HospitalInspections.org

Based on review and interview the facility failed to ensure that adequate Respiratory Therapist (RT) staffing was available for the facility or a process was in place to fill the responsibilities of the RT when only 1 RT was available. Failed to ensure that respiratory services were available to provide services and delivered in a safe manner in 2 of 2 (Patient #12 and #13) patient charts.

Review of occurrence reports revealed an incident that occurred on 10/11/21. The incident report was submitted on 10/12/21 by Staff #17 Respiratory Therapist (RT). Review of the incident report 120822-1 stated:

"RT was at bedside of ____ (Patient #13) when RT was paged to ER for cardiac arrest patient. At the time of overheard page, we were prepping ___ (Patient #13) for intubation and IV placement. RT left ____ (Patient #13) around 1235 to assist in code at ER, ____ (Patient #12) During the code of ____ (Patient # 12), RT was paged to assist with ____ (Patient #13). RT was unable to leave ____ (Patient #12) at that time due to the condition of ____ (Patient #12) RT ended up leaving the code around 1320 to assist in the intubation of ____ (Patient #13). ____ (Patient #13) was intubated at 1330. ____ (Patient #12) was pronounced at 1332. Both patients were affected by inadequate staffing of RT. Both patients were left during critical events."

An interview was conducted with Staff #4 Risk Manager on 11/2/21 at 9:32AM. Staff #2 was asked if she was aware of this incident and what role did Risk play in the investigation. Staff #4 reported that the incident was reviewed. Staff #4 stated, "it felt like more of an HR issue. It got sent to administration for any further review." Staff #4 stated that she had not done a root cause analysis into the complaint that resulted in a delay in patient care and a patient death. Staff #4 denied having any other written investigation into the incident other than the incident form itself. The following day on 11/3/21 Staff #4 brought in a timeline of events for both charts. There was no further work up or investigation into the incident.

An interview was conducted with Staff #17 on 11/2/21. Staff #17 stated that she placed the incident report because she was put in a bad position. Staff #17 confirmed that there is only one RT on each shift and if more than one patient was in need for services she had to decide who received care first.

Staff #17 stated on 10/11/21 that she was the only RT in the facility. Patient #13 was ordered to be intubated. Staff #17 was at the bedside getting ready with the Certified Registered Nurse Anesthetist (CRNA). Patient #13 needed a new IV line and the CRNA had placed a PICC line. The CRNA had ordered an Xray for proper placement when a code blue was called for the ER. The CRNA told Staff #17 to go to the Code, and he would let her know when the Xray was complete and Patient #13 cleared for intubation. Staff #17 stated she went to the Code called for Patient #12 who had coded at a restaurant and was brought in by ambulance. Staff #17 stated she worked the code when the medical surgical nurse came over and requested for her to return to Patient #13's bedside for the intubation. Staff #17 stated she was not sure how much longer she stayed in the ER with Patient #12, but the physician told her she could leave and the respiratory bagging process was turned over to the ER nurse. Staff #17 stated that she didn't want to leave the code but felt that she had no choice. Staff #17 stated that she was needed to assist with intubation to hold cricoid pressure. Not all staff have been trained to appropriately hold the cricoid.

According to the US National Library of Medicine National Institutes of Health Int J Crit Illn Inj Sci. 2014 Jan-Mar; 4(1): 42-49.
"Rapid-sequence intubation and cricoid pressure
Rapid sequence intubation
In clinical practice, it is generally understood that RSI is used when tracheal intubation must be performed in a patient who is suspected of having a full stomach or is at risk for pulmonary aspiration of gastric contents. The procedure involves three objectives:
Preventing hypoxia during the induction-intubation sequence.
Minimizing the time between induction and tracheal intubation when the airway is unprotected by the patient's reflexes or by the cuffed tracheal tube.
Applying measures to decrease the chances of pulmonary aspiration of gastric contents."

Staff #17 stated Patient #12 had died in the ER and Patient #13 was ventilated and transferred to another facility. Staff #17 reported Patient #13 had a delay in care for the intubation due to the code in the ER.

Review of Patient #13's chart revealed the Xray (for proper placement of the picc line) was read and dictated on 10/11/21 at 1:18PM clearing the patient for intubation. The intubation was recorded by the CRNA on 10/11/21 at 1:48PM. There was a 30-minute delay from the Xray report until the intubation. There was no documentation for the 30-minute delay.

Review of Patient #12's chart revealed Staff #17 documented at 1300 on 10/11/21. Staff #17 documented that Patient #12 had been intubated after multiple times at 1300. "Manual ventilations resumed as chest compressions were administered. Bilateral BS, CO2 color change-positive. Unable to initiate end tital co2 due to large presence of blood from ETT. Chest compressions and manual ventilations aborted at 1332 per MD." There was no documentation on when she left the patient bedside.

Staff #17 stated she did not feel it was safe to have only one RT on shift. Staff #17 stated after the incident on 10/11/21she took the issue to her direct supervisor Staff #2 DON. Staff #17 stated he agreed they needed more help and placed the position open. Staff #17 stated she conducted interviews for the position but the salary the facility was offering was below what other institutions were offering in the surrounding areas. She was unable to get anyone to accept the offer due to low pay.

An interview was conducted with Staff #2 on 11/4/21 concerning the RT concerns. Staff #2 stated they had a third party trying to recruit for the position. Staff #2 stated he felt the salary was comparable but was unable to tell me the salary or salary range. Staff #2 had not taken the staffing issue to QAPI nor had worked out any other plan to maintain patient and staff safety until the position could be filled.

Based on observation and interview, the facility failed to ensure that electrical equipment plugged in and in use next to a water station was safely operated in 1 department (Dietary Department) out of 11 departments observed.

Findings included:

A tour of the Dietary Department was made on the morning of 11-1-2021 with Staff #52 and #53. In the back corner of the kitchen, a small freezer for ice cream was observed approximately 18 inches from the wall on a cart. The electrical cord for the freezer was observed to be running across the floor to a plug in the wall behind the freezer. The plug did not have any indicators that it was a Ground Fault Interruption (GFI) plug that would automatically cut off power if there was a fault. Directly behind the freezer, a long red hose with a spray nozzle was observed connected to a water source and was curled up and hanging on the wall. There was a floor drain directly under the water source and hose. Above the water source was wall-mounted large soap dispensers.

Staff #53 was interviewed during the tour and asked if the water station was used and what it was used for. Staff #53 explained that the hose was used to spray/wash down the kitchen's tiled flooring. Staff #53 confirmed that this water station was used regularly. Staff #52 and Staff #53 did not know if the plug was GFI protected. Plant operations maintenance staff was contacted and it was confirmed that the electrical plug was not GFI protected. This presented the risk of water coming into contact with the back of the freezer approximately 18 inches from the wall where the water station was located creating an electrocution hazard for the staff.

Based on review and interview the facility failed to:

A) ensure that nursing was following physician orders for drug administration in 2 of 2 (Pt. #7 and #10) patient charts reviewed.
B) ensure that nurses had current competencies for cardiac drips and were oriented to their facility and units in 2 of 2 ( Staff #14 and #15) employee files.

Cross Refer to Tag C1049

C) ensure the policy for after-hours access to the pharmacy was specific to who could enter the pharmacy after hours and that policy/procedures were enforced.

Cross Refer to Tag C1016


D) ensure a contract or agreement was in place before shared services/personnel were provided at the facility in the Nuclear Medicine Department.

Cross Refer to Tag C1044

Based on observation, review of records, and interview, the facility failed to ensure the policy for after-hours access to the pharmacy was specific to who could enter the pharmacy after hours and that policy/procedures were enforced.

Findings included:

A tour of the Pharmacy was made on 11-1-2021 with Staff #54 present. A separate locked area was observed to contain medications available after hours when pharmacy staff were not available. A binder was located on a table and had an after-hours log / sign-out sheet and the policy that was currently being used by pharmacy and nursing staff.

Review of the 2-page policy in the binder, SUBJECT: AFTER HOURS ACCESS; REFERENCE: 730-110; EFFECTIVE 7-2003; REVISED: 2-2014, 6-2020, was as follows:

"POLICY: Access to the Pharmacy after normal hours will be restricted by established procedures.

PROCEDURE:

1. Whenever possible, the automated dispensers and/or floor stock supplies will be used to obtain required doses after normal Pharmacy hours. The removal of floor stock will be documented on the log provided. (The specific information required is outline in #4 below.) Whenever drugs are not available from floor stock supplies in unused containers, they may be obtained from the pharmacy.

2. Entry into the Pharmacy will be limited to licensed authorized personnel including the House Supervisor or those serving as Charge RN. Designated nursing personnel will be allowed access on each shift. A list of authorized personnel will be established and updated as needed. A witness will accompany the Charge RN to verify removal of the specifically required medication.

3. Only properly labeled medication may be removed from the Pharmacy. Quantities will be restricted to that required to meet the patient needs until the Pharmacy reopens. If the medication is not available in a unit-dose package, the entire original container should be taken. As an alternative, only the immediate dose should be removed.

4. The following information will be recorded on the after-hours log that remains in the Pharmacy.
Date and time of entry
Patient's name and room number
Medication name, strength and dosage form
Route of administration, dose and frequency prescribed
Number of doses removed
Nurse's signature and title
Witness' signature and title

5. If the medication is required for a new medication order, the electronic patient profile will generate a label in the Pharmacy.

6. Whenever necessary, the Pharmacist can be contacted for assistance. A Pharmacist and Clinical Pharmacist are available 24-hours per day.

7. The new order(s) must be added to the patient's electronic MAR upon validation by remote pharmacist.

8. The next morning, the Pharmacy personnel will review each entry in the sign out log against the physician's order and/or patient's profile and any new medication orders. The pharmacist will verify the after hours removals. The onsite Pharmacist will verify the entries during each visit."



There was a form in the binder titled UT Health Quitman, Policy and Procedure Manual, Pharmacy Department in the book. It was reviewed as follows:

"SUBJECT: Personnel authorized to remove medication from the Pharmacy after hours.

REVISED: NOVEMBER 2020

The personnel listed below are authorized to enter and remove medication from the Pharmacy as per the Pharmacy Policy and Procedure Manual."

The form contained 19 typed names of nursing staff members with their signatures. Two (2) additional names were hand-written on the form. One (1) had a signature and the other one did not.

There was a form titled After Pharmacy Hours Removal Verification Log with the following field to be completed by staff removing medications:
Patient's Name
RM#/Dept
Medication Name
Strength
QTY
Drug Form (Circle One)
Date & Time
2 Signatures Required
RPH

Review of the log entries from 8-30-2021 through 10-26-2021 showed the following:

On Sunday, 9-5-2021 at 2140 (9:40 PM) Staff #65 removed 100 units of Lantus (insulin) with no second signature as a witness.

On Tuesday, 9-14-2021 (no time of removal logged) Staff #64 removed 2 "NS irrigate 3000 ml" with no second signature as a witness.

On Wednesday, 9-15-2021 (no time of removal logged) Staff #66 removed 2 "NS irrigate 3000 ml" with no second signature as a witness.

On Thursday, 9-16-2021 at 0940 (9:40 AM) Staff #5 removed "3000cc Irrigation" marked as IV (intravenous), with no second signature as a witness.

On Wednesday, 9-29-2021 (no time of removal logged) Staff #27 removed "Zebra Tape 1 roll" with no second signature as a witness.

On Monday, 10-18-2021 (no time of removal logged) Staff #27 removed 2 liters of "D5LR" (Lactated Ringer with 5% Dextrose is a fluid normally given IV) with no drug form circled and no second signature as a witness.

On Tuesday, 10-26-2021 (no time of removal logged) Staff #64 removed 2 "NS irrigate 3000 ml" with no second signature as a witness.

A total of 9 entries were made without documentation of the time of removal.

An interview was conducted with Staff #54 at the time of survey. Staff #54 was asked if she was aware that the log was not being completed per the policy. Staff #54 stated that she hadn't noticed. Staff #54 was asked if the witness who was signing also had to be on the authorized access list as there were signature that were not on the list. Staff #54 stated that the witness did not have to be authorized to enter the pharmacy after hours since the person removing the medication should be authorized. The policy was again reviewed and specifically stated "Entry into the Pharmacy will be limited to licensed authorized personnel including the House Supervisor or those serving as Charge RN. Designated nursing personnel will be allowed access on each shift. A list of authorized personnel will be established and updated as needed. A witness will accompany the Charge RN to verify removal of the specifically required medication."


As written, the policy indicated that only authorized personnel could enter the Pharmacy after hours but did not give personnel on the authorized list the authority to authorize entry to others not on the list. As written, the policy only required a witness to accompany the "Charge RN". Since authorized staff were bringing in witnesses who were not on the list of authorized personnel, there was no signature to authenticate the witness' signature.

A Table of Contents for all Pharmacy policies was provided on 11-1-2021. The only policy found on the list regarding access to the Pharmacy after hours did not match the policy number the Pharmacy was actively using. The policy number for the policy being actively used was not found on the Table of Contents for all Pharmacy policies.

Review of policy "Title: 110After Hours AccessREVISION; Policy Number: 59823.1; Facility Approval Date: 09/11/2019Not Set; Effective Date: 9/11/2019 (sic)" was made. It was a 3-page policy that differed from the one being used. The policy being used showed that it was revised after (REVISED: 2-2014, 6-2020) the Effective Date of the policy in the Table of Contents. The policy that indicated it was in "REVISION" with an approval date "Not Set" was the policy available on-line to staff for reference rather than the policy that was in the Pharmacy log and being actively used.

Based on interview and document review the facility failed to ensure a contract or agreement was in place before shared services/personnel were provided at the facility in the Nuclear Medicine Department.

This deficient practice had the likelihood to cause harm to all Nuclear Medicine patients undergoing testing at the facility. No employee files were specific to the facility to include application, hospital orientation, department orientation and competencies for the department for which the employee was providing services in 3 (Staff #33, #34, and #35) of 3 employee files reviewed.

Findings Include:

An interview was conducted with Staff #39 on 11/3/2021 at 2:30 PM. Staff #39 was asked what days Nuclear Medicine tests were performed. Staff #39 replied, "We do all Nuclear Medicine on Monday, Tuesday, and Thursday." Staff #39 was asked which department employees completed the Nuclear Medicine studies. Staff #39 stated, "All of the employees come from Tyler. We do not have anyone here that is qualified to do them. Staff #33 does most of the nuclear medicine tests, but Staff #34 and Staff #35 also come." Staff #39 was asked who orders the radiopharmaceuticals for the nuclear medicine studies. Staff #39 stated, "Staff #33 logs onto our facility schedule to see what tests are scheduled and he does all the ordering for that week and it gets delivered here to this facility." Staff #39 was asked if the individuals that come to the facility are employees of the facility. Staff #39 replied, "No, we share employees with another hospital. They are actually out of Tyler." Staff #39 was asked how he could verify that the employees had competencies, and did he know if the facility had a contract with the facility providing the employees for the service. Staff #39 stated, "I do not have any competencies on any of the employees" and he was not aware of a contract because he was told they were "all part of a division and that the employees could be shared between hospitals. Staff #33 used to be employed at this hospital several years ago but left to go to the other facility, I think in 2018."

A review of the Nuclear Medicine schedule dated 6/1/2021-11/5/2021 confirmed 176 Nuclear Medicine tests were completed with employees that were not the facility employees. The employees were brought into the facility to perform the tests. Staff #39 confirmed these findings.

A review of the active employee list for the facility did not include Staff #33, #34, #35. An interview was conducted in the afternoon of 11/3/2021 with Staff #49. Staff #49 was asked if Staff #33, #34, and #35 worked at this facility why were they not on the active employee list. Staff #49 replied, "The employee can only be assigned to one location even if they work at other hospitals within the division."

A review of the employee file for Staff #33 was conducted with Staff #49 after 9:00 AM on 11/4/2021. Staff #49 confirmed the employee was a fulltime employee at another location and no hospital or departmental orientation was within the employee file for this facility. The only information provided in the employee file was an application and background check dated 2014. Competencies dated 5/4/2021 within the employee file were not for this facility. No competencies for this facility were provided.

Staff #49 confirmed all employee files are kept online and we just print what is needed. Staff #49 also confirmed that all employees could be shared between different locations depending on the needs of the facility.

An interview was conducted with Staff #29 on the morning of 11/4/2021. Staff #29 was asked about sharing employees. Staff #29 replied, "All employees are under the division of the corporation and can be shared with all facilities." Staff #29 was also asked if there was a contract or agreement between the two facilities since they were licensed differently. Staff #29 replied, "No, we are a divisional corporation and employees can be shared within each hospital if needed."

On the morning of 11/5/2019 Staff #1, #29, and #50 confirmed there was no documentation in the Governing Body Bylaws between the two facilities that allowed them to share employees. Staff #1, #29, and #50 also confirmed there was no contract or agreement between the two facilities.

Staff #1, #3, #29, #39, and #50 confirmed the findings.

Based on review and interview the facility failed to ensure that nursing was following physician orders for drug administration in 2 of 2 (Pt. #7 and #10) patient charts reviewed. Ensure that nurses had current competencies for cardiac drips and were oriented to their facility and units in 2 of 2 ( Staff #14 and #15) employee files.

Review of Patient #7's chart revealed she was brought to the ED (Emergency Department) by ambulance with dyspnea (shortness of breath) on 10/8/21 at 8:59AM. Patient #7 had a heart rate of 144 and respirations of 28. Patient #7 was placed on a cardiac monitor and labs were drawn.

Review of physician orders revealed Patient #7 was ordered Cardizem (a calcium channel blocker that slows your heart rate and relaxes your blood vessels) on 10/8/21 at 1702 (5:02PM). The order read to administer the medication intravenously and titrate at a rate of 5-15mg/hr. There were no parameters on the order (the nurse had no heart rate parameters ordered to determine when to titrate the drug up or down.) There was no Cardizem protocol to assist the nurse on when to titrate the medication.

Review of Patient #7's chart revealed Staff #14 (RN) increased the Cardizem to 10mg/hr on 10/8/21 at 1830 (6:30PM) due to the heart rate in the 130's. Staff #14 decreased the Cardizem back to 5 mg on 10/8/21 at 2045 (8:45PM) due to heart rate down to 98-111.

An interview was conducted with Staff #14 on 11/2/21. Staff #14 confirmed the physicians in the ED have not been consistent with placing parameters on the Cardizem orders. Staff #14 confirmed she had titrated Cardizem medications without written parameters. Staff #14 stated, "well, you just know that if the heart rate gets below 100 you need to decrease the medication." Staff #14 was asked if she had received any training for cardiac drips for this facility or if she was aware of any protocols for Cardizem at this facility. Staff #14 stated that she was not aware of a protocol and was unable to recall if any training or competencies were offered on cardiac drips. Review of Staff #14's employee file revealed there were no cardiac drip competencies or training.

Review of Staff #14's employee file revealed there were hands on competencies for stroke center but no further competencies on the use of ER equipment in the facility, orientation to the facility and department, or a background check. On 11/4/21 (three days later) the facility was able to find an "annual education day" nurse competencies dated 6/18/21 but there was no education for safe administration of cardiac drips.

Review of Staff #14's employee file revealed she signed a job description on 5/18/21. The job description stated, "As an employee at UT Health East Texas, I acknowledge that I have received and understand a copy of my job description. I attest that I have the required skills, education, experience and license (if applicable) necessary to fulfil the job duties listed." The facility is part of a health care system but licensed as an independent hospital. There was no information if Staff #14 was employed for the Quitman facility. The facility was unable to provide any information of governing bylaws for the system nor the facility that would clarify employee training, education, or sharing of employees throughout the system.

Review of Patient #10's chart revealed he presented to the ER with chest pain on 9/20/21 at 12:05PM.
Review of Patient #10's physician orders revealed Cardizem was ordered 4 times.
Order #1 Cardizem injection 10mg. 9/20/21 at 1243 by Staff #21 (ER Physician). The order was for frequency once 9/20/21 1245. Acknowledged by the RN at 1312.
Order #2 Cardizem injection 5mg. 9/20/21 at 1243 by Staff #21 (ER Physician).
Order #3 Cardizem 125mg in sodium chloride 0.9% 125ml (1mg/ml) infusion on 9/21/21 at 12:44PM. The order stated "ordering in verbal with read back mode but the physician signed the order at 12:44PM. The comment section stated "to reflect Cardizem gtt." There were no instructions to titrate the drug, what dosage to titrate, and no parameters.
Order #4 Cardizem 60 mg tablet on 9/20/21 at 1418.
There was no clear discontinuation of orders #1 or #2.

Review of Patient #10's Medication Administration Record (MAR) revealed the Nurse started the Cardizem drip at 1330 (1:30PM) intravenously at a rate of 5-15mg/hr. The MAR stated the patient was to be started at "5mg/hr and increase in 2.5mg/hr increments every____ (blank)." There were no parameters. The MAR stated to call the provider if SBP (systolic blood pressure) falls below 90. There were no written physician orders for the rate of 5-15mg/hr or increased increments. Review of the MAR revealed the RN increased the dosage to 7.5 mg on 9/20/21 at 1340 (1:40PM) and back to 5mg 1430 (2:30PM) with no written physician orders to increase or decrease the dosage.

An interview was conducted with Staff #15 on 11/2/21 at 3:00PM. Staff #15 was asked if she had ever titrated Cardizem without parameters. Staff #15 stated, "we have had to titrate without parameters it's not a standard." Staff #15 denied any knowledge of a protocol. Staff #15 stated the physicians verbally order the titration but forget to put the orders in. Staff #15 reported it's common for the physicians to give verbal orders but expect the nurses to place the orders. "The physicians can put in the orders just as easy as we can."

Review of Staff #15's employee file revealed an annual education day conducted on 6/17/21 from 1:10PM -5:15PM. Staff #15 did have an ER competency assessment for the Quitman facility dated 9/19/19 however, there was no education or competencies documented for cardiac drips.

Review of Staff #15's employee file revealed she signed a job description on 6/4/21. The job description stated, "As an employee at UT Health East Texas, I acknowledge that I have received and understand a copy of my job description. I attest that I have the required skills, education, experience and license (if applicable) necessary to fulfil the job duties listed." The facility is part of a health care system but licensed as an independent hospital. There was no information if Staff #15 was employed for the Quitman facility. The facility was unable to provide any information of governing bylaws for the system nor the facility that would clarify employee training, education, or sharing of employees throughout the system.

An interview was conducted with Staff #21 (ER MD) on the morning of 11/2/21. Staff #21 was asked about the orders for Cardizem and why the physicians are not putting in titration increments and parameters. Staff #21 stated that there were no options for him in the new computer system. Staff #21 created an order on the computer. There were no options for him to pick from. There was a comment box, but he was unable to comment. Staff #21 stated that he is in the ED while these drips are going on and staff are communicating with him, but he has not been able to get the order set fixed.

An interview was conducted with Staff #3 on 11/2/21. Staff #3 stated that IT went to the ER and realized the physician was putting the orders in as injectables and not intravenously. This was not allowing him to have options for parameters or to make comments. Staff #3 confirmed the ER physicians need further training in their computer system to ensure safe orders.

Based on observation, document review, and interview the facility failed to;

A. ensure medical records were stored and maintained in locations that were secure, had limited access, and protected from fire, floods, and damage.

B. follow the facility policy on scanning, retention, and transporting medical records.

Cross Refer to Tag C1102


C. ensure a properly executed informed consent for anesthesia was signed and in the medical record prior to the surgical procedure and/or anesthesia services in 7 (Patient #23, #24, #25, #26, #44, #45, and #46) of 7 records reviewed.

Cross Refer to Tag C1110

Based on interview, document review, and observations the facility failed to:

A. ensure medical records were stored and maintained in locations that were secure, had limited access, and protected from fire, floods, and damage.

This deficient practice had the likelihood of exposing protected health information of patients to unauthorized personnel.


Findings Include:


An interview was conducted with Staff #31 on 11/02/2021 at 1:10 PM. Staff #31 confirmed the facility medical records department would be closing and the staff had recently moved to remote only and did not have staff on site. Staff #31 was asked who the director for the medical records department was. Staff #31 stated, "I am the Divisional Director, but we are moving the medical records department because that space has been allocated to another department and I am the responsible person over this facility and one other facility." Staff #31 was then asked how the facility would store and secure the paper documents of each patient that was treated at the facility. Staff #31 replied, "The legal medical record is kept electronically. The staff scan the paper documents into the electronic health record and then those paper documents are sent to one of our other hospitals and stored there until they can be destroyed." Staff #31 again stated, "The legal medical record is the electronic version and not what is on paper." Staff # 31 was asked if the facility had a contract or an agreement with the offsite hospital to secure, protect, and store the patient's medical records. Staff #31 replied, "We do not need either. We are a division and therefore we do not need contracts or agreements for such services. Again, the legal medical record is the electronic version and we only keep paper documents for a short period of time. We are in the process of closing out all medical records that we can in the medical records department so that we can free up that space. Other than the records that are left in the medical records department we do not have any other patient records here. They are scanned daily and taken to the other hospital."


During an interview on 11/4/2021 after 10:00 AM Staff #1 and Staff #29 confirmed there was no contract or agreement with the offsite hospital to store patient medical records from the facility. Staff #29 also confirmed there was no statement in the Governing Body Bylaws allowing storage of medical records at an offsite hospital.


During an observation tour of the medical records department on 11/4/2021 after 12:00 PM an interview was conducted with Staff #32. Staff #32 was asked if all paper documents were scanned into the electronic health record in the HIM Department. Staff #32 stated, "I do not do medical records anymore. The departments are responsible for scanning the paper documents into the computer and then they send them to the lab to be picked up. We do not keep any of the documents here anymore." Staff #32 was asked how the medical records were transported to the other hospital. Staff #32 replied that the courier that picks up the lab specimens also picks up the medical records and transports them to Tyler. Staff #32 was then asked if a log of all paper medical records was documented before it left the facility. Staff #32 stated, "No there is no log that we make before we send them."

Staff #32 confirmed it would be impossible for the receiving facility to compare the incoming medical records without a documented log of the medical records leaving the facility.



An interview with Staff #46 and #47 was conducted in the afternoon on 11/4/2021. Staff #46 and #47 were asked how the medical records were transported once they were picked up at the facility by the contracted lab specimen couriers. Staff #46 replied, "He picks them up daily when he comes to get the specimens. They are placed in this file rack in an interoffice envelope labeled H.I.M." Staff #46 and #47 were asked if the medical records were locked in a container to secure the records during transport before leaving the facility. Staff #46 and #47 stated, "No, he just takes them out of here in the envelope."




An observation tour of the medical floor was conducted on 11/5/2021 in the afternoon. There were nine boxes of medical records found in a storage room on the medical floor. There were 4 unlocked metal filing cabinets, each with four drawers, that contained volunteer and staff information such as addresses, names, social security numbers and dates of birth.

An interview was conducted with Staff #2 on 11/5/2021 in the afternoon hours. Staff #2 stated that the storage room was where he kept all his training supplies for nurses. Staff #2 stated he was not aware of the 9 boxes marked as patient charts from 2016-2018. Staff #2 reported that the room could only be accessed by a key that was locked in the Pyxis. Staff #2 confirmed that all the nurses and pharmacy staff had access to the key and that would give them access to the records.




B. follow facility policy on scanning, retention, and transporting medical records.



A review of the facility policy titled, "Destruction of Medical Records Post Scanning-HIM-Corp", Policy Number:67943.1 with an approval date of 2/04/2021 was as follows:

" ...Purpose: To establish the policy and procedures for the maintenance, retention, preservation, and disposal of paper medical records for Ardent facilities post scanning.

Policy: The HIM department will scan medical records into EMR within 24 hours of receipt in the HIM Department. Once scanned into the EMR, the electronically stored version of the medical record, as well as any applicable media, will be deemed the legal medical record. Once scanned into the EMR the paper version of the medical records will be maintained for no less than 30 calendar days and no more than 120 calendar days in accordance with the records management use, maintenance and preservation guidelines and requirements. Upon expiration of this 120-day timeframe or less, the medical records will be eligible for destruction.

Procedure:
1) Upon completion of the document imaging process, records must be immediately stored in designated area by scan date.
2) HIM will monitor scanned dates to ensure scanned materials are destroyed no less that 30 calendar days and no more than 120 calendar days ..."





A review of the facility policy titled, "Medical Record Transport Policy-HIM-Corp" Policy Number: 73282.1, with an approval date of 5/24/2021 was as follows:

" ...Purpose: All Protected Health Information (PHI) in paper form must be tracked and transported in a secure manner to safeguard against damage, loss, theft or improper disclosure.

Procedure:
1) It is recommended that PHI being transported outside of the healthcare facility should be transported in a secure container such as a lockbox, tote, etc.
2) The sending facility should secure the transport container preferably with a locking device that should only be removed by the receiving facility. If using combination locks, obvious combinations such as 1,2,3 or 000 should not be used.
3) If the locking device has been tampered with or damaged during transport an incident report should be initiated by completing the web form in RADAR or reporting it to the Facility Privacy Officer.
4) The identity and validity of the person transporting the medical records should be verified by a facility staff member by checking the ID badge of the courier or transport person before records are allowed to be removed from the facility.
5) Each medical record (IP, OBV, SOP) that is transported should be tracked via a paper log or an electronic tracking system. Loose sheets can be tracked by the number of envelopes or packets sent or another quantifying method.
6) Paper medical records should be packed in a way that no PHI is visible using coversheets or other preventative methods.
7) The vehicle transporting the medical records should be locked at all times and should not be left unattended for reasons other than designated pick-ups at facilities, scheduled meal breaks, and restroom breaks. The secured transport containers should be out of plain sight within the vehicle need to be briefly unattended.
8) In the event of an accident or disabled vehicle, HIM Management should be notified immediately.
9) The sending facility should maintain a copy of the tracking log for at least 30 days and the receiving facility should check in all records and verify all records sent have been successfully received daily. If a record marked as sent was not received, HIM management should be notified immediately for appropriate follow up..."


Staff #1, #3, #31, #32 confirmed the above findings.

Based on document review and interview the facility failed to ensure a properly executed informed Anesthesia consent was signed and in the medical record prior to the surgical procedure and/or anesthesia services in 7 (Patient #23, #24, #25, #26, #44, #45, and #46) of 7 records reviewed.


This deficient practice had the likelihood to cause harm to all patients
undergoing surgery or anesthesia. Patients were signing the informed anesthesia consent without a documented anesthesia provider that would be providing the anesthesia.


Findings Include:


Patient #23

A review of the medical record for Patient #23 revealed the following:

Patient #23 was a 33-year-old female admitted to the facility on 11/3/2021 for an Esophagogastroduodenoscopy (EGD) by Staff #36.

A review of the Informed Consent for Anesthesia Services was as follows:

" ...I voluntarily request that anesthesia and/or perioperative pain management care (analgesia) as indicated below be administered to me (the patient). I understand it will be administered by an anesthesia provider and/or the operating practitioner and such other health care providers as necessary. Perioperative means the period shortly before, during, and shortly after the procedure ..."

General Anesthesia was initialed by Patient #23 and
Deep Sedation was initialed by Patient #23.

Patient #23 and Staff #43 signed the anesthesia consent on 11/3/2021 at 8:16 AM.



Patient #24

A review of the medical record for Patient #24 revealed the following:

Patient #24 was a 71-year-old female admitted to the facility on 11/3/2021 for an EGD and Colonoscopy by Staff #36.

A review of the Informed Consent for Anesthesia Services was as follows:

" ...I voluntarily request that anesthesia and/or perioperative pain management care (analgesia) as indicated below be administered to me (the patient). I understand it will be administered by an anesthesia provider and/or the operating practitioner and such other health care providers as necessary. Perioperative means the period shortly before, during, and shortly after the procedure ..."

General Anesthesia was initialed by Patient #24 and
Deep Sedation was initialed by Patient #24.

Patient #24 and Staff #43 signed the anesthesia consent on 11/3/2021 at 8:50 AM.



Patient #25

A review of the medical record for Patient #25 revealed the following:

Patient #25 was a 76-year-old female admitted to the facility on 11/3/2021 for a Colonoscopy by Staff #36.

A review of the Informed Consent for Anesthesia Services was as follows:

" ...I voluntarily request that anesthesia and/or perioperative pain management care (analgesia) as indicated below be administered to me (the patient). I understand it will be administered by an anesthesia provider and/or the operating practitioner and such other health care providers as necessary. Perioperative means the period shortly before, during, and shortly after the procedure ..."

General Anesthesia was initialed by Patient #25 and
Deep Sedation was initialed by Patient #25.

Patient #25 and Staff #43 signed the anesthesia consent on 11/3/2021 at 8:16 AM.


Patient #26

A review of the medical record for Patient #26 revealed the following:

Patient #26 was a 70-year-old male admitted to the facility on 11/3/2021 for an EGD and Colonoscopy by Staff #36.

A review of the Informed Consent for Anesthesia Services was as follows:

" ...I voluntarily request that anesthesia and/or perioperative pain management care (analgesia) as indicated below be administered to me (the patient). I understand it will be administered by an anesthesia provider and/or the operating practitioner and such other health care providers as necessary. Perioperative means the period shortly before, during, and shortly after the procedure ..."

General Anesthesia was initialed by Patient #26 and
Deep Sedation was initialed by Patient #26.

Patient #26 and Staff #43 signed the anesthesia consent on 11/3/2021 at 8:16 AM.



Patient #44

A review of the medical record for Patient #44 revealed the following:

Patient #44 was a 25-year-old male admitted to the facility on 10/21/2021 for an Appendectomy by Staff #62.

A review of the Informed Consent for Anesthesia Services was as follows:

" ...I voluntarily request that anesthesia and/or perioperative pain management care (analgesia) as indicated below be administered to me (the patient). I understand it will be administered by an anesthesia provider and/or the operating practitioner and such other health care providers as necessary. Perioperative means the period shortly before, during, and shortly after the procedure ..."

General Anesthesia was initialed by Patient #44.

Patient #44 signed the anesthesia consent on 10/21/2021 at 7:55 AM.
The Physician/CRNA signature was illegible.


Patient #45

A review of the medical record for Patient #44 revealed the following:

Patient #45 was an 82-year-old female admitted to the facility on 10/26/2021 for a Right Total Knee Replacement by Staff #63.

A review of the Informed Consent for Anesthesia Services was as follows:

" ...I voluntarily request that anesthesia and/or perioperative pain management care (analgesia) as indicated below be administered to me (the patient). I understand it will be administered by an anesthesia provider and/or the operating practitioner and such other health care providers as necessary. Perioperative means the period shortly before, during, and shortly after the procedure ..."

General Anesthesia was initialed by Patient #45.
Regional Block Anesthesia was initialed by Patient #45.

Patient #45 signed the anesthesia consent on 10/26/2021 at 6:59 AM.
The Physician/CRNA signature was illegible.


Patient #46

A review of the medical record for Patient #46 revealed the following:

Patient #46 was a 70-year-old female admitted to the facility on 10/29/2021 for a Ventral Incisional Hernia Repair by Staff #62.

A review of the Informed Consent for Anesthesia Services was as follows:

" ...I voluntarily request that anesthesia and/or perioperative pain management care (analgesia) as indicated below be administered to me (the patient). I understand it will be administered by an anesthesia provider and/or the operating practitioner and such other health care providers as necessary. Perioperative means the period shortly before, during, and shortly after the procedure ..."

General Anesthesia was initialed by Patient #46.

Patient #46 signed the consent for anesthesia on 10/29/2021 at 8:25 AM.
The Physician/CRNA signature was illegible.


An interview was conducted with Staff #8 in the afternoon on 11/3/2021. Staff #8 was asked if the process for Anesthesia consents was different than Surgical consents. Staff #8 replied, "No there is no difference the risks and benefits still have to be explained to the patient." Staff #8 was informed that an informed consent included the name of the provider that would be providing the services and that there were no names of any anesthesia providers on the anesthesia consents. Staff #8 confirmed the findings and said that the anesthesia was contracted and, in the contract, anesthesia agreed to follow all the facility policies. Anesthesia does not have their own policies.

After multiple requests, no Anesthesia Consent policy was provided.


A review of the Divisional policy titled, "Informed Consent Policy-DIV-AM" Policy Number: 46950.2 with a Divisional Approval Date: 6/8/2021 was as follows:


" ...Policy:
1) It is the policy of UT Health East Texas to fully comply with the Texas Medical Disclosure Panel's rules on informed consent for medical treatment and procedures.
2) Consent will be obtained in writing prior to performing surgical procedures, non-surgical invasive, diagnostic and/or therapeutic procedures, and all procedures in which anesthesia or sedation is used ...

Procedure:
...14) A separate consent must be obtained for anesthesia/moderate sedation for the procedures requiring full disclosure of specific risks and hazards documented as detailed in the Texas Medical Disclosure Panel's List A. It is the responsibility of a Licensed Independent Practitioner, credentialed to provide anesthesia services to obtain the informed consent for anesthesia. It is the duty of the treating physician to obtain a patient's consent for moderate sedation when given in surgery/procedure (s)he is performing ..."



A review of the facility policy titled, "Disclosure and Consent for Medical and Surgical Procedures-SS" Policy Number: 60094.1 with an approval date of 9/11/2019 was as follows:

" ...Purpose: To provide standard guidelines for the completion of the "Disclosure and Consent for Medical and Surgical Procedures" form.
Procedure:
6) Specific areas of completion:
a) Patients full name is recorded
b) Physician first and last name is recorded ..."


Staff #8, #29 and #43 confirmed the findings.

Based on interview and document review the facility failed to ensure that a Post-op evaluation was completed by an individual qualified to administer anesthesia prior to discharge in 4 (Patient #23, #24, #25, and #26) of 4 medical records reviewed. The facility failed to have an approved policy for Post anesthesia evaluations. The facility also failed to follow their own policy and have an anesthetists available to see all patients for complications

This deficient practice had the likelihood to cause serious harm or injury to all patients receiving anesthesia. Prior to discharge, the Certified Registered Nurse Anesthesia (CRNA) was relying on the Post Anesthesia Care Unit (PACU) Registered Nurse (RN) to report the Post procedure-evaluation requirements; Cardiopulmonary status, level of consciousness, blood pressure, level of activity, any follow up care or observations, and any complications occurring during post-anesthesia recovery to them via telephone.


Findings Include:


Patient #23

A review of the medical record for Patient #23 revealed the following:

Patient #23 was a 33-year-old female admitted to the facility on 11/3/2021 for an Esophagogastroduodenoscopy (EGD) by Staff #36.

A review of the informed consent for anesthesia revealed Patient #23 signed a consent for General Anesthesia and/or Deep Sedation on 11/3/2021 at 8:16 AM.

A review of the medical record, case tracking events, revealed Patient #23 was taken to the Recovery Room post procedure at 8:30 AM. The anesthesia stop time was 8:33 AM. (This is the time anesthesia is complete with procedural care and in the recovery room for recovery.) Staff #43 documented a Post Procedure evaluation at 8:34 AM. This was 4 minutes after Patient #23 was received in the Recovery Room and 1 minute after the anesthesia end time.

Further review of the medical record revealed the documented vital signs on the Post-procedure evaluation, to include temperature, blood pressure, respirations, pulse, and oxygen saturation by Staff #43 was the same documented vital signs on admission to the recovery room.

Patient #23 was discharged from the facility on 11/3/2021 at 8:55 AM by Staff #37. No additional documentation was located in the medical record by the anesthesia department.


Patient #24

A review of the medical record for Patient #24 revealed the following:

Patient #24 was a 71-year-old female admitted to the facility on 11/3/2021 for an EGD and Colonoscopy by Staff #36.


A review of the informed consent for anesthesia revealed Patient #24 signed a consent for General Anesthesia and/or Deep Sedation on 11/3/2021 at 8:50 AM.

A review of the medical record, case tracking events, revealed Patient #24 was taken to the Recovery Room post procedure at 9:08 AM. The anesthesia stop time was 9:13 AM. (This is the time anesthesia is complete with procedural care and in the recovery room for recovery.) Staff #43 documented a Post Procedure evaluation at 9:13 AM. This was 5 minutes after Patient #24 was received in the Recovery Room and the same time of the anesthesia end time.

Further review of the medical record revealed the documented vital signs on the Post-procedure evaluation, to include temperature, blood pressure, respirations, pulse, and oxygen saturation by Staff #43 was the same documented vital signs on admission to the recovery room.

Patient #24 was discharged from the facility on 11/3/2021 at 9:40 AM by Staff #37. No additional documentation was found in the medical record by the anesthesia department.



Patient #25

A review of the medical record for Patient #25 revealed the following:

Patient #25 was a 76-year-old female admitted to the facility on 11/3/2021 for a Colonoscopy by Staff #36.


A review of the informed consent for anesthesia revealed Patient #25 signed a consent for General Anesthesia and/or Deep Sedation on 11/3/2021 at 8:16 AM.

A review of the medical record, case tracking events, revealed Patient #25 was taken to the Recovery Room post procedure at 9:37 AM. The anesthesia stop time was 9:40 AM. (This is the time anesthesia is complete with procedural care and in the recovery room for recovery.) Staff #43 documented a Post Procedure evaluation at 9:40 AM. This was 3 minutes after Patient #25 was received in the Recovery Room and the same time of the anesthesia end time.

Further review of the medical record revealed the documented vital signs on the Post-procedure evaluation, to include temperature, blood pressure, respirations, pulse, and oxygen saturation by Staff #43 was the same documented vital signs on admission to the recovery room.

Patient #25 was discharged from the facility on 11/3/2021 at 9:56 AM by Staff #37. No additional documentation was found in the medical record by the anesthesia department.



Patient #26

A review of the medical record for Patient #26 revealed the following:

Patient #26 was a 70-year-old male admitted to the facility on 11/3/2021 for an EGD and Colonoscopy by Staff #36.

A review of the informed consent for anesthesia revealed Patient #26 signed a consent for General Anesthesia and/or Deep Sedation on 11/3/2021 at 10:52 AM.

A review of the medical record, case tracking events, revealed Patient #26 was taken to the Recovery Room post procedure at 11:17 AM. The anesthesia stop time was 11:20 AM. (This is the time anesthesia is complete with procedural care and in the recovery room for recovery.) Staff #43 documented a Post Procedure evaluation at 11:20 AM. This was 3 minutes after Patient #25 was received in the Recovery Room and the same time of the anesthesia end time.

Further review of the medical record revealed the documented vital signs on the Post-procedure evaluation, to include temperature, blood pressure, respirations, pulse, and oxygen saturation by Staff #43 was the same documented vital signs on admission to the recovery room.

Patient #26 was discharged from the facility on 11/3/2021 at 11:47 AM by Staff #41. No additional documentation was found in the medical record by the anesthesia department.


An interview was conducted with Staff #37 and #41 on the morning of 11/3/2021. Staff #37 was asked if the anesthesia provider came to the Post Anesthesia Recovery Room (PACU) and completed and post-procedure evaluation on all patients. Staff #37 confirmed that the anesthesia provider did not come to the PACU to complete the evaluation that they relied on the PACU RN to either tell them in person or call with the information to the procedure room. Staff #37 stated, "The turnover for these cases is so fast that most of the time the patients are discharged before anesthesia is available to see them. Usually the patients are ready to leave before anesthesia completes the next case they are on and we do not have an extra CRNA that completes the post procedure evaluation." Staff #41 confirmed the same information. Staff #41 stated, "They do come and see all the surgical patients just not the Gastrointestinal (GI) cases (EGD and Colonoscopy procedures).

An interview was conducted in the morning on 11/3/2021 with Staff #43. Staff #43 was asked if a post procedure evaluation was completed on the GI patients prior to discharge. Staff #43 replied, "No, I do not see them prior to discharge. I document the vital signs when I take the patient to the recovery room in my post procedure evaluation prior to proceeding with the next patient. The PACU RN will give me the additional information but they do tell me if there are any problems with the patient. They are usually discharged before I return to the PACU with the next patient. These are fast cases and they turn over pretty quickly."


An interview was conducted in the afternoon of 11/3/2021 with Staff #8. Staff #8 was asked why the anesthesia providers were not doing a complete post procedure evaluation in the PACU prior to the patient being discharged. Staff #8 replied, "Well I did not know that they were not. They should be seeing each patient before they are discharged home from the PACU and completing a post procedure assessment."

Staff #8 confirmed through interview and chart review that the anesthesia providers were not completing a post procedure evaluation to GI procedure patients prior to their discharge.

Staff #8 also confirmed the facility did not have an approved policy for Post procedure Evaluations for anesthesia.


A review of the facility policy titled, "Anesthesia Responsibilities for Outpatient Procedures-AS" Policy Number: 59138.2 with an approval date of 7/23/2020 was as follows:

" ...Purpose: To establish the responsibility of the anesthetist caring for patients having Outpatient Surgery.

Policy:
1)All patients receiving general, regional, sedation, or local with anesthesia standby will be seen preoperative by an anesthetist. A pre-anesthesia assessment, plan of anesthesia and the discussion with the patient and family regarding anesthesia options and risks shall be documented in the medical record.
2) Postoperative recovery will be done in the PACU.
3) Postoperative visits must be made before the patient is discharged from the PACU and Outpatient Surgery care. The patients status must meet discharge criteria prior to discharge from the facility. The patient may be discharged from facility by the CRNA, a licensed independent practitioner's or by medical staff approved discharge criteria.
4) Documentation of preoperative and postoperative anesthesia visits must be done on the anesthesia evaluation sheet by the attending anesthetist before the patient can be discharged.
5) The anesthetist must be available to see the patient, if there are any postoperative anesthesia complications in the Outpatient Surgery Department.

Responsibilities:

1) The anesthetist is responsible for all preoperative and postoperative care given to patients as related to anesthesia.
2) The PACU nurse and the Outpatient Surgery nurse are responsible for informing the anesthetist of any untoward effects that the patient may have in the postoperative period ..."



A review of the "Practice Guidelines for Post Anesthetic Care an Updated Report by the American Society of Anesthesiologists Task Force on Post Anesthetic Care", dated 2013 revealed the following:

"Guidelines

I. Patient Assessment and Monitoring

Perioperative and post anesthetic management of the patient includes periodic assessment and monitoring of respiratory function, cardiovascular function, neuromuscular function, mental status, temperature, pain, nausea and vomiting, fluid assessment, urine output and voiding, and drainage and bleeding."



Staff #8, #37, #43, and #45 confirmed the findings.

Based on observation, document review, and interview the facility failed to provide a clean and sanitary environment to mitigate the risks of possible hospital acquired infections in 9 departments (Dietary Department, Therapy Department, Pharmacy Department, Materials Management Department, Emergency Department, Laboratory, Sleep Lab, Respiratory Department, and Surgical Department), of 11 departments observed. The facility also failed to follow their policy to ensure temperature and humidity ranges were within the guidelines for the environmental control systems in the surgery department.

Findings Included:

Dietary Department

A tour of the Dietary Department was made on the morning of 11-1-2021 with Staff #52. The walk-in freezer was observed to have ice build-up on the floor, ceiling, walls, and shelves. Food boxes were observed to have ice on top of them also. Ice buildup from condensation or improperly functioning freezer can contain contaminants. Build up on food boxes and packaging could result in ice with contaminants falling into food during the unpackaging and thawing process.

A shelf in the food storage area was observed to have multiple packages of tortillas on the shelves. Three (3) packages of flour tortillas were noted to have preparation dates on the packages but no Use By date. Three (3) packages of green colored tortillas were not labeled at all as to the content, preparation date, or Use By date. Six (6) packages of large flour tortillas were not labeled at all as to the content, preparation date, or Use By date. Four (4) packages of corn tortillas were not labeled with the preparation date or Use By date. Nineteen (19) individual serving milk cartons were found to be expired on 10-31-2021 and available to serve. Six (6) bananas were observed on a tray covered with a plastic bag and available to be served. The bananas were laying on a paper tray liner that had been wet with an unknown substance and dried out. The dried fluid stain had dark spots throughout it. One (1) box of baking soda was observed on a shelf in the food storage area. It had been opened and was inside of a plastic zip lock bag. The box and/or bag was not labeled with the opening and expiration dates.

The 3-Compartment Dish Sanitizing room was observed. The first compartment/sink was used for washing dishes. The drain inside the compartment/sink was observed to have a build up of dark matter and green corrosion. The middle compartment/sink was used for rinsing dishes. The drain inside the compartment/sink was observed to have a build up of black matter. Staff #52 was interviewed during the tour. Staff #52 stated that the sinks were cleaned after use and that the sinks appeared to have not been rinsed completely. The water was turned on in effort to rinse the buildup away but was determined to a build up of material that required more than rinsing.

A large commercial mixer was observed on a metal stand in the kitchen food preparation area. The mixer was observed to have dried food splatter from the mixing process on the mixer surface above the mixing bowl. The mixer was observed to have a buildup of matter around the legs of the mixer where they contacted the metal stand. When and attempt to move the mixer was made, the mixer was found to be stuck to the stand. When it became unstuck and was moved, a heavy ring of matter was observed around where the mixer legs had been. An interview was conducted with Staff #52 and #53 on 11-3-2021. They confirmed that it had been several months since the Dietary Department had a baker and that the mixer had not been used since the baker left.

A coffee automatic dispensing machine was observed in the kitchen preparation area. A coffee filter basket was observed to be stored on top of the machine. The top of the machine was observed to have a heavy coating of dust with a coffee filter basket stored in a manner that allowed the basket to become contaminated with the dust. Staff #53 was interviewed on 11-3-2021. Staff #53 stated that the basket did not go to that coffee dispensing machine. Staff #53 stated that the coffee filter basket was no longer used and did not know why it was still being stored on top of the coffee dispense machine.

A commercial vendor style cabinet for displaying and keeping food/drinks cold was observed in the public cafeteria area. The bottom shelf of the inside of the case was observed to have dirt and debris on it. There was a dried white spill on the edge of the bottom shelf and down the outside bottom vent of the cabinet. The right hand door was observed to have a build up of dirt and matter around the magnet that helped keep the door closed. Staff #53 was interviewed during the tour. Staff #53 reported that the cabinet was cleaned over the weekend by weekend staff and should have been clean at the time of the tour.

A review of policy Title: Sanitation Standards for Food Service, Policy Number: 69159.1, Effective Date: 09/16/2020, was reviewed as follows:

"Food Supplies
1) General
a) Food shall be in sound condition, free from spoilage, filth or other contamination and shall be safe for human consumption.
b) Food shall be obtained from sources that comply with all laws relating to food and food labeling. The use of food in hermetically sealed containers that was not prepared in a food-processing establishment is prohibited.
...

3) Food Protection:
a) General: At all times including while being stored, prepared, displayed served or transported, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and overhead leakage or overhead drippage from condensation. ...


4) Food Storage:
a) General:
i) Food whether raw or prepared, if removed from the container or package which it was obtained, shall be stored in a clean covered container except during necessary periods of preparation or service. ...
...
iv) Food not subject to further washing or cooking before serving shall be stored in such a way that protects it against cross-contamination from food requiring washing or cooking.
...
vii) All food products shall be dated at the time they are received if date is not already on product.
(1) Boxes or individual containers shall all be labeled (with date) so that the date remains visible when unpacked from the case.
(2) New containers of product are always placed behind the previously received packages of the same product. In other words, rotate stock in the FIFO method. (First In First Out)
(3) Any shelved package which is open and all of the contents are not used at once, will have the remaining products transferred to an airtight container and labeled with the date it was opened.
(4) Frozen food products also will be dated when received and again after opening and transferring to another container. All dates will contain month, day, year.

Therapy Department

A tour of the therapy department was made on 11-1-2021 with Staff #20 present. The area contained physical therapy equipment/supplies for patient use, occupational therapy supplies, and speech therapy supplies. There was a hand washing sink located in the room. The cabinet door under the sink was opened and the cabinet was observed to have a panel installed just behind the door hinges that prevented staff from storing anything under the sink. The panel was secured with screws to material behind. A gap between the panel and cabinet wall revealed a portion of material that looked like a fiberboard. When observed, the fiberboard appeared to have a dark stain that looked as if it had absorbed water and/or water had been wicking from the bottom of the board up into the board. Staff #20 was interviewed during the tour. Staff #20 stated she had not noticed this discoloration because the cabinet is not opened for use. Staff #20 stated that unless the sink developed a water leak that spilled out of the cabinet to become visible, she would not know if there was a small water leak under the sink and behind the panel. Without routine inspection/observation of the area behind the panel. A small water leak could go unnoticed while providing and environment for bacterial, fungal, and viral growth.

Pharmacy Department:

A tour of the Pharmacy Department was made on the afternoon of 11-1-2021 with Staff #54, #56, and #57 present. In the After-Hours Pharmacy area, a dirty broom and dustpan were observed to be stored between stacked open storage bins and metal shelving with open storage bins that contained supplies and medications. Storage in this manner could promote contamination of supplies and medications. Inside the pharmacy area, medications and supplies were stored on two (2) open wire shelves without a liner to protect the products on the shelf from splashing of contaminants during floor cleaning. Plastic packaging for medication repackaging was observed to be stored loose and opened in a drawer that allowed for contaminants to come in contact with the insides of the packaging and potentially contaminating the medication packaged inside of it.

Materials Management

The Materials Management Department (Central Supply) was toured on 11-3-2021 with Staff #58 present. Supplies were observed to be stored on open wire shelving without a liner to protect the products on the shelf from splashing of contaminants during floor cleaning. Products for patient use such as sterile Foley Catheter kits (drainage tubing placed inside a patient's bladder for drainage and collection of urine) and paper gowns were being stored under liquids and chemicals that could potentially contaminate the patient use items if leakage were to occur.

An open bin of individual packages of snack chips were observed on a desk in the area. Two (2) large boxes of concentrated syrup flavoring for a frozen drink machine was observed stored on a wire shelf with patient use items stored on the shelf above it. Food items stored with patient use items creates an environment for potential insect, rodent, and pest infestation with contamination of patient use items.

Twenty-eight (28) 1000 milliliter bags of sterile fluids for patient use were observed being stored on an open wire shelf. On the shelf directly underneath the fluids, three large bags of water softener salt cubes and a dirty lid to an unknown container were being stored. This presented a condition where the sterile fluid bags could become contaminated with chemicals for water softening.

A bariatric bed was being stored in the Central Supply area. The bed had linens and a pillow on it and was identified as clean and ready for use. The hand-held bed control was observed to be soiled. When wiped with a cleaning cloth, the dirt was able to be removed. The fitted bottom bed linen was observed to have a dead ant on it by the headboard and hairs on the linen near the headboard and foot of the bed. There was a build up of what appeared to be rust and/or corrosion in the articulating joints on the siderails. When the linens were removed, the mattress cover was observed to multiple areas of damage to the cover allowing fluids to penetrate the protective cover. When the sides of the mattress cover were lifted, the underside of the covering was stained with dried fluids that had penetrated the covering. This presented conditions where infectious materials/fluids could not be cleaned from the mattress and provide a source of potential hospital associated infection to patients.


32143


Emergency Department
A tour of the Emergency Room was conducted with Staff #5 on 11-1-21. The following items were found:
Soiled Utility
Cructhes were found next to the dirty hopper.
Patient equipment marked clean in the soiled room. The equipment included wheelchairs, back boards, walkers and IV pumps.
The medication refrigerator in the medication room was found to be soiled with dust and hair on the inside.

Laboratory
A tour of the Laboratory was conducted on 11-4-21. The following items were found:
The chest freezer was found caked in ice. The freezer held lab testing supplies and reagents. The freezer was unable to be cleaned properly.
The upright freezer was covered in ice and unable to be cleaned appropriately. Immunoassay analytes were sitting in ice. The directions on the vials of the analytes stated not above -20 or below -70. The analytes were sitting on ice and unable to determine the true temperature.
The 3 small refrigerators were holding reagents and testing supplies. The freezers in the refrigerators had excessive ice buildup and could not be cleaned properly.

Sleep Lab
A tour of the Sleep Lab was conducted on 11-5-21. The following items were found:
The clothes washer was found wet. The washer was soiled with mildew and smelled a pungent smell.

Respiratory Department
A tour of the RT department was conducted on 11/2/21 at 2:00PM. The department was a combination of an office, clean patient supplies, and a stretcher for outpatient EKG's, EEG's, and PFT's. Ventilators, Vapotherms and Airvo's were cleaned and ready to use. In the back of the office were patient supplies and a stretcher for outpatients to walk past and expose clean patient supplies to their personal items. Staff #17 was unable to show how the supplies would not be contaminated.



40989

Surgery Department

An observation tour was conducted with Staff #8 and Staff #48 on 11/1/2021 at 9:55 AM. The Surgical Department had 2 Operating Rooms where sterile surgical cases were performed 5 days a week.

The following was observed:


OR#1 and OR#2

The floor in the operating rooms was two tone in color. The center of the floor where the OR bed was positioned was black and silver in color. The surrounding floor to the walls was a lighter color. In the center of the black flooring, the operating bed was positioned for surgical cases. Different surgical cases require a different position of the bed. The operating bed is a heavy bed and when it is locked it has 4 legs that hold the bed in place. The floor beneath the bed was noted to be cracked and exposing the concrete surface below in multiple places. The floor beneath the bed could possibly be contaminated with body fluids and other contaminants. The floor is mopped with a heavy wet mop in between each surgical case. This allowed for moisture to stay inside the unsealed cracks and splits and greatly increased the possibility for bacterial growth. The damaged floor could not be properly disinfected and sanitized therefore, placing each patient at a greater risk of acquiring a hospital acquired infection.


A review of the documents titled, "Temperature and Humidity Tracking Log for Clean/Sterile Storage" was as follows:

" ... Location_____________ Month/Year____________________

Temperature Range:___Max 75__Humidity Range:____Max 60%___

If the temperature or humidity are not within range notify Bio Med at 68745. Document actions taken (I,e, adjusting thermostat, close door, etc.) and the re-measure after 30 minutes to assure that the affected parameter is within acceptable range..."


The following documents were reviewed with Staff #8:


OR#1

September:

There was no documentation of the temperature or humidity for 9 of 30 days reviewed. There were 12 days the temperature was out of range. No documentation that Plant Services was notified, or corrective action taken.

October:

There was no documentation of the temperature or humidity for 10 of 31 days reviewed. There were 13 days the temperature was out of range. No documentation that Plant Services was notified, or corrective action taken.


OR#2

September:

There was no documentation of the temperature or humidity for 9 of 30 days reviewed. There were 17 days the temperature was out of range. No documentation that Plant Services was notified. Corrective action was documented for 2 of the 17 days.

October:

There was no documentation of the temperature or humidity for 10 of 31 days reviewed. There were 10 days the temperature was out of range. The humidity was out of range for 3 of 31 days. No documentation that Plant Services was notified. Corrective action was documented for 3 of the 10 days the temperature and humidity were out of range.


Ortho Supply Closet

September:

There was no documentation of the temperature or humidity for 10 of 30 days reviewed.

October:

There was no documentation of the temperature or humidity for 10 of 31 days reviewed.

Inside this closet were orthopedic implants for total joint procedures and consignment instruments from certain medical suppliers.


Sterile Supply Room

September:

There was no documentation of the temperature or humidity for 10 of 30 days reviewed.

October:

There was no documentation of the temperature or humidity for 11 of 31 days reviewed.


Sterile Processing Room

September:

There was no documentation of the temperature or humidity for 9 of 30 days reviewed. There were 10 days the temperature was out of range. No documentation that Plant Services was notified, or corrective action taken.

October:

There was no documentation of the temperature or humidity for 11 of 31 days reviewed. There were 8 days the temperature was out of range. No documentation that Plant Services was notified, or corrective action taken.


Decontamination Room

September:

There was no documentation of the temperature or humidity for 10 of 30 days reviewed.

October:

There was no documentation of the temperature or humidity for 11 of 31 days reviewed.


GI Procedure Room

September:

There was no documentation of the temperature or humidity for 8 of 30 days reviewed.

October:

There was no documentation of the temperature or humidity for 10 of 31 days reviewed. There were 9 days the temperature was out of range. No documentation that Plant Services was notified, or corrective action taken.


Anesthesia Supply Room

This room was not monitored for temperature or humidity. This room was used to store anesthesia supplies. Sterile supplies such as Central lines, some medications that are packaged inside sterile packages, Nerve block trays, peel packed sterile instruments used for a patient's airway, and sterile gloves. Some items, such as a Power Midline Catheter, were temperature sensitive that required storage temperatures between 68-77 degrees Fahrenheit.


An interview was conducted on 11/1/2021 after 10:00 AM with Staff #8. Staff #8 was asked what national guidelines the department followed regarding the temperature and humidity. Staff #8 replied, "Association of Perioperative Registered Nurses (AORN). This form is not the form that we have always used. This is one that corporate put out and it only shows the max ranges. I know there is a range that we should follow. I am going to see about getting this form changed back to the one that we used to use." Staff #8 was asked if there was any monitoring that was completed on the weekends or on holidays when the department was closed. Staff #8 replied, "No, because no one works on the weekends or holidays back here. We do not take call and we are only her Monday-Friday and no holidays." Staff #8 was asked how the facility ensured that there was no problems with the HVAC system over a weekend that would cause the instrument sets to sweat and be dry on Monday when they returned (Sterile instrument sets that retain moisture are considered contaminated and need to be reprocessed). Staff #8 replied, "Well I guess we will need to get that covered and train someone to do checks over the weekends." Staff #8 was then asked about the tears in the floor in both OR#1 and OR#2. Staff #8 stated, "We were told that the floors could not be waxed to create a seal over the torn surface so I have not been able to get anything done with them."



A review of the facility policy titled, "Environmental Control in the OR-SS" Policy Number: 60158.2 with an approval date of 3/24/2021 was as follows:

' ...Policy: To provide guidelines for the environmental control systems in the surgery department.

Objectives: These rooms are designed and maintained in accordance with the Department of State Health Services Title 25 Texas Administrative Code Chapter 133 Hospital Licensing Rules.
It is recommended that the:
1) Operating Room (O.R.) temperature be maintained between 68 degrees F and 75 degrees F and the relative humidity maintained between 20% and 60%.
2) Decontamination room temperature is maintained between 60 degrees F and 73 degrees F and the relative humidity has no recommendation.
3) Sterilization Room temperature is maintained between 68 degrees F and 75 degrees F and the relative humidity maintained between 20% and 60%.
4) Sterile Storage and Supply Room temperature less than 75 degrees F and relative humidity no greater than 60%..."



A review of the AORN Guidelines was as follows:

" ...Guidelines for Perioperative Standards and Recommended Practices. Association of perioperative Registered Nurses-2019 Perioperative Standards and Recommended Practices, e-AORN, Table 3.

"Temperature should be maintained between 68 degrees F to 75 degrees Fahrenheit (20 degrees to 24 Celsius) within the operating room suite. General work areas in sterile processing clean workroom should be maintained between 68 degrees to 73 degrees Fahrenheit (20-23 Celsius). Sterile storage room should be maintained below 75 degrees Fahrenheit (24 degrees Celsius). Sterile processing decontamination area should be maintained between 60 degrees to 73 degrees (16-23 Celsius).

Relative humidity should be maintained between 20% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, and should be maintained below 60% in sterile processing clean work room and sterile storage areas ..."


Staff #8 and Staff #48 confirmed the findings.

Based on review and interview the facility failed to have a multidisciplinary comprehensive care plan for 3 out of 3 (#20, 21, and 22) swing bed patient chart reviews.

Review of Patient #20's chart revealed he was admitted to the swing bed on 10/1/21. He was ordered and seen by Nursing, Dietician, Activities Director, Physical Therapist (PT), Occupational Therapist (OT) and Case Manager/Discharge Planner (CM). Each discipline had written a plan of care on their own separate notes but there was no multidisciplinary comprehensive care plan.

Review of Patient #21's chart revealed he was admitted to the swing bed unit on 11/4/21. He was ordered and seen by Nursing, Speech Therapist (SLP), Activities Director, Physical Therapist (PT), Occupational Therapist (OT). Each discipline had written a plan of care on their own separate notes but there was no multidisciplinary comprehensive care plan.

Review of Patient #22's chart revealed he was admitted to the swing bed unit on 10/26/21. He was ordered and seen by Nursing, Activities Director, and Physical Therapist (PT). Each discipline had written a plan of care on their own separate notes but there was no multidisciplinary comprehensive care plan.

An interview was conducted with Staff #20 (PT) and #27 (RN) on 11/5/21. Staff #20 stated they used to document together in a multidisciplinary care plan before the organization changed computer programs on 9/10/21. Staff #20 stated she does not have access to a multidisciplinary care plan since the change. Staff #20 confirmed that she care planned on her own notes. Staff #27 confirmed that the other disciplines do not have access to a multidisciplinary care plan.

Based on interview and review of records, the facility failed to ensure that 8 out of 8 nursing staff assigned the role of Emergency Department (ED) Charge Nurse (CN) (Staff #13, #16, #26, #61, #66, #67, #68, and #69) had completed necessary training consistent with their expected role of Administrator on Call (AOC)/Commander of the event as outlined in the Emergency Operation Plan.

Findings included:

On the morning of 11-2-2021, the policy Title: Emergency Operations Plan-EM; Policy Number: 66153.1; Effective Date: 03/25/2020 was reviewed with Staff #2 and Staff #70. During review of the policy under Chain of Command on page 1 of 44, the policy stated, "The current Emergency Department Charge Nurse will assume the role of AOC/Commander of the event. This session will be limited in scope of authority to respond to the current and immediate needs of the facility. Successor has the authority to grant privileges as needed and commit resource's (sic) as needed. This limited authority will continue until an UT Health Administrator arrives at the command center to assume this role."

Staff #2 was interviewed as to how the Charge Nurses were trained and knew what the processes for different events were. Staff #2 stated that there had been a recent turnover of Charge Nurses and he believed there was only one designated Charge Nurse. The other positions had not been filled. When it was explained that it didn't matter if the staff filling the Charge Nurse role in the ED was permanently assigned or not when the Emergency Preparedness Plan stated that the "current" person in that role assumed that responsibility, Staff #2 stated he did not believe that any of the nurses had the required training.

Review of training requirements on page 29 of the Emergency Operations Plan was as follows:
"3) Training and Identification of Staff:
a) Staff members are minimally trained relative to the codes for activation of the Emergency Operations Plan, and where to report for assignment. In addition, specific training is required for staff in accordance with the National Incident Management Systems (NIMS) as follows:

Staff Role:
Personnel likely to function as the Incident Commander, ...

NIMS Based Training:
ICS-100: Introduction to ICS or equivalent
ICS-200: Basic ICS or equivalent
FEMA IS-700: NIMS, An Introduction
FEMA IS-800: National Response Plan (NRP), and Introduction*

*Note: Personnel whose primary responsibility is emergency management must complete this training."

Staff #2 was asked to provide a list of ED nurses who were assigned the Charge Nurse role over the past two months and proof of required training as outlined in the Emergency Operations Plan. On the morning of 11-3-2021, Staff #2 advised that he had reviewed the list of Charge Nurses along with their training. None of the 8 nurses assigned as Charge Nurses had completed the training required by the Emergency Operations Plan.