HospitalInspections.org

Based on a review of documentation, clinical records and an interview with staff, the facility failed to appoint a chief executive officer who was responsible for managing the hospital. Failure to properly manage the hospital and follow all policies and procedures can compromise patient and staff safety and well-being.

Findings were:

Facility policy titled "Pre and Post Anesthesia Evaluation" states, in part:
"The post anesthesia evaluation shall include, but is not limited to, assessment of:
· Respiratory function, including respiratory rate, airway patency and oxygen saturation
· Cardiovascular function, including pulse rate and blood pressure
· Mental status
· Temperature
· Pain
· Nausea and vomiting
· Postoperative hydration"

A review of the clinical records for 3 surgical patients (patients #15, #16 and #17) revealed post anesthesia evaluations that consisted only of blood pressure, pulse, respirations, oxygen saturation and temperature. Airway patency, mental status, pain, nausea & vomiting and post operative hydration were not assessed. In an interview with staff #19 on 3-25-15 at 3:45 pm, staff #19 confirmed that the anesthesia record would contain any post anesthesia information and that it would not be documented anywhere else in the clinical record.

Facility position description for a Registered Nurse states, in part:
"REGULATORY REQUIREMENTS:
· Graduate of an accredited school of nursing
· Current state Registered Nurse Licensure, within state of practice
· Current BCLS certification
· M/S and ER - ACLS certified within six (6) months of hire
· M/S and ER - ENPC (Emergency Nurse Pediatric Course) or PALS (Pediatric Advanced Life Support) within one (1) year of hire
· M/S and ER - TNCC (Trauma Nurse Core Course) within one (1) year of hire"

A review of personnel files for 3 registered nurses (staff #8, #9 and #10) revealed that 1 of 3 registered nurses (staff #8) lacked the following requirements:
· ACLS
· ENPC or PALS
· TNCC

The hire date of staff #8 was 5-24-06. A review of nurse staffing schedules from the date of 11-16-14 to
3-7-15 revealed that staff #8 had worked shifts on the Med/Surg unit during the time period examined.

Facility position description for a Medical Surgical Unit LPN/LVN states, in part:
"REGULATORY REQUIREMENTS:
· Graduate of an accredited LPN/LVN program
· Current LPN/LVN licensure in State of Texas
· Current BCLS certification
· Successful completion of arrhythmia course"

A review of personnel files for 3 licensed vocational nurses (staff #5, #6 and #7) revealed that 3 of 3 licensed vocational nurses lacked the following requirement:
· Successful completion of arrhythmia course

A written statement provided by staff #20 stated "We don't have arrythmia course(sic) for LVNs." A review of nurse staffing schedules from the date of 11-16-14 to 3-7-15 revealed that staff #5, #6 and #7 had worked shifts on the Med/Surg unit (as well as shifts on the obstetrical unit) during the time period examined.

The above was confirmed in an exit conference with the facility Chief Executive Officer, Assistant Director of Nursing,Medical Records Director, Chief Nursing Officer, Chief Financial Officer, Chief Operating Officer and Dietary Manager on the afternoon of 3-26-15 in the facility conference room.

Based on observation and a tour of the facility, the infection control officer failed to develop and implement policies governing control of infections and communicable diseases. Failure to do so increases the risk of infections and communicable diseases for patients and staff.

Findings were:

During a tour of the facility on 3-26-15, the following observations were made:
· The stretcher mattress in ER rom #418 contained 2-1" cracks and a 1/2" crack in the mattress surface.
· The stretcher mattress in ER room #420 contained numerous puncture-type holes.
· The stretcher mattress in ER room #410 contained numerous tears in the mattress surface.
· The therapy table cover in PT room #912 contained a 2" tear.
· The therapy table cover in PT room #911 contained a 1/2" tear.
· 1 of 6 exercise bicycles in the PT area had a torn seat cushion.

Tears in the mattress surface prevent proper cleaning of the mattress and can harbor bacteria.

The above was confirmed in an exit conference with the facility Chief Executive Officer, Assistant Director of Nursing,Medical Records Director, Chief Nursing Officer, Chief Financial Officer, Chief Operating Officer and Dietary Manager on the afternoon of 3-26-15 in the facility conference room.