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Based on document review and interview the facility failed to ensure the patients needs were met by ongoing assessments in 4 (Patient #4, #8, #9, and #11) of 11 patient medical records reviewed. The facility also failed to follow their own policy and monitor vital Signs (VS) on patients while in the Emergency Department (ED) in 5 (Patient #4, #8, #9, #11, and #10) of 11 medical records reviewed.

The deficient practice could cause harm to all patients if vital signs (Blood Pressure, Temperature, Pulse, Respirations, and Oxygen Saturations) are not monitored to ensure there has been no change in condition after administration of medications and/or prior to discharge.

Findings:

Patient #4
A review of Patient #4's medical record revealed Patient #4 was an 11-year-old female that presented to the Emergency Department (ED) on 12/01/2021 at 6:48 PM.

" ...7:01 PM Presenting complaint: Parent states: She has a fever and I think she has COVID. Airway is patent with good air movement. The patient is breathing without difficulty. The patient is pink, warm, and dry. Heart rate is within normal limits. Patient is alert and oriented to person, place, and time. Patient is moving all appropriately. Pain: Complains of pain in head. Arm band placed and/or verified. Allergy band placed and/or verified. Patient placed in waiting room. with a chief complaint of fever and body aches.

The Registered Nurse (RN) triaged the patient at 7:00 PM as a Level 4-Semi Urgent.

Vital Signs (VS):
7:01 PM-Blood/Pressure (BP) 127/71, Pulse 110, Respirations 18, Temperature 99.5, Pulse OX 100% on room air, and Pain 2/10.
9:41 PM-Temperature 99.4 F

No medications administered

7:41 PM Patient Left ED ..."

Staff #6 stated, "There should be a set of VS taken on admission and discharge."

Staff #6 confirmed only one set of VS's was taken during the ED visit.

Patient #8
A review of Patient #8's medical revealed Patient #8 was a 6-year-old male that presented to the ED on 12/02/2021 at 11:51 AM.

Documentation by the Nursing Staff was as follows:
" ...11:53: Presenting complaint: Patient states: vomiting, fever, headache, sore throat x 1 day. Airway is patent with good air movement. The patient is breathing without difficulty. The patient is pink, warm, and dry. Heart rate is within normal limits. Pain: Complains of pain in head and throat.

The Registered Nurse (RN) triaged the patient at 11:53 AM as a Level 3-Urgent
...
Vital Signs (VS):
12:01 PM-BP (___), Pulse 93, Respirations 28, Temperature 98.7, Pulse OX 100% on room air, and Pain 8/10.
2:42 PM-BP (___), Pulse (___), Respirations (___), Temperature 98.9, Pulse OX (___), Pain (___)

Administered Medications:
12:35 PM Zofran (antinausea medication) 4 mg sublingual (under tongue)
2:42 PM Discharged to home ambulatory with family ...
2:43 PM Patient left the ED ..."

Staff #6 stated, "There should be a set of VS taken on admission and discharge."
Staff #6 confirmed there was no blood pressure taken on admission or discharge and only a temperature was taken at discharge.


Patient #9
A review of Patient #9's medical revealed Patient #9 was a 14-year-old male that presented to the ED on 12/02/2021 at 12:39 PM.

Documentation by the Nursing Staff was as follows:
" ...12:52 PM: Presenting complaint: Patient states: ground level fall today c/o pain to left forearm and wrist. Airway is patent with good air movement. The patient is breathing without difficulty. Pain: Complains of pain in left arm. At worst pain level was 10 out of 10 on pain scales. The level of pain that is acceptable is 0 out of 10 on a pain scale.
The Registered Nurse (RN) triaged the patient at 12:55 PM as a Level 3-Urgent
...
Vital Signs (VS):
12:52 PM-BP (___), Pulse 68, Respirations (___), Temperature 97.9, Pulse OX 99%, and Pain 10/10.

Administered Medications:
1:34 PM Ibuprofen 400 mg PO (oral)
...
3:22 PM Discharged to home ambulatory with family ...
3:23 PM Patient left the ED ..."

Staff #6 stated, "There should be a set of VS taken on admission and discharge."
Staff #6 confirmed there was no blood pressure or respirations taken on admission and there was no set of vital signs taken prior to discharge.


Patient #11
A review of Patient #11s medical revealed Patient #11 was a 10-year-old female that presented to the ED on 12/02/2021 at 5:14 PM.

Documentation by the Nursing Staff was as follows:
" ...5:11 PM: Presenting complaint: Caregiver states: Grandmother states was just released from Baptist Hosp psych yelling and cussing PD. Today Grandmother states was hit by child last night and had seizure. Brought in by Palestine PD pt yelling and cussing PD. On arrival to ER pt yelling. Airway is patent with good air movement. The patient is breathing without difficulty. The patient is pink, warm, and dry. Heart rate is within normal limits. Patient is alert and oriented to person, place, and time. Patient is moving all extremities appropriately. Pain: Denies pain at this time.

The Registered Nurse (RN) triaged the patient at 5:11 PM as Level 2- Emergent.
...
Vital Signs (VS):
5:11 PM-BP (___), Pulse 109, Respirations 22, Temperature 98.3, Pulse OX 100%, and Pain 0/10.
8:36 PM-BP 102/58, Pulse 81, Respirations 18, Temperature (___), Pulse OX 100%, and Pain 0/10.

Administered Medications:
No medications administered.
...
12/03/2022 06:55 Transfer: Anderson CO. Sheriff office ...
12/03/2022 7:06 AM: Patient left the ED ..."


Staff #6 stated, "There should be a complete set of VS's taken prior to discharge."
Staff #6 confirmed the last set of VS's were taken at 8:36 PM on 12/02/2022 and the patient was discharged on 12/03/2022 at 7:06 AM without a set of VS's documented. This was greater than 10 hours between vital signs.


Patient #10
A review of Patient #10s medical revealed Patient #10 was a 3-year-old male that presented to the ED on 12/01/2021 at 5:10 PM.

Documentation by the Nursing Staff was as follows:
" ...5:11 PM: Presenting complaint: Parent states: patient went to clinic for fever with abdominal pain and vomiting-told to bring him to ER-patient went unresponsive in car just PTA (prior to arrival) with shaking movement-upon arrival to ER-patient soiled clothes with loss of bowel and urine-no response to stimuli. Airway is patent with good air movement. Abnormal respirations are noted. The patient is pink, warm, and dry. Heart rate is within normal limits. Eye response: None. Verbal Response: None. Motor-Flexion (Decorticate).

The Registered Nurse (RN) triaged the patient at 5:18 PM as a Level 3-Urgent.
...
Vital Signs (VS):
5:31 PM-BP 98/63, Pulse (___), Respirations (___), Temperature (____), Pulse OX (___), and Pain (___).
5:32 PM-BP (___), Pulse 87, Respirations 29, Temperature 96.8 Rectal, Pulse OX 100%, and Pain (___).
5:50 PM-BP (___), Pulse (___), Respirations (___), Temperature 96.8 Rectal, Pulse OX (___), and Pain (___).
5:51 PM-BP 100/66, Pulse 108, Respirations 26, Temperature (___), Pulse OX 100%, and Pain 0/10.
6:10 PM-BP 97/63, Pulse 100, Respirations 20, Temperature (___), Pulse OX 100% on 15 lpm Non-rebreather mask, and Pain 0/10.
6:18 PM-BP 98/62, Pulse 98, Respirations 22, Temperature (___), Pulse OX 100%, and Pain 0/10.
7:53 PM-BP (___), Pulse 107, Respirations 22 (S), Temperature (___), Pulse OX 98% on 15 lpm Non-rebreather mask, and Pain (___).
8:11 PM-BP 98/92, Pulse 105, Respirations 22, Temperature (___), Pulse OX 100% Room Air, and Pain (___).
8:45 PM-BP 114/66 (auto), Pulse 95, Respirations 32, Temperature (___), Pulse OX 100% Room Air, and Pain (___).
...
10:51 PM BP 94/55, Pulse 120, Respirations 20, Temperature (___), Pulse OX 99% on 100% FIO2 ETT vent, and Pain (___).
Patient #10 was placed on a ventilator at 9:51 PM.

Administered Medications:
Ativan Lorazepam 1.5 mg at 17:24
Ativan Lorazepam 1.0 mg at 17:35
Ativan Lorazepam 1.0 mg at 17:40
Ativan Lorazepam 1.0 mg at 17:41
Ativan Lorazepam 1.0 mg at 17:47
Ativan Lorazepam 1.0 mg at 17:50 for seizure activity

11:33 Transfer: The patient was transported by helicopter.
11:35 PM-Patient left the ED ..."

Staff #6 confirmed there was no documented vital signs at time of discharge.

An interview was conducted with Staff #6 on 1/18/2023 at 12:25 PM. Staff #6 was asked why were there no vital signs documented on Patient #10 between the hours of 6:18 PM and 7:53 PM. Staff #6 replied, "Our monitors do not communicate with the computer program. So, if the nurse does not check the box to have the vital signs move over to the chart, then they do not show up in the medical record."

During an interview with Staff #1 it was confirmed Patient #10 remained on a monitor that automatically measured vital signs while he was in the ED. He also stated, "Sometimes when you have a moving patient or someone that refuses to leave the monitors on, they will not register. In this situation this child was having a seizure during some of the time that the monitor did not register but there was staff at his bedside the entire time he was here. He also had family in the room with him. Staff #1 confirmed you do have to make sure that you transfer the vital signs over to the chart because it will not automatically move them."

Staff #6 confirmed that vital signs were not always documented upon discharge. Staff #6 also confirmed that Patient #10 was on a monitor but not all vital signs were moved over, and some may not have registered due to seizure activity."


A review of the facility policy titled, "Assessment of the ED Patient" with an approved date of 11/2021 was as follow:

" ...PURPOSE:
Establish assessment criteria for all Emergency Department patients:

POLICY:
All patients presenting to the Emergency Department will be triaged and categorized as either Level 1-Critical Care (Priority One), Level II-Emergent (Priority Two), Level -Urgent (Priority Three), Level IV-Non-Urgent (Priority Four), or Level V-Routine (Priority Five).

All Patients presenting for treatment in the Emergency Department are assessed by an Emergency Department triage Registered Nurse (RN)

All patients admitted to the Emergency Department will have the following documentation
...
Initial vital signs shall be obtained depending on patient's condition;
Critical patients: ever 5-15 minutes, as needed;
Emergent patient: every 30 minutes =, as needed;
Urgent patient every 2 hour (sic), and
Non-urgent/Routine: On arrival and prior to discharge;
...
Patients classified as "Non-urgent (Priority Four), Routine (Priority Five) that are discharged within 60 minutes of triage that have received no medications need not have their vital signs repeated prior to discharge. All other patients will have a complete set of vital signs taken and recorded on arrival and at the time of discharge.

All patients presenting with stable vital signs on arrival and a chief complaint of suicidal ideation, hallucination, delusions, homicidal ideation, or any other psychiatric complaint (excluding pt with abnormal VS, overdose, ingestion of medications); only need a complete set of vitals signs on arrival and prior to discharge unless change in status are observed ..."

Staff #6 confirmed the nursing staff failed to follow the facility policy when documenting vital signs during assessment.

Based on observation, record review, and interview, the Infection Control Nurse failed to perform physical surveillance to reduce the risk of healthcare associated infections and infection control activities in the emergency department. Also, the facility's infection control plan was not followed.

Findings include:

Infection control rounds were made in the emergency room on 01/18/2023 and multiple infection control issues were found.

Infection Control Nurse #6 was asked how often surveillance rounds are made in the hospital. RN #6 stated, "I make weekly rounds." Surveyor requested rounding log for the emergency room. Infection Control Nurse #6 stated, "I don't have any rounding sheets." There was no way to know if the infection control nurse had identified the infection control issues that were found in the emergency room by the surveyors.

An interview with the Infection Control Nurse #6 on 01/18/2023 at 3:00 PM was asked when you complete the evaluation of a department per the infection control plan how was the follow-up monitoring and evaluation completed. Infection Control Nurse #6 reported the manager of the department was responsible. There was documentation to support that the infection control was evaluated and completed by the infection control nurse.

The only documentation provided to the surveyors was a power point titled, "Environmental Rounding" that was presented at the Quality Patient Safety meeting on 1/17/2023 for the December 2022 data.

"A review of the IP Plan IC.01.04.01: Based on the identified risks the hospital sets goals to minimize the possibility of transmitting infections.

A review of the Plan IC. O1.05.O1: The hospital has an infection prevention and control plan.

The infection prevention program is designed to incorporate recommendations, guidelines and regulations from multiple agencies including Centers for Disease Control and Prevention (CDC), Centers
for Medicaid Services (CMS), The Joint Commission (TJC), and Occupational Safety and Health Administration (OSHA), the Texas Administrative Code, and National Healthcare Safety Network (NHSN). Infection prevention activities, policies and procedures are also developed using evidenced based guidelines from other advisory committees and professional organizations, including but not limited to:
* Society for Health care Epidemiology of America (SHEA).
* Infectious Diseases Society of America (IDSA).
* Association for Professionals in Infection prevention/control and Epidemiology (APIC).

EVALUATION AND ACTIONS:
1. When evaluation identifies an area of concern, a specific problem or an opportunity for improvement, a corrective actions plan is formulated. The correction action plan is collaborative in nature and identified to include:
* Action appropriate for the cause, scope, and severity of the problem
* Person responsible for implementing the action
* Changes expected
* Time frame change expected to occur
* Time frame follow-up monitoring and evaluation will occur
2. When problems or opportunities for improvement are identified, actions taken/recommended will be documented in the Quality/Patient Safety committee minutes. All problems or opportunities will be addressed in Quality/Patient Safety Committee to assist with a resolution as needed. Infection Control and Employee Health issues will also be reported to the ICC (P&T committee) at the facility on a quarterly basis for physician review.
3. If immediate action is necessary, the Quality/Patient Safety Committee and ICC, or its designee, has the authority to institute any surveillance, prevention and control measures, if there is reason to believe that any patient or personnel is at risk.
4. Information from the Infection Control Performance Improvement Program will be reported every quarter to the ICC (P&T Committee) at PRMC. Minutes of these meetings are forwarded to Quality/Patient Safety Council, Medical Executive Committee, and BOT to assist in a timely and thorough implementation of recommended corrective measures and process outcome revisions.
5. The ICC (P&T Committee) at PRMC has the responsibility for infection prevention and control activities throughout the facility. This committee is governed by a physician having knowledge of infection control practices and performance improvement methodologies and guides the committee on decisions for improvement of care through the prevention and control of infections.
6. The responsibility and direct accountability for the surveillance, data gathering, aggregation and analysis is assigned to the Infection Control Nurse."

An interview on 01/18/2023 at 3:00 PM with RN #6 acknowledged there were no tracking, surveillance, or data analysis of the physical rounding conducted in the hospital. There was no report of a working plan to establish rounding with a tracking log for infection control surveillance and no follow-up monitoring or evaluation.

Based on observation and interview, the facility failed to monitor and provide a sanitary environment to minimize the transmission of infectious agents within 2 (emergency room and surgical waiting area) of 2 areas of the hospital that were observed.

These findings had the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the facility.

During a tour of the facility 01/18/2023 following infection control issues were observed:

Emergency Services:

Upon entrance to the emergency room observed a cut open cardboard box lying on a patient stretcher with monitoring tubing inside the box and plastic wrapping. The cardboard box had an unclean appearance.

Card board boxes harbor parasites, insects, and microorganisms.

"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAM1 ST46-Section 5.2 Receiving items).

Exam room #1

Observed broken hinges on the cabinet drawers that had very sharp edges. Patient and staff could easily have been cut by the sharp edges. There were numerous scratches in the paint of the cabinets and large areas of plaster missing from the wall.

Trauma room #1


Observed the hinges for cabinet door were broken off cabinets, so the doors were hanging off the cabinet.

Exam room #12

Observed large piece of equipment that was used to create a negative pressure room. The duct was taped with a large amount of black tape to a vent in the ceiling.

There was an intravenous tubing package in the room with a blood spot on the package.

The was a small black portable 2 drawer cabinet in the room that had dead bug, needle cap, dust, and dirt on the crease of the cabinet. Also, white spillage was running down the side of the cabinet. On top of this cabinet was
an intravenous tubing package. Observed blood on the package.
The monitoring screen in the room was covered in a thick layer of dust, the surveyor was able to "write" their initials in the thick dust.

There were dead bugs observed in the ceiling light fixture.

The room was cluttered and had an unclean appearance.

Pediatric Cart

Observed an 8 French foley catheter that had expired 12/31/2022 in the drawer.

There was hair and dust particles in the drawer of the pediatric cart.

Supply Storage Area

Observed clean and sterile supplies on the floor underneath the supply bins. The floor was covered in lint, trash particles, dust, and dirt around all 3 walls of the storage closet.

The tour was conducted with Staff #4 on the morning of 01/18/2023 and the infection control issues were observed and acknowledged by Staff #4 during the tour.



40989


An observation tour of the Emergency Room (ER) and Surgical Waiting Room was conducted on 1/18/2023 at 8:50 AM with Staff #2, #3, and #8.


Psychiatric Patient Room

An air vent on the ceiling was noted to be stuffed with tissue. In the corner was a portable vital sign machine that was soiled with dirt and dust.

Suture Cart

A portable suture cart was being stored in the main hallway of the ER. This cart was used to store sutures and supplies needed to repair lacerations (a deep cut or tear in the skin and/or muscle) on patients. The bottom of the cart was heavily soiled with dirt and dust. In the first drawer was an opened vial of 30 ml (milliliters) 1% Lidocaine (a medication used to numb the skin). The vial was labeled as a "Single Dose Vial." There was less than half of the medication remaining. Staff #2 confirmed the medication had previously been used and should not have been stored in the drawer for future use.

Trauma Cart

This red cart was stored in the main hallway for emergent trauma cases presenting to the ER. The base of the trauma cart was heavily soiled with dirt and dust.

Exam Room #9

The Mayo Stand (a portable stainless-steel stand used to hold medical supplies or instruments) was heavily soiled with dust at the base. This surveyor used a damp cleaning wipe and removed the dust leaving a clean line through the dust.

Medication Room

The floor in this room was noted to have trash, dirt, and dust. In the sink was a dried white residue.

Next to the sink was a portable GlideScope (a video laryngoscope used to aid the provider when placing a breathing tube into a patient). The base of the stand was soiled with a dried white substance, dirt, and dust.
The metal pill crusher was heavily covered with dirt, dust, a dried white substance, and a rust-colored stain around the base.

A portable ultrasound was stored in the room. On the top of the stand around the ultrasound probes there was a dried brown colored liquid, dirt, and dust. The base of the ultrasound was covered with dirt and dust. A large, automated medication dispensing system was stored in the room.

On the bottom right, where the IV (intravenous) fluids were stored, there was red, yellow, blue, and green hard plastic bins used to hold the IV fluids. The inside of the bins was heavily covered with trash, dirt, and dust. The bottom shelf on the inside of the cabinet was soiled with dirt and dust.

Staff #2 was asked who had the responsibility of ensuring the medication cabinet was clean. Staff #2 stated, "I think the pharmacy is responsible for cleaning the inside of the cabinet."

Multiple requests were made for a policy or protocol on cleaning the automated medication system. No documentation was provided.

RN #2 and RN #3 confirmed the medication room, the equipment, and the automated medication dispensing system needed to be cleaned and cleared of the trash, dirt, and dust.

Clean Equipment Room

This room was used to store clean equipment. The floor was noted with trash, dirt, and empty plastic bags. Inside the room was a multi shelf metal stand.

On the top shelf were 2 open cardboard boxes. In the smaller cardboard box was 10 boxes of single use Otoscope (an instrument used to look into a patient's ear) disposable covers for pediatrics and adults. Staff #2 confirmed the covers should have been placed in the supply room and not in the equipment room.

Card board boxes harbor parasites, insects, and microorganisms.

"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAM1 ST46-Section 5.2 Receiving items).

The second shelf stored cloth devises to aid in moving or transferring a patient. There was no indicator that the transfer devices were clean. Staff #2 could not confirm nor deny if cloth transfer devices were clean or dirty.

The bottom shelf stored patient monitors used to assess vital signs. The monitors were not identified as clean or dirty. Also, two portable vital sign monitors were stored in the room. Staff #2 confirmed if the equipment was clean, thee should be covered with a clear plastic bag. Only one piece of the equipment was covered with a plastic bag. The base of the monitors was heavily covered with dust and dirt. there was noted sticky and dirty adhesive on pole that held the monitoring equipment. A portable "InTouch Health" video monitor was also in the room. This equipment was used for telehealth services for Neurology. Staff #2 reported that the equipment could not be covered because the heat expelled from the monitor could damage the equipment if covered. The base was heavily covered with dirt and dust. The walls had been repaired with a white colored plaster and left unpainted. This area could not be sanitized to avoid contamination to the clean patient equipment.

A review of the facility policy titled, "LOW LEVEL DISINFECTION" dated and revised 5/2016 revealed the following:

"PURPOSE
The need for appropriate cleaning, disinfection of patient care items has been emphasized by published
reports documenting infection after improper decontamination processes. This policy is to establish guidelines
for low level disinfection of reusable non-critical patient care items.

PROCEDURE
Items used on multiple patients(noncritical), with intact skin, are to be wiped down between each patient, with
a hospital approved Environmental Protection Agency (EPA) registered disinfectant following the
manufacturer ' s instructions, paying strict attention to proper drying times.
Use an Environmental Protection Agency (EPA)-registered disinfectant following the manufacturer ' s
instructions because required contact time varies among products. Each disinfectant has a material safety
data sheet (MSDS) that contains information regarding safe handling and use of the solution."


Staff #2 and #5 agreed that the equipment was visibly dirty and should not have been placed into the clean equipment room.

Patient Nourishment Room

The cabinet below the sink had loose handles that were falling from the cabinet doors. Holes from missing screws and chipped paint were exposing the wooden surface. There was a coffee pot on top of the counter. The drawer directly beneath the coffeepot stored "Community Coffee" packets used to make coffee. Inside the drawer was a pair of scissors and moderate loose coffee grounds. When opening the next drawer, observed a dried liquid spill, brown in color on the door surface.

On the inside of the refrigerator door was a dried red colored liquid. In the freezer door was a thermometer. Surrounding the thermometer was a purple dried liquid. The thermometer was stuck to the surface by the dried liquid and could not be moved.

The drawer directly beneath the refrigerator was storing crackers for patients use. Inside the drawer was large amount of broken cracker crumbs. Stored in the cabinet beneath the refrigerator was a plastic container of 10 Ounces of "Thick-It". This product is used to thicken a patients liquids to aid in swallowing. There was no open date on the container. A 2-ounce bottle of Pedialyte was in the cabinet. The Pedialyte expired January 1, 2023. A container of 33.8 fluid ounces of Vital AF (liquid nutrition used for enteral feeding) expired July 1, 2022.

Staff #2 confirmed the expired products and the opened "Thick-It" and stated that the products should have been removed and a date should have been marked on the Thick-It product.

ER Hallways

Multiple blue painted doorframes throughout the ER Department were missing paint and exposing the bare metal surface. Metal cannot be sanitized to prevent the spread infectious diseases. Along the hallways, attached to the walls, were wooden chair rails painted blue. The wood was chipped and missing paint exposing the wooden surface beneath. The porous surface cannot be sanitized to prevent the spread infectious diseases.

An interview was conducted with Staff #5 on 1/18/2023 after 9:30 AM. Staff #5 stated, "We have been telling them that the doorframes and the chair railing need to be repainted, but nothing has been done."

Staff #2, #3, and #5 agreed that the ER and the equipment needed to be cleaned and cleared of all the dust, dirt, and debris.

Surgery Waiting Room

In the main hallway of the facility was a surgical waiting room. The waiting room was used for patients and families. Inside the waiting room was a microwave available for use. On the top of the microwave stand, in front of the microwave door was a white colored powder and old food particles. The inside of the microwave was very heavily soiled with dried food particles and dried liquid that was brown and white in color.

An interview was conducted with Staff #3 on 1/18/2023 after 10:00 AM. Staff #3 was asked how many housekeepers the ER has. Staff #3 replied, "There is only one assigned to the ER a day and they do good to keep up with just cleaning the rooms after a patient is discharge so that the staff can bring another patient back."