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.

SACRED OAK MEDICAL CENTER 11500 SPACE CENTER BLVD HOUSTON, TX 77059 July 12, 2018
VIOLATION: STANDARD TAG FOR OUTPATIENT SERVICES Tag No: A1081
Based on interview and record review, the partial hospitalization program (PHP) failed to ensure 10 of 10 sampled outpatient records contained the required patient information components per policy (Patients # 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30).

Findings include:

Record review on 07-12-18 of ten PHP patient records revealed the following:


a. History & Physical (H & P) Exam :

Patient # 21 : admitted to PHP program on 06-07-18; no H & P exam in record.


b. Registered Nursing (RN ) Assessments:

Seven patients had no RN assessments (Patients # 21, 22, 23, 24, 25, 28, and 30)

Three patients had completed nursing assessments forms but they were not signed or dated (Patients # 26, 27, and 29)


c. Psychosocial Assessments:

Five patients had no psychosocial assessments ( Patients # 21, 22, 23, 25, and 26 ).


d.Activity Assessments:

Five patients had no activity assessments (Patients # 21, 22, 23, 25, and 26).


e. Treatment Plan

Four patients did not have treatment plans ( Patient # 22, 23, 25, and 28). All four patients had been in the program greater than 7 program days.

During an interview on 07-12-18 at 11:00 a.m. with PHP Program Director # 15, she said, she was aware that the medical record requirments needed improvement and they would work to correct this.


Record review of facility policy titled "Assesssments & Reassessments", dated 3/23/18, read:

*"The nursing assessment shall be completed an RN on the first day of admission...

*The H & P is completed by a medical doctor within 12 months prior to admission or 30 days after admission..

*The psychosocial assessment shall be completed within seventy-two (72) hours of admission...

*The activity assessment must be completed by the Activity Therapist within seventy-two (72) hours of admission..."


Record review of facility policy titled "Master Treatment Planning & Patient Care", dated 3/23/18, read, " Policy: All patients shall have a Master Treatment Paln developed within seven (7) program days of admission..."
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, interview and record review:

Medical Staff:

The governing body failed to:

Appoint 3 of 3 physicians to the medical staff per the governing body bylaws.[refer A-0046]

Approve medical staff bylaws and rules and regulation per the governing body bylaws. [refer A-0048]

Grant clinical privileges to 3 of 3 physicians per the medical staff bylaws.[refer A-0363]


Patient Rights:

The governing body failed to ensure the rights of patients to receive care in a safe setting:

a. Four patients on suicide precautions had hazardous objects in their rooms ( Patient # 1, 2, 3, 4);

b. One patient eloped: facility failed to document, investigate, & implement preventative actions (Patient # 8);

c. Six patients were observed having difficulty navigating a known hazardous staircase at the facility outpatient location (Patients A, B,C,D,E,F). [refer A-0144]


The governing body failed to:

Ensure the right of one patient to remain free from verbal abuse (Patient # 5). [refer A-0145]


Outpatient Services

The governing body failed to :

Ensure outpatient services were provided in a safe setting. [refer A-0144]

Ensure 10 of 10 sampled outpatient records contained the required patient information components per policy (Patients #21, 22, 23, 24, 25, 26, 27, 28, 29, 30). [refer A-1081]
VIOLATION: MEDICAL STAFF - APPOINTMENTS Tag No: A0046
Based on record review and interview, the governing body failed to appoint 3 of 3 physicians per facility Governing Board Bylaws (Physician # 22, 23, 24).


Findings include:


Record review of facility Governing Board Bylaws, undated, read, "...Article 7: Hospital Governing Board Relationship with Medical Staff...7.2....The Board, after review and consideration of the recommendations Medical Executive Committee (MEC), shall be responsible for the appointment of the members of the Medical and Allied Health Professional Staff who are responsible for the provision of care, treatment, and services..."


On 07-11-18 at 9: 15 a.m., during an interview with Quality Director #1, she stated, she had been in her position since May 2018. The facility opened in August 2017. Quality Director was asked to provide all of the Governing Board meeting minutes since opening.


Record review of Governing Board meeting minutes revealed, one meeting was held on 5-10-18. There was two agenda items: approval of a pharmacy form and a "time & attendance" policy.


There were no governing body meeting minutes to verify the appointment of Physicians #22, 23, and 24 to the Medical Staff.


Interview on 07-12-18 at 1:45 p.m. with Executive Assistant # 23, she said, the directors met every month. She went on to say that the 05-10-18 governing board meeting minutes were the only governing body minutes located.
VIOLATION: MEDICAL STAFF - BYLAWS AND RULES Tag No: A0048
Based on record review and interview, the governing body failed to approve the Medical Staff Bylaws and rules and regulations.


Findings include:


Record review of facility Governing Board Bylaws, undated, read, "...Article 7: Hospital Governing Board Relationship with Medical Staff...7.1 Hospital Board of Trustees Approval of Medical Staff Bylaws: The Hospital Governing Board shall review and approve Medical Staff Bylaws, which shall provide for the organization and self governance of the Medical Staff and set forth its responsibilities..."


During an interview on 07-11-18 at 9: 15 a.m. with Quality Director #1, she stated, she had been in her position since May 2018. The facility opened in August 2017. Quality Director was asked to provide all of the Governing Board meeting minutes since opening.


Record review of Governing Board meeting minutes revealed one meeting was held on 5-10-18. There was two agenda items: approval of a pharmacy form and a "time & attendance" policy.


There were no governing body meeting minutes to verify their approval of the Medical Staff Bylaws and Rules & Regulations.


Record review of facility "Medical Staff Bylaws" and "Rules & Regulations" revealed an approval page for signatures of Medical Director, Medical Executive Committee, & Governing Board. The signature & date lines were blank for both the Medical Staff Bylaws and the Rules & Regulations.


Interview on 07-12-18 at 1:45 p.m. with Executive Assistant # 23, she said, the directors met every month. She went on to say that the governing body governing board meeting minutes dated 05-10-18 were the only governing body minutes located.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, and record review , the hospital failed to uphold the rights of 12 of 36 sampled patients.

The hospital failed to ensure patients receive care in a safe setting:

Four patients on suicide precautions had hazardous objects in their rooms (Patient # 1, 2, 3, and 4);

One patient eloped. The facility failed to document, investigate, and implement preventative actions (Patient # 8);

Six patients were observed having difficulty navigating a steep staircase at the facilty outpatient location (Patients A, B, C, D, E, F) .

refer A-0144


The hosptial failed to ensure the rights of one patient to be free from verbal abuse (Patient # 5).

refer A-0145
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, and record review, the facility failed to ensure care was provided in a safe setting for 11 of 36 sampled patients (Patient # 1, 2, 3 ,4, 8, and Patients A, B, C, D, E, F). The facility:

*Failed to ensure hazardous items were not readily available to four patients currently on suicide /self harm precautions (Patients # 1, 2 , 3, and 4 ).

*Failed to document, investigate, and implement preventative actions related to recent elopement of Patient # 8.

*Failed to ensure safe entry and exit into facility outpatient partial hospitalization program (PHP) for 6 patients ( Patients A, B,C, D, E, and F) .


Findings include:


Hazardous Items: Patients on Suicide Precautions:

Review of facility policy titled "Suicide Precautions," dated 5/2017, read, "Purpose: To ensure a safe environment for potentially self-destructive patients...Policy:...All harmful objects shall be removed from the patient's possession..."


Record review on 07-11-18 of current patients on "Close Observation" records revealed 11 patients were currently placed on suicide precautions.


Observations during initial tour of the facility on 07-11-18, between 9:30 and 10:30 a.m., revealed the following hazardous items in the rooms of 4 patients currently listed on "suicide precautions":


Patient # 1 and # 2 (roommates-both on suicide precautions): two (2) ink pens (approximately 3.5 inches in length) and a small can of chewing tobacco.

Patient # 3: shirt with thin straps able to be torn off, one ink pen, and one 16 ounce bottle of shampoo that contained alcohol.

Patient # 4: bra with thin straps able to be torn off and one ink pen.


Interview at the time of observation with Behavioral Health Staff (BHS) # 6, she stated the items found were hazards and removed them immediately.


Patient # 8 : Elopement:

Record review of Patient #8's clinical record revealed a "Psychiatric Evaluation," dated 06-27-18, that read, "...the patient is a [AGE] year old female...admitted to a (local) ER because of depression and psychosis...the patient was psychotic and believed that people are stealing her organs...Mental Status Exam:...mood is anxious with blunted affect...her thought process is disorganized. Her insight and judgement are limited...Diagnosis: Schizoaffective disorder, bipolar type..."


During an interview on 07-11-18 at 9:30 a.m. with Registered Nurse (RN) # 3, he stated, there had been a patient elopement in June, "I think it was on 6-27-18, not sure." RN # 3 went on to say the charge nurse, staff nurse, and administration were all aware this occurred. RN # 3 said, he thought a visitor for a different patient saw this patient outside and brought her back into the building. He later said the patient who eloped was Patient # 8.


RN # 3 stated, the patient exited the facility through a door on the first floor which remained unlocked. RN # 3 led surveyor down the 2nd floor stairwell and to the 1st floor door to which the patient exited the building.


Observation of the door revealed it had a security "badge swipe" mechanism that showed a red light. RN # 3 stated, "this red light meant the door was secured/locked and could not be opened without a badge swipe." RN # 3 did not swipe his badge and pushed open the door.


During an interview on 07-11-18 at 10:15 a.m. with Nurse Manager /RN # 2, she stated she was unaware of a recent elopement but would look for an incident report.


During an interview on 07-12-18 at 3:30 p.m. with RN # 5, she stated, a couple of weeks prior "one of my patients got out." RN # 5 said, the patient was in room 212, Patient # 8, the room at the end of the hall (second floor). RN # 5 said, "it was raining hard that day and that may have been the issue with the doors". RN # 5 reported that she informed Nurse Manager # 2 and the house supervisor about the incident but did not complete an incident report because she did not witness it. She said, she was at lunch and was unsure how long the patient was off the unit. RN # 5 did not know how Patient # 8 was able to exit the second floor.


During an interview on 07-12-18 at 4:15 p.m. with Quality Director # 1, stated, she did not receive an incident report regarding the elopement of Patient # 8. Surveyor showed Quality Director # 1 the door on the first floor to which Patient # 8 had eloped.


Observation at same time revealed Quality Director was able to push open the door without swiping her badge to unlock the door. Quality Director # 1 stated, she had no knowledge of how Patient # 8 eloped from the second floor to the first floor or how long she had been out of the building. Quality Director # 8 stated, the door should have been repaired and an incident report and investigation should have been completed.


Record review of facility policy titled " Occurrence Reporting: Quality/Risk Management," dated 1/2017, read, " Policy:...To provide ..mechanism of identification, tracking...and follow-up of all incidents that pose an actual or potential safety risk to patients...Definitions:...Near Miss: any process variation which did not affect the outcome but for which a reoccurrence carries a significant chance of a serious adverse outcome... Purpose: The Occurrence Report can help...administration in identifying potential areas of risk and implementing measures to prevent future claims..The benefits from prompt reporting include: corrective actions can be taken...Procedure:...c. Any hospital staff member who witnesses, discovers or has direct knowledge of an occurrence should complete an Occurrence Report with 2 hours..."


Unsafe Entry and Exit, PHP off-site location :


Observation on 07-12-18 at 8:30 a.m. of the hospital's off-site PHP location revealed the following:


A two (2) story building with a furniture store located on the first floor. The second floor had signage that indicated it was the location of the hospital's "Behavioral Health & Addiction Treatment Center."


On the right side of the building, there was an external set of concrete stairs that were attached to the building. The stairway contained 17 steps with an additional 4 steps that angled up from the main stairway. The steps were approximately 12 inches in height and appeared steep.


Continued observation on 07-12-18 at 8:45 a.m. revealed, two multi-passenger vans that pulled up to the facility near the external stairway. Approximately 15 people exited each of these two vans. The first group of 15 people had 2 persons observed with canes who struggled to navigate up the stairs ( Patients A and B), and one person with no assistive device who was observed to require staff to hold her arm and help up the stairs (Patient C).


Surveyor climbed the stairs in between the two groups and observed the second group of people from the landing at the top of the stairs. Two persons in the second group visibly struggled with the steps, one of them stumbled (Patients D). A third person was observed exiting the van and used a walker to ambulate. He left his walker at the bottom of the steps and was observed to have great difficulty going up the stairs. Although staff assisted him, at one time, he was observed stopping and grasping the handrail with both hands to steady himself (Patient F).


During an interview on 07-12-18 at 9:15 a.m. with Behavioral Health Staff (BHS) # 19 he stated, "we know the steps are steep and are a safety issue...that's why I think a lift has been ordered."


During an interview on 07-12-18 at 10:10 a.m. with PHP Program Director # 15, she stated, that a lift had been ordered for the exterior stairs but she was unsure when it would arrive. Surveyor requested a copy of the purchase order and information about the lift.


Record review on 07-17-18 of purchase order and invoice documentation provided by the facility revealed, the external lift for the PHP was ordered on 01-16-18 and delivered on 03-01-18.


During an interview via telephone on 07-17-18 at 3:30 p.m. with PHP Director # 15, she confirmed the lift had been delivered on 03-01-18. She went on to say she did not know the reason it had not been installed for over 4 months. PHP Director was unable to obtain an installation date; but said the lift required a verification inspection after installation.


Record review of PHP policy titled : "Patient Rights and Responsibilities," dated 3-23-18, read, "...Policy: (facility) shall adopt the Statement of Rights...all facility staff...performing patient care activities shall observe these rights...The Statement of Rights shall include...the patient's right to considerate...care provided in a safe environment..."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**




Based on interview and record review, the facility failed to ensure the right of Patient # 5 to be free from verbal abuse.


Findings include:


Observation on 07-12-18 at 1:30 p.m. revealed, Patient # 5 standing in the hallway. Patient # 5 approached surveyor and asked "are you the lady with the state?" He then asked to speak privately with the surveyor.


Continued interview with Patient # 5, he said, "I have a history of Chronic Obstructive Pulmonary Disease(COPD). I am on oxygen at night because I can't breathe well. Late yesterday afternoon, they had a fire drill and we all had to go outside. They made me stand right next to the people who were smoking and I couldn't breathe. I told the tech I couldn't breathe and she told me 'well, go stand over there if you can't breathe.' He said, the tech told him to stand in the sun and it was very, very hot. Patient # 5 went on to say the tech's tone was "very hateful and very intimidating". He then said, "I know a lot of people just think we are just wackos but we should not be treated that way."


Record review of the clinical record of Patient # 5 revealed, he was a [AGE] year old male, admitted to the hospital on 07-09-18 with diganosis of severe depression and alcohol dependence. Review of Patient # 5's History & Physical examination, dated 07-10-18, read, "history of COPD ..patient uses oxygen at night at 3 liters.." Review of nursing assessment, dated 7-10-18,read, "patient alert and oriented to person, time, and place..."


Review of facility "Patient Bill of Rights," read: "...3. You have the right to ..a humane environment...and are treated with respect and dignity...5. You have the right to be free from mistreatment, abuse..."
VIOLATION: CRITERIA FOR MEDICAL STAFF PRIVILEGING Tag No: A0363
Based on record review and interview , the governing body failed to grant clinical privileges per facility Medical Staff Bylaws to 3 of 3 physicians ( Physicians #22, 23, and 24).


Findings include:


Interview on 07-12-18 at 2:30 p.m. with Director of Infomatics #10, she stated, the facility had an agreement with a medical credentialing service to verify and provide information necessary to grant physician clinical privileges.


She went on to say, there were no physician credential files kept on site but the credentialing service sent portions of the files to her electronically.


Surveyor requested to review the approved delineated privileges for Physicians # 22, 23, and 24.


Review on 07-12-18 of the electronic credential files with Director of Infomatics # 10 revealed the following:


Physician # 23 : (attending psychiatrist) : no approved privilege list located; located only results from query of National Practitioner's Data Bank (NPDB).


Physician # 22 : (attending psychiatrist) : no approved privilege list found; located only a form with this physician's name on the top, titled "'Quality Review List" that read: " no approved privilege list."


Physician # 24 : (internal medicine physician):form entitled "Delineation of Clinical Privileges". There was a column tilted "REQUESTED" that contained check marks; there were two (2) other columns titled "GRANTED"and"DENIED." The form was was signed and dated by the "governing body," however, the "GRANTED" and "DENIED " columns were left blank.


Record review of facility "Medical Staff Bylaws", undated, read, "...Article 7 : Determination of Clinical Privileges:...7.1 Exercise of Privileges:: Every member...providing direct patient care...shall be entitled to exercise only those Clinical Privileges specifically granted to him by the Board..."
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**




Based on record review and interview, the facility failed to keep current nursing care plans for 5 of 20 sampled hospital patients (Patients # 5, # 6, # 8, # 10, and # 13 ).


Findings include:


Review of facility policy titled "Plan of Care", dated 3/2017, read, "Procedure: 1.The patient's needs are identified from the information contained on the initial intake form and the initial nursing assessment...6. Goals and objectives will be revaluated and as necessary, revised based on changes in the patient's condition, problems, needs and response to care.."


Patient # 5:

Record review of the clinical record of Patient # 5 revealed, he was a [AGE] year old male, admitted to the hospital on 07-09-18 with diagnosis of severe depression and alcohol dependence. Review of Patient # 5's History & Physical examination, dated 07-10-18, read, "history of COPD...patient uses oxygen at night at 3 liters.."

Interview on 07-12-18 at 1:30 p.m. with Patient # 6, he stated, he use oxygen at night to help him breathe.

Review of Patient # 5's "Individualized Interdisciplinary Treatment Plan" failed to reveal COPD and oxygen use listed as a problem.


Patient # 6:

Record review of the clinical record of Patient # 6 revealed, he was a [AGE] year old male, admitted to the hospital on 07-01-18 with diagnoses of psychosis and auditory hallucinations.

Review of Patient # 6's History & Physical examination, dated 07-02-18, read, "history of diabetes mellitus.." Review of physician orders for Patient #6 revealed an order dated 07-02-18 for Lantus insulin per sliding scale blood sugar results.

Review of "Diabetic Medication Administration Record (MAR)" for Patient # 6 revealed, between 07-02-18 and 07-05-18, Patient # 6 had been administered Lantus insulin six times based on blood sugar results.

Review of Patient # 6's "Individualized Interdisciplinary Treatment Plan" failed to reveal diabetes mellitus and sliding scale insulin listed as a problem.


Patient # 8

Record review of Patient #8's clinical record revealed a "Psychiatric Evaluation" dated 06-27-18, that read, "...the patient is a [AGE] year old female...admitted to a (local) ER because of depression and psychosis...the patient was psychotic and believed that people are stealing her organs...Mental Status Exam:...mood is anxious with blunted affect...her thought process is disorganized. Her insight and judgement are limited...Diagnosis: Schizoaffective disorder, bipolar type..."

During an interview on 07-11-18 at 9:30 a.m. with Registered Nurse (RN) # 3, he stated, there had been a patient elopement in June; "I think it was on 6-27-18; not sure." He later said, the patient who eloped was Patient # 8.

Interview on 07-12-18 at 3:30 p.m. with RN # 5, she stated, a couple of weeks prior "one of my patients got out." RN # 5 said, the patient was in room 212 - Patient # 8.

Review of Patient # 8's "Individualized Interdisciplinary Treatment Plan" failed to reveal elopement listed as a problem.


Patient # 13 :

Record review of the clinical record of Patient # 13 revealed, he was a [AGE] year old male, admitted to the hospital on 01-10-18 with diagnosis of Schizoaffective disorder, bipolar type and "underlying seizure disorder."

Review of Patient #13's "Individualized Interdisciplinary Treatment Plan" failed to reveal seizure disorder listed as a problem.

Review of Patient # 13's daily nursing assessments revealed, he experienced two petit mal seizures on 01-11-18. An additional seizure was documented on 01-12-18 that resulted in a fall. Patient # 13 being transferred to an acute hospital for evaluation and treatment.


Patient # 10 :

Record review of the clinical record of Patient # 10 revealed, she was a [AGE] year old female, admitted to the hospital on 01-08-18 with diagnoses of altered mental status, depression, and a history of dementia.

Review of Patient # 10's History & Physical examination, dated 01-09-18, read, " history of diabetes mellitus...pt will be on low dose sliding scale insulin.."

Review of Patient #10's "Individualized Interdisciplinary Treatment Plan" failed to reveal diabetes mellitus and sliding scale insulin listed as a problem.


During an interview on 07-12-18 at 1:45 p.m. with Nurse Manager # 2, she stated, all of the patient's active medical issues, as well as any change in condition should be addressed on their care plan.
VIOLATION: OUTPATIENT SERVICES Tag No: A1076
Based on observation, interview, and record review, the facility failed to ensure outpatient services met the needs of the patients in accordance with acceptable standards of practice and facility policy.


The hospital failed to ensure safe entry and exit into the facility's outpatient partial hospitalization program (PHP) for 6 observed patients and placed unknown numbers of other patients at risk.
refer: A-144


The hospital failed to ensure outpatient services complied with polices regarding availability of critical patient information such as medical History & Physical exam, Registered Nurse (RN) assessments, psychosocial assessments, and treatment plans.
refer A-1081