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.

INTRACARE NORTH HOSPITAL 1120 CYPRESS STATION DR HOUSTON, TX April 7, 2017
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: failure to make safety rounds every -15 minutes as per policy on the adolescent unit as required.

Findings included:

Record review of Policy & Procedure "Every-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."

Observation of the video dated 4/1/2017 revealed that safety rounds were not being done every 15 minute as indicated by policy:
1039 PM safety rounds on patients made by Employee F
1100 PM safety rounds made by Employee F
1125 PM safety rounds made by Employee S
1145 PM safety rounds made by Employee D

Observation of the video dated 4/4/2017 revealed that safety rounds were not being done every 15 minute as indicated by policy:
1211 AM safety rounds made by Employee D
0126 AM safety rounds made by Employee D

Observation of the video dated 4/5/2017 revealed that safety rounds were not being done every 15 minute as indicated by policy:
1111 PM Employee Q made safety rounds
1138 PM Employee Q made safety rounds
Rounds not made again till 4/6/2017 at 1231 PM

Interview with program manager Employee E on 4/7/2017 at 0945 AM revealed that all units have to make safety rounds every 15 minutes.