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 77074 Nov. 15, 2016
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure that 2 (Patients #10 and #11) of 14 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and Patient #14) received their psychiatric treatment in a safe setting, as evidenced by Patient #11 physically assaulting Patient #10 thus putting both patients at risk for harm.

TX 413

Findings included:

Record review of the Complaint by Patient #10 dated 06/15/2016 at 1222 revealed she was wrongfully sent to PICU and was then physically assaulted by a patient shortly upon arrival.

Record review of the Psychiatric Evaluation by Personnel #56 (MD) dated 05/12/2016 at 1752 revealed a 50-year-old-female admitted on [DATE] with suicidal ideation due to being "sleep deprived."

Record review of Physician Admission Order by Personnel #59 (MD) dated 05/11/2016 at 1610 revealed admission into PICU. Unit restriction and suicide and elopement precautions were ordered.

In an interview with Personnel #53 (QM) on 11/15/2016 at 0915, she stated Patient #10 was attacked from behind by Patient #11. She also stated the attack was unprovoked.

Record review of the Physician Orders by Personnel #56 (MD) dated 05/11/2016 at 1903 revealed an order to transfer Patient #10 to any unit where there was an available bed.

Record review of RN Narrative by Personnel #60 (RN) dated 05/11/2016 at 1930 revealed Patient #10 was transferred from Psychiatric Intensive Care Unit (Unit 1).

Record review of policy AIM 105, Admission Services, dated 06/2015 revealed: "Patient unit ... shall be made on the basis of ... The needs of the patient ... The needs of other patients on a unit ... The attending physician's request or approval ... Space available. Patients may be admitted to a unit and transferred to another unit based upon the patient's needs and other patient's needs."