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)
A0144 PATIENT RIGHTS: CARE IN SAFE SETTING
CFR(s): 482.13(c)(2)

The patient has the right to receive care in a safe setting.


This STANDARD is not met as evidenced by:
Based on observation, interview, and record review, the facility failed to ensure the rights of each patient to receive care in a safe setting on 2 of 2 patient care units (Unit 1-adult and Unit 2-child/adolescent). The facility failed to: (1) remove multiple known ligature risks that jeopardized the safety of 11 patients on Suicide Precautions (SP) that included bathroom faucets, push/pull door handles, and architechtural grade butt door hinges potentially usable for ligature during self-harm, (2) ensure that a patient diagnosed with Disorganized Schizophrenia on suicide precautions was prevented access to a glass light bulb and electrical wiring, (3) ensure unoccupied patient bedrooms were locked when unoccupied, (4) ensure that a personal hygiene item requiring poison control intervention in case of ingestion was inaccessible to patients, (5) ensure that a piece of plastic that can be used for self-harm was not accessible to patients, (6) implement an effective system to prevent patients on SP from accessing cutlery pthat can be used for to harm self or others, (7) make certain newly admitted patient on SP did not have personal clothing item potentially that can be used for self-harm. Findings included: (1) Ligature Risks: Observation on 04-04 17 at 2: 30 p.m. revealed the following: Unit 1 (adults) : Observation of all 19 occupied patient rooms revealed the following ligature risks in each room: bathroom faucets, push/pull door handles, and architechtural grade butt hinges [the identical risks were previously cited on 03-08-17 survey]. Record review of facility "Patient Census," dated 04-04-17 revealed the Unit 1 census was 28 patients; two(2) were on Suicide Precautions (Patient # 15, #16). Patient # 15: Record review of the medical record of Patient # 15 revealed he was admitted on 04-02-17 with a diagnosis of "Schizophrenia superimposed on a mildly intellectually disabled state". Physician order, dated 04/04/17 read : "... suicide precautions..." Patient # 15 was admitted to room 123-B where there are ligature risks easily accessible for self harm. Patient # 16: Record review of the medical record of Patient # 16 revealed she was admitted on 04-02-17 with diagnoses of bipolar disorder and polysubstance abuse. Admission orders dated 04-04-17, read: ...suicide precautions.." Patient # 16 was admitted to room 108-B where there are ligature risks easily accessible for self harm. Observation on 04-04 17 at 2: 30 p.m. revealed the following: Unit 2 ( adolescents/children) : Observation of all 11 occupied patient rooms revealed the following ligature risks in each room: bathroom faucets, push/pull door handles, and architechtural grade butt door hinges [the identical risks were previously cited on 03-08-17 survey]. Record review of facility "Patient Census", dated 04-04-17 revealed the Unit 2 census was 12 patients; three (3) were on Suicide Precautions (Patient # 1, # 2, # 10). Patient # 1: Record review of the medical record of Patient # 1 revealed she was admitted on 04-03-17 with a diagnosis of major depressive disorder with suicidal ideation. Physician order, dated 04/04/17 read : "... suicide precautions..." Patient # 1 was admitted to room 204-A where there are ligature risks easily accessible for self harm. Patient # 2 Record review of medical record of Patient # 2 revealed he was admitted on 03-17-17 with diagnoses of bipolar disorder and suicidal ideation. Observation on 04-04-17 of unit "bedboard" [whiteboard] and record review of "Precaution Sheets", dated 04-04-17 revealed Patient # 2 was on suicide precautions. Patient # 2 was admitted to room 205 where there are ligature risks easily accessible for self harm. Patient # 10: Record review of the medical record of Patient # 10 revealed he was admitted on 04-03-17 with a diagnosis of mood disorder/mood swings depressive disorder with suicidal ideation. Admission physician order, dated 04/04/17 read : "... suicide precautions..." Patient # 10 was admitted to room 221-B where there are ligature risks easily accessible for self harm. Multiple observations were done on 04-05-17 & 04-06-17 between 8:00 a.m. and 2:00 p.m. on Unit 1 and Unit 2 revealed the following: 04-05-17: Unit 1: three (3) patients were on suicide precautions ( Patients # 11, #15, 16) Unit 2: four(4) patients were on suicide precautions ( Patients # 1, #2,# 3) 04-06-17: Unit 1: two(2) patients were on suicide precautions ( Patients # 28, # 18) Unit 2: five(5) patients were on suicide precautions ( Patients # 1, #2, #3,# # 32, #33) Record review of the medical records for Patients 1, 2, 3, 11,15,16,18,28,32,33 revealed physician orders for suicide precautions on April 5 & 6, 2017. Observation on 04-07-17 between 9 a.m. and 11 a.m. revealed the following: Unit 1 (adults) : Observation of all 13 occupied patient rooms revealed the following ligature risks in each room: bathroom faucets, push/pull door handles, and architechtural grade butt door hinges [the same risks were previously cited on 03-08-17 survey]. Record review of facility "Patient Census," dated 04-07-17 revealed the Unit 1 census was 20 patients; two(2) were on Suicide Precautions (Patient # 15, #28). Record review of medical records for both patients revealed current physician orders for suicide precautions. Unit 2 (adolescents/children) : Observation of all 10 occupied patient rooms revealed the following ligature risks in each room: bathroom faucets, push/pull door handles, and architechtural grade butt door hinges [the same risks were previously cited on 03-08-17 survey]. Record review of facility "Patient Census", dated 04-07-17 revealed the Unit 2 census was 12 patients; two(2) whom were currently on Suicide Precautions (Patient # 2, #33). Record review of medical records for both patients revealed current physician orders for suicide precautions. During the interview on 04-07-17 at 11:10 a.m. with Chief Executive Officer (CEO) #1, he provided the following information in regards to the ligature risks (previously cited on 03-08-17 survey) : Faucets: waiting for a "prefab faucet shroud" to be developed. "This was supposed to be ready on 04-03-17 but the machine broke; should be ready by 04-10-17. We will test this to make sure it works before we order it. After it is ordered, it will be 4 to 5 weeks to be delivered and 1 week to install in all the patient rooms." CEO # 1 went on to say "the back up plan" was to order all new sinks which would be a 3 to 6 week delivery time; 2 to 3 week installation. Door hinges: ordered on 03-24-17; delivery expected in 2 to 3 weeks; 2 week installation time. Door handles: ordered on 03-23-17; up to 4 week delivery time; less than 1 week to install. When asked how facility verified in-room checks (of patient's on SP) on the night shift, CEO # 1 went on to say the facility did not presently have closed circuit TV video (CCTV) surveillance cameras. He said the CCTV cameras were placed in the coming year's capital budget. No other measures were put in place in the interim. During the interview on 04-06-17 at 1:45 p.m. with Chief Nursing Officer (CNO) # 2, she stated in addition to the staff training , Registered Nurse (RN) rounds were increased from every 3 hours to every hour. She went on to say these rounds included RN verification that SP was correctly documented on unit bedboard, nursing notes, observation sheets, and treatment plans. CNO # 1 did not include actual patient observation by the RNs during the rounds. CNO #1 went on to say that RNs reviewed the patients for need for 1:1 monitoring, especially for those at high risk. Record review of facility "Precaution Sheets", dated April 4, 5, 6, 7, 2017 failed to reveal any patients had been monitored 1:1 on any shift at any time. This was verified by interviews with charge nurses on both units on same dates. 17028 During an interview on 4/5/2017 at 7:45 am on the Adult Psychiatric Unit with Staff # 16 Charge Nurse, he stated when there are patients in their rooms the doors are kept opened and there was staff assigned to the hall to monitor the patients in their rooms. He stated, the staff is always on the hallway to ensure they are aware of the patients' locations. When the patients are not in their rooms the doors were locked with keys kept by staff. According to Staff (# 16), patients were "eyeballed" every fifteen (15) minutes and the observation was documented on the rounding sheet. Staff (#16) stated patients on Suicide Precaution are monitored more closely. However, Staff (#16) was not able to describe what "more closely" meant or show where the "more closely" monitoring was documented for patients on suicide precautions. ( 2) Light fixture risk: Observations in Room 123 on 04/05/17 at approximately 11:30 a.m. reflected a loose light fixture above the sink. Employee #5 acknowledged the potential for hiding contraband and access by patients to a light bulb and electric wiring at that time. The Patient Census dated 04/05/17 reflected Patient #15 was assigned to Room 123. Patient #15's Psychiatric Evaluation dated 04/01/17 at 2354 reflected Patient #15 had a history of Schizophrenia. The patient was intellectually disabled. He was admitted with increasingly bizarre behavior, was noted to be hallucinating and stated he "would rather die." Patient #15's Psychiatric Admission Orders dated 04/02/17 reflected the patient was on suicide precautions and on fifteen-minute observational checks. Employees #2 and #17 were interviewed regarding the loose fixture on 04/05/17 at approximately 12:05 p.m. Employee #17 stated, "I would not be surprised if the patient did it." 38015 (3) Unlocked patient rooms with identified ligature risks : [120, 126, 204, 210, 222, & soiled utility room] Observation on 4/4/17 at 3:25 p.m. of facility's child and adolescent unit hallways, accompanied by Registered Nurse (RN)#5, revealed an empty patient's room, #204. The door was closed but unlocked, allowing anyone to enter. RN #5 stated the room door should have been locked. Observation on 04/04/17 at 12:30 p.m. of facility's child and adolescent hallways, accompanied by RN#5, revealed an empty patient's room, # 210. The door was closed but unlocked, allowing anyone to enter. RN #5 stated that the room door should have been locked. Observation on 4/7/17 at 9:50 a.m. of facility child and adolescent unit hallways, accompanied by RN # 4, revealed an empty patient's room, # 222. The door was closed but unlocked, allowing anyone to enter. RN #4 stated that the room door should have been locked. Observation on 4/5/17 at 11:00 a.m. of facility child and adolescent unit hallways , accompanied by Mental Health Tech (MHT) Staff # 8, revealed an unlocked door to the "Soiled Utility Room", allowing anyone to enter. Inside this Soiled Utility room the following items were observed: a sharp metal dust pan, a broom, two (2) large approximately 25 gallon sinks, two (2) large plastic bag trash can liners, a sprinkler head, regular door hinges, large air vents protruding down from ceiling, and a wheelchair with removable leg rests. MHT Staff #8 stated that this door should have been locked. 28141 Observations on 04/07/17 at 9:31 a.m. revealed that Rooms 126 and 120 were unlocked. No patient was observed in the room at that time. Personnel #8 acknowledged at that time that he should have locked Room #126. Room 126 was observed unlocked again approximately three hours later, on 04/04/17 at 12:20 p.m. without a patient's presence in the room. Observation on 04-07-17 at 9:58 a.m. of Unit 2 patient "bedboard" [posted white board] revealed Patient # 18 was currently placed in room # 126 and was on Suicide Precautions. Record review of Patient # 18's physician order, dated 04-07-17 revealed SP had been in the room at that time. Personnel #8 acknowledged at that time that he should have locked Room #126. Room discontinued at 2:00 a.m. The white board had not been updated. Record review of facility's policy titled "Locks on Patient Room Doors", dated 4/2017, read: "Purpose: to help in establishing a safe environment for patients and to mitigate ligature risks in patient rooms...Procedure:...Vacant unoccupied rooms will be locked...occupied patient rooms will be locked when the patients are in scheduled activities or not in their rooms.." (4) Hazardous items Observations on 04/04/17 at 2:40 p.m. on the hospital's adult unit Room 125, Bed A, had a bottle with lotion that stated to keep the content "out of reach of children." Bed B's night stand had a bottle labeled as antiperspirant that noted to "call poison control in case of ingestion." Review of facility policy titled:" Search and Contraband", undated , read: "...Prohibited items-possessions that may create a safety risk for self or others:...toxic or hazardous liquids, materials, or aerosols..." (5) Hazardous item A piece of black plastic material potentially dangerous when ingested or inhaled was observed in the bathroom of Room 126 on 04/04/17 at approximately 2:25 p.m. Personnel #13 acknowledged the item and removed it. Record review of a blank facility "Environmental Services Daily Routine Quality Checklist" read: "...TASK: Clean shower stall..remove ...all debris.." (6) Accessibility of cutlery During the interview in the facility kitchen on 04-06-17 at 10:45 a.m. with Assistant Dietary Director # 37, she stated the facility used Styrofoam and plastic products because they have "many patients at risk to harm themselves". She went on to say patients on Suicide Precautions (SP) were not given any cutlery, salt, or ice. Dietary Director # 37 said, 'Nursing gives us the Diet Logs every day and it will indicate if a patient is on suicide precautions. We prepare the patient tray based on that". Review of the "Adult Diet Sheet"; "Adolescent Diet Log"; and the Children Unit Diet Log" , all 3 dated 04-06-17 failed to indicate any patient on any unit was on SP. Assistant Dietary Director # 37 said "according to the logs, no patients are on SP today." Observation on 04-06-17 at 11:15 a.m. on the Children's hall activity room revealed six (6) patients eating lunch. Further observation revealed after the children finished eating, they disposed of the trash from their trays into a large paper bag located on the floor by the wall. Patient # 32 was observed disposing of his trash which included plastic cutlery. At the time Patient # 32 placed his trash into the paper bag, Mental Health Tech (MT) # 7 had his back to this patient. No other staff was observing this patient. Further observation revealed Patient # 32 could have easily hidden the cutlery on his person with no staff noticing. Record review of facility "Precaution Sheet, Unit 2: Children", dated 04-06-17 ( 7A-7P) revealed Patient #32 was on Suicide Precautions. (7) Personal clothing: ligature risk Observation of room # 206 on 04-07-17 9:30 a.m. revealed a plastic basket that contained clothing. Within the basket a girl's tank-top style shirt with thin "spagetti straps" was observed . RN # 6 stated Patient # 33 had been newly-admitted to this room. She went on to say this patient was on Suicide precautions (SP). RN # 6 said the patient should not have a shirt with straps like this as they posed a risk. She removed the shirt from the room. Review of facility policy titled "Organization Ethics and Compliance", revised 5-18-16, read: "...Treatment of Patients:...The well-being and safety of patients should be the focus of all employees...Safe Patient Care: Safe environment safe care is essential to the well-being and recovery of psychiatric patients.....the hospital will promote a safety culture based on appropriate policies, systems,and equipment..."