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)
A0724 FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE
CFR(s): 482.41(c)(2)

Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.


This STANDARD is not met as evidenced by:
Based on observation and interview, the hospital failed to ensure that the facility and equipment were maintained to ensure an acceptable level of safety and quality. Findings included: Observation on 04/04/17 at 2:20 p.m. revealed a fist-sized hole in the wall of the hallway leading from the main entrance to the adult patient unit. A small cove in the hallway identified by Personnel #13 as space formerly occupied by washer and dryer was observed on 04/04/17 at 2:20 p.m. with water dripping from the space above the missing ceiling tile. Wet towels covered the floor. Observations on 04/07/17 at 9:26 a.m. revealed water dripping again through the ceiling into a trash barrel. Two wet towels were on the floor at that time. Observation on the hospital's adult unit Quiet/Activity Room on 04/04/17 at 2:55 p.m. revealed the paint on at least two walls was scraped off. Personnel #3 and/or Personnel #13 acknowledged the findings at that time. Two stained ceiling tiles were observed in the hospital's clean utility room and in the hallway in front of Room 123 on 04/05/17 at 11:40 a.m. Observations in the hospital's Partial Hospitalization Program on 04/06/17 at 12:25 p.m. revealed a central supply room with multiple brown spots, trash, and two bugs on the floor. A floor tile was missing. Personnel #23 stated on 04/06/17 at 12:30 p.m. that the room had not been checked. Observations in the hospital's Central Supply room on 04/06/17 at 2:20 p.m. revealed a rough cement floor without covering. Two light bulbs were burnt out. A rectangle hole sized approximately 15 centimeter times 10 centimeter was cut out of the wall's sheet rock and gave view onto the wood frame. Three walkers identified by Personnel #5 as "used" were leaning against two pair of wrapped crutches. Personnel #5 stated, the crutches were new and acknowledged that used and clean equipment were in close proximity. Three large ceiling tiles were missing and gave view to pipes in the floor above. A large piece of plastic was dangling down from the ceiling. 38015 Observation on 04-06-17 at 11:30 a.m. on the of children's unit revealed three large holes in the hall's walls in-between patient rooms on the children's unit. There was one hole next to patient room 205 approximately 6" x 3" with a 3"-5'' depth (6 inches x 3 inches with approximately 3-5 inch depth). Further observation revealed another hole in the wall of approximately the same dimensions as the first aforementioned hole. This second hole was located between patient rooms 205 and 206. A third smaller hole also in the corridor hallway walls, approximately 2" x 4" with approximately a 2"-3" depth (2 inches by 4 inches with approximately a 2-3 inch depth) was also located between patient rooms 205 and 205. 17028 Observation on the adult unit on 4/5/2017 at 9:15 am in the bath room shared by rooms 121 and 122 revealed an area of peeling ceiling plaster over the hand sink low enough for a patient to reach up and pull the peelings off. This material could be ingested by a patient. The rooms were occupied by patients. 23032 Observation in the facility kitchen on 04-06-17 at 10:30 a.m. revealed a large six(6) burner industrial gas stove top. The stove top was approximately 3 feet in height from the floor. The pilot lights on all six burners were lit and appeared to be approximately 3 inches in height. Heat was felt coming off the appliance as surveyor walked by the stove top. When asked at the time of observation, Dietary Director # 37 said she did consider this a safety hazard. She said "I was reaching over on the stove top one day and caught my shirt on fire." Dietary Director # 37 went on to say she had brought this to the attention to the contracted company she worked for "but this is the way they like it."