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.

CAMBRIDGE HOSPITAL LLC 7601 FANNIN HOUSTON, TX June 20, 2014
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, and record review, the facility failed to ensure Patient ID # 6 received care in a safe setting. The facility failed to ensure:
? Prudent and safe room assignments to protect vulnerable patients.
? Adherence to policy of no visiting of male/female patients in each other's rooms.
Findings include:
Intake TX # 138
Record review of complaint intake TX # 138 revealed [AGE] year old female Patient ID # 6 presented to a local Emergecny room (ER) on 06-05-14 for a forensic rape exam. Patient ID # 6 reported she was sexually assaulted by another patient on 06-04-14 at a psychiatric facility. She had been a patient there for about 3 weeks. Further review of documentation by ER Forensic nurse read: " (patient) says that a [AGE] year old male held her down and raped her ...penis to vagina ... male put a hand-glove on his penis before penetrating ... " Patient ID # 6 alleged the male patient also " hit her face thighs and hands... " ER Forensic nurse documented the patient informed the facility it was non-consensual; psychiatric facility did not notify law enforcement. ER Forensic nurse documented that psychiatric facility said " the [AGE] year old female (Patient ID # 6) had been placed in a males-only section due to 2 females picking fights. "
Observation on 06-18-14 at 9:30 a.m. of the 2nd floor adolescent unit revealed a census of 11 adolescents: five (5) males and six (6) females. Interview at the time of observation with Charge Nurse Registered Nurse (RN) ID # 2 she stated for safety reasons, adolescent males and females were assigned rooms on different hallways separated by the nurse ' s station and locked doors. Patient room assignments for this day were observed: female and male adolescents were housed separately per facility process.
Record review of facility " Occurrence Report Form, " dated 06-04-14 (9:30 PM) completed by RN/ID # 7 read: " It was reported male adolescent and female adolescent were involved inappropriate sexual behavior in room 210 after breakfast. Another patient watched the hall for staff. "
Observation on 06-18-14 at 9:30 a.m. revealed room 210 was the end room on the left side of a long hallway. It was the room furthest away from the nurse's station.
Interview on 06-18-14 at 3:40 PM with RN # 7 she stated she " worked the night shift beginning at 7 PM. On 06-04-14 during the change-of-shift report, the social worker informed us that Patient ID # 6 (female) and Patient ID # 7(male) had been a ' little close ' in the dayroom that day and to keep a close eye on them. A few minutes later another patient (ID # 10) came to me and reported that Patient # 6 and Patient # 7 had sex in her room (210) after breakfast that morning. Patient # 10 said they had been in and out of her room all day and no one saw them. Patient # 10 said she watched the hallway while the two had sex. " RN # 7 said that it was not indicated to her the sex was forced; " just that they were doing it. "
RN # 7 went in to say she immediately notified the Chief Nursing Officer (CNO) who advised her to complete an incident report. RN # 2 said although it was nearly 10 PM; she relocated the male Patient ID # 7 to a different hallway. RN # 7 went on to say she was unsure why the 2 girls (Patient ID # 6, # 10) were housed at the end of the hallway with male Patient # 7. She said they were the only patients on this hallway. RN # 7 said the next morning during report; she advised the day shift to move the 2 girls to the girls ' hallway.
Interview on 06-18-14 at 1: 10 PM with RN/ID # 4, she verified she was the day shift RN on duty the date of the alleged incident (06-04-14). RN # 4 said she was told by the night nurse the girls had been fighting and that was the reason they were placed on the boys hallway. RN # 4 said she was unaware that a sexual incident had occurred that day; no staff had reported anything to her. RN # 4 said this " must have happened when I was discharging another patient. " RN # 4 said that when she left that evening at 7 PM, the 2 girls (Patient # 6, Patient # 10) and the male (Patient # 7) remained as the only patients in the North hall.
Interview on 06-18-14 at 11:45 a.m. with Psychiatric (Psych) Tech ID # 3 he stated he was the tech on duty the day of the alleged incident (06-04-14). He went on to say that when he was making rounds that day he saw the male patient (ID # 7) and the 2 females (ID ' s # 6, and # 10) together in room 210. He said they were just standing in a group. Psych Tech # 3 said he told the male patient ' you are not supposed to be in here-you will get in trouble. ' He reported that when he came on duty he was told to take female Patient #6 to be in the room with another female (Patient # 10) on the boys hall. He said he was told the reason was Patient # 6 had been fighting with all the other girls. Psych Tech # 3 said when he left work on 06-04-14 at 7 PM, the 2 female patients (ID # 6, # 10) and the male patient (ID # 7) remained as the only patients on that hallway. Psych tech # 3 said usually the male and female adolescents were kept on separate halls.
Interview on 06-20-14 at 3:05 PM with Social Worker (SW) # 13 she stated she was aware that both female adolescents (Patient # 6, #10) were aggressive and had fights with other girls. SW # 13 said she thought the intention was good to relocate the girls but they should not have been placed in the boys ' hall with male Patient # 10. She said these adolescents have behavioral issues along with impaired judgment and poor decision-making skills.
Interview on 06-18-14 at 3:40 PM with the CNO/ ID # 1 she stated the adolescent boys and the adolescent girls were assigned rooms in different sections/hallways. Whenever possible patients were assigned to a private room. The DON went on to say that she was unaware the 2 female patients ( ID # 6, ID # 10) were assigned to the North hallway with male Patient # 10 on 06-04-14.
Record review on 06-18-14 of facility policy titled "Room Assignments and Responsibilities, " dated 09-07-12, read: " Purpose: To provide a safe environment for patients ...Procedure : High -risk patients will be assigned a room closest to the nursing station for evaluation, observation and supervision ...No male or female patient will share rooms or visit each other in their rooms at any time ... "
Record review on 06-20-14 of facility policy titled " Recognizing and Reporting Suspected Child, Adult, Disabled Person or Elderly Abuse, Neglect, Exploitation, " dated 09-17-12 read: "... Sexual Abuse ...Neglectful Supervision: Placing in, or failing to remove, the person from a situation that a reasonable individual would realize required judgment or actions beyond the child ' s level of maturity, physical condition or mental abilities and that results in bodily injury or substantial risk of immediate harm to that person.. "
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to protect 2 of 2 sampled patients ' right to be free of abuse (Patients ID # 6, # 8). The facility failed to:
? Fully investigate an incident of an alleged sexual assault (Patient ID #6) and an incident of physical assault (Patient # 8).
? Provide 7 of 7 staff required training regarding abuse and neglect (ID # 2, 3, 4, 7, 8, 9, and 10).
Findings include:
Intake TX # 138
Patient # 6:
Record review of complaint intake TX # 138 revealed [AGE] year old female Patient ID # 6 presented to a local ER on 06-05-14 for a forensic rape exam. Patient ID # 6 reported she was sexually assaulted by another patient on 06-04-14 at a psychiatric facility. She had been a patient for about 3 weeks. Further intake documentation by ER Forensic nurse read: " (patient) says that a [AGE] year old male held her down and raped her ...penis to vagina ... male put a hand-glove on his penis before penetrating ... " Patient ID # 6 also alleged the male patient also " hit her face thighs and hands... " ER Forensic nurse documented the patient informed the facility it was non-consensual. In addition it was documented that psychiatric facility said " the [AGE] year old female (Patient ID # 6) had been placed in a males-only section due to 2 females picking fights. "
Record review on 06-18-14 of clinical record of Patient # 6 revealed she was [AGE] years old and admitted to the facility with suicidal ideation with a plan to choke/strangle self.
Record review on 06-18-14 of facility " Occurrence Report Form, " dated 06-04-14 (9:30 PM) completed by RN/ID # 7 read: " It was reported male adolescent and female adolescent were involved in inappropriate sexual behavior in room 210 after breakfast. Another patient watched the hall for staff. "
Interview on 06-18-14 at 3:40 PM with Chief Nursing Officer (CNO)/ ID # 1 she said RN # 7 telephoned her on 06-04-14 when she became aware of the allegation that Patient # 6 and Patient # 7 had sex. The CNO said her investigation included the following:
? Interviewed both the female Patient # 6 and male patient # 7. Initially both denied intercourse took place. Later, Patient # 6 changed her story and stated they had intercourse. {Information was verified though record review of CNO progress notes dated 06-05-14, Patient # 6}.
? Notification of Child Protective Services (CPS) caseworker assigned to Patient # 6.
? Telephoned physician. Review of CNO progress note (Patient # 6) revealed physician was notified on 06-05-14 at 17:32 pm [20 hours after incident reported]. Physician then ordered Patient # 6 to have a forensic exam.
? Viewed video taken in the hallway -room 210. CNO stated alleged incident happened between breakfast and lunch. Interview on 06-20-14 at 10:25 AM with plant Operations staff ID # 14 he stated the video and the CNO viewed for 06-04-14 was from 1:00 PM to 5 PM. He further stated the video was no longer available, as it is set to records over in 7 days.
During this same interview with the CNO, she reported:
? She did not consider this a sexual assault or a sentinel event.
? The facility did not conduct a root cause analysis (RCA).
? She did not interview other staff members or possible witnesses.
? CNO did not investigate who made the decision to house a boy and 2 girls together on the same hallway. CNO stated she was unaware this was the case.
? CNO did not obtain and review ER medical records, including forensic exam conducted on Patient # 6.
? CNO/facility did not investigate any possible causative factors: staffing, training, staff decision-making skills, census and acuity of patients, etc..
Intake TX # 056
Patient # 8
Record review on 06-18-14 of clinical record of Patient # 8 revealed she was [AGE] years old and admitted to the facility on on [DATE] with suicidal ideation, depression and Bipolar Disorder.
Record review on 06-20-14 of physician progress notes for Patient # 8:
? 05-21-14 read: " ...Evaluated patient; 2 fist punches in face and head, dragged by hair ... '
? 05-22-14: " beat up and kicked by female peer ... "
Record review on 06-20-14 of nurse ' s notes, dated 05-21-14 read: " Patient (#8) sitting in the dayroom with Peers in the sofa ...peer approached patient and grabbed her by the hair and pulled her to the floor and stated to strike her in the face and head ... " [Record contained documentation that physician and parent was notified].
Record review of complaint intake TX # 056 revealed allegations that [AGE] year old female Patient ID # 8 was " attacked 3 times by the same girl on 05-21-14 ... the girls was moved to the boy ' s wing to solve the issues ... " Patient # 8 " was bruised on side, face was cut, dragged by her hair ... "
Record review on 06-18-14 of facility " Occurrence Report Form, " dated 05-21-14, read: patient in dayroom sitting on sofa/ peer said " shut up. " Patient responded you done have the right to say that, Peer started to strike patient many times... "
Further review of the Occurrence Report for Patient # 8 dated 05-21-14 revealed: Section C (described physical effects) was blank / not completed Section D. Severity of Effects was left blank/ not completed Section E. High Risks was left blank/not completed, Section F. Corrective Actions Taken was left blank/not completed, and the Comment section was left blank.
Interview on 06-20-14 at 4:00 PM with the CNO she stated all sections on the form need to be completed by the person who witnessed the event or occurrence. She went on to say the incomplete occurrence report for Patient # 8 was not acceptable as an investigation of physical peer-to- peer assault.
Record review on 06-20-14 of facility policy titled " Recognizing and Reporting Suspected Child, Adult, Disabled Person or Elderly Abuse, Neglect, Exploitation, " dated 09-17-12 read: " Management of suspected sexual assault, physical abuse or neglect will be given priority and will be investigated thoroughly ... "
Staff Training: Abuse & Neglect:
Records review on 06-20-14 of personal and training records for 4 RNs (ID #2, #4, #7, #8) and 3 Psych techs ( ID # 3, # 9, #10) failed to reveal documentation of training of abuse and neglect, and related reporting requirements, including prevention, intervention, and detection.
Interview on 06-20-14 at 4:00 PM with the CNO she stated she became aware in February 2014 that training for Abuse & Neglect was not being done at the facility. CNO reported this has since been added to the Orientation and Annual training.
Review of facility policies titled " New Employee Orientation Program " and Education and Training of Staff, " both dated 09/12, do not list training in Abuse & Neglect prevention, intervention, and reporting as required on-going training.
Record review on 06-20-14 of facility policy titled " Recognizing and Reporting Suspected Child, Adult, Disabled Person or Elderly Abuse, Neglect, Exploitation, " dated 09-17-12 read: " ...Staff Education: Appropriate staff shall receive education at orientation, and as needed, addressing how to recognize signs of possible abuse and neglect. Reporting of abuse/neglect, and follow-up. "