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 Oct. 31, 2012
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure that 7 of 12 sampled discharged patient records (ID # 15, # 16, # 18, #19, #20, #21, and # 23) contained a Discharge Summary per facility policy.

Findings include:

On 10-31-12 record review of 12 sampled discharged patient records revealed the following 7 records lacked a physician ' s Discharge Summary:

Patient ID # 15 was admitted to the facility on on [DATE] with a diagnosis of Schizoaffective Disorder. He was discharged from the facility on 09-10-12

Patient ID # 16 was admitted to the facility on on [DATE] with a diagnosis of Depression and ETOH (ethanol abuse). She was discharged from the facility on 09-11-12

Patient ID # 18 was admitted to the facility on on [DATE] with a diagnosis of Self Inflicted Wound; Schizoaffective Disorder. She was discharged from the facility on 09-06-12.

Patient ID # 19 was admitted to the facility on on [DATE] with a diagnosis of Schizophrenia. He was discharged from the facility on 09-15-12

Patient ID # 20 was admitted to the facility on on [DATE] with a diagnosis of Suicidal ideation. He was discharged from the facility on 09-05-12

Patient ID # 21 was admitted to the facility on on [DATE] with a diagnosis of Suicide Attempt. She was discharged from the facility on 09-26-12

Patient ID # 23 was admitted to the facility on on [DATE] with a diagnosis of Psychotic Disorder. She was discharged from the facility on 09-21-12.

Interview on 10-31-12 at 11:30 a.m. with Medical Records Director ID # 27, she reported the Discharge Summary should be completed 3 weeks of discharge.

Review of facility policy titled " Discharge Summary, " revised 04/1, read: Discharge Summaries will be completed within the timeframe set forth in the Medical staff Rules ... "

Review of facility Medical Staff Rules & Regulations, revised October 2010 read: " F. Discharge Summary: A Discharge Summary shall be entered into the record of all patients hospitalized over 48 hours within twenty-one(21) days after discharge ... "
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to fully investigate one (1) allegation of verbal abuse of Patient ID # 22 and one (1) allegation of physical abuse of Patient ID # 23:

1. Patient ID # 22 documented allegations of verbal abuse by Mental Health Technician (MHT) # 20 on 09-22-12.

2. Patient # 23 documented allegations of physical abuse by MHT # 15 on 09-22-12
( reported by Patient # 21)

Findings include:

Intake ID # TX 984

Review of Intake # TX 984 revealed facility " self-reported " the following to Adult Protective Services (APS). APS forwarded the complaint to the Texas Department of State health Services (TDSHS) for investigation. The intake read: : ' two patients at the facility filed two complaints on a tech named ( ) or ( ) that allegedly hit a patient ( name unknown) and was abusive to another patient ( name unknown) ...Two patients stated this tech was verbally abusive to other patients and used foul language and was disrespectful to patients in psych hospital ...Acting Director of Nurses has knowledge of incident and names of individuals involved, including a housekeeper who allegedly witnessed the incident. ...Incident occurred on 09-22-12; reported to patient Advocate on 09-24-12 ... "

Interview on 10-31-12 at 8:35 a.m. with facility Patient Advocate ID # 24 she had no responsibility for investigation of abuse, neglect, exploitation; this was done by the Director of Nurses (DON) or the Risk Manager. She went on to say she documented complaints on the Patient /Employee Complaint Form, copied the form, and gave the original to the facility Risk Manager (ID # 25). If the issue involved allegations of Abuse, Neglect, Exploitation, she also reported it to APS.

Interview on 10-31-12 at 2:10 p.m. with the facility Risk Manager ID # 25 he stated the facility Patient Advocate (# 24) conducted all facility investigations including those involving Abuse, Neglect, and Exploitation. He stated the investigation would include: talking with the patient, removing alleged perpetrator form unit; reviewing (or completing) an occurrence report; patient/staff/ witness interviews and statements, assessment of patient, informing family and physician.

Patient # 22

Record review on 10-30-12 of Patient # 22 ' s admission information revealed she was [AGE] years old and involuntarily admitted to the facility on on [DATE] with diagnosis of Suicidal Ideation and history of Bipolar Disorder and Depression. Patient ID # 22 was discharged from the facility on 09-25-12.

On 10-30-12 , record review of facility " Patient/Employee Complaint Form, " dated 09-22-12 completed by Patient # 22 revealed allegations of verbal abuse : " tech ( first name only) refuses to help me ....screaming and yelling at me and very hateful to me ... " The form was signed by Patient Advocate ID # 24 on 09-24-12 at 10: 00 a.m., on the line provided for " date resolved. "

Review of an additional " Patient/Employee Complaint Form, " dated 09-22-12 completed by a second patient (Patient ID # 21), corroborated Patient # 22 ' s complaint. This complaint read: " ...tech (first name only) has been yelling and refusing to get people clothes and snacks....talked rude and disrespectful ... " this form also documented " patient afraid of retaliation by techs. " The form was signed by Patient Advocate ID # 24 on 09-24-12 at 9:50 a.m., on the line provided for " date resolved. "

Neither the facility Patient Advocate ( ID # 24) or Risk Manager ( ID #25 ) was able to provide any documentation of an investigation that included assessment of patient, witness statements, interviews with patients and staff, occurrence reports, follow-up actions. Further review of Patient # 22 ' s clinical records failed to reveal any documentation related to patient ' s allegation of verbal abuse.

When requested, facility provided the personnel file of Mental Health Technician (MHT) ID # 21, stating this was the only tech with the nickname described in the two (2) complaints. After several staff interviews, surveyors determined facility had incorrectly identified the tech involved; the actual Tech named in the complaints was MHT # 20. This was confirmed and acknowledged by Acting DON, ID # 4.

On 10-31-12, record review of facility grievance forms revealed an additional complaint had been documented against MHT # 20 on 10-26-12. The complaint was regarding MHT # 21 not allowing patient to talk and failing to help patient obtain pain medication in a timely manner.

Patient # 23

Record review on 10-30-12 of Patient # 23 ' s admission information revealed she was [AGE] years old and involuntarily admitted to the facility on on [DATE] with diagnosis of Psychotic Disorder and history of Schizophrenia and Developmental Disorder. Patient # 23 was discharged from the facility on 09-21-12.

On 10-30-12, record review of facility " Patient/Employee Complaint Form, " dated 09-22-12 completed by Patient # 21 regarding allegations of physical abuse of a patient other than herself. The form read: "...I saw a tech (ID # 15) hit Patient (first name) for hiding a juice. The patient was crying ... " Additional information provided was the patient reported " a cleaning lady saw the incident and the patient ' s name was (first name only) ... " The form was signed by Patient Advocate ID # 24 on 09-24-12 on the line provided for " date resolved. "

Neither the faiclity Patient Advocate ( ID # 24) or Risk Manager ( ID #25 ) was able to provide any documentation of an investigation that included witness statements, interviews with patients and staff, occurrence reports, or follow-up actions.

On 10-30-12, interview at 11:45 a.m. with Patient Advocate ( ID # 24) she stated she was unable to identify the full name of the patient involved or confirm the facility had assessed her or spoken with the patient. She went on to say she heard the tech involved was terminated.

Interview on 10-31-12 at 2:10 p.m. with facility Risk Manager (ID # 25) he was unable to identify the full name of the patient involved or confirm the facility had assessed her or made attempts to contact her post-discharge.

On 10-31-12, surveyors determined the full name of the patient (Patient ID # 23 ) from review of the facility daily census on 09-22-12 and supplied the name to the facility. Patient # 23 had been discharged the day before the allegation was documented.

Review of the personnel file of MHT # 15 ' s personnel file revealed she had been terminated on 09-26-12 by the DON. There was a statement in the file by MHT # 15, dated 09-24-12. The statement did not include denial of hitting Patient #23.

Surveyor was unable to interview the DON, as she was out of the country on vacation. The Acting DON ( ID # 4) had no knowledge of either allegation of abuse involving Patient # 22 or Patient # 23.

Review of the facility " Master Occurrence Report Log " for 2012 failed to reveal that occurrence reports were written for the allegation of verbal abuse of Patient # 22 and allegation of physical abuse of Patient # 23, both reported on 09-22-12.

Review of facility policy titled " Abuse, Neglect and Exploitation Prevention-Adult and Children dated 05-2010, read: " ....8 ...c If an occurrence of unsafe behavior occurs the Charge Nurse will immediately implement a plan of action which includes ...Placing patient in private place ....d. the Nursing staff will complete an Occurrence Report for each patient involved in the occurrence within two (2) hours ..the nursing staff will: complete notification requirements ( administration, physician, and family) within 2 hours ...the nursing staff will document the corrective action plan on the Occurrence Report and in the medical record,,,the Risk manager will investigate and report findings to the Administrator and Corporate Compliance for further action as needed ... "

*Note: facility was previously cited on 12-01-11 for a Condition Level deficiency: Condition of Participation: Patient Rights CFR 483.12 .The deficiencies cited were related to patient abuse and neglect prevention and investigation.