HospitalInspections.org

Based on review of documentation and staff interview, the Governing Body failed to ensure they assumed full legal responsibility for determining, implementing and monitoring policies governing the CAH's total operation and that those policies were administered so as to provide quality health care in a safe environment.

Findings were:

In review of the facility Emergency Preparedness Plan, it was determined that the Emergency Preparedness Plan was not reviewed and updated at least every two years.

Form titled, "Concho County Hospital Maintenance Fire Safety Policy and Procedure Manual" stated, "This manual has been reviewed and approved by: Department Head signed 6/26/19, CEO signed 8/28/2019, and President of the Board of Directors signed 8/27/2019."

In review of the Medical Staff Bylaws, it was determined that the Bylaws had not been reviewed or approved since August 28, 2019.

In an interview with staff #2 on the afternoon of September 29, 2021 staff #1 stated, "I know that we recently sent several manuals to the Governing Board for review, but I am unable to locate the documentation that has the updated review date for Bylaws of the Medical Staff."

During a tour of the facility, the following was observed:

*Two unsecured oxygen tanks stored in a storage area in ER Suite #1.
*Blanket warmer Temperature log missing upper and lower temperatures and signature of staff monitoring the temperatures for the dates of September 6th and 26th 2021.
*Missing Crash Cart checks for dayshift on September 6th, 7th, and 10th, 2021. *Missing Crash Cart checks for nightshift on September 10, 2021.

Policy F5 Oxygen Storage stated in part, "...4. Each oxygen tank is secured in a designated cabinet. Cylinders are securely fastened with a chain at all times in an upright position. The area is free from clutter and easily accessible..."

In review of staff #5 credentialing file, it was determined that staff #5 was delinquent in renewing their Basic Life Support and Advanced Cardiovascular Life Support, both with a renewal date of January 2021.

The above findings were confirmed with staff #1 and staff #2 on the afternoon of September 29, 2021.

Based on review of documentation and staff interview, the facility failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least every two years.

Findings were:

In review of the facility Emergency Preparedness Plan, it was determined that the Emergency Preparedness Plan was not reviewed and updated at least every two years.

Form titled, "Concho County Hospital Maintenance Fire Safety Policy and Procedure Manual" stated, "This manual has been reviewed and approved by: Department Head signed 6/26/19, CEO signed 8/28/2019, and President of the Board of Directors signed 8/27/2019."

The above findings were confirmed with staff #2 on the afternoon of September 29, 2021.