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)
A0749 INFECTION CONTROL PROGRAM
CFR(s): 482.42(a)(1)

The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.


This STANDARD is not met as evidenced by:
Based on observation, interview, and record review, the hospital failed to develop an effective system for identifying and controlling potential infections. Patient accessible furniture and equipment were in need of repair and cleaning, Patient belongings / clothing were stored directly on the floor, Washing machine was not cleaned after each use, Clean linen was not stored in a manner to prevent contamination, Staff failed to sanitize their hands prior to donning gloves. Findings included: Observation on the hospital's adult unit's Quiet/Activity Room identified by Personnel #13 on 04/04/17 at 2:55 p.m. as patient care area reflected two chairs with ripped padding which would make it difficult to adequately clean and sanitize. The paint on at least two walls was scraped off. The wood veneer table top was broken in two places leaving it difficult to clean. A large black bug was observed in Room 120 on 04/05/17 at 12:10 p.m. across the room. Personnel #17 stated it was a spider and removed it. Observations on 04/05/17 at 11:40 a.m. in the hospital's adult unit clean utility room reflected one oversized and one regular sized wheel-chair covered with plastic. Employee #5 stated those wheel-chairs were clean. Both wheel-chairs were observed with dusty and grimy wheels. Employee #5 acknowledged the observations at that time and stated they needed to be cleaned. Review of undated Hospital Policy titled "Hospital Equipment Cleaning" reflected that "equipment used routinely during the day shall be cleansed after each use per national healthcare regulatory standards ...examples of these are wheel-chairs." 23032 Observation during initial tour on 04-04-17 between 2:30 p.m. and 3:30 p.m. revealed the following infection control issues on Unit 2 (adolescent and children's hallways): Patient belongings room: a. Floor was dirty with multiple areas of dark grime and stains, b. (3) large 30 gallon plastic bags overflowing with clothing were placed directly on the floor, c. Two (2) wire shelving units that contained various patient items: no plastic/impermeable barrier noted on the bottom shelf of either shelving unit. Interview with Chief Nursing Officer (CNO) # 2 at the time of observation, she stated the floor should be cleaned and the clothing bags should all be labeled and not be stored on the floor. CNO went on to say she thought all the wire shelving units had plastic barriers on the bottom; "these must have been missed." Patient laundry room: Observation of the washing machine revealed a thick film that covered most of the inside of the washer. Interview with CNO # 2 at the time of observation, she said the washer was used to wash the patients' clothing and it should be cleaned after every use by the techs. Record review of facility policy titled" Cleaning of Patient Washers and Dryers, undated, read: "...3. The hospital staff will spray the drum with disinfectant solution and allow to air dry following each use...Housekeeping will disinfect the machine daily.." Clean linen storage room: Observation of a large wire cart that contained stacks of linen revealed a wadded up towel and a plastic "golf club" mixed in with the "clean linen". Further observation revealed no plastic/impermeable barrier noted on the bottom shelf of the storage cart. Interview with CNO # 2 at the time of observation, she stated the bottom shelf should have a plastic barrier on the bottom. She acknowledged the linen could become contaminated when the floor was mopped. Review of facility policy titled" Handling of Clean and Soiled Linen", undated , read: "Clean Linen shall be handled, transported and stored by methods that prevents contamination and ensures cleanliness.." Hand Hygiene: Observation on 04-06-17 at 11: 00 a.m. revealed Mental Health Techs(MHT) # 8 and MHT# 9 preparing to serve lunch trays on the children's hallway. Both MHTs failed to sanitize their hands prior to donning gloves and serving lunch to the patients. Interview on 04-07-17 at 1:00 p.m. with Registered Nurse (RN) # 4, she stated hand hygiene should be performed before and after donning gloves. Record review of facility policy titled " Hand Hygiene",undated, read: "...Indication For Hand Washing and Hand Antisepis: Hands should be sanitized using the hospital approved waterless antiseptic agent in the following situations:...upon entering the work area...before eating or handling food..."