HospitalInspections.org

Based on observation and interview, the facility failed to include the address and telephone number for lodging a complaint with the state agency in the posting of patient rights in 4 of 4 off campus services locations.

On 4/16/2013 at 9:00 AM at the Sleep Disorder Treatment Center in Lindale, patient rights postings did not include information for filing a grievance or complaint with the state agency.

On 4/16/2013 at 10:30 AM, the Sleep Disorder Treatment Center at Turtle Creek did not have any patient rights information posted for patient or family review.

On 4/16/2013 at 11:30 PM at the Sleep Disorders Treatment Center at Southpark Drive, patient rights postings did not include information for filing a grievance or complaint with the state agency. .

On 4/16/2013, during the tour of all three Sleep Disorder Treatment Centers, the program manger confirmed there was no information included in the patient rights positing for name or address of the state agency to file a grievance or complaint.

On 4/16/2013 at 1:00 PM in the Wound Care Center, the patient rights postings did not contain the address or phone number for the state agency for a patient or family to file a grievance or complaint. The program manager confirmed the lack of information during the tour.

Based on interview and record review, the facility failed to ensure 15 (#s' 5, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 20, 23, 24 and 25) of 41 patients and/or their representatives were involved in care plans.

This deficient practice had the potential to cause harm in all in-patients.

Findings include:

1. Review of care plans revealed no documentation of patients and/or their representatives being involved in care planning on the following:

*Patient #9, admitted 04/07/13;
*Patient #12, admitted 04/07/13;
*Patient #5, admitted 04/13/13;
*Patient #20, admitted 04/13/13;
*Patient #10, admitted 04/14/13;
*Patient #11, admitted 04/14/13;
*Patient #7, admitted 04/14/13;
*Patient #8, admitted 04/10/13;
*Patient #23, admitted 04/15/13;
*Patient #25, admitted 03/31/13;
*Patient #24, admitted 04/14/13;
*Patient #17, admitted 04/14/13;
*Patient #16, admitted 04/12/13;
*Patient #15, admitted 04/12/13;
*Patient #14, admitted 04/15/13.

During an interview on 04/17/13 at 1:48 p.m., Staff #66 reported the documentation should be on the care plan. There was no designated place on the electronic chart for patient and/or representative involvement.

Based on observation and interview, the facility failed to ensure the privacy of 4 of 4 patients during hyperbaric oxygen treatments.

On 4/16/20134 at 1:20 PM, during a tour of the Wound Care Center, 4 male patients were observed in the hyperbaric oxygen treatment room. 3 of 4 male patients were receiving a hyperbaric oxygen treatment. 3 of 4 male patients were inside the hyperbaric chambers. The 4th male patient was not yet inside his chamber, but was receiving instruction prior to his first treatment. No privacy curtains were utilized between chambers. All 4 patients could see each other.

On 4/16/2013 at 1:20 PM, during the above tour, the program manager was questioned as to why privacy curtains were not being used? She confirmed no privacy curtains were utilized and responded, "The hyperbaric techs can't see the patients with the curtains pulled."

Based on interview and record review, the facility failed to ensure care plans were developed and kept current in 4 (#s' 5, 7, 8, and 11 ) of 41 charts reviewed.

This deficient practice had the potential to cause harm in all in-patients.

Findings include:

Review of care plans revealed the following:

*Patient #5 admitted 04/13/13, Patient #8 admitted 04/10/13 and Patient #11 admitted 04/14/13 did not have a completed nutrition assessment/care plan.

During an interview on 04/17/13 at 1:48 p.m., Staff #5 confirmed the assessment and care plans were missing.

*Patient #7 admitted 04/14/13 and Patient #8 admitted 04/10/13 had restraint care plans with the problems listed, but there were no expected outcomes listed.

During an interview on 04/16/13 at 11:45a.m., Staff #41 confirmed they were missing.

Based on interview and record review, the facility failed to ensure 4 (#s' 3, 5, 10 and 11) of 4 patients reviewed for blood administration received observation of vital signs during the process.

This deficient practice had the potential to cause harm in 4 patients.

Findings include:

1.) Review of the policy "Blood Transfusion Reactions," dated 01/27/10, revealed the following:

"All patients receiving blood/blood components shall be monitored for a transfusion reaction. The most severe, life threatening reactions usually start within the first fifteen minutes of the transfusion. During the transfusion the patient should be observed for:

d. Temperature elevation of 1.8 degrees
e. Sudden change in blood pressure or pulse"

Review of an "Assessment Report" dated 04/01/13 revealed Patient #3 was a 52 year old male admitted on 04/01/13 with a diagnosis of osteomylitis.

Review of blood transfusion records dated 04/05/13, 04/09/13 and 04/14/13 revealed patient #3 received a total of 4 units of blood. There was no documentation of vital signs taken during any of the blood transfusions.

During an interview on 04/17/13 at 10:41 a.m., Staff # 66 confirmed there were no vitals signs taken during the blood transfusion.


2.) Review of an "Assessment Report" dated 04/13/13 revealed Patient #5 was a 86 year old female, admitted on 04/13/13 with a diagnosis of a fall.

Review of blood transfusion records dated 04/14/13 and 04/15/13 revealed Patient #5 received one unit of blood each day. There was no documentation of vital signs taken during the blood transfusions.

During an interview on 04/17/13 at 1:48 p.m., Staff # 66 confirmed there were no vital signs taken during the blood transfusion.

3.) Review of an " Assessment Report" dated 04/14/13 revealed Patient #10 was a 64 year old male admitted with a diagnosis of gastrointestinal bleed.

Review of blood transfusion records dated 04/14/13 and 04/16/13 revealed Patient #10 received one unit of blood each day. There was no documentation of vital signs taken during the blood transfusions.

During an interview on 04/16/13 at 11:45 a.m., Staff #54 confirmed she had administered the blood transfusion on 04/16/13 and had not performed vital signs during the transfusion.

During an interview on 04/16/13 at 11:50 a.m., Staff #41 reported vital signs should be performed during blood transfusions.

4.) Review of an "Assessment Report" revealed Patient #11 was a 48 year old female admitted on 04/14/13.

Review of blood transfusion records dated 04/15/13 and 04/16/13 revealed Patient #11 received a total of 4 units of blood. There was no documentation of vital signs taken during any of the blood transfusions.

During an interview on 04/16/13 at 2:30 p.m., Staff #45 reported they only take vital signs at the beginning and end of the blood transfusions.

Based on observation and interview, the facility failed to provide preventive maintenance to medical equipment and ensure supplies were inventoried for the purpose of removing expired items from 2 of 2 emergency departments.

A tour of the Main Emergency Department (ER #1) on 4/18/2013 at 10:00 AM revealed 2 out of 3 ophthalmoscopes in the Emergency Department patient rooms did not have working lights and needed repair.

During an interview on 4/18/2013 at 10:00 AM, staff #58 confirmed that the lights on the ophthalmoscopes were not working.

A tour of the off site Emergency Department (ER#2) on 4/19/2013 at 9:00 AM revealed the following expired items:

- 3 boxes of Propylene sutures, sizes 3,4,and 5.
- 3 boxes of Dextrose found in a crash cart with an expiration of 3/2013.
-3 laryngeal mask airways (LMA) sizes 3,4, and 5 with an expiration date of 11/11/2011.
-1 IV bag of 250 ml Dextrose with an expiration of 3/2013.

During an interview on 4/19/2013 at 10:30 AM, staff #60 confirmed the the above items had expired.

Based on observation and interview, the facility failed to ensure sterile and/or clean supplies were protected from possible contamination in respiratory services supply room. The facility also failed to ensure soiled cardboard biohazard boxes were not placed in patient rooms.

While touring the respiratory therapy services supply room on 4/19/2013 at 10:30 am, the following observations were made:
1. Respiratory supplies were stored in storage room on wire racks. Wire racks were observed with sterile supplies on the bottom shelf, with no barrier to prevent contamination from cleaning solution and/or dirt or dust on floor.
2. Also observed supplies stored in shipping boxes on the top shelf of wire rack with sterile supplies stored directly underneath.
3. During a facility tour on 4/20/2013 at 10:00 am, the following observations were made:
-the facility used cardboard biohazard boxes to store and transport biohazard waste within and outside the facility;
-these boxes were delivered ("clean") to the facility by the biohazard waste company and stored in a trailer with biohazard waste;
-the "clean" boxes were then moved as needed into each patient care department's soiled utility room;
-when a patient was placed in isolation, a bin would be moved from the soiled utility room into the patient's room, where it would be used for biohazard waste disposal.

An interview with staff #1 on 4/20/2013 at 1:45 pm confirmed these findings:
The wire racks in the respiratory services supply room were missing a clear barrier on bottom shelves of racks, and shipping boxes were being used to store sterile/clean supplies on the top shelf of rack and sterile/clean supplies were stored underneath and were at risk for contamination. Also, the practice of storing these "clean" biohazard boxes in the soiled utility rooms and then using them in a patient room as part of the isolation protocol was a standard practice throughout the facility.