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 March 17, 2011
VIOLATION: QAPI Tag No: A0263
Based on interview and review of hospital documents the hospital governing failed to ensure the implementation of a quality improvement plan that includes all hospital departments and failed to ensure quality indicators were monitored.
Findings:

Per interview with hospital CEO on 3/17/11 at 10:45am, the hospital added two outpatient clinics to the hospital provider number on 1/13/2011 to include:
Hornwood Outpatient Center, 6648 Hornwood Drive, Houston, TX and
Baytown Outpatient Center, 2001 Cedar Bayou Drive, Baytown, TX
However, review of the Quality Improvement Program Plan did not include the integration of these outpatient services into the hospitalwide Quality Improvement Program. Review of Quality Improvement meeting minutes from 1/13/2011 to 3/1/2011 had no evidence outpatient services were monitored..

CROSS REFER TO A 0267
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview , review of the Quality Improvement Program Plan and review of performance improvement meeting minutes the hospital governing body was ineffective by failing to ensure the implementation of a quality improvement plan that includes all hospital departments. and ensures all quality indicators are being monitored.
Findings:

CROSS REFER TO A 0263
CROSS REFER TO A 0267
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, review of medical staff bylaws, review of physician credential files and review of 1 of 1 surgical clinical record, the medical staff failed to enforce its bylaws resulting in a practitioner performing surgery without the delineation of the privilege to perform surgery approved.
Findings:

Review of the clinical record reflected the patient, a [AGE] year old female who underwent surgery surgery on 3/11/2011 for removal of a bone in her foot. Present in the surgical suite were personnel #1, #3 and #21. Per personnel #21 at 10am on 3/16/2011 the practitioner who performed surgery on the patient was personnel #3, a doctor of podiatry medicine(DPM). Review of the credential file reflected personnel #3 was given temporary privileges on 3/11/2011. However, personnel #3 performed surgery without being given approval to perform surgery and without query of the national practitioners data bank (NYPD)in violation of medical staff by laws which require both.
VIOLATION: PHARMACEUTICAL SERVICES Tag No: A0490
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, facility failed to ensure its pharmaceutical service operationalized its policy and procedure to track schedule 2 control medications during receipt and disposition of control medications; failed to ensure expired medication were not stored with medication in stock for patient usage and failed to document medication administered as prescribed by the physician in 2 of 8 sampled patients reviewed for medication #s , 6 and 44,

Findings:

Review on 03/16/2011 of the facility's current policy and procedure on Controlled Drug Distribution and Accountability (issued 05/2010) directed staff as follows: " The facility has overall responsibility for controlled drugs. Records for controlled drugs shall be filed so they are readily retrievable and receipts and distribution can be established. C-11 records shall be separate from records of C- 111 through C-V and non controlled drugs. These records shall be retained for a period of five (5) years. "

The facility's current policy and procedure issued 05/10 directed facility ' s staff as follows; " Only the Director of Pharmacy or designee shall handle the receipt of C 11 drugs.
The person handling the receipt of C 11 drugs shall verify the quantities received and enter the quantities on a Perpetual Controlled Drug Inventory Record. The number of items received and the actual date of receipt shall be entered on the pharmacy copy of the DEA Form-222.
The DEA Form -222 shall be attached to the original invoice (and purchase order if any):
Facility ' s current Policy on Controlled Drugs Inventory (perpetual), issued 05/10 directed staff as follows: " A Perpetual Controlled Drug Inventory Record shall be used to aid in accounting for >11 (active, unstable stock as well as inactive, expired or otherwise unusable stock) C - 11 and C111 - CV drugs. A separate binder will be maintained for C-11 drugs and C111 - CV medications. "


On 03/16/2011 11:30 a.m. during tour of the facility's pharmacy, the surveyor requested from the chief pharmacist evidence that controlled drugs receipt and disposition were recorded,
The pharmacist informed the surveyor that her company had recently contracted to service the pharmacy and that she was unable to locate the facility's log documenting receipt and disposition of controlled drugs.
.

On 03/17/11 at 8:00 a.m. facility's director of clinical services provided copies of invoices and logs to the surveyor
On 03/17/11 during reconciliation of facility's C-2 controlled drugs, a DEA form 222 dated 11/17/2010 was observed on file. The surveyor and the chief pharmacist reviewed DEA form 222. DEA form 222 did not have the National Drug Code documented.
Review of form DEA 222 revealed documentation a packet of 10 carpuject Demerol 50 mg/ ml was received by the facility on 11/17/2010.

Review of the controlled drug log provided by the facility's CEO revealed no documentation indicating that the facility had received 10 carpuject Demerol 50 mg medication.

Observation on 03/17/11 at 9:10 a.m. of the facility's C- 2 stock of controlled drugs in the pharmacy revealed no evidence of Demerol 50 mg/ ml carpuject in stock.

Expired medication
On 03/16/2011 11:30 a.m. during tour of the facility's pharmacy The following medications were observed in stock in the cupboard which stored C-2 controlled substances:
Alprozolam 2 mg tablets Lot # P , 88 tablets expired on [DATE].

The surveyor immediately informed the chief pharmacist that controlled drug Alprozolam stored with other C- 2 medications were expired.

The chief pharmacist said she would inventory the Pixus drug dispensing system to ensure none of the expired medication was in the pixus.

Administration of Medication
Patient #6
Review on 03/16/2011 of patient # 6's clinical record ( physician's order and medication administration record) revealed a physician's order dated 12/16/2010 for Lovenox 40 mg subcutaneous daily.

Review of the patient's medication administration record revealed no documentation that Lovenox was administered on 12/17/2010.

On 03/16/2011 at 4:40 p.m. the surveyor reviewed the patient's clinical record with facility's director of nursing. She confirmed that the patient's record did not indicate that Lovenox was administered as prescribed by the physician.

Patient #44
Review on 03/17/2011 of patient # 44's clinical record ( Physician's order and medication administration record ) revealed the patient was admitted to the facility on [DATE] with diagnosis of paranoids Schizophrenia.

The clinical record revealed a physician's order dated 12/09/2010 for Buspirone 10 mg orally three times daily and and Trazadone 200 mg orally at bedtime.
Review of the patient's medication administration records revealed no documentation that Busperione was administered three times daily as prescribed by the physician on the following days:
The patient's medication administration records documented that Busperione was administered twice daily on 12/13/ 2010 , 12/18/2010 and 12 /19/2010 .

Further review of the the patient's clinical record ( medication administration record ) revealed Trazadone 200 mg was not documented as administered on 12/19/2010.

On 03/17/2011 at 2:40 p.m. the surveyor reviewed the patient's clinical record ( physician's order and medication administration records) with the director of nursing. She confirmed that there was no documentation that the patient was administered his medication as prescribed by the physician.

Cross reference A 494
VIOLATION: PHARMACY DRUG RECORDS Tag No: A0494
Based on observation, interview and record review, facility failed to ensure its pharmaceutical service operationalized its policy and procedure to track schedule 2 control medications during receipt and disposition of control medications.

Findings:

Review on 03/16/2011 of the facility ' s current policy and procedure on Controlled Drug Distribution and Accountability (issued 05/2010) directed staff as follows: " The facility has overall responsibility for controlled drugs. Records for controlled drugs shall be filed so they are readily retrievable and receipts and distribution can be established. C-11 records shall be separate from records of C- 111 through C-V and non controlled drugs. These records shall be retained for a period of five (5) years. "

The facility ' s current policy and procedure issued 05/10 directed facility's staff as follows; " Only the Director of Pharmacy or designee shall handle the receipt of C 11 drugs.
The person handling the receipt of C 11 drugs shall verify the quantities received and enter the quantities on a Perpetual Controlled Drug Inventory Record. The number of items received and the actual date of receipt shall be entered on the pharmacy copy of the DEA Form-222.
The DEA Form -222 shall be attached to the original invoice (and purchase order if any):
Facility ' s current Policy on Controlled Drugs Inventory (perpetual), issued 05/10 directed staff as follows: " A Perpetual Controlled Drug Inventory Record shall be used to aid in accounting for >11 (active, unstable stock as well as inactive, expired or otherwise unusable stock) C - 11 and C111 - CV drugs. A separate binder will be maintained for C-11 drugs and C111 - CV medications. "


On 03/16/2011 11:30 a.m. during tour of the facility's pharmacy, the surveyor requested from the chief pharmacist evidence that controlled drugs receipt and disposition were recorded,
The chief pharmacist informed the surveyor that her company had recently contracted to service the pharmacy and that she was unable to locate the facility's log documenting receipt and disposition of controlled drugs.
The pharmacist said she had requested the log from the out going pharmacist and was told by him that it was in the pharmacy.

On 03/16/2011 at 11:45 a.m. during an interview with facility's chief executive officer, the surveyor informed the CEO that there was no system in place in the pharmacy to track the receipt and disposition of controlled drugs. The CEO informed the surveyor that he would contact the contracted pharmacist to determine where the log could be found.

On 03/17/11 at 8:00 a.m. facility's director of clinical services provided copies of invoices and logs to the surveyor
On 03/17/11 during reconciliation of facility's C-2 controlled drugs, a DEA form 222 dated 11/17/2010 was observed on file.The surveyor and the chief pharmacist reviewed DEA form 222. DEA form 222 did not have the National Drug Code documented.
Review of form DEA 222 revealed documentation that a packet of 10 carpuject Demerol 50 mg/ ml was received by the facility on 11/17/2010.

Review of the controlled drug log provided by the facility's CEO revealed no documentation indicating that the facility had received 10 carpuject Demerol 50 mg medication.

Observation on 03/17/11 at 9:10 a.m. of the facility's C- 2 stock of controlled drugs in the pharmacy revealed no evidence of Demerol 50 mg/ ml carpuject in stock.

During interview with facility's chief pharmacist on 03/17 at 9:00 a.m., the chief pharmacist said she had no Demerol carpuject in stock in the pharmacy and she had no record of where the drug was dispensed.
She said she was not aware that this was delivered to the pharmacy since the log was not made available to her when she assumed the role of chief pharmacist

Further observation on 03/17/11 at 9:15 a.m. of the facility's a medication dispensing system ( pixus) revealed 2 Demerol 50/ mg carpuject ( national drug code # 0409 - 1178 -30 ) in stock in the Pixus system located in the Emergency center. A reconciliation of the facility's two other Pixus system revealed no evidence of Demerol 50 mgs/ ml carpuject.

During interview with facility s chief pharmacist on 03/17/11 at 9:30 a.m., the surveyor asked the pharmacist if it was possible to reconcile medication dispensed from the pixus in order to track who received Demerol 50 mg/ ml carpuject.
The pharmacist said the Pixus system was only capable of reconciling up to 31 days and so she was unable to determine where or whom the medication was dispensed to

During an interview on 03/17/2011 at 4:45 a.m. in the conference room the the director of clinical services said staff was reviewing patients' records to determine which patients had received Demerol 50 mg/ ml Carpuject injection.
VIOLATION: INFECTION CONTROL LOG Tag No: A0750
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to maintain a log of infections identified in the facility in seven of twelve sampled patients. Citing patients #1, #3, #4, #7, #8, #9, and #45.

Findings

Patient #8
Review on 03/16/ 20 10 of patient # 8's clinical record ( demographic data) revealed the patient was admitted to the facility on [DATE] with diagnosis of right lower lobe pneumonia .
The patient's clinical record ( physician's order ) indicated that the patient was treated with antibiotics of Levaquin 500 mg intravenous piggy back every 24 hours and Rocephin 1 gm intravenous every 24 hours.
The patients clinical record ( physician's order ) revealed an order dated 12/29/2010 for Zithromax 500 mg orally daily.

Subsequent review on 03/17/2011 of the patient's record revealed a physician's order dated 12/29/2010 for " AFB stain CS X3 "

Review of the patient's clinical record revealed no evidence that the specimen for AFB stain CS X three was collected and sent to the laboratory for analysis.


Review of a nurse's notes dated 12/29/2010 revealed the following entry " Informed for the need for sputum specimen. Respiratory notified of the need to induce sputum. Respiratory in to give nebulizer treatment and attempted to induce sputum - unsuccessful will continue to encourage."

Further review of the patient's clinical record revealed a respiratory therapist progress notes dated 12/29/2010 which indicated the following " Attempted sputum collection Pt unable."

Review of the patient's clinical record revealed no evidence that any other attempts were made to collect sputum specimen X 3 or that the physician was notified that the sputum specimen were not collected.

On 03/17/ 2011 the surveyor reviewed the patient's record with the director of clinical services and requested the laboratory result for the sputum culture and sensitivity X3. None was provided.

Further review of the facility's infection control log provided by the infection control director revealed no documentation indicating an order for culture and sensitivity of the patient's sputum and the result.







The facility's Infection Control Log (IC Log) submitted for review had no infections listed from January 2010 through December 2010. No infections had been documented on the IC Log for the year 2011 through to date of survey.

Facility's policy entitled: "Infection Control Plan" (issued 05/10) stated in part on Page 3:
"B. The Infection Control Coordinator and the Chief Nursing Officer shall be responsible and accountable for the active hospital-wide infection control program including, but not limited to: ..........."g. Review of reported patient infections, as appropriate, for determination as to whether an infection is nosocomial and the potential for preventive measures or interventions to minimize the risk of any further occurrence".

On page 4, the same policy stated in part at #10, the following:
"........The infection Control Program shall function under immediate direction of Administration, Nursing Service, and on at least a consultative basis, the following: .........."e: Pharmacy".

Patients with infections were not identified and listed on the Infection Control Log.

Patients with infections had not been analyzed as required by policy under "Infection Control Plan"

Pharmacy had not provided consult/input to the Infection Control Coordinator when antibiotics were ordered so that infections would be identified and listed on an IC log and an analyses performed on these infections.

The following patients with infections were not listed on the IC Log. Pharmacy failed to communicate to the Infection Control Coordinator when antibiotics were ordered on these patients:

Patient #1:
admitting diagnosis was UTI (urinary tract infection). Urine culture was negative. Patient was treated with Levaquin 500 Intravenously (IV) beginning on 8/26/2010, patient was started on Rocephin IV on 8/28/2010.

Patient #3:
Patient's sputum sent for culture on 8/29/2010 had many gram positive cocci in pairs and long chains, indicative of possible strep infection.

Patient #4:
Patient was diagnosed with UTI and dehydration. Urine cultured gram negative e-coli on 12/5/10. Patient was started on Bactrim. The culture and sensitivity revealed the e-coli was resistant to this antibiotic. Patient then started on Microbid on 12/7/2010.

Patient #7:
Patient was hospitalized from [DATE] through 12/22/2010. Patient was placed on Amoxicillin for "pharyngitis" on 12/18/2010.

Patient #8:
(see surveyor findings above)

Patient #9:
admitted s were 12/30/2010 through 1/10/2011. Urine microscopic/urine culture on 1/2/2011 showed 80,000 colonies/ml of mixed gram positive flora. Patient was started on IV Levaquin on admission. She was placed on oral Levaquin on 1/2/2011.

Patient #45:
admitted from 2/15/11 through 2/25/11. When patient was admitted he had a fever of 101.7. On 2/17/2011, physician ordered "Z-Pack" (zitromycin) "as directed".

Interviews with the Director of Nurses and the Infection Control Coordinator on the afternoon of 3/17/2011 confirmed above patient's infections had not been reviewed/analyzed and should have been listed on the IC Log. It was confirmed also that pharmacy had failed to inform the Infection Control Coordinator when antibiotics were ordered.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on review of the Quality Improvement Program Plan, review of Quality Improvement(QI) meeting minutes , review of the emergency room (ER) log, review of hospital transfer policy and review of Hospital Performance Data Base, the hospital failed to ensure all aspects of the
of the QI plan were monitored.
Findings:

1. Review of the QI plan reflected discharges against medical advice(AMA) will be monitored. Review of the ER log for time period 8/8/2010 to 2/18/2011 reflected 10 AMA discharges from the ER. However, review of QI meeting minutes for the same time period had no evidence AMA's were monitored.

Patient ER #:: 25, 26, 53, 81,283 ,306, 315, 360, 142, and # 58

2. Review of Hospital Transfer Policy at (G)(1) Quality Review Section, reflected medical staff shall review all transfers from the hospital to determine appropriateness of the transfer.
Review of Hospital Performance/ Database Performance Measures ,reflected one of the performance measures at (#7) reflected all emergency medical and psychiatric transfers will be monitored.
Review of the ER log for time period 11/21.2010 - 3/10/2010 reflected 21 transfers from the ER
However, review of Quality Improvement Committee meeting minutes for the same time period had no evidence patient transfers were monitored.

Patient ER #: 363, 386, 391, 408, 397, 411, 584, 697, 190, 1031, 648, 20, 1083, 1087, 584, 1101, 316, 1158, 1164, 1177, and #1200.

Lack of monitoring AMA's and all transfers was verified by personnel #34 at 2:20pm on 3/17/2011
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on review of the Quality Improvement Program Plan, review of Quality Improvement(QI) meeting minutes , review of the emergency room (ER) log, review of hospital transfer policy and review of Hospital Performance Data Base, the hospital failed to ensure all aspects of the
of the QI plan were monitored.
Findings:

1. Review of the QI plan reflected discharges against medical advice(AMA) will be monitored. Review of the ER log for time period 8/8/2010 to 2/18/2011 reflected 10 AMA discharges from the ER. However, review of QI meeting minutes for the same time period had no evidence AMA's were monitored.

Patient ER #:: 25, 26, 53, 81,283 ,306, 315, 360, 142, and # 58

2. Review of Hospital Transfer Policy at (G)(1) Quality Review Section, reflected medical staff shall review all transfers from the hospital to determine appropriateness of the transfer.
Review of Hospital Performance/ Database Performance Measures ,reflected one of the performance measures at (#7) reflected all emergency medical and psychiatric transfers will be monitored.
Review of the ER log for time period 11/21.2010 - 3/10/2010 reflected 21 transfers from the ER
However, review of Quality Improvement Committee meeting minutes for the same time period had no evidence patient transfers were monitored.

Patient ER #: 363, 386, 391, 408, 397, 411, 584, 697, 190, 1031, 648, 20, 1083, 1087, 584, 1101, 316, 1158, 1164, 1177, and #1200.

Lack of monitoring AMA's and all transfers was verified by personnel #34 at 2:20pm on 3/17/2011