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 June 23, 2011
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and review of 1 of 1 clinical record the patient there was a failure to protect the patient's right to make informed decisions by not providing education on medications administered.
Findings:

Review of the clinical record reflected the patient was admitted to the facility on [DATE]. On 5/17/11 Geodon 20mg IM PRN for agitation was ordered. The patient was given IM Geodon as follows:
5/17/11 2355
5/18/11 1415
5/19/11 1000
5/21/11 1530
5/23/11 0145
5/30/11 1200
5/31/00 0911
6/6/11 0130

The record had no evidence of patient education on Geodon.
This was verified by the director of nursing at 10:20am on 6/23/11.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, review of hospital policy and review of 1 of 1 clinical record the director of nursing failed to direct and monitor nursing by failing to ensure occurrence reports were filed for the administration of emergency medications, restraint, patient aggression, patient falls and failure to provide the patient with education on medications.
Findings:

1. Review of hospital policy titled: Occurrence Reporting
3.0 "An occurrence report should be filed for any of the following occurrence."

2.6 " An occurrence involving hostile action by a patient."

2.14 " Patient/visitor falls."

2.18 "Use of chemical restraint, drug, medication when used to manage patient's behavior."

2. Review of the patient's clinical record reflected the use the use of chemical restraints.:

On the following dates/times Haldol/Ativan/Benadryl IM "Now" was administered as an emergency medication:
5/19/11 11:00pm
5/20/11 8:00pm
5/22/11 1:32am
5/22/11 10:00am
No occurrence report was filed.

Geodon IM was administered for as a PRN for aggression as follows:
5/17/11 2355
5/18/11 1415
5/19/11 1000
5/21/11 1530
5/23/11 0145
5/30/11 1200
5/31/11 0941
6/6/11 0130
No occurrence report was filed.

3. The clinical record reflected the patient fell on [DATE]
5/29/11 0100 " fell off toilet lying on floor screaming."
No occurrence report was filed.

The lack of filing occurrence reports for the above was verified by the director of nursing at 10:10am on
6/23/11.

4. Cross Refer to A0131