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||Dec. 1, 2011|
|VIOLATION: PATIENT RIGHTS||Tag No: A0115|
|Based upon record review and interview, the facility failed to ensure the safety of 3of 3(#2, #8, #6) adolescent patients while receiving care. 1. Patient #2 was allegedly physically abused by Staff # 57. 2. Patient #8 was allegedly physically abused by Staff #57 and reported by patient #7 who was a witness. 3. Patient # 6 was physically abused by Staff #57. The physical abuse of Patient # 6 was witnessed by a contracted electrical worker. The facility failed to have a process in place for investigating allegations of abuse. The facility also failed to thoroughly investigate allegations of abuse made by Patient #2 against Staff #57. As a result of the lack of investigation to allegations of abuse of patient #2, there were witnessed incidents of abuse of patient #6 and #8 by Staff #57.
REFER TO TAG A-144
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based upon record review and interview, the facility failed to ensure the safety of 3of 3(#2, #8, #6) adolescent patients while receiving care. 1. Patient #2 was allegedly physically abused by Staff # 57. 2. Patient #8 was allegedly physically abused by Staff #57 and reported by patient #7 who was a witness. 3. Patient # 6 was physically abused by Staff #57. The physical abuse of Patient # 6 was witnessed by a contracted electrical worker.
1. Review of medical record of patient # 2 revealed patient was a[AGE] year old male admitted on [DATE] from a residential treatment program with diagnoses of Mood Disorder, Psychosis, ADHD (Attention Deficit Disorder), and ODD (Oppositional Defiant Disorder). Patient was admitted due to reports of hearing voices telling him to harm others, impulsive, and angry after he assaulted a peer. History reported patient witnessed his father kill his mother.
Review of the complaint information called to the agency ' s hotline revealed, " Patient # 2
reported on 11/7/11, his first day at the facility, Staff # 57 banged patient ' s head on a table several times for no reason. Patient has a small bruise underneath his left eye. Patient reported he does not feel safe at the facility.
Review of the occurrence report dated 11/8/11 at 8:00 am revealed the following: " On the above date and time, staff asked patient if he would like breakfast. The patient cursed at the staff and attempted to assault staff. " The occurrence report did not indicate who the staff member was involved in the verbal exchange with the patient. The occurrence report did contain a notation that the Nursing Supervisor was notified.
An interview was conducted with Staff #60 (Nursing Supervisor) on 12/1/11 at 2:00 pm.
Staff #60 reported she went to the unit to investigate the occurrence on 12/8/11. Staff #60 reported she interviewed patient #2 and he reported to her that Staff # 57 (Mental Health Technician) came into patient ' s room and threatened patient #2 and patient #2 told staff that he couldn ' t do anything to him because he did nothing wrong. Patient #2 reported to Staff #60 that Staff #57 pushed him to the ground and he started to pound his head on the ground and put his knee to his back to hold him down. Staff #60 asked patient #2 to write a statement describing the incident.
Review of patient #2 ' s written statement dated 11/9/11 revealed the following: Staff #57 " came in my room and said, ' Do you want me to put my hands on you now or later. ' I told him no and he repeated it. I told him you can ' t put your hands on me unless I am doing wrong. He asked me to stand and I refused to stand up and he pushed me to the ground and he started to beat my head to the ground and putting his knee in my back. I am scared to be here because what happened could happen again and staff try to tell me I came in with this bump but I did not and they took pictures of me after the incident. They told me I already did this, but I beg to differ. It was not. "
Review of pictures of patient #2 dated 11/8/11 revealed patient had a darkened area and swelling noted to his left eye and temple area. Review of the documentation of physical/medical issues during the admission process, did not indicate that the discoloration or swelling was present on admission.
Review of written statements related to this occurrence report revealed the following:
Staff #68 reported patient #2 " was admitted on [DATE] at 8:00 pm. Upon admission, I noted swelling to the left lateral eye. His lips were swollen and sore. Some bruises noted to face and upper body. "
Staff #69 written statement - " On 11/8/11 at 6:45 am, upon entering the unit, I observed patient #2 in the hallway. My initial observation of the patient was his left eye was black and swollen. I also observed the patient ' s bottom lip was swollen and scabbed. As I was redirecting the patient to go into his room, I asked the patient how he got his injuries. The patient states that he bites his lip. The patient also stated that he had his eye injury previous to coming to the hospital. Throughout the shift patient was observed intentionally irritating his left eye by pressing on it. I personally redirected the patient numerous times about not touching his left eye. The patient also stated to me that he got into a physical altercation with a peer from his placement prior to coming to the hospital. The patient stated that his peer at his placement gave him his black eye. The patient also stated that he was restrained several times before coming to the hospital by his placement staff for aggressive behavior and attempts to leave. "
Review of the nurse ' s admission assessment for patient #2 revealed no documentation that there was any problem with the patient ' s eye on admission. The diagram of the body on the assessment form did not have any markings on or around the patient ' s left eye.
An interview was conducted with Staff #60 on 12/1/11 at 2:00 pm. Staff #60 reported that when patient #2 made the allegations of abuse against staff #57, Staff #60 reassigned staff #57 to work on the general adult psychiatric unit until the investigation was completed. Staff #60 reported that patient #2 continued to make the allegations throughout his hospitalization and his story was consistent and never changed.
Staff #60 further reported there was no policy regarding investigating patient allegations of abuse, neglect, or exploitation. Staff #60 reported patient #2 was discharged from the facility on 11/18/11 and Staff #57 was then allowed to return to work on the adolescent unit and there was never any determination if the allegations of abuse were substantiated.
2. Interviews were conducted on 12/1/11 with Staff #50 and Staff #55 at approximately 2:30 pm. Both Staff #50 and Staff #55 reported there was no policy regarding the investigation of patient allegations of abuse, neglect, and exploitation. Staffs #50 and #55 were asked to bring all Occurrence Reports alleging abuse to surveyor for review.
The occurrence documents provided by Staff #50 and Staff #55 were as follows: A form titled " Patient/Employee Complaint Form " dated 11/17/11 was completed by patient #7 regarding patient #8. " Patient #8 was in the day room doing nothing and a tech (Staff #57) chased him around pushing him a number of times and hit him in the jaw eight times. Please do something about it. " Another written statement dated 11/18/11 at 11:34 am from staff #66 revealed " I was escorting a patient out after discharge. He informed me that a tall, bald tech (Staff #57) punched patient #8 in the face and punched him eight more times. He stated that this took place in the activity room and that ' s how the television was broken. The patient also stated that another dark, older tech (Staff #67) was present. There was no documentation that this patient complaint and employees written statement was ever reported to Nursing Supervisor, Patient Advocate, or Risk Manager. There also was no evidence of any investigation of the alleged abuse of patient #8 by staff #57.
An interview was conducted with Staff #60 on 12/1/11 at 2:00pm. Staff #60 reported she was not informed of the incident between patient #8 and staff #57 which allegedly occurred on 11/17/11. Staff #60 reported she found out about that alleged incident after receiving the report of physical abuse of patient #6 by staff #57 and to her knowledge the incident involving patient #8 was never investigated. Staff #60 also reported that the alleged incident involving patient #8 occurred 2 hours after Staff #57 returned to work on the adolescent unit.
3. Review of occurrence report dated 11/21/11 at 10:50 am revealed the incident occurred in the hallway in the adolescent unit. Patient #6 reported he was grabbed by neck and held in a choke hold then thrown to the ground by Staff #57. Patient complained of soreness around the neck. Further review of the occurrence report revealed patient #6 was agitated and using profanity and refusing redirection. Staff #57 placed patient in a choke hold and held him down on the floor. Staff #57 was immediately asked to leave the adolescent unit.
Review of written statement by Patient #6 revealed the following: " I feel like I was being abused in this situation. Because he (staff #57) had asked if I ' m a prostitute and I said ' Hell no ' then he got in my face. I told him to ' get the fuck out of my face. ' That ' s when he started to put his arm around my neck and took me down to the ground and slammed my head against the floor. I said ' You going to hit me again? ' He had his knee in my back the whole time and everyone in that hallway can tell you I never laid a hand on him. "
Review of the written statement by contracted electrical worker (#64) revealed the following: " I seen Tech (Staff #57) tell patient #6 to get into room. That caught my eye. Staff #57 did not see me. I was in doorway across the hall from the room. Staff #57 told patient #6 he needs to respect him and patient asked why two times. Patient said ' I didn ' t say a fucking thing ' . Patient did not put a hand or finger on staff #57. Staff #57 grabbed patient #6, threw him against the wall to the right hard, then spun him around to left, threw him to the ground. Staff #57 climbed on top and shoved patient ' s head onto the floor 2-3 times then was on top with knees into patient ' s side and back, all the time the tech saying you are going to respect me and I am not your friend. He stayed on top of him for at least 5 minutes. He gets up and must have seen me. I was going to get his name off his name badge but his badge disappeared. It was there when he got up off of patient but then disappeared when he realized I saw the incident. I went and told nurses at nurse ' s station. No one was there to witness what I seen until the very end just before he got up and off of patient. The other techs were at each end of hall, so they did not see the patient being abused. "
A written statement by Staff #65 on 11/21/11 revealed, " Patient #6 came onto the hall while the other patients were exercising. Staff #57 asked the patient was he going to participate. The patient began cursing the staff and pushed pass the staff bumping the staff. Staff #57 took the patient to the floor. "
A written statement by Staff #57 (alleged perpetrator) revealed, " On 11/21/11, in the hallway while all the patients were working out in the hallway, staff asked patient if he was going to participate. He replied by cursing saying ' Hell no, get the fuck out of my face and shut the fuck up ' then pushed by me in an aggressive manner bumping me. I then used the proper technique to keep the patient and myself safe, gave him verbal directives, then he stood up and was fine. Patient #6 then apologized and his behavior on the unit was fine. "
An interview was conducted on 12/1/11 at 2:00 pm with Staff #60. Staff #60 reported she instructed staff #57 to leave the unit immediately and proceeded to interview patient and witnesses. Staff #60 reported that 11/21/11 was the last day staff #57 worked at the facility.
An interview was conducted with Staff #54, Vice President of the Corporation and functioning in the capacity of Risk Manager, and Staff #55, Patient Advocate, on 12/1/11 at 2:30 pm. When survey findings were discussed with staff, they both acknowledged the discussion was the first of their hearing about these occurrences. Staff #54 reported there was no formal process for conducting investigations for abuse, neglect, and exploitation. He further reported they have a process for reporting abuse and neglect of patients when the abuse has occurred outside of the facility but there was nothing in place for abuse within the facility.
Review of Staff #57 personnel records revealed a form titled " Personnel Action Form " . The form contained the following information: Involuntary Separation due to Violation of Company Policy. Last Day Worked - 11/21/11. Not eligible for rehire. Review of section titled Miscellaneous Comments revealed " Patient Abuse-Confirmed.
|VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT||Tag No: A0145|
|Based upon record review and interview, the facility failed to have a process in place for investigating allegations of abuse. The facility also failed to thoroughly investigate allegations of abuse made by Patient #2 against Staff #57. As a result of the lack of investigation to allegations of abuse of patient #2, there were witnessed incidents of abuse of patient #6 and #8 by Staff #57.
REFER TO TAG - A-144