Survey Report For 450388 - 4.29.2019

4/29/2019 Survey Report for 450388
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
(X1) (X2) MULTIPLE (X3) DATE SURVEY

STATEMENT OF PROVIDER/SUPPLIER/CLIA CONSTRUCTION COMPLETED
IDENTIFICATION NUMBER
DEFICIENCIES
AND PLAN OF 450388 A. BUILDING __________ 11/14/2018
CORRECTION B. WING ______________
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
METHODIST HOSPITAL 7700 FLOYD CURL DR, SAN ANTONIO, TX, 78229
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES

PREFIX (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)
0000 Initial Comments

29242
The CMS - 2567 (Statement of Deficiencies) is an

official, legal document. All information must
remain unchanged except for entering the plan of
correction, correction dates and the signature
space. Any discrepancy in the original deficiency
citation (s) will be reported to Dallas Regional
Office (RO) for referral to the Office of Inspector
General (OIG) for possible fraud if information is
inadvertently changed by the provider/supplier, the
State Survey Agency (SA) should be notified
immediately.
An entrance conference was conducted on 11/13/2018

in the facility conference room. In attendance were
the Vice President of Quality and other facility
administrative staff. The purpose of the survey
(Complaint Investigations) and the survey process
were explained. An opportunity was provided for
questions and discussion.
Complaints TX00296820 and TX00297167 were

investigated for alleged violations of 42 Code of
Federal Regulations (CFR) Part 488 Subpart A
Medicare Conditions of Participation for Hospitals.
Complaint TX00296820 was found to be substantiated.

Related deficiencies were cited.
Complaint TX00297167 was found to be substantiated
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting
providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.)
Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of
correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these
documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program
participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER TITLE (X6) DATE

REPRESENTATIVE’S SIGNATURE
FORM CMS-2567 (02/99) Previous Versions Obsolete
https://qcor.cms.gov/hosp_cop/450388OSMJ11CVisit1.html 1/14

DEFICIENCIES
with Condtion Level deficiencies cited.
An exit conference was conducted in the afternoon of

11/14/2018 in the facility conference room. In
attendance were the designated facility
administrative staff. The preliminary findings of
the survey and the next steps in the survey process
were explained. The facility was found to be out of
compliance with the Medicare Conditions of
Participation set forth at 42 CFR Part 482. An
opportunity was provided for the facility to provide
evidence of compliance with those requirements for
which non-compliance had been found during the
survey. No such evidence was either alleged or
provided prior to exit from the facility.
It was determined the following conditions of

Participation were not met:
-Patient Rights
A0115 Patient Rights

482.13
Corrected On: 02/27/2019
participation


DEFICIENCIES
29242
Based on record reviews and interviews, the facility

failed to ensure that patients are free from all
forms of abuse for 1 of 1 patient (patient #1). The
facility failed to:
-Ensure that patients were protected from on-going
physical abuse by removing the alleged perpetrator
from patient contact.
-Ensure facility staff followed facility policy and
procedure in reporting physical abuse of a patient.
-Ensure nursing staff documented reports of alleged
abuse and conducted an immediate physical assessment
of the patient after the abuse was made known.
Refer to A0145 for evidence of findings.
The cumulative effect of these deficient practices

resulted in the facility's inability to meet the
Condition of Participation for Patient Rights.
A0145 Patient Rights: Free From Abuse/Harassment

482.13(c)(3)
29242

failed to ensure that patients were free from all
forms of abuse for 1 of 1 patients (patient #1). The
facility failed to:
participation


DEFICIENCIES
-Ensure that patients were protected from on-going
physical abuse by removing the alleged perpetrator
from patient contact.
-Ensure facility staff followed facility policy and
procedure in reporting physical abuse of a patient.
-Ensure nursing staff documented reports of alleged
abuse and conducted an immediate physical assessment
of the patient after the abuse was made known.
Findings Included:
Record review of the medical record for Patient #1

revealed that she was a 89 year old female with
diagnosis of severe end stage dementia, coronary
artery disease, and chronic kidney disease.
Patient#1 was being monitored by a non- recorded
video camera manned by staff.
Record review of the facility Patient Event Records,

dated 9/17/18 at 0632 revealed in part, the
following information:
-On 9/13/18 at 1830 Video Monitor Technician #1
(VMT) witnessed husband grab patient by face.
-On 9/13/18 at 1910, VMT#2 witnessed husband grab
patient by her face and hit her on her side.
- Supervisor notified: Yes, date 9/17/18 at 0633.
- Pre event condition: Confused.
-Event Severity: Unsafe situation could harm
-Further information related to cause: Patient hit
by family member.
-Type of Treatment: Other, sitter placed in room.
Record review of the video monitors log dated

9/13/18 shift 7P-7A revealed the following:
- "family member punched patient on the lower end of
her body. Reported it to house sup and called the
participation


DEFICIENCIES
unit and told Director of Telemetry unit.
Record review of the Hospital sitter log revealed

the following:
- 9/13/18 at 12:00 am to 9/19/18 at 3:00 pm- (1:1
sitter reason) Patient's pulling out life preserving
lines and restraints are contraindicated. Additional
details: caregiver was witnessed trying to hit
patient X2.
Record review of the facility Social Worker's

progress notes revealed in part the following
information:
-9/14/18 at 1609: "Case Manager (CM) was notified by

director of Telemetry and video monitors that
patient was seen being chocked and slapped by
husband. CM rendered initial assessment, patient was
not in the room, she was obtaining a colonoscopy
.... Husband states he is the primary care giver for
the patient and they live together in a single story
home."
-9/17/18 at 1422: "Called APS case worker for an

update. Informed patient was seen by weekend on call
investigator based on 2 cases called in over the
weekend. APS case worker communicated this was new
case not a previously opened case ... ... Also
stated that since it happened in a hospital was
instructed by supervisor to report cases to DHHS
(Department of Health and Human Services). "
- Plan: "DC disposition undetermined. Prior to
admission there was not an open APS case. However,
there were 2 cases called in this weekend. Weekend
on call person came out. Above information will be
communicated to patient's nurse, DC/Charge Nurse,
participation


DEFICIENCIES
and unit's Nurse CM."
Record review of the nursing notes dated 9/13/18 to

9/17/18 revealed that on 9/14/18 at 1816 nursing
staff documented the following: "Had a conversation
with investigator of APS. Stated patient has open
adult protective services case, they will follow up
with patient from now." Further review revealed that
on 9/15/18 at 2021 Adult protective services
(APS)visited the patient. There was no evidence that
nursing staff documented the incident of physical
abuse, assessed the patient immediately after the
abuse occurred, documented the reason for the APS
visit and/or notified patient #1's primary
physician. Continued review revealed that nursing
staff had documented that the patient's husband
(alleged Perpetrator) stayed at the patient's
bedside throughout her stay at the facility.
Record review of the physician's progress notes,

dated 9/14/18 at 0815 through 9/17/18 revealed no
evidence that Patient #1's primary physician was
notified of the witnessed physical abuse of patient
#1 that occurred on 9/13/18.
Further review of the facility documentation dated

9/13/18 to 9/19/18 revealed no evidence that
facility staff reported the abuse to the Department
of Health and Human Services.
Record review of the nursing discharge note dated

9/19/18 at 1439 revealed that the patient was
discharged home to the care of her husband (alleged
perpetrator).
Record review of the facility policy entitled:

participation


DEFICIENCIES
Abuse: Identifying, Documentation, and Reporting of
Suspected Abuse, Neglect, and Exploitation, reviewed
3/2015 revealed in part the following information:
- Procedure:
1.) All suspected maltreatment must be reported as
soon as possible before the end of the reporter's
shift to Adult Protective Services.
2.) Allegations that occur on facility premises
(adult and pediatric):
a) Call San Antonio Police to investigate, and
collect evidence if needed.
b) Report allegation immediately to all of the
following:
- Nurse Director/ Manager notifies administration
and legal as appropriate
- Treating Physician
- Hospital Administrator in house or on-call
- Quality/ Risk Manager
c)Preserve evidence: Do not touch, attempt to clean,
or discard anything associated with the allegation.
d) If there is an allegation of sexual assault or
rape, notify the SANE nurse immediately.
e) Submit a preliminary report to Department of
State Health Services. (Now HHSC)
f) Complete occurrence report by the end of the
shift and submit to Quality/ Risk Manager and
appropriate leadership.
6.) Elder Maltreatment: if the reported believes
that immediate protection for the elderly person is
advisable, the appropriate law enforcement agency
having jurisdiction over the place where the
incident occurred will be notified.... If the
patient resides in a nursing home, and the
maltreatment is suspected to originate in the
nursing home, an additional report must be made to
participation


DEFICIENCIES
The Texas Department of Aging and Disability....
In an interview conducted on 11/14/18 at 10:45 am,

the RN supervisor stated that the VMT reported to
her that he saw the patient's husband slapping and
chocking the patient. That day staff sent her
husband home, but he came back the next day. When
asked if she had documented the patient's
disposition after the alleged abuse she stated she
had not. When asked if she had reported the incident
to the Department of Health and Human Services, she
stated she was not aware she was required to do so.
In an interview conducted on 11/14/18 at 11:00 am

the RN Case Manager revealed that she was on duty
the day the physical abuse occurred. She stated that
the VMT called and told her that patient #1's
husband had hit her. She stated that she went to see
what was going on with the patient. When she got to
the room, the patient's husband was at the bedside.
The husband appeared very frustrated so she sent him
home and he came back the next day and sat at the
bedside with the patient. When asked if she had
assessed the patient after the physical abuse had
occurred, she stated she had but did not document
the assessment.

the Director of Telemetry revealed that he was aware
of an incident where the patient's husband shook her
face and that the initial report was called in to
APS. He further stated that he was not aware of any
other reports of abuse that were called in for the
patient.
In an interview conducted on 11/14/18 at 1:10 pm

participation


DEFICIENCIES
with the Chief Medical Officer (CMO)and the Director
of Patient safety, the CMO, was asked by the
surveyor why the patient's husband (alleged
perpetrator) was not removed from contact with
Patient #1 for the duration of her stay. He stated
that the husband was not removed because he was the
patient's responsible party. When asked by the
surveyor if the alleged abuse was called in to the
Texas Department of Health and Human Services
(HHSC), both the CMO and the Director of Patient
Safety stated that they were not aware that the
incident needed to be reported to HHSC.
A0395 Rn Supervision Of Nursing Care

482.23(b)(3)
29242
participation


DEFICIENCIES
Based on record review and interview, The facility

failed to ensure nursing staff documented reports of
alleged abuse conducted an immediate physical
assessment of the patient after the abuse was made
known, and notified the patient's primary physician.
Findings Included:
Record review of the facility Patient Event Records,

dated 9/17/18 at 0632 revealed in part, the
following information:
-On 9/13/18 at 1830 Video Monitor Technician #1
(VMT) witnessed husband grab patient by face.
-On 9/13/18 at 1910, VMT#2 witnessed husband grab
patient by her face and hit her on her side.
- Supervisor notified: Yes, date 9/17/18 at 0633.
- Pre event condition: Confused.
-Event Severity: Unsafe situation could harm
-Further information related to cause: Patient hit
by family member.
-Type of Treatment: Other, sitter placed in room.
Record review of the facility Social Worker's

progress notes revealed in part the following
information:
-9/14/18 at 1609: "Case Manager (CM) was notified by

director of Telemetry and video monitors that
patient was seen being chocked and slapped by
husband. CM rendered initial assessment, patient was
not in the room, she was obtaining a colonoscopy
.... Husband states he is the primary care giver for
the patient and they live together in a single story
participation


DEFICIENCIES
home."
Record review of the nursing notes dated 9/13/18 to

9/17/18 revealed that on 9/14/18 at 1816 nursing
staff documented the following: "Had a conversation
with investigator of APS. Stated patient has open
adult protective services case, they will follow up
with patient from now." Further review revealed that
on 9/15/18 at 2021 Adult protective services
(APS)visited the patient. There was no evidence that
nursing staff documented the incident of physical
abuse, assessed the patient immediately after the
abuse occurred, documented the reason for the APS
visit and/or notified patient #1's primary
physician. Continued review revealed that nursing
staff had documented that the patient's husband
(alleged Perpetrator) stayed at the patient's
bedside throughout her stay at the facility.
Record review of the physician's progress notes,

dated 9/14/18 at 0815 through 9/17/18 revealed no
evidence that Patient #1's primary physician was
notified of the witnessed physical abuse of patient
#1 that occurred on 9/13/18.
Record review of the nursing discharge note dated

9/19/18 at 1439 revealed that the patient was
discharged home to the care of her husband (alleged
perpetrator).

the RN supervisor stated that the VMT reported to
her that he saw the patient's husband slapping and
chocking the patient. That day staff sent her
husband home, but he came back the next day. When
asked if she had documented the patient's
participation


DEFICIENCIES
disposition after the alleged abuse she stated she

had not.
In an interview conducted on 11/14/18 at 11:00 am

the RN Case Manager revealed that she was on duty
the day the physical abuse occurred. She stated that
the VMT called and told her that patient #1's
husband had hit her. She stated that she went to see
what was going on with the patient. When she got to
the room, the patient's husband was at the bedside.
The husband appeared very frustrated so she sent him
home and he came back the next day and sat at the
bedside with the patient. When asked if she had
assessed the patient after the physical abuse had
occurred, she stated she had but did not document
the assessment.
A0397 Patient Care Assignments

482.23(b)(5)
29242

failed to ensure that nursing staff were provided
formal training in the use of Hoyer lifts before
staff used the lifts in direct patient care.
Findings Included:
Record review of the medical record for patient #2

revealed that he was a 58-year-old male with
diagnosis of Paraplegia, morbid obesity, Congestive
Heart Failure, Diabetes, and atrial fibrillation.
participation


DEFICIENCIES
Further review revealed that he required a Hoyer
lift for transfers due to his extreme weight.
Record review of the nursing notes dated 6/23/18 at

0323 revealed in part the following information:
-Pt wanting to be able to get out of the bed.
Explained that once the lift (Hoyer) was evaluated
by maintenance and patient worked with staff would
do the utmost to get patient out of bed.
Record review of the nursing notes dated 6/27/18 at

0425 revealed in part the following information:
-Nurse Practitioner called on 6/26/18 at 22:00 and
made aware of patient's bloody urine post
repositioning in Hoyer lift.....
In an interview conducted on 11/13/18 at 1:20 pm,

the Registered Nurse (RN) Manager stated that she
was not trained in the use of the Hoyer lifts, which
were installed on 11/2017. She stated that she had
to "reach out" to maintenance personnel regarding
how to use the Hoyer lift.

the RN charge nurse for the facility's 4th floor
unit revealed that none of the nursing staff on the
unit had any training on how to use the Hoyer lifts.
She further stated that nursing staff had to call
around to other units in order to find someone that
could use the lifts and to obtain the sling
components of the lift.

the 4th and 6th floor Nursing Supervisor revealed
that there are a total of 5 patient rooms on the 4th
floor which have Hoyer lifts installed in the
participation


DEFICIENCIES
ceiling. She further confirmed that nursing staff

have had no formal training in how to use the Hoyer
lifts.

the RN charge nurse for the Emergency Department
(ED) revealed that staff in the ED have to call
other units to find a Hoyer lift when needed. She
further stated that not all staff are familiar with
how to use the lifts. Staff would have to call the
other units to find someone who could show them how
to use the Hoyer lift.

the Director of Education confirmed that nursing
staff have not been formally trained on the use of
Hoyer lifts. She further stated that she normally
would work with the manufacturer of the durable
medical equipment in the training of hospital staff.
However, she was unaware that the new Hoyer lifts
had been installed, or that there was a need for
training, so no training was done.
participation


Survey Report For 450388 - 4.29.2019

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4/29/2019 Survey Report for 450388

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

(X1) (X2) MULTIPLE (X3) DATE SURVEY

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES

0000 Initial Comments

The CMS - 2567 (Statement of Deficiencies) is an

An entrance conference was conducted on 11/13/2018

Complaints TX00296820 and TX00297167 were

Complaint TX00296820 was found to be substantiated.

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER TITLE (X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

(X1) (X2) MULTIPLE (X3) DATE SURVEY

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP

with Condtion Level deficiencies cited.

An exit conference was conducted in the afternoon of

It was determined the following conditions of

A0115 Patient Rights

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER TITLE (X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

(X1) (X2) MULTIPLE (X3) DATE SURVEY

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP

Based on record reviews and interviews, the facility

Refer to A0145 for evidence of findings.

The cumulative effect of these deficient practices

A0145 Patient Rights: Free From Abuse/Harassment

Based on record reviews and interviews, the facility

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER TITLE (X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

(X1) (X2) MULTIPLE (X3) DATE SURVEY

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP

Record review of the medical record for Patient #1

Record review of the facility Patient Event Records,

Record review of the video monitors log dated

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER TITLE (X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

(X1) (X2) MULTIPLE (X3) DATE SURVEY

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP

unit and told Director of Telemetry unit.

Record review of the Hospital sitter log revealed

Record review of the facility Social Worker's

-9/14/18 at 1609: "Case Manager (CM) was notified by

-9/17/18 at 1422: "Called APS case worker for an

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER TITLE (X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

(X1) (X2) MULTIPLE (X3) DATE SURVEY

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP

and unit's Nurse CM."

Record review of the nursing notes dated 9/13/18 to

Record review of the physician's progress notes,

Further review of the facility documentation dated

Record review of the nursing discharge note dated