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.

AUSTIN OAKS HOSPITAL 1407 WEST STASSNEY LANE AUSTIN, TX June 30, 2014
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of documentation and interview, it was determined that the facility did not always provide patient care in a safe setting.

Findings were:

"Austin Oaks Staffing Grid " "Unit B: Child and Adolescent" stated that on the 7-3 shift, 16-20 patients required 4 staff. The 3-11 shift also required 4 staff members for 16-20 patients. On the 11-7 shift, only 3 staff members were required for 16-20 patients.

? On the evening of 5/16/14, there were 16 patients on the Child/Adolescent unit. One RN was assigned for the shift of 7p to 7a. Two Mental Health Technicians were assigned, leaving the staffing ratio at 16:3
? On 5/17/14, the Child/Adolescent unit had 16 patients. On the 7a-7p shift, there was one RN and 2 Mental Health Technicians assigned to the unit, leaving the staffing ratio at 3:16.
? On 5/18/14, the Child/Adolescent unit had 16 patients. On the 7a-7p shift, there was one RN and 2 Mental Health Technicians, leaving the staffing ratio at 3:16.
? On 5/18/14, the Child/Adolescent unit had 16 patients. On the 7p-7a shift, there was one RN and 2 Mental Health Technicians, leaving the staffing ratio at 3:16.
? On 5/19/14, the Child/Adolescent unit had 16 patients. On the 7a-7p shift, there was one RN and 2 Mental Health Technicians, leaving the staffing ratio at 3:16.

In an interview with the Director of Nurses on 6/30/14, it was acknowledged that the Child/Adolescent unit was not staffed according to company policy during the period of 5/16/14 through 5/19/14.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of documentation and interview, it was determined that the facility did not follow its own policies in regard to nursing services provided to its patients.

Findings were:

Facility policy entitled "Admission Assessment and Intake Process" stated in part "Once an individual is deemed medically stable, a Qualified Mental Health Professional shall conduct the Admission Assessment, in order to establish psychiatric needs. The admissions assessment shall include the following elements:
a) Chief complaint
b) History of present illness
c) Mental status assessment
d) Suicide risk assessment
e) Aggression risk assessment
f) Safety assessment
g) Substance abuse screen
h) Abuse/Neglect trauma history
i) Behavioral intervention screen to include contraindications by history
j) Family psychiatric history, living arrangements
k) Medical and or behavioral healthcare advance directives
l) Any stated alcohol use will have breathalyzer testing performed
m) Other relevant information"

Facility policy entitled, "Patient Valuables and Belongings" stated, in part, "Patient's belongings that are placed in the custody of the hospital will be logged in and secured and returned to the patient on discharge. Procedures:
1. In the admissions area, a safety check is conducted and patients are asked to turn in all contraband items ...
2. The items are placed in a container and remain with the individual conducting the admission assessment until the assessment is complete and the patient is taken to the unit.
3. When the patient is taken to the unit, the patient and any items confiscated are kept under constant observation until the unit admission process is initiated
4. The patient is taken to the exam room where two staff members are present and a search is conducted per the Search policy.
5. The person conducting the safety check removes any contraband or valuables that are not allowed on the unit and places them in a bin in the presence of the patient.
6. The patient and the staff then return to the unit, the staff inventories all items that will not be kept in custody by the patient during their stay ...
10. The patient or parent / guardian will review the inventory list and sign it; staff member doing the inventory will sign and date it."

Review of eleven randomly selected patient records revealed the following:

? No Intake Property Sheet was found in the medical record of Patient # 1
? No documented skin assessment was performed on Patient # 9 upon admission. No Intake Property Sheet was found in this patient ' s medical record.
? Patient # 11 had no Intake Property Sheet in the medical record and no documented Medication Reconciliation was performed upon admission.

In an interview with the Medical Records Clerk and the Director of Nursing on 6/30/14, the missing documentation was confirmed.
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a tour of the facility and staff interviews, the facility failed to ensure that the kitchen adhered to infection control practices to prevent cross contamination.

Findings were:

During a tour of the facility kitchen the morning of 6/30/14 accompanied by the Food Service Manager and the Director of Risk Management, the following was observed:
? In the food prep table drawer, there were four large spoons placed bowl up which contained a clear liquid. This moist environment presents a risk for cross contamination due to the potential for bacterial growth.
? There were two knives in the knife rack, available for use in food prep, which were in need of cleaning, as there was a white substance adhered to both sides of the blade. This presents a risk for cross contamination.
? In the dry food storage room, there was a dirty, corrugated cardboard external shipping box with shipping label attached on the top shelf of a wire shelving unit. Underneath the dirty box were patient food supplies available for patient use, including items such as various condiment packets and packages of assorted pasta. This presents a risk for cross contamination from the dirty shipping box.
? When asked by the surveyor to check the concentration of the sanitizer in the red bucket to ensure the concentration was within the proper range, the test strip indicated no sanitizer in the water. The kitchen manager added sanitizing solution, however the surveyor identified that the test strips expired on ,d+[DATE] (approximately 7 months previous). The kitchen manager then obtained test strips that were not expired and tested the solution that he had added sanitizer to and the solution at this time contained the proper concentration. However there was no way to determine that the proper concentration of sanitizer had been used to sanitize food prep surfaces as the test strips were expired. This was confirmed in an interview with the Risk Manager and the Food Service Manager.