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.

HOUSTON BEHAVIORAL HEALTHCARE HOSPITAL LLC 2801 GESSNER ROAD HOUSTON, TX 77080 April 12, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on record review and interview, the facility failed to ensure care in a safe setting for 1 of 4 sampled patients who voiced allegations of sexual boundary issues ( patient # 10).

The facility failed to fully investigate the alleged incident(s) and failed to inform the patients' physician of the alleged incidents.

Findings include:

Record review of facility incident log for 2018 revealed documented allegations made by Patient # 10 on 03-02-18.

Further review of the Incident Report, dated 03-2-18 : " Incident Type: Sexual Familiarity with a peer.....patient's roommate reported that patient # 10 had sex in the bathroom and bed of their room with another patient."

The Incident Report section titled " Initial Findings & Outcomes" ( "to be completed by Nursing Supervisors or Department Director") was left blank. The section for signature and date for "Follow-Up Action Taken " was left blank.

It was documented the patient advocate spoke with Patient # 10 and attempted to telephone the male patient, who was discharged . Patient # 10 and her roommate Patient # 11 both submitted written statements. There was no documentation to indicate the patients' physicians had been informed.

Record review of Patient # 10's clinical record revealed a "clinical summary intake", dated 2-23-18, that read: "... patient reports she was sexually assaulted a few days ago by an unknown person...review of admission orders, dated 2-24-18, revealed Patient #10 was placed on " SAO / [Sexual Acting Out] " precautions..." Patient #10 was on SAO precautions on the day of the alleged incident ( 3-01-18).

Interview on 04-12-18 at 1:15 p.m. with Director of Performance Improvement and Risk Management (PI/RM) # 3, he stated he recalled this incident being discussed at the morning flash meeting. He went on to say that both patients were close to discharge ; maybe even that day. He acknowledged the facility investigation and follow up should have been better documented. He further stated both patients' physicians should have been notified.

Record review of facility policy titled "Incident Report," dated 10-21-2014, read: "Purpose: ..The goal of this policy is to improve quality of services by identifying causes of the events and instituting corrective actions as necessary to minimize and/or eliminate the potential for injury..."

Record review of facility policy titled " Patient Rights & Responsibilities," dated 01-/10/2018, read: "...C. The Patient's Bill of Rights shall include, but is not limited to, the patient's right to:...3. Considerate, dignified, respectful care, provided in a safe environment, free form all forms of abuse, neglect, harassment and/or exploitation..."
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on interview and record review, the facility failed to ensure the treatment plan for 1 of 4 discharged patients was individualized based on findings of the psychiatric examination and nursing assessment ( Patient # 10).

The treatment plan for Patient # 10 did not include : Sexual Acting Out (SAO) precautions and current medical diagnosis of hypertension.

Findings include:

SAO Precautions:

Record review of initial preadmission evaluation , by MD psychiatrist, dated 2/24/18, read: "... Patient reports she was sexually assaulted a few days ago by an unknown person...review of admission orders, dated 2-24-18, revealed Patient #10 was placed on " SAO precautions..."

Record review of Patient # 10's "Master Treatment Plan," dated 2/24/18, failed to reveal SAO precautions listed as a problem.

Interview on 04-12-18 at 1:30 p.m. with with Director of Performance Improvement and Risk Management (PI/RM) # 3, he stated if SAO precautions were ordered, this should be noted on the treatment plan.

Record review of facility policy titled ""Sexually Acting Out Precautions", dated 03/01/2017, read: "...4. SAO precautions will be addressed on the Treatment Plan.."

Hypertension:

Further review of Patient # 10's clinical record revealed the following:

*"Clinical Summary Intake" , dated 2/23/18 ( 2330) it read: ...Patient's BP ( blood pressure) reassessed : 192/122..."

*Physician order, dated 03-01-18 (11:45) for Clonidine 01.milligram by mouth ..."
[Clonidine is a medication to control blood pressure]

*"Hand Off Risk Notification," dated 2/24/18 at 0221 (time) by receiving RN, read: "Identified Medical Conditions : Hypertension/high blood pressure.."

Record review of Patient # 10's "Master Treatment Plan," dated 2/24/18, listed hypertension as a "chronic". Hypertension was not addressed as a current, individual problem on Patient #10's "Individual Treatment Care Plan."

Record review of facility policy titled "Master Treatment Plan", dated 03/01/18, read: "l. Policy: A. Every patient shall have an individualized, comprehensive Master Treatment Plan. B. The needs...and goals of the patient are identified based on multi-disciplinary screening and assessments...lll. Procedure: A. The patient's needs are identified from the information contained on the initial intake form, initial nursing assessment....and psychiatric and medical evaluations..."