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Based on record review and interview, the facility failed to ensure the governing body appointed eligible candidates for medical staff membership as required by the facility Medical Staff Rules and Regulations, dated 2010.

Findings included:

Record review on 10/11/16 of nine physician/mid level practitioners files revealed that four of nine physician/mid level practitioners files (Files #3, 4, 5, and 8) were physicians who practiced at the facility with expired medical staff appointments to the facility medical staff. Physician #3's appointment expired 03/27/16. Physician #4's appointment expired 09/27/16. Physician #5's appointment expired 12/12/15. Physician #8's appointment expired 06/19/16.

Record review on 10/11/16 of the Medical Staff Rules and Regulations, dated 2010, revealed but was not limited to the following: "Except as otherwise specified herein, no person shall exercise clinical privileges in the hospital unless and until that person applies for and receives appointment (by the governing body) to the medical staff or is granted temporary privileges as set forth in these bylaws.

Interview on 10/11/16 at 11:10 AM with facility administrator confirmed the facility was "behind on credentialing their physicians" which included having the governing body appoint physicians to the medical staff.

Based on observation, record review, and interview, the facility failed to ensure specific patient rights were protected and promoted; and implement their written policy and procedures that protect and promote each patient's rights for 14 of 14 patients (Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) reviewed with a patient rights violation.

Specifically, the facility failed to:

1.) Ensure evidence that Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14 were informed of their patient rights orally and in writing, in advance of furnishing patient care, and prior to discharge. Findings were:

A.) Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14's medical records did not contain a signed copy of their patient rights or evidence they were informed of their patient rights,

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

C.) Patient's #1, #8, #9, #11, #12, and #14 had Medicare and their medical records did not contain evidence of a signed copy of the Centers for Medicare and Medicaid Services (CMS) form titled "An Important Message from Medicare about Your Rights;" (CMS-R-193); as required upon admission and prior to discharge. In addition, the facility's CMS-R-193 was outdated and did not contain the correct information as required by CMS, and

D.) 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), and was not posted in the Geriatric Mental Health Program area.

2.) 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 for reporting 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).

3.) Ensure patient rights for Patient's #8 and #13 reviewed with physical restraints; in accordance with the regulatory requirements and facility's restraint policy and procedures during the implementation of physical restraints that were used for safety and the management of behavior in the med surg area. Findings were:

A.) Patient #9 had physical restraints implemented for behavioral management on 09/15/16 at 16:00 PM and they were not released until 09/16/16 at 07:30 AM (15.5 hours in continual physical restraints); which exceeded the 4 hour time limit and facility policy, and

B.) Patient #13 had physical restraints implemented for safety on 10/08/16 at 22:00 and it us unknown and not documented when Patient #13 was released from the physical restraints.

Further reviewed revealed the regulatory restraint requirements were not met for monitoring, documentation, and assessments for Patient's #9 and #13.

Refer to A117, A145, and A154 for evidence of specific findings.

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

Based upon observation, record review, and interview, the facility failed to ensure evidence that 14 of 14 patients reviewed for rights (Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14); 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, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14's medical records did not contain a signed copy of their patient rights or evidence they were informed of their patient rights.

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

3.) Patient's #1, #8, #9, #11, #12, and #14 had Medicare and their medical records did not contain evidence of a signed copy of the Centers for Medicare and Medicaid Services (CMS) form titled "An Important Message from Medicare about Your Rights;" (CMS-R-193); as required upon admission and prior to discharge. In addition, the facility's CMS-R-193 was outdated and did not contain the correct information as required by CMS.

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), and was not posted in the Geriatric Mental Health Program area.


Findings included:

Review of the Facility's Policy and Procedure for Patient Rights and Responsibilities, last reviewed 09/2015 revealed in part, 2.5 "Each patient shall be given a copy of his or her rights and responsibilities upon admission." The facility "shall inform each patient, or when appropriate, the patient's representative of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible." 3.6.2 "The patient has the right to receive, at the time of admission, information about the hospital's patient rights policies and the mechanism for the initiation, review, and when possible, resolution of patient complaints concerning the quality of care.

1.) Record review of Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14's 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.

During an interview on 10/11/16 at 9:30 AM with the Facility's Administrator (FA) confirmed that Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14's 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. The FA stated Patients were provided a copy of the "Privacy Practices" and the facility could begin to have Patients sign a copy of the Patient Rights to place into their records for evidence.

2.) During an interview on 10/12/16 at 09:10 AM with the Admitting/Registration Clerk (RC #1) of the ER revealed that Patients were only given a copy of the Patient's Rights upon request, and only if they want them. This surveyor requested a copy of the Patients' Rights from this Registration Clerk; and there was not a copy available for review. RC#1 looked around in the cabinets, closet, and folders without being able to find a copy. RC #1 stated that she would need to ask the Administrator to get copies of the Patients' Rights. RC#1 also stated the facility did not have a copy of any Patients' Rights or other forms in Spanish for those Patients that were Spanish speaking only.

During an interview on 10/12/16 at 10:35 AM with the Inpatient Admitting/Registration Clerk (RC #2) stated that Patients were offered a copy of the Privacy Policies and HIPPA policy during registration. RC#2 was unable to provide this surveyor a copy of the Patients' Rights upon request. RC#2 confirmed she did not review any form titled Patient Rights with Patients; when registering patients for patient care.

3.) Review of the notice "An Important Message from Medicare about Your Rights," form (CMS-R-193) provided to this survey after request to the registration admitting clerk, revealed an approved date 05/07. As a hospital inpatient you have the right to the following:

-Receive Medicare covered services. This includes medically necessary hospital services and services you may need after you are discharged, if ordered by your doctor. You have a right to know about these services, who will pay for them, and where you can get them.

-Be involved in any decisions about your hospital stay, and know who will pay for it.

-Report any concerns you have about the quality of care you receive to the Quality Improvement Organization (QIO) listed here:
Texas TMF Health Quality Institute at 1-800-725-9216.

Review of the CMS website at: https://www.cms.gov/medicare/medicare-general-information/bni/hospitaldischargeappealnotices.html revealed the CMS-R-193 was updated on 07/10 and the form was provided in English and Spanish.

Further review of the CMS website revealed the following:

Regulations
Hospitals are required to deliver the Important Message from Medicare (IM), CMS-R-193 to all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospital inpatients. The IM informs hospitalized inpatient beneficiaries of their hospital discharge appeal rights. Beneficiaries who choose to appeal a discharge decision must receive the Detailed Notice of Discharge (DND) from the hospital or their Medicare Advantage plan, if applicable. These requirements were published in a final rule, CMS-4105-F: Notification of Hospital Discharge Appeal Rights, which became effective on July 2, 2007. The final rule and IM issuance guidelines (Manual Instructions) are posted below under " Downloads " .

August 2014 - IMPORTANT: UPDATING MEDICARE NOTICES WITH NEW QIO INFORMATION
Providers, suppliers, Medicare Advantage Organizations and Prescription Drug Plans should update their Medicare notices with the correct Quality Improvement Organization (QIO) contact information as quickly as possible, and no later than September 1, 2014. Please see http://www.qioprogram.org/ for QIO details.

The facility had not updated their Medicare Notice with the new QIO information which is KEPRO, telephone number 844-430-9504.

Review of Patient #1, #8, #9, #11, #12, and #14's medical records revealed they had Medicare insurance as their primary and their medical records did not contain evidence of a signed copy of "An Important Message from Medicare about Your Rights;" (CMS-R-193) as required upon admission and prior to discharge.

During an interview on 10/12/16 at 09:10 AM with RC #1 of the ER confirmed Medicare Patients were supposed to receive the Medicare Notice upon admission to the facility. RC#1 stated there was "high staff turnover" for the registration clerks, and "some of the girls don't know to do" the Medicare Notice.

During an interview on 10/12/16 at 10:35 AM with the Inpatient RC #2 revealed she did not have the form titled, "An Important Message from Medicare about Your Rights;" (CMS-R-193) as required upon admission and prior to discharge. RC #2 stated she did not use that form for Patient's with Medicare insurance.

4.) Observation on 10/10/16 at 02:00 PM of the facility's main admission lobby/waiting area, the Geriatric Mental Health Program area, and the Emergency Room Department area revealed there was not a posting 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 English and a second language which included the number of the Texas Department of State Health Services (DSHS) patient information and complaint line at (888) 973-0022; in English and Spanish.

During an interview at the exit conference on 10/12/16, the FA 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 English and a second language which included the number of the Texas Department of State Health Services (DSHS) patient information and complaint line at (888) 973-0022; in English and Spanish.

Based on observation, record review, 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 for reporting 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, Suspected Abuse Neglect/Rape, last revised 05/2005 revealed, reports of Abuse/Neglect were to be referred to the "Department of Protective and Regulatory" Services (DFPS) at "1-800-252-5400", and the local Police Department. Further review revealed the report needed to be done "within 30 days of becoming aware of the allegation or suspicion of abuse/neglect."

The facility's Abuse/Neglect Reporting 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.

Review of the facility's Geriatric Mental Health Abuse/Neglect Policy, last reviewed 01/16 revealed, "By law, all suspected cases of adult abuse or neglect will be reported to the State Department of Protective and Regulatory Services, Adult Protective Services at 1-800-252-5400."

Observation on 10/10/16 at 02:00 PM of the facility's admission lobby/waiting area and the Geriatric Mental Health Program revealed there was not a posting for display readily visible to patients, residents, volunteers, employees, and visitors with a statement of the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in accordance with the HSC §161.132(e); and which included the number of the Texas Department of State Health Services (DSHS) patient information and complaint line at (888) 973-0022; in English and Spanish.

During an interview on 10/12/16 at 03:15 PM with the Facility's Administrator (FA) confirmed the facility's policy regarding Abuse/Neglect & Reporting, last revised 02/2016 only included reporting abuse/neglect to DFPS and did not contain the information for reporting to the 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. Further interview, the FA stated new employees would sign a form during orientation regarding how to report abuse and neglect. After review of the facility form used for new employees regarding how to report abuse and neglect revealed "Incidents of Abuse and Neglect" were "Reportable to the Texas Department of Aging and Disability Services" (DADS) at 1-800-458-9858. The form used during new employees orientation did not contain any information regarding the specific state health care regulatory agency DSHS that has authority over allegations of abuse/neglect against the facility and/or facility employees; or a phone number to the DSHS agency (888-973-0022).

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 record review and interview, the facility staff failed to ensure patient rights for 2 of 2 Patients reviewed with physical restraints (Patient #8 and #13); in accordance with the regulatory requirements and facility's restraint policy and procedures during the implementation of physical restraints that were used for safety and the management of behavior in the med surg area.

Specifically,

1.) Patient #9 had physical restraints implemented for behavioral management on 09/15/16 at 16:00 PM and they were not released until 09/16/16 at 07:30 AM (15.5 hours in continual physical restraints); which exceeded the 4 hour time limit and facility policy.

2.) Patient #13 had physical restraints implemented for safety on 10/08/16 at 22:00 and it us unknown and not documented when Patient #13 was released from the physical restraints.

Further reviewed revealed the regulatory restraint requirements were not met for monitoring, documentation, and assessments for Patient's #9 and #13. These deficient practices affected Patient #9 and #13's rights, and resulted in this standard not being met.

Findings included:

Review of the facility's policy and procedures regarding Restraint and Seclusion, last reviewed 02/15 revealed the following in part:

Physical Restraints were any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he or she cannot easily remove, which restricts freedom of movement or normal access to one's body.

A physician's order is required for restraint. The order for restraint must specify the reason, the type of restraint, the extremity or body part to be restrained, and the duration of the restraint should also be documented.

Restraint orders shall not exceed 24 hours. A physician must assess a patient in restraint at least every 24 hours to determine if restraint is still necessary.

Restraint orders for behavior management are limited to the following: Adults- four (4) hours.

If the restraint is for behavior, a physician must perform a face to face assessment of the patient within one hour of restraint application even if the restraint is removed within one hour of application.

Medical Record Documentation included that the nurse shall document safety assessments and provision of care interventions not to exceed two-hour intervals for patients with supportive/protective devises and every 15 minutes for behavior management patients. Assessment and documentation of the patient during restraint shall include the following:
Signs of any injury associated with restraint,
Nutritional/hydration needs,
Circulation and range of motion,
Vital signs,
Hygiene and elimination,
Physical and psychological status and comfort,
Evidence of criteria met for the removal of restraint when applicable, and
The time of restraint application and discontinuation shall be evident in the medical record.

A registered nurse shall perform face to face evaluations of patients in restraint for behavior management at least every four hours for adults.

Hospital staff shall continuously assess for alternative to the use of restraint.

Monitoring the patient in restraint shall be documented at least every two hours and at least every 15 minutes if restraint is for behavior management.

The facility provided two monitoring forms used for Restraint/Seclusion as follows:

A Seclusion and/or Restraint Checklist that indicated "This form must be maintained with the seclusion and restraint record form for auditing purposes only. The form was a checklist and included the regulatory requirements for restraint and was in accordance with the facility's policy for restraints.

The second monitoring form was the "Seclusion/Restraint Documentation" monitoring form for every (Q) 15 minute checks.

1.) Patient #9

Review of Patient #9's records revealed he was a 90 year old male admitted on 09/13/16 for Congested Heart Failure. Physical Restraints were implemented for behavioral management on 09/15/16 at 16:00 PM and were not released until 09/16/16 at 07:30 AM (15.5 hours in physical restraints). Further reviewed revealed the regulatory restraint requirements were not met as follows:

Review of the Restraint/Seclusion Order Form for restraint ordered on 09/15/16 revealed the form had the checked off reasons for restraint as; A. Agitated, B. Fall risk/attempting to climb out, C. Overt actions toward staff, D. Confused, danger to self, disorientation, and G Combative/threat to others. The Type of Restraint was a Vest (Posey) and Soft Left and Right Wrists. The form had information for when patient was to be released from restraint that was blank. The start time was documented as "1600." There was no date and the End time on the form was blank. The Verbal Order (VO) was given by Physician A, but there was no documented Registered Nurse named, signed or a date and time of the VO. This detailed information was blank and incomplete on the form. Physician A signed the order on 09/16/16. The form indicated Behavioral Restraints were time limited to 4 hours for adults. There was an area for physician re-orders to be completed once the original time limited order had expired. This area was blank.

Review of the VO Physician order dated 09/15/16 at 16:30 documented the following: A Consult with Physician B (for Behavioral), Zyprexa 2.5milligrams (mg) Intramuscular (IM) now. "Release from restraints as soon as possible."

Review of Patient #9's Nursing notes revealed the following:
On 09/15/16 at 19:04 a Shift Summary was completed by Licensed Vocational Nurse (LVN)-A as follows: This AM Patient (PT) pleasantly confused. Able to redirect. @1400 PT's demeanor changed. Became very sarcastic, very demeaning to staff; call us names as fat slob, lying bitch. Also hitting at staff. Physician A made aware. Seroquel 25mg by mouth ordered. PT refused and threw water in this nurse's face. Then when I attempted to retrieve the fallen pill, PT swung, the call light, and hit me in the wrist. PT was grabbing at my scissors but was stopped. PT sitting at the foot of the bed insulting everyone he sees. Began to tear up all that he could reach throwing everything possible on the floor. Voiding on floor. PT noted to throw inner pot of BSC on the floor and push around the upside down frame. When instructed on fall risk, PT tried to hit nurse with it. PT was stopped. Reseated to on the bed. Half an hour later Patient was noted pushing a wooded chair in to the hallway with a garbage can in front of it. Attempted to redirect PT for safety and PT began to hit nurse with the chair. Code Yellow Called. Pt placed in the bed with soft wrist restraints and a pose vest restraint at 1600. Offering to show staff his penis. Very inappropriate. 17:10 Zyprexa 2.5mg IM in right gluteal. Wrist restraints removed. PT calm, Able to eat. Posey remains intact for now. No longer being hateful or inappropriate. Resumed being pleasantly confused.

The next nursing note was at 09/15/16 at 20:00 (4 hours after implementation of restraints) completed by LVN B: Received PT awake and alert, lying in bed with Posey vest in place. PT confused and disoriented but cooperative at this time.

The next nursing note was on 09/16/16 at 07:30 Registered Nurse B documented "Posey vest removed." PT. pleasantly confused.

On 09/16/16 at 18:10 RN B documented the Nursing Home (NH) would not accept Patient #9 back for readmission today, "since he was in a Posey vest last night. He must be out of restraints for 24 hours." PT will discharge back to NH in the morning.

There was no documentation in Patient #9's records for the following requirements in accordance with the regulatory requirements and facility's restraint policy:

A physician face to face assessment of the patient within one hour of restraint application.

Restraint order reviewed for behavior management following the 4 hour time limit.

Medical Record Documentation including that the nurse was to document safety assessments and provision of care interventions not to exceed two-hour intervals for patients with supportive/protective devises and every 15 minutes for behavior management patients.
Assessment and documentation of the patient during restraint shall include the following:
-Signs of any injury associated with restraint,
-Nutritional/hydration needs,
-Circulation and range of motion,
-Vital signs,
-Hygiene and elimination,
-Physical and psychological status and comfort,
-Evidence of criteria met for the removal of restraint when applicable, and
-The time of restraint application and discontinuation shall be evident in the medical record.

A registered nurse performing a face to face evaluation of patients in restraint for behavior management at least every four hours for adults.

Monitoring the patient in restraint shall be documented at least every two hours and at least every 15 minutes if restraint is for behavior management.

There was no evidence the Seclusion/Restraint Documentation form was used, or the Seclusion/Restraint Checklist form used.

Review of Patient #9's records revealed he was discharged back to the Nursing Home on 09/17/16 following 24 hours after release from restraint. Patient #9 had not received the behavioral consult by Physician B as ordered by Physician A on 09/15/16 before his discharge on 09/17/16.

2.) Patient # 13

Review of Patient #13's records revealed he was a 59 year old male admitted on 10/08/16 for Pneumonia. Review of the Restraint/Seclusion Order Form revealed a restraint ordered 10/08/16 at 22:00. The reason for restraint was documented as follows: #1. A. Agitated, B. Fall risk/attempting to climb out, D. Confused, danger to self, disorientation, and E. Attempting to pull out tube/line. The type of physical restraint included Vest (Posey) and Soft wrist restraints (left and right wrists). Patient #13 was to be released from restraint when the reasons described in #1 were no longer evident. The start time was 10/08/16 at 22:00. The VO was documented by Physician A on 10/08/16 at 21:50 and signed by Physician A on 10/10/16. The End time was blank. Time limits were indicated as Medical Restraints "24 hours, Behavioral Restraints 4 hours. There was an area for physician re-orders to be completed once the original time limited order had expired. This area was blank.

Review of the Telephone Order (TO) by Physician A dated 10/08/16 at 21:50 revealed, "May restrain for safety."

Review of Patient #13's nursing notes revealed the following:

On 10/08/16 at 22:14 RN-C documented Patient #13 "resistive to care and combative at times." New orders received from Doctor.

Further review of Patient #13's nursing notes revealed there was no documentation further regarding the physical restraints applied on 10/08/16 at 22:00. It is unknown when Patient #13's physical restraints were discontinued.

There was no documentation in Patient #13's records for the following requirements in accordance with the regulatory requirements and facility's restraint policy:

A physician face to face assessment of the patient within one hour of restraint application.

Restraint order reviewed following the expiration of 24 hours for a Medical Restraint; which included Behavioral management.

Medical Record Documentation including that the nurse was to document safety assessments and provision of care interventions not to exceed two-hour intervals for patients with supportive/protective devises and every 15 minutes for behavior management patients.
Assessment and documentation of the patient during restraint shall include the following:
-Signs of any injury associated with restraint,
-Nutritional/hydration needs,
-Circulation and range of motion,
-Vital signs,
-Hygiene and elimination,
-Physical and psychological status and comfort,
-Evidence of criteria met for the removal of restraint when applicable, and
-The time of restraint application and discontinuation shall be evident in the medical record.

A registered nurse performing a face to face evaluation of patients in restraint for behavior management at least every four hours for adults.

Monitoring the patient in restraint shall be documented at least every two hours and at least every 15 minutes if restraint is for behavior management.

There was no evidence the Seclusion/Restraint Documentation form was used, or the Seclusion/Restraint Checklist form used.

During an interview on 10/12/16 at 02:05 PM with the Facility's Administrator (FA) confirmed the above findings for Patient's #9 and #13; after review of the records. The FA stated it appeared by review of the records that Patient #13's physical restraints may have not been discontinued until the time of discharge on 10/11/16. The FA confirmed the facility's policy and procedures for restraint were not followed for Patient's #9 and #13; and further stated the facility had minimal restraints outside of the facility's Geriatric Psych Program area; that facility staff needed additional training.

During an interview on 10/12/16 at 01:35 PM with the Med Surg Charge RN stated that if a patient needed Physical Restraints; the Physician is notified for an order. The Charge RN stated the order for physical restraints was to be renewed every 24 hours and that Patients in restraints were to be checked with documentation every 15 minutes; using a "Flow Sheet" which was supposed to be in the patient's records. The Charge RN stated that patients were supposed to be monitored with documentation, and the physician notified after release from restraints. The Charge RN indicated the Physician was supposed to complete a physical assessment after release from physical restraints. The Charge RN confirmed that Patient #9 did not have the time of the restraint order, or the end time of the restraint documented on the Restraint/Seclusion Order Form. Charge RN confirmed there was not a physician assessment for Patient #9 and #13 following physical restraints in their records.

Based on record review and interview, the facility failed to ensure that each order for restraint used for the management of violent or self-destructive behavior was implemented in accordance with the facility's policy and procedures and the following time limits: (A) 4 hours for adults 18 years of age or older; and renewed with an additional order, up to a total of 24 hours for the re-implementation of another restraint. Specifically,

Patient #9 had physical restraints implemented for behavioral management on 09/15/16 at 16:00 PM and they were not released until 09/16/16 at 07:30 AM (15.5 hours in continuous physical restraints); which exceeded the 4 hour time limit and facility policy.

Findings included:

Review of the facility's policy and procedures regarding Restraint and Seclusion, last reviewed 02/15 revealed the following in part:

A physician's order is required for restraint. The order for restraint must specify the reason, the type of restraint, the extremity or body part to be restrained, and the duration of the restraint should also be documented.

Restraint orders for behavior management are limited to the following: Adults- four (4) hours.

Review of Patient #9's records revealed he was a 90 year old male admitted on 09/13/16 for Congested Heart Failure. Physical Restraints were implemented for behavioral management on 09/15/16 at 16:00 PM and were not released until 09/16/16 at 07:30 AM (15.5 hours in continuous physical restraints). Further reviewed revealed the regulatory restraint requirements were not met as follows:

Review of the Restraint/Seclusion Order Form for restraint ordered on 09/15/16 revealed the form had the checked off reasons for restraint as; A. Agitated, B. Fall risk/attempting to climb out, C. Overt actions toward staff, D. Confused, danger to self, disorientation, and G Combative/threat to others. The Type of Restraint was a Vest (Posey) and Soft Left and Right Wrists. The form had information for when patient was to be released from restraint that was blank. The start time was documented as "1600." There was no date and the End time on the form was blank. The Verbal Order (VO) was given by Physician A, but there was no documented Registered Nurse named, signed or a date and time of the VO. This detailed information was blank and incomplete on the form. Physician A signed the order on 09/16/16. The form indicated Behavioral Restraints were time limited to 4 hours for adults. There was an area for physician re-orders to be completed once the original time limited order had expired. This area was blank.

Review of the VO Physician order dated 09/15/16 at 16:30 documented the following: A Consult with Physician B (for Behavioral), Zyprexa 2.5milligrams (mg) Intramuscular (IM) now. "Release from restraints as soon as possible."

Review of Patient #9's Nursing notes revealed the following:
On 09/15/16 at 19:04 a Shift Summary was completed by Licensed Vocational Nurse (LVN)-A as follows: This AM Patient (PT) pleasantly confused. Able to redirect. @1400 PT's demeanor changed. Became very sarcastic, very demeaning to staff; call us names as fat slob, lying bitch. Also hitting at staff. Physician A made aware. Seroquel 25mg by mouth ordered. PT refused and threw water in this nurse's face. Then when I attempted to retrieve the fallen pill, PT swung, the call light, and hit me in the wrist. PT was grabbing at my scissors but was stopped. PT sitting at the foot of the bed insulting everyone he sees. Began to tear up all that he could reach throwing everything possible on the floor. Voiding on floor. PT noted to throw inner pot of BSC on the floor and push around the upside down frame. When instructed on fall risk, PT tried to hit nurse with it. PT was stopped. Reseated to on the bed. Half an hour later Patient was noted pushing a wooded chair in to the hallway with a garbage can in front of it. Attempted to redirect PT for safety and PT began to hit nurse with the chair. Code Yellow Called. Pt placed in the bed with soft wrist restraints and a pose vest restraint at 1600. Offering to show staff his penis. Very inappropriate. 17:10 Zyprexa 2.5mg IM in right gluteal. Wrist restraints removed. PT calm, Able to eat. Posey remains intact for now. No longer being hateful or inappropriate. Resumed being pleasantly confused.

The next nursing note was at 09/15/16 at 20:00 (4 hours after implementation of restraints) completed by LVN B: Received PT awake and alert, lying in bed with Posey vest in place. PT confused and disoriented but cooperative at this time.

The next nursing note was on 09/16/16 at 07:30 Registered Nurse B documented "Posey vest removed." PT. pleasantly confused.

Based on a review of facility documentation and staff interviews, the facility failed to have a physician or other licensed independent practitioner see the patient face-to-face within 1-hour after initiation of a restraint used for the management of violent or self-destructive behavior and according to facility policy for 1 of 1 patients reviewed (Patient #9) with restraint due to behaviors.

Findings included:

Review of the facility's policy and procedures regarding Restraint and Seclusion, last reviewed 02/15 revealed the following in part: If the restraint is for behavior, a physician must perform a face to face assessment of the patient within one hour of restraint application even if the restraint is removed within one hour of application.

Review of Patient #9's records revealed he was a 90 year old male admitted on 09/13/16 for Congested Heart Failure. Physical Restraints were implemented for behavioral management on 09/15/16 at 16:00 PM and were not released until 09/16/16 at 07:30 AM (15.5 hours in physical restraints).

Review of the Restraint/Seclusion Order Form for restraint ordered on 09/15/16 revealed the form had the checked off reasons for restraint as; A. Agitated, B. Fall risk/attempting to climb out, C. Overt actions toward staff, D. Confused, danger to self, disorientation, and G Combative/threat to others. The Type of Restraint was a Vest (Posey) and Soft Left and Right Wrists. The form had information for when patient was to be released from restraint that was blank. The start time was documented as "1600." There was no date and the End time on the form was blank.

Review of the verbal Physician order dated 09/15/16 at 16:30 documented the following: A Consult with Physician B (for Behavioral), Zyprexa 2.5milligrams (mg) Intramuscular (IM) now. "Release from restraints as soon as possible."

Review of Patient #9's Nursing notes revealed the following:
On 09/15/16 at 19:04 a Shift Summary was completed by Licensed Vocational Nurse (LVN)-A as follows: This AM Patient (PT) pleasantly confused. Able to redirect. @1400 PT's demeanor changed. Became very sarcastic, very demeaning to staff; call us names as fat slob, lying bitch. Also hitting at staff. Physician A made aware. Seroquel 25mg by mouth ordered. PT refused and threw water in this nurse's face. Then when I attempted to retrieve the fallen pill, PT swung, the call light, and hit me in the wrist. PT was grabbing at my scissors but was stopped. PT sitting at the foot of the bed insulting everyone he sees. Began to tear up all that he could reach throwing everything possible on the floor. Voiding on floor. PT noted to throw inner pot of BSC on the floor and push around the upside down frame. When instructed on fall risk, PT tried to hit nurse with it. PT was stopped. Reseated to on the bed. Half an hour later Patient was noted pushing a wooded chair in to the hallway with a garbage can in front of it. Attempted to redirect PT for safety and PT began to hit nurse with the chair. Code Yellow Called. Pt placed in the bed with soft wrist restraints and a pose vest restraint at 1600. Offering to show staff his penis. Very inappropriate. 17:10 Zyprexa 2.5mg IM in right gluteal. Wrist restraints removed. PT calm, Able to eat. Posey remains intact for now. No longer being hateful or inappropriate. Resumed being pleasantly confused.

The next nursing note was at 09/15/16 at 20:00 (4 hours after implementation of restraints) completed by LVN B: Received PT awake and alert, lying in bed with Posey vest in place. PT confused and disoriented but cooperative at this time.

The next nursing note was on 09/16/16 at 07:30 Registered Nurse B documented "Posey vest removed." PT. pleasantly confused.

There was no documentation in Patient #9's records that a physician face to face assessment was completed for Patient #9 within one hour of restraint application.

During an interview on 10/12/16 at 02:05 PM with the Facility's Administrator (FA) confirmed the above findings for Patient #9; after review of the records. The FA confirmed the facility's policy and procedures for restraint were not followed for Patient #9; and further stated the facility had minimal restraints outside of the facility's Geriatric Psych Program area; that facility staff needed additional training.

During an interview on 10/12/16 at 01:35 PM with the Med Surg Charge RN stated the Physician was supposed to complete a physical assessment after release from physical restraints. Charge RN confirmed there was not a one hour face to face physician assessment for Patient #9 in his record following the implementation of physical restraints.

Based on observation, interview and record review, the hospital failed to meet the requirement to ensure drugs were prepared in accordance with accepted standards of practice and failed to follow hospital policy because opened and undated medication vials were available for patient use. According to the United States Pharmacopeia (USP) General Chapter 797, "If a multi-dose has been opened or accessed (e.g. needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer date for that opened vial)."

Findings Include:

During a tour of the psychiatric wing of the hospital on 10/11/16 at 12:40 p.m., in the presence of S#10, observation in the medication room revealed an opened and partially used 20 ml multi-dose vial of Xylocaine 1% available for patient use. The vial lacked the date the vial was opened and the initials of the person that opened the vial.

In an interview on 10/11/16 at 12:40 p.m. in the medication room of the psychiatric wing of the hospital, S#10 confirmed the above findings and stated, "We've given two doses. It was opened on the 9th."

During a tour of the Medical/Surgical floor of the hospital on 10/11/16 at 12:55 p.m., accompanied by S#2, observation of the refrigerator in the medication room revealed an opened and undated vial of Tuberculin Purified Protein Derivative 5 TU/0.1 ml that was not initialed by the person that opened it.

In an interview on 10/11/16 at 12:55 p.m., S#2 confirmed the above findings.

Review of the hospital's policy no. 712.053 entitled, "Multiple-Dose Vials" on 10/12/16 at 2:40 p.m. indicated the policy stated, "All sterile parenteral medications and ophthalmic solutions that are maintained in multiple-dose vial containers (MDVs) will not be utilized, and must be discarded 28 days after opening," "When first opened, the vial will be dated and initialed."

Based on observation, interview, and record review, the facility failed to ensure that food and dietetic services organization requirements were met; and in accordance with the facility's policies and Texas Food Establishment Rules (TFER). Specifically, The Director of Food Nutrition Services (FNS) failed to ensure:

1.) The overall maintenance, cleanliness, and sanitization of the food and nutrition's service areas and equipment.

2.) Food intended for patient use was properly stored, labeled, and dated.

3.) The automatic ware washing machine was working properly including the required temperatures with corrective action noted for temperatures out of range.

This deficient practice could place the patients and employees at risk of food borne illnesses and/or infections.

Findings included:

Observations on 10/11/16 from 4:00 PM to 5:00 PM with the Food Service Manager (FSM) present of the FNS department (cafeteria and kitchen) revealed but was not limited to the following:

The cafeteria/serving line buffet area had spillage and built up substances on the bottom shelves where Styrofoam items were stored and left open for contamination;
The plastic container that contained the coffee stir sticks had white substance and other debris throughout the bottom;
The metal shelving in the coffee serving area was rusted and had debris present;
A blue trash can in the kitchen with trash was not covered and was not actively being used;
There was a build-up of grease on the kitchen stove top and in the oven;
There was grease build-up on one side of the vent hood;
There was dirt, debris, and cobwebs behind the stove;
The shelf where the food processor was kept was dirty with debris;
There was lint on the ice machine outside vent;
There was a black substance alone the lining of the ice machine lid;
The ice buckets next to the ice machine where blackened on the bottom;
There were no dates on Malt-O-Meal, bread crumbs, mashed potatoes, and cream of wheat that were kept in plastic containers;
There were no dates on chicken a la king, green bean, soup, and cheese that was covered with plastic wrap inside the heater;
In the walk-in freezer there were opened bags of vegetables with no date.
In the walk-in pantry, the plastic storage containers for individual cereal boxes were dirty with debris;
Inside the walk-in refrigerator and freezer, there was lint on fans and walls; the fans were rusted;
Inside the walk-in refrigerator had condensation dripping heavily from the ceiling; the ceiling had black and green substances throughout; the flooring had trash present; the metal racks were rusted and covered with lint and buildup of substances; there was an old box that had fallen behind the rack against the wall that had been there a long period of time and was disintegrating;
The metal rack that dishes were stored on were rusted;
The metal storage push rack was rusted and had debris with clean trays stored and a silver ware rack;
The metal shelving that stored the clean trays had dust and debris present;
The black mat on the shelving was dirty with debris and had large metal and plastic bowls stored;
There was a blender stored in the clean area with the lid dirty with a green substance;
The large sugar and flour containers had no date;
The flooring throughout the kitchen had buildup of substances and debris;
The large refrigerator temperature was at 44 degrees and there were no current refrigerator temperatures documented;
The QT-40 Hydrion Papers located on the wall next to the 3 compartment wash sinks used to test sanitization of the water had expired in 2011 (over 5 years ago).

Further observations of the ware washing machine revealed the temperature log for October 2016 was posted and indicated the wash temperature was to be at least 150 degrees and the Rinse temperature was to be at least at 180 degrees. The posted temperatures on the ware washing machine indicated the same for hot water sanitizing. Review of the documentation on the temperature logs revealed the following temperatures:
10/05/16: for Breakfast (B) 140 wash/121 rinse; Lunch (L) was 170 wash/140 rinse; and Dinner (D) was 160 wash/124 rinse.
10/06/16: B- 161 wash/126 rinse; L- 166 wash/112 rinse; D- Blank
10/08/16: B- 158 wash/124 rinse; L- 160 wash/124 rinse; D- 158 wash/124 rinse.
10/09/16 temperatures were all blank.
10/10/16 B- 124 wash/117 rinse.

The surveyor asked the Dietary Aide (DA #1) present to run the ware washing machine to see what the current temperatures were reading; and the wash temperature digitally read at 113 degrees and the rinse temperature at 108 degrees. The DA #1 stated you had to push the buttons on the machine to "re-scale" it when temperatures were low; and she kept pushing the buttons. The DA #1 stated that she was not aware there was a problem with the ware washing machine temperatures and was not sure who monitored the temperature log documentation.

Record review on 10/11/16 of County Department of Public Health report for facility dietary department, dated 09/20/16, revealed but was not limited to the following: " rusted shelves under preparation tables. Rusted preparation table drawers. Utensils stored in a dirty rusted drawers. Clean pans stored on a dirty black mat. Non Food Contact surfaces not clean: Walk-in cooler fans and racks, utensil drawers, standing fan in kitchen, mop sink room floor and sink: All needs cleaning. "

Record review of the " Special Meeting " for the dietary department revealed the dietary staff met on 09/21/16 and discussed the following: Health Inspection Report a. review report b. weekly walk through with dietary manager and c. everybody ' s responsibility.
Record review on 10/12/16 of facility Food Service In-Service, dated 10/07/16, revealed the following: 1. keeping the kitchen clean a. ice machine b. cafeteria 2. Tray line a. how should the tray look b. Special Diets c. timing of delivery d. New Procedure for tray pick-up 3. Working together as a team a. Communication and b. Consistency. In addition, assignments for cleaning the ice machine, the refrigerator, and the grills were made.

Record review of the Care Regional Food Service In-Service, dated 09/16/16, revealed the following: 1. Keeping kitchen clean a. sweep and mop 2X weekly b. Clean grills weekly c. Contact housekeeping to polish/wax floors 1 time a week. 2. Store Room Management 1. FIFO (first in and first out) b. orders. C. date all items 3. Working together as a team a. schedules b. help with the preparation c. job assignments

Record review of the facility Infection Control Surveillance Plan for 2016 revealed but was not limited to the following: The chairperson of the pharmacy and therapeutics committee will be responsible for the Infection Control Program within the facility. The Pharmacy and Therapeutics Committee is responsible for monitoring and evaluating the hospital wide Infection Control Program in conjunction with the Infection Preventionist. The Committee is multidisciplinary and meets on a quarterly basis and includes representatives from 1. Medical Staff. 2. Nursing 3. Infection Preventionist 4. Pharmacy 5. Other Departments on an as needed basis (Environment, Linen Services, Dietetic Services, Maintenance, Surgery, Physical Therapy, Radiology).

Record review of the Food and Nutrition Services Policy and Procedure, Dietary Guidelines, last revised 03/16, revealed but was not limited to the following: " In-service training and on the job training will be conducted by the Manager and the Consulting Dietitian using the following: A. Videos B. Use of models for preparing special diets C. Sanitation - booklets, films, special program, food handlers course D. Safety - special program, booklets, films. E. Equipment care and maintenance - use of equipment F. Disaster and Fire Plans G. Personal Hygiene Storage/Receiving/Issuing: Food, dry foods and canned goods are stored in a clean dry place. Sanitation: 2. all trash and garbage cans are lined with plastic liners; lids are on at all times and cleaned daily. 4. In-service training conducted by the Contract Dietitian on sanitation and proper procedures on cleaning. 6. Eco-Lab chemicals are used and serviced by Eco-Lab if necessary. "

Record review of the Food and Nutrition Services Policy and Procedure - Infection Control, last revised 08/2010, revealed but was not limited to the following: Equipment: 1. Dishwasher A. The dishwashing machine is automatic timed for a minimum of 60 seconds per cycle during the three stages of washing. B. The wash temperature is 120 degrees F. minimum. C. The rinse temperature is 100 degrees F. minimum. D. The final rinse temperature is 100 degrees F. minimum. 3. Ice Machine A. The outside of the machine is cleaned on a daily basis. B. The inside of the machine is cleaned on a regular basis. Housekeeping: 1. Equipment A. Food carts must be cleaned after each meal with a sanitizing solution. B. Work surfaces and equipment must be cleaned after each use with a sanitizing solution. 3. Environment A. Floors are wet mopped daily with a current germicidal cleaning solution.

Record review of the Food and Nutrition Services Policy and Procedure - Procedures in Food Preparation, Storage and Sanitation, last revised 08/2010, revealed but was not limited to the following: " All foods should be stored in clean, dry places. Keep refrigerator clean at all times. Dishwashing machine should be clean and working properly at all times; wash cycle 120 degrees F., rinse cycle 100 degrees F. Regular cleaning to insure that the equipment is properly maintained. "

Record review of the Food and Nutrition Services Policy and Procedure - Infection Control - Garbage, last revised 04/2002, revealed but was not limited to the following: " Containers will be easily cleanable, insect and rodent proof, and impermeable to liquids. All garbage cans shall have plastic bag liners. Lids must remain on cans at all times when not in continuous use. All garbage cans are cleaned daily. "

Record review of the Food and Nutrition Services Policy and Procedure - Infection Control - Cleaning Range Parts, Drip Pans, Oven Floors, Grease Traps, last revised 04/1999, revealed but was not limited to the following: " Food and Nutrition cleans large parts of range on the outside to prevent the spread of grease and soils to food preparations and dishwashing areas. Remove encrusted material with scraper or wire brush from items to be cleaned.
Record review on 10/12/16 of Food and Nutrition Services Policy and Procedure - Infection Control - Cleaning Procedure for Stainless Steel Equipment, Fire Extinguisher, Towel Holder, Trays, and Carts, last reviewed 03/2016, revealed but was not limited to the following: " Clean equipment after each use and at least once a week. A. wash all dust, grease or food particles away with hot suds. B. Rinse and wipe clean. C. Polish with a clean, dry cloth. D. Polish to a mirror finish. "

Record review of the Food and Nutrition Services Policy and Procedure - Infection Control - Cleaning Procedures for Pots, Pan, and Can Opener, last reviewed 03/2016, revealed but was not limited to the following: " Food and nutrition cleans all food residue and encrusted materials from cooking utensils and makes as near aseptic as possible for use during the next meal. Chemicals are automatically dispensed with pot and pan sinks. Sanitizer should be tested with test papers. "

Record review of the Food and Nutrition Services Policy and Procedure - Infection Control - Cleaning Procedures for Small Appliances, last reviewed 03/2016, revealed but was not limited to " Food and Nutrition has a method for cleaning and ensuring sanitation, proper working order, and safety of electrical appliances. These appliances are to be cleaned after each use. "

Record review of the Food and Nutrition Services Policy and Procedure - Infection Control - Ice Machine Cleaning, last revised 04/2005, revealed but was not limited to the following: " Clean the inside of the ice machine with current cleaning solution. This includes all surfaces, sides, and bottoms, walls and doors. Sanitize the ice machine with current sanitizing agent. "

Record review of the Food and Nutrition Services Policy and Procedures - Infection Control - Refrigerator Merchandise Dates, last revised 04/02, revealed but was not limited to the following: " Food and Nutrition Services will date all food merchandise in refrigerator.

Record review of the Hazardous Surveillance Form, dated 06/30/16, revealed this was the annual inspection of the " cafeteria " . There was no documentation regarding the cleanliness of kitchen area.

Interview on 10/12/16 at 10:00 AM with facility administrator revealed that Staff # 21 was the current FSM but she was still being supervised by Staff #19, the former Food Services Supervisor.

Interview on 10/12/16 at 10:50 AM with the Facility Administrator, the Dietitian, and Food Services Managers, (Staff # 19 and Staff # 21) revealed but were not limited to the following: Staff # 19 was the Food Services Manager from 11/30/15 until 04/30/16. Staff #21 began as Food Services Manager on 04/30/16. Staff #19 revealed she continues to supervise Staff # 21 as Food Services Manager. The dietary department began meeting on a regular basis 2 weeks ago. Their last meeting was October 7, 2016. Cleaning assignments were made at that meeting. They are going to begin a weekly walk-thru of the dietary area. The dietitian indicated she has worked at the facility for 2 years. She stated she plans to begin conducting walk-thrus on a regular basis after the local health department report of 09/20/16. They stated they have some new employees in the dietary department and they need ongoing training.

In accordance with the Texas Food Establishment Rules:

§229.164(o) (5) (B) ... "refrigerated, ready-to-eat, potentially hazardous food prepared and packaged by a food processing plant shall be clearly marked using calendar dates, days of the week, color-coded marks, or other effective means, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in subparagraph (A) of this paragraph:

(i) the day the original container is opened in the food
establishment shall be counted as Day 1; and

(ii) the day or date marked by the food establishment may not
exceed a manufacturer ' s use-by date if the manufacturer determined the use-by date based on food safety.

§229.164 (r) Labeling.

(1) Food labels.

(A) Food packaged in a food establishment, shall be labeled as specified in
law, including 21 Code of Federal Regulations (CFR) 101, Food Labeling, 9 CFR 317, Labeling, Marking Devices, and Containers, and 9 CFR 381, Subpart N, Labeling and Containers.

§229.165(f) (15) Warewashing machines, temperature measuring devices. A warewashing machine shall be equipped with a temperature measuring device that indicates the temperature of the water:

(A) in each wash and rinse tank

(16) Warewashing equipment, determining chemical sanitizer concentration.

Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.

(l) Utensils and temperature and pressure measuring devices.

(1) Good repair and calibration

Based on observation, interview, and record review, the hospital failed to ensure supplies were maintained and equipment had been inspected and maintained to ensure an acceptable level of safety and quality because expired supplies were available for patient use in the operating room, emergency room and on crash carts and equipment had not been inspected before use and periodically to ensure safety.

Findings Include:

During a tour of operating room B on 10/10/16 at 11:54 a.m., accompanied by S#5, observations revealed the following:
a. Disposable Core Biopsy Instrument with "use by 2016-07."
b. A lamp sitting on top of the anesthesia machine and a power ball mobile outlet did not have stickers to identify that the items had been tested prior to use.

In an interview on 10/10/16 at 12:03 p.m., S#5 confirmed the above findings. In regards to the disposable core biopsy instrument, S#5 stated, "That was another oversight." In regards to the lamp, S#5 stated, "It's used by the anesthesiologist during choley's."

During a tour of Exam Room #6 on 10/10/16 at 2:07 p.m., observations revealed the following:
a. A box of 6-0 chromic gut suture "exp Jan 15."
b. The cardiac monitor, exam light, overhead light and ophthalmoscope were due to be checked by or before "July 2016."

In an interview on 10/10/16 at 2:35 p.m., S#7 confirmed the above findings and S#8 stated, "I gave the bio-medical person a list of all equipment to be checked."

Review of the hospital's policy no. 500-01 entitled, "Criteria for Inventory of Electrical Equipment Testing" on 10/12/16 at 2:30 p.m. indicated the policy stated, "The frequencies will range from quarterly to as required Clinical and Non-clinical testing will not exceed annual frequencies" and "No equipment will be placed in use prior to this test being performed."

During a tour of the Intensive Care Unit on 10/11/16 at 12:10 p.m. accompanied by S#2, observations of the crash cart revealed suction tubing that expired "2016 01 03," and a pair of size 8 gloves that expired "2004 08."

In an interview on 10/11/16 at 12:10 p.m., S#2 confirmed the above findings and stated, "I'll have central supply check the cart."

During a tour of the Medical/Surgical floor on 10/11/16 at 12:30 p.m. and 1:00 p.m., accompanied by S#2, observations of the crash cart revealed the following:
a. A pair of size 8 ½ gloves that expired "2006 08" and two V-Link Luer Activated Devices with Vitalshield 0.25 ml that expired "08/16" and "01/16."
b. A sticker affixed to the defibrillator noted the next calibration was due "April 2014."

In an interview on 10/11/16 at 1:00 p.m., S#2 confirmed the above findings and stated, "I'll have central supply check the cart" and "Bio medical is coming."

34617

Based on observation, interview, and record review the facility failed to provide a clean, sanitary, and safe environment to avoid sources and transmission of infections and communicable diseases. Specifically, observations of the facility revealed the following:

1.) The Food Nutrition Services (FNS) kitchen area of the facility were unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

2.) Additional observations throughout the facility revealed;
a. Opened and partially used betadine solution was available in the operating room.
b. A laryngoscope blade that had been used for intubation of a patient was left in a blue exam glove in the operating room.
c. The endoscope disinfector had areas of rust such that it could not be properly cleaned.
d. An interior wall above the double doors of the emergency department had staining, a gap between the wall and ceiling with rust to the metal framing that supports the ceiling panels.
e. Dusty debris covered the defibrillator, suction canister and top of a crash cart.
f. Dusty debris covered the gasket of a medication refrigerator door, dirty tape partially covered a cracked opening in the interior of the door, and dirty tape was affixed to the top of the refrigerator.

These deficient practices placed the patients' health and safety at risk for the transmission of infections and/or communicable diseases.

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

Findings included:

1.) Observations on 10/11/16 from 4:00 PM to 5:00 PM with the Food Service Manager (FSM) present of the FNS department (cafeteria and kitchen) revealed but was not limited to the following:

The cafeteria/serving line buffet area had spillage and built up substances on the bottom shelves where Styrofoam items were stored and left open for contamination;
The plastic container that contained the coffee stir sticks had white substance and other debris throughout the bottom;
The metal shelving in the coffee serving area was rusted and had debris present;
A blue trash can in the kitchen with trash was not covered and was not actively being used;
There was a build-up of grease on the kitchen stove top and in the oven;
There was grease build-up on one side of the vent hood;
There was dirt, debris, and cobwebs behind the stove;
The shelf where the food processor was kept was dirty with debris;
There was lint on the ice machine outside vent;
There was a black substance alone the lining of the ice machine lid;
The ice buckets next to the ice machine where blackened on the bottom;
There were no dates on Malt-O-Meal, bread crumbs, mashed potatoes, and cream of wheat that were kept in plastic containers;
There were no dates on chicken a la king, green bean, soup, and cheese that was covered with plastic wrap inside the heater;
In the walk-in freezer there were opened bags of vegetables with no date.
In the walk-in pantry, the plastic storage containers for individual cereal boxes were dirty with debris;
Inside the walk-in refrigerator and freezer, there was lint on fans and walls; the fans were rusted;
Inside the walk-in refrigerator had condensation dripping heavily from the ceiling; the ceiling had black and green substances throughout; the flooring had trash present; the metal racks were rusted and covered with lint and buildup of substances; there was an old box that had fallen behind the rack against the wall that had been there a long period of time and was disintegrating;
The metal rack that dishes were stored on were rusted;
The metal storage push rack was rusted and had debris with clean trays stored and a silver ware rack;
The metal shelving that stored the clean trays had dust and debris present;
The black mat on the shelving was dirty with debris and had large metal and plastic bowls stored;
There was a blender stored in the clean area with the lid dirty with a green substance;
The large sugar and flour containers had no date;
The flooring throughout the kitchen had buildup of substances and debris;
The large refrigerator temperature was at 44 degrees and there were no current refrigerator temperatures documented;
The QT-40 Hydrion Papers located on the wall next to the 3 compartment wash sinks used to test sanitization of the water had expired in 2011 (over 5 years ago).

Further observations of the ware washing machine revealed the temperature log for October 2016 was posted and indicated the wash temperature was to be at least 150 degrees and the Rinse temperature was to be at least at 180 degrees. The posted temperatures on the ware washing machine indicated the same for hot water sanitizing. Review of the documentation on the temperature logs revealed the following temperatures:
10/05/16: for Breakfast (B) 140 wash/121 rinse; Lunch (L) was 170 wash/140 rinse; and Dinner (D) was 160 wash/124 rinse.
10/06/16: B- 161 wash/126 rinse; L- 166 wash/112 rinse; D- Blank
10/08/16: B- 158 wash/124 rinse; L- 160 wash/124 rinse; D- 158 wash/124 rinse.
10/09/16 temperatures were all blank.
10/10/16 B- 124 wash/117 rinse.

The surveyor asked the Dietary Aide (DA #1) present to run the ware washing machine to see what the current temperatures were reading; and the wash temperature digitally read at 113 degrees and the rinse temperature at 108 degrees. The DA #1 stated you had to push the buttons on the machine to "re-scale" it when temperatures were low; and she kept pushing the buttons. The DA #1 stated that she was not aware there was a problem with the ware washing machine temperatures and was not sure who monitored the temperature log documentation.

Record review on 10/11/16 of County Department of Public Health report for facility dietary department, dated 09/20/16, revealed but was not limited to the following: " rusted shelves under preparation tables. Rusted preparation table drawers. Utensils stored in a dirty rusted drawers. Clean pans stored on a dirty black mat. Non Food Contact surfaces not clean: Walk-in cooler fans and racks, utensil drawers, standing fan in kitchen, mop sink room floor and sink: All needs cleaning. "

Record review of the " Special Meeting " for the dietary department revealed the dietary staff met on 09/21/16 and discussed the following: Health Inspection Report a. review report b. weekly walk through with dietary manager and c. everybody ' s responsibility.
Record review on 10/12/16 of facility Food Service In-Service, dated 10/07/16, revealed the following: 1. keeping the kitchen clean a. ice machine b. cafeteria 2. Tray line a. how should the tray look b. Special Diets c. timing of delivery d. New Procedure for tray pick-up 3. Working together as a team a. Communication and b. Consistency. In addition, assignments for cleaning the ice machine, the refrigerator, and the grills were made.

Record review of the Care Regional Food Service In-Service, dated 09/16/16, revealed the following: 1. Keeping kitchen clean a. sweep and mop 2X weekly b. Clean grills weekly c. Contact housekeeping to polish/wax floors 1 time a week. 2. Store Room Management 1. FIFO (first in and first out) b. orders. C. date all items 3. Working together as a team a. schedules b. help with the preparation c. job assignments

Record review of the facility Infection Control Surveillance Plan for 2016 revealed but was not limited to the following: The chairperson of the pharmacy and therapeutics committee will be responsible for the Infection Control Program within the facility. The Pharmacy and Therapeutics Committee is responsible for monitoring and evaluating the hospital wide Infection Control Program in conjunction with the Infection Preventionist. The Committee is multidisciplinary and meets on a quarterly basis and includes representatives from 1. Medical Staff. 2. Nursing 3. Infection Preventionist 4. Pharmacy 5. Other Departments on an as needed basis (Environment, Linen Services, Dietetic Services, Maintenance, Surgery, Physical Therapy, Radiology).

Record review of the Food and Nutrition Services Policy and Procedure, Dietary Guidelines, last revised 03/16, revealed but was not limited to the following: " In-service training and on the job training will be conducted by the Manager and the Consulting Dietitian using the following: A. Videos B. Use of models for preparing special diets C. Sanitation - booklets, films, special program, food handlers course D. Safety - special program, booklets, films. E. Equipment care and maintenance - use of equipment F. Disaster and Fire Plans G. Personal Hygiene Storage/Receiving/Issuing: Food, dry foods and canned goods are stored in a clean dry place. Sanitation: 2. all trash and garbage cans are lined with plastic liners; lids are on at all times and cleaned daily. 4. In-service training conducted by the Contract Dietitian on sanitation and proper procedures on cleaning. 6. Eco-Lab chemicals are used and serviced by Eco-Lab if necessary. "

Record review of the Food and Nutrition Services Policy and Procedure - Infection Control, last revised 08/2010, revealed but was not limited to the following: Equipment: 1. Dishwasher A. The dishwashing machine is automatic timed for a minimum of 60 seconds per cycle during the three stages of washing. B. The wash temperature is 120 degrees F. minimum. C. The rinse temperature is 100 degrees F. minimum. D. The final rinse temperature is 100 degrees F. minimum. 3. Ice Machine A. The outside of the machine is cleaned on a daily basis. B. The inside of the machine is cleaned on a regular basis. Housekeeping: 1. Equipment A. Food carts must be cleaned after each meal with a sanitizing solution. B. Work surfaces and equipment must be cleaned after each use with a sanitizing solution. 3. Environment A. Floors are wet mopped daily with a current germicidal cleaning solution.

Record review of the Food and Nutrition Services Policy and Procedure - Procedures in Food Preparation, Storage and Sanitation, last revised 08/2010, revealed but was not limited to the following: " All foods should be stored in clean, dry places. Keep refrigerator clean at all times. Dishwashing machine should be clean and working properly at all times; wash cycle 120 degrees F., rinse cycle 100 degrees F. Regular cleaning to insure that the equipment is properly maintained. "

Record review of the Food and Nutrition Services Policy and Procedure - Infection Control - Garbage, last revised 04/2002, revealed but was not limited to the following: " Containers will be easily cleanable, insect and rodent proof, and impermeable to liquids. All garbage cans shall have plastic bag liners. Lids must remain on cans at all times when not in continuous use. All garbage cans are cleaned daily. "

Record review of the Food and Nutrition Services Policy and Procedure - Infection Control - Cleaning Range Parts, Drip Pans, Oven Floors, Grease Traps, last revised 04/1999, revealed but was not limited to the following: " Food and Nutrition cleans large parts of range on the outside to prevent the spread of grease and soils to food preparations and dishwashing areas. Remove encrusted material with scraper or wire brush from items to be cleaned.
Record review on 10/12/16 of Food and Nutrition Services Policy and Procedure - Infection Control - Cleaning Procedure for Stainless Steel Equipment, Fire Extinguisher, Towel Holder, Trays, and Carts, last reviewed 03/2016, revealed but was not limited to the following: " Clean equipment after each use and at least once a week. A. wash all dust, grease or food particles away with hot suds. B. Rinse and wipe clean. C. Polish with a clean, dry cloth. D. Polish to a mirror finish. "

Record review of the Food and Nutrition Services Policy and Procedure - Infection Control - Cleaning Procedures for Pots, Pan, and Can Opener, last reviewed 03/2016, revealed but was not limited to the following: " Food and nutrition cleans all food residue and encrusted materials from cooking utensils and makes as near aseptic as possible for use during the next meal. Chemicals are automatically dispensed with pot and pan sinks. Sanitizer should be tested with test papers. "

Record review of the Food and Nutrition Services Policy and Procedure - Infection Control - Cleaning Procedures for Small Appliances, last reviewed 03/2016, revealed but was not limited to " Food and Nutrition has a method for cleaning and ensuring sanitation, proper working order, and safety of electrical appliances. These appliances are to be cleaned after each use. "

Record review of the Food and Nutrition Services Policy and Procedure - Infection Control - Ice Machine Cleaning, last revised 04/2005, revealed but was not limited to the following: " Clean the inside of the ice machine with current cleaning solution. This includes all surfaces, sides, and bottoms, walls and doors. Sanitize the ice machine with current sanitizing agent. "

Record review of the Food and Nutrition Services Policy and Procedures - Infection Control - Refrigerator Merchandise Dates, last revised 04/02, revealed but was not limited to the following: " Food and Nutrition Services will date all food merchandise in refrigerator.

Record review of the Hazardous Surveillance Form, dated 06/30/16, revealed this was the annual inspection of the " cafeteria " . There was no documentation regarding the cleanliness of kitchen area.

Interview on 10/12/16 at 10:00 AM with facility administrator revealed that Staff # 21 was the current FSM but she was still being supervised by Staff #19, the former Food Services Supervisor.

Interview on 10/12/16 at 10:50 AM with the Facility Administrator, the Dietitian, and Food Services Managers, (Staff # 19 and Staff # 21) revealed but were not limited to the following: Staff # 19 was the Food Services Manager from 11/30/15 until 04/30/16. Staff #21 began as Food Services Manager on 04/30/16. Staff #19 revealed she continues to supervise Staff # 21 as Food Services Manager. The dietary department began meeting on a regular basis 2 weeks ago. Their last meeting was October 7, 2016. Cleaning assignments were made at that meeting. They are going to begin a weekly walk-thru of the dietary area. The dietitian indicated she has worked at the facility for 2 years. She stated she plans to begin conducting walk-thrus on a regular basis after the local health department report of 09/20/16. They stated they have some new employees in the dietary department and they need ongoing training.

2.) During a tour of operating room B on 10/10/16 at 11:51 a.m. accompanied by S#5, observations revealed the following:
a. An opened and partially used 8 ounce bottle of betadine solution was available for patient use.
b. A laryngoscope blade used to intubate a patient was left in a blue exam glove on top of the anesthesia machine.

In an interview on 10/10/16 at 11:51 a.m., S#5 confirmed the opened and partially used 8 ounce bottle of betadine solution was available for use in operating room B and stated, "It's a one-time use."

In an interview on 10/10/16 at 12:00 p.m., S#4 and S#5 confirmed the laryngoscope blade in a blue exam glove on top of the anesthesia machine had been used to intubate a patient during a prior case.

During a tour of the contaminated equipment/instrument room on 10/10/16 at 1:00 p.m. accompanied by S#5, observations revealed the Olympus Flexible Endoscope Disinfector had areas of rust such that it could not be properly cleaned.

In an interview on 10/10/16 at 1:00 p.m., S#5 confirmed the above findings.
During a tour of the emergency department on 10/10/16 at 2:45 p.m. observations revealed the following:
a. Brownish yellow staining of the interior wall above the left double door of the emergency department off the hospital corridor.
b. A gap between the wall and ceiling above the double doors of the emergency department with rust to the metal frame supporting the ceiling panels.

In an interview on 10/10/16 at 2:45 p.m., S#7 confirmed the above findings and stated, "It's a stain and when it rains, it kind of leaks."

During a tour of the Medical Surgical floor on 10/11/16 at 12:55 p.m. accompanied by S#2 observations revealed the following:
a. The refrigerator in the medication room had thick dusty debris on the gasket of the door that could not be wiped off with an open hand, a cracked opening to the inside of the door that was partially covered with dirty tape, and dirty tape affixed to the top front corners.
b. The defibrillator, suction canister and top of the crash cart was covered with dusty debris.

In an interview on 10/10/16 at 1:00 p.m., S#2 confirmed the above findings and stated, "I've ordered a refrigerator" and "I'm embarrassed."

Based on record review and interview the hospital failed to meet the requirement to maintain an operating room register that contains the total time of the operation because it did not include the time the operation began and ended.

Findings Include:

Review of the surgical register on 10/11/16 at 1:25 p.m. in the presence of S#3 revealed that the surgical register did not include the time the operation began and ended.

In an interview on 10/11/16 at 1:25 p.m., S#3 confirmed the above findings and stated, "We can add that."