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.

WEST OAKS HOSPITAL 6500 HORNWOOD HOUSTON, TX 77074 May 15, 2018
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure safety requirements were met for one (1) of 5 current sampled patients ( Patient # 1 ).

Findings include:

TX 003

Record review of Patient # 1's medical record revealed he was a [AGE] years old male admitted to the facility on on [DATE] for suicidal ideation with plan; aggression, violence, threatening others and property.

Further review of Patient # 1's medical record revealed a form titled:"Psychosocial Assessment-Adolescents & Children", dated 04-24-18 documented by LMFTA (Licensed Marriage & Family Therapist ) # 10 that read: "...History of Sexual Abuse (indicated by check mark):" (stepfather's) son sexually abused me ...":

Further review of Patient # 1's"Intake Integrated Assessment," dated 4/23/18, read: section titled: "ABUSE AND SEXUAL VICTIMIZATION/PERPETRATION (facility capitalization) ": History of abuse? "YES"; Describe: "physical & sexual" Perpetrator: "Mom's ex-husband's son". "Potential for Victimization" 'Victim of Sexual Abuse" was indicated by check mark :"Potential for Perpetration": "History" was indicated by check mark and underline. Form read: "If patient has been victimized, place on Sexual Victimization Protocol."

Record review of physician admission orders, dated 4-24-18, included the following: group, recreational, individual & family therapies; Precautions: unit restriction(UR), suicide precaution. There was no order for Sexually Acting Out (SAO) precautions. Patient # 1 was not placed on SAO precautions until after he made allegations of sexual assault by his roommate on 05-03-18.

Interview on 05-15-18 at 1:45 p.m. with Chief Nursing Officer (CNO) # 2, he sated the SAO precautions should have been ordered on admission.

Record review of facility policy titled "Levels of Observation," dated 2/18, read: "...Special/Precautions:...C. Sexual Acting Out (SAO) Precautions-Sexual Aggressor/ Sexual Victim...2. Patients who have history of being sexually abused/assaulted will be placed on this precaution. These patients may be at risk to be victimized again, or to act out sexually.."
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure 3 of 10 sampled patients had complete or updated treatment plans ( Patients # 1, 3, 8 ).

Findings include:

TX 003

Patient # 1:

Record review of Patient # 1's medical record revealed he was a [AGE] year old male admitted to the facility on on [DATE] for suicidal ideation with plan; aggression, violence, threatening others and property.

Record review of nurse's note, dated 05-02-18 (2135) read:" ...pt : accused his roommate- that roommate tried to sexually abuse him...." Patient # 1 was sent to local children's hospital for sexual assault exam the next day; returned to facility the same day.

Record review of Patient # 1's "Master Treatment Plan," initiated 4/25/18; updated 5/6/18, failed to reveal review /update related to allegation of sexual abuse and subsequent forensic exam.

Record review of Patient # 1's "Initial Nursing Treatment Plan", dated 4/25/18, showed "none" checked for category :"Risk of Sexual Victimization"; although Patient # 1 had several assessment notations on admission 4/23/18 of history of sexual abuse.

Patient # 3:

Record review of Patient # 3's medical record revealed he was a [AGE] year old male admitted to the facility on [DATE] with hypersexual activities (filming under his aunt's dress).

Record review of Patient # 3's "Initial Nursing Treatment Plan", dated 5/08/18 revealed " Inappropriate Sexual Behavior" listed as a problem, with documented Goal of : "(patient)will display appropriate boundaries with others" Target Date was 5/18/18. There were no interventions identified; no frequency of interventions; and no identified staff responsible.

Patient # 8:

Record review of Patient # 8's medical record revealed she was an adolescent female patient admitted on [DATE].

Record review of Patient # 8's "Initial Nursing Treatment Plan", dated 2/13/18 revealed " Assault / Aggression " listed as a problem. There were no interventions identified; no frequency of interventions; and no identified staff responsible.

Interview on 05-15-18 at 2:15 p.m. with Chief Nursing Officer (CNO) he stated the treatment plans should be updated when new problems arose and nursing should identify specific interventions, frequency, and responsible staff.

Record review of facility policy titled " Master Treatment Plan/Reassessment", dated 12/17, read: "10.. treatment plans ..are individualized for patients and used by each discipline..there are individual steps for pursuing & achieving long term goals. The frequency must be identified and the responsible staff...Treatment Plan reviews shall be completed every 7 days or initiated when there is a significant change .....which may include: b. Major change in a patient's behavior addition of a new problem."