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WEST OAKS HOSPITAL 6500 HORNWOOD HOUSTON, TX 77074 Feb. 13, 2019
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview, and record review, the facility failed to ensure care in a safe setting for 3 of 3 patients.

Two(2) patients on suicide precautions had safety hazards in their rooms;

One(1) patient had a prescribed medicated shampoo left in her room.

[Citing Patient IDs # 12, 17,18]

Findings included:

Review of facility policy titled "Levels of Observation", last revised date 5/2016, stated for suicide precautions, staff are to maintain a safe and therapeutic environment for all patients....additional safety interventions are implemented for patients on suicide precautions.

Patients 17 & 18:

Observation on 02-13-19 at 11:00 AM during a tour of Unit 1 showed the following in two patients' rooms:

Patient# 17: toothpaste, toothbrush, deodorant, body wash lotion;

Patient # 18: toothpaste, toothbrush, deodorant, body wash lotion.

Record review on 02-13-19 of physician orders for Patients 17 & 18 showed both of these patients were currently on suicide precautions (SP).

During an interview with Staff H, Registered Nurse (RN), at the time of observation, she stated these items were hazards and should not be left in the rooms of a patient on suicide precautions. She said staff made rounds after showers and personal care products were not to be left in rooms.

Patient # 12:

Continued observation on 02-13-19 at 11:15 AM in Patient #12's room showed a small clear "medicine cup" located on a shelf by the window. The cup had a small amount of red liquid in it.

Additional observation at this same time showed a full medicine cup of red liquid located on the shelf that contained Patient # 12's belongings.

During an interview at the time of observation with Staff H, RN charge nurse, she was unable to state what the red liquid was in these cups.

During an interview on 02-13-19 at 11:30 AM with Staff K , medication nurse Licensed Vocational Nurse (LVN ), she stated the red liquid was likely the medicated shampoo prescribed for this patient.

Review of the prescription bottle label for Patient # 12 showed "Ketoconazole Shampoo 2 % apply at night". Staff K removed the cap; the shampoo was red.

Record review on 02-13-19 of Patient # 12's Medication Administration Record (MAR) showed the following order, dated 02-06-19 :"ketoconazole topical 2% (Nizoral Topical)-every night at bedtime for 14 days for tinea capitus" [fungal infection that is also known as 'ringworm'].

During an interview on 02-13-19 at 11:45 AM with Staff H, charge RN, she stated shampoo should not be placed in a medication cup, as it could be accidentally ingested by a patient. She went on to say that medicated shampoo should be placed in a styrofoam cup by staff and given to the patient immediately prior to the shower. The cup should be disposed of right after the shower.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, nursing staff failed to complete a nursing assessment per shift for 2 of 7 current sampled patients on Unit 6 (Patient ID #1, # 5).

Findings included:

Record review of the facility policy titled "Nursing Documentation,"revised 1/2014, showed patients who are on precautions will have an assessment completed and documented every shift.

Patient # 1

Record review of Patient # 1's medical record showed she was a [AGE] year-old female admitted to the facility on on 02-11-19 at 9:25 AM with diagnosis of suicidal ideation and history of cutting. Physician admission orders, dated 2-11-19, included the following precaution levels: unit restriction, suicide precautions, elopement precautions, sexual-aggression and sexual-victimization precautions.

Review of the nursing assessments for Patient # 12 showed the initial nursing assessment was performed on 02-11-19 at 1:32 PM. Further review failed to reveal a documented nursing assessment on 02-11-19 for the 3 PM to 11 PM shift and for the 11 PM to 7 AM shift.

Patient # 5:

Record review of Patient # 5's medical record showed she was a [AGE] year-old female admitted to the facility on on 01-25-19 with aggression, impulsivity and bipolar disorder. Physician admission orders included the following precaution levels: unit restriction, suicide precautions, elopement precautions, assault/homicide precautions and sexual-victimization precautions

Review of the nursing assessments for Patient # 5 failed to reveal a documented nursing assessment on 02-08-19 for the 3 PM to 11 PM shift.

During an interview on 02-12-19 at 1:00 PM with Staff F, charge nurse, she was unable to locate the [above mentioned] nursing assessments for Patients # 1 and # 5. Staff F said there should be a documented nursing assessment for the day and evening shifts, and a "sleep note" for the night shift.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, interview, and record review, nursing services failed to ensure drugs and biologicals were prepared and administered according to accepted standards of practice.

[citing Patient # 12]

Findings included:

Record review of facility policy titled:"Electonic Medication Administration Record." dated 2/ , stated " observe patients taking medications." [In this case it was a topical medication).

Patient # 12:

Observation on 02-13-19 at 11:15 AM in Patient #12's room showed a small clear "medicine cup" located on a shelf by the window. The cup had a small amount of red liquid in it.

Additional observation at this same time showed a full medicine cup of red liquid located on the shelf that contained Patient # 12's belongings.

During an interview at the time of observation with Staff H, RN charge nurse, she was unable to state what the red liquid was in these cups.

During an interview on 02-13-19 at 11:30 AM with Staff K , medication nurse Licensed Vocational Nurse (LVN ), she stated the red liquid was likely the medicated shampoo prescribed for this patient.

Review of the prescription bottle label for Patient # 12 showed "Ketoconazole Shampoo 2 % apply at night". Staff K removed the cap; the shampoo was red.

Record review on 02-13-19 of Patient # 12's Medication Administration Record (MAR) showed the following order, dated 02-06-19 :"ketoconazole topical 2% ( Nizoral Topical) -every night at bedtime for 14 days for tinea capitus" [fungal infection that is also known as 'ringworm'].

During an interview on 02-13-19 at 11:45 AM with Staff H, charge RN, she stated shampoo should not be placed in a medication cup, as it could be accidentally ingested by a patient. She went on to say that medicated shampoo should be placed in a styrofoam cup by staff and given to the patient immediately prior to the shower. The cup should be disposed of right after the shower.