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Based on observation, it was determined that the facility failed to ensure the safety of its patients in all patient areas.

Findings were:

The male and female restrooms located in the admissions area had no emergency pull cords. If a patient or family member fell in these restrooms, there would be no way to call for help. In 6 of 10 patient rooms, the emergency pull cords were found wound around the safety railing next to the toilet rendering them inoperable.

In the Patient Bathroom near the laboratory and the radiology department the call light cord was coiled with a rubber band approximately 4 feet above the level of the floor. This presents a safety risk as a patient that had fallen would not be able to reach the cord in an emergency.

During a tour of the facility the morning of 7/29/14 accompanied by the Administrator, the fire door between the conference room and the patient hallway was observed to be held open with a rubber door stop, which would render it ineffective during a fire alarm or event. This was acknowledged by the facility Administrator when observed.

In an interview with the RN Hospital Nurse Manager on 7/29/14 the lack of and inoperable emergency pull cords were acknowledged.

Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its patients and staff.

Findings were:

" OSHA/Bloodborne Pathogen Regulations Policy #138-030-060 " stated in part " The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. "

Review of Hospital Dietary Department policy titled, "Clean Work Areas", Date Issued 2/23/05, stated, in part, "It is the policy of Hansford County Hospital District to protect the health and safety of its Dietary patrons by keeping work areas clean ...C. Each employee should maintain a clean and safe working area at times.

Review of the Hospital Dietary Department policy titled, "Equipment Temperature Checks", Last reviewed 5/23/12, stated, in part, "The date and the initials of the person checking and recording the temperatures must be recorded in the temperature log ...If the temperatures are not in the acceptable range, the dietary manager must be notified ..."
Review of the Hospital Dietary Department policy titled, "Food Temperatures" last reviewed 5/23/12, stated, in part, "It is the policy of Hansford County Hospital District to perform food temperatures in order to maintain safe temperature levels in food prepared for patients, residents, and other customers."

Review of Hospital Respiratory Care Department policy titled, "Infection Control" issue date 12/26/2007 stated, in part, "It is the policy of Hansford County Hospital District that Respiratory Care Staff will adhere to guidelines for the prevention and control of infectious organisms ...
l. Visually soiled disposable and/or permanent equipment will be appropriately disposed of or replaced with clean equipment ..."

Facility policy entitled "Central Sterile Area and Equipment (Autoclave)" stated in part "The Central Sterile area is a designated room (Autoclave Room) located in the Central Supply Department. It shall be kept clean and free of any items other than those used for the purpose of sterilizing instruments.
1. Only authorized CS department personnel shall have access to the Autoclave Room.
2. The Autoclave Room will be kept clean and organized, with autoclaving supplies stored in the cabinets and drawers when not in use ....Once instruments are sterilized, they will be returned to their respective departments."
Tour of the facility the morning of 7/29/14, accompanied by Staff #3 revealed the following:

· In the Central Storage room, there were dirty, corrugated external shipping boxes on the shelves with supplies available for patient use, including egg crate mattresses, gauze, Kerlix, and other patient care items.

· Dead bugs in fluorescent lights in all areas of the hospital including the radiology department, patient treatment floor, the laundry area, the Emergency Department, the dishwashing area and over the serving line in the kitchen. This indicated improper maintenance of the facility.
· "Sterile" packs were found under the sink in the Autoclave Room. These supposedly sterile supplies had, according to the technician who operated the Autoclave, been there for several years. The packs were labeled with a date from 2004. Supplies stored under a sink are at risk for water damage and cross contamination. The Autoclave Technician admitted to the survey team that she had had no documented training on how to operate the autoclave.
· In the patient supply area, mailing boxes were noted to be on shelves next to opened patient supplies. This practice can lead to cross contamination.
· In the laundry room, several ceiling tiles were noted to be water damaged, indicating a water leak. The air conditioning vents over the washing machines and dryers were coated with rust and dust. The tiles surrounding the small load washing machine were broken and missing and the molding had pulled away from the walls. These deficits indicated improper maintenance of the area. Two uncovered laundry carts were also found in the laundry room. These carts were situated under soiled ceiling tiles which could contaminate the clean linens stored on the uncovered linen carts. There was raised dust, dirt and debris in the under sink cabinet.

· In the Laundry room, the floor near the back external door was wet and there were multiple wet sheets and towels on the floor to absorb the water leaking in from the outside. The weather stripping for the top of the external door was hanging down and not intact. In an interview with Staff #7, Laundry Worker, she stated that there had been a leak for some time.
· In the employee dining room next to the hospital kitchen, there was a refrigerator/freezer which contained items for patient use. The refrigerator/freezer was in need of cleaning as there were orange drips inside the freezer and old dried food pieces in the base of the refrigerator. The door seals for the freezer and the refrigerator were in need of cleaning as they were black with what appeared to be mildew. There was no temperature log for the refrigerator or freezer, so there was no way to determine that food products were maintained at a safe temperature.

· In the Housekeeping closet, there was a raised layer of dust and a dead cricket and other bugs on an open bug sticky trap on the floor underneath the housekeeping supplies.
· In the kitchen, above the food prep area, there was a greasy dust coating on the ceiling tiles. On the ceiling tiles next to the wall, there was dust hanging from the ceiling.
· In the kitchen on the food prep table, there were white binder notebooks which were sticky and dirty. The drawers on the food prep table were in need of cleaning, and there were 3 chipped rubber spatulas in the drawer, which could not be properly cleaned; there was a glass loaf pan in the drawer which was greasy and dirty with drips which was used to store measuring spoons. There was a measuring spoon set which was dirty with a greasy substance and dried food, a rusted metal cookie cutter, a rusted oven thermometer which was dirty with dried food, a screwdriver, shelving brackets, and a metal screw in the utensil drawer, all available for patient food preparation. This presents a risk for cross contamination.
· In the kitchen, the large industrial mixer had food drips on the side, rust on the stem, and a greasy film on the mixer stand. There was a refrigerator which had a layer of greasy dust on top.
· In the kitchen, 3 opened and unlabeled milk containers were found in the refrigerator. The air filter on the ice machine was dusty as were the filters on refrigerator units. Tiles under the hand washing sink appeared to be disintegrating and had a sand-like appearance. In the dishwashing room, dust was noted on the air conditioning vents and on the fluorescent light fixtures on the ceiling. There was no thermometer available on the food line to measure food temperature.
· In the food storage area, 3 bins of potatoes were found under shelves of clean pots and pans. Several rotten potatoes were noted in the plastic bin containing small red potatoes. In the dry food storage area, several boxes of liquid nutritional supplement were stacked on the floor. Brown liquid was observed to be leaking onto the floor from one of these cartons. A large bin of individual cereal was also found in the food storage area. These individual cereals were not labeled with expiration dates. There was a gallon plastic container containing granola which was labeled opened 3/24/14, use by 4/24/14, available for use in food preparation. There was a 6 lb, 9 oz. dented can of apple pie filing. Staff #6, Dietary Manager stated that dented cans should not be in the food supply area. There were 2 gallon zip-lock baggies of noodles with no dated opened or use by date. There was a baggie of fruit punch mix labeled use by 7/14/14 and a baggie of powdered sugar dated 4/7/14, which Staff #6 stated should have been thrown away.
· In the dishwashing room, the fluorescent lights and the ceiling vents were coated with a raised layer of greasy dust.
· In the food serving line, the surveyor requested a food thermometer to check food temperatures. Staff #6, Dietary Manager went to his office to look for a food thermometer, then stated he didn't find one in his office. He returned to the kitchen and looked in four different utensil drawers in the food prep tables and was unable to find a food thermometer. A staff member was sent to the adjoining nursing home to obtain a food thermometer. There was no food thermometer in the kitchen to measure food temperatures. The use of a food thermometer is necessary to ensure that foods are cooked to a safe internal temperature to destroy any harmful bacteria that may be in the food and to prevent food-borne illness.
· In the food serving line, available for consumption, there was an opened 12 ounce bottle of mayonnaise with a use by date of 7/24/14, an opened 23 ounce bottle jar of mayonnaise that was not labeled with an opened or use by date, and a partially empty 20 ounce bottle of ketchup which was not labeled with an opened or use by date.
· In the walk in freezer in the kitchen, there was a bag of enchiladas which had a use by date of 7/20/14, a gallon zip lock bag of pork chops with a use by date of 7/28, and a deep pan of chili, which was only partially covered with foil and a use by date of 7/9/14. All the above food were available for patient meals.
· Review of the temperature checks form for the refrigerators and freezers revealed a column for the date, and a column for the temperatures to be recorded. There were no acceptable temperature ranges listed on the form and no instructions for staff for actions to log or to take if the temperatures were out of range; there was no space on the form for initials of the person checking and recording the temperatures, per policy. Staff #6 Dietary Manager acknowledged that the instructions were not on the form and not posted in the kitchen available for the staff.
· The Negative Pressure Room had 4 small tears in the mattress which made cleaning impossible and cross contamination likely. A spider web was found on the suction machine which indicated inadequate cleaning of the area. One ceiling tile in the nurses' station had a 3 inch by 6 inch hole. This hole in the ceiling tile could allow access of vectors into the facility. There was a bedside commode in the patient shower in need of cleaning, as there was a black substance adhered to the legs of the commode stand.
· In the Patient Hallway housekeeping room, there was a mop standing in approximately 2 inches of dirty water in a mop bucket.
· In the Nursing Station, the following was observed:
· There were 10 cases of 1000 ml normal saline IV bags stored on the floor in a closet.
· In the refrigerator, there was a vial of Rocuronium which expired on 3/14.
· The under sink cabinet was in need of cleaning as there was dust and raised debris, a gallon of molasses which had been opened and had sticky molasses dripped down the sides of the bottle. There was a 1.96 lbs box of dried milk which was covered in dust. There was an open cardboard box labeled "medication spoons" which contained hundreds of small plastic spoon. Some of the spoons were in an opened gallon ziplock bag, exposed to the dust under the cabinet. Supplies stored under a sink are at risk for water damage and cross contamination.
· In the Emergency Treatment Room, the small blue bins that held individual supplies were dirty. There was evidence of a water leak under the sink which could contaminate the supplies stored there. There was high horizontal dust on top of machinery and the stool that the physician used was torn. These tears made cleaning of the stool impossible. There was a layer of dust on the suction canister, and a layer of dust on the blanket warmer. The faucet at the hand washing sink was leaking and had been leaking for some time as there was a layer of build-up around the faucet. The cabinet floor underneath the sink was moist and there were blackened areas and raised dust and dirt, indicated moisture underneath the sink. There were supplies stored underneath the sink, including a bucket with metal utensils. Supplies stored under a sink are at risk for water damage and cross contamination. The moist environment presents a risk for bacterial growth and cross contamination.
· In Emergency Bays 1 and 2, there was high horizontal dust and 1 water stained ceiling tile which indicated improper maintenance of the area.
· In the Computerized tomography room, a grasshopper was noted on the wall and bugs were noted in all of the light fixtures. An uncovered wedge pillow was stored on the floor and the plastic covering on the CT bed was stained. An unloaded shipping box was observed on the floor behind the CT machine. There was used extension tubing on the oxygen tank. The Director of Radiology stated that the tubing was used on all of the patients that required oxygen while having CT scans.
· The radiology hallway was damaged with missing tiles and strips along the wall pulling from the floor. The floor appeared dirty and the double doors leading outside needed weather stripping. This open space could allow vectors access into the facility.
· In the Respiratory Therapy Department, there were water damaged cardboard storage boxes, containing patient care items available for patient use, including infant O2 sensors, O2 cannulas, and nebulizer tubes.
· In the Laboratory, in the phlebotomy tray, there were 2 drips of blood on a newborn heel stick lancet, available for use, and there was a plastic cup that had 2 blood stains. When asked Staff #17, Med Tech, stated that the cup was for "trash". The presence of blood in the phlebotomy tray, particularly on patient use items, presents a risk for cross contamination. Staff #17 confirmed the blood drips on the newborn lancet and removed it from the phlebotomy tray. There was a ceiling vent cover that was missing in the laboratory.
In an interview with the RN Hospital Nurse Manager, Staff #3 and the Staff #5, Plant Operations Manager on 7/29/14, the above infection control issues were confirmed.
· A portable air conditioning unit was found in the locked Medication Room immediately adjacent to the Nurse's Station. This portable air conditioning unit had been in use in this room since April 2013. This unit blew cool air into the room containing the electronic medication administration system, potentially preventing overheating of the electronic medication system. When staff member #5 was asked how often and who cleaned the air filter and emptied the water tank collector, he was unaware that the portable air conditioner had these two items and stated "no one was doing this routine maintenance". Additionally, staff members #2 and #3 were not aware that the filters in the air conditioning units required cleaning, along with water tank collector.
· This portable unit did not have the diffuser and hose connected to outside exhaust.

" ...LG PORTABLE AIR CONDITIONER
USER ' S GUIDE & INSTALLATION INSTRUCTIONS

...BASIC SAFETY PRECAUTIONS
This air conditioner is designed for normal household use. Do not use for cooling pets, foods, precision machinery, or art objects.
· Do not drink the water from the drain pan. Dispose of it properly outdoors or down the drain.
· Do not operate air conditioner without the filter securely in place. Operation without the filter could damage the unit.
· Clean the filter every two weeks, or more often if needed ...
...CLEANING THE AIR FILTER
The air filter should be cleaned every two weeks; depending on indoor air quality, more frequent cleaning may be needed. A dirty air filter will decrease airflow and reduce efficiency ...

...EMPTYING THE WATER COLLECTION TANK
Using the bottom drain port
When the internal water collection tank is full, FL will appear in the display and the air conditioner will turn off until the tank is emptied. Unplug the air conditioner, disconnect the exhaust hose from the back, and move the air conditioner to a suitable drain location or outdoors. You may also place a pan under the drain that will hold up to 1 quart of water. Remove the drain cap from the drain outlet. Once the water collection tank is drained, reinstall the drain cap, making sure it is on securely. Place the air conditioner in the desired location, reconnect the exhaust hose, and plug in the air conditioner ...
...Using the upper drain port
When the internal water collection tank is full. FL will appear in the display and the air conditioner will turn off until the tank is emptied. Place a suitable bucket under the upper drain port. Remove the drain cap. Press the Auto Clean button. Wait till water is drained out completely. Replace the cap, make sure it is on securely.
Reset your settings ...

In an interview with staff # 1, #2, # 3, and #5 on July 30, 2014 the absence of maintenance and documentation of this portable air conditioning unit was acknowledged.

Based on review of meeting minutes, state requirements for nurse staffing committee meetings and reports, and staff interview, the governing body failed to ensure that the Nurse Staffing Committee met on a quarterly basis and provided reports to the governing body on at least a semiannual basis.

Findings included:

Review of 25 Texas Administrative Code 133.41(o)(1)(F) stated, "The hospital shall establish a nurse staffing committee as a standing committee of the hospital ...
(iii) The committee shall meet at least quarterly ...
(iv) The responsibilities of the committee shall be to: ...
(V) submit to the hospital's governing body, at least semiannually, a report on nurse staffing and patient care outcomes, including the committee's evaluation of the effectiveness of the official nurse services staffing plan and aggregate variations between the staffing plan and actual staffing.

Review of Nurse Staffing Committee meeting minutes for the past year provided to the surveyor reflect meetings held on July 23, 2013, November 13, 2013, and June 5, 2014. In an interview with Staff #2 and Staff #3 the afternoon of 7/30/14 in the facility conference room, they confirmed that quarterly meetings of the Nurse Staffing Committee had not been held.

Review of Governing Body meeting minutes for the past year provided to the surveyor reflect that the Hospital Nurse Staffing Plan was reviewed and approved by the Hansford County Hospital District Board on November 20, 2013. Review of subsequent board meeting minutes revealed no documented evidence of a report to the Governing Body of nurse staffing and patient care outcomes, including the committee's evaluation of the effectiveness of the official nurse services staffing plan.

The above was confirmed in an interview with Staff #2 and Staff #3 the afternoon of 7/30/14 in the facility conference room.

Based on review of documentation, it was determined that the facility failed to conduct an annual review of its policies and procedures.

Findings were:

Policy and procedure manuals for the following departments had not been reviewed since 2012:

· Administrative Policies and Procedures
· Nursing
· Information Technology.
· Infection Control
· Dietary
· Radiology,
· Medical Records,
· Human Resources,
· Pharmacy,
· Physical Therapy

In an interview with the Chief Executive Officer on 7/29/14, it was confirmed that the facility had not reviewed its policies since 2012.

Review of documentation revealed that the facility ' s medical staff failed to authenticate verbal orders in a timely manner.

Findings were:
· Patient # 11 had a verbal order written by a nurse which had no medical staff authentication at all.
· Patient # 13 had a verbal order written by a nurse which had no medical staff authentication at all.

In an interview with staff #2 and #3 on July 30, 2014 the absence of documentation was acknowledged.

Based on review of documentation, it was determined that the facility failed to maintain complete medical records.

Findings were:
· Patient #25 had no nursing care plan present for admission of 4/11/2014.
· Patient #27 had no nursing care plan present for admission of 4/10/2014.
· Patient #35 had no nursing care plan present for admission of 6/17/14.
· Patient #12 had no nursing care plan present for admission of 3/25/2014.
· Patient #11 had no nursing care plan present for admission of 4/5/2014.
· Patient #33 had no history and physical present for the admission of 4/30/2014.
· Patient #33 had no history and physical present for the admission of 4/30/2014.
· Patient #30 had a history and physical dictated after the 24 hour requirement from admission of 6/29/2014.
· Patient #31 had neither a history and physical nor a discharge summary present for the admission of 3/142014.
· Patient #32 had neither a history and physical nor a discharge summary present for the admission of 4/15/2014.

In an interview with staff #2 and# 3 on July 30, 2014 the absence of documentation was acknowledged.

Facility policy entitled " Completion of Records "stated "A History and Physical is expected to be on the medical record within 24 hours of admission ....A discharge summary should be completed for all patients no later than 15 days following discharge. The principle and secondary diagnosis and procedures (including complications and comorbidities) must be recorded at the time of discharge, without the use of symbols or abbreviations at minimum on the face sheet/attestation form. The summary must recapitulate concisely:
1. The reason for hospitalization
2. The significant findings
3. The procedures performed and the treatment rendered
4. The condition of the patient on discharge
5. Any specific instructions given to the patient and/or family (diet, level of activity, medications, and follow up care.)