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 Oct. 16, 2020
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 5 of 5 patients (Patient ID#s 3, 4, 5, 6 and 17).

-Four (4) patients had hazardous items in their rooms;
-Five (5) patient's rooms had door closed but no locked, allowing anyone to enter

Findings included:

Record review of facility policy titled "Integrated Policy for Patient Search and Property Management," dated 2/20 showed the following information:

Prohibited Items-possessions that may cause a safety risk for self or others.

Observation on 10-15-20 at 9:44 AM during a tour of Unit 7 showed the following in four patients' rooms:

Patient #4: deodorant x 2, body lotion x 1;
Patient #5: toothpaste x 1, toothbrush x 1;
Patient #6: body lotion x 1;
Patient #17: Body lotion x 2, toothpaste x 1

During an interview with Staff D, Registered Nurse (RN), at the time of observation, she stated these items should not be left in the rooms of patients.

Observation on 10-15-20 at 9:44 AM during a tour of Unit 7 showed the patient's #3, #4, #5, #6 and #17 rooms empty with doors closed and unlocked, allowing anyone to enter.

During an interview with Staff D, Registered Nurse (RN), at the time of observation, she stated that the patient's doors are to be closed and locked when the patients are not in the rooms.

Interview with facility risk manager Staff C on 10-16-20 at 11:32 AM stated that the patient rooms should be closed and locked during programming hours.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview, and record review, the facility failed to fully implement a COVID-19 screening process for employees, visitors, and vendors per CDC guidelines and facility policy.

This deficient practice could contribute to widespread transmission of COVID-19 within the facility.

Findings included:

COVID-19 screening: employees, visitors, and vendors:

Record review of CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic,"updated July 15, 2020, recommended "...Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SARS-CoV-2 infection and ensure they are practicing source control. Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature =100.0F or subjective fever. Ask them if they have been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection...."

Record review of facility policy titled "Infection Disease Outbreak/Pandemic," dated 4/23/2020 showed:

*the facility followed CDC guidelines for the protection of patients, employees and visitors;

*all patients, staff, and visitors would be screened for infectious symptoms/and or acute respiratory illness.

Record review of a facility form titled "Employee/Visitor Screening Tool for COVID-19" showed screening questions that included: travel risk; close contact with COVID + person; symptoms [ fever/chills last 48 hours? cough / flu-like symptoms; recent loss of taste/smell.] There was a designated column for documentation of body temperature (target: less than 100 degrees F). Instructions at the bottom of the form included actions to take if a person had a fever or answered "yes" to any of the screening questions. Symptomatic persons were not allowed entry to hospital.

Observation # 1:

Observation on 10/15/2020 at 8:30 A.M. showed a portable sink and handwashing station set up outside of the facility front entrance. A staff person sat at a long table just beyond the handwashing sink. Two (2) persons were observed in line ; both washed their hands and approached the table. Staff G, Screener, measured their temperature with a hand-held "no-touch" thermometer. The the two(2) persons each looked through a document binder and signed a form. They entered the facility.

Surveyor # 1 approached the table and asked Staff G, screener: "Do we need to stop here?" Staff G said "yes, I need to take your temperature." Staff G measured the temperatures of Surveyor 1 & 2. Staff G failed to ask surveyors any of the COVID -19 screening questions and allowed them entry into the facility.

Observation # 2 :

Observation on 10/16/2020 at 8: 45 A.M. showed the same COVID-19 screening set-up in front of the hospital. Both surveyors performed hand hygiene at the outside sink. Staff G, screener, measured the temperatures of Surveyor 1 & 2. Staff G again failed to ask any of the COVID-19 screening questions. Surveyor # 1 asked : " Is there anything else we need to do?" Staff G directed surveyors to go to the front desk inside the hospital.

During the interview with Staff G, screener, three (3) persons were observed entering the hospital without screening. Staff G was asked why these persons entered without screening. She said she remembered screening them earlier.

At this same time a vendor ID# H , approached the table. Screener took her temperature--they looked through the binder. Staff G, screener, told the vendor: "oh you have a log in the pharmacy--right?" Vendor ID # H was allowed entry to the hospital without answering any COVID screening questions.

Staff G described the COVID -19 screening process. She stated that all employees , visitors and vendors had to have their temperatures checked and answer the COVID screening questions. The binder held screening forms for all the employees & vendors. They answered and signed the screening questions each time they entered.

Staff G stated the surveyors were not asked the COVID -19 screening questions yesterday and today because she was unsure who they were. It was decided the surveyors were visitors. Staff G then requested both surveyors complete the " Employee/ Visitor Screening Tool for COVID-19."