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 Oct. 24, 2014
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record review and interview, the facility's Governing Body failed to effectively monitor patient grievances to ensure they were fully investigated for appropriate outcomes and to monitor allegations of abuse in order to protect patients from perpetrators and to notify the state agency for 10 of 13 patients (#'s 4, 12, 13, 14, 15, 17, 18, 19, 23, and 24) reviewed for grievances and allegations of abuse.

-The Governing Body failed to ensure six grievances were investigated. (Refer to A119)

-The Governing Body failed to ensure four allegations of Abuse were investigated and reported to the state agency. The Governing Body failed to protect patients from alleged perpetrators of abuse. (Refer to A145)

These failed practices had the potential for wide spread harm to the facility's patients for abuse, neglect, and not having grievances addressed.

Refer to:

42 CFR 482.13(a)(2)
42 CFR 482.13(c)(3)
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview, the facility failed to protect and promote each patient's rights to have grievances and allegations of abuse investigated for 10 of 13 patients (#'s 4, 12, 13, 14, 15, 17, 18, 19, 23, and 24.

-The facility failed to ensure six grievances were investigated. (Refer to A119)

- The facility failed to ensure four allegation of Abuse were investigated, that patients were protected from the perpetrator, and that the abuse was called into the State Agency. (Refer to A145)

These failed practices had the potential for wide-spread harm to the facility's patients for abuse, neglect and not having grievances addressed.

Refer to:

42 CFR 482.13(a)(2)
42 CFR 482.13(c)(3)
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on records review and interviews, the facility failed to ensure prompt resolution of grievances and the governing body failed to ensure effective operation of the grievance process to review and resolve grievances for 6 of 10 patients (#'s 4, 24, 19, 15, 17, and 18) reviewed for grievances.

-Patient #'s 4, 24 and 19 had written grievances that were not investigated by the facility.

-Patient #'s 15, 17, 18, and 19 had acknowledgement letters given to them that stated the facility would investigate their grievances, but there was no documentation of a grievance that went along with what was in the letters and there were no investigations.

-The Governing Body failed to ensure an effective grievance process.

Findings include:

Patient #4

Record review of Patient #4's AMA (Against Medical Advice) form dated 5/20/14 revealed on page 3 a place to note why leaving AMA. Patient #4 stated there was a complete lack of communication with therapists and doctor. After days of requesting to get in contact with the doctor, the patient got no answers about what was going on with him or why he was on medications. It was signed by a patient representative. There was nothing to show the above concerns were investigated.

Patient #24

Record review of Patient #24's Patient Advocacy Report dated 8/5/14 from Unit 6 revealed a family member was upset the patient was never seen by a Psychiatrist as noted would be done in the Parent's Handbook. She was discharged 4 days later "without having been approached by the doctor and without any prior explanation." The family member was also upset the patient was prescribed a different medication than she had been taking. The patient was discharged without giving enough time to see if she was really stable emotionally or "maybe because she is so doped up from the effect of the medication that she has not been able to express how she really feels." The back of the sheet was blank.

Patient #19

Record review of Patient #19's Patient Advocacy Report dated 8/12/14 revealed on the back of the form written by Patient Advocate #64 the patient "experienced some anxiety due to the weekend staff..." Patient Advocate #64 wrote the patient was spoken to in a positive manner verbalizing the patient's feelings and "thanked her." There was nothing to show her anxieties over weekend staff were investigated.

Patient #'s 15, 17, 18, 19

Record review of the facility's complaint/grievance log revealed 4 acknowledgement letters all dated 9/3/14 in a pocket in the binder. The letters were addressed to Patients #'s 15, 17, 18, and 19. The letters stated their complaint was forwarded on to a supervisor to be reviewed and investigated.

Further review of the binder revealed there were no grievances that went along with what was written in the letters for all 4 patients.

Interview on 10/24/14 at 11:55 a.m. with Director of Intake #53, she said she used to be the Patient Advocate before the facility hired Patient Advocate #54. She was asked about the letters in the pouch. She said the Patient Advocates had training with Corporate Staff in August or September of 2014. She said they told her and another past Patient Advocate #64 to start listing complaints/grievances on a log. She said they also told them to start giving an Acknowledgement letter to everyone who wrote a complaint/grievance. She said the 4 letters were written by #64. She looked through the binder and was not able to find any grievance that went along with what was written in the letter. She said there might be another binder and she would go look for one. She said prior Risk Manager #68 was in the position during this time and the facility had not been able to find some of his things. By the time of exit on 10/24/14 at 4:00 p.m., no grievance forms or investigations were produced.

Record review of the facility's Policy and Procedure for Complaint/Grievance Procedure dated 10/11 revealed the following:

"Policy:...
It is the policy of (the facility) that every effort will be made to resolve a patient's complaint/grievance in a fair and equitable manner, and that all patient issues will be investigated and resolved promptly in accordance with the Texas Department of State Health Services (DSHS)"

During an interview on 10/24/14 at 2:20 p.m. with CEO #50, he was asked for the Governing Body's Policy and Procedure for Resolving Grievances. CEO #50 said the following was all he could find for Grievances.

Record review of the Board Of Governors 2014 Policies and Procedures revealed the following:

"11.4.1 Quality Management.
(a) The duties involved in the overseeing quality assessment and improvement are to:...
3. monitor corrective action to determine that it has been taken, is effective, and is maintained....
4. receive, analyze, and recommend action regarding any significant clinical findings from the Facility's risk management and patient safety program;
5. monitor the development of policies and procedures with respect to special treatment procedures, including restraints, seclusion, electroconvulsive therapy and other forms of anesthesia, and other special treatment procedures for children and adolescents;..."

There was nothing given by the CEO that addressed Resolving Grievances.

Interview on 10/24/14 at 2:30 p.m. with CEO #50, he said he represented the Governing Body of the facility. He said the facility had a Risk Management and Patient Safety committee that covered restraint/seclusion and level 3 and 4 incidents along with physical safety issues like broken concrete and citations from the city. He said these issues then went to the Medical Executive Board and on to the Governing Board. He said Performance Improvement and Patient Safety went hand in hand. When he was informed grievances had not been investigated or resolved, he said he was ultimately the person responsible for ensuring they were investigated properly.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on records review and interviews, the facility failed to ensure that patients were free from all forms of abuse in 4 of 10 patients (#'s 13, 12, 14 and 23) reviewed for grievances.

-Four patients reported verbal and mental abuse between September and October 2014 and none of the reports were investigated.

-None of the employees were suspended until the investigation was completed as per the facility's Policy and Procedure.

-No allegations of suspected abuse were reported to the state agency as per the facility's Policy and Procedure.

Findings include:

Patient #13

Record review of Patient #13's Patient Advocacy Report dated 9/7/14 revealed Patient #13 wrote a grievance stating he was on Unit 10 in the lunch room and a female tech from Unit 5 came to the lunch room and started cursing his peers and called him a (MF). She called another of his peers a "Bitch." "She talks to the clients like we in prison or not human.." He described the tech as being black, with long dread locks and pregnant. Patient #13 named the tech from Unit 5 as MHT (Mental Health Tech) #62 and said MHT #63 was present on Unit 10 and heard and saw everything. On the back of the sheet LMSW (Licensed Masters Social Worker) #64 wrote on 9/9/14 he was the Patient Advocate and validated the patients feelings and spoke to him about respect. Under Additional Notes he wrote, "Spoke with the supervisor about this issue."

Patient #12

Record review of a Patient Advocacy Report dated 9/7/14 revealed Patient #12 from Unit 10 stated she witnessed a very unprofessional exchange between the tech on Unit 5 who was pregnant and had long dread locks. She started yelling at people "especially two men in particular from unit 10....Almost every time we eat and she is in the cafeteria a rude exchange happens....Today she called a man in my unit a (MF) and as I walked by her to line up I heard her loud and clear call another man a 'Bitch' loudly and repeatedly. Patient #12 stated if patients were treated like animals or like they were in prison, then expect people to eventually act" animalistic and like prisoners." A Patient Advocate signed on 9/9/14 "needs more training for the nurses and the tech."

Patient #14

Record review of Patient #14 from Unit 4's Patient Advocacy Report dated 10/14/14 revealed the patient told Cafeteria worker #65 he wanted to wash his hands after he ate. Cafeteria worker #65 told him "That's trifling." When Patient #14 asked the worker what "I did she got angry and said 'You know what you did'. Pt. (Patient) went on to feel threatened by (Cafeteria Worker #64) at another meal." Patient Advocate #54 filed out the line as the Person handling the Complaint, but nothing was written on the back of the form.

Patient #23

Record review of Patient #23's Patient Advocacy Report from Unit 4 dated 10/15/14 revealed the patient stated Nurse #66 was rude and Nurse #67 hassled the patient when she got her medications. "I had anxiety issues. She caused by stress level to rize (sic) & my blood pressure rose. She gives me a hard time. I am under enough stress and I am detoxing. I have a lot on my plate & I feel I shouldn't be given a hard time. I am going thru enough....I asked Nurse #66 her name & she did not want to give it to me. I had to read her badge." Patient Advocate #54 signed the form on 10/16/14 stating the "Patient was met with." Nothing else was noted.

Interview on 10/24/14 at 11:55 a.m. with Patient Advocate #54, he said he had not been in the position very long. When he was asked about the verbal and mental abuse in the Patient Advocacy Reports, he said he had just had training today on Abuse and Neglect. He said now he knows how to handle those grievances, but he did not know before that.

Director of Intake #53 was present at this time and said she used to have the position of Patient Advocate and was training #54, but she had other duties and was not able to spend as much time as she should in training him. Director of Intake #53 was asked for any investigation reports she had on the above incidents. She said she did not have any. She said Prior Risk Manager #68 was the position during this time and the facility had not been able to find some of his things.

Record review of the facility's Policy and Procedure for suspected Abuse, Neglect and Sexual Exploitation dated 4/2013 revealed the following:

"Internal Reporting:

1. Any verbal or written grievance filed by a patient which alleges abuse, neglect, or sexual exploitation or

2. All witnessed event of suspected abuse, neglect or sexual exploitation shall immediately be reported to:
a. Nurse Manager/Program Director or Nursing Supervisor
b. Attending Physician
c. Director of Nursing or Administrator on Call
d. Risk Manager

3. An incident report shall be completed....

Investigation:

1. Employee shall be suspended until the investigation is completed...

3. The investigation will be initiated immediately by the Nurse Manager/Program Director or Nursing Supervisor, and shall include interviews documented, dated and signed by the person conducting the interview with:

a. The patient(s) involved in the alleged abuse
b. The staff member involved in the alleged abuse
c. Any Staff witnesses
d. Any patient witnesses
e. Any other witnesses

4. All documentation involving the alleged incident shall be forwarded to the Director of Risk Management or Chief Nursing officer within 24 hours or by the next working day. Any outstanding witness interviews shall be forwarded as soon as possible....

6. At the conclusion of the investigation, appropriate disciplinary action shall be taken as determined by Administration if the complaint is found to be valid....

External Reporting:...

1. Within 48 hours of receiving an allegation of suspected abuse, neglect or sexual exploitation on a licensed unit, the Director of Risk Management or the Chief Nursing Officer shall notify the Texas Department of State Health Services...."