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Based on observation and interview, the hospital did not ensure that all patient care equipment was safely maintained, in that, expired equipment was available for patient use in 2 of 2 patient care areas.

During hospital tours the afternoon of 07/13/10 with the Director of Nurses (Personnel #2), and with the Medication Nurse (Personnel # 5), the surveyor noted expired equipment was available for patient use in the following areas:
Emergency Department:
2- thoracic catheters, 32 French, expired 07/04.
1- CO 3 detector, expired 02/10.
3- 20 gauge angiocath needles, expired 06/10.
2- 25 gauge needles, expired 09/09.
1- 21 gauge needle, expired 03/09.
1- 23 gauge needle, expired 05/09.
1- 14 gauge angiocath needle, expired 12/07.
1- endotracheal tube, expired 02/10.

Medication Room on the Medical/Surgical Unit:
1- 22 gauge needle, expired 06/10.
6- 20 gauge angiocath needles, expired 10/09.
7- 20 gauge winged angiocath needles, expired 07/05.
1- 18 gauge angiocath needle, expired 09/09.
5- 18 gauge angiocath needles, expired 01/10.
4- 18 gauge angiocath needles, expired 04/10.

In interviews with the Director of Nurses (Personnel # 2) and the Medication Nurse (Personnel # 5) the afternoon of 07/13/10, they each observed and confirmed that the above expired equipment was available for patient use.

Based on observations and interviews, the hospital did not ensure that drugs and biologicals were appropriately stored in 2 of 2 patient care areas.

1) During a tour of the Medical/Surgical Unit the afternoon of 07/13/10, the surveyor observed that the door to the medication room was unlocked and open. The following unsecured drugs and biologicals in this medication room included:
-The Medication Cart that contained individual unlocked drawers which contained individual patient medications such as: Atenolol, Azithromycin, Zantac and Glipizide in tablet or injectable form.
-The open cabinet and shelves in the unsecured medication room contained biologicals such as intravenous fluids (IVF's) and drugs such as Lactinex tablets.
In an interview the afternoon of 07/13/10 with the Licensed Vocational Nurse (LVN) who was the medication nurse on that shift (Personnel #5), she was asked if the medication room was routinely left unlocked, and she said "yes." She confirmed that the medication room door had a lock which had not been used, and that the drugs and biologicals were unsecured.

2) During a tour of the Emergency Department (ED) the morning of 07/14/10, the surveyor observed open shelves of unsecured drugs and biologicals near the entry door of the ED located on a main visitor hallway, and included the following:
-The open shelves near the door contained biologicals such as bottle of sterile water and sodium chloride.
-An unlocked nightstand, also near the ED doorway close to visitor traffic, contained the following drugs: Toradol, Gentamycin, Acetylcysteine, Nitrostat, Pulmicort Inhalation,Glucagon, Dextrose 50% injectable, Ceftriaxone suspension, Phenytoin, Solumedrol, Xylocaine and Sodium Bicarbonate injectable.
In an interview the morning of 07/14/10 with the Director of Nurses (Personnel #2), she was asked if the drugs and biologicals in the ED were routinely kept in this unlocked area, and she said "yes." She confirmed that the above ED emergency medications were unsecured and located next to a visitor hallway.

The Pharmacy's "Procurement, Storage, Controlled Substances, Drug Samples, Formulary, and Out-of-date Medications" policy, undated, noted that "all legand drugs will be kept under lock."

Based on review of records and interview, the hospital's medical records were not complete in that the medical record entries for 17 of 18 patients (Patients #2, 3, 4, 5, 6, 9, 11, 12, 13, 14, 16, 19, 21, 23, 24, 25, and 26 ) discharged between 01/01/10 and 06/15/10 were not timed, dated, and/or authenticated as required by 25 Texas Administrative Code (TAC) 133.41 (j)(5).

25 TAC 133.41 (j)(5): Medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.

Findings:
"Discharge Summary" physician signature was not timed and dated for the following:
1) Patient #5 - Date of Discharge 04/23/10
2) Patient #19 - Discharged from observation status 04/26/10

"Physician's Orders" were not signed, timed, and dated by the physician and/or physician assistant for the following:
1) Patient #2 - Verbal orders taken by nurse at 16:15 and 19:00 on 06/03/10

"Physician's Orders" were not timed by the physician and/or physician assistant for the following:
1) Patient #2- 06/03/10 and 06/04/10
2) Patient #14 - 02/26/10
3) Patient #12 - 01/04/10
4) Patient #3 - 05/14/10
5) Patient #13 - 03/09/10

"Progress Notes" were not timed for the following:
1) Patient #12 - 01/07/10
2) Patient #2 - 06/04/10
3) Patient #3 - 05/15/10 and 05/16/10
4) Patient #9 - 02/06/10 through 02/08/10
5) Patient #11 - 03/20/10
6) Patient #16 - 03/21/10

"Vital Sign Sheet" was not signed for the following:
1) Patient #3 - 05/14/10 and 05/15/10
2) Patient #4 - 05/26/10 through 05/29/10

"Graphic Record Intake and Output" was not signed for the following:
1) Patient #2 - 06/03/10 and 06/04/10
2) Patient #3 - 05/14/10 through 05/16/10
3) Patient #5 - 04/21/10 through 04/23/10
4) Patient #11 - 03/23/10 and 03/24/10

"Emergency Room Physician's Notes" signatures were not timed for the following:
1) Patient #6 - 02/19/10
2) Patient #21 - 01/12/10
3) Patient #23 - 03/21/10
4) Patient #24 - 04/21/10
5) Patient #25 - 05/03/10

"Emergency Room Physician's Notes" were not signed, timed, and dated for the following:
1) Patient #26 - 06/05/10

During an interview the afternoon of 07/15/10, the Director of Nursing (Personnel #2) reviewed the medical records for Patients #2, 3, 4, 5, 6, 9, 11, 12, 13, 14, 16, 19, 21, 23, 24, 25, and 26. Personnel #2 was in agreement that dates, times, and/or signatures were missing.

The "Chart Analysis" policy approved 08/20/07 noted, "Practitioner entries in the chart must be signed, including his/her title, date and time."

Based on observation, review of records, and interview, the pharmacy did not ensure that:
1) outdated drugs were not available for patient use, according to their policy, and
2) their policy included rules where outdated biologicals were not available for patient use.

During a tour of the Emergency Department (ED) the afternoon of 07/13/10 with the Director of Nurses (Personnel # 2), the surveyor observed the following outdated drugs and biologicals:
1- Betadine solution 16 ounces, expired 04/02.
1- Xylocaine 1%, 20 milliliters, expired 04/04.
1- Lidocaine 1%, 10 milliliters, expired 04/05.
In an interview with the Director of Nurses (Personnel #2) the afternoon of 07/13/10, she confirmed that the above outdated drugs and biologicals were available for patient use.

During a tour of the Medical/Surgical unit's medication room the afternoon of 07/13/10 with the Medication Nurse (Personnel #5), the surveyor observed the following outdated drugs and biologicals:
50- BD Lactinex tablets, expired 06/11/10.
4- Bacteriostatic sodium chloride 10 milliliters, expired 04/10.
7- Liter bags of Lactated Ringer's intravenous fluid (IVF), expired 06/10.
4- Liter bags of Dextrose 5% Lactated Ringer's (D5LR) IVF, expired 06/10.
6- Liter bags of Dextrose 5% Normal Saline (D5NS) IVF, expired 04/10.
1-500 milliliter bag of 3% Sodium Chloride IVF, expired 04/10.
3-250 milliliter bag of Dextrose 5% Water (D5W), expired 04/10.
In an interview with the Medication Nurse (Personnel #5) the afternoon of 07/13/10 , she confirmed that the above outdated drugs and biologicals were available for patient use.

The Pharmacy "Procurement, Storage, Controlled Substances, Drug Samples, Formulary, and Out-of-date Medications" policy, undated, noted that "out-of-date medications are not to be used...such medications will be removed from stock and inventoried twice annually by the Pharmaceutical Return Specialist."
This policy did not include rules to ensure that outdated biologicals, such as intravenous fluids and other solutions, were removed from stock and therefore, not available for patient use.

Based on review of records and interview, the hospital failed to evaluate all patient care services in that the medical records of 16 of 17 patients (Patients #2, 3, 4, 5, 6, 9, 11, 12, 13, 14, 16, 19, 21, 23, 24, and 25) discharged between 01/01/10 and 06/15/10 were not timed, dated, and/or authenticated by the person responsible for providing or evaluating the services provided.

Findings:
"Discharge Summary" physician signature was not timed and dated for the following:
1) Patient #5 - Date of Discharge 04/23/10
2) Patient #19 - Discharged from observation status 04/26/10

"Physician's Orders" were not timed by the physician and/or physician assistant for the following:
1) Patient #2- 06/03/10 and 06/04/10
2) Patient #14 - 02/26/10
3) Patient #12 - 01/04/10
4) Patient #3 - 05/14/10
5) Patient #13 - 03/09/10

"Progress Notes" were not timed for the following:
1) Patient #12 - 01/07/10
2) Patient #2 - 06/04/10
3) Patient #3 - 05/15/10 and 05/16/10
4) Patient #9 - 02/06/10 through 02/08/10
5) Patient #11 - 03/20/10
6) Patient #16 - 03/21/10

"Vital Sign Sheet" was not signed for the following:
1) Patient #3 - 05/14/10 and 05/15/10
2) Patient #4 - 05/26/10 through 05/29/10

"Graphic Record Intake and Output" was not signed for the following:
1) Patient #2 - 06/03/10 and 06/04/10
2) Patient #3 - 05/14/10 through 05/16/10
3) Patient #5 - 04/21/10 through 04/23/10
4) Patient #11 - 03/23/10 and 03/24/10

"Emergency Room Physician's Notes" signatures were not timed for the following:
1) Patient #6 - 02/19/10
2) Patient #21 - 01/12/10
3) Patient #23 - 03/21/10
4) Patient #24 - 04/21/10
5) Patient #25 - 05/03/10

The hospital's Quality Assurance information dated 01/2010 through 06/2010 did not address the documentation of the missing times and dates for the authentication of the medical record entries by the person responsible for the services he/she provided. There was no indication that the missing signatures from the "Vital Sign Sheet" and "Graphic Record Intake and Output" were addressed in the hospital's Quality Assurance process.

During an interview the afternoon of 07/15/10, the Director of Nursing (Personnel #2) reviewed the medical records for Patients #2, 3, 4, 5, 6, 9, 11, 12, 13, 14, 16, 19, 21, 23, 24, and 25. Personnel #2 was in agreement that dates, times, and/or signatures were missing.

The "Chart Analysis" policy approved 08/20/07 noted, "The medical record will be analyzed to ensure that documents are complete and authenticated...Practitioner entries in the chart must be signed, including his/her title, date and time..."

Based on review of records and interviews, the hospital did not ensure that an ongoing program of activities was provided to meet, according to the comprehensive assessment, the interests, and the physical, mental, and psychosocial well-being for 2 of 3 residents (Patients #8 & #15).

The Swing Bed Policy Manual, last reviewed 05/18/09, noted in the "Swing Bed Rights of the Elderly" policy that the services provided by the hospital included "Patient Activities."

Patient #8 was admitted to Swing Bed status on 02/20/10, and had the "Swing Bed Requirements" form initiated by a registered nurse (RN). The RN did not check the assigned place on the form, "Activity Consults..., Activity Director at Senior Citizens Nursing Home- 754-4566," to notify the Activity Director for a need to assess this new swing bed patient.
There was no Activity Director assessment or activity notes documented in the record.

Patient #15 was admitted to Swing Bed status on 03/15/10, and had no documentation for notification of the Activity Director that her services were needed, as well as no documentation of any activity assessment or activity notes in the record.

Review of the "Activity Director Agreement" with the hospital had been in effect with the current Activity Director (Personnel #9) since 04/10/02, and included in her scope of work:
-"Organize a program of both individual and group activities based on the needs of the patients."
-"Plan, coordinate, and direct the activity program for Swing Bed patients. This program will consist of arts and crafts, diversional, intellectual, and physical activities."
-"Interview and process documentation of the individual Activities Plan."

In an interview the afternoon of 07/13/10 with the Activity Director (Personnel #9), she was asked how she was notified that her services were needed for newly admitted Swing Bed patients, and she said that "someone from the hospital Nurse's station calls her." She confirmed that she would not know of a new Swing Bed patient's need for assessment, unless she had been notified by the hospital.

Based on review of records and interviews, the hospital did not develop a comprehensive care plan that had been prepared by an interdisciplinary team that included the resident's attending physician, for 3 of 3 Swing Bed residents (Patients # 8, 15 & 17).

Medical Records for 3 reviewed Swing Bed residents noted the following:

Patient #8: Admitted to Swing Bed status on 02/20/10 with a diagnosis of Total Right Knee Replacement and history of Aspiration.
-The "Interdisciplinary Team Meeting" form initiated by the Medical Social Consultant (Personnel # 8)on admission, is a sign-in sheet for the various members and disciplines present for these meetings, but was blank.
-The "Swingbed Interdisciplinary Progress Notes" form, used to document individual discipline assessments for communication between disciplines was not present on this medical record.
-A "Swing Bed Requirements" form, also initiated by Personnel #8, was checked that "Care Plan Meeting on Tuesdays at 12:30 p.m. (only when patient is on swing bed)," however, no documentation was on the medical record to indicate a Care Plan Meeting or an Interdisciplinary Team Meeting had occurred for this resident.

Patient #15: Admitted to Swing Bed status on 03/15/10 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD).
-The "Interdisciplinary Team Meeting" form was blank.
-The "Swingbed Interdisciplinary Progress Notes" form was not present on this medical record.
-A "Swing Bed Requirements" form, used for inclusion for the "Care Plan Meeting on Tuesdays at 12:30 p.m. (only when patient is on swing bed)," was not in the record. There was no documentation on the medical record to indicate a Care Plan Meeting or an Interdisciplinary Team Meeting had occurred for this resident.

Patient #17: Admitted to Swing Bed status on 03/30/10, with a diagnosis of Status Post Motor Vehicle Accident (MVA) with Subdural Hematoma.
-The "Interdisciplinary Team Meeting" form was initiated and signed by a registered nurse (RN) on admission, but was blank.
-The "Swingbed Interdisciplinary Progress Notes" form used to document individual discipline assessments for communication between disciplines, but was not present on this medical record.
-A "Swing Bed Requirements" form, was also initiated by the same RN, who had checked that "Care Plan Meeting on Tuesdays at 12:30 p.m. (only when patient is on swing bed)." There was no documentation on the medical record to indicate a Care Plan Meeting or an Interdisciplinary Team Meeting had occurred for this resident.

In separate interviews on 07/13/10 with the Director of Nurses (Personnel #2), the Activity Director (Personnel #9) and the Physical Therapist (Personnel #10), when asked if the hospital had an interdisciplinary team that included the attending physician, and that implemented a comprehensive care plan for each Swing Bed resident, they each said "no."