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.

KINGWOOD PINES HOSPITAL 2001 LADBROOK KINGWOOD, TX Sept. 4, 2015
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 uphold the rights of 2 of 2 adolescent patients to receive care in a safe setting ( Patient # 1 and Patient # 2).

Patients # 1 and #2 were assigned as roommates, although each had a documented history of sexual abuse /victimization.

Patient #1 had SXV (sexual victim precautions) ordered; they were not fully implemented.

Patient # 2 had a history of sexual abuse and was not placed on sexual precautions.

Facility self-reported an alleged incident of sexual misconduct between Patient # 1 and Patient # 2.

Findings include:

TX 811

Review of facility policy titled "Precautions," review date 07/2014, read: Sexual Conduct Precautions...4. When possible, patients on Sexual Precautions of any type should be assigned a room by themselves or assigned a room monitor.."

Record review of facility self-reported incident revealed Patient # 1 alleged on the evening of 07-26-15 at approximately 8 p.m. to 9 p.m. that he and his roommate (Patient # 2) engaged in oral and anal sex. Patient # 2 denied the allegations. Facility documented they had begun an investigation.

Patient # 1 :

Record review on 09-04-15 of Patient # 1's clinical record revealed he was [AGE] years old and admitted on [DATE] with suicidal ideation; prior suicide attempt in April 2015.

*Psychosocial Assessment, dated 07-25-15 read: " History of sexual abuse....Deficits: impulse control."

*High Risk Notification Alert, dated 07-22-15,"risk of victimization...history of sexual victimization.."

*Physician admission orders, dated 07-22-15: read: "...sexual precautions.."

Although review of 07-22-15 census revealed several empty rooms available; Patient # 1 was assigned as the roommate of Patient # 2.

Patient # 2:

Record review on 09-04-15 of Patient # 2's clinical record revealed he was [AGE] years old and admitted on [DATE] with suicidal ideation, depression, and bipolar disorder.

*Psychosocial Assessment, dated 07-14-15, read: " History of physical emotional, and sexual abuse....Child Protective Services (CPS)-several placements; records indicate history of physical, sexual abuse, and neglect.."

*Review of physician admission orders, dated 07-12-15, failed to reveal Patient # 2 was placed on sexual precautions. He was placed suicide precautions only.

*Review of census for 400 hallway on 07-12-15 revealed Patient # 2 was placed with a roommate, although "overflow beds" were available.

Interview on 09-04-15 at 3:10 p.m. with Assistant Director of Nurses (ADON); she stated if a patient had a history of sexual abuse, they were admitted to a blocked room if available. She went on to say that 2 patients with history of sexual abuse should not be assigned as roommates.

Interview on 09-04-15 at 3:15 p.m. with Chief Executive Officer (CEO) # 1 he stated that Intake Assessment served as bed/board control. Intake had computer access to bed availability. The charge nurse could say yes/no to the assigned bed.

Review of facility policy titled" Room Assignment,"review date 06/2014, read: " Purpose: 1. to provide guidelines for the assigning of rooms for newly admitted patients, unit transfers, and intra-unit transfers, 2. Upon admission, patients shall be assigned rooms on the basis of gender...7. Special sleeping needs of a patient shall be addressed by the treatment team.. and room assignments made as determined to be necessary for medical or clinical reasons..."
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to fully analyze and implement important corrective actions related to an adverse event that involved 2 patients.

Facility began a timely Root Cause Analysis (RCA) following the adverse event; however, several key factors were not fully addressed.

Findings include:

TX 081

Record review of facility self-reported incident revealed Patient # 1 alleged on the evening of 07-26-15 at approximately 8 p.m. to 9 p.m. that he and his roommate ( Patient # 2) engaged in oral and anal sex. Patient # 2 denied the allegations. Facility documented they had begun an investigation.

Patient # 1 :

Record review on 09-04-15 of Patient # 1's clinical record revealed he was [AGE] years old and admitted on [DATE] with suicidal ideation, bipolar disorder, and major depressive disorder.

Patient # 2:

Record review on 09-04-15 of Patient # 2's clinical record revealed he was [AGE] years old and admitted on [DATE] with suicidal ideation, depression, and bipolar disorder.

Record review on 09-04-15 of facility RCA revealed a 15 page document completed by the facility Risk Manager (RM). Facility RM was unavailable for interview on date of on-site visit.

Several processes were identified as contributory to event, but not fully addressed by a "Plan of Action."

Facility RCA ( not all inclusive) :

1. Facility's RCA failed to address the current process of room / bed assignments. There was no analysis regarding current process and how it may have contributed to the incident. Nursing assessment / judgement is not currently a key component in the room assignment process. (refer to Tag A-0144)

2. Facility's RCA identified : "Communication between disciplines should occur when information learned..that presents a new risk or potential ordering of a precaution..." Facility's RCA failed to address communication processes among all diciplines, to include therapists/ counselors/ social workers. Improvement action chiefly addressed DON and RM to meet with nursing supervisors..."holding charge nurses and Mental Health Techs (MHT) accountable..."

*Review of Patient # 2's (admitted on [DATE]), Psychosocial Assessment, dated 07-14-15 by Licensed Clinical Social Worker (LCSW) # 8, read: "History of sexual abuse....Deficits: impulse control." Further review failed to reveal documentation this new information was communicated by the therapist to nursing. No sexual precautions were initiated on admission, only suicide precautions.

3. Facility identified lack of information available to intake staff by individuals accompanying patients. Facility failed to identify possible causes and identify potential improvement actions.

4. Facility identified that a room monitor was not observed (via video surveillance) for both patients during the timeframe of allegation. Facility failed to identify potential process failures & methods to improve.

5. Review of staff education titled" Eliminating/Reducing Opportunities For Sexual Acting Out Incidents" was primarily directed to MHTs ; and (according to to attendance records) was not begun until a month after the incident.

6. Facility did not follow-through on " Disciplinary action, termination...for staff involved in this incident based on findings."

Facility terminated the MHT who falsified patient observation round sheets;

Facility did not impose any discipline (verbal, written, or termination) of Registered Nurse (RN) # 5 who falsely attested that patient observation records were conducted.

Review of facility policy titled: "Risk Management-Performance Improvement Investigating,"dated 07-2014, read: "...Definitions: 2.1 Serious incidents-Serious incidents are patient incidents...involving highest risk to the hospital...2.3. Near Miss: a sub category of sentinel events that do not result in serious injury or death but which carry a significant chance of serious injury..if the event were to reoccur...3.5...The Risk Manager will analyze the incident...analysis should focus in identifying not only the direct cause(s) of the incident , but also on identifying any underlying causes that may reflect processes or system issues in need of further review..."