HCA Houston Healthcare Kingwood

“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: 38387 Based on review of the facility policy, record review, and confirmed in interview, the nursing staff failed to develop and provide a nursing care plan to provide nutritional needs for one of five patients reviewed (Patient #U). Findings included: Review of facility policy Diet Orders (PolicyStat ID 14877304, effective 022024) it stated “Upon admission the physician/approved discipline initiates a diet order in the patient’s medical record, including NPO status as applicable and inclusive of food allergies within 24 hours and prior to provision of food or meals...changes to a diet order require entry of a new diet order using approved procedures.” Review of Patient #U chart reveal he is a 65 year old male with complaints of worsening shortness of breath and right sided pleural effusion with failure to thrive s/p PEG tube. Review of the admission orders on 04/30/2026 for Patient #U revealed a dietary order: Tube Feeding Diet three times daily. Review of Patient #U chart revealed he had only 180 mL on 05/03/2026 midnight and no feedings on 05/04/26. His next feeding was not until 05/05/2026 at 12:00 PM. Review of the Patient #U’s record revealed no documentation of any dietary intervention to promote patient nutritional goals. In an interview with Staff #4 on 07/08/26 at 3:20 PM in the office confirmed the above findings. She stated that the patient needed procedures thoracentesis and pleural studies; therefore likely on NPO.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38387 Based on record reviews and interviews, it was determined the facility failed to ensure patients rights were protected and promoted for 1 of 3 patients reviewed (Patient #A) with an allegation of sexual abuse by Patient #A’s family member. Specifically, the facility failed to ensure the facility established and followed a written procedure for investigating allegations of abuse and neglect including methods to protect patients from abuse during investigations of allegations This deficient practice could compromise patient safety for all patients in the facility by failing to implement protections and further prevention of abuse, neglect and patient rights. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Patient Rights. Refer to A 0145 for evidence of specific findings.”

“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: 38387 Based on review of facility records and confirmed in interview, the facility failed to ensure the patient was free from all forms of abuse for one of three patients reviewed (Patient #A). Facility failed to establish and follow a written procedure for investigating allegations of abuse and neglect including methods to protect patients from abuse during investigations of allegations Findings included: Review of patient #A record revealed she was admitted via ambulance on 10/13/2025 for a fall at home. She has a history of dementia and atrial fibrillation. She suffered scalp laceration that was treated in the ED (emergency department). She was admitted to the 5th floor neuro IMU for further evaluation for possible pneumonia and sepsis. In an interview with Staff #4 on 02/03/2026 at 11:08 AM via phone, she stated she observed Patient #A’s son in the room ‘fondling’ the patient for a period of 1 to 2 minutes on 10/15/2025. She stated that she thought it was odd since the fingers were too close to her vagina. Furthermore, the disposable briefs Patient #A wore were easily distinguished if they were wet. There was no need to check. She stated that she notified the charge nurse and suggested utilizing the fall risk cameras to monitor the son when he’s in the room. Review of Patient #A’s chart revealed a Staff #4’s nursing note from 10/17/2025 5:58 PM, that included “Upon receiving report on 10/15, [staff #4] and student nurse notice that patient son was attempting to check patient brief while fondling the patient. Patient son did not seem bothered by nurse and student being in his presence while messing with patient genital area. This issue has been noticed by several staff prior to my first encounter with the patient and son. This concern was vocalized to charge nurse [Staff #5] and [staff #4] made suggestion of virtual sitter being needed to protect [staff #4] and those involved in patient care for the day.” In an interview with Staff #6 on 02/03/2026 at 11:30 AM in the office, she stated that once the charge nurse was notified on 10/15/2025, the house supervisor was called, and patient and safety were notified. She stated that it was determined that the son could remain a visitor, but the facility requested he leave the door open. She added the patient room was in line of sight of the nursing station. No increased precautions; hourly rounding stayed the same. Staff #4’s suggestion to utilize the fall risk cameras were not implemented. No incident report nor a report to the proper authority was made until a second alleged abuse incident occurred on 10/17/2025. Review of Patient #A record revealed Staff #4 nursing notes that included “during mdrs rounds, nurse concerns about son at bedside still arise which include pct [Staff #7] noticing and vocalizing that he also has concerns with son messing with patient genitals while checking or changing patient. This concern was brought to the attention of [Staff # 8, 9, #6, and charge nurse Staff #10] which initiated the need for APS to be involved and risk management director to be involved as well. APS notified and patient son was escorted off unit to provide safety to the patient until APS case has been settled. MD [Staff #11] made aware and patient daughter made aware with the presence of all involved.” In an interview with Staff # 7 on 02/03/2026 at 1:30 PM in the office, he recounted his observations on 10/17/2025. He stated that it was so disturbing that it’s not something he could easily forget. He stated that when he went into Patient #A’s room to change her disposable briefs, he observed Patient #A’s son putting his hands under the briefs (roughly 30 seconds) to check if the briefs were wet. He found it odd as the briefs themselves have an indicator when wet. There was no need to ‘check.’ He stated that he notified the charge nurse and social work. Social Work advised him to call APS. Review of the Patient Safety Analysis Workplace Violence Event #22832 report confirmed that the facility investigated the allegations of abuse by Patient #A’s son on 10/17/2025. Patient #A’s son was eventually escorted out of the facility on 10/17/2025 after their investigation. Adult Protective Services (APS) and police were called. In an interview with Staff # 12 on 02/03/2026 at 11:50 AM in the office, he stated that he was not made aware of the first incident on 10/15/2025. He also added that it’s customary for them to get a secondary witness when an alleged perpetrator is a family member. He stated that since the alleged perpetrator was the caretaker and son for a number of years, he didn’t want to make allegations until they were certain, requiring the secondary witness. Review of Patient #A’s chart revealed no documentation of a medical assessment of any injuries she may have sustained for either alleged abuse incidents from 10/15/2025 nor 10/17/2025. Surveyor requested a policy for investigation of any abuse/neglect. Facility provided the policy Workplace Violence Prevention Policy (PolicySTAT ID 17162067, effective 12/2024) when on site on 02/03/2026. The policy does NOT include a procedure on how to protect patients from abuse during investigations of allegations. Facility then provided another policy Abuse, Suspected Elder Abuse Policy (PolicySTAT ID 19856073, effective 02/2026) via email on 02/16/2026. Again, the policy does NOT include a procedure on how to protect patients from abuse during investigations of allegations.”

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 38387 Based on review of facility documents, review of medical records and interview, the facility failed to ensure all records documented discharge summaries with outcomes of hospitalizations, dispositions of care and provisions for follow-up care for one of three records reviewed (Patient #A). Findings included: Review of the facility policy Discharge Planning (PolicySTAT ID 16083717, effective 08/2024), it stated “discharge documentation will accurately reflect the final discharge plan and include the actual final disposition (home, nursing home, relatives house). Review of Patient #A’s record revealed she was discharged on 10/17/2025 to the patient’s daughter to her home. Review of her records revealed no discharge summary to include the outcome of hospitalization, disposition of care and provisions for follow-up care . In an interview with Staff # 13 on 02/03/2026 in the office, she confirmed that there were no discharge summary, only a discharge order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 38387 Based on review of facility policy, patient records, and confirmed in interview, the facility failed to ensure restraints were discontinued at the earliest possible time according to the physician orders and facility policy for two of ten patients (Patient #A, C) reviewed for restraints. Specifically, Patient #A and C remained in soft bilateral 2 point restraints while nursing documentation indicated they were sleeping, indicating they met criteria for release. Findings included: Review of facility policy Patient Restrain Policy (PolicyStat ID 17125388, effective 03/2025), under Order for Restraint with Non-Violent or Non-self Destructive Behavior, it stated “staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint when criteria for release are met.” Patient #A Patient #A is an 88 year old male who admitted on 07/08/2025 for right lower extremity pain and inability to bear any weight for several weeks. Review of Patient #A’s chart revealed an order for BUE (bilateral upper extremity) restraint ordered on 07/09/2025 at 10:29 PM. It was initiated on 07/09/2025 at 10:30 PM. Review of the order indicated the criteria for release of restraints is met when patient stops “attempts to remove device” Review of the Restraint Monitoring form revealed Patient #A was sleeping at 07/10/2025 at 12:22 AM to 04:30 AM. The restraint was not discontinued until 09:10 AM. Review of the Restraint Documentation flowsheet the nurse assessed the patient at 07/10/2025 at 12:00 AM and 2:00 AM and documented level of consciousness as ‘sleeping’ but selected ‘no’ for meets criteria for release. Patient #C Patient #C is a 73 year old female who presented to the ED on 06/28/2025 for worsening agitation and confusion. Prior to admission, pt reportedly had been attempting to wander around her neighborhood and became emotional, stating that she felt like she was being kept as a prisoner. Review of Patient #C’s chart revealed an order for BUE (bilateral upper extremity) restraint ordered on 06/29/2025 at 12:06 PM. It was initiated on 06/29/2025 at 12:06 PM. Review of the order indicated the criteria for release of restraints is met when patient stops “attempts to remove device” Review of the Restraint Monitoring form revealed Patient #C was sleeping on 06/30/2025 at 01:37 AM to 05:30 AM. In an interview with Staff #6 on 07/10/2025 at 3:10 PM, he acknowledged that both patients met criteria for release.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 37322 Based on observation, record review and interview of nursing plans of care revealed that nursing failed to evaluate each patient individually (ID#1, 3,5,6,7,8) to address their specific needs. Findings Included: Record review of the hospital policy dated 05/2025. “Support: Interdisciplinary Plan of Care” Purpose: To provide each patient with an individualized, plan of care, to determine priorities and to assist the patient in establishing achievable goals. Observation and record review on 06/13/2025 between 1115- 1215 of nursing care plans with the charge nurses on IMCU (ID# F) and IMU (ID#E), revealed the following: Patient (ID#1), who was admitted for sepsis and hypokalemia. Plan of care was vague, stating the problem of “infection alteration as the problem” expectation was for it to improve. Nothing else stated. Patient (ID#3) was admitted for infection of left foot and had a history of diabetes. Interview on 06/13/2025 at 1145 with the charge nurse (ID #H) stated the patient (ID#3) was depressed, but it was not addressed in the plan of care. Patient (ID#5, 6, 7, 8) were over 70 and their plan of care was also vague and did not address the patients’ specific needs related to ambulation, and possible infection. Interview during chart review on 06/13/2025 on the specific units with charge nurse (ID#H) of the IMCU at 1115 and charge nurse (ID#E) of IMU at 1215, both validated the findings.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 32143 Based on document review and interviews, the facility failed to: 1. have a policy or process to administer Midazolam (Versed-a benzodiazepine medication commonly used for sedation and anesthesia) off label (using a drug for a purpose not specifically approved by the FDA) for the use of a psychiatric behavioral medication emergency in 2 of 2(#7 and #17) patient charts reviewed. 2. ensure a physician assessed and reassessed patients before and after the administration of a chemical restraint. 3. ensure a physician performed a face-to-face evaluation within 1 hour of the administration of the chemical restraint in 2 of 2 (#7 and #17) patient charts reviewed. 4. ensure nursing deescalated, assessed, and reassessed 2 of 2 (#7 and #17) patient charts reviewed after the administration of a chemical restraint. Refer to Tag A0160”

“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: 32143 Based on review, observation, and interviews, the facility failed to; A. ensure nursing was assessing and reassessing patients for skin breakdown, potential for breakdown, and pain control in 1 of 1 (#9) patient charts reviewed. B. provide nursing documentation for patient assessments, incontinent care provided, turning and repositioning schedules for the patient, and assistance for ADLs (Activities of Daily Living such as Bathing, Dressing, Toileting, and Eating) to prevent further skin breakdown in 1 of 1 (#9) patient chart reviewed. Refer to A395 10135 The facility failed to ensure there were sufficient numbers of nurses and personal care attendants on 2 of 2 units reviewed for staffing (Hospital B 6th floor Medical Surgical unit and Hospital A 3 South Tower Surgical unit). Hospital B 6th floor Medical Surgical unit was either short a Registered nurse (RN) or a Patient care technician (PCT) 10 out of 15 days during the timeframe of 03/04-18/2025. Hospital A 3 South Tower Surgical unit was either short Registered nurses (RNs), Licensed vocational nurses (LVNs) or Patient care technicians (PCTs) 15 out of 15 days during the timeframe from 03/06-20/2025. Refer to A0392 for additional information. The facility failed ensure nursing kept current care plans that met the patients’ needs in 3 of 23 sampled patients (Patient #’s 9, 10 and 12). The facility failed to ensure: Patient #10 was started on a feeding timely after the family changed their mind about Hospice services 11/29/2024. Patient #10 was started on a tube feeding 6 days later on 12/05/2024. Patient #12 received daily weights and accurate intake and outputs as ordered by the physician. Staff failed to ensure Patient #12 received follow-up pain assessments after administration or pain medication. Facility staff failed to ensure there was treatment orders for Patient #12’s peritoneal dialysis (PD)port site. Patient #9 had care plan addressing skin breakdown. The skin breakdown included a surgical site to and an unstageable pressure sore. Refer to A0396 for additional information.”

“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: 32143 Based on observation and interviews the facility failed to ensure that the infection control program maintained a clean and sanitary environment to avoid the transmission of infection in 2 of 2 (Hospital A-ER and Hospital B ER-Pharmacy) departments. Refer to Tag A0750”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 32143 Based on document review and interviews, the facility failed to: 1. have a policy or process to administer Midazolam (Versed-a benzodiazepine medication commonly used for sedation and anesthesia) off label (using a drug for a purpose not specifically approved by the FDA) for the use of a psychiatric behavioral medication emergency in 2 of 2(#7 and #17) patient charts reviewed. 2. ensure a physician assessed and reassessed patients before and after the administration of a chemical restraint. 3. ensure a physician performed a face-to-face evaluation within 1 hour of the administration of the chemical restraint in 2 of 2 (#7 and #17) patient charts reviewed. 4. ensure nursing deescalated, assessed, and reassessed 2 of 2 (#7 and #17) patient charts reviewed after the administration of a chemical restraint. The facility had one provider number and one license number but had two hospitals on different campuses. Hospital- A was in Kingwood, and Hospital- B was in Cypress. The facilities had shared Governing Board meetings and Medical Staff meetings but two different CEOs. Patient #7 A review of patient # 7’s medical chart revealed he was a 24-year-old male who arrived at Hospital B’s Emergency Room (ER) on 8/30/24 at 1605. A review of the physician notes on 8/30/24 at 1511 stated, “24-yo male with past medical Struve anxiety, MDD, presents with complaints of suicidal ideation that has been going on since last month. Patient states that he wants to run across the freeway. Patient stated that he started taking his Lexapro and hydroxyzine a month ago. Patient reports he previously has been on it but has been off for some time. Patient also reports that he wants to beat up his male ex best friend. Patient is on EDO. Patient has previously been admitted to an inpatient psychiatric facility. Patient denies any other symptoms”. Also, the physician documented that the patient was “alert and oriented, suicidal, and homicidal ideation.” A review of the medical record revealed that the physician ordered a case manager referral. The case manager interviewed patient #7 on 8/30/24 and recommended inpatient care along with the Mental Health Authority. The Case manager proceeded to send admission criteria forms to multiple facilities to find inpatient psychiatric care for the patient. On 9/3/24, patient #7 was administered a Broset test. According to Nih.gov, the Broset Violence Checklist (BVC) is a tool used to assess the potential for violence in patients, especially within healthcare settings. It’s a 6-item checklist that helps predict imminent violent behavior by identifying specific behaviors like confusion, irritability, and threats. The BVC is used to help healthcare professionals take preventative measures and develop management plans. Scoring: Each behavior is scored as 0 (absent) or 1 (present). The scores are then totaled, and the total score indicates the level of risk: 0 = low risk, 1-2 = moderate risk, and 3+ = high risk. Patient #7 had been administered the test each shift with a score of 0. A review of the nurse’s notes dated 9/1/24 at 0724 revealed the test was given to patient #7. The findings revealed; - - BROSET - - Able to complete the Broset: Yes Confused: No Irritable: No Boisterous: No Verbal threats: No Physical threats: No Attacking objects: No Broset score total: 0 Broset risk type: Small” A review of the nurse’s notes dated 09/01/24 was as follows: “1650- “PT REFUSING TO TAKE SHOWER, PT STATES, “I DON’T CARE ANYMORE AND I’M FINE”. THE PT STATES “IF I HAD KNOWN I WAS GOING, TO HAVE TO WAIT THIS LONG TO GO TO A PLACE I WOULD NOT HAVE CALLED 911 TO COME GET ME”. “I AM READY TO LEAVE THIS PLACE”. PT DECLINES ANY FURTHER INTERVENTIONS. PT WILL NOT ALLOW VITALS TO BE OBTAINED AND ATTEMPTED TO REMOVE THE IV. Patient #7 was on every (q) 15-minute checks from the sitter. 1657- PT IS DEMONSTRATING WITHDRAWN BEHAVIOR. HE HAD A VISIT TODAY FROM HIS WIFE/GIRLFRIEND. SINCE THE VISIT, HE HAS BECOME DESPONDENT AND ASKING TO BE LEFT ALONE. PT STATES, “I AM USED TO BEING IGNORED”. 1705- PT REFUSED TO REMOVE THE SHEET FROM HIS HEAD WHEN ASKED BY THE STAFF. SECURITY ATTEMPTED TO REMOVE THE SHEET. THE PATIENT BECAME COMBATIVE AND HOSTILE. CHARGE NURSE ______, TWO SECURITY OFFICERS, AND A SITTER IN THE ROOM. DR. WU NOTIFIED OF THE PATIENT’S BEHAVIOR. MEDICATION ORDERED.” Further review of the medical record revealed there was no documentation of any de-escalation attempts, no documented evidence on how the patient was combative or hostile (such as verbal, physical, or both). The nurse documented that the patient had a sheet over his head. There was no documentation on why this was a problem. There was no documentation that the patient was attempting to harm himself with the sheet. A review of the physician orders revealed that patient #7 was ordered; Droperidol 2 mg intramuscular (IM) x1 (primarily used as an antiemetic and can be used as a sedative and tranquilizer for managing agitation). The Medication Administration Record (MAR) stated the medication was administered by the nurse at 1715 in the left buttock. Versed 5mg IM x1 (sedative primarily used as a moderate sedation before surgery or during a procedure) This drug may cause amnesia and requires monitoring. (Adverse effects: variations in blood pressure and heart rate, impaired balance and gait, sedation, respiratory depression, and retrograde amnesia. Adverse effects may be potentiated by other medications (like analgesics). The MAR stated the nurse administered the medication at 1708 in the left arm. Benadryl 50mg IM x1 (Antihistamine) The MAR stated the nurse administered the medication at 1708 in rt buttocks. There was no documentation that the patient was held to administer these medications. The nurse documented on 9/1/24 at 1807 that “Pt declined the dinner tray. Will hold at nurses’ station until he decides when he wants to eat” 1938 Pt in room eating dinner tray. Patient calm and cooperative at this time. When asked how he’s feeling replies, “I’m OK.” I’ll continue to assess behavior.” A review of the nurse’s notes revealed there were no vital signs taken until 9/1/24 at 1957, 3 hours post medication administration. There was no documentation that Patient #7 refused a vital signs assessment before 1957 (7:57 PM). A review of the policy and procedure titled, “Patient Restraint Policy,” failed to address the use and monitoring of chemical restraints/ emergency behavioral medications. A review “Addendum 2: 09/01/24 1709 ______(by ER physician)Patient Addendum -1708: patient agitated, aggressive, yelling, trying to leave, requiring chemical restraint with droperidol, versed, benadryl IM.” There was no face-to-face performed or documented. There was no physician assessment documented from a physician on 9/2/24. The next documentation by a physician was on 9/3/24 at 0630. Patient #17 A review of Patient #17’s medical record revealed he was a 15 y/o male brought to hospital A’s ER on 3/6/25 at 1239 for suicidal ideations. A review of the physician notes dated 3/6/25 at 1250 stated, “ 15-year-old male brought in by parents for concerns of aggressive behavior. According to mom and dad patient has had aggressive behavior. Does have a past medical history significant for aggressive behavior and depression for which he is on Risperidone, Abilify and Prozac. According to mom she states that he is a pathological liar and likes to skip school. He is made multiple accusations of sexual misconduct against teachers and principals at school and parents have had to change multiple schools because of his accusations and his behaviors and his refusal to go to school. Mom also suspects that he uses hard drugs to which the patient attests. He states he uses alcohol and marijuana almost daily. He also does methylphenidate, heroin and fentanyl injectables almost on a daily basis. Has multiple different drug dealers that come and go into the house. He has threatened to kill mom and dad and his siblings. Today got into an altercation at this time which is what prompted parents to call the cops and patient was placed in an EDO and brought to the emergency department. Attested to suicidal ideation to the nursing, staff, to me and to the psych assessor ...Acute Problem list: SI, Aggressive Behavior ...Psych assessor was able to evaluate the patient and recommended inpatient treatment. Patient has had a total of 3 rounds of conversation with the psych assessor and parents are on board with inpatient placement. Will initiate inpatient placement. Is requesting a fourth round of conversation with the psych assessor. Signed out to incoming physician awaiting transfer to a psych facility once accepted.” A review of the nurses notes dated 3/6/25 at 1250 stated, “- - SUBJECTIVE ASSESSMENT - - Patients description of reason for visit: PATIENT IS HERE FOR EVALUATION FOR VOMITING BLOOD OVER THE LAST SEVERAL DAYS /W ABDOMINAL PAIN. HISTORY OF GERD, EOE, POTS. SAYS HIS STOMACH HURTS AND HE CANNOT EAT. PATIENT ALSO DESTROYED PARENTS HOUSE EARLIER AND HE WAS ANGRY AND UPSET. PATIENT HAS BEEN SKIPPING SCHOOL AND WALKING HOME, WHICH UPSETS MOM. PATIENT REPORTS HE LEAVES SCHOOL BECAUSE THE ASSISTANT PRINCIPAL AT KINGWOOD HIGH SCHOOL IS FLIRTING WITH HIM AND ASKING FOR SEXUAL FAVORS. SAYS HE HAS NOT REFORTED IT BECAUSE NOBODY WILL BELIEVE HIM. PARENTS REPORT HE TOOK SOMETHING AND PATIENT ADMITS TO DRUG USE BEFORE ARRIVAL. PATIENT ADMITS TO SMOKING MARIJUANA, USING METH, INJECTING “DIRTY 30” WICH IS FENTYNAL AND PERCOCET TOGETHER. SAYS HE HALLUCINATES WHEN HE IS WITHRAWLING FROM DRUGS. SAYS HE GETS MAD AND HEARS THINGS. PAST TRAUMA OF SEXUAL ABUSE. STARTED USING DRUGS AT AGE 12. PATIENT SAYS HE HAS BEEN SUICIDAL AND HOMICIDAL IN THE PAST. SAYS HE DOES NOT WANT TO GO BACK TO A PSYCH FACILITY. SAYS HE WILL “SLIT HIS THROAT” IN FRONT OF EVERYONE IF HE HAS TO GO BACK. SAYS HE WANTS TO IMPROVE HIS RELATIONSHIP WITH HIS MOTHER. SAYS IF IT DOES NOT IMPROVE IN 1 MONTH HE WILL “BLOW HIS BRAINS OUT”. A review of the nursing notes revealed the patient had vital signs taken at 1250. On 3/6/25, at 1430, the nurse documented, “Virtual sitter in place waiting for pts physical sitter. Patient remains calm and cooperative.” 1530 sitter in place patient calm and cooperative ...1735- Pt agitated, does not want to stay as inpatient per teledoc recommendation Charge ERN spoke with pt and with mom. Mom agrees pt needs to stay for inpatient therapy. 1745 Pt loud voice, screaming obscenities “Fuck You” at mom and stepdad. Security called. 1804 Pt stated to the RN administering the meds, “tell my mom bye.” Security officers x2 with RNs adm meds IM. Pt cooperative with med administration.” A review of the MAR revealed the physician ordered Haldol 5 mg slow IV push x1 and Versed 2mg IV x1. on 3/6/25 at 1759. The nurse was unable to give IV due to pt removed IV and medication was given IM, but there was no order to change route for Haldol or Versed. The nurse documented, “ED MD aware and ok with adm route.” There was no documentation of de-escalation techniques used, there was no other behaviors documented other than screaming obscenities. There was no documentation of nurse observation during and after the administration of a moderate sedation drug, there were no vital signs taken until the patient was discharged at 2200. A review of the MD notes for 3/6/25 revealed a note on 03/06/25 at 1830: that stated, “I assumed care of this patient from the previous physician. Briefly, this is a 50-year-old (sic) male with an extensive psychiatric history with multiple psychiatric hospitalizations who came in after an altercation with his stepfather. Reportedly has been skipping school and being generally disruptive. In the Emergency Department, he became agitated, which warranted treatment with haloperidol and midazolam.” There was no documentation from the current or previous physician about the patient’s behaviors, if the patient was assessed before administering chemical restraints, or if the physician was aware of the medication administered by IM route. There was no documentation of a 1-hour face-to-face evaluation. An interview was conducted with staff #15 on 3/18/25 from hospital A. Staff #15 was asked for a restraint log. Staff #15 was able to produce a mechanical restraint log but not for chemical restraints. Staff #15 confirmed there was no restraint log for chemical restraints. She stated the logs could be pulled for violent and nonviolent restraints, but the facility was unable to provide one to the surveyor upon multiple requests. An interview was conducted with Staff # 67, the Director of QAPI, and the Chief Nursing Officer (CNO) for Hospital B on 3/19/25. The CNO stated that she was not aware of the physician administering Versed to patients for a psychiatric emergency. The CNO stated the facility did not have any policy or process for medical staff to use Versed off label for psychiatric emergencies. Staff # 67 stated that she was also unaware of the ER physicians ordering Versed as medication in a psychiatric emergency. Staff #67 stated that chemical restraints were not being monitored for restraint use in QAPI. An interview was conducted with the CEO of hospital B on 3/19/25. The CEO stated that the physicians have been notified and a memo was sent out to ED providers, Medical Director, Regional Medical Director, and Chief of Staff. The memo stated, “Use of Versed and Other Moderate Sedation Drugs on Behavioral Health Patients. Effective immediately, please cease the use of Versed and other off-label prescribing of moderate sedation drugs for behavioral health patients. In the coming days, we will convene the Pharmacy and Therapeutics Committee of the Medical Staff and Medical Executive Committee to revisit and revise our hospital policy to comply with state regulation. Please note that the utilization of anti-psychotic drugs for this patient population is acceptable. We wish to prevent off-label uses of moderate sedation drugs that do not comply with our current policy or that are not accompanied by appropriate patient safety monitoring and safeguards. Once Pharmacy and Therapeutics, Medical Executive Committee, and Board of Trustees have approved revised policy, we will communicate what is acceptable under such policy. In the interim, we will share a list of those medications on formulary that are acceptable to prescribe in these circumstances. Please note that this direction comes in follow-up to a recent survey by Texas Department of Health.” The CEO of Hospital A also provided the same letter to the physicians of the ER at Hospital A. An interview was conducted with Staff #52 and #6 on 3/20/25 at hospital A concerning the use of Versed. Staff #52 confirmed that patients from hospital A’s ER had also received Versed for behavioral health emergencies. Staff #6 stated that she was addressing restraints in QAPI but did not have any data or information to provide on chemical restraints for violent patients. 47892 An interview was conducted on April 3, 2025, after 3:30 PM with Staff #14. Staff #14 was asked if Patient #17 was continuously monitored by an RN trained in moderate sedation after he received an injection of Versed. Staff #14 stated that Patient #17 “had a patient sitter with a direct line of sight to Patient # 17 located outside his doorway.” Staff #14 was asked was the patient sitter an RN with moderate sedation training. Staff #14 stated, “Patient sitters are not RNs.””

“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: 10135 Based on interview and record review, the facility failed to ensure there were sufficient numbers of nurses and personal care attendants on 2 of 2 units reviewed for staffing (Hospital B 6th floor Medical Surgical unit and Hospital A 3 South Tower Surgical unit). Hospital B 6th floor Medical Surgical unit was either short a Registered nurse (RN) or a Patient care technician (PCT) 10 out of 15 days during the timeframe of 03/04-18/2025. Hospital A 3 South Tower Surgical unit was either short Registered nurses (RNs), Licensed vocational nurses (LVNs) or Patient care technicians (PCTs) 15 out of 15 days during the timeframe from 03/06-20/2025. This deficient practice had the likelihood to cause harm to all patients on the units. Findings include: Hospital B 6th floor Medical Surgical unit During confidential interviews the following was stated about staffing: “Lately staffing is kind of short. We are supposed to have 4 nurses and 1 charge nurse. When there’s not enough the charge nurse has to take patients. Sometimes we do not have techs. If respiratory is short staffed, we have to do the breathing treatments. The most patients we take is 6, but if there is no tech, one tech or no charge nurse that is too much. You can’t do the nursing part of the job. Somethings are passed on to the night shift.” When it comes to staffing” some days are better than others. Somedays there is not enough, and the charge nurse has to take a full load. The techs are 1:12 patients when there are 2 techs here. If there are not enough techs the nurses take on some of their assignments. When there is no free charge nurse there is no resource person for the floor.” “It would help to have an acuity tool. An acuity tool is in the making.” Review of “MS6 ASSIGNMENT SHEETS” and Staffing Grid Department Data Report revealed the following: On 03/16/2025 there was a census of 23 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was no charge nurse (CN), 4 registered nurses (RN) and 2 personal care technicians (PCT) working. The staffing matrix called for 1 CN, 4 RNs and 2PCTs. The floor was short a free-floating charge nurse. On 03/16/2025 there was a census of 24 on the 7:00 pm - 7:00 am shift. According to assignment sheets there was 1 CN, 4 RNs and 1 PCT working. The staffing matrix called for 1 CN, 4 RNs and 2 PCTs. The floor was short a PCT. On 03/15/2025 there was a census of 22 on the 7:00 pm - 7:00 am shift. According to assignment sheets there was 1 CN, 4 RNs and 1 PCT working. The staffing matrix called for 1 CN, 3 RNs and 2 PCTs. The floor was short a PCT. On 03/14/2025 there was a census of 21 on the 7:00 am - 7:00 pm shift. According to assignment sheets there was no CN, 4 RNs and 2 PCTs working. The staffing matrix called for 1 CN, 4 RNs and 2 PCTs. The floor was short a free-floating charge nurse. On 03/14/2025 there was a census of 21 on the 7:00 pm - 7:00 am shift. According to assignment sheets there was 1 CN, 4 RNs and 1 PCT working. The staffing matrix called for 1 CN, 3RNs and 2 PCTs. The floor was short a PCT. During an interview on 03/19/2025 after 1:25 p.m., Staff #35 said the extra RN did on-line education during the shift. On 03/13/2025 there was a census of 21 on the 7:00 am - 7:00 pm shift. According to assignment sheets there was no CN, 4 RNs and 1 PCTs working. The staffing matrix called for 1 CN, 4 RNs and 2 PCTs. The floor was short a free-floating charge nurse and a PCT. On 03/13/2025 there was a census of 24 on the 7:00 pm - 7:00 am shift. According to assignment sheets there was no CN, 4 RNs and 2 PCTs working. The staffing matrix called for 1 CN, 4RNs and 2 PCTs. The floor was short a free-floating charge nurse. On 03/12/2025 there was a census of 24 on the 7:00 pm - 7:00 am shift. According to assignment sheets there was no CN, 4 RNs and 2 PCTs working. The staffing matrix called for 1 CN, 4RNs and 2 PCTs. The floor was short a free-floating charge nurse. On 03/07/2025 there was a census of 21 on the 7:00 am - 7:00 pm shift. According to assignment sheets there was 1CN, 4 RNs and 1 PCT working. The staffing matrix called for 1 CN, 4 RNs and 2 PCTs. The floor was short a PCT. On 03/06/2025 there was a census of 22 on the 7:00 am - 7:00 pm shift. According to assignment sheets there was 1CN, 4 RNs and 1 PCT working. The staffing matrix called for 1 CN, 4 RNs and 2 PCTs. The floor was short a PCT. On 03/04/2025 there was a census of 24 on the 7:00 pm - 7:00 am shift. According to assignment sheets there was 1CN, 4 RNs and 1 PCT working. The staffing matrix called for 1 CN, 4 RNs and 2PCTs. The floor was short a PCT. During an interview on 03/19/2025 after 1:25 p.m., Staff #35 confirmed the shortages in staff. Hospital A 3 South Tower Surgical unit During confidential interviews the following was stated about staffing: “The unit has 36 beds. The staffing ratio is 6:1 for nurses and 12:1 for PCT’s. Because of high volumes I would like to see 1:5. This unit is medical, surgical, orthopedics, telemetry and trauma.” PCT’s “get 12 patients regularly, but occasionally more. We are able to get the work done it just takes longer.” “Sometimes there are not enough PCT’s. If we have 3 techs we have 12 patients. Can’t get all our task done if we are taking more patients. Examples given were Chlorhexidine baths not done and turning and repositioning are done every 2-4 hours.” The patient to nurse ratio is “6:1 and this is a trauma unit and it’s difficult at times. There are high turnover for admissions and discharges, acuity of patients high and were getting a little bit of everything.” As far as PCT’s “sometimes there are enough and the nurses pitch in with care when there’s not enough.” “Charge nurse takes patients if there are not enough nurses. When we are lucky, we have 3 PCT’s, but were averaging two. Day shift nurses have to help with cleaning patients, baths and vital signs. The night shift has to get their own vitals. With a 6: 1 ratio it is hectic. Patients have chest tubes, high acuity and total bedbound. One time I had a patient that was having seizures every 1-3 minutes and also had 5 other patients to take care of. 5:1 is an ideal ratio.” “We have been trying to get something done. It is almost impossible to take care of patients. Nurses go home crying.” “Not enough and were not supposed to talk about it. The ratio is 6:1 and it’s too many. We have a high rate of admissions and discharges. About 10-11 patients per shift, people coming and going for procedures, and assessments of patients in the AM. It’s hard to feel like we are spending quality time with patients. We have surgical patients who are non-ambulatory and can’t turn themselves. Somedays there are not enough techs to keep the butts dry. Three techs are not enough, we need 4. They pull our staff to other floors. We should not be running without a charge nurse because we have a lot of LVN’s. That responsibility falls on the RN’s. We are getting IMC and IMU stepdown patients. When Rapid response comes and assesses a patient, that patient is left here and unstable until moved. The nurse also has 5 other patients with that unstable patient. Patients are inappropriate for this floor. They can’t turn these people every two hours. I think pressure sores are directly related to the staffing. We get violent patients who are pending charges.” “We have high acuity patients, complex, a lot need close monitoring, have tubes, drains, foley catheters, and nasogastric tubes. We are a medical surgical unit on paper, but we are orthopedic, trauma, bariatric, general surgery, and snake bites. Everybody is so tired (physically) and tired of the ratio. A while ago there was no free charge nurse and last night there was only one tech for the entire floor. We are supposed to have 3 techs. It is too many people to change and turn and it I not done as often as it should. I don’t feel like I can care for the people like I should because I don’t have time. It’s not in the budget to have the staffing we need. I get anxiety when I come to work.” Staffing “is dangerous. We have 1:6 patient ratio and the acuity are so high. I don’t feel we give the patient care we should give because we don’t have the time. When a Rapid response is called on a patient your other 5 patients may suffer.The emergency department does not call report sometimes. You get a text from the unit secretary saying the new patient is in the room. The techs are burnt out. Two techs with this acuity, they barely have time to care for the patients.” Review of the facility’s Daily Rosters and Staffing Grid Department Data Report revealed the following: On 03/20/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 charge nurse (CN), 4 registered nurses (RN), 2 licensed vocational nurses (LVN) and 3 personal care technicians (PCT) working. The staffing matrix called for 1 CN, 4 RNs, 3LVNs and 3 PCTs. The floor was short an LVN. On 03/19/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was no CN, 3 RNs, 2 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1CN, 1 RN and 1LVN. On 03/19/2025 there was a census of 34 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was 1CN, 4 RNs, 2 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 PCT. On 03/18/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1CN, 3 RNs, 2 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN and 1LVN. On 03/18/2025 there was a census of 36 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was 1CN, 4 RNs, 2 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN. On 03/17/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 4 RNs, 2 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1CN, 1 LVN and 1 PCT. On 03/16/2025 there was a census of 35 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was no CN, 4 RNs, 2 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 CN and 1LVN. On 03/16/2025 there was a census of 36 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was no CN, 4 RNs, 2 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 CN and 1 PCT. On 03/15/2025 there was a census of 32 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was no CN, 5 RNs, 1 LVN and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 CN and 1 PCT. On 03/14/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 3 RNs, 3 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN. On 03/14/2025 there was a census of 32 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was no CN, 4 RNs, 2 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 CN. On 03/13/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 3 RNs, 3 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN. On 03/13/2025 there was a census of 35 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was no CN, 6 RNs, and 3 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 CN. On 03/12/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1CN, 3 RNs, 3 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN and 1 PCT. On 03/11/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1CN, 3 RNs, 3 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN. On 03/10/2025 there was a census of 34 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 3 RNs, 3 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 PCT. On 03/10/2025 there was a census of 36 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was 1 CN, 4 RNs, 2 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 PCT. On 03/09/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 2 RNs, 4 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 2 RNs and 1PCT. On 03/09/2025 there was a census of 36 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was 1CN, 4 RNs, 2 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 PCT. On 03/08/2025 there was a census of 35 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 4 RNs, 2 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 LVN and 1 PCT. On 03/08/2025 there was a census of 36 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was 1 CN, 4 RNs, 2 LVNs and 2 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 PCT. On 03/07/2025 there was a census of 35 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 3 RNs, 3 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN. On 03/06/2025 there was a census of 36 on the 7:00 am to 7:00 p.m. shift. According to assignment sheets there was 1 CN, 3 RNs, 3 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 4 RNs, 3 LVNs and 3 PCTs. The floor was short 1 RN. On 03/06/2025 there was a census of 36 on the 7:00 pm to 7:00 a.m. shift. According to assignment sheets there was no CN, 5 RNs, 1 LVNs and 3 PCTs working. The staffing matrix called for 1 CN, 3 RNs, 3 LVNs and 3 PCTs. The floor was short 1 CN. During an interview on 03/20/2025 after 11:05 a.m., Staff #47 confirmed the shortages and stated they were not using to the current staffing matrix. They were told by their division about 3 weeks ago that they have to staff 1 CN, 3 RNs, 3 LVNs and 3 PCTs. Review of the facility’s policy named “Nursing Master Staffing Plan with Guidelines for Staffing and Assignments” effective 04/2023 revealed the following: “Purpose: To ensure that a written facility plan for nurse staffing that ensures an adequate number and skill mix of nurses is developed, communicated, and adapted as necessary. Policy: ...2. Each patient care unit will be staffed in accordance with established guidelines that consider the following: a. Acuity of patients, b. Scope of services provided, c. Levels of intensity of the patients for whom care is being provided, d. Contextual issue (architecture, geography, availability of technology) and, e. Level of preparation and experience of those providing care (number, competency, and skill mix) ....””

“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: 32143 Based on review, observation, and interviews, the facility failed to; A. ensure nursing was assessing and reassessing patients for skin breakdown, potential for breakdown, and pain control in 1 of 1 (#9) patient charts reviewed. B. provide nursing documentation for patient assessments, incontinent care provided, turning and repositioning schedules for the patient, and assistance for ADLs (Activities of Daily Living such as Bathing, Dressing, Toileting, and Eating) to prevent further skin breakdown in 1 of 1 (#9) patient chart reviewed. The facility had one provider number and one license number but had two hospitals on different campuses. Hospital- A was in Kingwood, and Hospital- B was in Cypress. The facilities had shared Governing Board meetings and Medical Staff meetings but two different CEOs. A review of patient # 9’s medical chart revealed she was admitted to hospital A on 2/17/25 at 15:09. Patient #9 was living in a skilled nursing facility after she had a right above the knee amputation and had developed a wound to her upper rt groin. The rt above the knee amputation surgical site had dehisced (gape or burst opened), causing gangrene of the wound. A review of the physician notes dated 2/17/25 stated, “HISTORY OF PRESENT ILLNESS: A 64-year-old female who is known to have diabetes hypertension, stroke, right-sided weakness had a right BKA because of the peripheral vascular disease and diabetic leg. She presented to the hospital with a nonhealing wound. She has a wound VAC dressing on the right BKA recently done. Deny any fever or chills, not healing. She has been touching the wound for a long time now. She has a midline. She was getting antibiotics through the midline. ASSESSMENT AND PLAN: The patient was seen by ____ (physician), status post above-knee amputation, worsening right-sided wound, diabetes, hypertension, right groin wound with serous discharge, purulent s panning from the right groin. Blood cultures were negative. The patient requires wound VAC, which has been placed, but the whole healing area on the distal aspect of the stump has become gangrenous with a smell. I think it is more of a surgical case and therefore, I am going to consult the surgical team and to refashion the stump, I explained to the family at the bedside and they show full understanding and we have to refashion the wound, we have to give antibiotic judiciously and continue with penem (antibiotic) and Zyvox (antibiotic) ...” A review of the medical chart revealed that patient #9 was admitted to the 4ST medical floor on 2/17/25. There were no pictures taken of the patient’s buttocks or sacrum. A review of wound care notes dated 2/18/25 at 2025 revealed the wound care specialist (WCS) documented they were consulted to address the rt above the knee amputation (AKA) and rt groin wound. There was no documentation that the WCS documented any other wounds nor if the WCS did a skin assessment to look for any further wounds on the following assessments documented for 2/18/25, 2/20/25, and 2/22/25. A review of patient 9’s chart revealed she was moved to unit 3300. Nursing notes and photographs were found documented on 2/25/24 at 10:00 am. The unit nurse documented that the wound to the buttocks was a Maceration (softening and breakdown of skin due to prolonged moisture exposure) Posterior buttocks bilateral (both sides). There were pictures taken but no documented measurements or staging. The wound was described as “beefy red” with bloody drainage. A dressing was placed on the wound. The unit nurse also documented, “Peri area noted maceration, transferred from other unit. Some open areas noted, skin cleansed and Triad applied, pt placed on air mattress.” There was no documented staging or written measurements. The nursing note was provided by the wound care nurse during the patient chart review on 3/20/25. A review of the nurse’s notes dated 2/25/25 at 0830 stated the patient was non-ambulatory and required a 2-person assist. The patient was weak in all extremities. An “adult skin risk” assessment stated the patient was bedfast, mobility very limited, probably inadequate nutrition and potential problem for friction and shear. “Risk for pressure injury.” PT documented that the patient was in too much pain to participate in PT at 1320. There was no documentation that the nurse was aware that the patient’s pain had been addressed or treated. There was no nursing documentation of turning the patient or incontinent care until 2/26/25 at 0024. The nurse documented, Hygiene care provided: Extensive 2-person assist, 2-person assist with perineal care provided, and oral care provided. There was no documentation that the patient had received any other incontinent care or was being turned to prevent skin breakdown. There were no further nurses’ notes provided from 2/27/24 until 3/7/25. The surveyor was unable to determine if the patient was being turned, given ADLs, or addressing pain during this time period. On 2/27/25, the WCS documented wound care to the right groin and right AKA, but there was no documentation of the maceration to the buttocks or peri area, and no photos were found. On 2/28/25, patient #9 was transferred from unit 3300 to 3N per the notes provided by the WCS. No pictures were taken of the wound on her buttocks at the time when she arrived to 3N. A review of the Medication Administration Record (MAR) dated 3/1/25 at 1514 revealed the patient had a pain level of 10 on a pain scale of 1-10 being the worst. Patient #9 was administered Hydromorphone (narcotic) 0.25mg was administered IV. The nurse documented again at 1613 that a reassessment of the pain medication was done, but there was no documentation that the patient had any pain relief or what the patient’s pain level was. On 3/1/25 at 1649, the WCS documented that the patient had a surgical revision to the AKA on 2/28/24. The WCS documented, “Patient had a right revision on 2/28/25. Wound vac in place with adequate seal. Attempted dressing change to right groin wound, and patient started slapping wound care nurse and yelling, ‘No, No. Will attempt dressing change at a later date.” There was no further documentation that the nurse attempted at a later time that the patient’s pain was assessed or any attempt to find out why the patient did not want the dressing changed. On 3/3/25 at 1025 a.m., the WCS documented wound care to the right leg and groin, but there was no documentation that the patient was assessed for any further wounds, and there were no pictures or treatments to the buttocks area. On 3/4/25, patient # 9 was transferred back to 3300 per the notes provided by the WCS. Patient #9’s buttocks and sacrum had gone from a small wound to an unstageable wound, which was a reportable pressure injury. A review of the information provided by WCS revealed a picture of the buttocks and the left heel. There were no notes on the sizes or stage. On 3/5/25 at 1427, the WCS documented, “Left Buttock: Unstageable pressure injury (HAPI- Hospital Acquired Pressure Injury); 9.5x9.2 x UTD. (“UTD” stands for “Unstageable Full Thickness Skin or Tissue Loss - Depth Unknown) 90% black stable Eschar with edges shown pink and off-white discoloration, no drainage noted at this time, no odor detected ...” On 3/7/25 at 1729, the WCS documented, “Sacrum/Left buttock -Pressure injury, unstageable-Wound 100% covered with non-viable black soft eschar and dark tanned slough, boggy to touch. No exudate noted, malodorous. Edges irregular and undefined. Slough and eschar are firmly adherent to wound base. Cross-hatched with scalpel ...” A review of the nurse’s note dated 3/7/25 1400 shows that the patient had a urinary catheter placed at 1400. The patient was given Hygiene care at 1558, and it was stated the patient had already bathed today. “Hygiene care provided: Extensive. 1 person asst Perineal care provided: Extensive. 1 person assist.” There was no evidence that the patient was on a turning schedule. The patient chart revealed a dietary consult was done on March 7th, 2025. The dietician documented the initial visit at 1532. There were no nursing notes provided after 3/9/25. The notes for wound care were provided by the wound care specialist, staff #71 and #72. On 3/10/25 at 2025, the WCS documented, “WOUND TO LT BUTTOCK HAS SPREAD TO SACRAL AREA, OVER TO RT BUTTOCK AND DOWN TO LT UPPER LEG. WOUND HAS NOW BECOME A STAGE 4 AS BONE IS PALPABLE. SLOUGH AND LOOSE ESCHAR COVERING MOST OF WOUND BED. DEBRIDMENT RECOMMENDED AT THIS TIME FOLLOWED BY NPWT.” (NPWT- Negative Pressure Wound Therapy- is a type of therapy to help wounds heal.) On 3/12/25 at 1617, the WCN documented, “WOUND TO BUTTOCKS/SACRUM/PERINEUM STILL REQUIRES SURGICAL DEBRIDEMENT. IT WAS CLEANSED WITH VASHE AND PATTED DRY. URGOCLEAN TO WOUND BED AND COVERED WITH URGOCLEAN. MEPILEX COVERING URGOCLEAN. TRIAD TO PERIAREA. PT HAD MUCH AGITATION TODAY THAT SHE REQUIRE IM GEODON.” A review of the MAR revealed that the patient was not administered Geodon. On 3/14/25, the patient had a surgical debridement of the sacral ulcer and a diverting ostomy on 3/14/25. No wound care was provided. On 3/15/25 at 2025 the WCN documented, “Multiple sites of wound care provided. The right groin left buttocks/sacrum, right above the knee amputation surgical wound, left groin, and scattered open wounds to posterior thighs.” An interview was conducted with staff # 47, RN on the afternoon of 3/18/25. Staff #47 stated the patient was in contact isolation in room 353. Staff #9 stated the patient had been transferred to several floors during her hospital visit and stated the family had been with the patient and very attentive. Staff #47 stated she was aware of the patient’s wounds and the extensive care needed for the wounds. Staff #47 stated the patient had come to her floor on 3/10/25 and that the family had voiced their concerns to the staff and administration about the poor nursing care provided. Staff #47 stated that they had been short PCTs (patient care technicians or aides). Staff #47 stated that she had talked to the PCT caring for patient #9 concerning a turn schedule when the patient came to the floor, and the PCT stated they were unaware that patient #47 needed to be turned every 2 hours. Staff #47 stated that she felt that the issue was resolved, but there was no documentation to show the turning schedule or incontinent care provided. Staff #47 stated that Staff # 42 had been talking with the family about their concerns and grievances. Staff #47 stated Staff #42 had been writing the issues down and talking with administrative staff. Staff #42 was unavailable for interview due to being out of state at the time. Staff #47 did not have access to the notes but stated that Staff #42 had discussed it with RISK on 3/13/25. An interview was conducted with staff # 8, Director of Risk, and staff # 6 QAPI on the morning of 3/13/25. Staff #8 and #9 denied any complaints, grievances, or incident reports for patient #9. A review of the grievance log from 9/1/24 to 3/17/25 revealed that patient #9 was not on the log. An interview was conducted with patient #9’s sister and niece on 3/13/25 at 5:00 PM. Patient #9’s sister stated that she had been with the patient during her amputation and cared for her there and followed her to the skilled nursing facility where she was receiving rehabilitation services. The sister stated that patient #9 was going to the gym and was up to the wheelchair, alert, and oriented. The sister stated that she became more confused and became ill. The patient was sent to the hospital where she was diagnosed with gangrene of the newly amputated leg and had a wound on her right groin. She stated the patient was so confused and unable to turn, get up to the bathroom, or answer simple questions. The sister stated that she stayed with the patient as much as she could because the hospital was short-handed and no one to help turn her sister. The sister began to cry and stated that she would push the call light and the nurse would come in, turn off the call light, and walk back out. She stated that the nurse would not return, and she was not strong enough to turn the patient by herself. Patient #9 had chronic diarrhea and was laying in feces for a long time. The patient had pads underneath and diapers between her legs that were soaked in urine. The niece stated that the patient was very weak and unable to turn herself. On 2/28/25, the aide on unit 3300 found a small broken-down area on the patient’s sacrum and showed it to the niece and the nurse on duty. The niece took pictures of the patient’s bottom. The niece stated that the wound care nurses had been treating the patient’s wounds but had not looked at the patient’s bottom. The niece stated that by 3/4/25, the wound to her bottom was very large and deep, with black dead tissue in the middle. The niece stated that the nurses would just put a clear dressing over the wound, and there would still be feces in the wound. The niece stated that the nurse came in one time and put a dressing on the patient’s bottom, but it didn’t completely cover the wound, leaving it draining and exposed to the constant flow of loose stool. The niece stated that they were so upset and had multiple complaints to the staff, and staff #42 was the only person who had tried to help them. An interview was conducted on the morning of 3/20/25 with staff # 71 RN and #72 RN WCS. Staff #71 and #72 had brought all their wound care notes, photos, timelines, and incident reports to the interview. Staff #71 stated that patient #9 had developed hospital-acquired wounds since admission and that they had written and reported an incident report on 3/5/25 as the date the buttocks wound was discovered. Staff #71 confirmed the wound was found previously by a PCT and shown to the RN on 2/28/25, but the unit nurse failed to put in an incident report or a consult to wound care for the wound. Staff #71 and &72 confirmed they were unaware of the wound to the buttocks until 3/5/25. The incident report dated 3/5/25 stated the root cause of the wound was “Deep tissue injury (DTI) later opened to unstageable.” The patient was ordered an air mattress, moisture control, q2hr turns, no diapers, layers on top of (illegible) mattress to 1, Monitor nutrition, consult dietician, consult PT/OT to assist with mobility.” The nurse had documented on 2/25/25 that the patient had been placed on an air mattress. Staff #71 and #72 confirmed that she was not on an air mattress. Staff #71 provided an incident report dated 3/19/25 (while the surveyor was in the hospital). The incident stated that the patient was on a regular bed. Poor nutrition with delayed nutrition consult. Actions implemented, “utilization of wound care Webex for tracking air mattress orders/delivery. Partnering with dieticians to help educate nursing for indications for nutrition consult.” Staff #71 and #72 confirmed that these basic requests for patients with wounds were not ordered or initiated until 16 days after the patient was admitted with a wet gangrenous surgical wound to the right below the knee amputation and an open wound to the right groin. The patient was identified upon admission as bed-bound, required assistance to reposition, and was incontinent of bowel and bladder. Staff #72 stated the patient had developed wounds to her inner thighs and buttocks since her hospital admission and felt, in her professional opinion, that this occurred from shearing and excoriation from lying in urine too long. According to nih.gov, “Shear occurs when tissue layers move over the top of each other, causing blood vessels to stretch and break as they pass through the subcutaneous tissue. For example, when a client slides down in bed, the outer layer of skin remains immobile because it remains attached to the sheets due to friction.” This can be caused by pulling the patient up in the bed without using the proper technique. According to nih.gov, “Excoriation, or skin breakdown, from urine occurs due to prolonged skin exposure to urine, leading to moisture-related irritation and damage, often seen in individuals with incontinence ... The presence of urine, especially with its ammonia content, and bacteria in urine can break down the skin’s outer layer and impair its barrier function, leading to inflammation and further skin breakdown.””

“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: 10135 Based on interview and record review, the facility failed ensure nursing kept current care plans that met the patients’ needs in 3 of 24 sampled patients (Patient #’s 9, 10, and 12). The facility failed to ensure: Patient #10 was started on a feeding timely after the family changed their mind about Hospice services 11/29/2024. Patient #10 was started on a tube feeding 6 days later on 12/05/2024. Patient #12 received daily weights and accurate intake and outputs as ordered by the physician. Staff failed to ensure Patient #12 received follow-up pain assessments after administration or pain medication. Facility staff failed to ensure there was treatment orders for Patient #12’s peritoneal dialysis (PD)port site. Patient #9 had care plan addressing skin breakdown. The skin breakdown included a surgical site to and an unstageable pressure sore. This deficient practice had the likelihood to cause harm to all patients. Findings include: Patient #10 Review of the Emergency department (ED) record on Patient #10 was an 86 year old female who presented to the ED on 11/26/2024 at 11:57 p.m. with complaints of a change in mental status. Patient #10 had a history which included cerebral vascular accident, gastroesophageal reflux disease, and congestive heart failure. The ED assessment showed Patient #10 had a weight of 64 kilograms (140.8 pounds). A computed tomography scan dated 11/26/2024 revealed Patient #10 had scattered subarachnoid hemorrhage and a fracture of the skull. A physician’s order dated 11/27/2024 revealed Patient #10 was on strict intake and outputs. A physician’s order dated 11/28/2024 revealed Patient #10 was on support care, intravenous feedings and a naso gastric tube feeding starting on the 3rd day. Hospitalist notes dated 11/28/2024 revealed documentation that Patient #10’s the son refused the tube feeding at this time. During a confidential interview it was revealed that the nurses were asked daily when the tube feeding would be started and that the family did not refuse the tube feeding. Review of the intake and output record from 11/28/2024-12/04/2024 revealed Patient #10 was NPO (nothing by mouth) and had intravenous fluids infusing. Physician’s notes dated 11/29/2024 revealed they would clarify with the son about hospice and that a tube feeding was to be started on 11/30/2024. Review of case management notes dated 11/29/2024 revealed the Patient #10’s son decided he did not want hospice There was documentation that the physician was notified. A dietitian assessment dated 11/30/2024 revealed Patient #10 had a weight of 59.7 kilograms (131.34 pounds). The recommendation was to change the ADAT (advance diet as tolerated) to a regular diet. If unable to advance diet due to medical condition the recommendation was for nutritional support. There was documentation that the dietitian wanted Patient #10 started on PPN (peripheral parenteral nutrition) and the physician stated that the family wanted no intervention at this time. This was a significant weight loss of 9.46 pounds since presenting to the ED 4 days ago. Physician notes dated 12/02/2024 revealed the son and daughter wanted more care than just hospice done for Patient #10. Review of a swallow study dated 12/04/2024 revealed recommendations to keep the patient NPO and that she would benefit from alternate means of nutrition due to severity of deficits. Physician notes dated 12/05/2024 revealed there was a consult with nutrition, nasogastric tube inserted, and a trickle feeding was started. On 12/05/2024 a nasogastric tube was inserted, but no consent could be found. During an interview on 03/18/2025 after 2:01 p.m., Staff #34 confirmed the information in the chart. Staff #34 confirmed Patient #10 was not started on a feeding until 12/05/2024. Patient #12 Review of the ED record on Patient #12 revealed that she was a 68-year-old female who presented on 12/05/2024 with complaints of chest pain and bilateral leg swelling. Patient #12 had diagnoses which included coronary artery disease, hypertension and acute or chronic kidney failure. Patient #12 had a weight of 58.6 kilograms (128.92 pounds). Lab results dated 12/05/2024 revealed Patient #12 had the following: Low sodium 132 Low chloride 94 Elevated blood urea nitrogen 27.0 Low calcium 6.6 Low albumin 2.4 Low red blood cell counts 3.35. According to physician orders dated 12/06/2024 Patient #12 was to continue nightly peritoneal dialysis and was on a fluid restriction of 1.5 liters per day. Review of physician orders dated 12/06/2024 revealed orders for intake and outputs, daily weights and a renal diet. Review in take and outputs revealed from 12/06 to 12/09/2024 there was no intake and output documented. On 12/11, 13 and 14 there was no intake documented. The only documentation for meal intakes was poor, fair or good. There was no indication as to the percent of intake. There was no documentation of the physician ordered daily weights on the chart at all. The only weight on the chart was the admission weight of 58.6 kilograms (128.92 pounds). Pain There was a physician’s order for the pain medication Morphine sulfate 2 milligrams (mgs) intravenous (IV) every 4 hours prn pain 7-10. Review of pain assessment notes and medication administration records revealed that Patient #12 had a pain level of 6 for abdomen and bilateral leg pain on 12/06/2024 at 1223 midnight. There was documentation that medication was administered, but there was no documentation of what medication. At 3:13 a.m., Patient #12’s pain level of 9 for leg pain and a dose of morphine was administered. There was no documentation of a follow-up assessment. The next documentation of an assessment on the notes was at 9:00 a.m. and the pain level was a 6 for abdomen and bilateral leg pain. On 12/12/2024 at 4:11 p.m. Patient #12 had a pain level of 10 at 4:11 p.m. for left pain. Staff administered one tablet of the pain medication Norco. There was no follow-up assessment. Dressing changes on Peritoneal dialysis (PD) There was documentation in nurses’ notes and flow sheets that the PD site was cleaned on 12/07/2024, 12/08/2024, and 12/11/2024. There was no documentation of what was being used to clean the site. There was no documentation of a physician’s order on how to clean the PD site. During an interview on 03/19/2025 after 11:24 a.m., Staff #36 said that treatments to the port sites were done every other day with dialysis treatments. When the site needed to be cleaned any other time, he would stabilize it and call a dialysis nurse. During an interview on 03/19/2025 after 1:00 p.m., Staff #80 said the dressing on the port sites were changed on Monday nights. During an interview on 03/19/2025 after 2:14 p.m., Staff #13 confirmed not being able to find a treatment order for the nurses on the floor to use. Staff #13 had a call placed to the dialysis staff for treatment orders and none was provided as of 03/20/2025 at 5:25 p.m. According to the Nations Institute on Health website www.niddk.nih.gov revealed some of the following: “ Peritoneal dialysis is a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body ... Take care of your exit site, supplies, and catheter to prevent infections ... Clean your skin where your catheter enters your body every day, as instructed by your health care team ... ...Infection One of the most serious problems related to peritoneal dialysis is infection. You can get an infection of the skin around your catheter exit site or you can develop peritonitis, an infection in the fluid in your belly. Bacteria can enter your body though your catheter as you connect or disconnect it from the bags...” During an interview on 03/19/2025 after 2:14 p.m., Staff #13 confirmed there were no daily weight, intake and outputs were incomplete and there was no follow up pain assessment documented. Staff #13 confirmed they did not have a scale or policy to determine what poor, fair and good meant for the percent of meal intakes. 32143 Patient #9 The facility failed to provide a nursing care plan to the surveyor upon multiple request for patient #9. A review of patient # 9’s medical chart revealed she was admitted to the hospital on 2/17/25 at 15:09. Patient #9 was living in a skilled nursing facility after she had a right above the knee amputation and had developed a wound to her upper rt groin. The rt above the knee amputation surgical site had dehisced (gape or burst opened), causing gangrene of the wound. The patient received blood, multiple wounds were treated. The patient developed hospital acquired wounds that were treated and required surgical interventions. There was no nursing care plan in the patients chart upon review. The facility was asked multiple times for a completed medical record. Medical records were provided three times with no nursing care plans.”

“ORGANIZATION AND STAFFING CFR(s): 482.24(a) The organization of the medical record service must be appropriate to the scope and complexity of the services performed. The hospital must employ adequate personnel to ensure prompt completion, filing, and retrieval of records. This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to provide patient medical records upon request on 2 of 2(#9 and #12) patients. The facility had one provider number and one license number but had two hospitals on different campuses. Hospital- A was in Kingwood, and Hospital- B was in Cypress. The facilities had shared Governing Board meetings and Medical Staff meetings. The complaint survey for hospital A and B was conducted 3/18/25 through 3/20/25. The surveyors started requesting medical charts to be copied for the survey team on 3/18/25 from hospital A. Staff #6 and #8 stated they would be working on these requested charts. On 3/19/25 The survey team was at the hospital B campus and requested patient charts. Patient Charts were sent via email and complete. Patient # 12 was the only medical record that was not provided. On 3/20/25 after asking about the requested charts multiple times staff #6 and #8 had sent emails of different pieces of a chart but were not complete charts. Staff #8 stated the charts were too big to be sent and needed to put it on the drive. Staff #8 stated that the patient #9 was not complete because she was still inpatient. The surveyor explained that was ok, but the surveyor needed all of the chart up to 3/20/25. Staff #8 stated that was not a problem. In the afternoon of 3/20/25 staff #12 brought in a flash drive with patient charts. He stated that IT would come and watch the chart transference. The following charts were transferred from the drive to the surveyor’s computer for patient #16, #10, #3, #2, #1, #17, #23, #11, #22, #18, #9 and #21. The surveyor opened up the charts to make sure they downloaded and were able to be opened. The survey team exited. Upon review of the charts the next day the surveyor realized patient #9 and #21’s chart was missing multiple items, nurses notes, flow sheets, PT/OT notes, surgical notes, wound care notes and pictures. The drive also failed to have patient #12’s chart loaded. After multiple phone calls and emails to staff #6 she explained that she was trying to down load the information and was sending things in bits and pieces through email. On 3/26/25 staff #6 was asked to overnight the patient files if they were to big for email and the Tyler office address was given to her. On 3/26/25 staff #81 emailed and called the surveyor. Staff #81 stated she was with a contracted service to supply medical records for the facility and would assist in getting the medical records to the surveyor. Information was provided on what the surveyor needed. Some of the patient files came through to the Tyler office fax and was placed in the shared drive however, patient #9’s medical records faxes were blank. The information provided was the same information originally given on the drive and was still incomplete for patients #9 and #12. Staff #81 was able to send nursing notes through email on patient #9. Staff #81 requested that I send a chart request form for each chart requested to be sent along with a signed disclosure of protected health information form for each requested chart. The surveyor began to receive calls from Staff #82 concerning the medical records. Staff #82 stated that she worked at another contracted service different from staff #81 and she would be assisting me in getting the requested charts. Staff #82 stated that patient #9 was discharged from the facility and she would be able to send a closed completed chart. After multiple emails and phone calls staff #82 sent a disk of the patient charts overnight. The charts were not sent to the address requested but to the central office of CMS (Centers for Medicare and Medicaid Services) in Dallas, Texas on 4/1/25. The surveyor contacted CMS and they were unable to forward the information due to no CD drives available. The surveyor spoke with staff #81 and #82 and explained that I had not gotten the files and they were sent to the wrong address. The surveyor requested the charts be resent. The surveyor also stated that patient #12’s chart was never sent. The surveyor did not receive any further disk or patient medical record information requested. The CEOs of both hospital A and B was emailed and informed of the situation.”

“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: 32143 Based on observation and interviews the facility failed to ensure that the infection control program maintained a clean and sanitary environment to avoid the transmission of infection in 2 of 2 (Hospital A-ER and Hospital B ER-Pharmacy) departments. The facility had one provider number and one license number but had two hospitals on different campuses. Hospital- A was in Kingwood, and Hospital- B was in Cypress. The facilities had shared Governing Board meetings and Medical Staff meetings but two different CEOs. Findings; A tour of hospital A’s emergency Room (ER) was conducted on 3/18/2025 at 11:05 am with staff # 9 ER director and staff #62 RN scribe. Findings in the ER were as follows; ER holding area had missing tiles on the floor. The floor was heavily soiled with dirt, dust, and hair. The room had 5 IV stands that were found heavily soiled on the bottom with dust, dirt, and hair. A wound care metal supply cart was heavily soiled with dirt, dust, and hair. The top of the cart was soiled with dust, old pieces of tape, and tape residue. In the medical holding area (after the patient had been through triage) had a leather recliner and a blood pressure monitor on wheels. The leather chair had multiple rips and tears, leaving the chair vulnerable to spilled liquids, bodily fluids, and infected wounds that would not be able to be cleaned appropriately. The wall behind the chair was missing sheet rock. Lab supplies were found in a white plastic container used to carry from patient to patient to draw blood samples. The carrier was soiled with dust and old tape residue. Next to the white plastic container were swabs lying in a cardboard box. A Sono site ultrasound machine was found in the patient minor holding area. The machine was in the hallway, uncovered, and was soiled with dust, tape residue, and hair. Patient medical supplies were lying in open containers on the bottom of the machine next to the floor. The medical supplies were lying in dusty containers. 1 workstation computer on wheels was found to be open to a patient’s medical records in the hallway. The top workstations were soiled with dried liquids, dust, and hair. The patient’s plastic drinking cups were stacked on top of the soiled cart. The bottom of the cart was heavily soiled with dirt and dust. An EKG machine was found soiled with dust and dirt. On the side of the cart was an old (Coban) dressing tied to the machine holding leads. The old dressing was heavily soiled with dust. A patient bedside table was in the hallway holding cleaning wipes. The bottom of the table was heavily soiled with dust and dirt. Paint was missing from the bottom leg, exposing rusted metal. In a room marked “supply room” was the nutrition room. Inside the room was a coffee maker, Ice, refrigerator with juice, sandwiches, Jello, and applesauce. Inside the drawers and cabinets were spilled dried goods and liquids. The refrigerator was soiled with dust, hair, and spilled liquids. At the main nurse’s station were 3 rolling plastic carts with three-tiered drawers holding multiple lines, leads, and cords for telemetry and other equipment. The lines were shoved in the box and tangled. Some of the drawers had broken equipment in them with notes on top. The drawers were dusty and had unknown dried particles in the bottom of the bin. The nurses’ workstation and desk area were heavily soiled and dusty. Cabinets were opened in the nurse’s station area. Respiratory supplies were found shoved in a dirty and soiled cabinet. There was an unidentifiable plastic bag with a spilled brown liquid mixed with the patient’s supplies. A cardboard box was found in the cabinet with an outdated call system with lines wrapped up. On top of the equipment was an IV bag of normal saline. The area was not clean or monitored for medication storage. The flooring around the base of the nurse’s station was missing and had collected dirt, dust, and hair. The veneer on the side of the nurse’s station desk was missing, exposing bare wood. The clean supply room had shipping boxes on the floor; the floor was soiled with dust and dirt, and the counters were dusty and had old tape and tape residue. In an upper cabinet, two narcotic lock boxes were found to be empty but heavily soiled with a sticky brown substance, dust, and hair. Two patient stretchers, clean and ready for patients, had rips in the mattress, exposing materials that are unable to be cleaned properly. The beds were soiled with dirt, spilled dried liquid, and tape residue. In the behavioral health area of the ER, the nurse’s station was dirty with dust and clutter. The surveyor opened a drawer behind the nurse’s station. It was filled with patient medical supplies, batteries, and a flashlight. There was a metal box that stated, “toilet key.” The box was opened, and different medications (pills) were found loose in the box. Staff #9 stated, “I don’t know what to say.” He began to look at the pills to try to identify what the pills were and how they got there. Two nurses’ chairs were ripped and had the raw cushion exposed. The facility had two trauma rooms. One of the trauma rooms was occupied with a patient. Staff # 9 confirmed that the unoccupied trauma room was ready for a patient. The following issues were found; The stretcher had a clean sheet on top. The surveyor raised the mattress and had blood on her hands from the mattress, along with dried blood all over the bottom. Paper and trash were found under the mattress. The handle to raise the head of the stretcher was heavily covered in old tape. Old, used gloves were found under the bed. Opened and packaged patient medical supplies were found lying on the nurses’ work station. The station was soiled with dust and hair. The curtain in the room was heavily soiled with dirt and dried spilled liquids. Sterile patient supplies were found stored on the floor in containers, and some supplies were found on the floor exposed to dirt, hair, and dust. The baby bassinet and warmer were uncovered. The sheet and blanket on the bassinet were soiled with dust and littered with papers. All the glass doors to the patient supply cabinets were left open, exposing the sterile and clean medical supplies to the dirty environment. Staff #9 confirmed the finding and called in housekeeping and staff to properly clean the room before it was needed for an emergent trauma. An interview was conducted with staff #65, the ER housekeeper, on 3/18/25 at 12:30 pm. Staff #65 stated she and two other housekeepers were responsible for 18 rooms, bathrooms, and nurses’ stations of the ER, and she had only worked there for a few months. Staff #65 stated that she mops and does the trash in most rooms at least once a day. She stated that the nurses usually clean the rooms between patients. Staff #65 stated that she does not get paged or notified of any rooms to be cleaned. She stated that the nurses will ask her to clean if needed. 10135 Hospital B (Emergency department pharmacy) During an observation on 03/19/2025 at 5:31 p.m. the following was found: Nursing staff were observed coming in and out of the pharmacy room. Three walls inside the pharmacy room had bins of medical supplies, wound care dressings, respiratory supplies, intravenous supplies and bags of intravenous fluids. There were sterile supplies also in the bins. The bins were not covered to prevent cross contamination.The inside and outside of the bins were soiled with dust. Two unopened sterile thoracic catheters were laying on the floor underneath a shelf. The floor underneath the supply bins were littered with unopened medical supplies such as needles, syringes of saline flush, intravenous catheter and specimen cups. Open bins of sterile thoracostomy trays were stored next to the open trash can which was full of trash. Three bags of 5% Dextose IV fluids were stored in an uncovered bin on a table. The bin was soiled with dust and white debris. Thoracic catheters which expired on 9/11/ 2023 and 03/09/2025 were found stored in the room. Labels on some of the supplies revealed the following: Thoracostomy trays label read that they should be stored at a room temperature of 59-68 degrees. Lumbar puncture trays label read that they should be stored at a room temperature of 68-77 degrees. Dry suction water seal chest drain label read that they should be stored at a room temperature of 59-77 degrees. Bags on of intravenous solutions packaging read that they were to be stored at a room temperature of 77 degrees. There was no temperature and humidity gauges in the room. During and interview on 03/19/2025 after 5:31 p.m., Staff #76 confirmed the observations and that there was not a gauge in the room to monitor the temperature and humidity. Pharmacist #76 said she thought environmental services was monitoring it. On 03/19/2025 a request was made to see the monitoring logs. As of 03/20/2025 at 5:25 p.m. no logs were provided.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 23032 Based on interview and record review, the facility failed to fully uphold the patients’ right to informed decision making regarding their care and treatment. A sampled patient record failed to show a fully completed anesthesia consent as required by the Texas Administrative Code (TAC) Title 25, Part 7: Medical Disclosure Panel -rule 604.5 (1)- [ citing Patient ID # 1 ] Findings included: Record review of facility policy titled “ Consent for Treatment (Adults and Minors)’, last revised 12/2018, showed: an informed disclosure and consent form shall be obtained prior to all invasive diagnostic , surgical or medial procedures ( including blood administration, anesthesia administration , disposal off tissue. limbs, sterilization, photography, and observer. “ Review of Texas Administrative Code [TAC], Title 25, Part 7: Texas Medical Disclosure Panel 604.5 (1) showed “Disclosure and Consent: Anesthesia and /or Perioperative Pain Management (Analgesia) “ required the consent to include a listing of the names of all anesthesia providers [ Physician Anesthesiologist; Dentist Anesthesiologist; and Non-Anesthesiologist Physicians or Dentists]. In addition, the revision requires a listing of all anesthesia providers that are supervised by the former to include Certified Anesthesiologist Assistant ; Certified Registered Nurse Anesthesiologist; and Physician in Training. Record review on 10/16/2024 with Staff ID-M, RN showed: -Patient ID # 6 presented to the ER on 8/23/2024: was admitted as an inpatient. -Review of a form titled “ DISCLOSURE AND CONSENT-ANESTHESIA and/or PERIOPERATIVE PAIN MANAGEMENT (ANALGESIA) . The consent showed the Patient ID # 1 was to undergo a “left lower extremity angiogram and other indicated procedures.” The type of anesthesia to be administered , as indicated by check mark was “MODERATE SEDATION.” There were no anesthesia provider names listed or the names of any staff supervised by provider to administer anesthesia. Further review of the record showed Patient ID # 1 underwent an angiogram to the left lower leg on 8/27/2024. She received moderate sedation that included the administration of versed and fentanyl. The above findings were verified by Staff -M, RN at the time of review.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 23032 Based on interview and record review, the hospital failed to fully implement its policy related to patient formulation of advance directives for 1 of 4 current patients (Patient ID # 6) ; and 1 discharged patient (Patient ID # 1) . Findings included : TX00515220 Record review of facility policy titled “ Inpatient Do Not Resuscitate (DNR), Out of Hospital DNR, and Advance Directives Policy”, last reviewed 09/2027, showed: Procedure: NURSING : 5. Upon admission to the nursing unit, the patient’s nurse will check the Condition of Admission form and the admission assessment to determine if the patient has been asked about advanced directives. a) this information will be documented on the admission assessment form. b) if the information is not present, the nurse will request the information from the patient slash family and document on the admission assessment and request a copy be brought to the hospital to be placed in the chart. In the interim, substance of the advanced directive or the intent will be documented by the RN on the admission assessment. See. c.) Until a copy of the patient’s advance directive is on the chart, the nurse should make reasonable attempts to obtain the copy and document the attempts in the electronic medical record. A reasonable attempt is defined by attempting at the time of admission and again within the first 48 hours in the hospital stay. d) if the patient and /or family indicate these directives have been executed, the nurse will obtain copies or requests they be brought in and place them in the patient’s medical record. 6. During the patient’s hospitalization, any person who becomes aware that the patient has executed or revoked an advanced directive will notify the patient’s nurse so that proper documentation can be placed in the chart. Additionally, the attending physician will be notified. ~~~~~~~~~~~~~~~~~ Patient ID # 6: Record review on 10/16/2024 on 5 North Tower with Staff ID-F, RN, showed: Patient ID # 6: was admitted on 10/14/2024 Review of Nursing Admission Assessment showed a section titled “ADVANCE DIRECTIVES” that contained several questions. These included: - Question: Durable power of attorney ? answer was “YES” -Question : Copy of durable power of attorney on chart? This was left blank. Staff-ID-F said that the documents are scanned in registration, but there should be a copy in the patient’s chart. There was no copy located in the patient’s chart. ~~~~~~~~~~~~ Patient ID # 1: Continued record review on 10/16/2024 with Staff ID-M, RN showed: Patient ID # 6 presented to the ER on 8/23/2024: was admitted as an inpatient; and discharged on 08/28/2024. Review of Patient ID-#1’s ER nursing admission and her inpatient nursing admission showed inconsistencies related to documentation of a durable power of attorney/ ER Record: Question: Durable power of attorney ? answer was “NO” Inpatient record: Question: Durable power of attorney ? answer was “YES Question: Copy of durable power of attorney on chart? This was left blank. There was information provided regarding “surrogate decision maker” that included son’s name and telephone number.” There was no durable power of attorney located as a scanned documented for the 8/23/2024 admission. A fully dated and notarized power of attorney was located attached to a prior admission on 07/03/2024. During an interview on 10/06/24 at 10:40 AM with Staff ID-K, RN, she said that all advance directive documents are requested at each admission. They do not “carry over” from one admission to the next.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) 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 required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by:”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 46010 Based on observation, interview and record review, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CF R 489.24, Special responsibilities of Medicare hospitals in emergency cases. The facility failed to provide an appropriate medical screen exam for 1 of 25 Emergency Department patients reveiwed (Patient ID #1). Refer to tag A 2406 for additional information.”

“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: 46010 Based on record review and interview, the facility failed to ensure all patients who presented to the the emergency department (ED) received an appropriate and accurate medical screening examination (MSE) (Patient ID #1). The facility failed to assess allegations that were made to facility staff during the patient’s ED stay of child abuse and an unsafe living environment and act upon those allegations. Specifically, social work and Childrens Protective Services were not consulted, the psychiatric consultant was not made aware of these allegations, and ED physician documentation did not demonstrate any further investigation of these allegations or consideration of the possibility that discharging patient into care of mother, accused of abuse, might be unsafe. Findings Included: Record review of facility’s “Texas EMTALA - Medical Screening Examination and Stabilization Policy,” effective 01/23, stated “ ... 7 . Stabilizing Treatment Within Hospital Capability “The determination of whether an individual is stable is not based on the clinical outcome of the individual’s medical condition. An individual has been provided sufficient stabilizing treatment when the physician treating the individual in the DED has determined, within reasonable clinical confidence, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or with respect to an EMC of a woman in labor, that the woman has delivered the child and placenta; or in the case of an individual with a psychiatric or behavioral condition, that the individual is protected and prevented from injuring himself/ herself or others. For those individuals who are administered chemical or physical restraints for purposes of transfer from one facility to another, stabilization may occur for a period of time and remove the immediate EMC, but the underlying medical condition may persist and, if not treated for longevity, the individual may experience exacerbation of the EMC. Therefore, the treating physician should use great care when determining if the EMC is in fact stable after administering chemical or physical restraints. a. Stable. The physician or QMP providing the medical screening and treating the emergency has determined within reasonable clinical confidence, that the EMC that caused the individual to seek care in the DED has been resolved although the underlying medical condition may persist. Once the individual is stable, EMTALA no longer applies. (The individual may still be transferred; however, the “appropriate transfer” requirement under EMTALA does not apply.) b. Stabilizing Treatment Within Hospital Capability and Transfer. Once the hospital has provided an appropriate MSE and stabilizing treatment within its capability, an appropriate transfer may be effected by following the appropriate transfer provisions. (See Transfer Policy.) If there is a disagreement between the physician providing emergency care and an off-site physician (e.g., a physician at the receiving facility or the individual’s primary care physician if not physically present at the first facility) about whether the individual has been provided sufficient stabilized treatment to effect a transfer, the medical judgment of the transferring physician takes precedence over that of the off-site physician. Refer to the hospital’s Transfer Policy for additional directions regarding transfers of those individuals who are not medically stable. If a hospital has exhausted all its capabilities and is unable to stabilize an individual, an appropriate transfer should be implemented by the transferring physician. c. Stabilizing Treatment and Individuals Whose EMCs Are Resolved. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his or her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. The EMC that caused the individual to present to the DED must be resolved, but the underlying medical condition may persist. Hospitals are expected within reason to assist/provide discharged individuals the necessary information to secure follow-up care to prevent relapse or worsening of the medical condition upon release from the hospital. “ Record Review of Patient ID #1 Medical Record for date of service 4/4/2024 was performed with Pediatric Emergency Department Nursing Director Staff ID #64 on 5/21/24 at 1:00 pm. The following was noted in the facility’s electronic medical record. Atascocita EMS Run Record was reviewed. Patient ID #1 was brought by Atascocita ambulance to HCA Healthcare Hospital Kingwood on 4/4/2024 at 7:47 pm with “Benadryl Overdose.” Poison control had been called by EMS per their record. The record stated the patient had “taken 10 Benadryl pills with intent to harm herself.” The mother was present at the time EMS arrived to the scene. Detailed nursing assessment including a suicide risk scale had a calculated suicide risk level: “high risk” as performed by RN Staff ID #80. A suicide safe environment was initiated with a 1:1 sitter and Q 15 min log completed for duration of her ED stay. Staff RN # 78 documented “Rapid initial assessment: Subjective Assessment - Pt arrived via EMS on EDO unaccompanied by a parent for intentional ingestion of 10 25 mg Benadryl at 18:30. Pt endorses SI x 1 yr with previous plan and attempt to suffocate herself with a pillow last year. Pt states ‘I knew I was in trouble anyways and felt overwhelmed.’ After an argument with her mother prior to arrival, denies HI. Per EMS, pt with PMH of autism but no previous psych admits. Objective Assessment Patient arrived awake and mildly sleepy but GCS 15, ambulatory without difficulty, skin cool and mottled with brisk cap refill, afebrile, tachycardic, 100% on room air, abdomen soft and nondistended, PERRL, denies pain.” Unit Secretary Staff ID #77 documented on 4/4/24 at 9:21 pm that patient friend (redacted name) and her mother visited. Friends mom expressed concern for patient’s safety stated that “mom and grandmother verbally abuse patient and stepdad slammed her hand in a door multiple times about 2 weeks ago. She also stated that mom used patients phone for drug deals regularly. Friends mother is the one that called 911.” 4/5/2024 01:33 am Staff RN #78 documented “Teledoc in room for psych eval.” 4/5/2024 02:15 am Psychiatric Consultant Physician Assistant Staff ID # 79 documented “Telehealth Psychiatric Consult” stated “11 year old woman brought to the ED by her mother after suicide attempt by intentional medication overdose (10 Benadryl tablets). She endorses passive suicidal ideation and states that she no longer has a plan to overdose on medication. The patient states now that she realizes that “taking medication” was the wrong thing to do. She states she was feeling overwhelmed when watching her younger siblings. The patient’s mother states that patient has a history of autism.” The consult note goes on to state “Overall Risk Level Suicide- Low Risk”. Her assessment and plan stated “ ...patient is agreeable to an outpatient psychiatric appointment upon discharge-tentative 4/8/24. Safety plan and outpatient resources have been discussed with the patient and the patient’s mother voiced understanding of the safety plan.” On 4/5/2024 at 06:05 am Staff RN # 78 charts “Mom out of the room at this time to take her belongings to the car as MD states he is about to DC the patient. RN in the room, Patient is awake and alert, GCS 15. Ambulatory without difficulty. Skin warm and dry. No signs of distress. Patient reports she does feel safe at home and denies any concerns of abuse or neglect. RN discussed with (Physician Staff ID # 76) and she stated that patient denied any concerns on arrival. Advised RN that unit secretary mentioned that friends mother mentioned concerns to her and MD acknowledged. Pt denies any of these concerns.” 4/5/2024 at 06:06 am. Physician Staff ID # 76 makes the decision for discharge. 4/5/2024 at 6:24 am. Patient ID #1 is discharged home with her mother. Interview with Pediatric ED Physician Staff ID #71 on 5/21/2024 at 09:15 am. He stated that patients who present to the Pediatric ED with behavioral health complaints are evaluated thoroughly medically. He stated this would include a history and physical, bloodwork including toxicology labs and EKG. He stated that the facility obtains psychiatric evaluations utilizing the call schedule, which is published. He stated during the daytime hours, the psychiatric consultant providers may come in person. He stated after-hours, these can be performed using telehealth/video conference technology. He stated that he was unsure of the facility social work hours and commented that after-hours consults could be delayed as there was someone on call. Interview with Pediatric ED Nursing Director Staff ID # 64 on 5/21/24 at 10:00 am. She confirmed the facility has a social worker in-house who covers the emergency department from 8a-6pm daily. She stated after 6pm, that the case manager/social worker “takes call” for consults/issues. Interview with Pediatric ED Nursing Director Staff ID # 64 on 5/21/2024 at 1:30 pm. She performed electronic review of medical record and confirmed that Patient ID #1 had been brought by ambulance for evaluation after Benadryl ingestion with intent to harm herself. She confirmed that the there had been documentation by Unit Secretary Staff ID #77 on 4/4/24 at 9:21 pm which stated the patient’s home was “unsafe” and alleged physical abuse by an adult in the home as well as drug use/abuse by adult caregivers. She confirmed that the medical record revealed this information was relayed to Staff RN #78 and Staff MD #76. She confirmed she could not locate physician documentation addressing these allegations. She confirmed there was no evidence that social work consult had been ordered or performed. She confirmed she would have expected a social work consult to be performed and/or Childrens Protective Services (CPS) to be notified for safe discharge planning. Telephone Interview with Behavioral Health Team Provider Staff ID #79 on 5/21/24 at 2:00pm. She confirmed that she was the provider who performed the mental health assessment on Patient ID #1. She stated that she provided mental health team call from 8pm to 8am when on call. She stated consults are received in 2 fashions, both electronic, through “Patient Keeper and Meditech.” She confirmed that nursing and/or providers do not establish personal contact for consultations, usually. She stated that they “have the ability to iMessage,” through an electronic platform. She did not recall receiving additional information about Patient ID #1 to facilitate the consult. She denied visualizing the patient’s electronic medical record for facilitation of the consultation. She confirmed the behavioral health consultation was performed with Patient ID #1’s mother at the bedside. She confirmed that she documented patient’s mother brought her for care after Benadryl overdose based on what the mother told her. However, she stated that the historical information relayed was not confirmed by any other method. She stated that assessments are typically performed afterhours utilizing telehealth which included video ipad technology with a camera to allow visualization of the patient. She confirmed that she had no knowledge of the allegation of abuse, allegation of unsafe home environment or drug use/abuse in the home and stated it could have impacted her recommendations regarding patient’s ability to discharge home with a safety plan and follow-up as an outpatient. She stated that a message was sent to the Psych Plus office by her regarding Patient ID #1’s need to schedule follow-up appointment in their clinic. She was unable to confirm is there was a process established to follow-up with high risk patients, who fail to follow-up or miss appointments. Provider #79 stated that she had never been contacted or collaborated with a facility social worker regarding their social work assessment or safe discharge planning, at any point while taking psychiatric call for the facility.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 37490 Based on record review and interview the facility failed to ensure timely discharge planning evaluations were performed in three (3) of six (6) patients (ID#s 2, 3 and 6). Findings include: Record review of facility policy titled “Discharge Planning” dated 06/2021 showed the following information: Policy: It will be the policy of the case management department to initiate and assist the patient/family and physician with a safe and appropriate discharge within one business day of admission. Procedure: A. Patient Assessment 1. Within one business day to the facility, the patient’s primary nurse and CM/SW complete an initial screening evaluation of the patient for discharge needs. Review of medical record for patient (ID # 2) on 5/21/24 at 10:20 AM showed admission date of 5/14/24 discharge planning evaluation (DPE) completed on 5/16/24. Review of medical record for patient (ID # 3) on 5/21/24 at 10:25 AM showed admission date of 5/14/24 discharge planning evaluation (DPE) completed on 5/16/24. Review of medical record for patient (ID # 6) on 5/21/24 at 10:30 AM showed admission date of 5/13/24 discharge planning evaluation (DPE) completed on 5/15/24. Interview with RN Case Manager (ID# 65) on 5/21/224 at 10:30 AM, confirmed the above findings. She stated that the DPE is to be performed withing 24 hours of admission. She went on to say that she tries to see the patients as soon as she can once they arrive on the unit.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 46010 Based on observations, interviews and record review, the facility failed to ensure confidential patient information was discussed privately for 2/2 patients in the Emergency Department (Patient IDs # 2 and 3). Findings included: HHSC Intake for Patient ID #2 stated “I believe multiple patients rights were violated including right to personal privacy.” Complainant stated “His (ED NP staff ID #62) diagnosis was presented to us in the middle of a crowded waiting room with many more patients and families present. We were not prepared for this very public discussion about her personal care. Once he began delivering news, my mother requested a private conversation in a more secluded area. NP staff ID # 62 response was to place her in a corner of the same waiting room to discuss her condition.” The complaint further stated “This entire scenario recounted was repeated upon completion of the second round of testing in the ER. We had to again request privacy to receive information about testing results. Both instances are a violation of patient’s rights to privacy as on both occasions, other people were able to hear conversations regarding my mother’s health, without her consent.” Observation in ED waiting room on 1/17/2024 at 0815 am, surveyor was seated in chair in hallway approximately 20 feet away from results waiting area, down hallway. Patient ID #3 was seated in a wheelchair with male family member accompanying her. There were 5 other patients/families present in adjacent area, some seated closer to patient ID #3 than surveyor was seated. Staff physician ID # 61 entered the results waiting area and confirmed patient’s name. He pulled an adjacent chair up and sat down to patient’s level and introduced himself. He asked multiple medical historical questions including patients visits to doctors, urine testing and treatments and proceeded to discuss options for treatments including invasive procedures. Surveyor could hear the entire medical history, symptoms, labs results, options for treatments as well as patient/family questions. During an interview on 1/17/2024 at 08:20 am with ED Triage Nurse #68, she was asked to identify Physician Staff ID 61. She stated she thought he was a “resident.” She then went and asked him for his name and identified him as Staff Physician ID #61. Interview on 1/17/2023 at with ED Medical Director Staff ID #63, she was asked how patient’s confidentiality and privacy were maintained when care was being provided in the ED waiting room areas or results pending areas. She stated that patients should be moved by staff to the adjacent small cutout in the area behind the triage desk or pulled into an adjacent triage or rapid treatment space. Review of the facility’s “Patient Rights and Responsibilities” brochure, revised 07/2023, stated “To have his/her medical records, ... kept confidential ...” Review of facility’s “Notice of Privacy Practices”, dated September 2017, stated “Our responsibilities: We are required by law to maintain the privacy of your health information, provide you a description of your privacy practices and to notify you following a breach of unsecured protected health information. We will abide by the terms of this notice.””

“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: 46010 Based on interview and record review the facility failed to: A. ensure nursing staff consulted wound care professional(s) for all pressure injuries stage 3 and above per facility policy (Patient ID #12). B. ensure nursing staff reported pressure injuries acquired during hospital stay through facility-specific event reporting system to be investigated, tracked and trended per facility policy (Patient ID #1, 11, 12, 13). C. ensure nursing staff documented provider notification of new wounds per facility policy. (Patient ID #1, 11, 12, 13). D. ensure nursing implemented and documented interventions and care plan changes based on changes in patient wound condition as appropriate (Patient ID #1, 11,12, 13). Findings included: Record review of electronic medical records was performed with Quality Manager, Staff ID #53 on 1/18/24 at 10:45 am: Patient ID #1 - Patient #1 initial wound care consultation was performed on 4/13/23 and identified 2 small friction related skin tears on R/L buttock. Right measured 1x1x0.1 cm and left measured 1x5x0.2 cm. Wound care team re-evaluation was performed on 4/22/23 by Wound Care Staff ID #78. She identified 9 wounds/skin integrity issues. Four of these wounds were labeled deep tissue injuries by Wound Care Team member #78. Her consult reflects detailed instructions for bedside nursing wound care of her wound and says “Wounds stable, instructions placed in wound care for continued RN care. DC PT wound care following.” Staff ID #53 was unable to locate physician notification of new wounds. There were numerous wound care team evaluations and treatments including surgical debridement of a Stage 4 sacral wound in June/July 2023. Facility records showed wound care team evaluations on 8/4/23 and 8/15/23. Patient ID #1 wound care records reflected wound care team member Staff ID #75 performed a thorough assessment with measurements and photographs of 9 wounds on 9/16/23 (a month after prior wound care team engagement), including a large 11x12x1.8 cm Stage 4 sacral wound. The next wound care assessment/note was on 10/5/23 (19 days later). Subsequently the wound care team saw patient on 10/9/23. There was no reassessment prior to patient’s death on 10/22/23. Patient ID #11 - Admission nursing assessment performed on 1/1/24 revealed “necrotic unstageable L heel wound, R heel stage 4 wound, beefy red, and Stage 4 sacral wound.” There was no physician/provider notification noted for the wounds present on admission. The nursing plan of care did not reflect wound care treatment strategies and further wound prevention strategies in plan of care outside of an air fluid bed and turning every 2 hours which was inconsistently documented. Patient ID # 12 - Admission nursing assessment which showed patient was admitted on 12/5/23. Assessment performed on 12/5/23 at 5pm by nursing showed patient’s only wound was a “puncture site to right groin” which corresponded with patient’s recent endovascular procedure. Staff ID #53 confirmed the patient had been discharged to a skilled nursing facility on 1/17/24. She confirmed that that the nursing note on 1/15/24 mentioned patient had a “Stage 3 anterior sacral wound with eschar, necrotic tissue and foul odor.” She confirmed there was no evidence of wound care team consult ordered, no evidence of wound care team involvement and the physician’s notes and discharge summary failed to mention the wounds in their assessment or as a part of their discharge diagnosis. Staff ID #53 was unable to locate any orders related to wound care or wound care team consult. There was no evidence of nursing notification to the provider or unit based leadership regarding patient’s wound. There was no evidence of electronic incident reporting and therefore no quality analysis. Patient ID #13 Reviewed Patient ID #13 electronic record. She had a Stage 3 sacral wound, which progressed to Stage 4 sacral wound and was currently an inpatient in the facility. There was no evidence of provider notification or notification to unit based leadership. There was no evidence of electronic incident reporting and therefore no quality analysis. Record review of facility policy titled “Pressure Injury Prevention”, last reviewed 12/2022, stated, “All patients will be evaluated for skin breakdown through completion of a risk assessment process. This will occur upon admission; minimum of once per shift, following a change in medical condition and/or level of care and at discharge. Based on level of risk, nursing interventions will be initiated and will be captured on the patient’s plan of care. Regardless of risk, standard of care pressure injury prevention elements should be implemented on all patients.” The policy also states “Pressure Injury Interventions: Preventative measure should be applied based on individualized risk factors. Hospital Acquired Pressure Injury: 1. Prevalence of hospital acquired pressure injuries should be tracked, monitored, and reviewed regularly with an interdisciplinary team. 2. Root cause review should be done for all hospital acquired pressure injuries, Stage III and above, including DTIs. 3. The attending provider/practitioner, unit based leader and patient’s guardian will be notified as soon as possible. 4. Pressure injuries acquired throughout the hospital stay should be reported via the facility-specific event reporting system.” Interview with Wound Care Team member Staff ID #78 on 1/18/2024 at 08:55 am. She reviewed medical record and wound care photographs for Patient ID #1. She explained that the wound care team would be initiated via consultation entered in the medical record. She stated the wound care team would be consulted on all patients with stage 3 or greater wounds identified. She stated that the wound care team would then follow weekly unless they had a wound vac or required intervention necessitating increased frequency. She stated the bedside staff was responsible for shift skin care interventions/treatments and prevention strategies. She stated the patient was admitted on 4/11/23. She reviewed her progress note and wound photographs on 4/13/23 which was obtained for wound care consult for “sacral decubitus.” She stated the patient “did not have evidence of sacral decubitus at that point.” She stated the patient had 2 small friction related skin tears on R/L buttock. Right measured 1x1x0.1 cm and Left measured 1x5x0.2 cm. This was consistent with the wound photographs displayed in the GE photo system. She said the skin tears were likely moisture related as well as friction shearing from being dragged across bed/mattress for hygiene/cares. She stated photographs on 4/20/23 clearly showed wounds were “getting worse.” She stated that the patient had 9 wound diagnoses on her assessment on 4/22/23 and are reflected in her note. She stated her note at that time stated that wound care would be performed by bedside nurses and that the wound care team would discontinue involvement despite significantly increased number of pressure injuries because the “wounds were stable.” She reviewed wound care team documentation on 9/16/23 by her colleague Staff ID #75. She agreed patient had acquired significantly more complex wounds, a total of 9 wounds, including a Stage IV sacral decubitus that measured 11x12x1.8 cm and 3 unstageable pressure injuries. She was asked to show evidence in wound care team documentation of collaboration/notification with bedside staff, physicians and/or re-evaluation of interventions and she was unable to locate this information in the medical record. She was unsure of which staff member should be entering the acquired pressure injuries into the facility’s electronic reporting system. Interview with Unit Registered Nurse Staff ID#67 on 1/17/24 at 11:15 am. He stated that units had “Skin Care Champions”. He described these as unit-based nurses who had clinical interest and additional education related to wound care. He stated they round weekly in the unit. However, he stated there was no formal documentation of their skin assessments being performed on patients. He stated the bedside nurses were responsible for assessing and documenting skin care as well as providing most interventions. He confirmed there was a Braden Skin Assessment Scale utilized by the facility for skin risk assessment but stated he was not aware of a policy which correlated between patient’s risk factors and how that influenced or amended the nursing care plan. Interview 1/17/24 at 3:10 pm with ACNO Staff ID #58. She confirmed the facility had started a “CSIP” program which stands for Clinical Safety Improvement Program which is targeting wound care. She stated the facility is in the process of creating overarching structure for wound care program. She stated that the facility had implemented the use of “Wound Care Champions” on the units. She stated the facility was still in the process of creating a comprehensive wound care program with infrastructure. Interview 1/18/24 at 11:00 am with Staff ID #53, Quality Manager. She confirmed that the facility’s pressure injury prevention policy required patients who acquired Stage 3 or greater pressure injuries while in hospital, should have variances entered through Vigilanz electronic system, to facilitate quality tracking and follow-through. She confirmed there was no Vigilanz report entered for Patient ID #1, 12, 13 and 14 and therefore no quality or root cause analysis had been performed.”