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Based on record reviews and interviews, the hospital failed to meet the requirements of 42 CFR 482.1 as evidenced by failing to be primarily engaged in providing inpatient services. The regulation at 42 CFR 482.1 implements the statutory requirement at Section 1861(e) of the Social Security Act (Act). The regulation requires that: (i) Hospitals participating in Medicare must meet certain specified requirements and (ii) The Secretary may impose additional requirements if they are found necessary in the interest of the health and safety of the individuals who are furnished services in hospitals.

The Act defines hospital as: an institution that ". . . is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons..."

Findings:

Upon entrance to the hospital on 5-6-2019, it was determined that the hospital had a minimum of two inpatients so that care of the patients could be observed. The survey was continued at that time.

On 1-16-2019, a database worksheet had been completed. Staff #5 confirmed that no additions or deletions of services and service locations had been made since that time. The services for the following locations were determined to be:

Cleveland Emergency Hospital (CEH)
4 inpatient beds
2 operating room
1 endoscopy room
Emergency Department Services
Outpatient Radiology
Outpatient Laboratory

Texas Emergency Hospital (TEH)
12 inpatient beds
1 cardiac catheterization room
Emergency Department Services
Outpatient Radiology
Outpatient Laboratory

There were 3 Hospital Outpatient Department (HOPD) locations that provided emergency department services, outpatient laboratory services, and outpatient radiology services.

The hospital provided a report titled "Admit List" for the dates of 01/01/2019 thru 5/5/2019"; one for each inpatient hospital location. This was a total of 125 calendar days. Based off the information provided, it was determined the two inpatient locations had a combined total of 77 patients admitted for inpatient services. Further review revealed the following:

Month and Year Inpatient Admission
January 2019 13
February 2019 17
March 2019 12
April 2019 30
May 1-5, 2019 5



Month and Year Average Length of Stay (days)
January 2019 3.1
February 2019 1.9
March 2019 2.3
April 2019 1.7
May 1-5, 2019 3.0

Average Length of Stay for the combined locations from January 1, 2019 thru May 5, 2019 was calculated to be 2.1


Month and Year Average Daily Census
January 2019 1.3
February 2019 1.2
March 2019 0.9
April 2019 1.7
May 1-5, 2019 3.6

Average Daily Census for the combined locations from January 1, 2019 thru May 5, 2019 was calculated to be 1.1



Total Discharged Inpatients
CEH - 35
TEH - 42
Total - 77

Total Inpatient Days
CEH - 89
TEH - 86
Total - 175

Review of the admission and discharge patterns by day of the week from January 1, 2019 thru May 5, 2019 revealed the following:

Sunday: 7 admissions and 5 discharges
Monday: 13 admissions and 10 discharges
Tuesday: 14 admissions and 15 discharges
Wednesday: 11 admissions and 12 discharges
Thursday: 6 admissions and 7 discharges
Friday: 17 admissions and 13 discharges
Saturday: 8 admissions and 15 discharges


Review of surgical services provided at the two locations (CEH and TEH) was made. The following was determined:

Inpatient Surgeries
CEH - 5
TEH - 3
Total - 8

Outpatient Observation Surgeries
CEH - 12
TEH - 8
Total - 20

Outpatient Day Surgeries
CEH - 27
TEH - 2
Total - 29

Review of the volume of outpatient encounters through the Emergency Departments, Laboratory, and Radiology revealed the following:

CEH - 1,817 encounters
TEH - 2,350 encounters
HOPDs - 3,204 encounters
Total - 7,371 encounters

Outpatient Observation admissions:
CEH - 85
TEH - 128
HOPDs - 128
Total - 341

For the period of January 1, 2019 to May 5, 2019 the totals represent:

Inpatients - 77
Outpatient encounters - 7,712


Staffing Patterns

Inpatient Locations:
Hospital floors with certified inpatient beds were found to be staffed with sufficient nursing staff to provide care on all shifts and over the weekends and holidays. One inpatient admission occurred on New Year Day. No inpatient admissions occurred on Easter Day.


Discharge Planning

No evidence of discharge planning or a discharge planning assessment was found in patient charts for the months of January, February, March, and April 2019.
Cross-Refer to Tag A0799


Surgery:

Interview was conducted on 5-7-2019 with Staff #5 concerning the elements required to determine if a hospital was primarily engaged in inpatient services. In discussing the surgery patterns, Staff #5 confirmed that surgeries were scheduled Monday through Friday and that the hospital did not have an on-call surgery team available for after-hours or weekends. Staff #5 confirmed the majority of surgeries were performed as outpatient observation and day surgeries. Staff #5 stated that they do not have the staff to schedule on-call surgery teams.


40989

An interview was conducted on 5-9-2019 after 9:00 AM with Staff #50. Staff #50 was asked if the department has an on-call team for emergency surgeries. Staff #50 said, "We do not have an on-call team for surgery. We just don't have the staff and we are not required to take call here. We don't even have the staff to run two rooms."

Review of Policy and Procedure showed that it was the hospital's policy to have two surgical rooms staffed and have an after-hours, on-call team.

Review of Policy and Procedure titled, "STAFFING PATTERNS, SURGICAL SERVICES, REFERENCE #5014" was as follows:

" ...PURPOSE:

To establish staffing patterns for the Surgical Services Department.

POLICY:

The Surgical Services Department will be staffed for the operation of 2 rooms on Monday through Friday from 7 AM to 3 PM ..."



Review of Policy and Procedure, Subject: On-Call Staffing; Reference #5105; Revised: 02/20/19; was as follows:

"...PURPOSE:

The Surgical Services on-call team is comprised of an anesthesiologist, a registered nurse (Circulating RN) and an Operating Room Technician (Scrub Tech) or registered nurse with scrubbing experience.

All members of the on-call team should be in the hospital within 30 minutes of the time that they are called, under normal circumstances. (If the hospital does not have "captured call" where the on-call team stays in the hospital.)

PROCEDURE:

The Surgical Services Nurse Manager will compile a list each day with the names, phone numbers and beeper numbers of the staff on-call for that day.
..."

Based on review of records and interview, the governing body failed to:

A) 1. have written documentation of the annual fire building inspections by the local fire control agency to ensure the hospital is free from all fire hazards in 5 (Cleveland Emergency Hospital and Texas Emergency Hospital) of 5 locations.

2. ensure the facility was protected and properly closed during a weather event. There was no timely reentry or plan for 1(Porter) of 5 (CEH, TEH, Humble, Spring, and Porter) Emergency Departments (ED).

3. to have an approved and active Emergency Preparedness Plan to properly care for patients, divert patients, and safely close and secure the hospital during an emergent situation. The Plan provided was from 2015 and did not address the multiple counties for the Hospital Out Patient Departments (HOPD's). There were no risk assessments found or offered for 5 (CEH, TEH, Humble, Spring, and Porter) of 5 Emergency departments.

4. protect the facility's narcotics, contrast mediums, medical records, and equipment from the public. The facility was found unsecured and abandoned. A side door to the facility was left opened to the public with no employees in the building or grounds. The administration was informed of the unsecured building by surveyors in 1 (Porter) of 5 Emergency Departments.

The conditions and deficient practices were identified under the above Conditions of Participation and were determined to pose Immediate Jeopardy to patient/public health and safety, placed all potential patients/public at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Cross-Refer to Tag A0700


B) provide a process for physician oversight for mid-level practitioners. The facility had no evidence of physician oversight for 2 of 2 mid-level practitioners, Registered Nurse Practitioner #39 and #40.

Cross Refer to Tag A0049


C) ensure that all contracted services were evaluated for safety and effectiveness through the Quality Assurance / Process Improvement (QAPI) program for 5 out of 5 campus locations (CEH, TEH, HOPDs in Porter, Humble, and Spring).

Cross Refer to Tag A0084


D) 1. ensure all departments and services were involved in the Quality Assurance Process Improvement (QAPI) program for 5 (CEH, TEH, and HOPD locations at Porter, Spring, and Humble) out of 5 campuses. The Emergency Department, Respiratory Services, Food and Nutrition Department, Nuclear Medicine, and all contracted services were not involved in or evaluated by the QAPI program.

2. analyze quality indicator data being tracked and aggregated in order to identify trends or other aspects of patient care that would identify problems with processes of care, hospital services and/or operations for 5 (CEH, TEH, and HOPD locations at Porter, Spring, and Humble) out of 5 campuses. Information was being tracked and aggregated, but no evidence of data analysis for the purpose of identifying areas that may improve health outcomes, patient safety, and quality of care was found, with the exception of one Infection Control Process Improvement (PI) project and one Nursing PI project.

3. ensure that the QAPI plan was evaluated each year with a determination made on the number of distinct PI projects for the upcoming year for 5 (CEH, TEH, and HOPD locations at Porter, Spring, and Humble) out of 5 campuses.

Cross-Refer to Tag A0263


E) properly staff 4 (CEH, HOPD Porter, Spring and Humble) of 5 (CEH, TEH, HOPD Porter, Spring and Humble) emergency departments with adequate nursing staff. The facility utilized Emergency Medical technicians and Licensed Vocational Nurses in place of Registered Nurses for three months, March, April, and May of 2019.

Cross-Refer to Tag A0385


F) 1) provide discharge planning for in-patient discharge needs for 4 of 4 months (January, February, March, April 2019).

2) ensure the Registered Nurses documented the assessment of patient needs leading to impending discharge from January through April 2019.

Cross-Refer to Tag A0799

Based on record review and interview, the facility failed to provide a process for physician oversight for mid level practitioners. The facility had no evidence of physician oversight for 2 of 2 mid level practitioners, Registered Nurse Practitioner #39 and #40, from January through May 8, 2019.

This deficient practice had the likelihood to effect all patients of the facility.

Findings:

On the afternoon of 5/8/2019, interview with medical records (MR) staff #36, confirmed to her knowledge the MR department had no policy or process to review or track MR for physician oversight of the Registered Nurse Practitioners (RNP), who worked under them. Staff #36 called her supervisor, Staff #37, by phone who confirmed the MR department did not track physician oversight of their RNP's.

A review of MR revealed RNP #39 and #40 each worked under physician #38. Physician #38 had no method of tracking or reviewing the work provided by the RNP whom he supervised and had submitted no data to the Medical Staff for review.


On 5/8/2019 in the afternoon, an interview with the COO, staff #1, confirmed the Medical Staff had no process established for consistent review of oversight for the RNP's. She produced a plan that was yet to be presented to the Medical Staff and Governing Body, that established the chain of oversight and required review of 10% of the RNP's MR documentation which the state Board of Nursing requires to be in compliance with requirements to function as a RNP.

Based on review of records and interview, the Governing Body failed to ensure that all contracted services were evaluated for safety and effectiveness through the Quality Assurance and Performance Improvement (QAPI) program for 5 out of 5 campus locations (CEH, TEH, HOPDs in Porter, Humble, and Spring).

Findings:

A request was made on 5-6-2019 for all QAPI reporting data and meeting minutes. A review of the QAPI binder provided by Staff #4 was made on 5-7-2019. The binder contained an agenda and sign-in sheet for a Quality Council meeting held on February 7, 2019. No minutes for this meeting were found. The agenda included the approval of the previous meeting minutes. Minutes of a meeting conducted on October 18, 2018 were included.

An agenda was found for a Quality Council meeting held on April 12, 2019. No sign in sheet or minutes from this meeting were found. The agenda did not include approval of the previous meeting minutes and none were included.

Review of both agendas for 2019 and meeting minutes for the meeting in October 2018 did not contain any information about the evaluation of contracted services for quality and effectiveness.

An interview was conducted with Staff #4 on the afternoon of 5-7-2019. Staff #4 confirmed that the binder was complete. Staff #4 was asked to provide any additional information, evaluations, analysis, or reports that may have been reported through the QAPI program. No other information was provided.

Contracted services includes such areas as Emergency Department Physicians, Respiratory Therapists, Dietary/Food Services, and Registered Dietician.


28659


The facility's Governing Body had not reviewed and reconciled the contracts of the Dietary Management Services (FMG), which provided structure, policies, education, and hired the dietary manager, and the independently contracted Registered Dietician/Licensed Dietician who provided patient assessment of nutritional needs, recommendation to physician regarding appropriate dietary and patient education. The contracted RD/LD also provided guidance for the dietary manager, education to dietary staff, and provided on sight observation of food storage, and safe handling of food.


On the late morning of 5/7/2019, an interview with the facility's contracted Registered Licensed Dietician (RD/LD), staff #27, confirmed she was the dietary services oversight for facilities CEH, and TEH. She confirmed she was an independently contracted RD/LD, not associated with the management contract for the dietary department.


On 5/7/2019 in the afternoon an interview with staff #27, confirmed she had many years experience as a RD/LD. She provided documentation of her visits. The data offered as evidence of the report she submitted to the facility management included the following:

Temperature
Food Quality
Patient Refrigerator
Dining Room Inspection
Correct diet served
Consult Received for dietary triggers/orders
Nutritional consults

Adjacent to each word was a checkmark in a column identified by the word "Yes".

There were no comments or any other measurable data recorded for submission. The documents spanned February, March, April, and through May 7, 2019. The RD was asked why there was no narrative or other data recorded on the form? She replied, "They really only want a check list. They don't want to read all that other stuff".


During the interview, staff #27 confirmed she attended the QAPI meetings. She could not provide any measurable data that she submitted to the QAPI committee as evidence of what the dietary department was collecting, tracking, and analyzing data for the purpose of improving quality in the dietary services department. The RD/LD confirmed the Management services for the dietary department handled that.

On 5/6/2019, in the afternoon, an interview with the CEO staff #5, confirmed the facility used a contracted service to provide the nutritional needs of the patients and to provide policy, education, and guidance to the dietary department staff.

A review of the job descriptions for the RD/LD identified two (2) in use. One was found in the body of the contract for the RD/LD. The other was found in the policy manual of the contracted dietary services manual.

A review of the job description provided by the Dietary Management Service revealed the RD/LD was responsible to establish the Quality Improvement, including the improvement projects, data collection, tracking, and analyzing data for the QAPI program. No one on the management side or the RD/LD had put into use a mechanism to assess, collect, track, and analyze that data for the Dietary portion of the QAPI program.

A review of the menus in use by the facility's dietary department revealed, they had not been approved by the facility's RD/LD for use. The menus in use were not signed by a RD, and the most recently approved menus had been signed by a RD/LD no longer employed by the facility.

Neither the Dietary Management Services nor the RD/LD had provided Quality Improvement Guidance that included Quality assessment, improvement projects, collection of data, tracking and analyzing of the data to the dietary manager.

Based on observation, the facility failed to ensure patient records were protected from unauthorized access when 1 (HOPD Porter) of 5 hospital locations was evacuated during a weather event.

Findings:

On May the 8, 2019, at 8:45 AM, surveyors arrived at the CEH Emergency Department (ED) in Porter, Texas. The facility is a Hospital Outpatient Department (HOPD) of the hospital. There was a sign on the door that stated, "Due to inclimate (sic) weather this facility is diverting all patients to Cleveland Locations located at:" The sign gave two locations Deerbrook ED and Texas Emergency Hospital along with addresses to each. The surveyors watched several people try to enter the facility but the front door was locked.

The surveyors walked to the left side of the ED and found a side door open. The door was propped open by wet towels and bed spreads found on the floor, providing access to the ED by anyone from the public who came onto the property. The surveyors asked loudly if anybody was in the building multiple times with no answer. The surveyors walked directly into the building. The lights were still on in the facility. All of the computers were still running. There were no other individuals in the building. The building was unsecured and abandoned.

An interior door that separated the ED from a clinic next door was found to be unlocked providing access to the ED by anyone who had access to the clinic. The clinic was not owned or operated by Cleveland Emergency Hospital.

The laboratory had medical records accessible in an unlocked file cabinet. The papers and files had patient information available. Patient ED medical records were found in a file cabinet in the lower drawers close to the ground. The records were left unsecured and vulnerable to possible water damage.

Based on review of records and interview, the hospital failed to:

A) ensure all departments and services were involved in the Quality Assurance and Performance Improvement (QAPI) program for 5 (CEH, TEH, and HOPD locations at Porter, Spring, and Humble) out of 5 campuses.

B) analyze quality indicator data being tracked and aggregated in order to identify trends or other aspects of patient care that would identify problems with processes of care, hospital services and/or operations for 5 (CEH, TEH, and HOPD locations at Porter, Spring, and Humble) out of 5 campuses.

Cross-Refer to Tag A0273


C) ensure that the QAPI plan was evaluated each year with a determination made on the number of distinct PI projects for the upcoming year for 5 (CEH, TEH, and HOPD locations at Porter, Spring, and Humble) out of 5 campuses.

Cross-Refer to Tag A0309


Findings for A:

A review of the QAPI program was made on 5-7-2019. A binder was provided by Staff #4 that contained all of the QAPI meeting minutes, PI projects, and data that was being tracked.

An interview was conducted with Staff #4 on the afternoon of 5-7-2019. Staff #4 confirmed that the binder was complete. Staff #4 was asked to provide any additional information, evaluations, analysis, or reports that may have been reported through the QAPI program. No other information was provided.

Staff #4 was asked to provide a comprehensive list of departments that were participating in QAPI, PI projects in process, and data that was being tracked and analyzed. Staff #4 was not able to provide a comprehensive list.

The binder contained an agenda and sign-in sheet for a Quality Council meeting held on February 7, 2019. No minutes for this meeting were found. The agenda included a line item for the approval of the previous meeting minutes. Minutes of a meeting conducted on October 18, 2018 were included.

An agenda was found for a Quality Council meeting held on April 12, 2019. No sign in sheet or minutes from this meeting were found. The agenda did not include a line item for the approval of the previous meeting minutes and none were included.

Because of missing minutes and sign-in sheets, no record of what was actually discussed, who contributed to the meeting, or what had been approved could be determined. Based on records in the binder and interview with Staff #4 conducted on 5-7-2019, it was determined the following departments/services were not involved in the QAPI process:

Emergency Department
Respiratory Services
Food and Nutrition Department
Nuclear Medicine

Review of documents provided did not include any information on the evaluation and participation of contracted services.
Cross-Refer to Tag A0084

Based on review of records and interview, the facility failed to analyze quality indicator data being tracked and aggregated in order to identify trends or other aspects of patient care that would identify problems with processes of care, hospital services and/or operations for 5 (CEH, TEH, and HOPD locations at Porter, Spring, and Humble) out of 5 campuses.

Findings:

A document titled "ER Throughput" with patient encounters from 2-5-2019 through 5-5-2019 was reviewed on 5-6-2019. Upon quick review, there appeared to be clusters of patients who left the emergency department before triage (LBT), without being seen (LWBS), and against medical advice (AMA). Information for TEH on 2-11-2019 showed that 6 out of 20 patients seen in a 24-hour period left prior to completion of Emergency Department services. On 4-11-2019 at the HOPD - Humble location, records indicated that 3 out of 16 patients seen in a 24-hour period left prior to completion of Emergency Department services.

Review of the 2019 Quality Council meeting minutes and data reported was made. Data was found to be tracked and reported as percentages for benchmarking and compliance. No information was found that analyzed the data or hospital processes for possible trends or patterns that needed to be corrected.

An interview was conducted with Staff #4 on the afternoon of 5-7-2019 concerning the quality reporting. When asked about the Emergency Department's AMA's and LWBS, Staff #4 referred to a form titled, "Current Year AMA & LWBS Scorecard". Staff #4 stated that she tracked to ensure the hospital remained below the benchmark that had been set. The percentages that were being tracked fluctuated from month to month, but remained below the established benchmark. (Benchmarking is a process of measuring an organization's products, services, or practices against recognized leaders in the studied area for the purpose of improving performance. While it can be effective in comparing performance with another entity, it does not replace the analysis of a hospital's services or practices for the purpose of improving patient outcomes.)

When asked if the data was ever analyzed and trended to look at patterns that affected delivery of care, such as the clusters that had been observed on the ER Throughput report, Staff #4 confirmed that data was not broken down and trended for patterns that affected patient care, such as peak hours vs staffing, day of week, shift, staff rotations, physicians or processes that may hinder patient access to care. The month-to-month changes in percentages had not been analyzed to identify possible causes in the fluctuations.

Staff #4 was asked if she could provide analysis of any of the data for other items being tracked besides the AMA and LWBS, other than tracking the raw numbers and percentages for benchmarks. Staff #4 was unable to provide such analysis. All data provided in the quality reporting was shown to be at or below benchmark. No other data-driven process was seen to be implemented to identify areas that may improve health outcomes, patient safety, and quality of care, with the exception of Infection Control data and Process Improvement (PI) project concerning monitoring cleaning processes through ATP counts, and Nursing Emergency Resuscitation Evaluation and PI project for Rapid Response Team.

Based on review of records and interview, the hospital failed to ensure that the QAPI plan was evaluated each year with a determination made on the number of distinct PI projects for the upcoming year for 5 (CEH, TEH, and HOPD locations at Porter, Spring, and Humble) out of 5 campuses.

Findings:

A review of the QAPI program was made on 5-7-2019. A binder was provided by Staff #4 that contained all of the QAPI meeting minutes, PI projects, and data that was being tracked.

An interview was conducted with Staff #4 on the afternoon of 5-7-2019. Staff #4 confirmed that the binder was complete. Staff #4 was asked to provide any additional information, evaluations, analysis, or reports that may have been reported through the QAPI program. No other information was provided.

Staff #4 was asked to provide a comprehensive list of departments that were participating in QAPI, PI projects in process, and data that was being tracked and analyzed. Staff #4 was not able to provide a comprehensive list.

The binder contained an agenda and sign-in sheet for a Quality Council meeting held on February 7, 2019. No minutes for this meeting were found. The agenda included a line item for the approval of the previous meeting minutes. Minutes of a meeting conducted on October 18, 2018 were included.

An agenda was found for a Quality Council meeting held on April 12, 2019. No sign in sheet or minutes from this meeting were found. The agenda did not include a line item for the approval of the previous meeting minutes and none were included.

Policy Subject: Emergency Hospital Systems 2018-2019 Performance Improvement & Patient Safety Plan; Effective: 09/21/2018; MEC Committee Approval Date: (blank); Board Approval Date: (blank), was provided and reviewed.

Documents from the QAPI binder and the policy provided did not identify the distinct number of PI projects to be completed annually.

Based on observation, interview and record review the facility failed to properly staff 4 (CEH, HOPD Porter, Spring and Humble) of 5 (CEH, TEH, HOPD Porter, Spring and Humble) emergency departments with adequate nursing staff. The facility utilized Emergency Medical technicians and Licensed Vocational Nurses in place of Registered Nurses for three months, March, April, and May of 2019.

Refer to A 0392

Based on observation, interview, and document review, the facility failed to properly staff 4 (CEH, HOPD Porter, Spring and Humble) of 5 (CEH, TEH, HOPD Porter, Spring and Humble) emergency departments with adequate nursing staff. The facility utilized Emergency Medical technicians and Licensed Vocational Nurses in place of Registered Nurses for three months, March, April, and May of 2019.

This deficient practice had the likelihood to effect all patients of the hospitals emergency department.

Findings:


On the morning of 5/8/2019, in the conference room, the staffing plan and staffing grid for all of the hospitals Emergency Departments (ED) were reviewed. An interview with the Chief Nursing Officer (CNO) confirmed only campus B had a a full compliment of Registered Nurses (RN's) who worked the ED. The CNO confirmed that only on campus "B" were RN's exclusively placed on the schedule.


The staffing planning and grid reflected the following approved staffing pattern. All facility locations followed a 12 hour first shift (7:00 AM to 7:00 PM), and a 12 hour second shift (7:00 PM to 7:00 AM), to staff for a 24 hours period. Facility CEH and TEH also included a mid shift (1:00 PM to 10 PM)


CEH
First shift, 2 RN's, 1 Mid shift RN for 5 hours
Second shift, 1 RN, mid shift (RN 3 hours), 1 Licensed vocational nurse (LVN) or Emergency Medical Technician (EMT).

On 5/8/2019 in the late afternoon an interview with staff #25, the Director of Nursing, confirmed she was available to come in and cover when they were short. Staff #25 was asked if she had been coming in routinely at 10:00 PM every evening to provide the RN coverage until 7:00 AM and then attending to her clinic duties? She did not confirm this.

From 10:01 PM until 7:00 am, the ED has 1 RN and 1 LVN or EMT.


THE
First shift, 2 RN's, 1 Mid shift RN for 5 hours, and an LVN/EMT
Second shift, 1 RN, mid shift (RN 3 hours), LVN EMT.


HOPD (Porter, Spring and Humble) do not utilize a mid shift RN
First shift, 2 RN's, 1 LVN/EMT
Second shift, 1 RN, 1 Licensed vocational nurse (LVN) or Emergency Medical Technician


On 5/8/2019, in the afternoon, an interview with the CNO confirmed facility THE was staffed on paper utilizing both RN's and LVN/EMT's, however, the reality was facility TEH utilized only RN's for all positions. All other facility depended on both LVN or EMT services within the ED shift.


State Administrative Code, chapter 773

"(b) Notwithstanding other law, a person who is certified under this chapter as an emergency medical technician-paramedic or a licensed paramedic, is acting under the delegation and direct supervision of a licensed physician, and is authorized to provide advanced life support by a health care facility may in accordance with department rules provide advanced life support in the facility's emergency or urgent care clinical setting, including a hospital emergency room and a freestanding emergency medical care facility."

An EMT is permitted by law to participate in life saving action, such as a code, inside the Hospitals Emergency Department, and that only by permission of the medical staff and approved by the Governing Body.


On 5/8/2019, during an interview with the Chief Executive Officer (CEO), the CEO was overheard to say, "He was not aware an EMT could not be hired to work in a hospital along side a RN in the ED".

A review of the hospitals Medical Staff guidelines and Governing Body rules and regulations failed to identify any clear path of approved skills an EMT was allowed to perform while in the hospital.


Review of the State Board of Nursing Scope of Practice Licensed vocational Nurse (LVN).

"The LVN scope of practice is a directed scope of practice and requires appropriate supervision of a registered nurse, advanced practice registered nurse, physician assistant, physician, dentist, or podiatrist. The LVN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws, rules, regulations, and policies, procedures, and guidelines of the employing health care institution or practice setting. The LVN is responsible for providing safe, compassionate, and focused nursing care to assigned patients with predictable health care needs".

"Though the BON does not regulate employers, and the NPA (Nurse Practice Act) and Board rules are not prescriptive to specific practice settings, the Board believes triage, telephonic nursing, and/or being on-call to handle urgent/emergent issues are all beyond the scope of practice for LVN's. Of concern to the Board are situations where the LVN would be required to independently engage in assessment (either telephonically or face-to-face) for purposes of triaging a patient.

The Board's concerns are based on the fact that LVN's are not educationally prepared to perform triage assessments, either telephonically or in the role of the health care professional initially assessing a patient face-to-face to determine treatment priorities in any setting".


On 5/8/2019, an interview with the CNO confirmed both LVN and EMT were utilized in the ED. The CNO also confirmed that should a code be called the LVN could function as a scribe during the code or she could be the soul nurse available in the ED for patient care until the Code was completed. There was no second RN staffed, on the second shift, to attend other patients that might be in the ED at the time of the code.


On the morning of 5/9/2019 an interview with Staff RN #54 the ED charge Nurse confirmed there was only an LVN, tech or EMT on the medical surgical unit at night. The mid shift RN worked only 3 hours of the night shift (second shift). This left the LVN unsupervised from 10:00 PM until the shift change at 7:00 AM, 9 hours. Staff #54 confirmed if the LVN required assistance one of the two RN's from the ED would assist the LVN on the medical surgical unit. When the LVN required a bathroom break or meal break one of the two RN's from the ED would cover the medical surgical unit. This left one RN in the ED and One RN in the Medical surgical unit for up to 30 minutes (lunch) and two 15 minute breaks.

This was confirmed by staff #25 the Director of Nursing.


32143

A tour was conducted on 5/7/19, at 9:00 AM, at the Hospital Outpatient Department (HOPD) in Humble, Texas. The Emergency Department (ED) has six exam rooms. There was 1 RN full time, 1 RN in orientation, and a EMT present. Staff #56 stated that Staff #59 was in orientation. Staff #56 stated there is usually just one RN and one LVN/EMT/Paramedic per shift. Staff #56 was asked if she takes a lunch break. Staff #56 stated, "yes". Staff #56 confirmed she was docked for that lunch time period of 30 minutes. When the RN takes a break the LVN or EMT/Paramedic is left unsupervised by an RN.

Based on observation and interview, outdated medications were available in the crash cart for patient use in 1 of 2 crash carts opened.

A tour was conducted on 5/7/19, at 9:00 AM, at the Hospital Outpatient Department (HOPD) in Humble, Texas. The Emergency Department (ED) had 2 crash carts. Crash cart #1 had the following emergency medications that were outdated and ready for patient use:

1.) 50% Dextrose injectable x 2 expired 3-19.

2.) Atropine Sulfate injectable 0.1 mg/ml x 2 expired 2-19.

Staff # 56 confirmed the findings. Staff #56 stated, "they should have been caught."

Based on review of documentation and interview, the facility failed to insure the Registered Dietician approved menus and provided a measurable data for use in the quality program from March, April, and May of 2019.

This deficient practice had the likelihood to effect all patients of the facility.


Findings:


On the morning of 5/7/2019, interview with the Dietary department manager confirmed she had menus for use but the menus had not been authenticated by the current Registered Dietician (RD/LD) and approved by her for use.

On 5/7/2019 in the late morning the Chief Executive Officer confirmed, the signature on the menus being used by the dietary department belonged to a person who was no longer employed by the facility.

The dietary department had no Registered Dietician approved menus in use.

On 5/7/2019, in the afternoon, an interview with the Registered Dietician, staff #27, confirmed she had many years experience as a RD/LD. She provided documentation of her visits. The data offered as evidence of the report she submitted to the facility management included the following:

Temperature
Food Quality
Patient Refrigerator
Dining Room Inspection
Correct diet served
Consult Received for dietary triggers/orders
Nutritional consults

Adjacent to each word was a checkmark in a column identified by the word "Yes".

There were no comments or any other measurable data recorded for submission. The documents spanned February, March, April, and through May 7, 2019. The RD was asked why there was no narrative or other data recorded on the form? She replied, "They really only want a check list. They don't want to read al that other stuff".

All available dietary staff (#26, #28, #29, and #30) were interviewed for interaction with the RD. All agreed they recognized the RD and who she was, but none of the Monday through Friday staff had any interaction with the RD, either in group or 1 on 1. The only staff who confirmed interaction with the RD was the weekend cook, staff #30.

A review of the job description for the contracted consultant RD/LD included:

7. Calculate feeding requirements as indicated for enteral, parenteral, and oral therapeutic diets, to include the major and minor nutrients required.

9. Conduct nutritional education for food service staff and other Medical Treatment Facility medical team.

10. Participate and assist in the monitoring, collecting, and evaluating of data to improve nutritional efficiency.

11. Develop indicators based on need, and in compliance with all regulatory agencies, for an effective Continuing Quality Improvement Program.


On 5/6/2019, an interview with the Dietary Manager confirmed, to her knowledge she had not received any quality indicators from the RD/LD to implement in the department.

Based on observation, documentation review, and interview, the facility failed to insure dietary staff were competent to perform their duties in 5 of 5 areas (Food storage in the cooler, food storage in the freezer, monitoring and recording AM and PM temperatures for the cooler and freezer, and testing of the sanitizing solution in the three sink compartment).

This deficient practice had the likelihood to effect all patients of the facility.

Findings:

On 5/6/2019 during an afternoon tour of the kitchen the following observations were made.

Cooler:

Ketchup was stored without a date opened or use by date identified on the bottle.

Mayo was stored without a date opened or use by date identified on the bottle.

Hot Sauce was identified with a date opened of 12/12/2018. No use by date was identified.

Soy Sauce was identified opened on 1/15/2019 and without a use by date on the label.

A plastic container of Lasagna from an earlier meal was identified with no use by date.


The Dietary Manager, staff #26, confirmed the findings. She indicated that the Lasagna was served for a weekend meal and the weekend cook had forgotten to label it, staff had forgotten to label the condiments and close the containers on the frozen vegetables.

A review of the temperature logs for the cooler revealed blank days where no temperature was recorded and temperatures that were recorded outside the recommended temperature range. Below are examples of recorded temperatures and recommended temperatures which were 33 degrees low and 40 degrees high.

May recordings of AM temperature and PM temperatures.

5/1/2019 AM 27 degrees. No PM temperature was recorded.

5/2/2019 No AM or PM temperature was recorded.

5/3/2019 No AM or PM temperature was recorded.

5/4/2019 AM 35 degrees.

5/5/2019 AM 29 degree and a temperature had been written, the temp had been completely inked out, initials were found in the next column, but no temperature was recorded for the PM.

5/6/2019 AM 28 degrees for the AM.


April

4/4/2019 the PM temperature was 30 degrees.

4/5/2019 the PM temperature was 30 degrees.

4/7/2019 the AM temperature was 29 degrees.

4/8/2019 the PM temperature was 30 degrees.

4/9/2019 the AM temperature was 30 degrees.

4/11/2019 the AM temperature was 30 degrees.

4/12/2019 the AM temperature was 31 degrees and the PM temperature was 30 degrees.

4/13/2019 the AM temperature was 32 degrees and the PM temperature was 30 degrees.

4/14/2019 the AM temperature was 31 degrees and the PM temperature was 30 degrees.

4/17/2019 the Am temperature was 30 degrees.

4/18/2019 the AM and PM temperatures was 30 degrees.

4/20/2019 neither the AM nor the PM temperature was legible.

4/21/2019 the AM temperature was 20 degrees.

4/23/2019 the AM temperature was 32 degrees and the PM temperature was 31 degrees.

4/24/2019 the AM temperature was 32 degrees and the PM temperature was 30 degrees.

4/25/2019 the AM temperature was 25 degrees. There was no PM temperature recorded.

4/26/2019 the AM temperature was 23 degrees. There was no PM temperature recorded.

4/27/2019 the PM temperature was not recorded.

4/28/2019 the PM temperature was not recorded.

4/30/2019 the PM temperature was not recorded.


The form contained the following instruction. "If refrigerator temperature is above 40 degrees please contact your food services director immediately". There was no instruction if the temperature was below 33 degrees which would freeze foods and potentially leave them un-usable. No corrective action was documented.


Freezer

A box of frozen green beans and a box of yellow squash was observed with a card board box. The box had been left opened, the internal liner had been left open to the air as well. The vegetables were exposed to the free air circulating in the freezer. This would create damage to the product by freezer burn or cross cross contamination.

Observed in the freezer were three (3) thermometers. The Dietary Manager was asked "why". She replied they needed three to insure the temperature was taken. When she was asked why, she replied she wasn't sure if one wasn't working or a staff couldn't read the thermometer properly.

A review of the temperature logs for the freezer revealed blank days where no temperature was recorded and temperatures that were recorded outside the recommended temperature range. Below are examples of recorded temperatures and recommended temperatures which was "normal range below Zero".


May: recorded in degrees.
No temperatures were recorded for May 2 and 3. A PM temperature was recorded on May 4, 2019 of Zero degrees. No corrective action was documented.


April:
No PM temperature was recorded for 10 days.
4/7/2019
4/8/2019
4/9/2019
4/10/2019
4/19/2019
4/25/2019
4/26/2019
4/29/2019
4/30/2019

Temperature that were recorded Zero or above
4/11/2019 AM Zero.
4/11/2019 PM 22 degrees above Zero.
4/27/2019 PM Zero.

No corrective action was documented.


Also during the kitchen tour, a staff, that was identified by the Dietary Manager as a newly hired tech, was observed at the three compartment sink. He was hand washing pots and pans. The three sinks, each had been filled for use. The new hire, staff #28, explained what the three compartments were for. He directed the surveyor to the test strips where the third compartment of the sink held the final rinsing sanitizer for the pot and pans.

The test strip was removed and staff #28 explained, he dipped the test strip in to the solution of water and sanitizer to insure the correct strength. He could not recall the correct strength.

The surveyor dipped the test strip in the third compartment and asked the Dietary Manager how long should it stay in the water? She replied 10 seconds. No timer found identified for use. The manager was asked, "how do you now when ten seconds are completed". She replied, "you count them out". A fresh test strip was obtained and after counting 10 second, the test strip was removed and found to be 150 parts per minim (ppm). This was less than the 200 ppm the manufacturer recommended for effective sanitizer strength.

A discussion regarding the competencies of the staff who worked in the dietary department revealed the manager was short a full time cook and she had been filling in as the cook to allow the part time cook a break. She also confirmed she had been provided little orientation to the facilities policies but had been given support from the contracted management service. She was aware education for her staff had been delayed, related to her cooking, rather than educating and monitoring her staff. The Dietary manager confirmed she had been in her position about 3 months.

On 5/7/2019, in the morning, an interview with the Regional Director for the contracted management service staff #31, provided documentation the company had a very thorough education training program that included teaching, demonstration and testing, however little or no testing had been provided for the dietary staff since the contract had been negotiated and implemented.

Based on review, observation, and interviews, the Governing Body failed to:

A.) have written documentation of the annual building fire inspections by the local fire control agency to ensure the hospital is free from all fire hazards in 5 (Cleveland Emergency Hospital, Texas Emergency Hospital, and three HOPD facilities in Porter, Humble, and Spring Texas) of 5 locations.


Refer to Tag A0715


B.)

1.) ensure the facility was protected and properly closed during a weather event. There was no timely reentry or plan for 1(Porter) of 5 (CEH, TEH, Humble, Spring, and Porter) Emergency Departments (ED).

2.) to have an approved and active Emergency Preparedness Plan to properly care for patients, divert patients, and safely close and secure the hospital during an emergent situation. The Plan provided was from 2015 and did not address the multiple counties for the Hospital Out Patient Departments (HOPD's). There were no risk assessments found or offered for 5 (CEH, TEH, Humble, Spring, and Porter) of 5 Emergency departments.

3.) protect the facility's narcotics, contrast mediums, medical records, and equipment from the public. The facility was found unsecured and abandoned. A side door to the facility was left opened to the public with no employees in the building or grounds. The administration was informed of the unsecured building by surveyors in 1(Porter) of 5 Emergency Departments.

The condition and deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient/public health and safety, placed all potential patients/public at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to Tag 0724

Based on interview, the facility failed to have written documentation of the annual building fire inspections by the local fire control agency to ensure the hospital is free from all fire hazards in 5 (Cleveland Emergency Hospital, Texas Emergency Hospital, and three HOPD facilities in Porter, Humble, and Spring Texas) of 5 locations.


This deficient practice had the likelihood to cause harm to all patients and staff.


Findings:

An interview was conducted with Staff #5 and Staff #42 on 5/7/2019 after 9:00 AM. Staff #42 was asked to provide the written evidence that the facility had regular fire safety inspections by the local fire control agency. Staff #42 stated, he was recently placed as the "Interim" Plant Operations Director and he would locate the information or contact the local Fire Marshall for the documentation. Staff #5 stated, they recently terminated the Plant Operations Director but he would be able to provide the documentation.

An interview with Staff #1 was conducted on 5/8/2019 after 8:30 AM. Staff #1 was asked about the fire control agency inspections. Staff #1 said, "We asked for a fax confirmation from the Fire Marshall but have not received it."

After multiple requests, no written documentation or perceived documentation was provided during this survey for 5 (CEH, TEH, or HOPD facilities located in Porter, Spring, or Humble Texas) of 5 facilities for any dates of regular inspections from the local fire control agency. Staff #42, Staff #5, and Staff #1 confirmed the findings.

Based on observation and interview, the facility failed to:

1.) ensure the facility was protected and properly closed during a weather event. There was no timely reentry or plan for 1 (Porter) of 5 (CEH, TEH, Humble, Spring, and Porter) Emergency Departments (ED).

2.) to have an approved and active Emergency Preparedness Plan to properly care for patients, divert patients, and safely close and secure the hospital during an emergent situation. The Plan provided was from 2015 and did not address the multiple counties for the Hospital Out Patient Departments (HOPD's). There were no risk assessments found or offered for 5 (CEH, TEH, Humble, Spring, and Porter) of 5 Emergency departments.

3.) protect the facility's narcotics, contrast mediums, medical records, and equipment from the public. The facility was found unsecured and abandoned. A side door to the facility was left open to the public with no employees in the building or grounds. The administration was informed of the unsecured building by surveyors in 1(Porter) of 5 Emergency Departments.

The condition and deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient/public health and safety, placed all potential patients/public at risk for the likelihood of harm, serious injury, and possibly subsequent death.


On May the 8, 2019, at 8:45 AM, surveyors arrived at the CEH Emergency Department (ED) in Porter Texas. The facility is a Hospital Outpatient Department (HOPD) of the hospital. There was a sign on the door that stated, "Due to inclimate (sic) weather this facility is diverting all patients to Cleveland Locations located at:" The sign gave two locations Deerbrook ED and Texas Emergency Hospital along with addresses to each. The surveyors watched several people try to enter the facility but the front door was locked.

A phone call was made to the main campus and spoke with Staff #5 concerning the facility closure. Staff #5 reported that the facility was closed due to flooding in the area. Staff #5 was asked when he was planning to come check on the facility and prepare the facility for opening. Staff #5 stated, "I was planning to go check on it sometime this afternoon." There was no timely reentry planned for this facility. Staff #5 was informed the surveyors were waiting at the facility. Staff #5 stated he would come to the facility and let us in.

On 5/8/19, at 9:19 AM, the surveyors began to look around the outside of the facility for plant maintenance and physical environment. On the right side of the building was a medical clinic. The buildings are attached. The outside door to the clinic was locked but no note. The following issues were found:

9:21 AM- There was an alcove between the two buildings with a putrid smell coming from the alcove. On the ground was a very large rat trap that catches the rodent on the inside of the box. The strong smell was coming from the trap. The trap was sitting next to an open pipe that goes directly into the building.

9:23 AM- The surveyors walked to the left side of the ED and found a side door open. The door was propped open by wet towels and bed spreads found on the floor. The surveyors asked loudly if anybody was in the building multiple times with no answer. The surveyors walked directly into the building. The lights were still on in the facility. All of the computers were still running. There were no other individuals in the building. The building was unsecured and abandoned.

9:24 AM- A room, with a key pad lock, was found with a sign that said, "Pharmacy." The door was not locked. When the surveyor entered the door it was a medical supply room with no pharmacy items located. A door behind the nurse's station also said, "Pharmacy." That door had a regular door handle that was locked.

9:29 AM - The surveyors opened a door and walked into a hallway. An employee break room was to the left. Inside the room was a full platter of salad and Garlic bread. There was multiple salad dressing containers and food opened and left a pungent smell. As the surveyors walked through the hallway it was realized that this was not part of the ED but the clinic next door. The surveyors went back through the opened door that had a lock key pad and a sign that said "Staff Only". The ED was easily accessible from the clinic. Staff #5 confirmed at 10:13 AM that the clinic was not part of the facility and was privately owned.

9:37 AM- The CT Scanner was found running in the building. There was no air-conditioning running in the building and it had become very warm. The CT scanner room was extremely warm and a thermometer in the facility showed 82 degrees. According to block imaging.com, "Proper temperature is critical to your system's operation and must meet certain specifications. Operating temperature in a CT exam room should be kept as close to 72° F as possible (never to exceed 75° F or fall below 64° F)." There was no evidence that anyone checked on the CT scanner and evaluated the safety in the room since water was on the floor beneath the equipment.

9:38 AM- The keys to the CT scanner's medication cabinet was found lying on the desk. The keys opened the cabinets and vials of Isolve-300 and Visipaque were found easily accessible to anyone that walked into the unlocked, unsecured facility. According to the FDA These drugs are contrast mediums. The contrast should be monitored with medical supervision. The contrast can cause "Cardiovascular Disorders: arrhythmias, cardiac failure, conduction abnormalities, hypotension, myocardial infarction, and possible death."

10:08 AM- Staff #1 and #5 entered the facility. The surveyor opened the front door and let them in. Staff #5 asked how we got into the building and we showed how the side door was still propped open. Staff #5 was asked why there was no one here watching the facility. Staff #5 stated, there was flooding last night and the staff locked up and went home. Staff #5 stated, "Maybe the doctor left it open." Staff #1 and #2 was asked why the facility was left open with machines and computers on? Staff #1 reported, she was told the staff had secured the facility.

Staff #1 and #5 were asked where the Emergency Preparedness manual was and why was it not enforced. Staff #1 had a binder in her hand that stated, "Emergency Preparedness." The binder was from the main campus. There was no binder located for staff access in the Porter ED location. The COO stated the manual for the facility was locked up in her office. The manual was not available for employees to properly close the facility in a safe manner. The Plan provided was from 2015 and did not address the multiple counties for the Hospital Outpatient Departments (HOPD's). There were no, found or offered, risk assessments conducted for Montgomery county (Porter).

10:15 AM- A woman walked into the facility from the door between the ED and the clinic. She said, "Hi, I was checking to see if you got any flood damage." The surveyor spoke with the woman and she stated she worked as the marketer for the clinic next door. She also stated that she uses the interior door to come over to the ED. The woman was asked if they shared the breakroom with the clinic. The woman stated, "Yes, all the time. They can come over here whenever they need to use it." The marketer confirmed the door between the two facilities was not locked and was used frequently. Staff #1 and #5 confirmed they were not aware that the door between the two facilities was not locked.

10:17 AM- the staff opened the Pharmacy room. A metal cabinet was attached to the wall and had a lock on it. The cabinet was opened and narcotics were inside. The surveyor and nurse counted the narcotics to make sure they were all there. The medications counted were under a double lock and key. However, sitting above the cabinet was a small metal box with a handle. The box was picked up and opened. Inside the box was Propofol (Anesthetic) 200 mg/20 ml #4, Ketamine (Anesthetic, Sedative) 500 mg/10 ml #3, Etomidate (Anesthetic) 40 mg/20 ml #5, Fentanyl (Narcotic) 100 mcg/2 ml #25, and Versed (Sedative) 2 mg/2 ml #10. In the unlocked refrigerator of the pharmacy room was an unlocked box of injectable Ativan 2 mg/1 ml #8. The medications were not under a double lock and key.

10:30 AM- The laboratory had medical records accessible in an unlocked file cabinet. The papers and files had patient information available.

10:33 AM- Patient ED medical records were found in a file cabinet in the lower drawers close to the ground. The records were left unsecured and vulnerable to possible water damage.

Based on observation, record review, and interview, the facility failed to maintain a clean and sanitary environment to ensure patient's health, safety and mitigate risks of possible hospital acquired infections in 16 (Supply Room, Patient Room #219, Patient Room #220, Patient Isolation room, Medication room, Sterile Supply Room, Cardiac Catheterization Lab (CCL), Sterile Processing Room, Decontamination Room, the Pre-op Patient Restroom, Operating Room (OR) #1, Operating Room #2, Procedure Room #2, Dietary Department at TEH, Emergency Department at TEH, and Emergency Department in Humble, Texas) of 16 areas observed.



Findings:

An observation tour was conducted with Staff #49 on 5/8/2019 after 9:30 AM at Texas Emergency Hospital. The following observations were made:


SUPPLY ROOM

Inside the supply room was a clean linen cart that was used to store clean linen for patients. The linen cart was noted to have no protective barrier on the bottom shelf between the floor and the clean linen. The cover over the linen cart was open on the side and the vinyl was noted to be torn exposing the clean linen to possible contaminants.

PATIENT ROOM #219

Patient Room #219 was clean and prepared for a new patient admit. In the bathroom, the hand rail in the shower was covered with rust and hard water stains. The floor around the toilet was soiled with dirt, dust, and debris.

PATIENT ROOM #220

Patient Room #220 was clean and prepared for a new patient admit. In the bathroom, the handrails in the shower were covered with rust, debris and hard water stains. On the toilet, hair, dirt, and dust were noted.

PATIENT ISOLATION ROOM

Inside the Patient Isolation Room, under the sink was heavily soiled with dirt, dust, and debris. The plumbing fixtures were intact but there were open holes where the plumbing connected to the wall leaving an entry for rodents or insects. On the base of the window seal paint was missing and exposing the porous material underneath. The porous material cannot be sanitized to prevent the spread of infectious diseases.


MEDICATION ROOM

In the medication room where patient's medications are prepared the following was observed: under the sink was visibly covered with heavy dirt, dust, and debris. Inside the patient medication refrigerator dust and debris was observed. On the top shelf inside of the refrigerator was noted to have water pooled. The freezer was soiled with a brown colored stain.

STERILE SUPPLY ROOM

In the sterile supply room were multiple wire racks on wheels used to store patient supplies. Four wire racks were observed to have no barrier between the patient supplies and the floor. This is a risk of cross contamination of dirt, dust, and debris onto patient items.

Staff #49 confirmed the findings.


CCL

Review of the CCL Temperature Logs for the months of March, April, and May 1-5, 2019 was as follows:

Review of the Temperature Log for March 2019 revealed the following:

CCL - The temperature was documented out of range 20 of 21 days. There was no temperature documented for March 25,2019.


Review of the Temperature Log for April 2019 revealed the following:

CCL - The temperature was documented out of range 20 of 21 days. There was no temperature documented for April 8, 2019.


Review of the Temperature Log for May 1-6, 2019 revealed the following:

CCL - The temperature was documented out of range 4 of 4 days.



An interview was conducted on 5/7/2019 with Staff #9. Staff #9 was asked what recommendations and guidelines were followed for patient safety. Staff #9 said, "We follow Association of Operating Room Nurses (AORN) guidelines."

Staff #9 confirmed the findings.



Review of the Policy titled, "INFECTION PREVENTION AND CONTROL MEASURES FOR THE CARDIAC CATH LAB, Reference #4001 revealed the following:

" ...Temperature of the procedure rooms shall be maintained at 68 to 75 degrees F. (AORN,2018) ..."



Review of the AORN Perioperative Standards and Recommended Practices,

"...Temperature should be maintained between 68 degrees F to 75 degrees Fahrenheit (20 degrees to 23 C) within the operating room suite. General work areas in sterile processing should be maintained between 68 degrees to 73 degrees F.

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..."



An observation tour was conducted on 5/9/2019 with Staff #48 after 9:00 AM at Cleveland Emergency Hospital. The following was observed:


STERILE PROCESSING ROOM

In the sterile processing room the autoclave (equipment used to sterilize surgical instruments) was visibly soiled with several large white stains and dust. The rubber seal around the door was split in several places. This could cause the autoclave to fail during processing of sterile instruments by not allowing it to create a seal to maintain temperature to ensure sterility of all instruments processed for patient use.

DECONTAMINATION ROOM

In the decontamination room, under the sink, the cabinet was heavily soiled with dirt, dust, and debris.


PRE-OPERATIVE PATIENT RESTROOM

The air conditioning return vent in the pre-op patient restroom was heavily soiled with dirt and dust.

Staff #48 confirmed the findings.


OR TEMPERATURE/HUMIDITY LOGS

The temperature was out of range for 49 of 49 days reviewed.


Review of the Surgical Services Temperature Log for the months of March, April, and May 1-9, 2019 was as follows:

Review of the Temperature Log for March 2019 revealed the following:

OR#1 - The temperature was documented out of range 15 of 21 days.

OR#2 - The temperature was documented out of range 16 of 21 days.

Procedure Room #2 - The temperature was documented out of range 6 of 21 days.


Review of the Temperature Log for April 2019 revealed the following:

OR #1 - The temperature was documented out of range 15 of 21 days.

OR #2 - The temperature was documented out of range 19 of 21 days.

Procedure Room #2 - The temperature was documented out of range 15 of 21 days.


Review of the Temperature Log for May 1-9, 2019 revealed the following:

OR #1 - The temperature was documented out of range 6 of 7 days.

OR #2 - The temperature was documented out of range 7 of 7 days.

Procedure Room #2 - The temperature was documented out of range 6 of 7 days.

Staff #6 confirmed the findings.


An interview was conducted with Staff #6 on 5/9/2019 after 9:30 AM. Staff #6 was asked what guidelines the operating room followed. Staff #6 said, "we follow AORN guidelines and recommendations." Staff #6 was asked to provide a current policy on temperature and humidity ranges for the surgical services are. Staff #6 said, "we do not have a specific policy in our department for the temperature and humidity ranges."

Review of the AORN Perioperative Standards and Recommended Practices,

"...Temperature should be maintained between 68 degrees F to 75 degrees Fahrenheit (20 degrees to 23 C) within the operating room suite. General work areas in sterile processing should be maintained between 68 degrees to 73 degrees F.

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."




32143

Humble Emergency Department

A tour was conducted on 5/07/2019 at 9:00 AM at the Hospital Out Patient Department (HOPD) in Humble, Texas. The following items were found:

The mattress in the triage room was soiled with a heavy sticky substance.

Clean biohazard supplies were stored with dirty biohazard materials.

Frozen dinners found in the freezer was found to have no expiration dates.

In the Lab and Sonogram room employee items (back packs, purses ect.) were found stored in the same cabinet as medical supplies.

Biohazard trash was found in clean patient rooms.

In exam room 5 the metal trash can was broken and rusted. The bed spread had a rough surface and long black hairs were stuck to the spread. The bed was soiled underneath the mattress with dust and hair.

A Broselow Pediatric Resuscitation Bag had 2 McGill forceps. The forceps were laying open in the bag and had not been sterilized.


28659

TEH failed to maintain a sanitary environment in 5 of 5 areas, Dietary department, Emergency Department negative pressure room, Emergency department crash cart, Medication room in the Emergency Department. and a laboratory draw station for outpatient use, in the Emergency Department.

Dietary Department:

On the afternoon of 5/6/2019 a tour of the dietary department identified the following:

A newly hired staff member was observed working at the three compartment sink. The sanitation rinse sink was observed with water 3/4 of the way full. Staff #26 was asked where the litmus strips were to test the sanitation solution strength. The strips were produced and a small piece was removed and dipped into the water. Staff #26 was asked how long he left the strip in the rinse before lifting and comparing the color of the strip tape to the color chart provided by the manufacturer. She stated 10 seconds. Observation of the work area did not locate a timer. Staff #26, the Dietary Director confirmed the staff counted off 10 seconds.

A new test strip was dipped for 10 seconds (counted out) and compared to the color chart provided by the manufacturer. The color indicated 150 parts per minim (ppm), rather than the 200 ppm recommended by the manufacture of the sanitizing solution. The color was confirmed by the Dietary Director.

After review of the educational material provided by the management company representative, staff #31 confirmed the desired sanitation strength should read 200-400 ppm. The sanitation rinse was not of sufficient strength to provide effective rinse of kitchen cooking utensils against residual bacteria.

Review of the dietary policy did not identify a policy or procedure established by the facility for manual washing, rinsing and sanitizing pots and pans used in preparing patient nutritional needs. An educational plan with teaching, and testing was provided by staff #31. The management company provided printed educational material which indicated the desired strength of the sanitizing solution should be 200 ppm. If the water was cool the rinse should last 1 full minute. If hot water was used the rinse could be reduced to 30 seconds. No sanitation log was provided for review and no timer was available for use.

This was confirmed by staff #26.


Emergency Department (ED):

On 5/7/2019 during a tour of the ED, staff #33 identified room #9 as the negative pressure room. This room would be used to house a patient with a contagious air born disease such as Tuberculosis. The room had 1 door into an ante room, preceding entry into the actual patient care room. The ante room demonstrated negative pressure when tested with a piece of tissue laid on the floor. The room's negative pressure pulled the tissue into the ante room. However, the patient room had a second doorway which exited directly into the common hallway immediately across from the nurses station. A piece of tissue which was rested on the floor outside this second exit did not demonstrate negative pressure. The tissue was forced back and away from the door into the common hallway.

This was confirmed by staff #33.


Medication room:

The medication storage and preparation room used by the ED nurses was identified to have 2 pieces of equipment available for crushing medications for ease of swallowing and 1 piece of equipment used for cutting patient medication into a fractionalized dose. All three pieces were observed with powdered residue of white and brown coloring. One of the 2 pill crusher was affixed to the counter top and was visibly soiled. This was witnessed and confirmed by staff #33.


Crash Cart ED:

The crash cart identified in the ED was observed to contain:

1. A 10 cc syringe of normal saline was identified in drawer #1, the expiration date was 11/2018.

2. A long dark human hair was identified in drawer #4.

3. 1 green top blood collection tube expiration date of 4/30/2019.

4. One purple top blood collection tube expiration date of 3/31/2019.

Lab:

Draw station outside of the ED
1. 14 micro tubes used for blood collection expired 4/30/2019

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


A. provide discharge planning for in-patient for 4 of 4 months (January, February, March , and April, 2019).


This deficient practice had the likelihood to effect all patients of the facility.


Findings:


On the morning of 5/8/2019, on the medical surgical unit (MSU) the staff nurses (Staff #24 and #34) were interviewed regarding discharge planning. Both staff indicated they would call the financial manager to come speak with the patient if they need out of hospital assistance.

The Registered Nursing (RN) staff reported the newly hired discharge planner had started yesterday, 5/7/2019. The discharge planner had not begun the discharge planning process.



B. ensured the Registered Nurses documented the assessment of patient needs leading to impending discharge from January through April 2019.


Refer to A 0806

Based on record review and interview, the facility failed to ensure the Registered Nurses documented the assessment of patient needs leading to impending discharge from January through April 2019.

This deficient practice had the likelihood to effect all patients of the facility.


Finding:


On the morning of 5/8/2019, the medical records for patients #1, #2, #12, #13, #19, #20, #21, #22, #23, #24, and #26 were reviewed. No discharge planning assessment was identified in any of these medical records.

Interview with staff #24 and #34 confirmed the nurses did not do discharge planning. They would simply notify the financial manager who would come speak with the patients.

The above staff reported the position of discharge planner had been filled the day before and there had been no designated discharge planner prior to yesterday.

Based on document review and interview, the facility failed to follow its own policy on required training.

This deficient practice had the likelihood to cause harm to all surgical patients.

Findings:

An interview was conducted on 5/9/2019, after 9:00 AM, with Staff #50. Staff #50 was asked how often do they perform Malignant Hyperthermia drills. Staff #50 said, "I haven't done one since I have been here and I have been her a while."

Review of document titled, "MANAGEMENT OF PATIENT WITH MALIGNANT HYPERTHERMIA (MH), REFERENCE #8061" was as follows:

" ...Surgical Services clinical staff shall receive education regarding malignant hyperthermia, and the proper management of a patient with malignant hyperthermia ..."

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

1. Ensure that the physician documented a complete History and Physical (H&P) and/or update to include changes in the patient's condition prior to the surgical procedure in 5 (#7, #8, #9, #10, #11, #12, #15, #16, #17, and #18) of 10 patient charts reviewed.

2. Ensure the physician had privileges to perform a History and Physical and/or update the History and Physical in 2 (#15 and #18) of 10 patient charts reviewed.

This deficient practice had the likelihood to cause harm to all surgical patients.


Findings:

PATIENT #9
A review of Patient #9's medical record revealed the history and physical update documented by Personnel #18, did not contain a time that indicated any changes in the patient's condition prior to surgery/invasive procedure on 3/7/2019. A review of the history and physical dated 3/5/2019 did not indicate Patient #9 had a medical emergency prior to surgery/invasive procedure.

PATIENT #11
A review of Patient #11's medical record revealed no history and physical update documented by Personnel #43 in the medical record that indicated any changes in the patient's condition prior to surgery on 4/22/2019. A review of the history and physical documented by Staff#18 was not signed nor timed and did not indicate Patient #11 had a medical emergency prior to surgery.

Staff #6 confirmed the findings.

PATIENT #12
A review of Patient #12's medical record revealed no history and physical update documented by Personnel #52 in the medical record that indicated any changes in the patient's condition prior to surgery on 5/3/2019. A review of the history and physical did not indicate Patient #12 had a medical emergency prior to surgery.

Staff #6 confirmed the findings.

PATIENT #15
A review of Patient #15's medical record revealed no history and physical update documented that indicated any changes in the patient's condition prior to surgery on 5/3/2019. Personnel #19 does not have privileges to perform H&P's nor H&P updates. A review of the history and physical documented by Staff #11 prior to admission, did not indicate Patient #15 had a medical emergency prior to surgery.

Staff #6 confirmed the findings.

PATIENT #18
A review of Patient #18's medical record revealed no history and physical update documented by Personnel #19 in the medical record that indicated any changes in the patient's condition prior to surgery on 5/3/2019. Personnel #19 does not have privileges to perform H&P's nor H&P updates. A review of the history and physical documented by Staff #11 on 5/2/2019 was prior to admission and did not indicate Patient #18 had a medical emergency prior to surgery.

Staff #6 confirmed the findings.


An interview was conducted on 5/9/2019 with Staff #6. Staff #6 was asked if all the physicians had privileges to perform a History and Physical. Staff #6 stated, yes they do. A review of the Physician roster in the surgical services department revealed Staff #19 did not currently have privileges to perform History and Physicals.

Staff #6 confirmed the findings.


Review of the Medical Staff Bylaws, Rules and Regulations approved January 30, 2019, revealed the following:


" ...16.7 HISTORY AND PHYSICALS

a. General

i. There must be a complete history and physical examination (H & P), and an update, as applicable in the medical record of every patient (inpatient or outpatient) prior to surgery, or a procedure requiring anesthesia services, moderate or deep sedation procedures, except in emergencies.

ii. H&Ps may only be performed by EMERGENCY HOSPITAL SYSTEMS, LLC. physicians, Oral maxillofacial surgeons, or other qualified licensed individuals authorized in accordance with State law and Credentialed and privileged to complete H&Ps and required updates at the hospital.

iii. The H&P may be handwritten or transcribed, but always must be placed within the patient's medical record within 24 hours of admission or registration or prior to procedure whichever occurs first as described below in Timeframe for completing and Updating H&P's. Documentation of ``See dictated H&P DOES NOT meet the intent of this requirement. In these instances, if the timeframe's are met as defined below, a handwritten H&P containing all required elements would suffice.

b. Responsibilities

i. Privileges- H&Ps and required updates may only be completed by an individual who has been granted privileges by the hospital to do so ....

c. Time Frame for Completing and Updating -A durable, legible copy of the H&P must be completed and recorded in the patient's medical record as follows:

i. Inpatients

l) H&P will be completed within 24 hours after admission or prior to surgery or procedure requiring anesthesia, deep or moderate sedation, whichever occurs first; or

2.) If using a H&P that was perfumed up to 30 calendar days prior to admission, an update documenting any changes in the patient's condition is completed 24 hours after the inpatient admission or registration, but prior to surgery or procedure requiring anesthesia, deep or moderate sedation, whichever occurs first.

3) H&P performed greater than 30 calendar days prior to admission or procedure as described above ARE NOT ACCEPTABLE.

ii. Outpatients requiring H&P as required by the medical staff

1) H&Ps may be completed up to 30 calendar days prior to outpatient procedure provided an update documenting any changes in the patient's condition is completed prior to surgery or procedure requiring anesthesia, deep or moderate sedation, whichever occurs first; and

2) The update occurs at the time of (day of) and prior to the outpatient procedure.

3) H&Ps performed greater than 30 calendar days prior to procedure as described above ARE NOT ACCEPTABLE.

d. Update Requirements

i. The update must document the examination by an appropriate privileged practitioner of any changes in the patient's condition since the patient's H&P was performed that might be significant for the planned course of treatment.

ii. The update must be documented even if no changes have occurred with the patient's status. In this case the update should reflect the patient's H&P was reviewed, the patient was examined and no changes have occurred in the patient's conditions since the H&P was completed.

iii.The update must be on or attached to the H & P.

e. Cancellation/Delay of Procedures-Elective inpatient or outpatient surgery/invasive procedures will be canceled delayed until a complete history and physical examination is recorded in the medical record.

g. Dentists, Podiatrist, Maxillofacial Surgeons-Dentists, podiatrist, and maxillofacial surgeons shall be responsible for recording in the medical record a history and physical examination relative to the portion of the patient's history and physical which relates to their specialty and for which they have clinical privileges. Any medical problem present on admission or arising during the hospitalization of a dental or podiatric patient shall become the responsibility of a qualified physician ..."

Based on record review, the facility failed to ensure post-operative progress notes contained all the required information in 4 (#7, #8, #9, #10, #11, #12, #15, #16, #17, and #18) of 10 patient charts reviewed.

This deficient practice had the likelihood to cause harm to all surgical patients.


Findings:


PATIENT #7
A review of Patient #7's post-procedural note dated 5/2/2019 revealed, Staff #18 did not include the following required element:

1. The Post-operative note did not identify the type of anesthesia administered.

Review of Patient #7's intra-operative procedure record dated 5/2/2019 revealed moderate sedation was administered during the procedure by Staff #10 and Staff #11.


PATIENT #8
A review of Patient #8's post-procedural note dated 3/26/2019 revealed, Staff #18 did not include the following required elements:

1. The Post-procedural note did not identify the type of anesthesia administered.

2. Date and time of the procedure

Review of Patient #8's intra-operative procedure record dated 3/26/2019 revealed moderate sedation was administered during the procedure by Staff #10 and Staff #11.



PATIENT #11
A review of Patient #11's post-operative note dated 4/22/2019 revealed, Staff #43 did not include the following required elements:

1. The Post-operative note did not identify the assistant.

2. The Post-operative note did not contain the findings of the procedure.

Review of Patient #11's intra-operative surgical record dated 4/22/2019 revealed Staff #10 was listed as the assistant during the surgical procedure.



PATIENT #16
A review of Patient #16's post-operative note dated 5/6/2019 revealed, Staff #52 did not include the following required element:

1. The Post-operative note did not identify the assistant.


Review of Patient #16's intra-operative surgical record dated 5/6/2019 revealed, Staff #10 was listed as the assistant during the surgical procedure.




A review of the Medical Staff Rules and Regulations approved January 30, 2019 was as follows:

"...2.9 Operative/ Post Procedure Reports

a. Operative/post procedure reports are required for all invasive surgical procedures, invasive procedures requiring anesthesia, deep sedation or moderate sedation, circumcisions and other procedures as may be required by the MEC.

b. Operative/post procedure reports must be written immediately after procedure. Immediately is defined as a "upon completion of the procedure and before the patient is transferred to the next level of care." If the surgeon/physician performing the procedure accompanies the patient from the procedure setting to the next unit or area of care, the post procedure report may be written in that unit or care area. NOTE: Documenting in the medical records, "See Dictated Report", DOES NOT meet the intent of this requirement.

c. A brief operative/post procedure report shall be handwritten in the medical record immediately after surgery/procedure and shall contain:

i. Name and hospital identification number of the patient;

ii. Date and time of the procedure;

iii. Name(s) of the physician(s) and assistants or other practitioners who performed the procedure and procedural tasks (even when performing those tasks under supervision), including names of physicians or practitioners name(s) and a description of the specific significant procedural tasks that were conducted by practitioners other than the primary surgeon/practitioner (significant surgical procedures include: opening, closing, harvesting grafts, dissecting tissue, removing tissue, implanting devices, altering tissues);

iv. Pre-operative diagnosis;

v. Post-operative diagnosis;

vi. Name of specific procedure performed;

vii. A description of techniques, including procedural technique and related findings;

viii. Type of anesthesia used;

ix. Complications, if any;

x. Estimated blood loss;

xii. Prosthetic devices, grafts, tissues, transplants, or devices implanted, if any;

xiii. Gross pathology observed visually or by palpation;

d. A detailed operative report, containing the elements described above, shall be dictated within twenty four (24) hours following surgery/procedure, and filed in the patient's medical record as soon as possible after surgery/procedure. When the operative report is not placed in the medical record immediately after surgery, a progress note shall be entered..."

Based on review of records and interview, the facility failed to ensure a physician was appointed as director of respiratory care services to supervise and ensure services were appropriately administered within the scope of services offered in 2 of 2 inpatient hospital locations (CEH and TEH).

Findings:

Review of the physician credentialing and physician staff roster did not reveal an identifiable director of respiratory care.

Staff #22 was interviewed on the morning of 5-7-2019. Staff #22 stated that she did not know of a physician who was appointed as respiratory director.

Staff #1 was interviewed later that morning. Staff #1 stated that Staff #35, a respiratory therapist, was the respiratory director. The requirements for a physician to be appointed as the Director of Respiratory Services was reviewed with Staff #1. Staff #1 confirmed that no physician had been appointed.

Based on document review and interview, the facility failed to develop a Comprehensive Emergency Preparedness Plan meeting the requirements of the Emergency Preparedness Program (EPP). This presents a risk that facility staff will not be prepared to respond in an emergency in 5 (Cleveland Emergency Hospital, Texas Emergency Hospital, and three HOPD facilities in Porter, Humble, and Spring Texas) of 5 locations.

The facility failed to ensure:


A. The Emergency Preparedness Plan (EPP) was reviewed annually.

Refer to Tag E0004


B. The EPP was based on an approved All Hazards Risk Assessment

Refer to Tag E0006


C. The EPP included a current developed Communication Plan

Refer to Tag E0029


D. The EPP had primary/alternate means for communication in the facility

Refer to Tag E0032


E. EPP met all EP Testing Requirements

Refer to Tag E0039



This deficient practice had the likelihood to cause harm to all patient's and staff.


Findings:

An interview was conducted on 5/06/2019 after 11:00 AM with Staff #5 and Staff #1. Staff #1 was asked if the EPP was separate for each facility or was there one EPP that applied to all facilities. Staff #1 said, "The EPP was for all campuses and each campus maintains a copy of the EP Plan."

An interview was conducted on 5/07/2019 after 8:30 AM Staff #42 at Texas Emergency Hospital (TEH). Staff #42 was asked where the EPP was located at this facility. Staff #42 replied, "I'm not usually here at this location but I will try and locate it for you. The employee that was the director of the Plant Operations Department is the one that keeps this information and he was terminated 5/02/2019." Staff #42 was asked if the policies and procedures were included in the EPP. Staff #42 said, "yes they are."

Staff #5 confirmed the information.

On 5/07/2019 after 9:30 AM, documentation that was titled, "Cleveland Emergency Hospital Emergency Operations Plan, January 2016" was presented to this surveyor. The reference #2201 had an effective date of 8/22/2015 with a revised date of 1/07/2016. The document had an approval date of 12/02/2015 by the "EOC Committee" and a "Board" approval date of 12/18/2015.


On 5/08/2019 before 11:00 AM Staff #1 presented documentation titled, "Texas Emergency Hospital Emergency Plan, January 2016." The reference #2201 had an effective date of 3/15/2018. The document contained no revision date. The approval date by the MEC (Medical Executive Committee) was 3/13/2018 and the "Board" approval date was 3/15/2018. This document was obtained from the HOPD located in Porter, Texas by Staff #1 and brought to the TEH Campus for review. This document was obtained by Staff #1 at the HOPD in Porter, Texas from a locked office. This EPP was not readily available to all staff in the event of an emergency.


An interview was conducted with Staff #1 on 5/8/2019 after 1:00 PM. Staff #1 was asked if the two documents were the same. Staff #1 said, "They should be the same. Staff #1 was asked why the dates of approval and revisions were different. Staff #1 confirmed the findings but could not explain the difference in dates.

Based on document review and interview, the facility failed to update the Emergency Preparedness Plan at least annually in 5 (Cleveland Emergency Hospital and Texas Emergency Hospital and three HOPD facilities located in Porter, Humble, and Spring) of 5 locations.

This deficient practice had the likelihood to cause harm to all patients and staff.

Findings:

1. A review of the document titled, "Cleveland Emergency Hospital Operations Plan, Reference #2201" revealed the last date of revision was 1/07/2016 with a "Board" approval date of 12/18/2015.

2. A review of the document titled, "Texas Emergency Hospital Emergency Operations Plan, Reference #2201" revealed no revision date and a "Board" approval date of 3/15/2018.

An interview was conducted with Staff #1 on 5/8/2019 after 1:00 PM. Staff #1 was asked if the two documents were the same. Staff #1 said, "They should be the same." Staff #1 was asked why the dates of approval and revisions were different? Staff #1 confirmed the findings but could not explain the difference in the dates on 2 (Cleveland Emergency Hospital Emergency Operations Plan and Texas Emergency Hospital Emergency Operations Plan) of 2 documents reviewed.


This could delay a response by staff to any natural or man-made disaster emergency.

Staff #1 and Staff #42 confirmed the findings.

Based on document review and interview, the facility failed to have an approved documented facility-based and community-based risk assessment using an "all-hazards" approach in 5 (Cleveland Emergency Hospital, Texas Emergency Hospital and three HOPD facilities located in Porter, Humble, and Spring) of 5 locations.


This deficient practice had the likelihood to cause serious harm to all patients and staff.


Findings:


1. A review of the document titled, "Cleveland Emergency Hospital Emergency Operations Plan", reference #2201 with a board approval date of 12/18/2015 revealed the following:

" ...A list of priority concerns will be developed from the HVA and are evaluated annually. The HVA will include the ability to provide services, the likelihood of those events occurring, and the consequences of those events. Form 1 is the HVA assessment tool used. The hospital's HVA is reviewed annually by the LEPC ..."

No approved facility-based, community-based risk assessment or Hazard Vulnerability Analysis was included. No further documentation was provided.


2. A review of the document titled "Texas Emergency Hospital Emergency Operations Plan", Reference #2201 dated January 2016 with a board approval date of 03/15/2018 revealed the following:

No approved facility-based, community-based risk assessment or Hazard Vulnerability Analysis was included. No further documentation was provided.

Staff #1 confirmed the findings.

Based on document review, the facility failed to have an updated, at least annually, Communications Plan in 5 (Cleveland Emergency Hospital, Texas Emergency Hospital and three HOPD facilities in Porter, Humble, and Spring) of 5 locations.


This deficient practice had the likelihood to cause harm to all patients and staff.


Findings:


1. A review of the document titled, "Cleveland Emergency Hospital Emergency Operations Plan," reference #2201 revealed the following:

" ...Emergency Communication and Notifications Plan, page 23 of 61 of the Cleveland Emergency Hospital Emergency Operations Plan revealed a revision date of 1/07/2016 ...

This was three years past the annual renewal date requirement.

Staff #1 and Staff #42 confirmed the findings.

Based on interview and observation, the facility failed to have back up communication resources in place that were readily available for use in 1 (Cleveland Emergency Hospital, Texas Emergency Hospital and three HOPD facilities in Porter, Humble, and Spring Texas) of 5 locations.

This deficient practice had the likelihood to cause harm to all patients and staff.

Findings:


An interview was conducted with Staff #42 and Staff #51 on 5/7/2019 after 9:00 AM. Staff #42 and Staff #51 were asked where the back-up communication was stored and what alternate means of communication is available during an emergency. Staff #42 stated they have back up portable radios (walkie-talkies) that are stored in the maintenance office.


An observation tour was conducted at the Texas Emergency Hospital on 5/7/2019 after 9:00 AM with Staff #42 and Staff #51. Visual observation was made by this surveyor of the back-up communication equipment. It was noted, during the tour, the back-up communication equipment for use during an emergency was not readily available. There was no power available to the back-up portable radios (walkie-talkies) nor was the equipment being charged through an electrical outlet to ensure emergency communication was readily available.

Staff #42 and Staff #51 confirmed the findings.

Based on interview and document review, the facility failed to ensure the Emergency Plan Testing requirements were met in 5 (Cleveland Emergency Hospital, Texas Emergency Hospital and three HOPD facilities in Porter, Humble, and Spring) of 5 locations.

This deficient practice had the likelihood to cause harm to all patients and staff.

Findings:

An interview was conducted on 5/7/2019 after 9:00 AM with Staff #1 and Staff #23. Staff #1 and Staff #23 were asked when was the last emergency exercise conducted to test the emergency plan. Staff #1 said, "We were involved in the "Every 15 Minute Drill" that the local high school puts on not long ago."


After requesting the documentation for the Emergency Exercise Plan to include the date, personnel, agency, and other healthcare entities involved on 5/7/2019 after 9:00 AM and again on 5/8/2019 after 9:00 AM, no documents were provided. Staff #1 and Staff #23 were asked to provide documentation of any emergency plan drills, community-based, facility-based, or an actual emergency that required the facility to fully activate their emergency plan for the last 3 years. No such documentation was provided at any time during the survey.


A review of the documents titled, "Texas Emergency Hospital Emergency Operations Plan, Reference #2201, page 5 of 61," and "Cleveland Emergency Hospital Emergency Operations Plan, Reference #2201, page 5 of 61," revealed the following:


" ...1. OVERVIEW ...
The newly revised plans and procedures will be exercised and reviewed to determine and measure functional capability ..."


Staff #1 and Staff #42 confirmed the findings.