HospitalInspections.org

43549

Based on observation and interview, the facility failed to maintain a safe environment for 93 of 93 (all) patients at the facility, as shown by the presence of peeling paint on the awnings and support beams throughout the central patient courtyard and walkways between buildings.
Also by having mold on the walls, ceiling, and air duct in 1 of 4 rooms in the A hall between units.

During a tour 02/27/23 at 13:25 with staff #12 Director of Nursing Education mold was noted on the ceiling, wall, air vent and light fixture in room A407A. The room was used as office space with 2 desks being used.
When interviewed 02/27/23 at 13:28 staff #12 confirmed the mold on the afore mentioned surfaces. He stated the area was office space for Utilization Review staff and he was not sure whom else. He added that at times patients may be in an office.

During a tour 02/28/23 at 14:30 with staff #12 Assistant Director of Nursing the curling, flaking paint was observed. The paint was curled up and easily lifted in sheets of paint up to several inches long. Staff #12 was asked if she thought it could be a patient hazard. She looked closely and touched an area of peeling paint which easily broke off. She then stated she saw how it posed a hazard and confirmed it could be ingested.

During an interview 02/28/23 at 15:45 with staff #6, Director of Environmental Services stated he knew the paint was peeling throughout the open courtyard area. He stated it was not on his list for repair. He stated he would need to begin a bid process to get the work done.

A. Based on review of the facility policy, record review and interview, the facility failed to ensure that a Registered Nurse reassessed a patient, based on the patient's needs, but at least every 12 hours after the initial comprehensive nursing assessment in 1 (#K) of 3 sampled patient records.

Findings include:

Review on 03/01/2023 of the facility's current policy titled Nursing Assessment and Reassessment of Patients, Policy ID #200.46, last revised and Approved 03/31/2020, revealed the following information: "All patients admitted to Houston Behavior Healthcare Hospital shall have a nursing assessment completed by a Registered Nurse on admission and at a minimum every shift
thereafter."

Review of the facility's current job description received from the Director of Risk Management on 01/18/23 at 14:20 via email, for the Licensed Practical Nurse, unknown date, that the LPN Job description was reviewed and/or revised revealed the following information:

"The LPN/LVN contributes to the assessment of the health status of individuals and groups, participates in the development and modification of the plans of care.

"Implements and/or suggests care strategies within the LVN scope of practice, providing safe care."

"Provides information to RNs and others as needed for the assessment, care planning, and provision of care of patients."

"Is responsible on collecting and documenting clinical data on patients during admission and the patient's stay."

Record review of patient (#K) admitted on 02/16/23 and was still a current patient as of 02/28/23, Diagnosis of Schizoaffective disorder and epilepsy. Date of birth 07/05/1998.
Record review of the Daily Nursing Assessment Notes for patient (#K) revealed the following information:

On the Nursing Assessment assigned to be completed 02/21/23 assessment boxes were lined through, but the sheet was not signed or dated by a nurse as the person who lined assessment areas. For patient #K. The reverse side of the document had a narrative note that was initialed (illegible) but lacked a signature or title of the author.

The 02/26/23 Daily Nursing Assessment Note for patient #K was completed by a LVN employee (#13) at 08:45 am co-signed by Employee (#14) [No time indicated] confirming that she read LVN's assessment for patient (#K).

When Interviewed 02/28/23 at 14:50 the Chief Nursing Officer confirmed the findings and stated all nursing staff had training on assessments and documentation, but she would be instituting more approaches