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.
|SUN BEHAVIORAL HOUSTON||7601 FANNIN STREET HOUSTON, TX 77054||Aug. 3, 2016|
|VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS||Tag No: A0116|
|Based on observation and interview, the facility failed to ensure that patient rights and the complaint line was clearly displayed and readily visible to patients, volunteers, employees and visitors entering the facility.
Observation of the lobby on 08/02/2016 at 0900 revealed that the facility had not posted a statement of duty to report abuse and neglect that included the complaint line phone number.
In an interview with CEO #52 on 08/02/2016 at 1500, he stated the complaint line phone number should be posted.
Observation of the lobby on 08/03/2016 at 1300 revealed that the patient rights and complaint line phone number were not prominently and conspicuously posted for display in the lobby that was readily visible to patients, volunteers, employees, and visitors.
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|Based on observation, interview and record review, the facility failed to ensure that 1 of 4 units had an RN physically present to supervise and evaluate the nursing care for each patient.
Observation on 08/02/2016 at 0930 of the first floor revealed two units: an inpatient Adolescent Program and an outpatient Adult Partial Hospital Program. The two programs were separated by a nurse ' s station and an accordion wall that divided the nurse ' s station into two nurse ' s station - one for each program. There were two patients on the Adolescent Unit. Staff included RN # 58 and MHT #67 on the Adolescent Unit. There was no RN on the Partial Hospital Program.
In an interview with Personnel #51 and RN #53 on 08/02/2016 at 0930 they stated:
There was three patients in the Adult Partial Hospital Program.
Two therapists and the van driver (an MHT) are on the unit during programming times.
There was no full time RN for the Partial Hospital Program.
The RN from the Adolescent Unit provided oversight for the Partial Hospital Program " temporarily until the census is up. "
Record review of Policy & Procedure, Staffing - Nursing dated 12/14/2015 revealed: " The staffing pattern ensures the availability of a registered nurse 24 hours a day. "
|VIOLATION: USE OF RESTRAINT OR SECLUSION||Tag No: A0154|
|Based on interview and record review, the facility failed to protect 1 (Patient #1) of 10 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and Patient #10) patients from mistreatment and abuse.
In an interview with RN #53 on 08/02/2016 at 1430, she stated Mental Health Technician (MHT) #59 secluded and " manhandled " Patient #1 in the patient ' s room. " What he did is inexcusable. He put his hand on Patient #1 ' s neck and turned him. "
In an interview with Personnel #51 on 08/02/2016 at 1300, she stated Patient # 1 was restrained and secluded in his room by MHT #59 on 05/21/2016. She also stated this incident was not self-reported to the state regulatory agency.
In interviews with Patients #2, #3, #4, #5, #6, #7, #8, #9, and Patient #10 on 08/03/2016 (0905-1005), they stated they had not witnessed nor experienced abuse from staff.
Record review of Policy & Procedure, Patient Rights and Responsibilities dated 12/14/2015 revealed: " Purpose: To ensure all hospital staff and contract staff shall observe these patients ' rights ... SUN Behavioral Houston has adopted the Statement of Patient Rights, in accordance with all Federal and State Regulatory requirements ... [P]atient ' s right to ... Remain free from restraint and seclusion of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. "