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Based on observation and a tour of the facility, the facility did not have a housekeeping and preventive maintenance program to ensure that the premises were clean and orderly.

Findings were:

During a tour of the facility on 2-17-11, several floor tiles in the trauma anteroom were noted to be broken and have missing pieces, preventing the floor from receiving adequate cleaning.

The above was confirmed in a meeting with the Administrator, the Chief Nursing Officer and the Medical Chief of Staff on the afternoon of 2-17-11 in the basement boardroom.

Based on a review of documents, the facility's govening body was not responsible for implementing and monitoring policies and ensuring that the policies were administered so as to provide quality health care in a safe environment.

Findings were:

Facility (administrative department) policy Section II, Policy #9 titled Performance Evaluations states, in part, " Employees ' performance should be evaluated by their immediate supervisor at least one time each year, within 30 days of their anniversary date. "

During a review of personnel files on 2-16-11, 15 of 20 employees (#1, #2, #4, #6, #7, #8, #9, #10, #11, #12, #14, #15, #17, #18 & #19) had been employed with the facility for at least one year but had not received an annual evaluation within the last 12 months.

Facility job description titled " Charge Nurse " states, in part, " C. Licensure, Registry or Certification: Registered Nurse currently licensed by the State of Texas, BCLS, ACLS, PALS and TNCC required. "

During a review of personnel files on 2-16-11, 2 of 12 registered nurses (#7 & #12) did not possess the required certification outlined in the job description for Charge Nurses. In a discussion with the Chief Nursing Officer on 2-16-11, all registered nurses employed by the facility should be able to perform the duties outlined in the " Charge Nurse " job description.

The above was confirmed in a meeting with the Administrator, the Chief Nursing Officer and the Medical Chief of Staff on the afternoon of 2-17-11 in the basement boardroom.

Based on a review of documentation, the facility failed to maintain a central log on each individual who comes to the emergency department, as defined in ?489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged.

Findings were:

During a review of documentation on 2-16-11, it was discovered that a complete emergency room log was not maintained for patients seen in the facility ' s emergency department during the time period of 3-24-10 through 2-16-11. The log maintained did not contain the following information:

*whether or not the patient had refused treatment
*whether or not the patient had been refused treatment
*whether the patient had been transferred, admitted, stabilized and transferred
or discharged

The above was confirmed in a meeting with the Administrator, the Chief Nursing Officer and the Medical Chief of Staff on the afternoon of 2-17-11 in the basement boardroom.