DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
671774 A. BUILDING __________
B. WING ______________ 		02/03/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HARBOR HOSPICE OF SOUTHEAST HOUSTON LP 11990 KIRBY DRIVE, HOUSTON, TX, 77045
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
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 REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0517      
39332 Based on record review and interview, the hospice failed to ensure the rights of 1 of 1 Patient (#1) to be free from neglect by an agency employee, in that: CNA #51 left Patient #1 unattended and unassisted which led to Patient #1's fall and an injury to Patient #1's nose. This failure places all patients at risk of harm and potentially at risk of injury. Findings include: Record review of TULIP/HHSC complaint intake information received on 2/1/2021 showed in part under general intake notes the following " ... [PATIENT 1] WAS AN INPATIENT HOSPICE CLIENT FOR ABOUT A MONTH. ON 1/20/2021 [PATIENT 1] HAD A FALL WHICH CAUSED HER TO OBTAIN A FRACTURED NOSE AND SOME BRUISING ON HER TAIL BONE. THE [PATIENT 1] WAS PLACED BACK IN BED AFTER THE FALL. ONCE HER FAMILY MEMBER CAME TO VISIT HER THAT DAY [PATIENT 1] WAS SENT OUT TO [Hospital] BY THE FAMILY'S REQUEST ..." Record review of Patient #1's clinical record revealed diagnoses of brain tumor (Cerebral Meningioma), Facial nerve damage (Trigeminal Neuralgia), and Fall risk. Record review of the agency's complaint and incident investigation record titled "Complaint Form" Patient #1 fell on the floor and had "Abrasion on her nose ..." Record review of the electronic information provided by the Identifier 101 revealed bruising and bloodstain to Patient #1's nose. Record review of a nurses' note titled "Shift Running Document" read in part; " ...assisted bedside CNA [CNA #51] with transferring patient to bed. Patient was found on the floor mat while bed alarm was going off. Patient was very weak, drowsy had no straight [strength] to stand up. Patient started to shake appear [sic] like she was having a seizure, ...patient had a small scratch with a little blood on her nose ..." Record review of Patient #1's Initial assessment record revealed she was forgetful and confused; had bowel and bladder incontinence with "Considerable assistance required" in the area of self-care. Interview via telephone with Identifier #101 on 02/02/2021 at approximately 10:46 AM, she stated that CNA #51 informed her that CNA #51 transferred Patient #1 onto the bedside commode and left the Patient's room and by the time she returned, Patient #1 was already on the floor ..." Identifier #101 added that Patient #1 was transferred to the hospital and she later found out that Patient#1 had sustained a fractured nose. Interview via telephone with RN #52 and in-person with the Administrator on 02/03/2021 at approximately 1:30 PM, RN #52 stated that when she was performing patient's rounds on 01/22/2021 at approximately 7:00 AM, she observed CNA #51 transferring Patient #1 onto the bedside commode; a few minutes later, she heard a sound from Patient #1's room and when she got there, the patient was on the floor. She added that CNA #51 also came back into Patient #1's room and both transferred Patient #1 into her bed. During an interview with the Administrator on 02/02/2021 at approximately 1:00 PM, she stated that she was informed that Patient #1 was found on the floor but she did not know that CNA #51 assisted Patient #1 onto the bedside commode and left the patient room. She added that she later found out from Identifier #101. When the surveyor requested to speak with CNA #51, the Administrator stated that CNA #51 was terminated on 01/29/2021 and no longer worked for the agency. The Administrator added that CNA #51 was supposed to stay with Patient #1 and that CNA #51 was terminated because she was not complying with the agency's policies and procedures.