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.

CYPRESS CREEK HOSPITAL 17750 CALI DRIVE HOUSTON, TX 77090 Nov. 24, 2020
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, interview and observation the facility failed to ensure that nursing staff protected patients from self-harm in 7 out 7 (#ID 1, 9,11,13,14,15,16,17) patients who were identified as high risk for self-harm (cutters).

1. Record review of the interdisciplinary plans did not address skin assessment for patients with high risk for self-injury (cutters) as a deferred or active problem.

2. The facility failed to identify the risk of cohosting patients that were identified as cutters and non-cutters.

3. The facility failed to ensure that nursing performed daily skin assessments for patients identified as high risk for self-injury.

Findings Included:

Facility policy reviewed dated 9/9/2019 "Unit Searches for Contraband" stated: Purpose: To provide a safe environment for all patients, visitors, and staff .....into the patient care areas.

No additional documentation was provided regarding policies and procedures concerning ongoing and discharge assessments of high risk patients regarding self-harm (cutters).

The facility "Teen's Bill of Rights" (no date) stated; You have the right to be treated with respect and dignity in a place that is clean and where you are protected from harm.

Record Reviewed:

Patient (ID#1) was admitted [DATE] and discharged on [DATE] she was on the unit for 6 days, putting her at risk for developing or learning cutting from her roommate (ID#11) who was admitted [DATE] to 10/21/20 for a total of 14 days, who was a cutter.

Patient (#11) did not have visible signs of cutting during the initial assessment but according to the medical record dated 10/08/20 the patient stated she was a cutter. Record review of the medical record dated 10/15/20 was noted by the nurse, patient had superficial marks on her inner forearm bilaterally from "several days ago". No additional documentation was noted in the record regarding her skin.

Patient (ID#9) was admitted on [DATE] to 09/11/20 for a total of 23 days. Record review of Initial skin assessment date 08/20/20 revealed patient had scars from cutting, no additional skin assessments were documented during hospitalization .

Patient (ID#13) was admitted on [DATE] to 11/02/20 for a total of 26 days. Initial skin assessment revealed patient had scars from cutting, no additional skin assessments were documented during hospitalization .

Patient (ID#14) was admitted on [DATE] to 11/24/20 for a total of 11 days. Record review Initial skin assessment dated [DATE] revealed patient had scars from cutting, no additional skin assessments were documented during hospitalization .

Patient (ID#15) was admitted on [DATE] to 11/23/20 for a total of 14 days. Record review of the initial skin assessment dated [DATE] revealed patient had scars from cutting, no additional skin assessments were documented during hospitalization .

Patient (ID#16) was admitted on [DATE] to 11/23/20 for a total of 12 days. Record review of the Initial skin assessment dated [DATE] revealed patient had scars from cutting, no additional skin assessments were documented during hospitalization .

Patient (ID#17) was admitted on [DATE] to 11/26/20 for a total of 8 days. Record review of Initial skin assessment dated [DATE] revealed patient had scars from cutting, no additional skin assessments were documented during hospitalization .

Patients (ID#9,13,14,15,16,17) had a history of cutting that was verified during the visual skin and body assessment on admission. The patients (ID#9,11,13,14,15,16,17) were not physically rechecked during their hospitalization to ensure they were not physically injuring themselves.
Furthermore, the cutting behavior was not addressed during discharge to alert the guardian of the behavior.

Patient (ID#1) did not have a history of cutting and was verified during visual skin and body assessment on admission. She was placed in a room with a patient who was a known cutter (ID#11). Initial skin assessment revealed patient had no scars from cutting, no additional skin assessments were documented during hospitalization . Once discharged on [DATE] home the family reported that patient (#ID 1) had lacerations on arms.

Interview with the Interview with the CNO (ID#53) at 11/23/20 @1011 who stated, we do not do another skin check unless there is a doctor's order because of privacy. He also stated patients tell on each other and we would know if a patient is cutting.

Interview with RN Assist Director of Nurses (ID#64) at 11/23/20 @ 1545 who stated, "patients will only start cutting if they never were a cutter if they learn it from someone like a roommate and becomes a copycat".