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 Nov. 2, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview and record review, the facility failed to ensure patients' rights to receive care in a safe setting, as revealed by the fact that seven out of a total of 19 patients on the children's unit (Unit 5) were not wearing an identification wristband.

Findings included:

#TX 993

Observation on 10/31/18 at 10:00 am of facility's Unit 5, the Children's unit, revealed there were seven (7) patients out of a total census of 19 patients, with no identifier wrist bands being worn.

In an interview on 10/31/18 at 10:15 am, MHT Staff #56 stated that everyone should have been wearing a wristband. She added that staff were familiar with all the children, including the med nurses. She also stated that the children like to pull-off their wristbands. However, MHT Staff #56 stated it was definitely a safety issue when it came to medication administration and for general identification of all patients, and proceeded to have the issue corrected immediately.

Record review of facility policy titled "Procedure for Initial Identification of a Patient" dated 3/17, it stated "Action steps: ....Patient will be given a wrist band with their name and date of birth."

Record review of facility policy titled "Electronic Medication Administration Record" dated 7/2016, it stated "B. Check the 6 Rights each time a medication is given: Right Patient: Positively identify the patient by two (2) means before giving the medication. Look at the patient's picture and ID wrist band ...".


Based on observation, interview, and record review, the facility failed to ensure the patients' rights to care in a safe setting as revealed by eight (8) out of 20 vacant patient rooms being unlocked.

Finding included:

#TX 993

Observation on 10/31/18 at 10:20 of facility's Unit 5 revealed there were five (5) vacant patient rooms, which housed two patients at a time, that were unlocked (Rooms 504, 505, 506, 507, 508).

In an interview on 10/31/18 at 10:20, MHT Staff #56 stated that all of the vacant rooms should have been locked because it was a patient safety issue; a patient might be able to sneak into an unlocked room and cause self-harm and/or harm to others.

Observation on 10/31/18 at 10:35 am of facility's Unit 8 revealed there were three vacant patient rooms which were unlocked (Rooms 801, 806, and 807).

In an interview on 10/31/18 at 10:40 am, MHT Staff # 57 stated that all vacant patient room doors should have been locked for patient safety reasons.

Record review on 10/31/18 at time of survey of the facility's Patient Handbook, dated August 2018, page 17 of 32, stated "PATIENT ROOMS .....Patient rooms will be closed and locked during programming hours."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on record review and interview, the facility failed to ensure that 1 of 15 sampled patients did not have restraint and seclusion orders signed by a physician, as evidenced by Patient #10 having four (4) out of seven (7) restraint and seclusion orders which were unsigned by a physician.

Finding included:

#TX 9933

Record review on 11/1/18 at time of survey of Patient #10's medical records revealed the patient was restrained and secluded on seven (7) separate occasions. Four (4) out of the seven (7) orders were not signed by the physician (9/20/18, 9/21/18, 9/24/18/ and 10/5/18).

In an interview on 11/1/18 at 12:00 pm, QAPI Director Staff #54 stated that all of the orders for the restraint and seclusions for Patient #10, should have been signed by the physician.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
The registered Nurse failed to supervise and evaluate the care for each patient, by ensureing the correct dates were written on the patients rounding document.

1. Record review of Patient #15's Observation sheets revealed that there were two Observation Sheets Dated 4/10/2018 sheet one form 0045 till 0700 had the patient documented at being in Intake, Sheet two had the patient in her bedroom laying down.

Interview #1 with the Director of Performance Improvement (PI) Staff # 54 on 11/1/2018 at 10:30am revealed that the Director of Performance Improvement acknowledged that Patient # 15 had two different 15-minute safety round sheets that indicated the patient was in two different places at the same time. Sheet One indicated patient was in her bedroom and sheet two indicated she was in Intake. She said it was mistake in documentation of the date.

Interview with CNO-Staff #52 on 11/1/2018 at 1100 he expressed that the nurses dated it wrong and that to "error is human".

2. Record Review of Patient #1's Observation rounds/precautions revealed two observation sheets with the same date of 4/10/2018 showing that the patient was in two different places at the same time.

3. Record review of Patient #14's Observation sheet dated 8/9/2018 from 1845 to 2145 showed the patient in two different places at the same time. Sheet one indicated the patient was in her room and sheet two indicated that she was in intake.

4. Record Review of Patient #18's Observation sheets revealed 2 Observation sheets with the same date and times. Multiple time spans with patient being documented in different areas.

5. Record Review of Patient #6's Observation sheets revealed 5 sheets dated 10/23/2018 4 of the observation sheets were Every 5 minute rounds and the other 1 sheet was every 15-minute rounding sheet. Sheet one had patient in intake from 1535 till 1555 sheet two had the patient in their room from1530-1545 then in the dining room from 1545 till 1630.