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HOPEBRIDGE HOSPITAL 5556 GASMER DRIVE HOUSTON, TX Nov. 5, 2015
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure that Patient #7 ' s medications were distributed in a timely manner. This failure resulted in Patient #7 receiving her first dose of 2 of 3 medications a day late.

Findings included:

Record review of the Emergency Medical Treatment and Labor Act (EMTALA) Log in the Admissions Department revealed that Patient #7 arrived to the hospital on [DATE] at 1015 and was taken to the unit at 1520.

Record review of Psychiatric Admission Orders by MD #66 on 08/03/15 at 1300 revealed admission orders that included medications. The orders were signed off by RN #67 on 08/03/15 at 2000, 4 hours and 40 minutes after arrival to the unit.

Record review of Patient #7 ' s Medication Administration Record dated 08/03/15 revealed:
Gabapentin was given at 2100 as prescribed by RN #67,
Simvastatin was not given at 2100 by RN #67 as prescribed, and
Tizanidine was not given by RN #67 as prescribed.

In an interview with Pharmacist #69 on 11/05/15 at 1225, she stated her office hours are 0830 - 1700, Monday - Friday. She also stated there was a medication locker available to the RN Supervisor after hours. Simvastatin and Tizanidine would not have been in the medication locker. She stated she would have provided the medication for the patient had the RN taken off the orders prior to 1700.

Record review of Policy & Procedure, Medication Administration, dated 05/2010, revealed scheduled medication administration times of 0900, 1300, 1700 and 2100. " Orders are to be initiated by the next scheduled time for administration unless specified with a different start time or date ... Complete medication orders will be faxed to the Pharmacy ... The attending physician must be contacted any time a medication is withheld or not given as prescribed unless the medication is held based on specified parameters within the order ... A medication occurrence report is completed for omitted / missed dose ... "

In an interview with CNO/CCO #52 and Pharmacist #69 on 11/05/15 at 1225, they stated a medication occurrence report had not been completed for the 2100 doses of Simvastatin and Tizanidine scheduled for 08/03/15 at 2100. They could not find any evidence that the physician had been notified of the occurrence.
VIOLATION: REPORTING ADVERSE EVENTS Tag No: A0508
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure that the attending physician was notified when 2 of 3 medications were not administered due to availability.
Findings included:

Record review of the Emergency Medical Treatment and Labor Act (EMTALA) Log in the Admissions Department revealed that Patient #7 arrived to the hospital on [DATE] at 1015 and was taken to the unit at 1520.

Record review of Psychiatric Admission Orders by MD #66 on 08/03/15 at 1300 revealed admission orders that included medications. The orders were signed off by RN #67 on 08/03/15 at 2000, 4 hours and 40 minutes after arrival to the unit.

Record review of Patient #7 ' s Medication Administration Record dated 08/03/15 revealed:
Gabapentin was given at 2100 as prescribed by RN #67,
Simvastatin was not given at 2100 by RN #67 as prescribed, and
Tizanidine was not given by RN #67 as prescribed.

In an interview with Pharmacist #69 on 11/05/15 at 1225, she stated her office hours are 0830 - 1700, Monday - Friday. She also stated there was a medication locker available to the RN Supervisor after hours. Simvastatin and Tizanidine would not have been in the medication locker. She stated she would have provided the medication for the patient had the RN taken off the orders prior to 1700.

Record review of Policy & Procedure, Medication Administration, dated 05/2010, revealed scheduled medication administration times of 0900, 1300, 1700 and 2100. " Orders are to be initiated by the next scheduled time for administration unless specified with a different start time or date ... Complete medication orders will be faxed to the Pharmacy ... The attending physician must be contacted any time a medication is withheld or not given as prescribed unless the medication is held based on specified parameters within the order ... A medication occurrence report is completed for omitted / missed dose ... "

In an interview with CNO/CCO #52 and Pharmacist #69 on 11/05/15 at 1225, they stated a medication occurrence report had not been completed for the 2100 doses of Simvastatin and Tizanidine scheduled for 08/03/15 at 2100. Pharmacist #69 stated she did not have a fax line in the pharmacy and orders could not be faxed to her.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on interview and record review, the facility failed to ensure that staff assisted 1 of 1 patients as soon as possible to create a written request (4-hour letter) for discharge from services.

Findings included:

Record review of Adult Consents and Admission Agreement dated 08/03/15 [not timed] revealed a signature by Patient #7 and a witness signature by Admission Coordinator #72. Patient #7 singed a request to be admitted as a voluntary patient into the hospital.

Record review of Wrap-Up Group note by Patient #7 on 08/06/15 at 0900 revealed: " I need my family. Please let me go home. " RN #74 signed the form.

In an interview with Utilization Manager (UM) #73 on 11/05/15 at 1045, she stated she received a phone call from Patient 7 ' s husband on 08/06/15 around 0930. He said his wife had been asking for the 4-hour letter paperwork all night. RN #74 told UM #73 the patient had not asked for the 4-hour letter. UM #73 then asked for a 4-hour letter. RN #74 stated she was too busy and would do it later. UM #73 asked again for a 4-hour letter. RN #74 stated the patient was an involuntary patient. UM #73 did not find a warrant in the chart. She phoned Court Liaison #75. The Court Liason stated the patient was a voluntary patient. UM #73 also stated that the unit was " chaotic " and that there was a lot of people in the nurse ' s station. UM #73 did not provide the patient with a 4-hour letter at that time.

Record review of Individual Therapy Progress Note by LMSW #76 on 08/06/15 at 1230 revealed that Patient #7 was upset and wanted information about " how to get discharged . " LMSW #76 explained to her the process of signing a 4-hour letter.

Record review of a Written Statement by RN #74 darted 08/06/15 [not timed] revealed that Patient #7 " came to the nursing station demanding " a 4-hour letter. RN #74 told Patient #7 she would get the 4-hour letter after she finished with an emergency on the unit involving a suicidal patient. Patient #7 said, " OK. " RN #74 gave the 4-hour letter to the patient to sign and phoned MD #66, who requested Patient #7 be held for 24 hours until he could do a face to face evaluation.

In an interview with CCO/CNO #52 on 11/04/15 at 1350, she stated that RN #74 was attending to a patient with a seizure episode and suicide attempt during the time that Patient #7 wanted to sign the 4-hour letter. CCO/CNO #52 added, " You can ' t put this off. "

In an interview with CCO/CNO 52 on 11/05/15 at 1120, she stated that either LMSW #76 (therapist) or UM #73 should have assisted Patient #7 with the 4-hour letter. She also stated, " Training needs to be done. Staff didn ' t assist the patient. "

Record review of Request for Release from Voluntary Admission FOUR HOUR LETTER revealed:
Patient #7 signed the request on 08/06/15 at 1312.
RN #74 notified MD #66 of the request on 08/06/15 at 1315.
On 08/06/15 at 1315 MD #66 ordered that the patient be held for 24 hours so that a physician in-person examination could be completed.

Record review of the Patient ' s Bill of Rights (part of the hospital ' s Adult Patient Handbook) [no initiation or revision date] revealed: " Voluntary Patients - Special Rights
1. You have the right to request discharge from the hospital. If you want to leave, you need to say so in writing or tell a staff person. If you tell a staff person you want to leave, the staff person must write it down for you.
2. You have the right to be discharged from the hospital within four hours of requesting discharge ... If your doctor thinks you may meet the criteria for court-ordered services or emergency detention, he or she must examine you in person within 24 hours of your filing the discharge request. "

Record review of Policy & Procedure, Patient Right to Request Voluntary Discharge, dated 07/21/15, revealed: " Immediately upon receiving a request for release, a nurse on the patient ' s unit shall contact the patient ' s physician. Under no circumstances, shall the physician be contacted later than four (4) hours from the time of the request for release ... Initiation of a request for release shall be documented on the nursing progress notes and 24 Hour Patient Data Sheet. "
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation and interview, the facility failed to ensure that potentially hazardous chemicals and objects were secured behind locked doors on 1 of 4 units.

Findings:

Observation of the Adult Female Unit on 11/05/15 at 0920 revealed that the housekeeping storage room, which opened into a patient hallway, was unlocked. The housekeepers were not visible in the hallway. There were mops and brooms and bottles of cleaning supplies on the shelves of the storage room. The lock on the door had both a keypad and a key lock. RN Supervisor #70 had Housekeeper #78 lock the door.
In an interview with RN Supervisor #70 on 11/05/15 at 0920, he stated the door is supposed to be locked and is supposed to be checked each morning as part of the environmental rounds.
In an interview with Mental Health Technician (MHT) #54 on 11/05/15 at 0922, she stated, " Housekeeping has the key to lock it. They are the only ones with a key. "
In an interview with Housekeeper #78 on 11/05/15 at 0923, she stated, " Staff won ' t lock it back. I lock it and come back and it ' s unlocked. "