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Based upon observation, record review, and interview, the facility failed to ensure evidence that 9 of 27 patients reviewed for rights (Patient's #1, #2, #3, #6, #10, #11, #25, #26, and #27); were informed of their patient rights orally and in writing, in advance of furnishing patient care, and prior to discharge. Specifically,

1.) Patient's #1, #11, #25, #26, and #27 medical records did not contain a signed copy of their patient rights or evidence they were informed of their patient rights.

2.) Patient's #1, #2, #3, #6, #10, #11, #25, #26, and #27 medical records did not contain evidence or documentation within their medical records whether or not advance directives had been executed by the patient or patient's representative, or information provided to the patient regarding advance directives.

3.) Patient Rights information was not posted or available upon interview at the facility's main registration/admission area, or at the facility's registration area of the Emergency Room (ER) Department.

4.) The required State Law posting to notify patients or patient representatives of the statement of duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language with their right to contact the appropriate complaint line number was not posted at 2 of 2 entrances/waiting areas (Entrance/Main Lobby, and Entrance/Emergency Room Waiting).

Findings included:

Review of the facility's Patient Rights and Responsibilities policy effective 7/1/15 revealed "prior to, or at the time of registration, the patient shall be fully informed of their rights."

Review of the Patient Rights, undated, revealed as a patient; you have the right to information, at the time of admission, about the hospital's patient rights policy(ies) and the mechanism for the initiation, review, and when possible, resolution of patient complaints concerning the quality of care. In addition, the patient has the right to formulate advance directives.

1.) Record review of Patient's #1, #11, #25, #26, and #27 medical records revealed there was no evidence or documentation that Patients were given a copy or informed of their Patient's Rights either orally and/or in writing. The medical records contained a form; Conditions of Admission and Authorization for Medical Treatment with an area for Patient Rights. The Patient was to initial acknowledgment for agree or disagree that the patient had been given information and instructions regarding their Patient Rights. These areas of the forms for Patient's #1, #11, #25, #26, and #27 were blank without acknowledgment.

During an interview on 1/17/18 at 11:45 AM with the Infection Prevention - Registered Nurse (IP-RN) confirmed after review of the records that Patient's #1, #11, #25, #26, and #27 medical records did not contain evidence or documentation that Patients were given a copy or informed of their Patient's Rights either orally and/or in writing.

During an interview on 1/17/18 at 2:10 PM with the Registration Clerk #1 stated during registration for admission that patients were to be offered a copy of the patient rights and patient grievance process; and also patients were supposed to initial the Patient Rights area; as acknowledgment they were informed of their rights.

2.) Review of the facility's Conditions of Admission obtained for all Patients upon admission revealed an area for Advanced Directives. The Advance Directive area indicated, acknowledgment that the patient had been given information regarding the State's Law on living wills and advance directives.

Additionally, there were four areas to be completed that were as follows:
_____ I have executed an Advance Directive and have been requested to supply a copy to the Hospital.
_____ I have reviewed the Advance Directive on file at the Hospital and it is my current Advance Directive.
_____ I have not executed an Advance Directive.
_____ I have received information about Advance Directives as required by federal law.

Review of patient medical records revealed the following:

Patient #1, who was a 75 year old inpatient, conditions of admission for advance directives was blank with no documentation whether or not an advance directive had been executed; or information provided.

Patient #2, conditions of admission for advance directives was blank with no documentation whether or not an advance directive had been executed; or information provided.

Patient #3, who was a 63 year old inpatient, conditions of admission for advance directives was blank with no documentation whether or not an advance directive had been executed; or information provided.

Patient #6, who was a 45 year old inpatient, conditions of admission for advance directives was blank with no documentation whether or not an advance directive had been executed; or information provided.

Patient #10, who was an 85 year old patient, conditions of admission for advance directives was blank with no documentation whether or not an advance directive had been executed; or information provided.

Patient #11, who was a 54 year old patient, conditions of admission for advance directives was blank with no documentation whether or not an advance directive had been executed; or information provided.

Patient #26, who was a patient in a swing bed and with Medicare, conditions of admission for advance directives was blank with no documentation whether or not an advance directive had been executed; or information provided.

Patient #27, who was a patient in a swing bed and with Medicare, did not have a conditions of admission form in his record with information regarding advance directives and whether or not an advance directive had been executed; or information provided.

During an interview on 1/17/18 at 11:45 AM with the IP-RN confirmed the above records after review that; conditions of admission for advance directives were blank with no documentation whether or not an advance directive had been executed, or information provided.

During an interview on 1/17/18 at 02:10 PM with the admission registration clerk #1 stated that patients were provided with the conditions of admission form and indicated the registration clerk would have the patient initial the appropriate advance directives information; if the patient had or did not have advance directives. The registration clerk #1 stated advance directive information would be provided to the patient upon request.

3.) Observations conducted in the facility with the IP-RN present on 1/17/18 at 2:30 PM of the facility's lobby/waiting/registration area and the Emergency Department lobby area revealed there was not a posting of the patient bill of rights posted in a public area that was readily visible to patients, residents, employees, and visitors.

During an interview with the IP-RN on 1/17/18 at 2:35 PM confirmed there was not a posting of the patient bill of rights in the hospital's waiting areas or hallways.

4.) Observations conducted in the facility with the IP-RN present on 1/17/18 at 2:30 PM of the facility's lobby/waiting/registration area and the Emergency Department lobby area revealed there was not a posting for display in a public area that is readily visible to patients, residents, volunteers, employees, and visitors; a statement of the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in accordance with the HSC, and ensure the statement contains the number of the Texas DSHS patient information and complaint line at (888) 973-0022; and in a second language appropriate to the demographics of the community served (Spanish).

An interview with the IP-RN on 1/17/18 at 2:35 PM confirmed there was not a posting in the facility for display readily visible to patients, or patient representatives of the statement of the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in a second language which also included the number of the Texas Department of State Health Services (DSHS) patient information and complaint line at (888) 973-0022; and in Spanish.

Based on record review, observation, and interview, the facility failed to ensure their policies and procedures protected patient's rights to be free from all forms of abuse or harassment while a patient in the facility. Specifically, the facility's procedures for; how to report abuse/neglect/exploitation were not specific and did not include the reporting requirements regarding allegations of abuse/neglect against the facility and/or facility employees to the appropriate state health care regulatory agency that has authority and licenses the facility; Department of State Health Services (DSHS) at (888) 973-0022; and in accordance with the Health and Safety Code §161.132(b).

This deficient practice could affect the prevention of possible unidentified abuse, neglect, or mistreatment for all patients in the facility; by compromising their safety.

Findings included:

Review of the facility's Policy and Procedures titled, Assault, Abuse, and Neglect Reporting, revised 4/2013 revealed the following purpose: To provide appropriate guidelines on whom to call and notify in reportable injuries such as assault and battery, abuse (child and adult) and neglect. The Procedures for reporting abuse only included reporting to the Department of Protective and Regulatory Services (DFPS) at 1-800-252-5400 or online at

Further review revealed the facility's Abuse and Neglect policy did not have any further information regarding the specific state health care regulatory agency (Department of State Health Services) that has authority over allegations of abuse/neglect against the facility and/or facility employees was provided within the policy; or a phone number to the DSHS agency (888-973-0022) was provided within the policy.

Observations conducted in the facility with the Infection Prevention Registered Nurse (IP-RN) present on 1/17/18 at 2:30 PM of the facility's lobby/waiting/registration area and the Emergency Department lobby area revealed there was not a posting for display in a public area that is readily visible to patients, residents, volunteers, employees, and visitors; a statement of the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in accordance with the HSC, and ensure the statement contains the number of the Texas DSHS patient information and complaint line at (888) 973-0022; and in a second language appropriate to the demographics of the community served (Spanish).

During an interview with the IP-RN on 1/17/18 at 2:35 PM confirmed there was not a posting in the facility for display readily visible to patients, or patient representatives of the statement of the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in a second language which also included the number of the Texas Department of State Health Services (DSHS) patient information and complaint line at (888) 973-0022; and in Spanish.
During an interview on 1/17/18 at 3:00 PM with the Facility's Interim Chief Nursing Officer (CNO) confirmed after review of the facility's policy for reporting Abuse and Neglect (last reviewed 4/2013) did not contain the specific information for reporting abuse and neglect to the appropriate agency that licensed the facility [DSHS] or the appropriate state health care regulatory agency [DSHS] for allegations of abuse associated with the facility or an employee of the facility. The CNO further stated upon an allegation of abuse and/or neglect an investigation would be conducted by the facility's quality department.

Health and Safety Code §161.132(b) indicates: b) An employee of or other person associated with an inpatient mental health facility, a treatment facility, or a hospital that provides comprehensive medical rehabilitation services, including a health care professional, who reasonably believes or who knows of information that would reasonably cause a person to believe that the facility or an employee of or health care professional associated with the facility has, is, or will be engaged in conduct that is or might be illegal, unprofessional, or unethical and that relates to the operation of the facility or mental health, chemical dependency, or rehabilitation services provided in the facility shall as soon as possible report the information supporting the belief to the agency that licenses the facility [DSHS] or to the appropriate state health care regulatory agency [DSHS].

Based on review of documentation and interviews, it was determined that the governing body failed to ensure that every department of the hospital was involved in the facility Quality Improvement Committee Meetings.

Findings included:

Review of facility Quality Improvement Committee meetings for the following dates: 02/28/2017, 03/28/2017, 04/25/2017, 05/30/2017, 06/27/2017, 07/27/2017, 09/26/2017, 10/24/2017, 11/02/2017, and 12/13/2017 did not reveal any participation from the dietary department. The Dietary Manager's name was listed on each meeting but he had not signed as attending the meeting.

Interview on 01/18/2018 at 11:32 AM with the facility dietitian revealed she did not attend Quality Improvement Committee Meetings. She stated the dietary department takes quality measures such as food temperatures and refrigerator temperatures. She stated she writes a yearly summary for the Chief Executive Officer but she did not know what is done with that information.

Interview on 01/18/2018 at 11:40 AM with the Dietary Manager revealed he had worked at the facility less than a month and was considered a temporary employee at this time.

Interview on 01/18/2018 at 2:26 PM with facility registered nurse who served as assistant quality assurance director confirmed there was no evidence that Dietary Manager had attended the Quality Improvement Committee meetings listed above nor had he provided any information to be shared in the meetings.

Based on record review and interview, the facility failed to ensure that patient medical records were completed, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided; and in accordance with the facility's policies and procedures for 9 of 27 patient records reviewed (Patient #3, #8, #12, #16, #20, #21, #22, #24 and #26).

Findings included:

Review of the facility's Medical Staff By Laws, approved on 1/19/17 revealed 6.2.10 Preparation and Completion of Records and Other documentation; so that they are timely, legible, dated, timed, complete, and accurate.

Review of Patient #3's Emergency Department's (ED's) record from 11/8/17 revealed the Physician Documentation (T-Sheet) was signed by the physician; but there was no date and time documented.

Review of Patient # 8's ED record from 11/2/17 revealed the ED Physician Record was signed by the physician; but there was no date and time documented.

Review of Patient #12's ED record from 12/23/27 revealed the ED Physician Record was signed by the physician; but there was no date and time documented. The ED Physician Record documented a medication order for Ativan.

Review of Patient #16's Hospital Disclosure and Consent for Medical and Surgical Procedures dated 7/17/17 were blank. Patient #16 came to the outpatient surgical services department for a colonoscopy.

Review of Patient #20's Anesthesia Consent from 7/25/17 revealed it was blank with no information and no signatures. Further review of her record revealed Patient #20 received Versed (a Benzodiazepine used for anesthesia) and a Topical Anesthetic for a cataract procedure to her Left eye.

Review of Patient #21's ED record from 1/7/18 revealed the Physician Documentation was signed; but there was no date and time documented. The ED Physician Record with ordered Depakote level, and Foley Catheter was signed by the physician; but there was no date and time. The Required Inpatient Orders for admission for Patient #21 was blank and was not signed by the physician, no date and no time. The Risk Screening and Physician Orders dated 1/7/17 [1/7/18] were signed by the Physician; but there was no date and time.

Review of Patient #22's ED Physician Record from 1/15/18 revealed the physician ordered a breathing treatment and signed the form; but there was no date and time. The Required Inpatient orders for admission were blank which included the Medical necessity and length of stay according to 42 CFR 412.3

Review of Patient # 24's ED Physician Record from 11/13/17 revealed the physician ordered morphine sulfate, normal saline and Zofran. The physician signed the ED Physician Record; but there was no date and time of the orders.

Review of Patient # 26's medical record from 2/28/17-3/4/17 revealed the Physicians Certification/Re-Certification for Swing Bed was blank with no signatures, date, or time. In addition, the Activity Care Plan was blank and not completed.

During an interview on 1/17/18 at 11:45 AM with the Infection Prevention - Registered Nurse (IP-RN) confirmed the above records after review that; were incomplete, undated, untimed, and not authenticated in written or electronic form by the person responsible for providing or evaluating the services provided.

Based on observations, interviews and record review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. The facility failed to:

1.) Ensure wound care staffs were trained in and practiced established infection control measures in the disinfecting of the Hyperbaric chambers between patient uses; and

2.) Ensure wound care nursing staffs disposed of blood soiled bandages and biological waste materials in the appropriate biohazard waste receptacles.

This deficient practice placed all patients receiving treatment in the wound care department at an increased risk of contracting infections.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Infection Control.

Refer to A0749 for evidence.

Based on observations, interviews and record review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. The facility failed to:

1.) Ensure wound care staffs were trained in and practiced established infection control measures in the disinfecting of the Hyperbaric chambers between patient uses; and

2.) Ensure wound care nursing staffs disposed of blood soiled bandages and biological waste materials in the appropriate biohazard waste receptacles.

This deficient practice placed all patients receiving treatment in the wound care department at an increased risk of contracting infections.

Findings included:

1.) Observations conducted on 01/17/18 from 2:30 pm to 3:00 pm of the facility's wound care department revealed the following:
- 2 hyperbaric chambers which were available for patient use.
-1 hyperbaric technician (HBO)
-1 Registered Nurse (RN), who also functioned as the Wound Care Department Manager

In an interview conducted on 01/17/18 at 2:40 pm, the Wound Care RN Manager was asked by the surveyor to elaborate on how staffs were disinfecting the hyperbaric chambers between patient uses. The wound care manager stated that a single HBO Tech was responsible for disinfecting the hyperbaric machines, and that he was currently out due to illness. When asked who would be responsible for the disinfection process while the tech was out, the Manager stated that her second HBO tech (HBO Tech #2) would then be responsible.

In an interview conducted on 01/17/18 at 2:50 pm, HBO Tech #2 revealed that she had not been trained in the disinfection of the hyperbaric machines. She further stated that she did not know what chemical solutions to use when wiping down the machines. HBO Tech #2 then showed the surveyors a sealed acrylic (plexi-glass) scratch removal and polishing kit, and stated that she would use it to disinfect the hyperbaric machines.

During continued interview conducted on 01/17/18 at 3:00 pm, The Wound Care RN Manager was asked by the surveyors if she had been trained/ was aware of the disinfection procedure for the hyperbaric chambers. She revealed that she was not, but would use disinfection wipes to wipe the gurney down. When asked if there was a policy and/or procedure governing the disinfection of the hyperbaric machines (infection control) the RN Manager gave the facility's policy and procedure manual to the surveyor and stated, "Here, you find it."

In an interview conducted on 01/18/18 at 10:15 am, the Medical Director for the wound care department revealed that staffs only disinfected the gurney to the hyperbaric chambers and nothing else. During further interview, the medical director revealed that when he was practicing as a military wound care physician that he never disinfected the hyperbaric chambers between patient uses, preforming up to 4 patient sessions back to back in a day.

Record review of the facility hyperbaric chamber maintenance logs for the time period of October 2017- January 2018 revealed the following: Clean and disinfect chamber, stretcher, and gurney.

Record review of the facility policy entitled: Cleaning Environment, Patient Equipment and Medical Devices, Revised on 11/2017 revealed in part the following information:
- All reusable patient care equipment shall be cleaned and disinfected prior to use on another patient.

Record review of the employee records for the Wound Care department revealed a staff compliment of only three staff members (HBO Tech #1, HBO Tech #2 and the Wound Care RN Manager). Further review revealed that neither the Wound Care RN Manager nor HBO Tech #2 had been trained in the disinfection process for the hyperbaric chambers.

2.) Observations conducted on 01/17/18 at 3:15 pm of the wound care treatment room revealed a bloody blue disposable pad and bloody bandages which had been discarded into a non-hazardous (normal) garbage can. Further observations revealed the treatment room did not have a biohazard container available for staff use.

In an interview on 01/17/18, at the time of discovery, the Wound Care RN Manager revealed that she had just done a dressing change on a patient in the treatment room prior to the surveyor's arrival on the unit. When asked how she normally disposes of blood and drainage soiled bandages, the RN Manager stated that she normally rolls the soiled supplies up and walks them across the unit to a biohazard can located in another patient care treatment area.

Record review of the facility policy entitled: Regulated Medical Biohazardous Waste, revised on 04/2014 revealed in part the following:
- OSHA has determined regulated waste to include: Bulk blood and blood products, blood and body fluids.
- Regulated waste is to be discarded in the biohazard waste receptacles.