HospitalInspections.org

Based on interview and record review, the facility failed to maintain a list of physicians who were on-call for duty to provide further evaluation and/or treatment in that, for the last 6 of 6 months (07/01/16 to 12/31/16) there was no list of physicians on-call.

Findings included:

A tour to the emergency department (ED) was conducted on 12/05/16 at 1:30 PM with Personnel #12. Personnel #12 was asked to provide a list of ED on-call physicians from 07/2016 to 12/2016. Personnel #12 informed the surveyor that the hospital did not have an on-call list because the staff knew it was only Physician #9 (General Surgery) who was always on-call, every day for 12 months.

The facility's "Rules and Regulations of the Medical Staff" reviewed 11/04/16 required "Article VIII Emergency Care...11. C. A call roster will be posted daily and "Emergency On Call physicians must be present or available for consultation by telephone and be physically able to reach the hospital within 30 minutes...D. Medical Staff members shall rotate on the Emergency On Call roster..."

Based on interview and record review the hospital failed to ensure a complete copy of the Patient Rights and Responsibilities was posted in the hospital's main lobby and was included in the patient's admission packet. The process for resolution of patient complaints concerning their quality of care was not included. The hospital's average daily census was 5.

Findings included:

A tour of the hospital's main lobby on 12/05/16 at 12:15 PM revealed the hospital's Patient Rights and Responsibilities was posted, but did not contain the information about resolution of patient complaints.

A review of the patient's admission packet on the afternoon of 12/05/16 revealed information regarding the resolution of patient complaints was not included.

During an interview with Personnel #72 on 12/07/16 at 11:20 AM she confirmed the information regarding resolution of patient complaints was part of the Patient Rights and Responsibilities.

A review of the hospital's Patient Rights and Responsibilities with a review date of 10/30/14 reflected the following, "...An issue can be addressed most promptly by speaking with your nurse or another health care professional involved in your care. If you feel that your issue is not being resolved or being addressed by the hospital, you may also phone or write: The Texas Department of State Health Services at: Complaint Hotline: 1 (888) 973-0022 Fax: (512) 834-6663...Texas Department of State Health Services P O Box 149347 Austin, TX 78714-9347 or 1100 West 49th Street Austin, Texas 78756..."

Based on interview and record review, the hospital failed to inform 1 of 1 patient, Patient #29 the right to make informed decisions, in that Patient #29 was allowed to sign the anesthesia informed consent without discussing his condition, alternative forms of anesthesia and treatment, risks, benefits, and side effects of the alternatives to anesthesia. Patient #29 received a regional anesthesia and nerve block to the left shoulder prior to anesthesia preoperative evaluation on 12/06/16.

Findings included:

On 12/06/16 at 9:37 AM the surveyor visited Patient #29 in the preoperative area. Patient #29 informed the surveyor that he received a "block" in his left shoulder. Review of the patient's medical record indicated an anesthesia informed consent that only had the patient's signature (dated and timed 12/06/16 at 8:35 AM) and a witness signature. The informed consent did not reflect what type of anesthesia was expected to be used. There was no anesthesia preoperative evaluation.

In an interview on 12/06/16 at 10:21 AM Personnel #59 was informed of the above findings. She confirmed the findings and stated she would visit Patient #29 in the preoperative area.

Facility policy ADMIN.03.03 "Informed Consent for Procedures" reviewed 08/15 required "3...the patient...must be given the opportunity to give an "informed consent" prior to administration of anesthesia..."

Facility policy AN 01.04 "Basic guidelines of Anesthesia Care" reviewed 12/15 required "1...A. Pre-anesthetic evaluation...performed by a physician, CRNA...The person performing the evaluation should do the following: 1. Review chart. 2. Interview the patient to...Discuss medical, surgical...and drug history...Perform examination that would provide information...in decisions regarding risk and management..."

Based on observation, record review and interview, the hospital facility failed to ensure care in a safe setting by the contracted dialysis provider testing the product water immediately prior to each patient shift (treatment) to determine the patient's dialysis treatment would be safe from chlorine (bleach), in that,
10 of 10 dialysis treatments (10/13/16, 10/14/16, 10/17/16, 10/19/16, 10/21/16, 10/24/16, 10/26/16, 10/28/16, 10/29/16, and 10/31/16) occurring since July 2016 were completed after the expiration date of the chlorine test strips currently available for use to determine the patient's safe dialysis treatment.
Findings included
During two tours in the dialysis treatment and storage rooms on 12/06/16 ending at 2:45 PM, the surveyor found expired chlorine testing strips labeled, "RPC Ultra Low Total Chlorine Test Strips S402 Use by: July 2016" available for use in the dialysis treatment room. Personnel #3 was informed of the expired chlorine testing strips. Personnel #3 was asked to see the chlorine testing strips available for use. Personnel #3 did not find any other available chlorine testing strips or mechanism available to determine the patient's safe dialysis treatment in the dialysis treatment or storage rooms.
The Monthly Treatment Log reflected 10 treatments had been completed since the expiration date of the chlorine testing strips. Those treatments were provided on 10/13/16, 10/14/16, 10/17/16, 10/19/16, 10/21/16, 10/24/16, 10/26/16, 10/28/16, 10/29/16, and 10/31/16.
There was no expiration date documented with the Chlorine testing to ensure the 10 completed dialysis treatments were performed safely.
During an interview on 12/06/16 ending at 2:45 PM, Personnel #3 was informed of the expired chlorine strips found on the first tour of the dialysis treatment room. Personnel #3 examined the expiration date of the strips and confirmed the strips were expired. Personnel #3 accompanied the surveyor to the dialysis treatment and storage rooms. Personnel #3 was asked to see the chlorine testing strips available for use. Personnel #3 did not find any other available chlorine testing strips or mechanism available to determine the patient's safe dialysis treatment in the dialysis treatment or storage rooms.
The dialysis provider's 7/11/16, "Safety Checks Pretreatment and Monitoring" policy required, "Safety checks will ensure that the treatment has started and is progressing safely...Dialysis treatment records are the primary means of documenting the daily care of hemodialysis patients. These records should contain complete information about the treatment...machine parameters and safety checks...Pretreatment...Check machine bleach residual... "

Based on record review and interview, the facility failed to ensure the quality program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement), in that,

the facility's 2015-2016 quality program did not include the dialysis service review of quality, safe care provided to dialysis patients treated.

Findings included

The 2015-2016 quality program did not include the dialysis service review of quality, safe care provided to the dialysis patients treated.

During an interview on 12/06/16 at 11:29 AM, Personnel #3 was asked for the the dialysis service quality reported to Quality. Personnel #3 stated, "That has not been reported."

Based on record review and interview, the facility failed to ensure a registered nurse (RN) supervised and evaluated the care, in that,
6 of 10 dialysis treatments (10/13/16, 10/14/16, 10/17/16, 10/19/16, 10/21/16, and 10/28/16) reviewed did not have complete dialysis orders and there was no documentation a registered nurse verified the patient's order with the patient's physician prior to treating the patient.
Findings included
Patient #15's 10/28/16 dialysis treatment order did not designate a treatment length, post dialysis care, and medication packing for the patient's dialysis catheter. There was no documentation a registered nurse verified the patient's order with the patient's physician prior to treating the patient.
Patient #16's 10/13/16 and 10/14/16 dialysis treatment order did not designate post dialysis care and medication packing for the patient's dialysis catheter. There was no documentation a registered nurse verified the patient's order with the patient's physician prior to treating the patient.
Patient #16's 10/17/16, 10/19/16, and 10/21/16 dialysis treatment order did not designate a treatment length, post dialysis care, and medication packing for the patient's dialysis catheter. There was no documentation a registered nurse verified the patient's order with the patient's physician prior to treating the patient.
During an interview on 11/06/16 ending at 2:45 PM, Personnel #3 was informed of the above findings. Personnel #3 reviewed the patients' records and confirmed the findings.
The dialysis provider's 7/11/16, "Safety Checks Pretreatment and Monitoring" policy required, "Safety checks will ensure that the treatment has started and is progressing safely...Dialysis treatment records are the primary means of documenting the daily care of hemodialysis patients. These records should contain complete information about the treatment...vascular access in use...machine parameters...dialysis prescription delivered...length of treatment...medications given..."

Based on observation, interview, and record review, the hospital did not ensure that 1 of 1 personnel (Personnel #56) wore a dosimeter during a procedure on 12/06/16. This particular monitoring device measured doses of radiation that an individual was exposed to.

Findings included:

On 12/06/16 at 10:30 AM Personnel #56 was observed transferring Patient #31 from the restricted area to the postoperative unit. Personnel #56 was wearing a lead apron. She was asked for her title. Personnel #56 replied she was a registered nurse (RN) and performed circulating duties during Patient #31's pain management procedure (right sacro-iliac steroid injection). Personnel #56 was asked if she wore a dosimeter since the equipment used in the procedure emitted radiation particles. She replied she was not wearing a dosimeter during Patient #31's procedure.

In an interview on 12/06/16 at 3:30 PM Personnel #2 was informed of the above findings and confirmed that the RN should have worn a dosimeter.

Facility policy RAD.04.08 "Operating and Safety Procedures" revised 08/15 required "9. Personnel Monitoring Requirement: Any adult...must use an individual monitoring device such as dosimetry badge..."

Based on interview and record review the hospital failed to ensure that the test strip and temperature ranges were documented on 2 (12/2-3/16) of 5 days on the Dish Machine Sanitation Record.

Findings included:

During a tour of the kitchen on 12/06/16 between 10:30 and 11:00 AM the Dish Machine Sanitation Record was reviewed. The record was missing documentation of the test strips and the temperature for the dish machine on 12/02/16 and 12/03/16.

During the tour Personnel #7 accompanied the surveyor. She said the test strip and temperature results should have been documented on the above dates.

A review of the Food and Nutrition Services policy with a review date of 8/2016 reflected, "...All staff are required to document test strip range and temperature of dish machine on the sanitation record..."

Based on observation, interview, and record review the hospital failed to maintain an overall hospital environment in such a manner that the safety and well-being of patients is assured in that,

A. 1 of 2 ice machines, the Intensive Care Unit ice machine, did not have routine maintenance or cultures.

B. 1 of 1 decorative wall water fountain did not have routine maintenance or cultures.

Findings included

A. During a tour of the Intensive Care Unit on 12/06/16 at 2:20 PM, Personnel #12 was asked when the last time the ice machine had been cultured or had routine maintenance. Personnel #12 stated they were unsure when the last time the ice machine had been cultured, they had called for the ice machine to get routine maintenance since it had been a while since it had been used. Personnel #12 stated that Personnel #21 would have the records.

B. During a tour of the hospital on 12/07/16 at 9:30 AM, the surveyor observed a decorative wall water fountain hanging on the wall outside the Human Resources department with water running from the top to the bottom reservoir.

During an interview on 12/07/16 at 9:40 AM, Personnel #3 was asked for the maintenance and culture records for the ice machine in the Intensive Care Unit, Personnel #3 stated there were no records. Personnel #3 was asked for the policy and procedures for maintenance and cultures on the ice machine and none were forthcoming. Personnel #3 was asked for the maintenance and culture records for the wall water fountain. Personnel #3 stated they did not have any and she would have the fountain taken off the wall.

Based on observation, interview, and record review, the chief executive officer, medical staff, and director of nursing services failed to identify problems and/or addressed problems identified by the infection control officer or officers. They failed to implement successful corrective action plans in the affected problem areas, in that:

A. 2 of 4 healthcare providers (Personnel #8 and # 58) did not appropriately perform hand hygiene after taking off their gloves in operating room (OR) #2;

B. 3 of 5 healthcare providers (Personnel #4, #58, and #59) did not appropriately restrained their hair in the restrictive area;

C. 1 of 2 physicians (Physician #57) entered the postoperative unit with a mask hanging down on the neck;

D. 1 of 1 foam strap that fell on the floor was used by the tracer patient to support the neck and head during the surgical procedure;

E. 1 of 1 main door to the restricted area was kept opened the entire time the procedures were occurring on 12/06/16; and

F. 6 of 8 needle holders and 7 of 10 twin curved forceps were sterilized with their tips in a closed position. These instruments should have been sterilized in an opened position.

Findings included:

A. On 12/06/16 at 10:52 AM the following was observed:

A tracer patient, Patient #29 was followed to OR #2 for his scheduled procedure (left shoulder arthroscopy...rotator cuff repair...). Personnel #8 wore gloves and provided direct patient care. She then took off her gloves and donned on a pair of sterile gloves to disinfect Patient #29's surgical area. She did not appropriately performed hand hygiene prior to putting on the sterile gloves.

Personnel #58 was in OR #2 and assisted the anesthesia provider and the physician. She took off her soiled gloves and opened a sterile package. Personnel #58 did not appropriately perform hand hygiene after taking off their gloves.

B. On 12/06/16 at 9:25 AM Patient #29 was followed to the preoperative area. At 10:20 AM, Personnel #4 was observed entering the preoperative area from the restricted area. He was wearing a skull cap and the hair at the nape of the neck and side-burns were not restrained. Personnel #4 was asked where he came from. He replied that he was in the OR doing circulating duties for Patient #30's procedure (left carpal tunnel release). Personnel #4 was asked if the facility adhered to AORN (Association of periOperative Registered Nurses) Standards and Recommended Practices. He replied that they do.

During Patient #29's procedure on 12/06/16 at 10:52 AM, Personnel #58 and #59 did not restrain their hair. Multiple strands of hair was observed on the side and nape of the neck.

C. On 12/06/16 at 10:21 AM Physician #57 was observed entering the postoperative unit with a mask hanging down the neck. Personnel #2 informed the surveyor that she told Physician #57 to take off his mask.

D. On 12/06/16 at 11:07 AM a foam strap fell on the floor. Personnel #58 picked it up and handed it to the physician. The foam strap was used to support the neck and head of Patient #29 during the surgical procedure.

E. On 12/06/16 at 10:44 AM the surveyor with Personnel #2 went to the restricted area to wait for Patient #29 to be transported to OR #2. The surveyor observed that the only door to the restricted area was permanently opened. Personnel #2 was asked why the door could not be closed. Personnel #2 replied that they do not have a device that opened and shut the door but had planned to put the device early next year. Personnel #2 was asked how long they have performed surgeries with the door to the restricted area permanently opened. She replied about nine months.

F. During a tour of the sterile supply room on 12/06/16 at 11:35 AM with Personnel #2 and #55 the surveyor observed 6 needle holders and 7 twin curved forceps were sterilized with their tips in a closed position. The arrangement of these instruments had not allowed the point of the greatest bio-burden, to be directly exposed to the sterilizing agent, as their tips were in the closed position. These instruments were stored hanging by the wall. Personnel #2 and Personnel #55 confirmed the surveyor's observation.

In an interview on 12/06/16 at 3:30 PM, Personnel #2 was informed of the above findings and confirmed the findings. She confirmed that the facility adhered to AORN Standards and Recommended Practices and Centers for Disease Control and Prevention Guidelines (CDC).

Facility policy IC.01.06 "Hand Hygiene" reviewed 09/16 required "...Perform hand hygiene...after removing sterile or non-sterile gloves."

Facility policy SURG 01.04 "Attire for Surgical Services" reviewed 09/17/15 required "F. Masks...6. mask should not be hung around the neck or placed in pockets."

The AORN 2014 edition Recommendation IV, page 53 reflected "...All personnel should cover head and facial hair, including side-burns and the nape of the neck, when in the semirestricted and restricted areas ...IV.a ...Head coverings designed to contain hair and scalp skin will minimize microbial dispersal. Skull caps may fail to contain the side hair above and in front of the ears and hair at the nape of the neck ..."

The AORN 2014 edition Recommendation III page 120 reflected "2. Doors to operating and procedure rooms should be closed except movement of patients, personnel, supplies, and equipment...Leaving the door open can disrupt pressurization...increase airborne contamination."

The AORN 2014 edition Recommendation XII, page 548 reflected "XII.c. Instruments with hinges should be opened ...be disassembled...for sterilization...Sterilization occurs only on surfaces that have direct contact with the sterilant...XII.c.1. Instruments should be kept in the open and unlocked position using instrument stringers, racks, or instrument pegs designed to contain instruments..."

Based on interview and record review, the hospital's qualified member of the medical staff in the emergency services did not ensure that 1 of 2 emergency equipment in the emergency department was periodically tested as required.

Findings included:

The "Crash Cart Guidelines" undated required daily checks for the following: "1. Check contents on top of cart. Check expiration dates of electrodes and Quick-combo pads. 2. Inspect power source...3. Press on and test at 30 joules. 4. Verify lock number: All lock numbers must be documented..."

During a tour of the Emergency Department (ED) with Personnel #12 on 12/05/16 at 1:30 PM the surveyor observed the emergency cart located in ED room #2. The emergency cart was not regularly tested according to the log book, thus was not ready for patient use in an emergency. Personnel #12 was asked how often the staff inspected the emergency cart. He replied every shift (7 AM and 7 PM).

On the following dates the emergency cart that contained a defibrillator, portable suction machine, and oxygen tank was not inspected:

- 07/16/16 (7 AM), 07/21/16 (7 PM), and 07/24/16 (7 AM)
- 08/07/16 (7 AM), 08/21/16 (7 AM), and 08/24/16 (7 PM)
- 09/01/16 (7 PM), 09/15/16 (7 PM), 09/20/16 (7 AM), 09/21/16 (7 AM), and 09/26/16 (7 PM)
- 10/19/16 (7 AM), 10/225/16 at (7 AM), and 10/30/16 (7 PM)
- 11/14/16 (7 AM)
- 12/03/16 (7 PM)

On 12/05/16 at 1:40 PM Personnel #12 confirmed the surveyor's findings.

Facility policy CL.03.19 "Crash Cart-Checking Procedures..." effective 02/16 required "Emergency Crash Carts will be maintained...and checked at the beginning of each shift and after each use. The defibrillators will be checked and tested during this process."