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Based on review of documentation and interview with staff, it was determined the facility failed to supervise and evaluate the nursing staff as 1 of 2 medical records reviewed where the patients received blood transfusions did not have proper documentation. The facility also failed to follow its own policy.

Findings included:

The facility policy entitled, "Blood Administration" stated "Packed red blood cells will be given by the Registered Nurse only on the written order of the physician."

The facility policy entitled, "Nursing Process" stated, "Intervention-Implementation: This is the phase of the nursing process in which the nurse initials and completes actions necessary to accomplish defined goals ...The quality of the recording or documentation gives direct evidence of the status of and the direction for continued problem solving."

A review of the medical record of patient #2 revealed that there was no documentation in the nurse's notes that a Registered Nurse initiated the first unit of blood on 10/29/2011 and assessed the patient for an adverse reaction.

In an interview with staff member #4 at 10:45 on 2/15/2012, it was confirmed there was no documentation by a Registered Nurse.

Based on review of documentation and interview with staff it was determined the facility failed to have verbal order authentication dated and timed within 48 hours as 12 of 30 medical records reviewed had verbal orders where the authentication by the physician was not dated and timed. The facility also failed to follow its own policy.

Findings included:

The facility policy entitled, "Authentication/Author identification" stated, "Procedure: 2. Each entry shall be dated and timed."

A review of the Medical Staff Bylaws stated, "Article XV, Rules and Regulations, 8. All orders for treatment will be in writing ... At the next visit, the attending Physician will sign such order."

A review of the medical records revealed that 12 of 30 medical records reviewed had verbal orders where the authentication by the physician was not dated and timed. Patient records #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 contained verbal orders that were signed by the physician but were not dated and timed.

In an interview at 8:45am on 2/15/2012 with staff member #19, the above was confirmed and that all entries must be signed, dated and timed.

Based on observation, review of documentation, and interviews with facility staff, the facility failed to assure that the menus meet the needs of the patients as 10 of 21 daily menu forms only had a menu for a regular diet and not for soft/bland, low fat, low sodium and diabetic/low calorie diets in violation of facility policy.

The findings were:
The facility policy entitled "Diet Manual" reflected "4. The most commonly ordered diets are written on menu forms: Regular, Soft/Bland, Low Fat, Low Sodium, and Diabetic/Low Calorie."

During a tour of the facility on the morning of 2/13/12 in the company of staff member #7, the 21 day menu cycle forms were reviewed which revealed that for each day there was a column for regular diet, soft/bland, low fat, low sodium, and diabetic/low calorie. Out of the 21 daily menu forms, 10 only had the menu column for a regular diet filled in and the columns for soft/bland, low fat, low sodium and diabetic/low calorie diets were blank. For the days that the columns for soft/bland, low fat, low sodium and diabetic/low calorie were blank, the cooking staff would have no menu for the soft/bland, low fat, low sodium and diabetic/low calorie diets. In an interview with staff member #7 on 2/13/12 at 3:00 pm, she confirmed that the daily menu forms were incomplete.

Based on observation, review of documentation, and interviews with facility staff, the facility failed to assure that a current diet manual was available for use in the facility as the diet manual in use was the 1988 edition and was last approved by the medical staff in 9/93 in violation of facility policy.

The findings were:
The facility policy entitled "Dietary Manuals" dated 10/25/95 reflected "To ensure that nursing staff and physicians have easy access to a current diet manual of therapeutic diets to assist in ordering diets and nutritional teaching, a diet manual will be kept at the nursing station."

During a tour of the facility on the morning of 2/13/12 in the company of staff member #7, the diet manual observed in the dietary office was the Texas Dietetic Association Diet Manual, 5th Edition, 1988. The diet manual was approved by the medical staff in 9/93. In an interview with staff member #7 on 2/13/12 at 3:00 pm, she confirmed that this was the most current diet manual in the facility.

Based on observation, review of documentation and interviews with facility staff, the facility failed to maintain the hospital to ensure the safety of the patient as the following were observed: numerous instances of holes in floor coverings, wall finishes and ceiling tiles; evidence of multiple roof water leaks; an uncovered electrical junction box; a wall framed with wood studs uncovered on one side; the emergency room door was unlocked at all times without staff members in view; open outdoor trash receptacles; no fire drills conducted since 1/10/09; and expired medical supplies in patient care areas available for patient use.

The findings were:
Cross refer to CFR 482.41(a) A0701
Cross refer to CFR 482.41(b)(6) A0713
Cross refer to CFR 482.41(b)(7) A0714
Cross refer to CFR 482.41(c)(2) A0724

Based on observation, review of documentation, and interviews with facility staff, the facility failed to maintain the physical plant and overall hospital environment to assure the safety and well-being of patients in violation of facility policy as the following were observed: numerous instances of holes in floor coverings, wall finishes and ceiling tiles; evidence of multiple water leaks; the emergency room door was unlocked at all times without staff members in view; there was an uncovered electrical junction box and other unsecured electrical devices; and a wall framed with wood studs with no sheetrock covering.

The findings were:
The facility policy entitled "Nursing Safety" dated 10/20/98 reflected "3. All department employees shall report ...unsafe conditions, acts or safety hazards to supervisor. and 6. Nurse call signal lights must be attached to patient's bed or within reach."

The facility policy entitled "Sanitary Facilities and Controls" reflected "E. Floors: 1. All floors shall be kept clean and in good repair. F. Walls and Ceilings: 1. All walls and ceilings, including doors, windows, skylights and similar closures, shall be kept clean and in good repair."

During a tour of the Emergency Department at 2:15pm on 2/13/2012 with staff members #4 and #6, the following maintenance issues were observed:
In the patient waiting room and the hallway to the exam rooms:
1) There was one broken ceiling tile.
2) There were 2 white ceiling tiles with brown staining.
In the old sterilizing room, the following was observed:
1) There were approximately 19 small holes approximately 1 cm in size on the left wall.
2) The brown base board on the left was missing approximately 2 feet.
3) There was one white ceiling tile with brown staining.

The ambulance entrance to the hospital was observed to also be the patient entrance according to signage on the door. The entrance remained unlocked from the outside to the inside of the facility at all times and staff members were not located in view of the glass doors which created a potential safety hazard for the patients and staff, as the unlocked glass doors were not monitored.

In an interview the afternoon of 2/13/2012 with staff members #4 and #6, the above findings were confirmed.

During a tour of the Nursing Unit at 3:10pm on 2/13/2012 with staff member #4, the following maintenance issues were observed:
1) There were 4 broken ceiling tiles at the nurses' station.
2) There were 4 round light fixtures with exposed light bulbs in patient rooms.
3) In the hallway of the Nursing Unit, there was an overhead ceiling recessed fluorescent light fixture had an unknown liquid inside.
4) In Room 17, 2 electrical junction box covers with a wire through them behind the head of the patient bed had fallen out of the wall and were on the floor.
5) In Room 19, there was a leak under the sink.
6) In Room 23, a nurse call light box on the wall had fallen out of wall and was hanging down from a wire coming out of the wall.
7) In Room 27, there was a broken tile in the shower.
8) In the supply room, there was a broken floor tile.
In an interview on the afternoon of 2/13/2012 with staff member #4, the above findings were confirmed.

During a tour of the Laboratory at 4:05 pm on 2/13/2012 with staff member #3, the following maintenance issues were observed:
1) 2 ceiling mounted fluorescent fixtures without any covering.
2) 1 round and 1 square ceiling light fixture without covers with light bulbs exposed.
3) A yellow plastic bag inside a round ceiling air vent of a storage room.
4) An approximately 1 foot by 1/4" crack in a pillar in the employee locker room.
5) 2 cracks in the ceiling approximately 7" long and 2" wide.
6) Approximately 28 broken 1"x 1" ceramic floor tiles.
7) 3 round ceiling air vents with no grill covers.
8) 18 white ceiling tiles with brown stains in the laboratory department above testing areas.
9) A broken ceiling tile which exposed wiring above.
In an interview the afternoon of 2/13/2012 with staff members #2 and #3, the above laboratory findings were confirmed. In an interview the morning of 2/14/2012 with staff member #20, the above laboratory findings were reconfirmed.

During a tour of the facility on 2/14/12 starting at 9:10 am in the company of staff member #20, the following maintenance issues were observed:
1) Broken plaster in wall behind hand washing sink in the kitchen.
2) An uncovered electrical junction box with exposed bare copper wires in kitchen behind the ice machine.
3) 3 broken ceramic tiles in kitchen mop sink room.
4) Broken plaster in the left wall of the dietary and housekeeping storage room.
5) Broken and cracked plaster in the hallway wall near housekeeping mop room.
6) A wet ceiling tile with brown stains in visiting physician exam room.
7) A wall framed with wood studs with no sheetrock covering in the radiology supply room.
In an interview with staff member #20 on 2/14/12 starting at 9:10 am, he confirmed the above listed items were in need of repair.

Based on observation, review of documentation and interviews with facility staff, the facility failed to properly store trash in violation of facility policy as two dumpsters located outside of the loading dock areas were observed to be uncovered.

The findings were:
The facility policy entitled "Sanitary Facilities and Controls" reflected "S. Garbage Disposal, 4. All food waste and rubbish should be kept in containers that do not leak and have tight-fitting covers."

During a tour of the facility on the morning of 2/14/12 in the company of staff member #20, two dumpsters located outside the loading dock area were observed to be uncovered with the lids in the open position. In an interview with staff member #20 on 2/14/12 starting at 9:10 am, he confirmed that the lids of the dumpsters were open and stated that they should be closed.

Based on observation, review of documentation, and interviews with facility staff, the facility failed to follow the written fire control plan as the last fire drill conducted was on 1/10/09 in violation of facility policy.

The findings were:
The facility policy entitled "Fire Safety and Prevention" dated 5/8/07 reflected "11. Fire drills, not involving patient participation, are rehearsed by hospital personnel at least once per quarter per shift."

In an interview with staff member #22 on 2/14/12 at 11:10 am, he stated that the last fire drill conducted was over a year and a half ago. Review of documentation revealed that the last fire drill documented was held on 1/10/09 at 1:45m pm.

Based on observation, review of documentation, and interviews with facility staff, the facility failed to maintain supplies to ensure an acceptable level of safety and quality as expired medical supplies were found in patient care areas available for patient use.

The findings were:
The facility policy entitled "Nursing Safety" dated 10/20/98 reflected "All equipment and supplies must be properly stored."

During a tour of the facility conducted on the morning of 2/14/12 in the company of staff member #21, the following expired medical supplies were found in available for patient use in the central supply room:
1) Ethilon 6-0 suture, 1 box of 12, expired 7/10.
2) Ethilon 6-0 suture, 1 box of 12, expired 7/11.
3) Ethilon 5-0 suture, 1 box of 12, expired 1/12.
In an interview with staff member #21on 2/14/12 at 10:40 am, she confirmed that the above listed medical supplies were expired and should have been removed.

During a tour of the Emergency Department at 2:15pm on 2/13/2012 with staff members #4 and #6, the following expired supplies were found available for patient use:
In the "2 Bed Emergency Room":
1) Sterile water, 1000 ml bottle, expired 3/11.
2) Sterile water, 1000 ml bottle, expired 9/11.
3) 0.45% Sodium Chloride, 1000 ml bottle, expired 11/11.
4) Quick Combo Pacing/Defibrillator Pad, Adult, expired 10/28/11.
5) Vacutainer blood collection set, x2, expired 1/12.
6) Green top lab tube, x2, expired 7/2011.
7) Blue top lab tube, x2, expired 5/11.
8) Red top lab tube, expired 3/11.
9) Purple top lab tube, expired 4/11.
In the "Trauma Room":
1) Green top lab tube x2, expired 7/11.
2) Blue top lab tube x2, expired 5/11.
3) Red top lab tube x2, expired 3/11.
4) Purple top lab tube x2, expired 4/11.
5) Luer lock expired 5/11.
In an interview the afternoon of 2/13/2012 with staff members #4 and #6, the above findings were confirmed.

Based on observation, documentation, and interviews with facility staff the facility failed to maintain a sanitary environment and to avoid sources and transmission of communicable diseases as several instances of inadequate cleaning were observed.

Findings included:
The facility policy entitled, "Sanitary Facilities and Controls" stated, "Monthly Cleaning Schedule A) Defrost freezers monthly, B) Clean ice machine monthly. The Weekly Cleaning Schedule, all areas listed below clean weekly: 10) ovens, 11) refrigerators/freezers, 12) pantry, 13) store room, 14) large clock, 15) all shelves, 16) mop room. The Daily Cleaning Schedule: 1) clean all counter tops, stove tops, food carts after each use; 2) wipe down refrigerators, ovens, canisters daily; 3) clean toaster, microwave, can opener after each use; 4) wipe all counter tops and tables in snack area after each meal served; 5) clean sinks after each meal; 6) clean ice chest daily; 7) take out trash when ? full or after each meal; 8) wash trash cans daily inside and out including lids; 9)sweep and mop floors daily and as needed."

The facility policy entitled, "Infection Control Responsibilities, Housekeeping Department" stated, "1. All patient areas should be cleaned daily. This includes all horizontal surfaces except the ceilings."

The facility policy entitled, "Nursing Safety" stated "Purpose: To provide as safe as possible environment for all patients, visitors and employees." The policy stated, "3. All department employees shall report defective equipment, unsafe conditions, acts, or safety hazards to supervisor." Further review revealed, "General Patient Safety: 1. Keep patient rooms clean and tidy at all times."

During a tour of the facility on 2/13/2012 and 2/152012, the following was observed:
1) During a tour of the kitchen with staff member #7, the cleaning logs were reviewed and the following was revealed: the monthly cleaning which included defrosting freezers and cleaning the ice machine was not done on 12/2011 and 1/2012. Weekly cleaning which included cleaning of ovens, refrigerators/freezers, pantry, store room, large clock, all shelves, and mop room was not done on the first week of 2/2012. Daily cleaning which included clean all counter tops, stove tops, food carts; wipe down refrigerators, ovens and canisters; clean toaster, microwave, can opener; wipe all countertops and tables; clean sinks; clean ice chest; take out trash; and sweep and mop floors was not done on 12/9/11, 12/23/11, 12/24/11, and 12/25/11. In an interview with staff member #7 on 2/13/12 at 2:50 pm, she confirmed that the monthly, weekly and daily cleaning schedules were not completed on the dates noted above.

2) During a tour of the laboratory with staff member #3 the following was revealed: an air vent in the back hallway had a thick layer of visible dust and an unknown substance had leaked from the ceiling down the wall in multiple streaks above a doorway. In an interview with staff member #3 at 4:45pm on 2/13/2012, the dust on the vent and leak from the ceiling above the doorway were confirmed.

3) During a tour of the physical therapy department with staff members #4 and #24, the following was observed: a blue exam table had a tear at the head of the bed with approximately 8 tears ranging from a ? inch to 1 ? inches exposing the netting and foam underneath. The tears made cleaning impossible and cross contamination likely. The base of the Vigor Gym had the black edges hanging off in areas and other areas of the base were taped exposing the wood underneath. In an interview with staff members #4 and #24 at 9:55am on 2/14/2012, the torn blue exam table and the damaged Vigor Gym were confirmed.