Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391

Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 670072 (X3) Date Survey Completed 04/07/2017
Name of Provider or Supplier Hopebridge Hospital Street Address, City, State 5556 Gasmer Drive, Houston, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0115 PATIENT RIGHTS
CFR(s): 482.13

A hospital must protect and promote each patient's rights.


This CONDITION is not met as evidenced by:
Based on observation, interview, and record review, on April 4-7, 2017, the facility failed to ensure the rights of each patient to receive treatment in a safe setting. Eleven (11) of 33 patients (Patients #1, #2, #3, #10, #11, #15, #16, #18, #28, #32, #33) were placed in rooms with known multiple ligature risks present and easily accessible for use to harm self or others. These eleven (11) patients were on suicide precautions. This deficient practice posed a likelihood of serious harm or death for current and potential patients with suicidal ideation on the adult and adolescent units. Refer to 482.13(c)(2) - [A-0144]