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 May 18, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to ensure safe room assignments for 2 of 12 patients (ID#s 9 and 10)

Findings include:

Review of patient census for 5/4/2018 revealed patients (ID# 2) and patient (ID#10) to be assigned as roommates in room 314 on the Children's unit.

Review of patient census for 5/5/2018 revealed patients (ID#2) and patient (ID#9) to be assigned as roommates in room 326 on the Adolescent Boys unit.

Medical record for patient (ID#2) revealed the following:
Initial Psychiatric evaluation by MD (ID# 65) dated 4/27/18 states:
Patient (ID# 2) is a [AGE]-year-old male admitted for aggression and suicidal behaviors. He refused to cooperate further. Per staff, patient (ID# 2) was showing his penis to his old roommate and asked to have sex. Similar event with another 2 peers also. Now on sexually acting out (SAO) precautions.

Physicians order by MD (ID# 65) dated 4/27/2018 states: continue unit restriction (UR), Suicide precautions (SP), Assault precautions (AP), elopement precautions (EP) and sexually acting out precautions (SAO)-perpetrator.

Interview with COO/CNO (ID# 53) on 5/18/2018 at 11:15 am he stated, that patients on SAO precautions should be in blocked room. He went on to say that the decision is individualized based on the nature of why the patient was placed on SAO precautions. When asked specifically if a male patient with a history of exposing himself to other males should be placed in a blocked room, he stated "yes."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and interview, the facility failed to document a physician's order for the transfer of 1 of 1 patients and the care provided at receiving hospital. (ID# 1)

Findings include:

Medical record review of patient (ID # 1) revealed Nurses note for 5/5/2018 stating: Patient was sent to Hospital this morning via ambulance for suspected inappropriate act between her and another peer. Morning Nursing Supervisor called mom this morning and gave consent for her daughter to be sent to the hospital. Report given to Nurse at (emergency room ) ER. Patient left via stretcher. Medical record revealed no written or verbal order from a physician for the transfer of patient (ID#1) or documentation of the care received at the receiving hospital once patient (ID#1) returned to facility.

Interview with Chief Medical Officer (ID# 53) on 5/18/208 at 9:34 AM revealed that he told the nurse on the phone to send the patient (ID # 1) to the hospital for an assessment and considered that an order.

Review of facility policy titled Transfer to Another Facility dated 1/2018 revealed:
Procedure:
If the physician on call issues orders for the transfers of a patient by telephone, those orders shall be recorded in the patient's medical record, read back and signed by the hospital nursing staff member receiving the order, and countersigned by the physician authorizing the transfer as soon as possible.

Review of facility policy titled Telephone, Verbal and Written Orders for Medication dated 5/2018 revealed:
Procedure:
-Record the verbal/telephone order immediately in the patient's medical record or, for pharmacists, on a prescription form as appropriate.
-Indicate either telephone or verbal order in written record.
-Sign the written record and indicate level of licensure.
The prescribing practitioner must date, time and authenticate the telephone/verbal order within the time designated by state law.

During an interview with CNO/COO (ID # 53) on 5/18/2018 9:17 AM he stated that the policy titled Telephone, Verbal and Written Orders for Medication is for all orders, not just medications.

During later interview on 5/18/18 at 11:15 AM with COO/CNO (ID#53) when asked if the nurse that accepted patient (ID # 1) back to the unit received report from the receiving hospital, he stated "they were so upset with what happened, they did not want to talk to us."