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 Sept. 12, 2018
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on review of facility documents and staff interview, the facility failed to correct the previously cited deficiencies as evidence by:

* Failed to ensure that the Plan of Correction regarding the condition and overall hospital environment was implemented and fulfilled by the facility completion date.

* Issues with the hospital environment and construction to maintain the safety of patients persisted during the survey on 09/10/18 to 09/12/18.

Findings included:

During a tour of the facility inpatient areas on 09/10/18 the following observations were made:

* In the dining room area, the female restroom had metal soap dispensers on the wall that were not break away. This presents a risk of patient injury, including ligature risk. As of survey exit on 09/12/18 the metal soap dispensers had been removed in the female restroom.

* In the dining room area, the male restroom had regular fixtures present on the sinks, presenting ligature risks. There also was an exposed screw observed in the divider between urinals. Metal toilet paper holders were observed the stalls with screws present in the hardware. In an interview on 09/10/18 the Director of Plant Operations stated the facility had ordered anti-ligature fixtures for the male restroom and "they may actually be here". The Director of Plant Operations showed the surveyor the boxes of new anti-ligature fixtures for placement in this restroom.

* During observation of lunch on 09/10/18 a surveyor noted that patients (male and female) were using the restroom independently and unmonitored. At times a Behavioral Health Specialist would be observed standing beside the restroom door, but did not escort patients into the bathroom.

* It was observed the fire alarm strobes in the restrooms remained uncovered. In an interview on 09/10/18, the Director of Plant Operations confirmed the strobes were the same as before. He stated the facility had ordered globe covers for the strobes from Grainger. The Director of Plant Operations provided the surveyor an invoice from Grainger that the strobe cover stopper domes were ordered on [DATE]. As of survey exit on 09/12/18 the strobe dome cover were not in place.

* In the seclusion room it was noted that an emergency call system was located in the wall of the ante room, where staff would be located to visually monitor patients in seclusion. This surveyor pushed the alarm button with the Director of Plant Operations present. The Plant Operations stated the alarm should produce an audible alarm at the nursing station. The surveyor and Director of Plant Operations approached the nurses station, no alarm was audible. The Director of Plant Operations then identified that the alarm system was not plugged in appropriately at the nurse's station, upon plugging the system back in, the alarm was audible. In interview on 09/12/18 the facility Quality Director confirmed that the seclusion room has been utilized once in the past.

* 5 rooms of patients on suicidal precautions were entered by surveyors. In two rooms metal hardware with screws were observed exposed in a shelf that had missing doors. This presents a risk of injury to patients on suicidal precautions.

* In the laboratory area, laminate flooring was observed with tape present in an area approximately 6 inches X 2 feet.
* Chips were observed in wall plaster throughout the facility.

* In patient room 217 A, cabinet handles were missing exposing the porous cabinet material beneath, making thorough cleaning impossible.

* In the nursing station of the men's unit:

- The area under the sink had large old water stains, appeared dirty and a large laminated item that appeared to be a cabinet shelf was lying on the cabinet bottom over the old stains.

- Drawer bottoms had dirt and debris. One drawer had old pieces of stained tape on the front and an approximate 2.5" x 1" piece of foam and tape which adhered to the bottom of the drawer above. When one drawer was opened, the other drawer opened as well.

- A cabinet labeled "hydration station" contained a Styrofoam cup with the initial "M" which appeared to be in use and had a lipstick stain on one side. The cabinet also contained approximately 8 drinking cups which appeared to belong to employees and to be in use.

Tour of the kitchen on 9/10/18 revealed the following:

* A bottle of hand sanitizer but no working sink/no water.

* 2 warming trays with dirty aluminum trays set atop 1 inches of cloudy water with floating food debris.

* Dirty aprons hanging in the storage room adjacent to the kitchen.

* Corrugated shipping boxes, open with food (cereal) and kitchen supplies inside.

* Cup holders, next to the non-working refrigerator (used for storage) had batteries and bugs inside.

* The Coke machine was found to be leaking water into the kitchen.

* The kitchen floor (not a patient area) was dirty, with debris build up in corners.

* An telephone outlet was found dangling from the wall. Ten cove lights were counted in the kitchen. Only 2 worked, leaving the area dark.

* High horizontal dust was found on shelving.

Tour of the medication room on 9/10/18 revealed the following:

* 5 ceiling tiles with water stains-which indicated water leaks.

* Tape on the countertops and floor. When the medication refrigerator was moved aside, copious amounts of dust was found.

* dirt and sheet rock dust was found in all corners.


During observation of the inpatient facility on 09/12/18 the following observations were made:

* Upon entering the waiting area of the facility a large puddle of water was observed to the left of the doors approximately 3 X 3 feet in size. The leak was being absorbed by sandbags and towels and was not contained and continued to spread across the floor towards the reception desk. This presents a safety risk and infection control issues with the potential for mold and or bacterial growth.

* As of survey exit on 09/12/18 the ant-ligature fixtures had not been placed in the male restroom, the toilet paper holders had been removed.

* Wet ceiling tiles were observed, and active dripping leak was observed with a bucket catching the droplets by the window, and a puddle collecting near the window in the dining room. One ceiling tile in the male hallway was observed to be wet an bowing out. In the large walk in cooler a large puddle of water that covered the bottom of the cooler was observed. The leak appeared to be originating from the seam in the citing and around the sprinkler head. The Director of Plan Operations stated that roof leak was being addressed that day by the construction crew working at the facility.


During a tour of the Partial hospitalization Program (PHP) on 09/11/18 the following observations were made:

* The facility had active renovations being completed at the facility. In an interview, the Director of Plant Operations stated the construction and renovation had been on-going, prior to their employment staring in July 2018. The Director of Plant Operations was asked if the PHP had a contact or an agreement with the construction company outlining the renovation plans for the facility. The Director Plant Operations stated he didn't know, but would look for one. The Assistant Manager of the PHP stated that construction and renovations were ongoing, but was unable to provide a start or completion date for the construction contract. A contract was provided to the surveyor with no signatures or dates present on the form.

* Several rooms were labeled as "closed for repair". Two rooms with such signs were observed with open doorways only blocked with a table placed in the doorway. Both rooms had a strong odor of paint and/or dry wall. Dust and debris was visible in the doorway to these rooms. The Director of Plan Operations was asked how patients are protected from these construction areas. They stated that the construction crew puts up plastic in the evening. No plastic was present during this observation to prevent patient exposure to renovations dust and debris.

* In the hallway outside the dining room laminate flooring was observed to be raised and uneven. In the hallway between a group room and a room used for storing construction supplies, it was noted that the laminated flooring was bubbled up and not flush with the base underneath. All this uneven laminate presents a safety risk and tripping/fall hazard to patients. In interview, staff member #1 stated the PHP originally had carpet, they were unsure if this laminate was new or not.


A tour of the Partial hospitalization Program (PHP) kitchenette on the morning on 9/11/18 revealed the following:

* Dirt and debris on the floor, including what appeared to be small bits of food and crumbs.
* Dirty microwave.
* Stove appeared dirty.
* Refrigerator labeled "Patient Refrigerator" included opened milk with no date.
* Cabinet exteriors appeared dirty with light droplet stains.
* Chipped counter tile.
* A food warmer that did not appear clean.


The kitchenette had just been cleaned and was ready for preparation of patient food.

* The male and female restroom were observed to not have anti-ligature fixtures. Protruding metal handles were present on the sinks presenting a ligature risk. Male and female patients were observed throughout the morning utilizing these restrooms independently with no staff monitoring.

* It was observed no lift was present for patient use. The only patient entry point into the building remains the steep steps that were observed during the survey conducted on 07/12/18. During observation on 09/11/18 a female patient was observed with a stiff shuffling gait, a female patient with cane, and a male with a walker, the stairs at could be difficult to traverse for patients with altered gait and assistive walking devices. This presents a fall and safety risk for these patients.


PHP Lift:

The facility based Plan of Correction for the prior survey conducted 07/11/18 to 07/12/18 stated that the "Governing Body will ensure the lift is installed at PHP location by 08/26/18". The completion date on that Plan of Correction was listed as 08/28/18. In an interview on 09/10/18 the Director of Plant Operations was asked about placement of the lift at the PHP. This employee confirmed that the lift was not currently installed at the PHP. They stated, "We're still waiting on a permit from the city. The drawings have been drawn up, but it's in the works, but the lift is here."

During observation of the PHP on 09/11/18, it was observed no lift was present for patient use. The only patient entry point into the building remains the steep steps that were observed during the survey conducted on 07/12/18. In an interview, the Director of Plant Operations stated that the facility was still waiting on city approval for the lift. They added that a sidewalk will need to be poured to access where the lift will be located. This had not been done.

The Director of Plant Operations was asked to provide all documentation on the lift including schematics and application to the city for approval of the lift. On 09/11/18 the Director of Plant Operations provided an invoice for the "Highlander Commander Vertical Platform Lift" that showed a shipped date of 02/22/18. As of the survey exit date on 09/12/18 no documentation had been provided that a plan had been submitted to the city for approval of the lift placement at the PHP.

The above findings were confirmed on 09/12/18 with staff members #1 and 2.