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CYPRESS CREEK HOSPITAL 17750 CALI DRIVE HOUSTON, TX 77090 Dec. 17, 2015
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview and record review, the facility failed to ensure the safety of its patients as evidenced by:
2 of 2 patients (Patient #9 and Patient #10) were not provided safe care on the Psychiatric Intensive Care Unit resulting in them having " sexual intercourse. "
3 of 7 staff members (RN #81, MHT #58 and LVN #82) did not get the required training before returning to work.
6 of 6 patients (Patient #1 #4, #5, #6, #7, and Patient #8) did not have all of their precautions transcribed from the Physician ' s Orders to the observation rounds sheets.
2 of 6 patients (Patient #1 and Patient #5) did not have precautions renewed every 24 hours.

Findings included:

TX 473

Record review of a Written Statement by Patient #9 dated 11/07/2015 [misdated, not timed] revealed: Patient #10 " came into my room and went into my bathroom. I followed him and we had sex. We had consensual sex and he ejaculated in me. "

Record review of a Written Statement by Patient #10 dated 12/07/2015 [not timed] revealed: Patient #9 and I " engaged in sexual intercourse and she wanted me to. "

Record review of Video Surveillance of 12/07/15, 17:30 - 18:30, revealed Patient #9 went into her bedroom at 1802. Patient #10 went into Patient #9 ' s room at 1803. At 1827 Patient #10 left Patient #9 ' s room. There was no evidence of 15 minute rounds being made 1800 - 1830.

In an interview with Personnel #51 on 12/18/2015 at 1050, he stated:
The incident between Patient #9 and Patient # 10 happened on 12/07/2015.
There were four staff working - RN #61, LVN #75, MHT #76 and MHT #77.
MHT #76 ' s last round before the incident was at 1745.
RN #61 and MHT #76 took a newly admitted patient into an exam room to do a visual/skin assessment. MHT #76 missed the 1800 and 1815 rounds.
Staff began preparing for the visiting hour scheduled 1830 - 1930.
Once the video was reviewed and it was discovered that MHT #76 had documented rounds that she had not made, she was " terminated immediately. "
" There has been a zero tolerance for not performing rounds and or fraudulent documentation for the past two years. "
" No one could work another shift until they signed an attestation of understanding the observation rounds policy. "
The supervisor presented a packet to the staff while they were working. " Staff was pulled aside for the training and it was discussed. "

Record review of Written Statement by MHT #76 on 12/09/2015 [not timed] revealed: MHT #76 was with RN #61 doing a search on Patient #16, a newly admitted patient. MHT #76 also took a patient ' s car keys to admissions between 1800 and 1900.

In an interview with Personnel #51 on 12/18/2015 at 1050, he stated that the action of RN #61 to pull MHT #76 from her patient rounds assignment to assist with the visual/skin assessment was not considered as having contributed to the observation rounds not being performed timely by MHT #76.

In interviews with 7 staff members (RN #81, MHT #58, LVN #82, MHT #80, RN #61, RN #83 and LVN #84), 3 of them (RN #81, MHT #58 and LVN #82) stated they did not get the required training prior to returning to work.

Record review of 6 of 6 patient ' s charts (Patient #1 #4, #5, #6, #7, and Patient #8) revealed that they did not have all precautions transcribed from the Physician ' s Orders to the observation rounds sheets.

Record review of 6 patient charts (Patient #1, #4, #5, #6, #7 and Patient #8) revealed that 2 of the patients (Patient #1 and Patient #5) had precautions that were not renewed by the physician every 24 hours.

In an interview with Interim CNO #53 on 12/18/2015 at 1400, he stated:
Precautions should be transcribed from the physician ' s orders to the patient ' s rounds sheet so that individuals performing the rounds know the precautions the patient is on.
Precautions are to be assessed and renewed every 24 hours or discontinued.
Each night it is the responsibility of the RN to write the precautions on the physician ' s orders so that the physician can renew or discontinue the precautions the following day.

Record review of Job Description/Performance Evaluation for Mental health Technician (no date) revealed: " Job Responsibilities ... 14. Completes relevant flow sheets and other medical records forms legibly, accurately and in a timely manner ... 18. Maintains a safe, orderly and therapeutic physical environment for patients ... Primary Criteria/Responsibilities ... 1. Provides a safe environment by conducting and documenting 15 minute patient and environmental rounds as scheduled ... 11. Understands special precautions for suicidal patients, assaultive patients, patients on elopement precautions and sexually acting out patients. Maintains a safe environment of care and recognizes safety risks/considerations of each age group served ... 19. Ensures the correctness of special precautions listed in patient chart. "

Record review of Psychiatric Technician Review (no date) revealed: " 2. Complete initial rounds and ensure you have seen EVERY patient and maintain records. Documentation of rounds should be done in a timely fashion ... Not sooner or later than 15 minutes. "

Record review of Policy & Procedure: Safety Precautions (revised 02/2011) revealed: " Sexual Precautions ...11. The need for continued precautions will be reviewed daily by the physician ... 13. The order for renewing sexual conduct precautions will be written by the physician every 24 hours. "

Record review of Policy & Procedure: Level of Observation (revised 02/2011) revealed: " 5. Staff will complete the patient observation record as rounds are made, using the coding system described on the record. "

Record review of Patient Safety Observation Round Sheet (no date) revealed 14 levels of observation listed. Beside each was a box to check (if applicable to that patient). Two options were Potential for Sexual Acting Out-Aggression (SAO-A) and Potential for Sexual Acting Out-Victimization (SAO-V).
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observation, interview and record review the facility failed to ensure that there was an adequate number of personnel on 2 of 2 units (adolescent unit and General Adult Unit) to provide safe care to all patients as needed.

Findings included:

TX 473

Adolescent Unit.
Observation of the adolescent unit on 12/17/2015 at 1015 revealed 16 patients. Mental Health Technician (MHT) #58 was providing a 1:1 while awake to Patient #3. Patient #3 was asleep in her room. MHT #60 was outside with some of the patients. Charge RN #57 and LVN #59, medication nurse were on the unit.

In an interview with RN #57 on 12/17/2015 at 1015, she stated that if Patient #3 awakened, the staffing coordinator would come to the unit to assist with watching the patients. She also stated the staffing coordinator ' s office was not on the unit.

In an interview with Personnel #51 on 12/18/2015 at 1430, he stated a staff member had called in sick thus creating the staff shortage on the adolescent unit.

Record review of the Staffing Report dated 12/17/2015 revealed adolescent unit census of 16.

Record review of the Staffing Grid revealed the adolescent unit should have been staffed with two licensed staff (one of them an RN) and two MHTs for 14-16 patients. (The staff providing the 1:1 was not counted in the staffing grid.)


General Adult Unit.
Observation of Unit 4, the General Adult Unit on 12/18/2015 at 1200 revealed one staff member, RN #61, rounding on patients.

In an interview with Unit 4 RN #61 on 12/18/2015 at 1200, she stated that she was on the unit alone and that the other staff member was off the unit with patients.

Record review of the Staffing Report dated 12/18/2015 revealed Unit 4 General Adult census of nine, five blocked beds and two assigned staff, RN #61 and RN #85.

Record review of the Staffing Grid revealed the General Adult Unit should have been staffed with two licensed staff (one of them an RN) at all times.