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 6, 2013|
|VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT||Tag No: A0145|
|Based on interview and record review, the facility failed to provide training on abuse and neglect to 1 of 4 Mental Health Technicians (MHT/ Staff ID # 5) during orientation per the facility policy.
TX # 098
Record review on 03-06-13 of the personnel and training files of MHT # 5 revealed a form titled " New Employee Site-Wide Orientation, " dated 10-16-12. The form was a checklist with 12 topics listed and initials of the trainer to the side of each topic. The space for initials next to " Abuse, Neglect, and Exploitation " was left blank.
Interview and record review on 03-06-13 at 12: 45 p.m. with Human Resources (HR) Director / Staff ID # 13, she was unable to locate evidence that MHT # 5 had received training on Abuse & Neglect during his initial orientation on 10-16-12. She went on to say Abuse & neglect training was required upon hire and annually thereafter.
There was documentation provided later that MHT # 5 had attended an Abuse & Neglect In-Service on 12-27-12, two (2) months after he began work.
Record review of facility policy tilted " Abuse, Neglect Exploitation Definitions, " revised date 12/12, read: " Training: All staff will undergo training on Abuse Neglect and Exploitation policies at their initial orientation and annually thereafter ... "
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to ensure a Registered Nurse(RN) supervised and evaluated the care for one (1) of 7 sampled patients with documented elopement incidents (Patient ID # 11). The facility failed to ensure:
1. Patient ID # 11 was placed on "elopement precautions" in a timely manner based upon the admission nursing assessment.
2. Nursing followed chain-of-command policy regarding physician notification of patient change of condition.
3. An effective staffing process to help prevent patient elopement on the 2nd floor.
These three (3) deficient nursing practices contributed to Patient # 11's elopement from the facility and subsequent physical altercation with two (2) Mental Health Technicians (MHT). Following the elopement and after Patient # 11 was returned to his room, a security guard witnessed MHT (Staff ID # 4) holding the patient in a "choke hold."
TX # # 098
Patient # 11:
Record review on 03-05-13 of Patient # 11's clinical record revealed he was a [AGE] year old male admitted to the facility on on [DATE] for Psychosis and aggressive behavior. Patient # 11 had a history of Bipolar Disorder and polysubstance abuse. It was documented that he had "thrown a brick threw his parents' window;" he was admitted the facility under an Emergency Detention Order.
Record review on 03-05-13 of facility investigation of abuse allegations voiced by Patient # 11 revealed he had eloped from the facility on 02-08-13 at approximately 5:32 a.m.
Review of facility incident report dated 02-08-13 completed by the RN charge nurse (Staff ID # 11) revealed the following (synopsis of report):
Patient # 11 eloped from the unit through the back door, east of the men's unit, as staff was admitting a new patient. The new patient was exhibiting psychotic and manic behavior, and refusing to be searched. Prior to elopement, Patient # 11 was anxious, pacing, paranoid and delusional with increased agitation, demanding to be discharged immediately. He had been refusing all his scheduled and "as needed" medication. Nursing made several attempts through verbal and non-medical interventions to calm and de-escalate the patient's situation, but he continued to exhibit agitation and aggression. When Patient # 11 eloped, supervisor was immediately notified, as well as the police department, Director of Nurses and Administrator on call. The patient was found and picked up in a vehicle by the security officer and charge nurse as he was walking on a road near the facility and "looking for a ride downtown." He was returned to the facility at 5:55 a.m.; he exhibited no resistance.
1. Timely placement on Elopement Precautions issue:
Record review of Patient # 11's " Comprehensive Assessment Tool," completed on 02-06-13 (at 2115 hours) by an RN upon admission of Patient # 11 identified him as an "Elopement Risk " and "Potential for AWOL." In addition, the following components were checked as " yes" on the assessment: 1. "patient states desire to be out of facility " and 2. "special behavior management considerations."
Record review of the physician orders for Patient # 11 failed to reveal an order for "elopement precautions ' until after the patient had eloped. The physician order was dated 02-08-13 and written at 6:00 a.m.: "OK to place patient on EP (elopement precautions)."
Interview on 03-06-13 at 12:00 p.m. with the Chief Nursing Officer (CNO/ Staff ID # 2) she acknowledged Elopement Precautions for Patient # 11 should have been ordered upon admission on 02-06-13 when he was assessed by an RN as being at risk for elopement. She went on to say when a patient was placed on Elopement Precautions, the staff keep a" much closer watch "on the patient and the patients were "unit restricted. "
2. Notification of Physician / Chain of Command issue:
Record review on 03-05-13 of Patient # 11' s Nursing Notes documented by RN # 12,
dated 02-08-13, excerpts read as follows:
02-08-13:(time 0050): " pt is very combative, paranoid, and disorganized...refused his med and continues to pace in hallway ...
02-08-13: (time 0200): " pt out of room, agitated and delusional ...continued to refuse his medication ...placed call to Dr ( ) , no answer, left message ...
02-08-13:(time 0230): " pt is getting more irritable, agitated, and delusional ...paged Doctor ( ) for emergency med, no answer left message ... "
02-08-13: (time 0330): " pt pacing in hallway ...yelling ...
02-08-13 (0517): pt is agitated and getting aggressive. Place call to Doctor
( ), no answer, left message is getting more irritable, agitated, and delusional ...paged Doctor ( ) for emergency med, no answer left message.
02-08-13 (0532): " pt kicked the back doors and eloped ... "
02-08-13 (0555): " ...pt was found by staff and brought to unit ...placed call to doctor ( ) for emergency meds ...no answer ... "
Review of physician orders for Patient # 11 revealed an order for " Emergency Administration of Psychotropic Medications"(Haldol, Ativan and Benadryl) dated 02-08-13 (time 10:30 a.m.). RN documented " MD ordered meds during rounds." This order was written 8 hours after the initial attempt by nursing to obtain an order for emergency psychotropic medication for Patient # 11.
Interview on 03-05-13 at 3:15 p.m. with the CNO (Staff ID #2) she stated she had been at the facility in her position for a month. She went onto to say that prior to this incident; the process for physician notification and follow up needed improvement. She stated the policy was that if a physician did not return a call or page in a timely manner regarding a patient condition; the supervisor should be notified who in turn would notify the unit medical director if necessary.
The CNO (Staff ID # 2) acknowledged that had Patient # 11 been medicated with an emergency psychotropic he may not have eloped. The CNO(ID # 2) further stated the nursing supervisor was on the unit prior to the elopement of Patient # 11 and failed to follow chain of command notification. The nursing supervisor should have contacted the medical director for an emergency medication order.
Review of facility policy titled"Change in Patient Condition-Chain of Command Notification," revised 04/12, read: " 2. In the event there continues to be concern about the patient's condition, follow further nursing and medical stave chain-of-command. The nursing supervisor (in house) and administrator (on call) will determine the need to initiate the following steps: Notification of the Medical Director of the unit ...the Chief of Service ...the Chief of Staff ...The nurse assigned to the patient or supervising the care of the patient is responsible for notification and communication to the medical staff regarding significant changes or significant deterioration in the patient's condition and for assuring that there is physician response."
3. Staffing issue:
Interview on 03-05-13 at 3:15 p.m. with the CNO (Staff ID # 2) she stated that Patient # 11 eloped through the magnetically secured double doors on the men's unit , into the back hallway's fire escape door , down the stairs and out of the building. He was able to break through the secured magnetic doors because they were designed to give way with a certain amount of sudden, high pressure.
The CNO (ID # 2) went on to say the hallway in the men's unit was very long and it would be impossible for one tech to make it to one end of the hallway from the other even if a patient was witnessed breaking though the magnetic doors. The CNO (ID # 2) further stated after Patient # 11' s elopement, nursing staffing pattern was reviewed. The facility now had a tech stationed at each end of the hallway 24 hours a day. The CNO acknowledged this was implemented after Patient # 11's elopement.
Observation on 03-05-13 at 3:30 p.m. on the 2nd floor mens' unit revealed a long hallway with 2 sets of magnetic doors. A tech was observed at each end of the hallway at the time of observation.
|VIOLATION: MEDICAL RECORD SERVICES||Tag No: A0450|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to ensure that medical records were legible and complete for 4 (four) of 21 sampled patients (Patient ID #s 3, 9, 11, 12).
Patient ID # 9: an illegible abbreviation (physician order) led to incorrect monitoring precautions.
Patient ID#s 3, 9, 11, 12: incomplete / inaccurate documentation of " levels of monitoring " per physician orders.
These deficient practices contributed to these patients being placed on incorrect levels of monitoring and observation, placing them at increased risk for harming themselves or others, or elopement.
TX # 098
Patient # 9
Record review on 03-05-13 of Patient # 9 ' s clinical record revealed he was [AGE] years old and admitted to the facility on on [DATE] for Psychosis and Suicidal Ideation. Review of the " Comprehensive Assessment Tool, " dated 02-18-13 read " hearing voices telling him to get a knife and kill himself. " Further review revealed documentation: " patient had suicidal and homicidal ideation with the potential to harm himself...recent history of attempts ... discussed plan. "
Record review of the physician orders for Patient # 9 revealed the following:
2-18-13 (admission orders) read: precautions: " every 15 minute checks, suicide precautions. "
02-19-13 physician order (handwritten by a nurse) for physician signature for renewal of patient monitoring levels. There was a handwritten " Q (every) 15 " and a handwritten, illegible letters that appeared to be " SR " with the line of the " R " written over a pre-printed line in the page. There was no order for suicide precautions on 02-19-13.
02-21-13 physician order (handwritten by a nurse) for physician signature for renewal of patient monitoring levels. There was a handwritten " Q (every) 15 " and a handwritten " SZ " (seizure).
This same order for monitoring levels of " every 15 minute " checks and " SZ (seizure) " precautions were written on 2-23-13; 02-25-13; 2-27-13; 2-28-13;
3-01-13; and 03-03-13.
There were no orders for suicide precautions written after the initial admission order written on 02-18-13.
Interview on 03-06-13 at 12:00 p.m. with the Chief Nursing Officer(CNO/ Staff ID # 2) she acknowledged the handwritten order on 02-19-1 was not legible but it appeared to be an " SR " possibly meaning " suicide risk. " She went on to say the proper abbreviation for suicide precautions was " SI " and not " SR. " The CNO reviewed all of the physician orders for Patient # 9 and said it looked as if the nurse on 02-21-13 interpreted the SR as " SZ " and she and all the nurses thereafter began writing SZ, which meant " seizure precautions. " The CNO acknowledged that the " SR " was not an acceptable or legible abbreviation. She went on to say the nurses should have clarified the order with the physician rather than assuming it meant " seizure precautions. " The CNO stated this was a patient safety issue and said Patient # 9 should have been placed on suicide precautions.
Review of facility policy titled " Charting, " dated 05/10 read: " ...Documentation Guidelines: A. All entries in the medical record must be legible ...D. Symbols and abbreviations shall be used only if the Medical Executive Committee has approved them... "
Patient ID ' s 3, 9, 11, 12
Interview on 03-06-13 at 12:00 p.m. with the CNO(Staff ID # 2) she stated the level of patient monitoring was to be documented every shift for every patient on the " Rounds Monitoring Form." The CNO acknowledged she had identified a problem in this area and they were working on this.
Review of the medical records of 21 sampled patients revealed the following issues related to documentation of the level of patient monitoring:
Patient ID # 3
Patient ID # 3 was [AGE] years old admitted on [DATE] with Schizoaffective Disorder. He was discharged from the facility on 03-05-13.
Physician order, dated 02-25-13 for the following monitoring precautions read: " Q (every) 15 minutes; UR (unit restriction), suicide, assault, elopement. " This order was in effect until 03-01-13 when the physician orders all monitoring precautions discontinued except the Q 15 minute checks.
Record review of the " Rounds Monitoring Form " for Patient # 3 for February & March 2013 failed to reveal any documented precautions for the following dates:
Day Shift: Feb. 26 and March 1, 3, and 5
Night Shift: [DATE] and March 1, 2, 3, 4
Patient ID # 9
Patient ID # 9 ' was [AGE] years old and admitted to the facility on on [DATE] for Psychosis and Suicidal Ideation. He was discharged from the facility on 03-05-13.
Physician order 2-18-13 (admission orders) read: precautions: " every 15 minute checks, suicide precautions. " This order was r recopied illegibly on 02-19-13 and changed to seizure precautions (in error).
Record review of the " Rounds Monitoring Form " for Patient # 9 for February & March 2013 failed to reveal any documented precautions for the following dates:
Day Shift: Feb. 19, 21, 26, 28 and March 3
Night Shift: [DATE], 28 and March 2, 3
Patient ID # 11
Patient ID # 11 was a [AGE] year old male admitted to the facility on on [DATE] for Psychosis and aggressive behavior.
Physician order, dated 02-06-13 for the following monitoring precautions read: " Q (every) 15 minutes; suicide, assault. " An additional physician order for elopement precautions was written on 02-08-13.
Record review of the " Rounds Monitoring Form " for Patient # 11 for February 2013 failed to reveal any documented precautions for the following dates:
Day Shift: Feb. 8, 10,11,12,13
Night Shift: [DATE],13, 14
Patient ID # 12
Patient ID # 12 was a [AGE] year old male admitted to the facility on on [DATE] for Schizoaffective Disorder.
Physician order, dated 02-17-13 for the following monitoring precautions read: " Q (every) 15 minutes; unit restriction, suicide, assault, and elopement. " These precaution levels were in effect until 02-21-13, when all were discontinued except the " every 15 minute checks. "
Record review of the " Rounds Monitoring Form " for Patient # 12 for February 2013 failed to reveal any documented precautions for the following dates:
Day Shift: Feb. 17,18,19,21
Night Shift: [DATE]