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.

WEST OAKS HOSPITAL 6500 HORNWOOD HOUSTON, TX April 27, 2012
VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure timely referral of concerns for 1 of 10 sampled patients (ID # 2). The facility failed to address Patient ID # 2 ' s concerns in a timely manner according to the established facility process.

Findings include:

TX # 651

Review of Patent ID# 2 ' s clinical record revealed she was [AGE] years old and admitted to the facility on on [DATE]. Her medical history included the following: depression, anxiety, and alcohol abuse Review of a History & Physical Exam, dated 02-07-12, revealed Patient ID # 2 was 6 weeks pregnant.

Further review of Patient ID # 2 ' s record revealed she was discharged on [DATE] Against Medical Advice (AMA). Review if the facility " AMA Discharge " form ( completed by Patient ID # 2), dated 02-10-12 read: " ...see attached Patient Advocacy Report detailing AMA discharge reasons. "

Review of the Patient Advocacy Report, dated 02-09-12 revealed a detailed account of several concerns documented by Patient ID # 2; mainly issues concerning her physician. Patient ID # 2 wrote: " ... I have contacted the Patient Advocate twice by phone while here, and have never received an acknowledgement for my calls at all... "

Interview on 04-25-12 at 2:30 p.m. the facility Patient Advocate (ID # 53) she stated she was familiar with Patient ID # 2. The Patient Advocate stated Patient # 2 was very dissatisfied with her physician and felt she was being kept in the hospital too long. She went on to say Patient ID # 2 was discharged AMA and was very unhappy the doctor did not give her certain prescription refills.

Patient Advocate (ID # 53) went on to say that Patient ID # 2 left her a couple of voice mails on a Friday (2-10-12) but was not able to speak with her before she was discharged . She went on to say that Patient ID # 2 completed the facility ' s " Patient Advocacy Report Form, " which was used to document grievance/concerns. Staff filed the form in Patient ID # 2 ' smedical record instead of routing it to the Patient Advocate, per the facility policy.

Patient Advocate (ID # 53) said Patient ID #2 also filed a complaint with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Review of the JCAHO Complaint, dated 02-20-12 documented by Patient ID # 2 detailed concerns regarding the patient ' s physician, medications, and length of stay. Portions of the complaint read: " ...In fact, the Patient Advocate NEVER (capitalization by Patient ID # 2) returned any the three (3) calls I made to them, both while inpatient and after my release ... "

Review of the facility response to the JCAHO, dated 03-30-2012 read: " ...Voice message from the patient was on Patient Advocate ' s voice mail the day before (Friday). Patient discharged before speaking with advocate. The patient used the patient advocate form to document her reasons for leaving AMA and so the form was not placed in the advocate box but placed in the medical record where it was found when the chart was reviewed for the complaint. A letter of follow-up will be sent to the patient regarding the results of the complaint review ... " The response to the JCAHO complaint was documented by the Paitent Advocate ( ID # 53).

On 04-25-12, surveyor requested a copy of the facility follow-up letter sent to Patient ID # 2. Facility failed to present the letter prior to surveyor exit on 04-27-12.

Review of facility policy titled " Complaint / Grievance Procedure, revised 10/2011, read: " Patients are given information on complaint ...process on admission ...Patient can write your complaint ... and an advocate or appropriate supervisor will contact the patient to discuss the complaint ... "

Review of facility Patient Handbook, distributed to patients upon admission, read: " ...Grievance Procedures: 1. Try to resolve the matter informally ....a hospital representative will meet with you to investigate the grievance and inform you of resolution within 7 days ...If you are not satisfied with the resolution, you may appeal it with the Patient Advocate ... "
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to administer drugs to 2 of 10 sampled patients (Patient ID #s # 1 and # 6) according to accepted standards of practice:

Patient ID # 1 and Patient ID # 6 were both administered medications to which they had documented allergies.

Findings include:

Intake TX # 863

Review of the clinical record of Patient ID revealed he was [AGE] years old and involuntarily admitted to the facility on on [DATE] with a diagnosis of Paranoid Schizophrenia. Patient # 1 was admitted for " increased agitation and delusions. "

Review of the facility " Nurse to Nurse Transfer Form, " dated 02-10-12 for Patient ID # 2: read: Allergies: Haldol & Cogentn. "

Review of the Medication Administration Records (MAR) for Patient # 1 dated 02-11-12, 02-12-12l and 02-13-12 listed " Allergies: Haldol & Cogentin. "

Review of physician order, dated 02-14-12, timed 1015, read " Ativan 2 milligram (mg ) Intramuscular (IM) ; Haldol 5 mg IM; Benadryl 50 mg IM Now. "

Review of physician order, dated 02-14-12, timed 1130, read " Discontinue (D/C) Haldol / Cogentin Allergy. . "

Review of the form " Emergency Administration of Psychotropic Medication, dated 02-14-12, revealed Patient # 1 as administered Haldol 5 mg IM at 1030, prior to the allergy being discontinued.

Interview on 04-27-12 at 11:30 a.m. with the facility Performance Improvement (PI) Director ( Staff ID # 53) she stated the Haldol should not have been given to Patient ID # 1, as he had a documented allergy. She went on to say it was likely the allergy was discontinued (by physician order) after the medication as given.






Review of physician order for Patient ID # 6 , dated 3/21/12 on 4/26/12 revealed order the following medications:
Tegretol-for seizure/Trileptal-mood/Klonopin-anxiety. Documentation under the section for " allergies " revealed: Geodon, Haldol, Thorazine, and Mellaril.
Physician order dated 3/22/12 reviewed on 4/26/12 revealed order for Haldol 5 milligrams (mg) by mouth twice a day. Physician order dated 3/26/12 reviewed on 4/26/12 revealed order for Haldol 10mg-time 2020pm. At 2138pm on 3/26/12, Haldol was increased to 10mg by mouth twice a day.
Review of medication administration record (MAR) for Patient ID # 6 dated 3/22/12 reviewed on 4/26/12 revealed patient received Haldol 5mg by mouth given at 2100pm. MAR dated 3/23/12 to 3/26/12 revealed Patient ID # 6 received Haldol 10mg by mouth at 09am and 2100pm respectively. Patient # 6 received the morning dose 10 mg of Haldol on 3/27/12 before he was discharged . There was documentation of Patient ID # 6 being allergic to Haldol on all the MARS.
Interview with Staff # 53 on 4/27/12 at 11:30am in the conference room revealed " it is usually given in combination of Benadryl and Ativan " and that nursing staff may not have passed the information to the physician and the pharmacist.

Review of the facility policy titled " Medication Administration, review date 5/09, read " Process of medication order ...D. An RN will review the order for completeness, appropriate dosing, any potential allergy or drug reaction..."
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on observation, interview, and record review, the facility infection control officer failed to effectively implement policies to control infections and communicable disease on 4 of 5
(Units 1, 2, 3, and 5) adult care units:

1. Community restrooms (2) and shower stalls (4) on Unit 5 contained large amounts of black " mold-looking " substances, dirty grout, and brown stains on the floor of the shower and up the sides. In addition each of the 4 shower stalls had styrofoam cups of liquid soap. There was a large amount of rust on a bench, one each located in each shower room.

2. Three (3) direct care staff (ID #s 66, # 67, # 68) were allowed to work without a TB skin test, as required by facility policy.

3. Clean laundry was transported uncovered from one unit to another (Unit 1 to Unit 2); Staff ID # 64 failed to perform hand hygiene after handling soiled linen and then clean linen.

4. Paper bags were utilized as trash receptacles in two (2) community restrooms on Unit 5; in the pantry of Unit 5, and in patient room # 303.

5. Cardboard boxes of supplies were stored directly on the floor on Unit 5; an opened bag of adult briefs was located on the floor in a supply room.

Findings include:

TX # 279

1.

Observation on 04-25-12 at 2:00 p.m. during initial tour of the facility revealed two (2) community restrooms (one labeled " Women, " the other " Men " ) located in Unit 5.

Further observation revealed each of the 2 community restrooms contained 2 tiled-shower stalls. Each of the 4 shower stalls (2 in the women ' s; 2 in the men ' s restrooms) had black " mold-like " substances; dirty grout; and brown stains on the floor of the shower stalls and up the sides. In addition, each of the 4 shower stalls had Styrofoam cups of liquid soap.

Continued observation revealed each of the 2 community restrooms had a wooden bench with metal legs located outside the shower stalls. Each of the two (2) benches had a large amount of rust on the metal legs.

Interview at the time of observation with the Director of Nurses (DON/ Staff ID # 51) she stated the restroom and shower conditions on Unit 5 were not acceptable and would be corrected immediately. She went on to say that each patient is issued a cup of liquid soap for their own use for showers. The cup of soap should be discarded and not left in the shower.

Interview on 04-26-12 at 9:30 a.m. with the Maintenance/Housekeeping Supervisor (ID # 57) he stated the restrooms and showers were " deep cleaned " every month but the facility would increase the frequency based upon the condition of the Unit 5 common restrooms. He went on to say the facility had ordered and just received a new steamer machine.

Record review of the facility form titled " Housekeeping Unit 5 & 6 Assignments(Daily Cleaning Outline ) " undated , read: " ... 8:00 am: " clean community restrooms-restrooms will be free of odor, mildew, stains, calcium deposits, trash, used soap, etc ...3:00 p.m. " clean community restrooms-restrooms will be free of odor, mildew, stains, calcium deposits, trash, used soap, etc ... "

Record review of facility policy titled " Housekeeping Related To Infection Control, " dated 01/2012, read: " ...Nursing shall notify the Housekeeping Department immediately to disinfect and thoroughly clean soiled and /or contaminated areas. "

Review of the facility patient roster dated 04-25-12 revealed the census for Unit 5 was 14 patients.

2.

Review of facility personnel files revealed 3 of 10 employee files reviewed did not have evidence of a TB test prior to beginning work. Review of the files revealed the following:

Staff # 66 (Mental Health Tech /MHT): date of hire was 01-23-12. It was documented in his employment " Medical History Questionnaire " that Staff # 67 had a TB skin test (PPD-Purified Protein Derivative) done on 11-04-11. There was no copy of this TB Test -results unknown and not verified.

Staff # 67: MHT: date of hire was 02-06-12. No evidence of TB skin test done.

Staff # 68 MHT: date of hire was 03-19-12. It was documented in her employment " Medical History Questionnaire " that Staff # 68 had a TB skin test done on 03-14-12. There was no copy of this TB Test -results unknown and not verified.

Interview on 04-25-12 at 2:30 p.m. with the Infection Control Nurse (Staff # 55) he stated all employees are required to have a TB test prior to hire and annually.

Review of facility policy titled " Employment and Annual Medical Assessment, dated May 2007, read: " ...It is the policy of Texas West Oaks Hospital that all employees are required to have a medical assessment prior to beginning work and annually there after ...The employment medical review will, at a minimum, consist of: a. health questionnaire b. TB test ... "

3.

Observation on 04-25-12 at 2:10 p.m. during initial tour of the facility revealed Housekeeping Staff (ID # 64) removing clean laundry from the clean laundry closet located on Unit 1; she placed the linen on a cart. Staff ID # 64 retrieved dirty laundry from the floor and placed into a yellow bin in the soiled utility room.

Further observation revealed Staff # 64 failed to perform hand hygiene after touching the soiled laundry bin and prior to re-handling the clean laundry on the cart. Further observation revealed Staff # 64 walking toward the exit door of Unit 2 with the uncovered cart containing linen. Interview at this same time with Staff # 64 she reported she was " taking the linen to Unit 2. " She went on to say she knew the linen should be covered but she forgot.

Interview at this same time with the DON, she stated Staff # 64 should have washed her hands after touching the soiled linen barrel and the linen should have been covered prior to transport.

Record review of facility policy titled " Housekeeping Related To Infection Control, " dated 01/2012, read: " ...Clean linen shall remain covered while being transported to the different hospital units ... "

Review of the facility patient roster dated 04-25-12 revealed the census for Unit 1 was 17 patients; Unit 2 was 20 patients.

4.

Observation on 04-25-12 at 2:00 p.m. during initial tour of the facility revealed two (2) community restrooms (one labeled " Women, " the other " Men " ) located in Unit 5. Observation inside each restroom revealed paper bags stored directly on the floor; each was approximately 2/3 full of trash.

During this same observation time, Patient ID # 8 was seen entering and exiting the female restroom twice. Staff Nurse (ID # 59) stated " she has diarrhea; we are checking for C.Diff. " (C.Diff is Clostridium Difficle; a highly contagious bacterium affecting the colon causing diarrhea). Surveyor confirmed Patient ID # 8 was transferred to another unit later that day and placed on contact isolation precautions.

Observation on 04-25-12 at 2:05 p.m. revealed a paper bag containing trash located directly on the floor in the " Pantry " on Unit 5.

Observation on 04-25-12 at 2:15 p.m. revealed a paper bag located directly on the floor in room 303 (in Unit 3) which was 2/3 full of trash.

5.

Observation on 04-25-12 between 2:00 p.m. and 3:00 p.m. during initial tour of the facility revealed the following:

" Pantry " on Unit 5: one (1) 40 count cardboard box of Styrofoam cups stored directly on the floor.

Supply " hallway " -Unit 5: one (1) 40 count cardboard box of Styrofoam cups stored directly on the floor.