Houston Methodist Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 37322 Based on observation, record review and interview the facility failed to ensure 7 of 7 crash carts were checked daily, ensuring the patients right to have a functioning crash cart in the emergency department. Findings Included: The facility policy “Code Blue Emergency Crash Cart Supplies” Effective Date: 10/01/2025 Date Revised/Reviewed: 10/01/2025 Nursing Leadership will ensure daily checklist completion to ensure cart supplies are intact and functioning. Observation of the 7 ED logs on the 7 ED carts on 05/06/2026 at 1400 revealed the emergency carts were not checked daily per hospital policy: 1. Pedi/Neonatal cart: had not been checked since 05/04/2026, missing checks 05/05-06/06- 2. Room 1: intake, had not been checked since 05/04/2026, missing checks on 05/05-06/2026 3. Room 4: missing checks 3. Station 5: had not been checked since 05/04/2026, missing checks on 05/04-06/2026 4. Station 6: two carts, had not been checked since 05/03/2026, missing checks on 05/04-06/2026 5. Station 7: carts had not been checked since 05/03/2026, missing checks on 05/04-06/2026. Interview with nurse (ID#5) who validated the findings, and stated the night shift checks the carts and the carts should be checked once a day per policy.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 37490 Based on record review, and interview, the facility failed to conduct a complete medical screen examination, to determine whether an emergency medical condition exited, for (1) one (Patient #1) out of (21) twenty-one medical records reviewed of patients having arrived at the facility’s emergency department seeking treatment. The facility failed to complete the medical screen evaluation (MSE) for patient #1’s leg and back pain. The patient was escorted out of the facility by hospital security staff and then was brought back into the facility after a 911 call with Houston Fire Department (HFD) seeking treatment again shortly later. Patient ID #1 then left Against Medical Advice (AMA). Patient ID #1 returned a third time with Police Department Crisis Team with a new behavioral health complaint of suicidal ideation. She was taken by facility A staff to Facility B Emergency Department via wheelchair without a medical screen examination being performed. Findings included: Record review of facility policy titled “Emergency Department Medical Screening Procedure,” dated 11/9/2021 showed the following information: “III. PROCEDURE 3.1 General Procedure: Pursuant to HM Official Procedure PCPS002, when an individual Comes to the Emergency Department, the ED must provide an appropriate Medical Screening Examination within the capability and capacity of the ED, including ancillary services routinely available to the ED, to determine whether or not an Emergency Medical Condition exists. The Medical Screening Examination must be conducted by a Qualified Medical Personnel, as permitted in the applicable hospital’s rules, bylaws or regulations. No Houston Methodist Entity may delay providing an appropriate Medical Screening Examination or any necessary stabilizing treatment in order to inquire about the individual’s method of payment or insurance status, to collect payment, or to seek authorization from a third-party payor. HM hospitals may follow reasonable registration processes as long as the registration process does not delay any Medical Screening Examination or treatment, nor discourage individuals from remaining in the ED for evaluation or treatment. An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services as described in this Section 3.1. 3.2 ESI AND MSE: All individuals who come to the Emergency Department will be triaged utilizing the Emergency Severity Index (“ESI”) five level triage tool and will receive an MSE by a QMP to screen for an Emergency Medical Condition. An individual who Comes to the Emergency Department and who, after undergoing an MSE by a QMP, is deemed to have an Emergency Medical Condition will be provided with any necessary stabilizing treatment, or transferred to another facility in accordance with PCPS002 I. Determination of Non-Emergency Medical Condition 4.1 Except for the population described in Section 4.2, an individual who comes to the Emergency Department who, after undergoing an MSE, is assessed as not having an Emergency Medical Condition, will continue through the ED care process as described below. If at any time it is determined that an individual who previously was assessed not to have an Emergency Medical Condition is reclassified as having an Emergency Medical Condition, then the individual will receive all necessary stabilizing treatment or be transferred to an appropriate medical facility, in accordance with PC/PS02, regardless of that individual’s ability to pay for such treatment. All individuals, regardless of the ESI level at which they are triaged, will receive an MSE by a Qualified Medical Personnel prior to any inquiry about the individual’s ability to pay, and any individual determined to have an Emergency Medical Condition will receive all necessary stabilizing treatment or be transferred to an appropriate facility, in accordance with PCPS002, regardless of that individual’s ability to pay for such treatment.” Medical record review at Facility A failed to locate a central log entry or medical record encounter for Patient ID #1 who presented with law enforcement to Facility A for evaluation on 6/26/2024 in the early morning hours. Review of the Houston Methodist Hospital Medical record for patient #1 dated 06/25/24 reflected: History of Present Illness Patient #1 is a 39 y.o. female with a PMHx of sickle cell disease, bipolar disorder, diabetes, DVT on Eliquis, HIV presenting to the ED due to back pain and leg pain that started recently. Pt reports that she fell while on the bus and also reports that she was beat by her boyfriend. Pt c/o of diffuse back pain as well as leg pain. Pt is very sedate and has slurred speech, needing to be aroused at the beginning of her evaluation. Pt is also demanding IV narcotics. Pt also interrupted meeting with another pt with yelling. Pt was seen at this facility earlier today for syncopal episode. Medical Decision Making Patient with back pain and leg pain. Labs were considered to rule out strain, sprain, fracture, dislocation, radiculopathy. I reviewed previous ER notes, Discharge summary, Clinic note, Labs, CT, XR, US, and EKG. Orders Placed This Encounter naloxone (NARCAN) 0.4 mg/mL injection 0.4 mg acetaminophen (TYLENOL) tablet 1,000 mg Details: “Patient demanding IV Dilaudid for her chronic pain. Patient states that she has since been out of her medications. Review of the patient is a she is recently filled multiple patient medications. Patient also stated that she has a history of sickle cell SS however review of her lab work shows she does not have any sickle cell disease. Hemoglobin have always been mildly anemic but nowhere near level for patient for sickle cell SS. Patient became increasingly aggressive. At one point patient barged into another patient’s room I was interviewing another patient and was incredibly disruptive and yelling at me plan for IV narcotics. Security was called and patient was escorted off the premises. (Encounter 2 begins here). Patient then rechecked. VSS. Patient refusing attempts of lab draws or line placement. Lab work was ordered for further evaluation patient became frustrated with complaints patient has not received IV narcotics patient eventually left AGAINST MEDICAL ADVICE threatened to report everyone to the board.” ED Timeline (Included): 23:10 ED Notes Pt was agitated, aggressive, and yelling while in intake, as she was being taken to CT via wheelchair. Pt started to yell at ED attending as he was in another room with another patient. Security called as per request by Dr. Pt escorted out. 00:15 ED Quick Updates - Free Text: Contacted CT, CT does not have patient at this time 00:27 ED Quick Updates Free Text: brought in again by HFD. was told that pt called 911 from the outside 01:46:24 ED AMA Disposition Patient #1 was seeking treatment for leg and back pain, patient was escorted out of the facility prior to MSE completion. Patient returned to the facility after calling 911 and was not reassessed for change in condition and previous course of treatment. No labs or imaging was completed prior to the patient being escorted out or prior to leaving against medical advice (AMA). There was no evidence of Patient ID #1’s third encounter located in Facility A electronic medical record or central log. Per interviews and record/video footage review, she presented a third time with Texas Medical Center Crisis Team Police force with new complaint of suicidal ideation. Medical record review of Facility B’s records for Patient ID #1 shows that Patient #1: Arrival 6/26/24 at 03:14 am, “Acuity-Emergent” Means of Arrival - Other”, Method of Arrival “Other”; “Arrival Complaint - Patient brought in from a (Facility A) employee”; ED Encounter created 03:14 am; Chief Complaint “Altered Mental Status.” Review of Facility B Video Footage labeled “Camera 12” and identified by Facility B Security Staff ID #97 as Facility B Emergency Department Ambulatory Entrance dated 6/26/2024 at 03:08:25 am. The clip shows an African American female patient, identified by Facility B Director Of Quality Staff ID #96, as Patient ID #1. The patient is seated in a wheelchair and bent over at the waist, wearing a gold top and pants. The wheelchair is being pushed by a uniformed male with a dark jacket and pants on. The male staff member who is pushing the wheelchair speaks to Facility B female employee seated behind the desk. She comes from behind the desk at 03:09:17 am and appears to stoop down to patient level. At 03:09:26 am she is speaking to the patient and the patient is noted to slowly sit up in the chair. 03:10 am she hands patient her purse which is draped over back handle to wheelchair. 03:10:48, the male employee walks to adjacent hallway and retrieves a wheelchair. He transfers patient’s personal purse/bag and another clear belonging bag to back of Facility B’s wheelchair. He stimulates the patient and points for her to move to other wheelchair. The patient is noted to stumble and walk toward wheelchair and has white sheet (which she arrived with), draped around her shoulders. He pushes the original wheelchair out the door and leaves patient unattended, slumped over in wheelchair, in the hallway at 03:12 am. Interview with ED Nursing Director #52 on 8/5/24 at 11:04 she stated that if a patient leaves the ED, has a change in condition, and/or shift change occurs, the patient should be reassessed. When reviewing medical record for patient #1, she stated that the patient technically should have been reassess after she was escorted out of the facility and returned via 911. It looks as if the staff saw that the patient was still in the system and continued down the path from her earlier encounter. She stated that she would have expected that the staff would have at least asked if anything had changed. Video interview with Facility A Security Officer Staff ID #69 on 8/6/24 at 06:15 am. He recalled the events of June 25 night shift. He stated Patient ID #1, (he did not recall her name), “was ‘discharged’ and it was our job to ensure she was safely escorted off the premises.” Once she was “discharged, she was on the front sidewalk on Fannin Street” adjacent to Facility A and she called fire department and they brought her back in a wheelchair to the ED. He stated “medical staff tried to engage in appropriate medical care and she was not able to be treated.” He stated “she was escorted off the premises by Facility A security staff. While being escorted off the premises, she made the statement she was going to lie on Fannin street and kill herself.” He stated “a big discussion” ensued between Facility A team (he did not identify who was involved in this discussion). He stated that she had been returned the facility for a third time that night by Texas Medical Center (TMC) police officer with their “crisis team” who stated “he couldn’t’ leave her out there. She was not in the condition to be left out.” Security staff ID #69 stated “medical staff had exhausted all opportunities and she had to be escorted off.” He stated that Facility B hospital was the next available facility. Staff ID #69 stated he needed to “get her out of the building, we can’t keep taking her back to the same place. They didn’t want her back in the ER.” He said “I was trying to avoid her laying in the street and getting killed.” He stated “she wasn’t alert and she wasn’t moving and I don’t know if she was dead or alive.” He confirmed that he rolled patient, in the wheelchair to Facility B and dropped her off in their ED. He confirmed he had not completed any security or facility incident reports. He stated that Facility A dispatch and night shift security manager were aware of the encounters with Patient ID #1. In summation, Patient ID #1 was a 39-year-old female who presented to Facility A initially for the evaluation of back and leg pain in the setting of reported traumatic injuries which included a fall and physical assault. The medical screening examination was inappropriate as it lacked thorough history, physical examination, imaging, and laboratory components, that would be needed to evaluate for emergency medical conditions. No emergency medical condition was identified. Citing aggressive, disruptive behavior, Patient ID #1 was escorted from the emergency department by security staff at the direction of the medical team. Patient ID #1 represented a short while later to Facility A for a second encounter and refused treatment and subsequently left against medical advice. Patient ID #1 presented for a third encounter that shift, accompanied by Texas Medical Center police crisis team, after making a statement that she was suicidal with a verbalized plan. Facility A security staff transported Patient ID #1 via wheelchair to Facility B emergency department without Facility A performing a medical screen examination for her new mental health complaints and without coordinated transfer.”

“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: 37490 All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances for the purposes of these requirements. Based on record review and interview, the facility failed to identify allegations of neglect and investigate as a grievance in 3 of 3 patients (ID#s 1, 2 and 19). Findings included: Neglect defined by CMS (Centers for Medicare and Medicaid) Services: a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Record review of facility policy titled,” Patient Grievance” dated 6/13/2023, showed the following information: I. POLICY/ GENERAL STATEMENT Houston Methodist is committed to creating an open environment of communication in which patients, patients’ legally authorized representatives (LARs)/companions, family members, and visitors feel comfortable relaying comments regarding care received and services delivered. II. DEFINITIONS Grievance-a patient grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient or the LAR/companion regarding the patient’s care, discrimination, abuse or neglect issues related to the hospitals compliance with the Centers for Medicare and Medicaid Services (CMS) Hospital Conditions of Participation ... If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation and/or requires further actions for resolution, then the complaint is considered a grievance. A written complaint is always considered a grievance whether from an inpatient, outpatient, released/discharged patient or his/her LAR/companion regarding care provided, abuse or neglect or with the hospital’s compliance with the Conditions of Participation. All verbal or written complaints regarding discrimination, abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered a grievance. Record review of Patient ID #2’s medical record showed the following: Case Management Progress Note dated 1/26/2024: Patient reported that he felt as though the HMH was being abusive for a number of reasons including but not limited to: PCA not putting ointment on his wound, he had not had pain medication today, attending has not come to see him in 5 days ... Medical record for patient ID# 2 showed no evidence of investigation to claims made by patient 1/26/2024. Record review of patient complaint/ grievance logs showed no entries for patient ID #2. Review of complaint information documented on complaint log for patient ID# 19 showed the following: Received via patient letter 10/21/23, patient (ID# 19) reported that during his surgery 10/12/23 he stopped receiving anesthesia because his IV fell out. Referred to contracted anesthesia group, MD spoke with patient on 10/26/23 to discuss and answer questions. Patient appreciation of follow-up call to address concerns. No facility investigation was documented (i.e. review of intra-operative record, IV restarts, review of patient vital signs) Interview with patient liaison staff ID H on 2/6/24 at 11:20 am, he stated that allegation of abuse and neglect are recorded and tracked on the grievance log. He went on to say that complaint are issues that are handled in real time and that they are not logged; only issues that is likely to escalate into a grievance are logged. 23032 Patient ID# 1 Review of complaint intake TX00486403 showed allegations that Patient ID #1 developed a hospital-acquired pressure ulcer and multiple infections during her hospital admission. Record review of patient complaint/ grievance logs showed no entries for Patient ID #1. During an interview on 2/06/2024 at 12:20 PM with Staff ID-F, nursing director, she stated a family member of Patient ID # 1 left a voice mail and asked to speak to her about care issues. The daughter was upset that her mother had a urinary tract infection (UTI) and felt that we had contributed to that. Also, she had concerns about one nurse’s actions when she was setting up pressure bags for an arterial line. The nurse manager of the unit, Staff ID- G asked to return the call, as she had developed a “rapport with the daughter.” Staff ID- G was unavailable to interview or contact at the time of survey; she was on leave. The Nursing director said she knew the nurse manager spoke with the daughter. Unsure of the outcome of the call; unknown if there was any documentation by Staff-G of the call. During an interview with patient liaison, Staff ID H on 2/6/24 at 10:25 AM, he stated he received a call to speak with the daughter of Patient # 1 . He spoke with her outside the room in CVICU. He said all he could recall was she was upset about the infections. The daughter had already spoken with the nurse manager, Staff ID-G. The patient liaison asked her if she wanted to file a formal complaint, she said no. He gave her his card and said to call him if things did not get resolved. The patient liaison said there was no documentation of the concerns expresssed or the interaction During a telephone interview on 02/07/2024 at 12:30 PM with Staff ID-X, MD she stated that she had spoken with the daughter of Patient ID # 1 after the patient came under her care in CVICU. The daughter expressed concerns that her mother had developed a pressure ulcer while in the hospital and also a UTI that contributed to Patient # 1’s sepsis. MD said she tried to help her understand her mother’s deteriorating condition and the treatment plan of care.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 37490 Based on interview and record review, the facility failed to report a patient allegation of abuse to the appropriate authorities and/or regulatory agency per facility policy (Patient ID# 2) Findings included: Record review of facility policy titled: “Reporting Suspected Abuse, Neglect, or Exploitation of Victims of Family Violence,” dated 08/31/2023 showed the following: I. General Statement Texas law requires medical professionals, including physicians, nurses, physician assistants, and emergency medical technicians to provide specific information to patients suspected of having sustained, which includes abuse, neglect, and exploitation. The purpose of this procedure: 1. To guide THMH’s (Houston Methodist Hospital) 1st 2/5 with state and federal laws to report abuse comment, exploitation family violence and or their family members. Reporting is required whether the abuse is alleged, suspected, or observed. 2. To ensure all patients who are victims or suspected victims of abuse, neglect, family violence, or exploitation are identified, assessed, offered counseling, education, treatment, and protection ... Under the Texas law, for reporting abuse, neglect, or exploitation any individual who observes or has a reason to suspect abuse, neglect, or exploitation of children, the disabled, or the elderly, is required to report the allegation to the Texas Department of family and Protective Services (DFPS). Within THMH, Case Management Department, SW Case Manager staff are available 7 days per week on a consultative basis from 8am to 5:00pm, and after business hours until midnight. To report Abuse or Neglect of children, the elderly, or people with disabilities, call ... Alleged or suspected abuse, neglect, or exploitation of disabled and elderly patients requires reporting under Federal and Texas Law. Record review of Patient ID #2’s medical record showed the following: Case Management Progress Note dated 1/26/2024- SW (social work) received call from pager operator regarding patient refusing to discharge. SW contacted pat’s RN and informed her SW would meet with patient at the bedside. Met with patient at bedside ... Pt. stated that HMH (Houston Methodist Hospital) was “trying to discharge me to a place that abused me and I am scared.” Patient reported that he felt as though the HMH was being abusive for a number of reasons including but not limited to: PCA not putting ointment on his wound, he had not had pain medication today, attending has not come to see him in 5 days ... SW attempted to discuss solutions for a discharge plan, patient would only discuss how HMH was “refusing a safe discharge.” ... Patient stated that he has requested MHM be investigated and provided telephone number for investigator with Health and Human Services. Patient contacted HHS while SW was at bedside, voicemail was left requesting her to call SW. Interview with Case Manager ID M on 2/6/24 at 11:20 am, she stated that patient ID#2 filed two (2) discharge appeals. While the second appeal was in progress the facility received notification that there was a current investigation regarding allegation of abuse for patient ID#2 at the facility the was to be discharged to. She stated that her management team was made aware. After the second appeal was denied and based on conversation with supervisors, we were not sure if allegations were substantiated and had to discharge him back to the facility. It was not reported to DFPS because the patient said that he had reported the facility. Interview with Case Management Manager ID N on 2/6/2024 at 11:45 am, she stated that patient ID#2 alleged abuse after his discharge appeals had been denied. He told the staff that he had reported this to HHS. She stated that the facility did not make a report of the alleged abuse because the patients stated that he already did. She went on to say that they called the facility to discuss the allegation and they stated that there was no abuse. The social worker was in contact with the investigation but was not given findings of the investigation, or guidance. The patient’s condition did not support abuse and he was discharged to the facility. Record review of incident/ variance logs showed no documentation of alleged/ reported abuse for patient ID # 2. Record review of patient complaint/ grievance logs showed no alleged/ reported abuse for patient ID #2.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 37490 Based on record review and interview, the facility failed to implement an effective and safe discharge planning process that resulted in modification of the discharge plan after allegation of abuse for 1 of 1 patient (Patient #2). Findings included: Record review of facility policy titled: “Discharge Planning,” dated 09/19/2023 showed the following information: POLICY AND GENERAL STATEMENT Discharge planning is the formalized process through which a program of continuing and follow up care is planned and carried out for all patients. It is an interdisciplinary process designed to achieve, within projected time frames, stated goals that lead to the timely release of patients either to their homes or facilities or programs with a lower level of care. Discharge planning is undertaken to ensure that patients remain in a health care organization only for as long as medically necessary. Definitions: A. Discharge Plan: documented evidence that through initial and ongoing psychosocial and physical assessment, each patient’s post-hospital needs are identified, and an action plan to meet those needs is developed and implemented. Procedure: E. The discharge plan is reassessed and modified as patient’s condition/ or support system changes to determine any change in, or addition to identified discharge needs during care coordination rounds and team collaboration. III. Responsibilities of Health Care Providers 3. Case Management and Social Work Department C. Regularly reassess treatment plan and discharge plan to anticipate and initiate planning for alternate levels of care when inpatient care is no longer indicated. E. Assist patient and family in finding options for appropriate post hospital care including post-acute care data on quality measures and resource use measures applicable to patient needs, goals of care and treatment preference per system PCP S029 patient freedom of choice. H. Documents in electronic medical record any education or list of providers provided to the patient and/or family. Record review of facility policy titled “Patient Freedom of Choice,” dated 12/08/2022 showed the following information: GENERAL STATEMENT Patients requiring health care items or services following discharge from a Houston Methodist Hospital must have the freedom to choose the supplier or provider for the necessary item or service. Medicare beneficiaries are guaranteed this right under federal law. All patients, regardless of payment or payment source, must have their freedom of choice respected. This procedure also addresses those situations when patients request assistance from the hospital and making a choice. I. PROCEDURE A. Patient Choice: The discharging employee must inform the patient that the patient has the freedom to choose among providers or suppliers for post-hospital items or services. A patient must be provided with information on quality and resource use measures data that is relevant to his or her goals of care and treatment preferences in order to assist with his or her choice of post-hospital items or services provider or supplier. 1. If a patient’s discharge planning evaluation determines that the patient will need the services of a HHA (home health agency), SNF (skilled nursing facility), IRF (inpatient rehabilitation facility), or LTACH (long term acute care hospital), the discharging employee provides the patient with the applicable list maintained by each Houston Methodist Hospital in accordance with federal law. The discharging employee may tell the patient his physician’s recommendation (if any), which are my the patient’s insurance or health plan. 3. Documentation: the discharging employee will document the patient’s choice in the medical record. B. Patient’s Refusal to Choose 1. If a patient refuses to choose or asks the discharging employee to choose, the discharging employee may make the selection and, then, get the patient’s agreement with the post-hospital item or service selection. 3. Documentation: the discharging employee shall document in the medical record that the patient asked the hospital to select the provider. Record review of Patient ID #2’s medical record showed the following: Case Management Progress Note dated 1/26/2024- SW (social work) received call from pager operator regarding patient refusing to discharge. SW contacted pat’s RN and informed her SW would meet with patient at the bedside. Met with patient at bedside ... Pt. stated that HMH (Houston Methodist Hospital) was “trying to discharge me to a place that abused me and I am scared.” Patient reported that he felt as though the HMH was being abusive for a number of reasons including but not limited to: PCA not putting ointment on his wound, he had not had pain medication today, attending has not come to see him in 5 days ... SW attempted to discuss solutions for a discharge plan, patient would only discuss how HMH was “refusing a safe discharge.” ... Patient stated that he has requested MHM be investigated and provided telephone number for investigator with Health and Human Services. Patient contacted HHS while SW was at bedside, voicemail was left requesting her to call SW. Interview with Case Manager ID M on 2/6/24 at 11:20 am, she stated that patient ID#2 filed two (2) discharge appeals. While the second appeal was in progress the facility received notification that there was a current investigation regarding allegation of abuse for patient ID#2 at the facility the was to be discharged to. She stated that her management team was made aware. After the second appeal was denied and based on conversation with supervisors, we were not sure if allegations were substantiated and had to discharge him back to the facility. Interview with Case Management Manager ID N on 2/6/2024 at 11:45 am, she stated that patient ID#2 alleged abuse after his discharge appeals had been denied. He told the staff that he had reported this to HHS. She stated that the facility did not make a report of the alleged abuse because the patients stated that he already did. She went on to say that they called the facility to discuss the allegation and they stated that there was no abuse. The social worker was in contact with the investigation but was not given findings of the investigation, or guidance. The patient’s condition did not support abuse and he was discharged to the facility. The medical record for patient ID# 2 showed no documentation of alternate post-hospital care choices provided or reviewed with patient ID#2 after he made allegation of abuse at planned post-acute facility and he was discharged back to that facility.”

“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: 37490 Based on record review and interview, the facility failed to follow established Grievance Management Process in 1 of 3 grievances reviewed. (ID # 1) Findings include: Review of facility policy titled “Patient Grievance” dated 06/13/23 showed the following information: I.POLICY/GENERAL STATEMENT Houston Methodist is committed to creating an open environment of communication in which patients, patients’ LAR (legally authorized representative)/ companions, family members and visitors feel comfortable relaying comments regarding care received and services delivered. Each hospital has established a process for prompt resolution of a patient’s grievance or concerns and informs each patient who to contact to file a grievance. Each hospital encourages employees to resolve and report patient concerns to hospital management. Each hospital has established A measurement process for documenting and continuously improving the service and satisfaction of patients, families, and visitors. II. DEFINITIONS Grievance: a patient grievance is a written or verbal complaint (with the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient or the LAR/companion regarding the patient’s care, discrimination, abuse or neglect issues related to the hospital’s compliance with the Centers for Medicare and Medicaid services (CMS) hospital conditions of participation or certain billing complaints. Review of facility policy titled “Grievance Management Process” dated 06/2018 showed the following: Quality Statement: To ensure proper handling of all complaints and grievances and notification to our risk and quality departments. Proper implementation of the procedure contributes to compliance with the CMS conditions of participation; patient rights; DNV/NIAHO standards, and TDH. IMPLEMENTATION 1. A patient or their LAR reaches out to the hospital through various means of communication, which includes but is not limited to, written and verbal communication. 2. The grievance is received by the patient liaison, guest relations management, resolution specialist, or quality and risk management from the department receiving the information from the patient and/4 the patient’s LAR directly. 3. The guest relations management, resolution specialist and patient liaisons work as a team to process the grievance. Interview with physician (ID# 59) on 11/7/23 at 1115 stated that he received communication he thinks via email from the unit manager (ID # 65) and liaison regarding the medical decision making for patient (ID#1). He stated that he has at least two calls to the family regarding the care provided to their family member that passed away. Review of email thread beginning 4/27/22 sent to physician (ID# 59) on 5/1/22 included communication from guest relations, unit leadership and risk management regarding the medical care and documentation for patient (ID#1). Interview with guest relations staff (ID# 55) on 11/7/23 at 1355 stated that there was no documented grievance for patient (ID#1). He also stated that communication in email thread provided by (ID# 59) would meet the definition of a grievance.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 37490 Based on record review and interview, the facility failed to ensure medications were administered as physician order in 3 of 6 patient medical records reviewed (ID#s 1, 2, and 7). Findings include: Record review of facility policy titled “Medication Administration” dated 01/31/2023 showed the following information: III. Procedure A. Administering Medications 1. Verify physician/ APP order 2. Check medication stop date as ordered, as applicable 5. The nurse administering the medication should ascertain the following: a. Right medication b. Right patient c. Right dosage d. Right route e. Right time f. Right reason for which the medication is being administered Review of medical record for patient (ID #1) showed order for propofol (DIPRIVAN) continuous infusion 10mg/mL dated 10/7/22 at 1445. D/C (discharge) order was written on 10/8/22 at 1129. The continuous infusion was stopped 10/7/22 by RN (ID# 68) at 1604. The medical record showed no documented reason for infusion to be stopped prior to D/C order. Review of medical record for patient (ID# 2) showed order for Acetaminophen (TYLENOL) 650 mg tablet, oral, every six hours PRN (as needed) for fever, Fever GREATER than 100.5 F. Medication Administration record for patient (ID# 2) showed medication administration 9/17/22 at 0132. Documented temperature for patient (ID #2) closest prior to administration was 97.8 F on 9/16/23 at 1900. Review of medical record for patient (ID# 7) showed order for Acetaminophen (TYLENOL) 650 mg tablet, oral, every six hours PRN (as needed) for mild pain (score 1-3). Medication administration record for patient (ID#7) showed administration of Acetaminophen 650mg oral on 10/31/23 at 1538. Pain documented for patient (ID# 7) prior closest to administration was documented at “0” at 1500 on 10/31/23. Review of medial record for patient (ID# 7) also showed order for fentanyl (SUBLIMAZE) injection 25 mcg, IV (Intravenous), every 2 hours PRN for severe pain (score 7-10). Medication Administration Record for patient (ID#7) shows administration of fentanyl 25mcg by RN (ID# 70) on 11/4/23 at 0533, with pain documented at 0533 of “0”. Interview with RN staff (ID# 65) on 11/8/23 at 1005 confirmed the above findings.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 37490 Based record review and interview, the facility failed to follow established process for requesting to amend protected health information (PHI) in 1 of 1 patient (ID#1). Findings include: Record review of facility policy titled “Patient’s Right to Request an Amendment of Protected Health Information” dated 11/21/2022 showed the following information: I. POLICY AND GENERAL STATEMENT Houston Methodist respects the patient’s right to request an amendment protected health information. Exceptions to information that may be amended, and the circumstances in which Houston Methodist may deny a patient’s request for amendment, are provided by law. III. PROCEDURE A. Patient’s Request for Amendment of PHI 1. Is that if a patient disagrees or believes his/her Phi is incomplete or incorrect, the patient has the right to request an amendment of this information. 2. All requests will be directed to the health information management (HIM) department for handling. The HIM department will provide a patient with the request for amendment form to complete. 4. If the patient does not submit the amendment request form but does provide a written request, the request must contain the following elements: a. patient’s name; b. patient state of birth, Social Security number, or medical record number c. patients mailing address d. date and description of information to be amended e. reason for amendment f. dated signature of patient or QPR (and legal authority of such individual, if the request is not signed by the patient). F. Denying a Request for Amendment 1. A request for amendment will be denied if: a. Houston Methodist did not create the PHI, unless the originator of the information is no longer available to act upon the requested amendment; b. Houston Methodist designated record set does not contain the PHI in the request; c. information is not available for patient access and addressed in Houston Methodist policy, IM08 ... d. PHI Is accurate and complete 2. If the amendment is not accepted, based upon the review and determination of the author of the entry, the HIM department will provide the patient with a timely written denial. 3. The denial will be written in plain language and contain: a. the basis for the denial; b. The patient’s right to submit a written statement disagreeing with the denial and how the patient may file such a statement. The patient will be directed to send the statement of disagreement to Houston Methodist c. a statement that, if the patient does not submit a statement of disagreement, the patient may request that Houston Methodist provide the patients request for amendment and the denial with any future disclosures of the Phi that is subject of the amendment; and d. a description of how the patient may complain to Houston Methodist or the secretary of the Department of Health and Human Services. Since Houston Methodist’s Entity Business Practices Officer provides oversight for the complaints process, the description will provide this individual’s name or the title and telephone number as contact person, or the name or title and telephone number of a designee assigned by the Houston Methodists entity business practices officer ... Interview with pathologist (ID# 58) on 11/7/23 at 1330 she stated that she received a call from family member of patient (ID#1) stating that she disagreed with the clinical history in the autopsy report and requested that it be amended. She stated that she did not know how the call was routed directly to her. She stated that she discussed the request Director of Autopsy (ID# 64) and it was decided that change would not be pertinent to her report. Interview with Medical Director of Pathology (ID# 63) on 11/7/23 at 1335 she stated that she also was included in a discussion to amend the autopsy report. She stated that she advised pathologist (ID# 58) not to make the change as clinical history is not a requirement and it was already incredibly comprehensive. When asked if the family member was referred to medical records with their request, she stated “No, the report is not part of the medical record.” Interview with HIM Director (ID# 56) on 11/7/23 at 1343 she stated that the autopsy is part of the medical record when performed at the facility. She confirmed that there was no documented request for the amendment of autopsy report for patient (ID#1).”