Pam Rehabilitation Hospital of Clear Lake

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 37490 Based on record review and interview, the facility failed to ensure the grievance resolution process was completed and documented in 1 of 3 patient related grievances (ID# 8). Findings include: Review of facility policy titled “Grievance Resolution Process,” last revised October 21, 2024 showed the following information: PURPOSE To protect and promote the rights of each patient, a patient has been established to promptly resolve patient grievances. This process is delegated to a grievance committee. POLICY All patients have the right to initiate the grievance resolution process...If the patient care complaint cannot be resolved at the time of complaint by the staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or require further actions for resolution, then the complaint is a grievance. The surveyor asked to review all documentation regarding grievance for patient (ID#8). Two letters were provided. Review of letter of acknowledgement to patient (ID# 8) dated 6/11/2025 stated the following: We want to thank you for bringing your concerns to us regarding the care we provided you while you were a patient at PAM Health Rehabilitation of Humble. As a follow-up, I would like to share the process that we will initiate to investigate your concerns. We will review your medical record and speak to staff involved to have a better understanding of the issues you have outlined....We will follow-up with you when the investigation is complete. Review of response letter to patient (ID#8) dated 6/17/2025 showed the following: The hospital was advised of a concern regarding inconsistent timely response to requests. As a result of the investigation, we have reeducated the staff... Interview with Interim Director of Quality Management (ID# 52) on 8/13/2025 at 3:00 pm she confirmed there was no documentation of investigation steps taken in the resolution process.”

“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: 37490 Based on interview and record review, the facility failed to ensure nursing provided intervention/ timely intervention on needs of a patient in pain in 1 of 4 patients (ID# 6). Findings Include Record review of facility policy “Guidelines for Nursing Care” last revised March 20, 2024, revealed “Pain: Assessment and Documentation - Upon Admission, Pain reassessed within 4 hours after PRN pain intervention.” Medical record review for patient (ID#6) showed the following: Admission assessment on 02/12/2025 1953 showed pain scale documented “10” with no documented intervention. Nursing assessment on 2/14/2025 at 1456 showed pain scale “4”. Physician order for Tramadol 50 mg by mouth every six hours PRN for pain scale 4-6. Indication: Pain Medication administration record showed Tramadol 50 mg was given 2/14/2025 at 22:23. Interview with Nurse Manager (ID 54) on 8/13/2025 at 11:00 am confirmed the above findings, Patient (ID#6) had no ordered intervention for a pain level of 10 and the physician should have been contacted. She also stated that the Tramadol administered on 2/14/2025 was not a “timely” intervention.”

“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: 37490 The hospital failed to ensure that an RN supervised and evaluated the care of 2 of 4 patients (ID#s 3 and 8). Findings include: Record review of facility policy “Guidelines for Nursing Care” last revised March 20, 2024, revealed “Hygiene - if no contraindication, bath/shower - Three times/week/and PRN.” Medical record review of Patient ID #3 showed physician order to start 7/30/2025 0900 for Bathing three times a week, Monday, Wednesday, Friday. Review of multidisciplinary notes showed hygiene care for patient (ID# 3) was not provided per physician order. Medical record review of Patient ID #8 showed physician order to start 12/04/2024 08900 for Bathing daily. Review of multidisciplinary notes showed hygiene care for patient (ID# 3) was not provided per physician order. Interview with Nurse Manager ID #54 on 08/13/2025 at 11:25 am, she confirmed the above findings.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 37490 Based on record review and interview, the facility failed to thoroughly and effectively identify, address and resolve a grievance for 1 of 1 patient (Patient #2). Findings included: Review of facility policy QM 11 dated January 15,2024, showed the following information: I. PURPOSE To protect and promote the rights of each patient, a process has been established to promptly resolve patient grievances. This process is delegated to a grievance committee. IV. PROCEDURES 5. The Director of Quality Management or designee will meet with the patient to discuss their complaint and resolve the issue if possible. If the complaint is unable to be resolved, the grievance process will be initiated. Should the grievance involve more than one specific concern, each concern will be addressed individually in the written response. The hospital must adequately provide information to address each item stated in the requirement. Review of grievance for patient (ID#2) stated that the patient developed pressure wounds on both feet and buttocks. Medical record review for patient (ID#2) showed the following: Date of admission 7/3/23 Initial nursing skin assessment on 7/3/23 at 23:45 showed no wounds with bilateral feet mentioned on skin assessment, but there is no description. 7/6/23 wound care consult order for sacral breakdown. 7/7/23 shows wound care order for cavilon to be applied to sacral redness. 7/8/23 wound care consult note shows bilateral feet deep tissue injury and Moisture Associated Skin Damage (MASD) on buttocks. Interview with nurse manager (ID# 55) on 8/14/24 at 2:15 PM she confirmed no wounds were documented on the initial nursing assessment for patient (ID#2). She went on to say that during the nursing assessment if a wound is identified, the nurse is to consult wound care and take pictures of the wound. Review of grievance letter for patient (ID#2) states that wounds were present on admission.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 37490 Based on record review, and interview, the hospital failed to ensure the right of privacy for 1 of 3 patients (Patients #13) in that multiple documents with protected patient information, including patients first and last name, medical record number, patient room location, medication orders, laboratory orders, respiratory and dietary orders, as well as consult orders, disclosing diagnosis, were sent to another patient. Findings included: Review of facility policy QM 19 titled “Patient Rights and Responsibilities,” dated Dec 5, 2023, showed the following: ... 6. Patients have the rights to: m.) Confidential treatment of all communications and records pertaining to the patient’s care and stay at the hospital. All patients will receive a separate “Notice of Privacy Practices” that explain privacy rights in detail ... Record review of facility policy HIM IV-02 “Release of Information” dated 4/20/22 showed the following information: POLICY 5.1 PAM Health shall protect and maintain the confidentiality of PHI when responding to a request for release of information. Record review of Medical Record Request for patient (ID# 1) showed request was for two accounts (both admissions) for the patient. The requestor was sent 1361 pages of medical records. Fourteen of those pages included protected information for patient (ID#13), a patient at another facility. The information included the following: patients first and last name, medical record number, patient room location, medication orders, laboratory orders, respiratory and dietary orders, as well as consult orders, disclosing diagnoses (i.e., wound care consult for sacral ulcer). Interview with Director of Health Information Management (ID# 54) on 8/14/24 at 1030 am confirmed the above findings. She stated that the information is sent via a third party and the information is not checked by the facility. The third-party vendor does a quality check. In the past we did do quality checks but there haven’t been any issues that have prompted us to do so.”

“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: 37490 Based on interview and record review, the facility failed to ensure Registered Nurses (RN) A. assessed patients every twenty-four hours, as per facility policy in 3 of 5 patients (Patient ID#s: 1, 2 and 12). B. implemented doctors orders in 1 of 3 patients (ID# 2) Findings included: Review of facility policy NSG 24 titled “Guidelines for Nursing care,” dated March 2024, showed the following: PURPOSE: To outline nursing routines, and guidelines for patient care. POLICY To ensure quality patient care, certain standards of care must be upheld. The following table outlines basic nursing tasks and designates minimum frequency with which these tasks must be performed to maintain quality care. A specific physician order will supersede the minimum frequencies noted below. Assessment: Every Shift and with significant condition changes. RN must assess once every 24 hours. LPN (licensed practical/vocational nurse) may gather data for RN to conduct the assessment. A.) Medical record review for patient (ID# 1) showed missing day shift assessment for 1/21/24, both day and night shift assessment were performed by LVN on 1/22/24, and both day and night assessments were performed by LVN on 1/27/24. Medical record for patient (ID# 2) showed the day and night shift assessment performed by LVN on 7/10/23, day and night shift assessment performed by LVN on 7/13/23, and 7/16/24 day shift did not have completed shift assessment. Medical record review for patient (ID#12) showed shift assessment from night shift 8/8/24-night shift 8/10/24 were all performed by LVN. B.) Medical record review for patient (ID#2) showed order written on 7/4/23 for cardiac telemetry for 5 days. Patient was placed on telemetry 7/10/2024. Interview with nurse manager (ID# 55) on 8/15/24 at 9:45 am, she confirmed the above findings and stated that each patient should be assessed by a registered nurse (RN) every 24 hours. If not, the RN should cosign the LVN assessment. She stated that the facility uses a third-party company to monitor patients on telemetry and that they have the capability to have 5-6 patients on a telemetry monitor. She went on to say that the order, may not have been caught or that there may have not been enough telemetry boxes for patients.”

“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: 37490 Based on record review and interview, the facility failed to ensure patients medical record requests were being completed and delivered as requested in 2 of 3 patients (ID# 1 and 3) Findings included: Record review of facility policy HIM IV-02 “Release of Information” dated 4/20/22 showed the following information: PRUPOSE/SCOPE 5.2 To provide guidelines for responding to a request for protected health information (PHI) in accordance with state laws, and with the final privacy and security rules of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. 5.3.1.2 Release of health information/PHI shall be in accordance with all applicable legal, accrediting, regulatory agency and HIPAA requirements, and accordance with PAM policy. Information released to authorized individuals or agencies shall be limited to the minimum necessary required to fulfill the purpose sated on the authorization. Record review of Medical Record Request for patient (ID# 1) showed request was for two accounts (both admissions) for the patient. The requestor was sent 1361 pages of medical records. The pages did not include information requested from both hospital admissions. The second admission information was not included. Record request for patient (ID# 3) showed request from attorney to include requests for medical treatments authorizations to insurance carrier/claims adjuster. The pages sent did not include any information regarding insurance/ claims adjuster documentation. Interview with Director of Health Information Management (ID# 54) on 8/14/24 at 1030 am confirmed the above findings. She stated that the information is sent via a third party and the information is not checked by the facility. The third-party vendor does a quality check. In the past we did do quality checks but there haven’t been any issues that have prompted us to do so. She went on to say that she was not sure if they have access to the financial information in the patient’s record.”