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INTRACARE NORTH HOSPITAL 1120 CYPRESS STATION DR HOUSTON, TX Aug. 23, 2016
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, record review and interview, the facility failed to provide a safe environment as evidenced by:

1. 6 of 6 adolescent patients (Patient # 4, #6, #8, #14, #18 and Patient #22) were left unattended by staff members, and
2. 1 of 1 (Mental Health Technician [MHT] # 52) improperly removed soiled linens from Patient #8 ' s room.

Findings included:

1. Patients left unattended.

Record review of Nursing Notes for Patient #4 by RN #63 02/04/2016 at 1925 revealed: A code was called on another unit at 1900. Patient #4 got into a physical fight with a peer [Patient #6]. Patient #4 sustained a " bruise on left forehead and cheek. " Patient #4 stated that Patient #6 " smacked me 5-7 times on forehead and cheeks. ' "

Record review of Psychiatric Reassessment for Patient #4 by MD #58 dated 02/04/2016 at 2024 revealed: Patient #4 was involved in an altercation with a peer. Patient #6 hit Patient #4 in the face resulting in " slight swelling ... infraorbital area (left). "

Record review of Nursing Notes for Patient #6 by RN #63 on 02/04/2016 at 1925 revealed: While staff was engaged in a code, Patient #6 got into a " physical fight " with Patient #4.

In an interview with RN #51 on 08/22/2016 at 0935, she stated:
Patient #4 was hit by Patient #6;
Mental Health Technician (MHT) #65 assigned to watching the boys left them unattended when he responded to a " code white " on the adolescent female unit; and
MHT #65 should not have left the adolescent boys unattended.

In an interview Youth Services Program Manager Personnel #61 on 08/22/2016 at 1115, he stated he investigated the fight between Patient #4 and Patient #6. He also stated:
MHT #65 responded to a code [crisis situation] on the adjacent unit, thus leaving the adolescent boys unattended in the day room;
It was during this time that Patient #4 and Patient #5 got into the physical altercation; and
MHT #65 should not have left the patients unattended.

Observation of the male adolescent unit on 08/22/2016 at 1118 revealed four patients (Patient #8, #14, #18 and Patient #22) - two in the day room and two in their bedrooms. RN #66 was in the nurse ' s station. The day area was not visible from the nurse ' s station. There was no staff member in the hallway or day area to monitor the patients. RN #51 called for MHT #52, but there was no response. She knocked on several of the doors to the patient ' s rooms. She found MHT #52 in room 257 with the door closed removing soiled linens.

Record review of the adolescent boy ' s Observation Record Every 15 Minutes on 08/22/2016 at 1120 revealed:
Patient #14 - rounds not documented for 1045, 1100 and 1115;
Patient #8 - rounds not documented for 1100 and 1115;
Patient #22 - rounds not documented for 1045, 1100 and 1115; and
Patient #18 - rounds not documented for 1100 and 1115.

In an interview with MHT #52 on 08/22/2016 at 1120, he stated he knew he was supposed to be with the patients but was helping housekeeping strip the bed for a discharged patient. He was aware of not being current on the rounds but was engaged in helping a patient get prepared for discharge.

In an interview with RN #51 on 08/22/2016 at 1400, she stated MHT #52 should have been watching the patients, should not have been engaged in housekeeping duties and should have been current with the every 15 minute rounds.

Record review of Policy & Procedure " Q-15 Minute Patient Rounds " dated 07/2014 revealed: " Unit staff shall conduct visual rounds every 15 minutes 24 hours a day on the inpatient units ... Nursing staff shall document rounds on the individual patient ' s Observation Record sheet. "

Record review of Policy & Procedure " Code White " dated 04/2016 revealed: " The Code White team will respond promptly to all crisis situations. Code White Team Members will wait for a staff member to relieve them if they are supervising patients. "


2. Removal of soiled linen.

Observation of the male adolescent unit on 08/22/2016 at 1118 revealed MHT #52 carrying soiled linen next to his body. He was not wearing gloves.

In an interview with MHT #52 on 08/22/2016 at 1120, he stated he was helping housekeeping strip the bed for a discharged patient. He stated he knew he was supposed to be wearing gloves and not have the linens touching his clothing.

In an interview with RN #51 on 08/22/2016 at 1400, she stated MHT #52 should have been wearing gloves and carrying the soiled linen away from his clothing.

Record review of Policy & Procedure " Infection Prevention Handling of Linen " dated 08/2014 revealed: " Handling of soiled linen: Soiled linen is handled in such a manner as to prevent cross contamination of the hospital environment. Care will be taken not to carry soiled articles close to the body or clothing ... Gloves are to be worn when handling soiled linen. "