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Based on observation and interview with staff, the hospital failed to ensure that all patient care equipment is maintained in safe operating condition, as the Hydrocollators in the offsite physical therapy locations were not monitored for safe temperatures prior to use by patients.

Findings were:

A tour of the offsite physical therapy locations of the hospital was conducted the morning of 1/7/14. The offsite location at 505 North Main in Sweeny, TX, and the location at 301 Dance Drive in West Columbia, TX, both utilize a Hydrocollator, which is a liquid heating device that is used to heat and store hot packs for therapeutic uses. According to the manufacturer, the optimum safe temperature is 160 - 166 degrees F, and should be measured prior to using with patients. There was no temperature log or thermometer with which to measure temperature prior to use with patients.

In an in-person interview conducted the morning of 1/7/14 at the physical therapy site on north Main in Sweeny, Staff # 6, the office personnel at the location, verified the finding that the Hydrocollator did not have a record of temperatures prior to utilization by patients. Additionally, Staff # 8, the physical therapist at the Dance Street location in West Columbia, acknowledged that there was no record of temperature verification for their Hydrocollator prior to patient use.

Based on observation, review of documentation, and interview with staff, the facility failed to have policies to ensure that outdated drugs and biologicals were not available for patient use; expired medications and sterile supplies were found in 2 areas of the facility.

Findings were:

A tour of the facility was conducted the morning of 1/7/2014. In the outpatient wound care center, a bottle of sterile water was found which had expired in 2011; 5 sterile wound dressings, 5 boxes of gloves, and a box of betadine swabs were found which had expired in 2012. Also found was a can of topical spray which had expired in 6/2013; 2 boxes of gloves; 2 boxes of culture swabs; 2 central line kits; and 30 sterile dressings were found which had expired in 2013. All items were found available for patient use. In an in-person interview conducted at the time of the tour, Staff #8, Hyperbaric Oxygen Wound Care RN, verified the expiration dates on the items found on the unit.
Also found during the tour of the facility were 10 intravenous catheters which had expired in 2013. These were stored on the emergency crash cart located in the medical surgical area at the nursing station. This finding was confirmed by RN Charge Nurse, Staff #2, during the tour of the unit.
Review of facility policies and procedures revealed that there was no policy concerning monitoring patient care areas for outdated drugs and biologicals. An in-person interview was held with Staff #1, the facility Director of Nursing, the afternoon of 1/7/14. Staff #1 acknowledged that the facility did not have policies regarding removing outdated medications and sterile supplies from patient care areas.

This requirement is not met as evidenced by:
Based on observation, interviews with facility staff, and review of documentation; the facility failed to ensure that drugs and biologicals are stored in accordance with State and Federal requirements. Observed two anesthetic carts in the surgery department unlocked and without direct monitoring.

Findings were:
A tour of the facility was conducted on the afternoon of 1/7/14. The anesthesia carts in the surgical procedures room and one operating room were observed unlocked. The anesthesia carts contained controlled drugs such as Propofol: a controlled drug used as a general anesthetic. The two operating rooms were observed unlocked and not directly monitored by the surgical staff.

An in-person interview was conducted at the time of the tour with Staff #7, confirmed the above anesthesia carts were unlocked.

Review of the pharmacy policy titled: Controlled Drugs: Anesthesia Documentation, Storage, states " Controlled drugs shall be stored in a locked cabinet within the surgical suite. "

Based on observation, interviews with facility staff, and review of documentation; the facility failed to provide complete sterilization of surgical instruments. Observed 20 closed and 7 hinged instruments in closed and hinged positions in the sterile supply room which had been sterilized, packaged, and were available for patient use.

Findings were:

A tour of the facility was conducted on the afternoon of 1/7/14. In the sterile supply room, 20 closed and 7 hinged instruments were observed in closed and hinged positions which had been sterilized, packaged and were available for patient use.

An in-person interview was conducted at the time of the tour with Staff #8, Surgical Technologist, confirmed the above surgical instruments had been sterilized and packaged in the closed and hinged position.

Review of the surgery facility policy manual included the manufacturers guide entitled, General Surgical Instrument Sterilization Guide, states that " all ring handled instruments must be autoclaved in the fully open position to prevent cracking of the box lock.
The Centers for Disease Control and Prevention (CDC) article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf, states on page 74 that hinged instruments and instruments that close should be opened during the process of sterilization.

Based on review of records and interview with staff, the facility failed to ensure that Swing Bed patients were informed of their right to choose a personal attending physician for 5 of 5 applicable patients whose records were reviewed.

Findings were:

Review of the records of patients #3-#7 revealed that none of the individuals were informed of their right to choose a personal attending physician. This finding was confirmed by staff #1, the facility Director of Nursing during an interview conducted the afternoon of 1/7/14.

Based on review of records and interview with staff, the facility failed to ensure that Swing Bed patients were informed of their right to perform or refuse to perform work for the facility for 5 of 5 applicable patients whose records were reviewed.

Findings were:

Review of the records of patients #3-#7 revealed that none of the individuals were informed of their right to refuse to perform services or perform services for the facility if he or she chooses. (This right also includes paramaters for performing servies if the patient chooses, and these items were not included in the patients' medical records.) None of the patients performed services for the facility. This finding was confirmed by staff #1, the facility Director of Nursing during an interview conducted the afternoon of 1/7/14.

Based on review of documentation, and interview of staff # 1, the swing bed facility failed to inform the resident of right to privacy in written communication, as review of 5 of 5 swing medical records did not contain right to privacy in written communication.
Findings
Review of 5 of 5 (# 3-7), swing bed resident medical records, did not contain the right to privacy in written communication, receive and send mail.
In an interview on the afternoon of 1/7/2014 the finding were confirmed by staff #1.

Based on review of documentation, and interview with staff # 1, the swing bed facility failed to inform the patient of personal property rights; review of 5 of 5 swing bed patient medical records did not contain rights of personal property.
Findings
Review of 5 of 5 (# 3-7), swing bed patient medical records, did not contain the rights of personal property.
In an interview on the afternoon of 1/7/2014 the finding were confirmed by staff #1.

Based on review of documentation, and an interview with staff # 1, the swing bed facility failed to inform the patient of rights of married couples; review of 5 of 5 swing bed patients medical records did not contain rights of married couples.
Findings
Review of 5 of 5 (# 3-7), swing bed patients medical records did not contain the rights of married couples.
In an interview on the afternoon of 1/7/2014 the finding were confirmed by staff #1.