. Findings included : During an interview on 6/9/2026 at 11 AM with Staff-E, Quality Director, she stated that staff were educated in organ donation via a module in HealthStream titled” Supporting Families of Patients With Brain Death.” Review of the content of the module titled “Supporting Families of Patients With Brain Death” showed it covered consent and importance of discretion and sensitivity. The module failed to address: -The role of designated requestor. -Transplantation and donation. -Quality Improvement activities. -Role of the organ procurement organization”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 40989 Based on document review and interview the hospital failed to: 1. have an organized nursing service that ensured safe staffing levels for patient care on 2 (ICU and IMU) of 2 patient care units reviewed. 2. follow the hospital policy titled, “Nursing Master Staffing Plan with Guidelines for Staffing & Assignments”, Policy Number: 7368084 with a last revised date of 11/2022”. Refer to Tag A0392 3. ensure 1 (Patient #1) of 1 patient medical records reviewed had complete wound assessments documented in the medical record. 4. ensure wound care was provided in 2 (Patient #2 and #3) of 2 patient charts reviewed 5. follow the hospital policy titled “Wounds and Skin Assessment, Documentation, and Photography”, Policy Number 12332773 with a last revised date of 9/2022. Refer to Tag A0395 6. keep a current nursing care plan for 1 (Patient #1) of 1 patient medical records reviewed. Refer to Tag A0396”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 48749 Based on observation, document review, and interview the hospital failed to ensure: A. to provide and maintain a clean and sanitary environment to avoid sources and transmission of infection in 3(Emergency Department, Intermediate Medical Unit, and Intensive Care Unit) of 3 areas observed. The hospital failed to follow its “Standard Precautions” policy. Cross Refer to Tag A 0750”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 40989 Based on document review and interview, the hospital failed to have an organized nursing service that ensured safe staffing levels for patient care on 2 (Intensive Care/Cardiac Care Unit and IMU) of 2 patient care units reviewed. Also, the facility failed to follow the hospital policy titled “Nursing Master Staffing Plan with Guidelines for Staffing & Assignments,” Policy Number: 7368084, with a last revised date of 11/2022. Findings include: Intensive Care Unit (ICU)/Cardiac Care Unit (CCU) The ICU/CCU was a 30-bed unit. A review of the ICU/CCU staffing schedules dated 3/25/2025-3/30/2025 revealed two shifts, day shift (7:00 AM- 7:00 PM) and night shift (7:00 PM-7:00 AM). The review was as follows: 3/25/2025- 7:00 AM-7:00 PM-Patient Census-26 -Short 2 Registered Nurses (RN) 3/25/2025- 7:00 PM-7:00 AM-Patient Census-27 -Short 2 RNs 3/26/2025- 7:00 PM-7:00 AM-Patient Census-26-Short 1 RNs 3/27/2025- 7:00 AM-7:00 PM-Patient Census-28 -Short 1 RN 3/27/2025- 7:00 PM-7:00 AM-Patient Census-30 -Short 1 RN 3/28/2025- 7:00 AM-7:00 PM-Patient Census-30 -Short 1 RN and 1 Patient Care Tech (PCT) 3/28/2025- 7:00 PM-7:00 AM-Patient Census-30 -Short 1 RN 3/29/2025- 7:00 AM-7:00 PM-Patient Census-30 -Short 3 RNs 3/29/2025- 7:00 PM-7:00 AM-Patient Census-30 -Short 2 RNs 3/30/2025- 7:00 AM-7:00 PM-Patient Census-29 -Short 2 RNs 3/30/2025- 7:00 PM-7:00 AM-Patient Census-30 -Short 2 RNs An interview was conducted with RN Staff #13 and RN Staff #14 on 4/01/2025 at 11:03 AM after 2:00 PM. RN Staff #13 was asked if the Charge Nurse was assigned to direct patient care. RN Staff #13 confirmed the charge nurse was not assigned patients. RN Staff #14 was asked if the unit had a PCT at night. RN Staff #14 confirmed the unit did not have a PCT at night, and there was only one PCT during the day for 30 patients. RN Staff #14 confirmed the nurses were responsible for the total care of the patients they were assigned. RN Staff #13 and #14 were asked what the nurse-to-patient ratio on the unit was. RN Staff #13 stated, “It is usually 1:2, but sometimes the nurses get 3. At times, they are only assigned 1 patient depending on the acuity of the patient.” RN Staff #13 and #14 were asked if the unit used an acuity tool to determine the staffing needs of the unit. RN Staff #14 confirmed that the ICU/CCU currently did not have an acuity tool, but they were working on finalizing one. On 4/01/2025 after 11:03 AM, RN Staff #13 and #14 confirmed the ICU/CCU were routinely short on nurses according to the staffing matrix/grid that they were required to follow, and there was no current acuity tool used to determine the staffing needs of the unit. An acuity system identifies the amount of nursing care needed for each patient on a unit based on the level of intensity, nursing care, and tasks needed for each patient. The system allocates resources based on patients’ needs, not according to raw patient numbers. An acuity tool allows each nurse to score his or her patients, based on acuity, for the upcoming shift and can report this information to the charge nurse, who then assigns patients before the shift change. This tool allows the Charge Nurse to determine if the staffing needs can be increased or decreased for the upcoming shift. Intermediate Care Unit (IMU) The IMU was a 24-bed unit. All patient rooms were private rooms. A review of the IMU staffing schedules dated 3/25/2025-3/31/2025 revealed two shifts, day shift (7:00 AM- 7:00 PM) and night shift (7:00 PM-7:00 AM). The review was as follows: 3/25/2025- 7:00 AM-7:00 PM-Patient Census-24 -Short 2 PCTs 3/25/2025- 7:00 PM-7:00 AM-Patient Census-23 -Short 1 PCT 3/26/2025- 7:00 AM-7:00 PM-Patient Census-24 -Short 1 Unit Secretary (US) and Short 1 PCT 3/26/2025- 7:00 PM-7:00 AM-Patient Census-23-Short 2 PCTs 3/27/2025- 7:00 AM-7:00 PM-Patient Census-23 -Short 1 RN and 1 US 3/28/2025- 7:00 AM-7:00 PM-Patient Census-23 -Short 2 PCT 3/28/2025- 7:00 PM-7:00 AM-Patient Census-21 -Short 1 PCT 3/29/2025- 7:00 AM-7:00 PM-Patient Census-22 -Short 1 PCT 3/30/2025- 7:00 AM-7:00 PM-Patient Census-There was no census for the Day shift available for review- Short 3 PCTs until noon (12:00 PM) and then short 2 PCTs until 7:00 PM 3/30/2025- 7:00 PM-7:00 AM-Patient Census-24 -Short 2 PCTs 3/31/2025- 7:00 AM-7:00 PM-Patient Census-24 -Short 1 PCT 3/31/2025- 7:00 PM-7:00 AM-Patient Census-22 -Short 2 PCTs An interview was conducted with RN Staff #18, Staff #19, and Staff #20 on 4/02/2025 at 10:38 AM. The nursing staff was asked to explain the nurse staffing on the IMU Unit. RN Staff #18 stated, “Short, always short. A lot of our patients are critical on this unit. They can still be on cardiac drips, require restraints, have an altered mental status and a number of other things, and when we have to do total care on a patient, it takes away the time for other patients as well.” The nursing staff was asked how often you turn patients who are in bedbound. The RN staff stated, “They should be turned every 2 hours, but sometimes we can barely get that done. A lot of times, we do not have the assistance it takes to get them turned.” RN Staff #19 was asked if there was a specific person who relieved the nurses for a lunch break. RN Staff #19 stated, “No, we just tell the charge nurse that we are going to lunch and have them watch the patients. We take our phones with us, and they would call us if they needed to”. RN Staff #19 was asked if the lunch break was automatically deducted from their time or if they had to clock out for lunch. RN Staff #19 confirmed the staff had to clock out for lunch. RN Staff #17 was asked if the charge nurse had assigned patients. RN Staff #17 stated, “No, the charge nurses are not assigned patients. The charge nurses are assigned to all the codes and rapid responses. They help with admissions and discharges when they can. Sometimes, we do not have a unit secretary, and the charge nurse has to fill that role also. The unit secretary is sitting with a psychiatric patient today, so the charge nurse has to field all the phone calls and act as a unit secretary today as well.” An interview was conducted with RN Staff #10 and #11 on 4/02/2025 after 2:30 PM. RN Staff #10 and #11 when the unit is short PCTs and how do they cover those positions for that shift. RN Staff #10 and #11 replied that they used to place a Licensed Vocational Nurse (LVN) or an RN in to fill that role, but corporate stopped us from doing that. RN Staff #10 stated, “We are looking to fill some positions for the PCT role, but we have to make sure that the person will be a good fit for our unit.” Staff #10 was asked how they will cover those positions until someone is hired. RN Staff #10 said, “We will just have to be short. Our nurses will have to do total care on patients until those positions can be filled.” An interview was conducted with Chief Nursing Officer (CNO) Staff #21 on 4/02/2025 at 8:38 AM. CNO Staff #21 was asked if the staffing matrix/grids for the ICU/CCU and the IMU units had gone through the Nurse Staffing Committee or to the Governing Body for approval. CNO Staff #21 stated, “The staffing grids are standard staffing grids from corporate”. CNO Staff #21 was asked when was the last time the Nurse Staffing Plan had been reviewed. CNO Staff #21 could not give a date or year when the plan was reviewed. CNO Staff #21 confirmed she was new to the position, effective January 2025. CNO Staff #21 was asked if the staffing matrix/grid or the acuity tool had been approved by the Nurse Staffing Committee, Medical Staff, or the Governing Body. CNO Staff #21 stated, “You will not find that in any meeting minutes by the Governing Body”. A review of the policy titled “Nursing Master Staffing Plan with Guidelines for Staffing & Assignments,” Policy Number: 7368084 with a last revised date of 11/2022” was as follows: “ ...Policy: 1. The purpose of the Nursing Director and Manager Council is to solicit and receive input from the nursing staff involved in direct patient care regarding staffing requirements, evaluation of staffing plans, and staff retention and recruitment. 2. Each patient care unit will be staffed in accordance with established guidelines which consider the following: a. Number of patients, b. Scope of services provided, c. Levels of intensity of the patients for whom care is being provided, d. Contextual issues (architecture, geography, availability of technology), and e. Level or preparation and experience of those providing care (number, competency, skill mix). 3. The unit nurse leader has the ultimate responsibility for staffing assignments on the unit. Staffing will be sufficient to ensure prompt recognition of changes in patient condition and to ensure interventions are appropriate... 4. It is the responsibility of the Chief Nursing Officer in cooperation with the Nursing Director and Manager Council, to develop, approve, and implement criteria for employment, deployment, and assignment of nursing staff among units and departments and includes consideration of: a. The requirements and qualifications for employment as a nursing staff member (see job descriptions for each nursing unit). b. The process used and elements considered when assigning patient care responsibilities (see “Procedure” below). c. The mechanism used for determining the deployment of nursing staff members among departments (see “Procedure” below). d. Standards established by the Texas Nurses Association, the Texas Hospital Association, the Texas State Board of Nurse Examiners, the Texas Organization of Nurse Executives, and other regulatory bodies, where available. ...5. The Nursing Director and Manager Council is responsible for re-evaluating the staffing requirements on at least an annual basis and for making necessary revisions to each unit’s plan as condition warrants. Each plan is approved annually by the Chief Nursing Officer. a. Evaluation of staffing effectiveness will begin at the unit level and will encompass all disciplines. b. Annual evaluation of the staffing plan will be based on nursing-sensitive patient indicators, nursing sensitive patient outcomes, operational outcomes, and validated patient complaints relative to nurse staffing. c. The Nursing Director and Manager Council will address identified trends. d. Evaluation of the staffing plan and actions taken to improve staffing will be reported at least annually to the hospital leadership and Board of Trustees. ...7. Staffing Mix: the number and mix of nursing staff required to meet the identified patient requirements for nursing care for each unit will be identified and will be utilized in daily staffing in each unit. The number of qualified nurses required to deliver nursing care to patients who require a specific level of care will be considered to assure coordination, supervision, and direction of nursing care is provided for care given by other nursing staff members. Consideration is given in the staffing plan to the utilization of registered nurses, patient care assistants, unit secretaries, and technicians according to identified patient requirements for nursing care, and the scope of nursing practice permitted by applicable law and regulation ...” An interview was conducted with CNO Staff #21 on 4/02/2025 at 8:38 AM. CNO Staff #21 confirmed the Nurse Staffing Plan had not been reviewed annually, and it had not been reported to the Board of Trustees on an annual basis as required by the hospital policy. CNO Staff #21 was asked if the patient care units did not have an acuity tool how would the staff know when to increase or decrease staffing. CNO Staff #21 confirmed there was no approved acuity tool for any patient care unit and the Nurse Staffing Plan did not give clear direction on when to increase or decrease staff. A confidential interview was conducted with Staff #6 on 4/01/2025 after 3:00 PM. Staff #6 confirmed that nurse staffing was a challenge in the hospital and that the hospital was staffing to a bare minimal grid. It was confirmed that the nurse staffing for the hospital was always short hospital wide. Staff #6 confirmed the staffing matrix/grid, nor the acuity tool being used had been approved by the Nurse Staffing Committee, Medical Staff, or the Governing Body of the hospital.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 40989 Based on record review, policy review, and staff interviews, the nursing staff failed to: 1. ensure 1 (Patient #1) of 1 patient medical records reviewed had complete wound assessments documented in the medical record. 2. ensure wound care was provided in 2 (Patient #2 and #3) of 2 patient charts reviewed 3. follow the hospital policy titled “Wounds and Skin Assessment, Documentation, and Photography”. Findings: Patient #1 A review of Patient #1’s medical record was conducted in the afternoon on 4/02/2025 with Staff #6. Patient #1 was a 67-year-old male who arrived at the Emergency Room (ER) by helicopter with symptoms of a possible stroke on 11/11/2024. Patient #1 was admitted to the Intensive Care Unit (ICU) on 11/11/2024. A review of the nursing assessment documented on 11/26/2024 at 8:00 AM by RN Staff #22 revealed a Pressure Injury (an injury to the skin and underlying tissue from prolonged pressure in the area) to the posterior (back) right heel. The documentation was as follows: “ ...Pressure Injury Posterior Right Heel- Instance list status: Active Pressure Injury on admission: No Pressure Injury staging: Deep tissue injury Wound surrounding tissue appearance: Purple Skin alteration details: Boggy, Dusky Red Wound surrounding tissue temperature: Warm Wound drainage description: Serous Wound drainage amount: none Wound cleansing: Normal saline Dressing status: Open to air Dressing type: Moon boots, elevate, and float heels ...” There was no measurements of the wound doumented, no photographs of the wound, and no documentation that the physician was notified of the pressure injury. A review of the nursing assessment documented on 12/02/2024 at 10:30 AM by RN Staff #23 revealed a stage 2 pressure injury to the coccyx (tailbone). There were no measurements of the wound, no photographs of the wound, and no documentation that the physician was notified of the wound. The documentation was as follows: “ ...Pressure Injury: Coccyx Instance list status: Active Pressure Injury on admission: No Pressure Injury staging: Stage 2 Wound drainage odor: No odor Wound drainage amount: none Wound cleansing: Perineal/skin cleanser/Prot barrier crm/oint/wip Dressing intervention: changed Dressing type: Foam ...” There was no measurements of the wound doumented, no photographs of the wound, and no documentation that the physician was notified of the pressure injury. An interview was conducted in the afternoon with Staff #6 on 4/02/2025. Staff #6 confirmed that the nursing staff failed to follow the hospital policy and take photographs of new wounds or pressure injuries, measure wounds according to length and width, and notify the physician of any new wounds. 48749 2. Findings include: Patient #2 A review of Patient #2’s electronic health record (EHR) revealed the patient arrived at the hospital emergency department (ED) on 03/29/2025 at 9:04 PM via Emergency Medical Services (EMS) from a local nursing home. The ED Physician documented that Patient #2 presented to the ED for fever, altered mental status (a change in a person’s mental function, awareness, or behavior), rash, and a purulent (pus; thick, yellow liquid indicating infection) wound on the wrist. The patient received an intravenous (IV) antibiotic and IV fluids during the ED visit. There was no documentation found to support that Patient #2 received wound care while in the ED or that orders were written by the ED physician for wound care. Patient #2 was admitted to the hospital on 03/30/2025 at 1:59 AM for Sepsis and purulent cellulitis (potentially serious bacterial skin infection) of the left forearm. Patient #2 was moved from the ED to a patient room at 3:15 AM. A review of the floor nurse’s “Patient Assessment” note completed on 03/30/2025 at 3:15 AM revealed that the nurse did not document or identify that Patient #2 arrived on the floor with a wound. There was no documentation found to support that the patient’s wound was evaluated and treated between the dates of 03/29/2025 through 03/31/2025 by the nursing staff. There was no documentation found to support that the nursing staff contacted the Physician for wound care orders. Further review of Patient #2’s chart revealed that an order for a wound care consult was placed on 03/31/3025 at 7:27 PM. Staff #2 evaluated and completed wound care for Patient #2 on 04/01/2025 at 10:50 AM. The patient’s wound pictures and measurements were taken at the time of the consult. A review of Staff #2’s note revealed the following; “Skin alteration: - - Other CELLULITIS Anterior Arm left - - Instance list status: Active Skin alteration details: Edematous, Slough, Yellow Wound surrounding tissue appearance: Edematous Wound surrounding tissue temperature: Warm Wound drainage description: Serous Wound drainage amount: Scant Wound drainage odor: No odor Wound cleansing: Normal saline Dressing status: Open to air Dressing intervention: Changed Dressing type: Fiber/silver, Gauze bandage roll, Non adhering Packing removed: No Alteration photographed: Yes Wound/skin alteration comments: HAS EDEMA NOTED WITH SOME DISCOLRATION HAS AREA OF YELLOW SLOUGH NOTED THAT IS MOIST. CLEANED WITH NS, COVERED WITH AQUACEL AG, XEROFORM, KERLIX. ELEVATED ON PILLOW. PATIENT HAS SOME CONFUSION NOTED Wound dressing change date: 04/01/25 Document advanced wound measurements: Yes Wound length cm: 2 Wound width cm: 3 Wound depth cm: 0.3” In addition, on 04/02/2025, there was no documentation to support that a shift assessment was completed on the day shift. Patient #3 A review of Patient #3’s electronic health record (EHR) revealed the patient arrived at the hospital’s ED on 03/24/2025 at 1:13 PM via EMS from a local nursing home. At 1:25 PM, the ED Physician documented that Patient #3 presented to the ED for fever, previous history of traumatic brain injury, and a stroke. The patient was noted to have left-sided paralysis. The patient received an intravenous (IV) antibiotic and IV fluids during the ED visit. Further review revealed the ED Physician did not document or address the sacral decubitus ulcer. A review of the ED nurse’s “Patient Assessment” note completed on 03/24/2025 at 11:13 PM revealed that the nurse documented that Patient #3 had a superficial wound to the left elbow, a pressure ulcer stage (a classification that stages bedsores based on the depth of the tissue damaged) #1 right ankle wound, a stage #1 left lower leg wound, a stage #1 right heel wound, and a stage #4 sacrum ulcer. There was no documentation found that the ED Physician identified all of the patient’s wounds or wrote wound care orders while the patient was in the ED. Patient #3 was admitted to the hospital on 03/24/2025 at 3:54 PM for Sepsis, Pneumonia, and a Urinary Tract Infection. Patient #3 was moved from the ED to a patient room at 1:38 AM on 03/25/2025. A review of the admitting Physician’s note on 03/24/2025 at 8:10 PM revealed that the Physician documented, “Patient has a very low, deep sacral decubitus ulcer with some erythema in the surrounding region.” Also, the Physician documented in Patient #3’s plan “concern for deeper infection at site of sacral decubitus ulcer.” There was no documentation found to support that the admitting Physician ordered wound care or preventative measures for Patient #3’s sacral decubitus ulcer. Further review of Patient #3’s chart revealed the patient was not referred to the wound care nurse until 03/27/2025 at 8:18 AM. Wound care orders were not ordered by the Physician until 03/28/2025. A review of Patient #3’s wound care note by Staff #2 revealed the following; “Skin alteration: - - Pressure injury Posterior Sacrum - Instance list status: Active Pressure injury present on admission: Yes Pressure injury staging: Stage 4 Skin alteration details: Muscle, Slough, Pink, PURPLE Wound surrounding tissue appearance: Pink, Macerated Wound surrounding tissue temperature: Warm Wound drainage description: Serosanguineous Wound drainage amount: Small Wound drainage odor: No odor Wound cleansing: Normal saline, Wound cleanser Dressing status: Drainage present, Intact Dressing intervention: Changed Dressing type: Foam, Gauze Packing removed: Yes Alteration photographed: Yes Wound/skin alteration comments: HAS A CHRONIC ULCER TO SACRAL AREA. CLEANED WITH NS THEN PLACED VASHE MOIST GAUZE TO WOUND AND COVERED WITH FOAM Wound dressing change date: 03/27/25 Document advanced wound measurements: Yes Wound length cm: 4 Wound width cm: 4 Wound depth cm: 1.5 Wound undermining direction: 9 o’clock, 1 o’clock Wound undermining cm: 3” Also, Patient #3 was not ordered a specialty bed (a bed designed to prevent and treat bedsores by redistributing pressure, stimulating blood flow, and promoting circulation through a system of air cells that constantly inflate and deflate) for treatment of a Stage #4 sacral decubitus ulcer until 03/27/2025 at 1:45 PM. A review of the hospital’s “Wound and Skin Assessment, Documentation, and Photography” policy dated 09/2022 revealed the following: “PURPOSE: 1. Provide standard definitions for pressure injury-related classifications. 2. Provide evidence-based guidelines for pressure injury prevention. 3. Outline the standard of care for skin care, risk assessment, prevention, and treatment of pressure injuries. 4. Outline documentation requirements for nursing. POLICY AND PROCEDURE STATEMENTS: 1. All patients will be evaluated for skin breakdown through the completion of a risk assessment process. This will occur upon admission, a minimum of once per shift; following a change in medical condition and/or level of care; and at discharge. 2. Based on the level of skin risk, nursing Interventions will be initiated and will be captured on the patient’s plan of care. 3. Regardless of risk, standard of care pressure Injury prevention elements should be Implemented on all patients. Risk Assessment 1. Each patient with admission orders will be assessed for skin risk and the presence of any alterations in skin integrity. If a wound is identified, the following should be included in the documentation: a. Wound type; b. Anatomic location of the wound; c. Wound Photography; d. Wound length and width; and e. Description of wound bed, drainage, tissue type present. 1. Reassessment of skin risk will occur, at minimum, once per shift; following a change in medical condition and/or level of care; and at discharge. STANDARD OF CARE: 1. Comprehensive skin and tissue assessments will be performed as outlined above, and recorded in the electronic medical record. 2. The nurse will use visual, touch, and palpation techniques to differentiate temperature and tissue differences. This includes: a. Particular focus given to the skin over the bony prominences, including the sacrum, heels, hips, pubis, thighs, and torso. Include the occiput in a head-to-toe skin assessment for neonates and young children. i. Assess for signs of maceration, paying attention to skin fold/creases, particularly in obese patients. ii. Assess skin texture/maturity for neonates. b. Assess vascular/perfusion status of the lower limbs, heels, and feet. c. When possible, lift preventive dressing(s) and assess skin and/or wounds under dressing, and assess the skin and soft tissues underneath any medical devices. d. For darkly pigmented skin, consider assessment of skin temperature and sub epidermal moisture as an adjunct assessment strategy. 3. Interventions and an Individualized plan of care will be implemented and documented as appropriate. 4. The nurse should notify the provider/practitioner of any new or existing wound. 5. The nurse will consult the Skin Care Champion or Wound Care professional for all pressure Injuries stage 3 and above (Including Deep Tissue Injuries). 6. The nurse will initiate bundle Intervention strategies for patients identified as high risk based on individualized risk factors. Interventions at a minimum should include silicone foam dressings, heel boot protectors, and determine need for a specialty mattress.” An interview with Staff #1 and Staff # 6 was conducted on the afternoon of 04/02/2025. Staff #1 and Staff #6 confirmed the findings. An interview with Staff #2 was conducted on 04/02/2025 at 1:30 PM. Staff #2 reported that wound care is documented in the integumentary section of the “Patient Assessment” form. Staff #2 stated, “I will see open, draining wounds, sacral wounds, and complicated wounds. I take pictures and stage them. The staff can call me for any concerns, I don’t necessarily need a consult ordered.” Staff #2 reported that any staff can order a specialty bed for a patient, it does not require the wound care nurse to order one.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 40989 Based on document review and interview, nursing failed to update and keep a current nursing care plan for 1 (Patient #1) of 1 patient medical records reviewed. Findings: A review of Patient #1’s medical record was conducted in the afternoon on 4/02/2025 with Staff #6. Patient #1 Patient #1 was a 67-year-old male who arrived at the Emergency Room (ER) by helicopter with a possible stroke on 11/11/2024. Patient #1 was admitted to the Intensive Care Unit (ICU) on 11/11/2024. A review of the Nursing Care Plan dated 11/11/2024-12/06/2024 revealed there was no diagnosis or new problem related to an alteration in skin integrity until 12/03/2024. This was 7 days after the nurse documented the deep pressure injury to the right heel on 11/26/2024 at 8:00 AM. A review of the nursing assessment documented on 11/26/2024 at 8:00 AM revealed a Pressure Injury (an injury to skin or underlying tissue due to prolonged pressure to a specific area) to the posterior right heel. There were no measurements of the wound, no photographs of the wound, and no documentation that the physician was notified of the wound. An interview was conducted in the afternoon with Staff #6 on 4/02/2025. Staff #6 was asked how often the Plan of Care was updated. Staff #6 replied, “The Plan of Care should be updated whenever there is a change with the patient that requires additional care or when the patient has met the outcome of a specific goal. Staff #6 confirmed that the nursing staff failed to update the nursing plan of care when there was a change in the condition of the patient.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48749 Based on observation, record review, and interview, the facility’s infection prevention and control program failed to provide and maintain a clean and sanitary environment to avoid sources and transmission of infection in 3(Emergency Department, Intermediate Medical Unit, and Intensive Care Unit) of 3 areas observed. The hospital failed to follow its “Standard Precautions” policy. These findings had the likelihood to cause harm by increasing the risk of infection to all patients and staff at the facility. During a tour of the facility on 04/01/2025 at 10:00 AM with Staff #1 and Staff #6, the surveyor observed the following infection control issues: Emergency Department (ED): *There was dried blood on an intravenous pole (IV) (a pole designed to hang bags of medications and fluids) in trauma room #30. *There was an unknown black substance on the wheels and foot pedals of the stretcher. Also, there was an accumulation of dust and debris on the storage tray and base of the stretcher in trauma room #30. *There was an accumulation of dust and debris in the cabinet storing sterile supplies. Also, the storage cabinet was cluttered and disorganized in trauma room #30. *There was an accumulation of dust on the base of the Glidescope (a video laryngoscope that provides a view of the vocal cords and is used to help with endotracheal intubation in patients with difficult airways), the Bladder Scan (a portable ultrasound used to scan the bladder), and the vital sign machine at the nurses’ station. *There was an unknown clear dried substance on the tray of the glidescope. *There was an unknown dried brown and yellow substance on the mattress cover of a stretcher in the hallway. *There was an accumulation of dust and debris on the exterior and base of an ultrasound machine (a non-invasive imaging technique that uses high-frequency sound waves to create pictures of internal organs and tissues) at the nurses’ station. Also, there was an unknown clear dried substance on top of the machine and around the wands. There was an accumulation of dust in the lubricant holder. *There was an open cardboard box of blood culture bottles on the counter at the nurses’ station. “External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material, serve as generators of and reservoirs for dust.” (AAM1 ST46-Section 5.2 Receiving items). * There were two open bottles of glucometer test strips (small, disposable strips used with a glucometer to measure blood sugar levels) that did not have a date of opening, a date of discard, or staff initials written on the label. * There was an accumulation of dust and debris on the pill crushers in the medication room. *There was an accumulation of dust and debris in the bottom interior of the Pyxis (An automated medication dispensing system) in the medication room. Intensive Care Unit (ICU): *There was no date of opening or expiration written on an open bottle of sparkling water and Gatorade in the patient nutrition refrigerator. Also, there were staff personal items stored in the patient nutrition refrigerator. *The laminate on the counter around the sink at the nurses’ station was worn away and chipped. This had the likelihood to prevent thorough cleaning and disinfecting of the countertop surface. * There was chipped paint and an accumulation of rust on the base of two IV poles in the clean equipment room. *There was an accumulation of dust and debris in the bottom interior of the Pyxis in the medication room. ICU room #24 *There were chipped, peeling, and broken sections of the nurse’s desk. * There was an unknown dried brown substance on a ceiling tile above the bed. *There was an accumulation of dirt and debris build-up behind the door. *There was chipping and peeling of the laminate on the counter next to the sink. Intermediate Medical Unit (IMU): IMU room #312 *There was sealant and peeling of a floor tile by the door. * There was a section of the baseboard peeling away from the wall. *The particle board of the cabinet was broken and separating. *There was a hole in the drywall. *There was an unknown dried black substance on the wall around the dry erase board. *There was an unknown brown paper material stuck on the wall. *There was an unknown gray substance dried on the wall. *There was chipping and peeling on the laminate of the door entering the room. *There was an unknown dried brown substance on the bottom of the patient’s refrigerator. *There were multiple spots of unknown dried brown substances on the inside of the shower curtain. *There was an accumulation of dust on the air vent and an unknown dried brown substance on the ceiling tile. * There was an accumulation of dust and dirt on the base of the patient Hoyer lift (a medical equipment that is used to safely transfer patients from one place to another) in the hallway. * There was an unknown dried brown substance on the exterior of the Pyxis in the medication room. * There was an accumulation of dust and debris in the bottom interior of the Pyxis. A review of the hospital’s “Standard Precautions” policy dated 02/2024 revealed the following; “C: Environmental Cleaning: 1. Cleaning of all medical equipment and devices, including computers and technological devices, that enter patient care areas is important to prevent transmission of infectious organisms. 2. Noncritical patient care equipment should be cleaned and disinfected after each patient use. 3. All soiled medical equipment and devices should be handled in a manner that prevents the transfer of microorganisms to others and the environment. 4. Contaminated equipment that must be cleaned and disinfected must be stored in an area that is separate from clean supplies and equipment. 5. HCP should wear gloves when handling equipment that is contaminated or visibly soiled and perform hand hygiene immediately after removal of gloves. 6. Soiled linen should be handled utilizing a method that prevents microorganisms from being transmitted to other people and the environment. 7. Patient care equipment that has been soiled with blood, body fluids, secretions and/or excretions must be handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other patients and environments. 8. Reusable equipment in contact with non-intact skin, blood, body fluids, or mucous membranes must be cleaned with a hospital-approved disinfectant before it is used for the care of another patient. Do not relocate this equipment to other patient room or clean utility room until it has been properly cleaned.” A review of the hospital’s contracted environmental services “Emergency Room Cleaning” policy dated 12/2024 revealed the following; “SECTION V. ER IN-BETWEEN CASE {TURNOVER) CLEANING After a patient is discharged from the ER and leaves the exam room where they were being treated, the room must be cleaned and disinfected before anyone else is treated in that room. During the in-between case clean, also called the turnover clean, perform the following tasks: * Remove trash and contaminated linens, * Pick up trash/debris, * Clean and disinfect all high-touch surfaces, * Refill dispensers, and * Mop. Check your facility agreement for specific in-between-case cleaning responsibilities. Remove Trash & Contaminated Linens *After placing wet floor signs per HHS standards, start by donning PPE, then remove trash and anything that’s contaminated. *When emptying the trash, remember safety first. Avoid any protruding needles or other sharp objects, and if trash must be compacted, use a smaller bucket or your dustpan. NEVER use your hands to compact trash. Remove the trash liner using both hands, holding the bag away from your body, then replace the liner. *Any contaminated towels, washcloths, or gowns that you pick up should be placed in a plastic liner and/or an approved contaminated linen container. *Next, check the cubicle curtains. If they’re visibly soiled, request that they be removed and cleaned or replaced. *Check sharps containers. If the sharps container is ¾ full, it must be closed and transported to the designated storage area. A new sharps container should replace the one that was removed. If changing out sharps containers is not housekeeping’s responsibility, notify an ER nurse or your manager. *With a lobby broom and dustpan, pick up all debris/trash inside the room to prevent the spread of bacteria to other areas. Use a putty knife on gum or any substance stuck to the floor. Clean And Disinfect High-Touch Surfaces *Clean all examination or treatment rooms, making sure to change cleaning cloths after each room/area. Work around the room, systematically changing cleaning cloths frequently. *Check and clean all high-touch surfaces and anything that is visibly soiled. High-touch surfaces include the following items: door facings, cabinet facings, and door handles; thermostats, light switches, picture frames; furniture; exam room tables (e.g., Mayo stands). under the tray, including the leg and base, if applicable; and countertops. *Clean the stretcher mattress, handrails, the IV pole, and handles for pushing/pulling the stretcher. Check the mattress for any visible tears and punctures. If visibly soiled, the undercarriage of the stretcher should be cleaned. Also, clean the following items: sink basin, faucet handles, and spout; portable toilets; and walls, including room dividers. Pay special attention to spillage on walls behind trash receptacles. *Reusable cleaning cloths should be placed in a soiled linen bag. If you use disposable cleaning cloths, discard them properly.” An interview with Staff #1 and Staff # 6 on the afternoon of 04/01/2025. Staff #1 and Staff #6 confirm the surveyor’s findings found during the tour. An interview with Staff #3 on 04/02/2025 at 3:20 PM. Staff #3 stated, “I do surveillance rounds on each unit once a week and then complete an environment of care every 6 months. After I complete the rounds, I send them in an email to each department director. I do my follow-ups one week after I send the emails. I continue to report findings that have not been corrected, and I report them up to the Quality Director.” Staff #3 reported that some findings go up the chain to corporate leadership. Staff #3 reported that the hospital’s shower curtains were sent up to leadership and were to be replaced throughout the hospital, but that they have not all been corrected. Staff #3 reviewed the pictures with the surveyor and confirmed many of the same findings during Staff #3’s surveillance rounds.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 23032 Based on record review and interview, the facility failed to: a. document assessment of patient’s condition at discharge; b. provide necessary medical information to the post-acute care facility upon patient’s discharge [citing Patient # 1] . Findings included: TX00478176 Record review of facility policy titled “Discharge Planning,” dated 07/2020, showed: “...Procedure: A. Nursing/Medical Staff & other patient care disciplines: f. Upon discharge, the patient’s condition and status of current patient problems are assessed and documented in the medical record. Discharge Education / Instruction: All disciplines are responsible for documenting all discharge instructions provided to the patient/family. The hospital transfers or refers patients, along with necessary medical information to appropriate facilities, agencies, or outpatient services as needed for follow-up care...” a. Patient’s condition at discharge not assessed / documented : Review of Patient ID # 1’s clinical record showed he was 80 year old male with past history of hypertension, diabetes, multiple falls, dementia, and pulmonary edema. Patient # 1 was transferred to facility on 10/19/2023 from another acute care hospital. He permanently resides in a long term care nursing facility. He was discharged on 10/31/2023. The last nursing assessment of Patient # 1 was documented on 10/31/2023 at 1455. Review of the Discharge instructions showed Patient ID # 1 signed “Patient Signature Page” on 10/31/2023 at 1 PM. Review of the nursing progress notes on 10/31/2023 failed to documentation of when Patient # 1 was actually transported off the unit. b. Patient information was not provided to post-acute care facility prior to discharge: Interviews were conducted on 11/08/2023 between 10 and 10:30 AM with three (3) staff RNs on Patient Unit 1-South (Staff ID #s F,G, H). All three RNs said that when a patient is discharged and returning to a long-term care facility/ nursing home: a nurse -to- nurse report is given via telephone. The patient’s current condition, hospital course, and medications are reviewed. All 3 RN’s said this report should be documented in the medical record by the nurse who conducted the report telephone call. Review of Patient #1’s case management progress notes showed “clinicals” were faxed to nursing home on 10/20/2023 and “Savanna had been notified.” Case management note dated 10/31/2023 at 1220 PM showed transport arranged with Texan EMS; DC (discharge) packet at nurses’ station. Review of the nursing notes on the day of Patient ID # 1’s discharge, 10/31/2023, failed to show documentation that a nurse-to-nurse report telephone call had been conducted. There was no documentation that the “Discharge Packet” of patient information had been given to EMS prior to patient transport. During an interview on 11/08/2023 at 3:10 PM with Staff- F, Director of Nurses (DON), she said the expectation is that nursing would assess the patient’s condition prior to discharge. Staff-F went on to say the nurse caring for the patient was responsible for calling report to the nursing home. The date, time, and name of staff spoken with should be documented in the medical record. Staff-F was unable to locate documentation of report being called to the nursing home prior to Patient ID# 1’s discharge.”