The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HOPEBRIDGE HOSPITAL 5556 GASMER DRIVE HOUSTON, TX Feb. 11, 2011
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, review of written statements and review of 1 of 3 clinical records , there was a failure to monitor and supervise nursing services resulting in the death of a patient.
Findings:

Citing patient #3, a [AGE] year old male. Review of the psychiatric evaluation reflected the patient was mentally retarded and psychotic. he resided at a personal care home where it was reported the patient was not eating, not acting the same and lying on the floor with tremors.
it was noted the patient was admitted on [DATE] at 4:52pm with physician orders from the personnel dated 1/27/2011 for "Diet: Soft, chopped meat texture, dime size pieces."

Admission physician orders included the following:
1:1 (staffing)
Fall precautions
Mechanical soft diet

Review of nursing progress notes reflected on 2/3/2011 at 4:50pm the patient was observed in his wheelchair at the table in the activity room choking and another patient performed the Heimlich procedure on him. The patient was observed holding his mouth wide open with eyes bulging and hands beating on the table. Psychiatric Technician #52 attempted to lift the patient from the wheelchair to a standing position. Heimlich procedure not successful. There was a call for additional staff. Code Blue called and CPR began. patient had stopped breathing and became a bluish/gray color.
At 5:54pm the patient was transferred to an outside hospital emergency room .

Review of the menu for food served to the patient for 2/3/2011 reflected the patient was served a roast beef sandwich and chips for the dinner meal.

Although the patient was ordered to be on 1:1 staffing,In arms length at all times, there was no staff with the patient at the time and as nursing notes indicated, another patient in the room was the one to initiate the Heimlich maneuver.

Review of the Code Blue sheet reflected the code was called at 1700.hrs However the ER physician did not arrive until 1713 hrs and ordered staff call 911. Paramedics arrived at 1722 hrs and took over. the patient was transferred to an outside ER at 1750 hrs.

Review of the rounds sheet for documentation of every 15 minute observation on 2/3/2011 appeared to have been falsified as follows:

All 15 minute observations from the time the code was called to the time the patient was transferred to an outside ER noted the following:

1700
Location: activity room
Visual appearance: calm
Behavior: composed

1715
Location: activity room
Visual appearance: calm
Behavior: composed

1730
Location: activity room
Visual appearance: calm
Behavior: composed

1745
Location: activity room
Visual appearance: calm
Behavior: composed

1800
Location: activity room
Visual appearance: calm
Behavior: composed
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, review of written statements and review of 1 of 3 clinical records , there was a failure to protect patient's right to receive care in a safe setting resulting in the death of a patient.
Findings:

Citing patient #3, a [AGE] year old male. Review of the psychiatric evaluation reflected the patient was mentally retarded and psychotic. he resided at a personal care home where it was reported the patient was not eating, not acting the same and lying on the floor with tremors.
it was noted the patient was admitted on [DATE] at 4:52pm with physician orders from the personnel dated 1/27/2011 for "Diet: Soft, chopped meat texture, dime size pieces."

Admission physician orders included the following:
1:1 (staffing)
Fall precautions
Mechanical soft diet

Review of nursing progress notes reflected on 2/3/2011 at 4:50pm the patient was observed in his wheelchair at the table in the activity room choking and another patient performed the Heimlich procedure on him. The patient was observed holding his mouth wide open with eyes bulging and hands beating on the table. Psychiatric Technician #52 attempted to lift the patient from the wheelchair to a standing position. Heimlich procedure not successful. There was a call for additional staff. Code Blue called and CPR began. patient had stopped breathing and became a bluish/gray color.
At 5:54pm the patient was transferred to an outside hospital emergency room .

Review of the menu for food served to the patient for 2/3/2011 reflected the patient was served a roast beef sandwich and chips for the dinner meal.

Although the patient was ordered to be on 1:1 staffing,In arms length at all times, there was no staff with the patient at the time and as nursing notes indicated, another patient in the room was the one to initiate the Heimlich maneuver.

Review of the Code Blue sheet reflected the code was called at 1700.hrs However the ER physician did not arrive until 1713 hrs and ordered staff call 911. Paramedics arrived at 1722 hrs and took over. the patient was transferred to an outside ER at 1750 hrs.

Review of the rounds sheet for documentation of every 15 minute observation on 2/3/2011 appeared to have been falsified as follows:

All 15 minute observations from the time the code was called to the time the patient was transferred to an outside ER noted the following:

1700
Location: activity room
Visual appearance: calm
Behavior: composed

1715
Location: activity room
Visual appearance: calm
Behavior: composed

1730
Location: activity room
Visual appearance: calm
Behavior: composed

1745
Location: activity room
Visual appearance: calm
Behavior: composed

1800
Location: activity room
Visual appearance: calm
Behavior: composed