HospitalInspections.org

Based on observation, interview and record review the Governing Body failed to:

Ensure the physical plant and environment was a safe environment for staff, contactors, and patients as staff and contactors continued working in the unsafe and dirty environment of the old medical section of the hospital despite hospital plans for demolition of the old section. In addition, storing clean medical supplies, linen, and emergency supplies in an area of disrepair and unsanitary conditions present a safety and infection control risk for the staff, contractors, and all patients treated at the Muleshoe Area Medical Center. There were also multiple exit signs that were not illuminated in several departments and an extension cord was used as permanent wiring. There were unsecured large oxygen tanks stored outside the hospital which could cause a hazardous condition as the oxygen tanks could act as projectiles if the tanks fell to the ground. Cross refer to C0221

The facility failed to provide a preventive maintenance program to ensure that all essential mechanical, electrical and patient care equipment was maintained in safe operating condition as hospital equipment available for patient use was observed without current inspections by the contracted biomedical service. The hydrocollator available for use in patient care had no daily temperatures recorded for the 2016 calendar year which could result in unknown improper heating of the equipment which could potentially result in patient harm. Cross refer to C0222.

The facility failed to ensure drugs were stored according to acceptable standards of practice as outdated medications were found in the patient care areas available for patient use potentially causing unsafe or ineffective medications to be used in patient care. Cross refer to C0224.

There were multiple departmental areas throughout the hospital found with excessive dust, dirt debris and insufficient door seals. Cross refer to C0225.

Based on observation, staff interviews, and documentation review the hospital failed to ensure a safe environment for staff, contactors, and patients as staff and contactors continued working in the unsafe environment of the old medical section of the hospital despite hospital plans for demolition of the old section. There were exit signs which were not illuminated which could hinder evacuation in an emergency, and an extension cord was used as permanent wiring causing patients to step over multiple electrical cords to reach therapy equipment. There were unsecured large oxygen tanks stored outside the hospital which could cause a hazardous condition as the oxygen tanks could act as projectiles if the tanks fell to the ground.

Findings included:

During a tour of the old medical section of the hospital accompanied by Staff #6 and Staff #14 on the morning of 3/1/16, the exit light above the external door was not illuminated and had the cover hanging down with exposed electrical wires. This potentially could have hindered evacuation of staff and contractors. The hanging cover potentially could have injured staff and/or contractors if it fell during the delivery and pick up of the hospital linen.
In the Central Supply department housed in the old medical section of the hospital accompanied by Staff #6 and Staff #14, the exit signs over the external doors of the central supply department were not illuminated. This potentially could have hindered the evacuation of staff in case of an emergency and could be a potential electrical hazard due to the exposed electrical wires.
These safety issues were confirmed in an interview during the tour with Staff #6 and Staff #14. Staff #14 stated the external door of the back hallway is used for hospital linen delivery and pick-up.

During a tour of the Physical Therapy Department the morning of 3/1/16, the following was observed:
· The exit sign over the exit door of the Physical Therapy department was not illuminated. This potentially could have hindered the evacuation of the department in case of an emergency. This was confirmed in an interview with Staff #25, Physical Therapy Department Assistant.
· In the physical therapy activity area, there was an extension cord which was extended across the floor into middle of the patient therapy area. This area contained therapy equipment, such as a treadmill and other therapy equipment. A pedestal floor fan, a staff computer on an over-bed table, and a CD player nearby on the floor were plugged into the extension cord, creating a safety risk with electrical cords on the floor between the therapy equipment, the CD player, and the fan. Patients and staff were required to step over the various cords to reach the therapy equipment creating a safety hazard. In addition, extension cords should not be used as permanent wiring.
These safety issues were confirmed in an interview during the observation with Staff #25, Physical Therapy Department Assistant and Staff #6.

During a tour of the kitchen the morning of 3/1/16, the exit sign over the external door of the kitchen was not illuminated. This potentially could have hindered the evacuation of the kitchen in case of an emergency. This was confirmed in an interview with Staff #6, cook.

During a tour of the external grounds on the afternoon of 3/1/2016 accompanied by Staff #6, 12 large oxygen cylinders were observed unsecured in a row next to secured oxygen cylinders in a locked fenced area behind the hospital. There was also 1 large unsecured oxygen tank stored against the fence. This potentially could have resulted in hazardous conditions as oxygen tanks could act as projectiles with the escape of oxygen if the tanks fell to the ground. There was a large chain observed on the ground at the end of the row of unsecured oxygen tanks. This safety issue was confirmed in an interview with Staff #6.

Record review of hospital Board of Directors meeting minutes dated May 28, 2015, stated in part, "...8. Mr. Howell stated he was able to get another quote for the Hazardous Material Assessment for $3,686.00. This will be paid by Preferred. Mr. Smyer asked if this was just part of the process of tearing down the old nursing home. .. " Record review of the " V-TECH ENVIRONMENTAL SERVICES - Pre-Demolition Asbestos Survey " dated August 3, 2015, stated in part "...A pre-demolition asbestos inspection was conducted at Muleshoe Area Hospital District's former medical clinic on July 8, 2015 ..."

Based on observation and interview, the facility failed to provide a preventive maintenance program to ensure that all essential mechanical, electrical and patient care equipment was maintained in safe operating condition.

Findings included:

During a tour of the Physical Therapy department the morning of 3/1/16, there was an ultrasound machine available for use in patient care which had not been inspected by the contracted biomedical service. There was another ultrasound machine available for use in patient care which was overdue for inspection by the contracted biomedical service, last inspected 1/2015. A pedestal floor fan available for use in patient care area had not been inspected by the contracted biomedical service. In an interview with Staff #25 during the observation, she confirmed the lack of inspection and stated that the ultrasound machine was "old" and was not being used. Staff #25 confirmed the 2015 biomedical inspection sticker and the absence of a biomedical inspection sticker on the floor fan.

Review of the 2016 temperature log form for the hydrocollator available for use in patient care found no daily temperatures recorded for January, February, or March. There were no hydrocollator cleaning logs available for review during the tour on the morning of 3/1/16 which could result in unknown improper heating of the equipment. In an interview with Staff #25 during the tour, she confirmed the blank temperature log form and absent cleaning logs.

Review of facility "Hydrocollator Packs" policy stated, in part, "to utilize hydrocollator packs in the care and treatment of patient ...Assess patient's alertness and age for heat tolerance and ability to determine excessive heat..." Review of facility "Cleaning Hydrocollator" policy stated, in part "The hydrocollator will be cleaned to maintain cleanliness of hot packs ..."

During a tour of the Housekeeping/Central Supply Department the morning of 3/1/16, in the equipment storage area, there were two large whirlpools which had not been inspected by the contracted biomedical service. In addition, old medical equipment with no biomedical inspection stickers were found dusty and in need of cleaning. In an interview with Staff #6 during the observation, she confirmed the lack of inspection and stated that this equipment was no longer in use.

During a tour of the Emergency Department the afternoon of 3/1/16, the following equipment was observed available for patient use in the patient exam room that was overdue for inspection by the contracted biomedical service:
· Neonatal monitor, last inspected 1/2015.
· Gomco Suction machine, last inspected 7/2013.
· Pulse oximeter, last inspected 7/2013.
In an interview with Staff #6 during the observation, she confirmed the lack of inspection and stated that this equipment was not being used.

Based on observation and interviews, the facility failed to ensure drugs were stored according to acceptable standards of practice as outdated medications were found in the patient care areas available for patient use potentially causing unsafe or ineffective medications to be used in patient care.
Findings included:
During a tour of the hospital patient care area the afternoon of 3/1/16 accompanied by Staff #2, Director of Nursing, in the medication storage cabinets in the patient care area in a plastic box labeled "Antidote Kit", the following expired medications were found:
· Naloxone 0.4 mg/ml, quantity of 2, expired 11/1/15.
· Atropine Sulfate 0.4 mg/ml, quantity of 4, expired 1/2016.
· Activated Charcoal pellets, 25 grams, quantity of 1, expired 8/2015.

Based on observation, staff interviews, and documentation and interviews, the facility failed to ensure the premises were clean and orderly as multiple departmental areas throughout the hospital were found with excessive dust, dirt debris and insufficient door seals. An external door in the kitchen had 4 holes in the door which presents a risk for contamination from the weather and the entry of insects and other environmental contaminants such as dust and debris.

Findings included:

During a tour of the kitchen area the morning of 3/1/16 with Staff #6 and Staff #13 the following items were observed to be in an unsanitary condition with a covering of grease and dust, including raised fluffs of dust, on horizontal surfaces, which indicated a lack of proper cleaning:
· Observation revealed excessive dust on the horizontal surfaces of the dishwashing area above the sink and on Sani Quad containers attached to the back wall.
· Excessive dust was observed on and hanging from the top of the dishwasher enclosure. Excessive dust was observed on the horizontal shelves that were used for storage of clean plates, dessert cups, glasses, and cups that were available for patient use.
· Excessive dust and raised fluffs of dust was observed on the shelf above the food prep area, on top of the oven, the stand-alone freezer, and the stand-alone refrigerator.
· There was a buildup of dust and grease on the oven warmer with clean dishes stacked on it.
· Observation also found dust in the corners of a steel delivery cart that was used to deliver patient trays to the floors.

On the morning of 03/01/16 during an in-person interview with hospital cook #13, when asked about the excessive dust on the clean dishes storage shelves and horizontal surfaces in the dietary department, staff #13 stated "Yes. It's dusty. I try to keep everything clean."
Hospital staff #6, #12, and #13 confirmed the above dusty and greasy equipment and horizontal surfaces found in the dietary department.

During a tour of the kitchen's paper goods storage room containing disposable items for meals, accompanied by Staff #7, Kitchen manager, the floor was observed in need of cleaning, especially under the shelving units and a cart. The floor was dirty with dust, debris, and plastic eating utensils, and a dead insect was found near the Styrofoam cups and other eating implements available for use in patient meals. When the cart was rolled away from the wall, the floor underneath was grimy and in need of cleaning. When asked if housekeeping cleaned this room, Staff #7 said that he wasn't sure who cleaned the room.

The external door in the kitchen had insufficient door seals or weather stripping, leaving a gap between the doors and the frame with outside light visible seen from inside the building. This external door also had 4 holes in the upper portion of the door, each hole approximately 5/8 inch in diameter. There was light visible from the outside from the 4 holes. The lack of weather stripping or seals and the 4 holes in the door presents a risk for contamination from the weather and the entry of insects and other environmental contaminants such as dust and debris. This was confirmed in an interview with Staff #6 and Staff #12.

During a tour of the old medical section of the hospital accompanied by Staff #6 and Staff #14 on the morning of 3/1/2016, surveyors observed the Central Supply and Housekeeping departments were located in this section. During a tour of the old medical section the following was observed:
· There were multiple dusty ceiling vents. There was excessive dust and debris on counter tops, cabinets, window sills, and baseboards. There was dirt and debris on the hallway floors with missing, broken, and uneven floor tiles that presented potential tripping hazards.
· Ceiling tiles were missing, broken, discolored, water stained, and incorrectly installed. Electrical wires were hanging from the ceiling.
· This part of the hospital had inadequate lighting and the light fixtures were not in good repair. There were walls with holes, damaged corners, and water stains. There were .5 inch to 1 inch cracks above internal hallway doors. Old medical equipment with no biomedical inspection stickers were found dusty and in need of cleaning. There was also equipment stored on the floor.
· There was a gallon bottle of a peach-colored thick liquid which had no label indicating contents, the name or initials of the person who mixed the solution and the date that the solution was mixed.
· In an adjoining room to patient supplies there was a bathroom which was in need of cleaning. There was a thick layer of dust and brown dirt in the window sill and the cabinet and floor in the bathroom had a thick layer of dust and brown dirt. This room adjoined the patient supply room which contained sterile patient supplies, including IV needles, syringes, face masks, hydrogen peroxide, gauze sponges and other supplies, available for patient use. In a closet in the patient supply room, the floor was in need of cleaning and there was a dead insect on the floor. This presents a risk of cross contamination.
· There was a box of spinal needles which appeared old and yellowed with no expiration date available for patient use. The inventory labels adhered to the needle packets were stiff and yellowed. In an interview with Staff #14, she stated that "those are old" and confirmed that the needles "need to be thrown out."
· The external door in the housekeeping hallway had insufficient door seals or weather stripping, leaving a gap between the doors and the frame with outside light visible seen from inside the building. The lack of weather stripping or seals in the door presents a risk for contamination from the weather and the entry of insects and other environmental contaminants such as dust and debris.
· In the Disaster Supply storage room, there was a thick layer of dust on high and low horizontal surfaces. There were 2 cases of bottled water on the floor.
The above findings were confirmed during the tour in an interview with Staff #6 and Staff #14.

In addition an external door and hallway was used by hospital staff for the hospital linen delivery and pickup by the contracted linen services provider. Emergency equipment was observed stored in a room in this section. Staff #14 stated " There are plans to have [the old medical section] torn down. "

The above findings in the old medical section of the hospital present a safety risk and health hazard for staff and contractors working in the unsanitary environment in the old medical section. There is a risk of contamination of supplies, linen and emergency supplies and equipment. Staff go back and forth between the unsanitary and dirty area of the old medical section and the patient care area with patient linen, medical supplies, (including IV needles, syringes, face masks, hydrogen peroxide, gauze sponges and other supplies) and emergency medical supplies. This back and forth travel by staff presents a risk for cross contamination as long as these supplies, linens and staff remain housed in the old medical section as observed by the surveyors on 3/1/16 and 3/2/16.

During a tour of the Physical Therapy Department, there was a layer of dust on high and low horizontal surfaces. There were multiple therapy equipment with tears in the vinyl which made thorough cleaning impossible. There was a massage chair with a 1.5 inch tear in the vinyl, 1 treatment table with 2 inch tears in 2 corners of the head cushion vinyl, 1 treatment table with a 2 inch tear in one corner of the head cushion vinyl, and 1 low therapy table with a half inch hole in the vinyl. The observations were confirmed in an interview during the tour with Staff #25, Physical Therapy Department Assistant.

In the Physical therapy department storage area with an external door, there was an abundance of dead leaves on the carpeted floor, covering an area approximately 4 x 6 feet. The entire storage area was in need of cleaning, as there was debris and dust on the entire surface of the floor and dust on high and low horizontal surfaces. Exercise equipment and therapy equipment supplies were stored on the floor. This was confirmed in an interview during the observation with Staff #25, Physical Therapy Department Assistant and Staff #6.

During a tour of the surgical suite (no longer used for surgery; used for storage and offices) was the following observed:
· There were 2 out of 3 housekeeping carts with a mop sitting in the mop bucket in dirty water. After use, mops should be cleaned and placed in a position that allows them to air-dry without soiling walls, equipment, or supplies as standing dirty water presents a risk for the growth of bacteria.
· Also on 3 out of 3 housekeeping carts there were gallon jugs with a green liquid which had no label indicating contents, the name or initials of the person who mixed the solution and the date that the solution was mixed. This presents a safety risk.
· There were also 2 quart spray bottles containing a yellowish liquid which were unlabeled in the surgical suite.
· There were 4 tall shelving units containing uncovered linen, including sheets, gowns, pillow cases which were available for patient use. Not covering linen could have potentially caused clean linens to be contaminated from airborne dust or infectious agents.
The above findings in the surgical suite were confirmed during the observation by Staff #6.

During a tour of the Emergency Department Monitor room the afternoon of 3/1/16, there was dust observed on high and low horizontal surfaces. There was uncovered linen, including patient gowns, towels, washcloths and sheets which were available for patient use. Not covering linen could have potentially caused clean linens to be contaminated from airborne dust or infectious agents. These findings were confirmed during the observation by Staff #2, Director of Nursing.

During a tour of the Patient Nourishment room the afternoon of 3/1/16, the following was observed:
· There were 2 large containers of unidentified liquid on the countertop, and the containers were not labeled with the contents, the date or initials of person filling the containers. In an interview with Staff #17, LVN, he stated that the containers held water, however the date filled or expiration date was unknown as there was no label.
· In the refrigerator, there were 2 zipper lock baggies, each containing a sliced meat and cheese sandwich which had no label to indicate the date placed in the refrigerator or the use by date. This presents a risk for a food-borne illness if eaten beyond the safe date.
· The metal grate in the ice machine had rusted and was in need of cleaning.
The above findings in the Patient Nourishment room were confirmed during the observation by Staff #17, LVN.

Review of facility, "Cleaning Schedule" stated, in part, "...All areas of the hospital are cleaned daily by housekeeping. Some areas are cleaned twice a day. Housekeeping employees are available to come clean any gross contamination as soon as possible ...All pails, bins, cans, and other receptacles intended for use routinely are inspected, cleaned and decontaminated as soon as possible if visibly contaminated ...Housekeeping supervisor is responsible for setting up our cleaning and decontamination schedule and making sure it is carried out within our facility ..."

Record review of hospital Board of Directors meeting minutes dated May 28, 2015, stated in part, "...8. Mr. Howell stated he was able to get another quote for the Hazardous Material Assessment for $3,686.00. This will be paid by Preferred. Mr. Smyer asked if this was just part of the process of tearing down the old nursing home. .." Record review of the "V-TECH ENVIRONMENTAL SERVICES - Pre-Demolition Asbestos Survey" dated August 3, 2015, stated in part "...A pre-demolition asbestos inspection was conducted at Muleshoe Area Hospital District's former medical clinic on July 8, 2015 ..."

Based on record review and hospital staff interviews the hospital failed to ensure that staff were properly trained in disaster procedures which could potentially lead to staff not knowing what to do in non-emergency situations which could cause patient and staff harm.

Findings included:

Review of facility documents on the afternoon of 3/2/16 in the administrator's office revealed no fire drills for the 3-11 shift for the first and fourth quarter of 2015 and no fire drill for the 11-7 shift for the third quarter of 2015. In addition the review of facility documents found no disaster drills available for review during the survey. Staff #16 confirmed fire drills were not performed in the above quarters. When asked the date of the last disaster drill or training, Staff #2 stated "The actual disaster drills are overdue."

Based on observation, interview and record review the Governing Body failed to:

Ensure the physical plant and environment was a safe environment for patients as there were multiple exit signs that were not illuminated in several departments and an extension cord was used as permanent wiring. There were unsecured large oxygen tanks stored outside the hospital; provide a preventive maintenance program to ensure that all essential mechanical, electrical and patient care equipment was maintained in safe operating condition; failed to ensure drugs were stored according to acceptable standards of practice as outdated medications were found in the patient care areas available for patient use potentially causing unsafe or ineffective medications to be used in patient care; and there were multiple departmental areas throughout the hospital found with excessive dust, dirt debris and insufficient door seals. Cross refer to C0220.

Ensure that the Nurse Staffing Committee maintained the mandated committee membership and met on a quarterly basis; failed to develop, implement, maintain and approve a written, effective, ongoing, organization-wide, data-driven Patient Safety Program; and failed to ensure that staff were provided with job specific orientation and training, job descriptions, and performance evaluations to safely and effectively performed their job duties. Cross refer C0241

Review patient care policies at least annually with the advice of a group of professional personnel including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists; ensure drugs were stored according to acceptable standards of practice as outdated medications were found in the patient care areas available for patient use potentially causing unsafe or ineffective medications to be used in patient care; identify areas for potential transmission of infections as tourniquets used in obtaining blood specimens were re-used without disinfecting between patients thereby creating a risk for cross contamination; and ensure that dietary services were provided in accordance with recognized dietary standards to provide a sanitary environment for the preparation, service and storage of food and failed to ensure sanitary practices were followed in food storage and food preparation and sanitization. These deficient practices had the potential to cause food- borne illnesses to all patients. Cross refer C0270

Carry out or arrange for a periodic evaluation of its total program at least once a year; review patient care policies at least annually with the advice of a group of professional personnel including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists; evaluate and include available reports from the Dietary Department in the Performance Improvement Program and to make changes to improve care in the facility; and ensure implementation of corrective actions for quality of care issues in the hospital. Cross refer C0330

Based on review of documents, interviews, and state requirements for nurse staffing committee meetings and safety programs, the governing body failed to ensure that the Nurse Staffing Committee maintained the mandated committee membership and met on a quarterly basis; failed to develop, implement, maintain and approve a written, effective, ongoing, organization-wide, data-driven Patient Safety Program; and failed to ensure that staff were provided with job specific orientation and training, job descriptions, and performance evaluations to safely and effectively performed their job duties.

Findings included:

Review of 25 Texas Administrative Code (TAC) 133.41(o)(1)(F) stated, "The hospital shall establish a nurse staffing committee as a standing committee of the hospital ...
(i) The committee shall be composed of: (I) at least 60% registered nurses who are involved in direct patient care at least 50% of their work time and selected by their peers who provide direct care during at least 50% of their work time; (II) at least one representative from either infection control, quality assessment and performance improvement or risk management; (III) members who are representative of the types of nursing services provided at the hospital; and (IV) the chief nursing officer of the hospital who is a voting member ...(iii) The committee shall meet at least quarterly."
Review of the Muleshoe Area Medical Center Nurse Staffing Charter, stated, in part, "The Nurse Staffing Committee of Muleshoe Area Medical Center Shall consist of the following members: ...Direct care nurses comprising at least 60% of committee membership, selected by ballot by their peers ...The hospital safe staffing committee will meet quarterly, as required, but the Hospital may elect to hold a meeting more frequently if deemed needed. The Regular meetings will be scheduled for January, April, July and October, and will be during the second week of the month to be announced."

Review of Nurse Staffing Committee meeting minutes for the past year provided to the surveyor on 3/2/16 revealed that a meeting had not been held since August 2015, approximately 7 months. In addition, due to nurse turnover and nurses on extended leave, the committee was not comprised of 60% of direct care nurses. In an interview with Staff #2, Director of Nursing the afternoon of 3/2/16 in the facility Administrator's office, she confirmed that quarterly meetings of the Nurse Staffing Committee had not been held and the committee membership was not complete.

Review of the personnel records the afternoon of 3/2/16 in the facility Administrator's office accompanied by Staff #2 revealed the following:
Review of 1 out of 1 phlebotomist records (Staff #15) revealed no documented evidence of a job description in her personnel folders. Staff #2 acknowledged that Staff #15 did not have specific job descriptions detailing qualifications and duties for her position.
Review of 3 out of 20 staff (Staff #26-Physical Therapist, Staff #12-Cook, Staff #13-Cook) did not have any documented evidence of specific orientation and training for competency for their position.
Review of 3 out of 20 staff (Staff #20-Director of Nursing, Staff #21-Registered Nurse, Staff #20-Certified Nursing Assistant) revealed no documented evidence of a current annual evaluation. The last evaluation for Staff #20 was 4/23/09, the last evaluation for Staff #21 was 2/3/14, and the last evaluation for Staff #20 was 2/17/14.
Review of the personnel health record for 1 out of 2 Certified Nursing Assistants (Staff #20) revealed no documented evidence of Tuberculosis screening.
Review of the personnel health record for 1 out of 3 Kitchen Employees, Staff #19, Cook, revealed no documented evidence of Hepatitis B screening, vaccine, or declination.

Lack of job specific orientation and training presents a risk that staff members will not have the knowledge or skills to provide patient care or perform their duties in a safe and competent manner. Lack of a job description or performance evaluation presents a risk that staff members will not understand or receive feedback on the duties, responsibilities, skills, and knowledge necessary for safe performance or to provide safe patient care.

Review of facility policy, "Preventive and Post Exposure Policy and Procedure for Immunizations and Tuberculosis Surveillance", Employee Health Department for "All hospital areas", stated, in part, "All new employees ...will be screened for tuberculosis by the two-step method using Mantoux skin test. All regular employees will be tested yearly at the time of the employee's yearly evaluation ...Hepatitis B Vaccine will be made available to all employees who have the potential for occupational bloodborne pathogen exposure ...Should the employee initially decline the vaccine, a waiver must be signed, but if at a later date decides to accept the vaccine, it will be provided."

The above findings involving hospital personnel records were confirmed in an interview with the Director of Nursing the afternoon of 3/2/16 in the facility Administrator's office.

25 TAC 133.48(a)(2) The hospital must develop, implement and maintain an effective, ongoing, organization-wide, data-driven Patient Safety Program (PSP).
(A) The governing body must ensure that the PSP reflects the complexity
of the hospital's organization and services, including those services furnished under contract or
arrangement, and focuses on the prevention and reduction of medical errors and adverse events.
(B) The PSP must be in writing, approved by the governing body and made available for review by the department. It must include the following components:
(i) the definition of medical errors, adverse events and reportable events;
(ii) the process for internal reporting of medical errors, adverse events and reportable events;
(iii) a list of events and occurrences which staff are required to report internally;
(iv) time frames for internal reporting of medical errors, adverse events and reportable events;
(v) consequences for failing to report events in accordance with hospital policy;
(vi) mechanisms for preservation and collection of event data;
(vii) the process for conducting root cause analysis;
(viii) the process for communicating action plans; and
(ix) the process for feedback to staff regarding the root cause analysis and action plan.

25 TAC 133.48(a)(3) The hospital must provide patient safety education and training to staff who have responsibilities related to the implementation, development, supervision or evaluation of the PSP. Training must include all PSP components as set out in paragraph (2)(B) of this subsection.

This requirement is not met as evidenced by:

Based on a review of hospital documentation and staff interview, the governing body failed to ensure that the hospital developed, implemented and maintained an effective, ongoing, organization-wide, data-driven Patient Safety Program (PSP), in writing, approved by the governing body, and made available for review by the Texas Department of State Health Services, as specified in 25 TAC Operational Requirements, 133.48(a)(2). In addition, the facility failed to provide documented evidence of staff training of the Patient Safety Program, according to the requirements of 25 TAC Operational Requirements, 133.48(a)(3).

Findings included:

In an interview with the Director of Nursing the afternoon of 3/2/16, a request was made by the surveyor to review the hospital Patient Safety Program. The regulation, 25 TAC, Chapter 133.48 was reviewed with the Director of Nursing. The Director of Nursing stated that the facility did not have a Patient Safety Program in writing, approved by the governing body; there was no documented evidence of a Patient Safety Program provided to the surveyor.

Review of the personnel records for 20 out of 20 hospital staff (Staff #2, 6, 7, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 26, and 30) revealed no documented evidence of Patient Safety Program training.

The above findings were confirmed in an interview the afternoon of 3/2/16 with facility Administrator and the Director of Nursing in the facility Administrator's office.

Based on observation, interview and record review the facility failed to:

Review patient care policies at least annually with the advice of a group of professional personnel including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists. Cross refer C0272

Ensure drugs were stored according to acceptable standards of practice as outdated medications were found in the patient care areas available for patient use potentially causing unsafe or ineffective medications to be used in patient care. Cross refer C0276

Identify areas for potential transmission of infections as tourniquets used in obtaining blood specimens were re-used without disinfecting between patients thereby creating a risk for cross contamination. Cross refer C0278

Ensure that dietary services were provided in accordance with recognized dietary standards to provide a sanitary environment for the preparation, service and storage of food and failed to ensure sanitary practices were followed in food storage and food preparation and sanitization. These deficient practices had the potential to cause food- borne illnesses to all patients. Cross refer C0279

Based upon record review and interview, the facility failed to review patient care policies at least annually with the advice of a group of professional personnel including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists.

Findings included:

Review of policies and procedures revealed each department of the facility had their own policy and procedure manual that was reviewed and approved periodically by leadership, including the Department Supervisor, a member of the Board of Directors, the Chief of Staff, The CEO/Administrator, or the Department Medical Director.

The facility failed to review policy and procedure manuals at least annually, including but not limited to, the following departments:
· Laboratory - Last reviewed 11/7/14
· Total Quality Management - last reviewed 7/24/14
· Swing Bed - last reviewed 7/24/14
· Medical Records - last reviewed 7/24/14
· Pharmacy - last reviewed 7/24/14
· Respiratory Therapy - last reviewed 7/24/14
· Dietary Department - last review undated
· Central Supply Department - last reviewed 7/24/14
· Housekeeping Department - last reviewed 7/24/14
· Radiology Department - last reviewed 7/24/14
· Physical Therapy - last reviewed 7/24/14

The above findings were confirmed in an interview with the facility Administrator the afternoon of 3/2/16 in the facility Administrator's office.

Based on observation, review of documentation and interviews, the facility failed to ensure drugs were stored according to acceptable standards of practice as outdated medications were found in the patient care areas available for patient use potentially causing unsafe or ineffective medications to be used in patient care.
 
Findings included: 
 
During a tour of the hospital patient care area the afternoon of 3/1/16 accompanied by Staff #2, Director of Nursing, in the medication storage cabinets in the patient care area in a plastic box labeled "Antidote Kit", the following expired medications were found:
· Naloxone 0.4 mg/ml, quantity of 2, expired 11/1/15.
· Atropine Sulfate 0.4 mg/ml, quantity of 4, expired 1/2016.
· Activated Charcoal pellets, 25 grams, quantity of 1, expired 8/2015.
 
Review of facility pharmacy policy, "Expiration Dates" policy 09-03 stated, in part, "Expiration dates of drugs and devices shall be checked during the monthly medication area inspections and all drugs and devices scheduled to expire during the next month shall be removed from stock."
 
An in-person interview was conducted with Staff #2 the afternoon of 3/1/16 who acknowledged the above findings of the expired medications which were available for patient use.

Based on observation and interview, the facility failed to identify areas for potential transmission of infections as tourniquets used in obtaining blood specimens were re-used without disinfecting between patients, thereby creating a risk for cross contamination.

Findings included:

A tour of the phlebotomy area of the laboratory was conducted the morning of 3/1/16 accompanied by Staff #6, Swing Bed Coordinator. Observation of the blood drawing/phlebotomy equipment revealed one tourniquet among the lab specimen tubes used for collection of patient blood specimens. In an interview with Staff #15, phlebotomist, she was asked if she cleaned the tourniquets in between patients for blood draws or if she used a new tourniquet for each patient. Staff #15 stated she did not clean the tourniquet in between patients and uses (and re-uses) each tourniquet "for about a day."
The World Health Organization, "Guidelines on Drawing Blood: Best Practices in Phlebotomy" (2010) states, in part, "Tourniquets are a potential source of methicillin-resistant Staphylococcus aureus (MRSA), with up to 25% of tourniquets contaminated through lack of hand hygiene on the part of the phlebotomist or reuse of contaminated tourniquets."

The above findings were confirmed in an interview with Staff #24, Laboratory Technologist the morning of 3/1/16 in the laboratory. Staff #24 immediately provided Staff #15 with a box of new tourniquets and instructions to dispose of tourniquets after use with each patient.

Based on observation, interview, and document review, the facility failed to ensure that dietary services were provided in accordance with recognized dietary standards to provide a sanitary environment for the preparation, service and storage of food and failed to ensure sanitary practices were followed in food storage and food preparation and sanitization. These deficient practices had the potential to cause food- borne illnesses to all patients.

Findings included:

During a tour of the kitchen the morning of 3/1/16, Staff #7, Dietary Manager was observed in the kitchen food preparation area without a hair restraint when the surveyors arrived for the tour. When asked, Staff #7 stated, "I should be wearing a hair net." Current dietary standards require that a hair restraint should be worn in the food prep area to prevent hair from contaminating and contacting exposed food, equipment, and utensils.

When asked for a food thermometer, Staff #7 opened a desk drawer and handed the surveyor a food thermometer with a blue outer probe case. The blue case of the thermometer was in need of cleaning, as it was sticky and greasy and what appeared to be dried food was adhered to the surface. Upon opening the case, the temperature probe was observed with an oily substance and sticky to the touch and there was also what appeared to be dried food adhered to the temperature probe. The use of a clean food thermometer is necessary to ensure that foods are cooked to a safe internal temperature to destroy any harmful bacteria that may be in the food and to prevent food-borne illness.

The following are observations by the surveyors during the tour of the kitchen the morning of 3/1/16, accompanied by Staff #7, Staff #6, and Staff #12.

In the kitchen stand-alone refrigerator, the following was observed:
· A metal tub which was covered in foil containing what appeared to be grease which was not labeled with a date or the contents.
· Sour cream packets, 1 ounce each, quantity of 14, which expired 2/25/16.
· One 40 ounce package of sliced ham which was unsealed and sitting exposed to air in liquid without a label to indicate the date opened or use-by date.
· Two zipper-lock bags which were hand-labeled "Turkey" and the handwritten use-by date was "12-31."
· There was a zipper-lock bag lying unsealed and opened containing a partial sliced tomato and piece of an onion without a label indicating the date opened or use-by date.
· There were pieces of lettuce and pieces of celery wrapped in plastic wrap which were not labeled or dated.
All the above food items were available for use in patient meals.
The above findings in the refrigerator were confirmed during the observation by Staff #12.

In the kitchen stand-alone freezer, the following was observed:
· 4 zipper-lock bags containing a meat substance without a label describing contents or date opened or use-by date. Staff #12 stated the bags contained ham chunks.
· 1 zipper-lock bag containing a meat substance without a label describing contents or date opened or use-by date. Staff #12 stated the bag contained turkey chunks.
· 1 container of beef chorizo with a manufacturer date expired 2/2/16.
· Chopped nuts in a gallon zipper-lock bag without label describing contents or date opened or use-by date.
· Frozen rolls, quantity of approximately 28 in a gallon zipper lock bag without label describing contents or date opened or use-by date.
· Sunflower seeds kernels, 2 pound bag which had been opened without label indicating date opened or use-by date.
All the above food items were available for use in patient meals.
The above findings in the stand alone freezer were confirmed during the observation by Staff #12.

During a tour of the dietary department on the morning of 3/1/16 accompanied by the hospital Swing Bed Coordinator, Staff #6 and dietary manager, Staff #7 the following food items were observed without open or use-by dates in the walk-in freezer:
· 1 small plastic bag of chicken
· 1 small plastic bag of taquitos
· 5 half opened packages of ground meat
· 1 small plastic bag that contained an unknown blackened substance
· 1 plastic bag of chopped turkey
· 1 small plastic bag of ground meat
· 1 small plastic bag of frozen pancakes
· 1 small plastic bag of unknown meat
· 1 plastic bag of macaroni and cheese
· 1 plastic bag of green beans
· 1 plastic bag of mixed vegetables.

The refrigerator contained the following opened items without open or use-by dates:
· 1 large plastic container of croutons,
· 1 five pound plastic container of cottage cheese,
· 1 plastic container of whipped topping,
· 1 unlabeled partially filled cola bottle with tan liquid without a date, and
· 1 bottle of coffee creamer.
· There was 1 container of chocolate fudge with an expired date of 2/23/16.

The pantry contained the following opened food items without open or use-by dates:
· 1 bag of Hershey's cocoa,
· 1 bottle of honey,
· 1 bag of angel food cake mix,
· 1 large plastic container of croutons,
· 1 plastic container of cookies.

The following undated large plastic bins were stored directly on the pantry floor:
· 1 plastic bin of dried potatoes,
· 1 plastic bin of macaroni pasta,
· 1 plastic bin of rice,
· 1 plastic bin of flour, and
· 1 plastic bin of corn meal.
· There were 3 bags of gelatin deserts, 1 bag of sweetener, and 1 bag of peppered gravy mix without opened or use-by dates stored on pantry shelves.
· There was 1 opened bag of white flour tortilla mix with an expired date of 7/13/15.


In the kitchen food prep area, the following was observed:
There was an industrial manual can opener mounted to a food prep table, which was dirty with a thick brown/black substance on the blade, the handle, the shaft, and the mount, increasing the risk of food contamination. In an interview with Staff #12, she stated that the can opener was being used and confirmed that the can opener "needs to be cleaned".

On the shelf above the food prep area, there were various items which presented a risk for cross contamination to exposed food below, including the following:
· A tube of moisturizing lotion
· Cardboard salt and pepper containers, which appeared old and were greasy and dirty, with portions of the cardboard container peeled and worn off.
· A soufflé cup containing a granular substance which appeared to be seasonings without a label describing contents or use-by date.
· A plastic drinking cup containing at least 25 metal cola pop top pull tabs with a brown, sticky substance adhered, which appeared to be old cola.
· A plastic box containing personal items not used in food prep, such as a small Bible, pencil, mirror, old garlic cloves, a plastic plate and various other items.
These items, stored in the food prep area above the space used for exposed food preparation present a risk for cross contamination. These findings were confirmed in an interview during the observation with Staff #6.

Observation of the cooking utensils used in patient food preparation revealed:
· There was a dried substance which appeared to be food on the potato peeler.
· There was a dried white substance on the slicer.
· There were 5 open plastic bins underneath the food prep table containing food prep utensils which were available for use in preparing patient food. Staff #12 confirmed that the utensils were ready for use. In each of the 5 utensil bins, there was a paper liner underneath the utensils, which had stains and oil spots. There were crumbs and debris in the bottom of each of the utensil bins.
· In the first bin, there were several long black hairs on the cooking utensils. There was dried food observed on the large spoons and ladles. There was a rubber spatula with several chunks of rubber missing and tears in the rubber, which prevents effective cleaning. Staff #12 stated the spatula should be thrown away. The large bowls of the spoons and ladles were stored with the bowl up, which presents a risk for contamination with dust. Several of the spoons and ladles had water spots inside the bowl indicating they were put up while still wet.
· In the second bin, there was a food particle, an onion skin approximately 2 x 1.5 inches lying on the utensils. The spoons were stored with the bowls up.
· In the fifth bin, there was a basting brush which was dirty and sticky with several chunks of a white sticky substance adhered to the bristles and handle which appeared to be food.
The above findings involving the cooking utensils were confirmed during the observation by Staff #12 and Staff #6.

During a tour of the kitchen area the morning of 3/1/16 with Staff #6 the following items were observed to be in an unsanitary condition with a covering of grease and dust, including raised fluffs of dust, on horizontal surfaces, which indicated a lack of proper cleaning:
· Observation revealed excessive dust on the horizontal surfaces of the dishwashing area above the sink and on Sani Quad containers attached to the back wall.
· Excessive dust was observed on and hanging from the top of the dishwasher enclosure. Excessive dust was observed on the horizontal shelves that were used for storage of clean plates, dessert cups, glasses, and cups that were available for patient use.
· Excessive dust and raised fluffs of dust was observed on the shelf above the food prep area, on top of the oven, the stand-alone freezer, and the stand-alone refrigerator.
· There was a buildup of dust and grease on the oven warmer with clean dishes stacked on it.
· Observation also found dust in the corners of a steel delivery cart that was used to deliver patient trays to the floors.

On the morning of 03/01/16 during an in-person interview with hospital dietary manager Staff #7, Staff #7 stated the opened food items should have had open dates on them.
During an in person interview with a hospital cook Staff #12, when asked what the tan liquid in the opened coke bottle found in the refrigerator was, Staff #12 stated " I have no idea. We are supposed to label everything. We should put dates on them. "
During an in person interview with hospital cook, Staff #13, when asked about the excessive dust on the clean dishes storage shelves and horizontal surfaces in the dietary department, staff #13 stated " Yes. It is dusty. I try to keep everything clean. "
Hospital staff #6, #7, #12, and #13 confirmed the above undated and expired food items, dusty and greasy equipment and horizontal surfaces found in the dietary department.

The external door in the kitchen had insufficient door seals or weather stripping, leaving a gap between the doors and the frame with outside light visible seen from inside the building. This external door also had 4 holes in the upper portion of the door, each hole approximately 5/8 inch in diameter. There was light visible from the outside from the 4 holes. The lack of weather stripping or seals and the 4 holes in the door presents a risk for contamination from the weather and the entry of insects and other environmental contaminants such as dust and debris. This was confirmed during the observation the morning of 3/1/16 with Staff #6.

Observation of the kitchen paper goods storage room containing disposable items for meals, accompanied by Staff #7, Dietary manager, revealed that the floor was in need of cleaning, especially under the shelving units and a cart. The floor was dirty with dust, debris, and plastic eating utensils. A dead insect was found on the floor near the Styrofoam cups and other eating implements available for use in patient meals. When the cart was rolled away from the wall, the floor underneath was grimy and in need of cleaning. These findings were confirmed with Staff #7 during the observation of the kitchen paper goods storage room.

During a subsequent tour of the kitchen the afternoon of 3/2/16 at 3:50 pm, Kitchen Staff #32 was asked by the surveyor for the sanitizing solution used for sanitizing food contact and food preparation surfaces. Staff #32 revealed a white, unlabeled bucket approximately 1/2 full of a clear liquid in the dishwashing area of the kitchen. There was no label on the bucket to indicate the contents, or the date and time the solution was last prepared; Staff #32 confirmed that the bucket was not labeled. Staff #32 stated that the previous shift had prepared the solution.

When asked which sanitizing agent was used in the solution, Staff #32 stated "bleach." When the surveyor asked Staff #32 to test the solution with a test strip to determine the concentration of the solution, Staff #32 obtained a test strip from another area of the kitchen and dipped it into the solution. The strip instantly turned black when inserted into the solution, revealing an excessively high concentration. Reviewing the test strip scale confirmed that the solution was greater than 400 parts per million (ppm), when the range should be 50-150 ppm after 7-10 seconds. Further review revealed that the test strips expired 1/25/14. Another tube of test strips available expired 1/1/16. When asked for a log indicating the frequency of changing the sanitizing solution and testing the concentration of the solution, Staff #32 stated that a log was not maintained and there was no documented evidence provided to the surveyor to indicate that sanitizing solutions were being tested and regularly changed.

On request by the surveyor, Staff #32 prepared a fresh bucket of sanitizing solution and demonstrated adding roughly one capful of the bleach container to approximately half a bucket of water. Staff #32 stated this was how the sanitizing solution was mixed. The inexact method of mixing the solution presents a risk that the concentration of the sanitizing agent will not be at the proper strength, either too weak (ineffective) or too strong. Staff #32 then tested the solution with a result of greater than 400 ppm in approximately 2 seconds.

When asked for the cleaning solution used to clean food preparation surfaces before sanitizing, Staff #32 stated "we don't have a cleaning solution, we just use the bleach water." Pathogenic microorganisms and physical contaminants can be introduced into food and cause foodborne illness when food-contact surfaces are not properly cleaned and sanitized. Cleaning removes food and soils from a surface, while sanitizing reduces the number of microorganisms on that surface to a safe level.

At 5:15 pm on 3/2/16, a final tour was conducted of the kitchen accompanied by the facility Administrator, who observed the testing of the sanitizing solution with greater than 400 ppm, the expired test strips, the unlabeled sanitation bucket, and the lack of cleaning solution. The Administrator confirmed the above findings.

The above findings present a risk for cross contamination of patient food without proper cleaning and sanitizing of food contact surfaces. These findings were confirmed during the observations by the Administrator and Staff #32 in the kitchen the afternoon of 3/2/16.

Review of facility policy, "Cleaning and Sanitizing Kitchen Surfaces and Equipment", Reference #4015, stated, in part, "Food contact surfaces that are non-immersable (sic) (i.e. mixers ...counters ...) are to be cleaned by:
· Wiping with a towel/rag dipped in hot soapy water to wash
· Wiping with a towel/rag dipped in hot water to rinse
· Wiping with a towel/rag dipped in sanitizing solution (following manufactures (sic) instructions)
· Allow to air dry."
A chart in the above policy for "Sanitizing Methods" stated that Chlorine solution should be 50 ppm-100 ppm using a test strip for effectiveness after an exposure time of 7-10 seconds.

During observation in the refrigerator of the Patient Nourishment room the afternoon of 3/1/16, there were 2 zipper lock baggies, each containing a sliced meat and cheese sandwich which had no label to indicate the date placed in the refrigerator or the use-by date. This presents a risk for a food-borne illness if eaten beyond the safe date. The above findings in the Patient Nourishment room were confirmed during the observation by Staff #17, LVN.

Review of facility policy, "Patient Nourishments and Floor Stock-Non Routine Occurances (sic)" Reference #2010, stated, in part, "Code dates or date of preparation must be observed, and food items discarded according to expiration date or the third day from date of preparation."

Review of facility policy, "Nutritional Services Department Safety", Reference #3001, stated, in part, "The department Manager is responsible for maintaining safety standards, developing safety rules, supervising and training personnel in departmental standards ...The Manager of Nutritional Services is responsible for making a cleaning schedule and monitors compliance as safety is closely related to proper cleaning maintenance."

Review of the personnel records of the afternoon of 3/2/16 in the facility Administrator's office accompanied by Staff #2 revealed the following:

Review of 2 out of 2 Dietary staff (Staff #12-Cook, Staff #13-Cook) did not have any documented evidence of specific orientation and training for competency for their position. Lack of job specific orientation and training presents a risk that staff members will not have the knowledge or skills to perform their duties in a safe and competent manner.

Review of the personnel folder for Staff #7, Dietary Manager revealed a Food Protection Manager Certification issued on 6/4/13, expiration date 6/4/18. The position description for the Dietary Department Manager stated, in part, "The Dietary department will be kept in a clean and sanitary manner to support food handling safety through the effective management of the dietary staff ...Qualifications: ...Proficient level of knowledge of food handling and safety procedures ...Ability to demonstrate responsible use of food, supplies, and cleaning agents ...Properly operate equipment for food preparation and cleaning within the department."

Review of facility policy, "Storage and Use of Leftovers", Reference #4004, stated, in part, "All left over food items shall be handled and stored so as to prevent contamination and compromise food safety ...All leftover food for storage in refrigerator is put into storage containers with lids, sealable bags covered with plastic or foil wrap. These are labeled with the name of the item and dated. A "use by" date may be included which is no longer than 3 days from preparation ...Leftover items which are not frozen, are held no longer than 3 days ...When leftover portions of food are frozen and then thawed, the food must be consumed within 24 hours or discarded."

Review of facility policy, "Food Thermometers", Reference #4006, stated, in part, "To prevent contamination and control the rate of bacterial growth food thermometers are properly used and sanitized ...Clean, sanitize and store thermometer in a case/holder between uses."

Review of facility policy, "Safe Food Storage", Reference #4007, stated, in part, "All food should be sealed, covered or wrapped securely. If any food is only partially used, the container is to be marked with an "open date". All chemicals and cleaners are to be properly labeled ...Frozen foods moved to the refrigerator to thaw will be dated with the "pulled date" and the "use by date". Dry Good Storage ...Products will be marked with the delivery date.'

Review of the resource entitled, "Food Safety it's our business" (Texas A&M AgriLife Extension Service, 2012) provided by the hospital Administrator the afternoon of 3/2/16 as the reference guide used by the hospital dietary department revealed the following:
"Using a Food Thermometer. Keep thermometers clean and sanitized ...
Storing Frozen Foods ...Date mark and store food in moisture-proof wrappings ...Discard out of date packages ...
Date Marking. Date marking is especially important to help prevent unsafe bacterial growth from Listeria monocytogenes. Date marking should include the food product, name of person who prepared food (optional), and date and time prepared or date to be thrown out ...
Maintain all equipment and utensils so they remain smooth and non-absorbent; free of cracks and chips ...
Cleaning and Sanitizing. All equipment, food-contact surfaces, and utensils should be kept clean and sanitized ...Cleaning is the removal of dirt, soil, food particles, or grease from surfaces by cleaning agents. Sanitizing is the reduction of most of harmful microorganisms on a clean surface through the usage of heat or chemicals to safe levels ..."

Review of the Muleshoe Hospital Dietary Consulting Report for the past 7 months revealed the dietary issues observed above related to food storage, labeling, expired food had been previously identified. The Report contained the following assessments and comments:
· June 2015 - Proper dates/labels on foods-needs improvement. Undated items in fridge.
· July 2015 - Proper dates/labels on foods-needs improvement. No products past "use-by" dates-needs improvement. Date freezer items, throw out condiments > 2 months.
· August 2015 - Proper dates/labels on foods-date freezer items for rotation, date jalapenos and bread crumbs in upright fridge, clean top of dishwasher.
· November 2015 - Proper dates/labels on foods-needs improvement. No products past "use-by date-needs improvement. Date healthshakes, throw out old diced turkey, date chocolate and caramel syrup.
· December 2015 - Proper dates/labels on foods-needs improvement. Date whipped topping and croutons in fridge, foil wrapped item in fridge needs food item and date on outside. Date dry goods in containers in pantry.
· February 2016 - Proper dates/labels on foods-needs improvement. No products past "use-by" date-needs improvement. Condiments >3 months old need to be discarded, some expired milks ...Cottage cheese expired ...date dry good packaging for rotation (mash potatoes, potato chips, gelatin mix etc.). Date ketchup and tortillas in fridge. Employee drink in dry goods pantry with no lid and on shelf above food.

A request was made by the surveyors for the current dietary manual in use. Staff #7 provided the Texas Dietetic Association Medical Nutrition Therapy Manual for 2008. This manual was most recently revised in 2013; the hospital was using an outdated dietary manual. This was confirmed in an interview with Staff #7 the afternoon of 3/2/16.

The above findings were confirmed the afternoon of 3/2/16 with the facility Administrator during the tour of the kitchen and in the facility Administrator's office.

Based on hospital staff interviews and record review the hospital failed to ensure patient medical records were completed with dated and/or signed physician orders as 2 of 24 patient records contained orders with no dates and/or signatures by the physician.

Findings included:

Review of 24 hospital patient medical records on the morning of 3/2/16 in the administrator ' s office found that Patient #1 did not have a diet order signed or dated by the physician. Patient #2 did not have and admission order dated or signed by the physician.
An in-person interview was conducted with Staff #6 the morning of 3/2/16 who acknowledged the above findings of physician orders without dates or signatures.

Based on observation, interview and record review the facility failed to:

Carry out or arrange for a periodic evaluation of its total program at least once a year. Cross refer C0331

Review patient care policies at least annually with the advice of a group of professional personnel including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists. Cross refer C0334

Evaluate and include available reports from the Dietary Department in the Performance Improvement Program and to make changes to improve care in the facility. Cross refer C0337

Ensure implementation of corrective actions for quality of care issues in the hospital. Cross refer C0342

Based on review of records and interview with staff, the facility failed to carry out or arrange for a periodic evaluation of its total program at least once a year.

Findings were:

Review of records revealed that the facility did not conduct a periodic evaluation of its total program at least annually. This was acknowledged by the facility Administrator during an in-person interview on 3/2/16 at 3:45 pm in the Administrator's office. As the current Administrator had been at the facility for less than a year, he consulted with the Administrative Assistant, Staff #33. When asked if she was aware of an annual program evaluation, Staff #33 stated, "No, we have not done one since I've been here; I've been here for 2 years."

Based upon record review and interview, the facility failed to review patient care policies at least annually with the advice of a group of professional personnel including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists.

Findings included:

Review of policy and procedure manuals on 3/1/16 and 3/2/16 in the Administrator's office revealed the facility failed to review policy and procedure manuals at least annually, including but not limited to, the following departments:
· Physical Therapy - last reviewed 7/24/14
· Laboratory - Last reviewed 11/7/14
· Dietary Department - last review unknown - undated
· Medical Records - last reviewed 7/24/14
· Swing Bed - last reviewed 7/24/14
· Pharmacy - last reviewed 7/24/14
· Respiratory Therapy - last reviewed 7/24/14
· Total Quality Management - last reviewed 7/24/14
· Central Supply Department - last reviewed 7/24/14
· Housekeeping Department - last reviewed 7/24/14
· Radiology Department - last reviewed 7/24/14

The above findings were confirmed in an interview with the facility Administrator the afternoon of 3/2/16 in the facility Administrator's office.

Based on available documentation and interview, the facility failed to evaluate and include available reports from the Dietary Department in the Performance Improvement Program and to make changes to improve care in the facility.

Findings included:

Review of the Muleshoe Area Medical Center Performance Improvement Plan provided to the surveyors stated, "The objective of the Performance Improvement Plan is to assure quality care while reducing and/or eliminate unnecessary correctable risks, hazards, inefficiencies, and expense within the hospital ...
2. Establish an on-going monitoring and reporting system for problem and or improvement identification.
3. Objectively assess the cause and scope of identified problems.
4. Establish priorities for the resolution of identified problems or opportunities for improvement and implement appropriate mechanisms for problem solving.
5. Assure that corrective action is appropriate and sustained through on-going follow-up of problem solving activities and evaluation of the effectiveness of action taken."

Review of the Performance Improvement Meeting Minutes for January 19, 2016 revealed the following report from the Dietary Department:
"Dietary reported on October, November, and December. Three areas were monitored with several indicators in each area monitored. All areas met threshold."

Review of the Muleshoe Hospital Dietary Consulting Reports for the past 7 months provided to the surveyor on 3/1/16 revealed identification of on-going food and dietary issues with the following assessment and comments:
· June 2015 - Proper dates/labels on foods-needs improvement. Undated items in fridge.
· July 2015 - Proper dates/labels on foods-needs improvement. No products past "use-by" dates-needs improvement. Date freezer items, throw out condiments > 2 months
· August 2015 - Proper dates/labels on foods-date freezer items for rotation, date jalapenos and bread crumbs in upright fridge, clean top of dishwasher
· November 2015 - Proper dates/labels on foods-needs improvement. No products past "use-by date"-needs improvement. Date healthshakes, throw out old diced turkey, date chocolate and caramel syrup.
· December 2015 - Proper dates/labels on foods-needs improvement. Date whipped topping and croutons in fridge, foil wrapped item in fridge needs food item and date on outside. Date dry goods in containers in pantry.
· February 2016 - Proper dates/labels on foods-needs improvement. No products past "use-by" date-needs improvement. Condiments >3 months old need to be discarded, some expired milks ...Cottage cheese expired ...date dry good packaging for rotation (mash potatoes, potato chips, gelatin mix etc.). Date ketchup and tortillas in fridge. Employee drink in dry goods pantry with no lid and on shelf above food.

During a tour of the facility kitchen on 3/1/16 and 3/2/16 accompanied by Staff #7, Dietary Manager, Staff #6, Swing Bed Coordinator, Staff #12, Cook, and the facility Administrator, observation, interview, and document review revealed that the facility failed to provide a sanitary environment for the preparation, service and storage of food and failed to ensure sanitary practices were followed in food storage and food preparation in accordance with recognized dietary standards. This had the potential to cause food- borne illnesses to all patients. The kitchen was in need of cleaning and there were food items in the refrigerators and freezers that were expired and that were not dated as identified in the above reports. These items were confirmed during the tour of the facility kitchen on 3/1/16 and 3/2/16 accompanied by Staff #7, Dietary Manager, Staff #6, Swing Bed Coordinator, Staff #12, Cook, and Administrator.

There was no documented evidence that the Performance Improvement Committee reviewed or was aware of the above identified problems, assessed the scope and cause, established priorities for the resolution of identified problems, assured that corrective action was taken, evaluated, and sustained. There were no documented discussions, process changes, or recommendations for improvement based upon the information provided in the Consultation reports.

The above findings were confirmed in an interview with the facility Administrator the afternoon of 3/2/16 in the facility Administrator's office.

Based on the review of available documentation and interviews, the Performance Improvement committee failed to ensure implementation of corrective actions for quality of care issues in the hospital.

Findings were:

Review of the Muleshoe Area Medical Center Performance Improvement Plan provided to the surveyors stated, "The objective of the Performance Improvement Plan is to assure quality care while reducing and/or eliminate unnecessary correctable risks, hazards, inefficiencies, and expense within the hospital ...
3. Objectively assess the cause and scope of identified problems.
4. Establish priorities for the resolution of identified problems or opportunities for improvement and implement appropriate mechanisms for problem solving.
5. Assure that corrective action is appropriate and sustained through on-going follow-up of problem solving activities and evaluation of the effectiveness of action taken."

Review of the Performance Improvement Meeting Minutes for January 19, 2016 revealed that problems had been assessed and identified in the Emergency Department through the QAPI program, however there was no documented evidence to determine if there was follow up and resolution of identified problems. January 2016 QAPI reporting from the Emergency Department revealed "9 of 32 indicators fell below threshold of 85% or above. The plan of action was to "in-service/re-train staff, return variance forms for nurses to review their trends, and sign loop closure forms. This is to be completed by February 15th, 2016."
In an interview with the Director of Nursing at 4 pm on 3/2/16 in the facility Administrator's office, she confirmed that the follow-up portion of the QAPI program was "still evolving" and though problems and corrective actions had been identified, there was, however, no documented evidence provided to indicate on-going follow-up of corrective action and consequently no evaluation of the effectiveness of action taken.

The above findings were confirmed in interview with the facility Administrator and Director of Nursing the afternoon of 3/2/16 in the facility Administrator's office.