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1307 CLEVELAND STREET

FRIONA, TX 79035

COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS

Tag No.: C0812

Based on interview and inspection, it was determined that the facility failed to have required signage poster in its intake area per state regulations. Further, it was found that the facility did not always follow it's own policy in regard to reporting animal bites.

Findings were:

The Emergency Department Posting Requirement of Human Trafficking, a result of House Bill 2552, 85th Legislature, Regular Session, is the newest signage requirement. The law requires hospital emergency departments to display signs in English and Spanish notifying individuals that no one may force a person to have an abortion and also clarifying that it is illegal for someone to force an individual to engage in sexual acts. The signs also must include a telephone number to an organization that assists victims of human trafficking or forced abortions. In addition, hospitals licensed under Chapter 241 of the Health & Safety Code must post these signs in all patient rooms and restrooms in their emergency departments as of Jan. 1, 2018.

Tour of the Emergency Department area on 6/6/22 revealed no required signage concerning human trafficking. This was confirmed by the Director of Quality.

Facility policy entitled "Initial Treatment of Animal Bites" stated in part "All animal bites are to be reported to City or County law enforcement by the physician or Registered Nurse on duty."

On 5/7/22, patient # 4 was seen in the ED after being bitten by a dog. There is no documented evidence that the bite was reported to City or County Law enforcement.

The Director of Nurses confirmed the lack of notification to City or County law enforcement on 6/7/22.

MAINTENANCE

Tag No.: C0914

Based on observation and interview, it was determined that the physical plant was not always maintained appropriately.

Findings were:

Tour of the facility on June 6, 2022 revealed the following:

The radiology department had broken tile in back of the CT scanner and a broken ceiling tile above the machine.

The laboratory had stained ceiling tiles which indicated water leakage.

The Director of Nurses and the Director of Quality acknowledged the above damage during the tour on 6/6/22.

RECORDS SYSTEM

Tag No.: C1102

Based on record review and interview the facility failed to maintain a clinical records system in accordance with written policies and procedures the facility failed to ensure ensure that all verbal orders must be authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient.

Findings include:

Review of the "Parmer Medical Center Medical Staff Rules and Regulations
a. General Conduct of Care ...
3. ...All duly authorized persons accepting verbal orders shall repeat the verbal order back to the physician. The responsible medical staff member shall authenticate all such orders within 48 hours...
4. Verbal orders for medications are accepted only by personnel so designated within their sphere of competence, (licensed nurse, registered pharmacist, licensed respiratory therapist, licensed laboratory personnel, licensed radiology personnel and physical therapy) and are authenticated by the prescribing practitioner within 48 hours..."

Review of Patient # 6 medical record reflected th following STAT verbal orders entered and readback successfully on 5/18/22.
CBC Auto Diff
Comprehensive Metabolic Panel
Troponin T HS Gen 5
Routine Urinalysis
Chest X-Ray 1 view
EKG Nursing 12 Lean Rhythm
Myoglobin
IV 0.9% Sodium Chloride
Foley Catheter 14 FR
All above orders are pending physician signature on 6/7/22.

Review of Patient # 7 medical record reflected the following verbal orders entered and readback successfully on 1/4/22:
Remdesivir 100 mg in NS 100 times one dose
Lovenox inj 100mg/1ml 80 mg qday
Humulin-R (insulin REG) inj 100 units/1ml 15 Units times one dose
Fingerstick Blood Sugar
Humulin-R (insulin REG) inj 100 units/1ml Per Protocol
Combivent Respimat Inhaler 4g 1 puff Q6H
All above orders are pending physician signature on 6/7/22.

Staff # 7, Director of Nursing, verified the above findings.

INFECTION PREVENT SURVEIL & CONTROL OF HAIs

Tag No.: C1208

Based on observation, interview, and record review, the facility failed to provide a clean and sanitary environment to avoid sources and transmission of infection when disinfecting the blood glucose monitor.

Findings include:

During an interview, on the afternoon of 6/6/22, while touring the facility's Emergency Department, when asked how the facility disinfects the blood glucose monitor, Staff # 9, Emergency Department Technician stated, "We wipe it with the wipes between patients." When asked what the contact time for the wipes was, she replied "30 seconds."

During an interview, on the afternoon of 6/6/22, while touring the facility's Emergency Department, when asked what the contact time for the wipes used to disinfect the glucometer, Staff # 11, Licensed Vocational Nurse, stated, "one and a half minute."

During an interview, on the afternoon of 6/6/22, while touring the facility's Emergency Department, when asked what the contact time for the wipes used to disinfect the glucometer, Staff # 14, Registered Nurse, stated, "one minute."

Review of facility policy and procedure "Cleaning of Equipment", revised 10/10/16 reflects
1. To clean equipment after patient use using the approved Sani-cloth AF3 wipes, clean the areas with the sani-cloth(s) to remove all soiled areas. Area must be clean. After cleaning, use another sani-cloth to disinfect the areas. The contact time for Sani-cloth AF3 is 3 minutes ...
9. Blood Glucose monitoring devices should be cleansed and disinfected after each patient use ..."

Staff # 7, Director of Nursing, verified these findings.