Clear Lake-Amg Specialty Hospital

“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 record review and interview, the facility failed to ensure nursing provided hygiene and bathing daily, per their institutional policy, in 3 out of 3 patient records reviewed (Patient ID #s 1, 9, 10). Findings Included: Record review of facility policy “Guidelines for Nursing and Respiratory Care” last reviewed December 2023, stated “Hygiene - Patient bathed/hair combed/shaved - Daily .... Bed linen change - Daily and PRN.” Medical record review of electronic medical records with Chief Clinical Officer (CCO) Staff ID # 79 on 9/10/2024 at 2:10 pm confirmed the following entries for bathing/hygeine: Patient ID #1 7/26/24 - Linen change and bath performed 7/27/24 - Linen change and bath performed 7/28/24 - Linen change and bath performed 7/29/24 - Linen change and bath performed 7/30/24 - No Linen change or bath performed 8/1/24 - No Linen change or bath performed Patient ID #9 9/3/24 - Linen change performed, No bath and no entry regarding why it was not performed 9/4/24 - Linen change and bath performed 9/5/24 - No linen change or bath performed 9/6/24 - Linen change and bath performed 9/7/24 - Linen change and bath performed 9/8/24 - Linen change and bath performed 9/9/24 - Linen change and bath performed Patient ID #10 9/3/24 - Linen change and bath performed 9/4/24 - Linen change and bath performed 9/5/24 - No linen change or bath performed 9/6/24 - Linen change performed and no bath performed 9/7/24 - Linen change and bath performed 9/8/24 - Linen change and bath performed 9/9/24 - Linen change performed and no bath performed Interview with CCO Staff ID #79 on 9/10/2024 at 2:45 p.m., she confirmed the facility policy stated bathing or showering and linen change would be provided daily and as needed/requested. She confirmed the medical records for Patient ID #1, 9 and 10 failed to demonstrate this has been performed as per policy. Interview with Director of Nursing Staff ID # 54 on 9/10/2024 at 2:55 pm, she confirmed that the unit practice is for patients assigned to even numbered patient rooms to receive scheduled baths and linen changes on day shift. She stated that patients assigned to odd numbered rooms would receive baths on night shift.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 46010 Based on record review and interview, the facility failed to ensure that the physical plant, and the overall hospital environment, had a process that ensured the safety and well-being of patients. The facility failed to conduct and document multi-disciplinary environment of care rounds per facility policy. Findings Included: Record review of Environmental Department documentation for Environment of Care rounds. The facility was unable to produce records from May 2024 to current. A “Hazard Surveillance Assessment” Environmental Tour tool was last completed on 4/17/2024 by Staff ID #78. Record review of facility policy titled “Environment of Care: Environmental Tours”, last reviewed January 2023, stated “Policy: Environmental tours will be conducted on a monthly basis by a two member team involving the Safety Officer or designee and the Infection Control Practitioner or designee. The team will identify and issue recommendations to correct situations of non-compliance .... Upon conclusion of the survey, all areas of non-compliance will be communicated in the form of a written report to department manager.” Interview 9/11/2024 at 11:05 am with Facility Director Staff ID #78. He confirmed that he could not locate evidence or documentation of environment of care rounds from May 2024 to current. He confirmed the facility has a policy which included monthly environment of care rounds. He stated that he would be initiating these in September as he had just been re-hired in August 2024 and he had not been present during the period of lapse.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 46010 Based on record review and interview, the facility failed to prepare a comprehensive written discharge care plan with instructions in 4 out of 4 discharge medical records reviewed (Patient ID #s: 2, 26, 27, 28). The facility failed to provide: 1) an updated, accurate discharge medication reconciliation/medication list 2) comprehensive treatment and care after discharge instructions, which included post-acute services contact information 3) failed to provide specialty physician names, follow-up information, and the timing/interval of the follow-up appointment and contact information for scheduling. Findings Included: Record review of facility policy titled “Case Management LTAC Discharge Planning”, last reviewed December 2023, stated “IV. Nurses C. Confirm that follow-up appointment(s) has been made. D. Provide patient and family/caregiver with the discharge instruction sheet on prescribed treatment, medications (including food/drug interactions), the nutrition plan, activity level, and scheduled follow-up appointments. (All written instructions and prescriptions should be in layman’s terms.)” Record review of facility policy titled “Medication Reconciliation”, last reviewed December 2023, stated “Medication reconciliation includes providing the patient (or family as needed) with written information on the medications the patient should be taking when he or she is discharged from the hospital, and explaining the importance of managing medication information to the patient when he or she is discharged from the hospital. At the time of discharge to the next level of care, copy of the discharge medication list will be forwarded to the receiving facility or sent home with the patient.” Interview on 9/11/2024 at 1:20 pm with Director of Case Management Staff ID #60. She confirmed the facility was unable to provide evidence of comprehensive case management/discharge planning packets and instructions which included accurate, updated medication list, follow-up interval and contact information for specialty follow-ups. In addition, she was unable to provide evidence of the completed discharge information packet which had been provided to patients and/or families at discharge for Patient ID #s: 2, 26, 27, 28. Interview on 9/11/2024 at 2:15 pm with Director of Pharmacy Staff ID #65. She confirmed that the medication reconciliation for Patient ID #2, 26, 27 and 28 were not completed.”