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Based on record review and interview, the facility failed to ensure there was an organized nursing service.


The facility failed to:


A. ensure safe staffing and nursing supervision to respond to patient needs and care of the patient population of each department or nursing unit in 4 (TEH, CEH, Porter and Humble HOPD) of 4 units observed.

Refer to A tag 0392


B. ensure that nursing staff had current competencies in administering cardiac medications in 1 (Medical Floor at Cleveland Hospital) of 1 areas observed.

Refer to A tag 0397 for


C. ensure medications were administered in a safe manner in 2 (Patient #'s 9&10) of 10 patients reviewed. The facility failed to ensure nursing staff who were titrating Nicardipine and Dobutamine (Cardiac mediations) had a valid physician's order.

D. ensure there was a policy/procedure in place for nursing staff to follow on titrating mediations.

Refer to A tag 0405


E. ensure that verbal orders were completed with a date, time, and dosage.

F. ensure that verbal orders were clearly and accurately written to prevent medication errors and promote safe medication administration.

G. ensure that verbal orders were authenticated promptly by the ordering practitioner.

H. develop and implement a policy on verbal orders.


Refer to Tag A 407


It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients who needed cardiac Intravenous drips at risk for the likelihood of harm, serious injury, and possibly subsequently death.

Based on review and interviews, the facility failed to ensure safe staffing and nursing supervision to respond to patient needs and care of the patient population of each department or nursing unit in 4 (TEH, CEH, Porter and Humble HOPD) of 4 units observed.

The nurse staffing schedule was reviewed on 7/15/19 for CEH; 27 out of 30 shifts were short an RN. Review of the schedule revealed there was no Registered Nurse (RN) scheduled/assigned to the Medical Surgical Unit (MS). Only a Licensed Vocational Nurse (LVN) was scheduled (An LVN must be supervised by an RN). An RN was scheduled to work the Over Flow (OF) shift. Staff #24 confirmed the "OF" nurse position was an RN that may have to help in the ED or MS floor. The "OF" RN was supposed to go back and forth. The OF RN had been used as a 1:1 if the patient was on a medication gtt or needed intensive care. Staff #24 confirmed that the LVN had been alone on the MS floor with patients. Staff #24 stated, "I thought they could be over here without an RN if an RN was available." Staff #24 was asked if he had a patient in the ED he was treating, and the other RN was on a 1:1, how was an RN available? Staff #24 confirmed in that instance an RN would not be available. Staff #24 confirmed that this was a common occurrence and they stay short staffed.

Review of the nurse staffing schedule for TEH facility was short an RN in 30 out of 30 shifts. Review of the schedule revealed there was an RN and LVN on each shift. There was no RN available when the RN was clocked out for a meal break. There must be a RN physically present on the premises and on duty at all times.

A tour was conducted at the HOPD in Porter, Texas on 7/15/19. Review of the nurse staffing schedule revealed 26 shifts out of 30 shifts were short an RN. The facility was left with only one RN on the evening shifts and weekends for the Emergency Department. Review of the nursing schedule revealed an RN, LVN, and paramedic on duty. When the RN was on lunch break or had a trauma case, the nurse would not be readily available to supervise or provide appropriate care.

An interview with Staff #41 on 7/15/19 in the afternoon stated she knew the HOPD's were working short but she had hired 4 nurses and was hoping to get them on board soon. Staff #41 stated she was supervising 3 of the 3 HOPD's units. Staff #41 had no plan in place when there was not an RN available at all times. Staff #41 stated they would continue to keep the facility open and see patients even though there were unsafe staffing levels. Staff #41 confirmed the facility had used staffing agencies before but does not believe she would be able to use them at this time.

An interview was conducted with Staff #4 on 7/16/19 in the afternoon. Staff #4 stated she was new to the position but was aware they were short staffed and was currently interviewing to get staff for the HOPD's and main TEH and CEH. Staff #4 was unable to provide a staffing matrix.

Based on record review and interview, the facility failed to ensure that nursing staff who were caring for patients that were on cardiac drip medication had training and current competencies to administer and titrate cardiac medications in 2 (Staff #23 & 29) of 2 staff reviewed.

It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients who needed cardiac Intravenous drips at risk for the likelihood of harm, serious injury, and possibly subsequently death.


Review of medical records on July 16, 2019 revealed the following:


PATIENT # 9

Review of the physician's orders for Patient #9 revealed the following:

6-14-2019 7:30 P.M.
"Ween Dobutamine to off keeping SBP (Systolic Blood Pressure) >100." There was no parameters listed for decreasing the amount of mcg or the intervals to decrease the Dobutamine for the nurse to follow.

Review of the Daily Nurse's Note revealed the following:

6-14-2019
8:00 P.M. Dobutamine decreased to 4.3 mcg/kg/minute - Vitals were documented as BP 118/60.

8:30 P.M. Dobutamine decreased to 3.4 mcg/kg/minute - Vitals were documented as BP 137/64.

9:05 P.M. Dobutamine decreased to 2.8 mcg/kg/minute - Vitals were documented as BP 131/60.

10:00 P.M. Dobutamine decreased to 2 mcg/kg/minute - Vitals were documented as BP 119/55.

10:51 P.M. Dobutamine discontinued. Vitals were documented as BP 119/55.

Staff #23 was noted as the nurse.


PATIENT #10

Review of the physician's order for Patient #10 revealed the following:

3-11-2019 9:15 P.M.
"Start Nicardipine drip at 5 mg/hr. Titrate to SBP (Systolic Blood Pressure) < 150 mmhg." There was no parameters listed for the milligrams or the intervals to decrease the Nicardipine for the nurse to follow.

Review of the Daily Nurse's Note revealed the following:
3-11-2019
10:15 P.M. Nicardipine drip started at 5 mg/hr.

3-12-2019
12:15 A.M. Nicardipine drip decreased to 2.5 mg/hr.

2:00 A.M. Nicardipine drip stopped at this time.

Staff # 29 was noted as the nurse.


An interview with Staff #24 on July 16, 2019, after 3:00 P.M. revealed the following:

Staff #24 was asked what the facility policy was on titrating mediation drips, specifically cardiac medication drips. Staff #24 stated there was not a facility policy, as it was not allowed.

Staff #24 was asked what training the nurses were given at the facility on IV Cardiac medication administration. Staff #24 stated there was no specific facility policy or training for staff.

Staff #24 stated the nurses had extensive experience and they used that to determine competencies. Staff #24 stated the facility did not have any specific training or competencies relating to patients on cardiac medications or titrating medications.

Staff #24 confirmed the above findings.

Based on observation and interview, the facility (CEH) failed to:

A. ensure medications were administered in a safe manner in 2 (Patient #'s 9 & 10) of 10 patients reviewed. The facility failed to ensure nursing staff who were titrating cardiac mediations (Nicardipine and Dobutamine) had a valid physician's order.

B. ensure there was a policy/procedure in place for nursing staff to follow on titrating mediations.


It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients who needed cardiac Intravenous drips at risk for the likelihood of harm, serious injury, and possibly subsequently death.


Review of medical records on July 16, 2019, revealed the following:


PATIENT # 9

Review of the physician's orders for Patient #9 revealed the following:

6-14-2019 7:30 P.M.
"Ween Dobutamine to off keeping SBP (Systolic Blood Pressure) >100." There was no parameters listed for decreasing the amount of mcg or the intervals to decrease the Dobutamine for the nurse to follow.

Review of the Daily Nurse's Note revealed the following:

6-14-2019
8:00 P.M. Dobutamine decreased to 4.3 mcg/kg/minute - Vitals were documented as BP 118/60.

8:30 P.M. Dobutamine decreased to 3.4 mcg/kg/minute - Vitals were documented as BP 137/64.

9:05 P.M. Dobutamine decreased to 2.8 mcg/kg/minute - Vitals were documented as BP 131/60.

10:00 P.M. Dobutamine decreased to 2 mcg/kg/minute - Vitals were documented as BP 119/55.

10:51 P.M. Dobutamine discontinued. Vitals were documented as BP 119/55.


PATIENT #10

Review of the physician's order for Patient #10 revealed the following:

3-11-2019 9:15 P.M.
"Start Nicardipine drip at 5 mg/hr. Titrate to SBP (Systolic Blood Pressure) < 150 mmhg" There was no parameters listed for the milligrams or the intervals to decrease the Nicardipine for the nurse to follow.

Review of the Daily Nurse's Note revealed the following:
3-11-2019
10:15 P.M. Nicardipine drip started at 5 mg/hr.

3-12-2019
12:15 A.M. Nicardipine drip decreased to 2.5 mg/hr.

2:00 A.M. Nicardipine drip stopped at this time.


An interview with Staff #24 on July 16, 2019 after 3:00 P.M. revealed the following:

Staff #24 was asked what the facility policy was on titrating mediation drips, specifically cardiac medication drips. Staff #24 stated there was not a facility policy, as it was not allowed.

Staff #24 was asked what training the nurses were given at the facility on IV Cardiac medication administration. Staff #24 stated there was no specific facility policy or training for staff. Staff #24 stated the nurses had extensive experience and they used that to determine competencies.

Staff #24 confirmed the above findings.

Based on record review and interview, the facility (CEH) failed to:

A. ensure that verbal orders were completed with a date, time, and dosage.

B. to ensure that verbal orders were clearly and accurately written to prevent medication errors and promote safe medication administration.

C. ensure that verbal orders were authenticated promptly by the ordering practitioner.

D. develop and implement a policy on verbal orders.

The above findings were noted in 2 (Patient #'s 9 & 10) of 10 patients reviewed.

It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients who needed cardiac Intravenous drips at risk for the likelihood of harm, serious injury, and possibly subsequently death.


Findings:


PATIENT #9

Review of Physicians Orders revealed the following:

6-14-2019 7:30 P.M.

"Ween Dobutamine (Heart mediation used to increase cardiac output) to off keeping SBP (Systolic Blood Pressure) >100." There was no parameters listed for decreasing the amount of mcg or the intervals to decrease the Dobutamine for the nurse to follow.


6-14-2019
"VOTRB from Physician #39 - Start Dobutamine at 5 mcg/kg/min." - The order had not been authenticated as of 7-16-2019, over 1 month ago.


6-14-2019
"VOTRB From Physician #39 - Increase Dobutamine to 10 mcg/kg/min." - The order had not been authenticated as of 7-16-2019, over 1 month ago.


6-14-2019
"VOTRB - Pt can have Toradol (Narcotic pain medication used for moderate to severe pain) 30 mg IVP every 6 hours PRN Pain. The order did not list any parameters for pain levels. The order had not been authenticated as of 7-16-2019, over 1 month ago.,


6-14-2019
"O2 2 lpm Nasal Cannula - The order did not list any parameters for oxygen levels.
Dobutamine decrease to 5 mcg/kg/min. The order had not been authenticated as of 7-16-2019, over 1 month ago.


Review of Patient #9's medical record for TEH revealed a copy of the same order. The order had been initialed by an illegible signature. There was no date and time with the initials. There was no way to determine who signed the order and what time it was signed.



PATIENT #10

Review of the physician's order for Patient #10 revealed the following:

3-11-2019 3:40 P.M.
"V/O Physician # 39 - Tramadol (Narcotic Medication used to treat moderate to severe pain) 50 mg PO Q 6 hours PRN Pain. There was no parameters listed for pain levels.

Phenergan 12.5 mg IVP every 6 hours PRN nausea. D/C Zofran." VORB by illegible RN. The orders had been initialed by an illegible signature. There was no date and time with the initials. There was no way to determine who signed the order and what time it was signed.


3-11-2019 8:35 P.M.
"Mag Level- may use blood in lab. Hydralazine (Blood Pressure Medication) 20 mg IVP (Intravenous Push) x 1 now" by illegible RN. The orders had been initialed by an illegible signature. There was no date and time with the initials. There was no way to determine who signed the order and what time it was signed.


3-11-2019 9:15 P.M.
"Transfer to overflow for 1:1 nursing. Start Nicardipine drip at 5 mg/hr. Titrate to SBP (Systolic Blood Pressure) < 150 mmhg" by illegible RN. There were no parameters listed for the milligrams or the intervals to decrease the Nicardipine for the nurse to follow. The orders had been initialed by an illegible signature. There was no date and time with the initials. There was no way to determine who signed the order and what time it was signed.


3-14-2019 6:00 A.M.
"TORBV Physician #39/Staff #40 -

1. Hold Lisinopril & Hydralazine for Systolic <110.

2. Discontinue Lasix.

3. Imodium 2 mg PO every 6 hours PRN loose stools.

4. Normal Saline @ 75 ml/hr X 1 liter "

The orders had been initialed by an illegible signature. There was no date and time with the initials. There was no way to determine who signed the order and what time it was signed.


Staff #24 confirmed the above findings.

A request for a facility policy on verbal orders was made to Staff # 1. Staff 1 was not able to provide any policy on verbal orders as of the exit date of 7-17-2019.

Based on observation, interview, and record review, the facility (TEH and CEH) failed to provide a sanitary environment to avoid sources and transmission of infectious and communicable diseases. The facility failed to:


A. ensure 1 patient care area at TEH (Cath lab Post Anesthesia Care Unit) of 2 areas observed were free from mold and mildew.

B. ensure 1 patient supply room at TEH (2nd floor supply room) of 1 that stored sterile supplies was free from mold and mildew.

C. ensure 1 laundry/environmental services room at TEH had remediation performed prior to resuming laundry services. It was observed laundry room had a mushroom growing from the wall.

D. ensure 1 OR department at TEH of 1 observed was free of mold, mildew, and standing water. The operating room was not in use; however, it was next to Cath Lab PACU area where patient care was being performed.

E. ensure the infection control officer for the facility was notified of the mold/mildew issue identified in the laundry room and as reported in a work order 6-18-2019. The infection control officer was not aware of the mold/mildew issue identified and had no knowledge of any remediation taken in the laundry room to ensure the mold/mildew was completely removed prior to resuming laundry services in the area.

It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death.


F. ensure the temperature in the Operating room (OR) at CEH was within acceptable standards to inhibit microbial growth, reduce the risk of infection, promote patient comfort, and assure the physical safety of all patients. The temperature and humidity were out of range for 30 of 37 days reviewed. There was no documentation on the log to indicate corrective was action taken and the temperature on follow up after corrective action was done.

G. ensure a sanitary/clean environment in 3 (Patient room 156, Patient room 157, and Housekeeping storage room 166) of 3 areas observed at CEH.

H. have a trained professional to perform the N95 Fit testing for current employees.


Refer to TAG A0749

Based on observation, interview, and record review, the facility (TEH and CEH) failed to provide a sanitary environment to avoid sources and transmission of infectious and communicable diseases. The facility failed to:


A. ensure 1 patient care area at TEH (Cath lab Post Anesthesia Care Unit) of 2 areas observed were free from mold and mildew.

B. ensure 1 patient supply room at TEH (2nd floor supply room) of 1 that stored sterile supplies was free from mold and mildew.

C. ensure 1 laundry/environmental services room at TEH had remediation performed prior to resuming laundry services. It was observed laundry room had a mushroom growing from the wall.

D. ensure 1 OR department at TEH of 1 observed was free of mold, mildew, and standing water. The operating room was not in use; however, it was next to Cath Lab PACU area where patient care was being performed.

E. ensure the infection control officer for the facility was notified of the mold/mildew issue identified in the laundry room and as reported in a work order 6-18-2019. The infection control officer was not aware of the mold/mildew issue identified and had no knowledge of any remediation taken in the laundry room to ensure the mold/mildew was completely removed prior to resuming laundry services in the area.

It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death.


F. ensure the temperature in the Operating room (OR) at CEH was within acceptable standards to inhibit microbial growth, reduce the risk of infection, promote patient comfort, and assure the physical safety of all patients. The temperature and humidity were out of range for 30 of 37 days reviewed. There was no documentation on the log to indicate corrective was action taken and the temperature on follow up after corrective action was done.


G. ensure a sanitary/clean environment in 3 (Patient room 156, Patient room 157, and Housekeeping storage room 166) of 3 areas observed at CEH.


H. have a trained professional to perform the N95 Fit testing for current employees.




During an observation tour on July 16, 2019, after 1:30 P.M. at TEH, the following observations were made:


CARDIAC CATH LAB PACU (POST ANESTHESIA CARE UNIT)

There were ceiling tiles with brown colored stains that appeared to be water stains. There were ceiling tiles with black colored stains that appeared to be mold/mildew. The room had a musty smell that was very strong when entering the room.

On July 16, 2019, Staff #15 was asked to remove one of the ceiling tiles that was stained with black substance. When the ceiling tile was taken down, a green substance that appeared to be mold was covering the back of the tile. The area of the ceiling that had multiple black stains on the tiles were adjacent to an operating room that was not in use at the time of the survey. There was a double door that went into the operating room. The doors were taped with yellow tape that was labeled "Caution". The doors would open, and the operating room could be easily accessed by pushing the door open.

Review of the Cath Lab procedure logs for March 26, 2019 to July 1, 2019 revealed 23 patients received patient care in the Cath lab PACU during that time frame. The monthly totals are as listed below:

March 2019 - 1 Patient
April 2019 - 3 Patients
May 2019 - 6 Patients
June 2019 - 12 Patients
July 2019 - 1 Patient



SECOND FLOOR MEDICAL FLOOR

On July 16, 2019, after 2:00 P.M., when exiting the elevator, the hallway next to the radiology/employee health nurse office was observed. The ceiling tiles had brown colored stains that appeared to be water stains. The Air Conditioning duct was covered in rust.


PATIENT SUPPLY ROOM ON THE SECOND FLOOR

During a tour with Staff # 17 the following observations were made:

The patient supply room on the second floor contained sterile surgical supplies, i.e., Obstetrical Surgical Packs, Chest Tubes, Radial Art lines, and Foley catheters. The room stored clean respiratory supplies; oxygen masks, oxygen cannulas, and respiratory treatment supplies. The room also stored clean patient supplies.

During the tour, an adjoining room was observed. The room appeared to be an old bathroom. Outside the room on the floor, standing water was observed. There were two plyboards standing on the floor leaning on the wall. The plyboards were covered with black substance that appeared to be mold and mildew. Staff #15 was asked to turn the plyboard over for observation. The boards were covered with a green substance that appeared to be mold. The ceiling tiles outside the room and above the door frame was missing. The wall inside the ceiling was covered in a black substance that appeared to be mildew. While looking at the open ceiling tiles, an employee was observed to open an area on the roof. When this area was opened, the surveyor could see to the outside. There was no barrier. The wooden shelves on the outside of the room that stored forms being used at the facility were covered in a black substance that appeared to be mold/mildew. The laminate was peeling and missing pieces from the trim. The door frame was covered in rust and a black substance that appeared to be mold/mildew. The ceiling tiles in the hallway outside of the room were covered in a black substance that appeared to be mold/mildew.

Inside the room, the condition was in disarray. There was a sink that was covered in dead bugs that appeared to be roaches. The ceiling tiles were missing on the inside of the room as well. There was a buildup of a black substance that appeared to be mold on partial ceiling tiles that were laying on the floor. There was a buildup of dirt, dust, and debris on all surfaces of the floor. There was a wooden board laying underneath the commode lid. There was a spider web and spider in the corner of the room. The Fire sprinkler system alarm was hanging from the ceiling by a wire.


A review of the temperature logs for the sterile supply room revealed the following:

May 2019
The temperature and humidity were not checked 9 of 31 days.

The temperature was out of range 16 of 31 days.

The humidity was out of range 22 of 31 days.


June 2019
The temperature and humidity were not checked 10 of 30 days.

The temperature was out of range 5 of 30 days.

The humidity was out of range 20 of 30 days.


July 2019 (July 1-15, 2019)
The temperature log was not dated by month. Staff #15 confirmed the log was for July 2019.

The temperature was not checked 5 of 15 days.

The humidity was out of range 10 of 15 days.


The temperature and humidity were out of range of 52 of 76 days checked.


Review of the AORN Perioperative Standards and Recommended Practices,

"Relative humidity should be maintained between 20% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, instrument processing areas, and sterilizing areas and should be maintained below 60% in sterile storage areas."



FAMILY WAITING ROOM ON 2ND FLOOR (MEDICAL FLOOR)

On July 16, 2019, when entering the family waiting room the following observations were made:

The room was hot. The thermostat on the wall was not working. There was a black substance covering the air conditioning vents that appeared to be mildew.

Staff #15 was asked if the air conditioning was working. Staff #15 confirmed it was not working in that room. Staff #15 was asked how long it had been down. Staff #15 stated he wasn't sure but the facility had been dealing with air conditioning problems for a while. Staff #15 also stated that the roof had many leaks and they had gotten bids to repair the problems.


OPERATING ROOM (NOT IN USE) ADJACENT TO PATIENT CARE AREA (CATH LAB PACU)

During a tour on July 16, 2019 the following observations were made:

There was water standing on the floor in the hallways. The area was in disarray. There was trash, pieces of ceiling tiles covered in black substance, equipment, stretchers, metal rebars, plastic buckets with painting supplies stored on the floor. There were ceiling tiles bulging that had brown and black stains that appeared to be water/mildew stains. Multiple ceiling tiles were missing, and the ceiling was exposed. There was water noted inside the fluorescent light covers.


An interview on July 16, 2019 after 2:00 P.M. with Staff #15 revealed the following:

Staff #15 stated he was not aware of the condition of the above areas. Staff #15 stated he was aware of the roof leaks and the air conditioning problems. Staff #15 stated bids to fix both issues had been submitted to administration.


Review of work orders from Texas Emergency Hospital revealed the following:

5-7-2019
Issue: At TEH- Wet ceiling tile in the X-Ray Department (near the old mammography room)

5-8-2019
Issue: At TEH - I think due to rain yesterday, there was a leak. There are new wet spots and the tile directly over my chair appears to be warped or drooping.

5-24-2019
Issue: At TEH on the 1st floor in room #111 there is a leak from the ceiling near the air vent. Reported by housekeeping.

6-18-2019
Issue: At TEH - I believe I have mold growing on the sheet rock in my office by the outlet by the door.


Review of the temperature and humidity logs for the Operating Room at CEH on 7-16-2019 revealed the following:

JUNE 2019

OR Room #1

The temperature was documented out of range 13 of 21 days reviewed. One day was not documented. The humidity was recorded out of range 20 of 21 days reviewed. One day was not documented.



OR Room #2
The temperature was documented out of range 17 of 21 days reviewed. One day was not documented. The humidity was documented out of range 20 of 21 days reviewed. One day was not documented.

STERILE SUPPLY ROOM
The temperature was documented out of range 20 of 21 days reviewed. One day was not documented. The humidity was documented out of range 20 of 21 days reviewed. One day was not documented.

PROCEDURE ROOM 2
The temperature was documented out of range 19 of 21 days reviewed. One day was not documented. The humidity was documented out of range 20 of 21 days reviewed. One day was not documented.


JULY 2019
OR Room #1
The temperature was documented out of range 10 of 16 days reviewed. The humidity was documented out of range 10 of 16 days reviewed.

OR Room #2
The temperature was documented out of range 10 of 16 days reviewed. The humidity was documented out of range 10 of 16 days reviewed.

STERILE SUPPLY ROOM
The temperature was documented out of range 10 of 16 days reviewed. The temperature was documented out of range 10 of 16 days reviewed.

PROCEDURE ROOM
The temperature was documented out of range 9 of 16 days reviewed. The humidity was documented out of range 10 of 16 days reviewed.


An interview with Staff # 11 on July 16, 2019 after 9:00 A.M. revealed the following:

Staff #11 stated the Operating Room Department had experienced with the previous circulator maintaining the required temperature. The previous circulator was no longer employed at the facility. Staff #11 said the Operating Room had taken over regulating the temperature and humidity in July. Staff #11 provided a log of maintenance notification when temperature where out of range for July. There were two days noted on the corrective measures log. The corrective measure log did not address all the temperature and humidity reading out of range for July 2019.

Review of the facility policy titled, "Temperature and Humidity in the Surgical Areas" with a revised date of 6-3-2019 revealed the following:

"POLICY:
Operating Rooms: Temp 65-70 degrees
Humidity 20-70 %....
Sterile Storage Areas: Temp 65-70 degrees
Humidity 35-75%...

If temperature and humidity if above or below standards, notify maintenance and place a work order.
Temperature and Humidity will be checked again prior to patient transfer or opening of operating room suite ..."


Staff #11 confirmed the above findings.



Review of the AORN Perioperative Standards and Recommended Practices,

"Relative humidity should be maintained between 20% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, instrument processing areas, and sterilizing areas and should be maintained below 60% in sterile storage areas.

Low humidity increases the risk of electro static charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored, or procedures are performed.

Humidity should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system.

Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system."



40989

An observation tour was conducted with Staff #5 on 7/16/2019 after 9:00 AM at CEH. The following was observed:


Patient Room Number 156

Under the soap dispenser, next to the sink, there was missing paint and tears in the sheetrock exposing the porous material. The porous material cannot be sanitized to prevent the spread of infectious diseases. The base of the toilet was noted to have a brown colored stain. Staff #5 was asked if this was dried urine or rust. Staff #5 could not verify as to which one it was. The top of the toilet was noted to have dirt, dust, and yellow colored spots on the surface. Staff #5 verified this patient room was clean and sanitized for a new patient.


Patient Room Number 157

The base of the toilet was noted to have a brown colored stain. Staff #5 was asked if this was dried urine or rust. Staff #5 could not verify as to which one it was. On the top of the toilet next to the seat, human hair was seen. Attached to the vital signs machine is a pulse oximetry (used to measure a patient's oxygen level) cable. A disposable, single use item used to connect to the patient for measurements was found still attached to the cable from the previous patient that had been discharged. Staff #5 verified this patient room was clean and sanitized for a new patient.



Room 166 HOUSEKEEPING

In the housekeeping closet, the floor was noted to be covered with heavy dirt, dust, and debris. Inside the hopper (an in the floor sink area) was heavily soiled with dirt, dust, and debris. Paint was peeling away from the walls around the top rim of the hopper. A used and dirty mop head was found on top of the faucet. To the right was a shelf that was being used to store clean mop heads that were left uncovered. This places all patients at risk for cross contamination of infectious disease.


An interview was conducted with Staff #5 on 7/16/2019, after 9:00 AM. Staff #5 was asked if anyone had reported any mold or mildew to him. Staff #5 said, "No, no one has reported anything to me about mold or mildew from any of the facilities."


Staff #5 confirmed the findings.



36827


LAUNDRY/ENVIRONMENTAL SERVICES ROOM at TEH

During an observation tour on July 16, 2019, after 1:30 PM, Staff #3 approached surveyor and stated that the Infection Control Staff #5 had advised Staff #3 that surveyors had expressed concern about mold. Staff #3 stated that he had recently been made aware of a problem in a part of the building that was not currently being leased by the hospital. Staff #3 escorted surveyor to a room that housekeeping staff was using as an office area and to process sheets for the physician sleep rooms in TEH and CEH.

The room was observed to have a washing machine and dryer in the room. A plastic laminate style covering was observed to cover the bottom half of the wall, with painted wall board on the top half. The top edge of the plastic laminate style covering was observed to be pulled away from the wall board. There was what appeared to be mold and mildew growth between the covering and wall board. The wall board above and surrounding the area appeared to be bubbled and peeling due to water damage.

Staff #3 stated that mushrooms had been found growing from the space between the laminate and wall board. Staff #3 stated the mushrooms had been removed and the area had been cleaned by hospital staff. Staff #3 confirmed that professional remediation services had not been used. He stated that he did not think it was a problem that needed Staff #5's involvement. Staff #3 and Staff #5 both confirmed that Infection Control had not been advised of the problem with mold, mildew, and fungus growing in the facility. Staff #3 stated that since the hospital didn't actually lease the housekeeping office/laundry space where the mushrooms were found to be growing, he did not see it to be a problem for the hospital.

Staff #3 was asked about source of the water damage. Staff #3 stated the roof had been damaged by the winds during Hurricane Harvey in August of 2017. Staff #3 stated that the insurance company denied the claim to have the roof structure replaced due to the hurricane damage not being covered under the policy. Staff #3 stated that the landlord has the roof repaired when a leak has been identified. Staff #3 confirmed that the hospital does not perform any type of plant-wide inspection for leaks and standing water after heavy rain events, despite knowing that the entire roofing structure has been recommended for replacement due to hurricane damage. During the facility tour, standing water had been observed in hospital leased areas (2nd floor sterile supply room) and unleased areas (un-used and closed off operating room area) after the facility had experienced heavy rains the previous day.



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Based on review and interview, the facility failed to have a trained professional to perform the N95 Fit testing for current employees.

Review of the OSHA guidelines 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, which describes Standard and Transmission-Based Precautions used for infection control stated, "The hospital environment contains hazards such as bacteria, viruses, and chemicals that may be inhaled by personnel and cause injury or illness. When needed Respirators and other personal protective equipment (PPE) are used as a last line of defense when exposures cannot be reduced to an acceptable level using other methods. Each facility should develop policies and procedures which address the control methods used at their institution.

Healthcare personnel who care for patients with ATDs must work in close proximity to the source of the hazard; even with controls in place, they are likely to have a higher risk of inhaling infectious aerosols (droplets and particles) than the general public. These personnel, and others with a higher risk of exposure related to the tasks they perform (e.g., lab or autopsy workers), must often be protected further through the proper use of respirators.

N95 respirator-A generally used term for a half mask air-purifying respirator with NIOSH approved N95 particulate filters or filter material (i.e., includes N95 filtering facepiece respirator or equivalent protection).
Fit test-The use of a protocol to qualitatively or quantitatively evaluate the fit of a respirator on an individual."


An interview with Staff #31 on 7/16/19 at 3:16 PM revealed, she had been involved in the fit testing for the N95 masks. Staff #31 was asked if she was performing the fit test and if she had signed any test stating she had. Staff #31 stated, "no." I am not trained to do the fit test. Staff #31 stated, "well, now that I'm thinking about it I may have signed a couple last year but that's it."

Staff #31 was asked about the current procedure for fit testing. Staff #31 stated that she takes the employee to the respiratory department and the Respiratory Director performs the test. Review of the current fit test forms revealed Staff #31 had signed the form stating she had performed the test and not a Respiratory Director. Staff #31 was shown the forms. Staff #31 stated, "well maybe I did but I was just scribing for the respiratory therapist. I didn't realize they never signed the forms." The surveyor was unable to talk to the respiratory director. Staff #31 stated they were not working at the facility during survey.


Kitchen:

A tour was conducted in the kitchen on 7/16/19. A cleaning schedule was found for the ice machine posted on the side of it. The schedule showed the ice machine was cleaned on 6/7/19. The surveyor took a clean white paper towel and wiped the top of the machine. The towel was covered in a black and green mold type substance. The Dietary Director confirmed the findings.