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)
A0395 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:
Based on record review, observation, and interview, the hospital's nursing staff failed to supervise and evaluate the nursing care for two of two patients (Patients #15, #20) according to the patients' needs. 1)Although Patient #15 had a 50 pound reported weight loss during the two months prior to his hospital admission, nursing failed to verify the patient's reported weight on admission and to obtain a dietary consult for the patient who was under-weight and refused at least three meals at the time of survey, 2)Although Patient #20 had been noted to be losing weight during his partial hospitalization treatment, nursing did not weigh the patient for two and one half months. Findings included: 1) On 04/05/17 at 11:15 a.m., Patient #15 was observed in the adult unit's dining room. Patient #15 was very slender. He refused his lunch meal. Personnel #12 reported the patient did not eat breakfast. On 04/05/17 at 1635, Patient #15 was observed eating only his dinner roll and refused to eat the rest of the meal. Hospital Intake Assessment dated 04/01/17 at 11: 24 a.m. reflected Patient #15 had lost 50 pounds during the two months prior to his admission. Vital Signs Flow Sheet dated 04/06/17 reflected the patient weighed 131 pounds. Personnel #20 was interviewed by telephone on 04/06/17 at 9: 11 a.m. and denied that the Patient #15 was weighed during the hospital intake process because the patient was "non- responsive." On 04/06/17 at 4:00 p.m. Personnel #5 stated a dietary consult was ordered at that time. Personnel #2 acknowledged that Patient #15's reported weight on admission had not been verified through hospital personnel. According to the National Institute of Health, Patient #15 had a body mass index of 17.8 and was under-weight. (https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm) 2) Patient #20's Psychiatric Progress Notes dated 04/05/17 reflected that nursing reported the patient's "ongoing weight loss." During an interview on 04/06/17 at 11:55 a.m., Personnel #24 stated the physician saw Patient #20 the day prior to the interview and noted the patient's weight loss. Personnel #24 denied weighing the patient at that time and stated the last time that the patient was weighed was on 01/18/17.