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 July 30, 2015
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview and record review the facility failed to:

Ensure the patient's right to a safe, hazard-free environment on 5 of 5 patient units;

Provide a safe setting for a patient by inappropriate room assignment; and

Fully investigate an elopement incident involving two adolescent girls.

Wide spread safety issues were identified that placed all patients at risk for possible serious harm and death.

(Refer to Tag A-144 for details.)
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the facility failed to:
Ensure the patient's right to a safe, hazard-free environment on 5 of 5 patient units;
Provide a safe setting for a patient by inappropriate room assignment; and
Fully investigate an elopement incident involving two adolescent girls.

Wide spread safety issues were identified, including, but not limited to, non-ligature resistant hardware in patient bathrooms and easily accessible plastic trash bags, cleaning supplies, pencils and hygiene products.

Findings included:

Children's Unit:

Observation on 07/29/15 from 1100 to 1300 revealed the following:
4 of 4 patient rooms had non-ligature resistant hardware in the bathrooms.
Plastic trash bags were in the patient care areas and Nurses Station.
Doors to 4 of 4 patient rooms could not be secured to keep patients out of empty, unauthorized rooms.
Environmental rounds were not done on a daily basis.
Room 308, an activities room, was unlocked and open thus providing the patients access to electrical cords, a plastic table cover, live electrical outlets and metal containers.
Room 307, a therapist's office, did not have a lock on the door that would prevent patient access to electrical cords, computer cords, live electrical outlets and electronics.

Adolescent Boy's Unit:

Observation on 07/29/15 from 1100 to 1300 revealed the following:
5 of 5 patient rooms had non-ligature resistant hardware in the bathrooms.
Plastic trash bags were in the patient care areas and Nurses Station.
Doors to 5 of 5 patient rooms could not be secured to keep patients out of empty, unauthorized rooms.
Environmental rounds had not done on a daily basis.
2 pencils were found in room 315, a patient's bedroom.
7 of 7 round sheets that document the whereabouts and activities of the patients were 30-60 minutes behind schedule.

Adolescent Girl's Unit:

Observation on 07/29/15 from 1100 to 1300 revealed the following:
7 of 7 patient rooms had non-ligature resistant hardware in the bathrooms.
Plastic trash bags were in the patient care areas, Nurses Station and room 325 (the quiet room).
Doors to 7 of 7 patient rooms could not be secured to keep patients out of empty, unauthorized rooms.
Environmental rounds had not been done on a daily basis.

Adult Male Unit:

Observation on 07/29/15 from 1100 to 1300 revealed the following:
15 of 15 patient rooms had non-ligature resistant hardware in the bathrooms.
Plastic trash bags were in the patient care areas and Nurses Station.
Doors to 15 of 15 patient rooms could not be secured to keep patients out of empty, unauthorized rooms.
Environmental rounds had not been done on a daily basis.
7 of 15 patient rooms had hygiene products either in the bedroom or bathroom.
The light in the bathroom of room 223 was not working.
The lid to the toilet in room 227 (the quiet room / seclusion area) lifted off.
The door to the Environmental Services room was unlocked thus providing the patients access to cleaning chemicals, equipment and supplies.
Room 216 had a hospital bed in it that was not ligature resistant.
Room 218 had no shower curtain.

Adult Female Unit:

Observation on 07/29/15 from 1100 to 1300 revealed the following:
10 of 10 patient rooms had non-ligature resistant hardware in the bathrooms.
Plastic trash bags were in the patient care areas and Nurses Station.
Doors to 10 of 10 patient rooms could not be secured to keep patients out of empty, unauthorized rooms.
Environmental rounds had not been done on a daily basis.
9 of 10 patient rooms had hygiene products either in the bedroom or bathroom.
Room 210 had a hospital bed in it that was not ligature resistant.
Room 205 had metal handles attached to the base of the bed that were not ligature resistant.
Room 209 had no shower curtain.


Non-ligature resistant hardware in the patient bathrooms:

In an interview with Mental Health Technician (MHT) #67 on 07/29/15 at 1035, she stated the door hinges and sink faucets were not ligature resistant. She also stated, "Staff is going to restructure the bathrooms" to reduce the ligature risk.

In an interview with Registered Nurse (RN) Supervisor #68 on 07/29/15 at 1115, he stated that the "door hinges in the bathrooms are a ligature risk." He stated he has spoken to Chief Nursing Officer (CNO) #53 about this.

In an interview with CEO #52 on 07/29/15 at 0845, he stated that a risk assessment of the environment had been done. He identified the sink faucets and bathroom doors as being non-ligature resistant.

Record review of the Quality/Risk Facility assessment dated [DATE] revealed the following safety risks: "Door hinges, faucets, bathroom, ... cords, wires, containers (such as games - metal domino boxes) live electrical outlets, fire station apparatus, sheets/linen, unsecured doors (monitoring) and safe discharge measures."


Pencils, hygiene products and hospital beds in bedrooms:

In an interview with Risk Manager #51 on 07/29/15 at 1130, she stated the patients are not allowed to have pencils or hygiene products in their rooms. She stated the hospital beds should not be on the units.


Patient #7:

Observation of the assignment board in the Nurses Station of the Adolescent Unit on 07/28/15 at 1000, revealed Patient #7 was on Sexually Acting-Out Precautions (SAO). She shared a bedroom with Patient #8.

Record review of Pre-Admission Exam and Certification, dated 07/22/15 at 1818, revealed: Patient #7 "angry because staff won't let her be around a certain female peer without supervision from RTC staff. Patient had an attraction toward a female peer and speaks inappropriately to her. The other patient doesn't want her advances. Became suicidal."

Record review of Initial Psychiatric Evaluation by Medical Doctor (MD) #70, dated 07/23/15 at 1600, revealed: Patient #7 "Bisexual. Wants relationship with female peer."

Record review of Physician's Orders by MD #70, dated 07/23/15 at 1600, revealed Patient #7 was placed on Sexually Acting-Out precaution. The precautions had been continued on a daily basis as of 07/28/15 at 1010.

In an interview with RN #60 on 07/28/15 at 1010, he stated that Patient #7 was admitted from a residential treatment center (RTC) because the patient was trying to have sex with another female patient. RN #60 believed Patient #7 needed to be in a private room but was not put in a private room because "a memo" went out that said we couldn't block rooms.

Record review of the memo dated 04/16/15 from CNO #53 revealed: "[E]ffective immediately no beds will be blocked automatically due to special precautions such as SAO or a patient's sexual orientation. Each patient is considered on an individual basis and treatment planning and intervention based on their current behaviors. All blocked beds must be approved thru and in conjunction with the treatment team and approved by the CNO and physician based on current real time behavior."

In an interview with Risk Manager #51 on 07/28/15 at 1010, she stated, "We usually block the other bed if a patient has a history of sexual aggression toward another patient." She was not aware that Patient #7 was not in a blocked room. "I would put her in a blocked room."

In an interview with CNO #53 on 07/28/15 at 1600, she stated that not all patients placed on SAO are in blocked rooms. "It's evaluated on an individual basis." She stated Patient #7 should have been in a blocked room.

Record review of the Quality / Risk Facility assessment dated [DATE] revealed: "Education programming needs ... Prevention of Sexual Aggression / Sexual Victimization ... Proper room assignments ... Effective prescription of precautions ... Effective monitoring of patients."

Record review of "Levels of Observation" policy, dated May 2010, revealed: "Sexual Acting-Out Precautions ... Patient should be assessed for the need for a private room (blocked bed)."

Record review of "Sexual Acting Out (SAO)" policy, dated May 2010, revealed: "The below interventions will be considered but not limited to ... Move to a private room (if patient cannot be moved to a private room, obtain order for 1:1 SAO intervention)."


Incomplete investigation by Risk Manager #51 for elopement of Patients #1 and #2:

Record review of Nursing Assessment Note by RN #57, dated 05/26/15 at 1115, revealed the patient missing. Patient #1 "eloped from the stair exit that was disarmed by the storm."

Record review of Nursing Assessment Note by RN #62, dated 05/26/15 at 1030 revealed that Patient #2 and her roommate could not be found on the unit. "Apparently the girls went down the back stairwell ... all the doors were unlocked due to the power outage."

In an interview with Risk Manager #51 on 07/28/15 at 0930, she stated that there had been a power outage. "The elevator was not working. The girls went through the double doors to Stairwell A and got out." She again stated, "The electricity went out the morning of the elopement."

In an interview with Risk Manager #51, Plant Operations Manager (POM) # 63, Chief Executive Officer (CEO) #52 and CNO # 53 on 07/28/15 at 1610, inconsistent information was provided. Both POM # 63 and CEO #52 told the Risk Manager #51 that the electricity did not go out. CEO # 52 explained that the port to the key pad for the double doors went out thus disarming only that door. They did not know how long the door had been disarmed. Pharmacist #64 discovered the disarmed lock. Risk Manager #51 then stated she had been flooded in at home on 05/26/15 (the day of the elopement) and had written her Root Cause Analysis (RCA) from inaccurate information. She could not produce the RCA.

In an interview with Risk Manager #51 on 07/28/15 at 1545, she stated she did "immediate training" to staff on the adolescent unit and reviewed the policy and procedures on elopement and precaution levels. She stated she could not provide training material or a list of staff that received the training.

In an interview with Risk Manager #51 on 07/29/15 at 1000, she produced an RCA dated 05/28/15 for Patients #1 and #2. She stated she conducted her RCA based on inaccurate information and should have conducted a more in-depth investigation.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on interview and record review the facility failed to ensure an ongoing program for Quality Assurance Performance Improvement (QAPI). Quality indicators were not being measured, analyzed and tracked.

Findings included:

In an interview with Risk Manager #51 on 07/30/15 at 1505, she stated she was hired in November 2014. She wanted monthly QAPI meetings. "At the beginning of the year" it was decided to do "quarterly meetings." She stated monthly meetings are "better." "It's hard to pull everything together monthly." She identified 2 quality indicators to measure, analyze and track: (1) Hand off from shift to shift by the Mental Health Technicians and (2) hand off of patients from Admissions to the unit. She had not aggregated any of the data this year, partly because she is helping in other areas of the hospital. Her goal over the next 2 months is to get to a place where QAPI is "functioning" and "leadership is working together."

In an interview with CEO # 52 on 07/30/15 on 1630, he stated he did not know that the QAPI meetings had been changed from monthly to quarterly. "I knew the Medical Executive meetings were changed to quarterly."

Record review of the Medical Executive Committee Meeting Minutes, dated 06/04/15 at 1130, revealed: "Action Plan - A monthly Performance Improvement meeting is scheduled with the Multidisciplinary Leadership Team to review outcomes and areas of needed improvement ... How Monitored ... - Attendance at each quarterly meeting with pertinent and specified reporting of quarterly data."

Record review of the Quality Manual (undated) revealed: "Top management, ... Hospital Senior Leadership Team, reviews the organization's quality management system, at planned monthly Quality Council meetings to ensure its continuing suitability, adequacy and effectiveness ... The following individuals attend Management Reviews: CEO, Chief Operating Officer, CNO, President of the Medical Staff (or designee), ICO, Management Representative, Director of Clinical Services, Director of Outpatient Services, Director of Intake/Admissions."
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, interview and record review the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Wide spread infection control issues were identified on 5 of 5 patient units, including rusty hardware in patient bathrooms, mold in a quiet room and dirty patient use equipment.

(Refer to Tag A-749 for details.)

Based on observation, interview and record review the facility failed to designate an Infection Control Officer who was qualified through experience and training to develop the Infection Control Department.

(Refer to Tag A-748 for details.)
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on observation, interview and record review the facility failed to designate an Infection Control Officer who was qualified through experience and training to develop the Infection Control Department.

Findings include:

Observation on 07/29/15 at 1230 of room 325, the Quiet Room on the Adult Male Unit revealed a 6-inch thick stained foam pad on the floor. Two soiled sheets were sitting on the pad.

In an interview with Infection Control Officer (ICO) #69 on 07/29/15 at 1400, she stated she was placed in the ICO position on 05/28/15. She stated she had "no hands on experience" in infection control and has had "no infection control education. I just use resources." She looked at the Infection Control entry in the Performance Improvement minutes for July 2015 and stated she couldn't comment on the information because she didn't recognize it. The only problem she noted with the foam pad in the quiet room was that it was on the floor.

In an interview with Risk Manager #51 on 07/30/15 at 1110, she stated that ICO #69 reported to her. Risk Manager #51 and Pharmacist #64 "provide oversight along with feedback from CNO #53." Risk Manager #51 stated that ICO #69 was oriented by the previous ICO and that no one with Infection Control certification has provided oversight to ICO #69. Risk Manager #51 mentioned to "administration" that consultation was needed in Infection Control. She stated ICO #69 came to the facility with infection control experience at her previous place of employment.

In an interview with Human Resources (HR) Director #71 on 07/30/15 at 1530, she stated that the job description for ICO #69 had not made it into the personnel file.

Record review of a letter from Personnel #71 to ICO #69, dated 05/12/15, revealed an offer for the position of Infection Control Nurse with a start date "no later than May 28, 2015." ICO #69 accepted the position on 05/12/15.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview and record review the facility failed to provide a sanitary environment on 5 of 5 patient units and failed to ensure that the Infection Control Officer maintained a sanitary hospital environment.

Wide spread infection control issues were identified, including, but not limited to, rusty hardware in patient bathrooms, mold in a quiet room and dirty equipment stored in the quiet room.

Findings included:

Children's Unit:

Observation on 07/29/15 from 1100 to 1300 revealed the following:
4 of 4 patient rooms had rusty bathroom fixtures and hardware.

Adolescent Boy's Unit:

Observation on 07/29/15 from 1100 to 1300 revealed the following:
5 of 5 patient rooms had rusty bathroom fixtures and hardware.

Adolescent Girl's Unit:

Observation on 07/29/15 from 1100 to 1300 revealed the following:
7 of 7 patient rooms had rusty bathroom fixtures and hardware.
Mold was noted on the ceiling of room 325, the quiet room.

Adult Male Unit:

Observation on 07/29/15 from 1100 to 1300 revealed the following:
15 of 15 patient rooms had rusty bathroom fixtures and hardware.
In room 217, an unoccupied room that had just been cleaned for a new patient, a pair of blue disposable pajamas had been left around the pipes of the toilet.
4 of 15 patient rooms had dirty laundry on the floor.

Adult Female Unit:

Observation on 07/29/15 from 1100 to 1300 revealed the following:
10 of 10 patient rooms had rusty bathroom fixtures and hardware.
2 of 10 patient rooms had dirty laundry on the floor. The items on the floor in room 213 were bloody.


Room 325:

In an interview with CNO #53 on 07/29/15 at 1115, she stated the ceiling in room 325, the quiet room, had mold on it.


Room 325, the Quiet Room on the Adult Male Unit:

Observation on 07/29/15 at 1230 of room 325 revealed a 6-inch thick stained foam pad on the floor. Two soiled sheets were sitting on the pad. A dirty shower chair and mop were stored in the room. A window was rusty. Mold was on the ceiling.

In an interview with ICO #69 on 07/29/15 at 1400, she stated her "main issues to tackle" have been "patients eating in rooms and handling of linens." She stated she does environmental checks "at least once a month." Environmental checks were done "last month on the adolescent and children's units. The only problem she noted with the foam pad in the quiet room was that it was on the floor. She stated there is no system in place for patients to store hygiene supplies.

In an interview with Risk Manager #51 on 07/30/15 at 1110, she stated she sees Infection Control issues in the hospital as being: (1) "Housekeeping is now at full staff" and "has the ability to do necessary cleaning," (2) "Brown water comes and goes," (3) "new equipment is needed," and (4) "handwashing by staff."

Record review of Infection Prevention Plan and Scope of Responsibilities 2015, dated March, 2015, revealed: "[I]nfection prevention goals: ... Ensure that all patients ... are provided with a clean and safe environment ... To meet patient expectations of safe environment."

Record review of Policy and Procedure, "Infection Control Overview for Environmental Services," dated 06/01/13, revealed: "All mattresses and pillows shall be covered with plasticized covers."

Record review of Policy and Procedure, "Environmental Services Infection Control Policy," dated August 2013, revealed: "All soiled mops and rags shall be placed in the soiled mop and rag containers located in Housekeeping Department at the end of each shift."