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Based on record review, and interview of six of six (ID # AA, B, BB, EE, J, I, F) employee files, revealed six employees had no training or competencies noted in their files.

Findings Include:

Record review of six employee files on 03/02/2022 at 1100 (ID # AA, B, BB, EE J, I, F) that included registered nurses and other ancillary staff revealed no competencies or recent training related to their current position.

Interview and observation on 03/02/2022 at 1200 with the DON (ID# B) presented a book of competencies, revealed no competencies and training of staff. She stated that was all she had and vertified the staff should have competencies and training. The book contained nurse licenses and certifications for basic and advanced life support.

Based on observation, interview and record review, the facility failed to ensure that the pharmacy was secure at all times.

Findings include:

Record review of facility policy titled "Pharmacy Security Measures;" dated 4/2021 showed the following:
Policy: To ensure the safety and security of pharmaceutical products and narcotics within this facility a very strict policy of pharmacy entry must be followed at all times.

Procedure:
1. The pharmacy must be securely locked at all times.

Observation on 2/28/2022 at 1:12 PM showed the pharmacy sliding glass window to be unlocked and able to opened by the surveyor, no one was present in the pharmacy.


Interview with pharmacy technician (ID AA) on 2/22/2022 at 1:20 PM, she stated that the glass window is only locked when she leaves for the day.

Interview with pharmacist (ID CC) on 3/1/2022 at 11:15 AM, he stated that the pharmacy window should be locked at all times, especially when there is no one in the pharmacy.

Based on interview and record review, the facility failed to comply with the fire drill requirement per National Fire Protection Association (NFPA) guidelines and state regulation.

a. The facility failed to conduct all required fire drills of "one per shift per quarter" for year 2021.

b. The facility failed to fully develop, approve, and implement a Life Safety Plan that included fire drills.

Findings included:

a. Fire drills:

Record review of NFPA guidelines 101 showed : the facility shall conduct one fire drill per shift per quarter.

Record review on 03/2/2022 of facility fire drills from January 2021 through Dec 2021 showed:

-one fire drill conducted on 09/29/2021. The drill was a listing of of many staff names on a legal pad. A handwritten heading at the top that read: " Fire Drill 9/29/2021." There was no time of day, location of drill, or post-evaluation of the fire drill.

During an interview on 3/02/2022 at 1: 15 PM with Staff D, Assistant Administrator, she verified the 9/29/2021 fire drill was the only fire drill conducted by facility in 2021.

Record review of a DRAFT facility policy titled "Fire/Life Safely Plan, "undated, showed the following:

Pages 29-30:

- fire drills will be conducted 1 per shift per quarter.
- staff responsibilities were delineated
- fire drills will be critiqued and submitted to Safety Officer and Patient Safety Committee.

b. Fire Drill policy:

During an interview with Staff Q, Risk Management /Ancillary Services, on 03/02/2022 at 11:15 AM, he stated the "Fire/Life Safety Plan"was a 'work in progress' and not yet completed or approved by the Governing Body.

Based on staff interview and record review, the governing body failed to ensure the medical staff bylaws were followed. When receiving a self-reported notice of a Board of Nursing investigation by a nurse practitioner on a re-credentialing application, there was no acknowledgment of receipt of notice or follow-up/further investigation performed by administration or the medical staff peer review committee.

Findings include:

1) Record Review

a) Record review of Bylaws performed on March 2, 2022 at 1030am. Riceland Medical Center "Board of Directors Bylaws" approved these Bylaws on October 27, 2021. On page 10, under section "7.2 Appointment and Termination of Staff", the policy states, "The Directors shall act upon applications for appointment, reappointment, specific Clinical Privileges and assignments of responsibilities within the Staff ... 7.2-5 All applications for appointment to the Staff shall be in writing and shall be addressed to the CEO of the Hospital. They shall contain full information concerning the applicant's education, licensure, practice, competence, previous performance and Hospital experience, and any unfavorable history with regard to licensure and Hospital Privileges."

b) Credential File Review performed on 2/1/22 at 1430 for Staff X. Staff X had been granted temporary privileges on Sept 9, 2014. He was fully re-credentialed November 29, 2016, January 29, 2019 and October 27, 2021. There is a "Biennial Medical Staff Reappointment Application" packet signed and dated by Staff X, "3/9/21". In this packet, he answers the question #1 "Are you currently under investigation by a hospital, state licensing agency or other professional health care organization? X Yes". The packet asks for "Yes answers to provide details on a separate sheet of paper."

A handwritten note accompanying this application states: "In January 2019, Board of Nursing reported that I had over a certain number of controlled prescriptions. Over the recommended number for the year. Requested a list of charts. Charts have been submitted but have had no ruling. Lechter Law Firm in Austin handling the case. Have been advised to just wait on Board of Nursing to respond. My attorney reports that the long time frame indicates that there is no major offense. He suspects it will be dropped." NP Signature matching signature found in credentialing packet noted.

2) Interviews:

a) Staff D, Assistant Director of Administrative Services, on 3/2/22 at 1055am. Staff D verified that it is her signature notifying the nurse practitioner for re-appointment granted October 27, 2021. Staff D reviewed Staff X file. Staff D stated "This was overlooked. It should have been picked up by medical staff office." She denies that the current administrative team is aware of this re-application notice in Staff X's packet. Staff D states "this was not internally investigated." "I did not speak to Staff X about this issue." She further states the "normal process would have been for us to investigate this issue and follow-up."

b) Staff A, Administrator interviewed in his office 3/2/22 at 1235. Staff A states, "I am not aware of this issue." He states I would expect "communication or verification from the investigating agency that it is OK to continue practicing." Staff A states the expected practice for this pending board investigation would be the "provider would be put on probation pending outcome of the investigation." Staff A states the provider's "supervising physician - Staff U - should have been notified of a pending investigation" as well. Staff A states "if there is an issue identified by the Board, a formal board ruling goes through Medical Staff committee." Staff A states he would expect communication related to any investigation and follow-up by administrative team should be reflected in the credentialing file.

Based on interview and record review, the facility failed to ensure the nutritional needs of patients were met according to facility policy.

A Registered Dietitian (RD) failed to conduct an evaluation of 4 of 6 sampled patients assessed as "high-nutritional risk" [Patient ID# s: 39, 40, 41, 42]

Findings included:

Record review of facility policy titled "Initial Nutritional Screening," dated 01/01/2021, showed:

-Nursing will send a referral to Dietary identifying patients as being at high nutritional risk.
-Those patients will have one or more of the following conditions: new onset diabetes; tube feeding (enteral feeding); TPN feeding (parenteral feeding); diagnosis of malnutrition.
-The Dietary Manager will collect data and further screen patient for Registered Dietitian to evaluate.

During a telephone interview on 03/02/2021 at 9:20 AM with Staff ID-O, Registered Dietitian, she stated the following: 2/07/2021

-she was contracted by facility and usually came on-site at least one time a month.
- there were 'triggers"for her to come to facility to evaluate patients.
- the Dietary Manager performed the initial nutritional screening exam that identified the triggers. These triggers included:

a. patients with multiple wounds (pressure ulcers)
b. significant weight loss (5%)-malnutrition
c. renal patients-ESRD- [end stage renal disease]
d. patients on ventilators
e. Albumin less than 2.8
f. new onset diabetes
g. patients receiving tube feedings.

Staff ID-O was asked if the patient conditions (a-g) she named made these patients a "high nutritional risk." Staff ID- O said " yes". She verified these were the patients who required an evaluation by a registered dietitian.

Record review of facility "Diagnosis Index Report" for admission dates in February 2021 showed multiple patients with one or more of the following diagnoses:

-malnutrition
-pressure ulcers (decubitus)
-g-tube feeding
-a separate list of patients who were ventilator-dependent was reviewed.

A random selection of six (6) patients with a diagnosis that classified them at high-nutritional risk was selected for review.

Record review on 3/2/2022 with Staff C- ADON, and Staff B- DON showed the following:

Patient ID # 39:

H & P dated 2/07/2021, showed : 94 year old female patient admitted on 02/07/2021 post-COVID-19 from a different hospital; lethargic /not eating; getting dehydrated . Stage IV decubitus to left buttock. Nursing admission assessment in EMR showed- "patient is at nutritional risk." Dietary was not notified and Patient ID # 39 was not evaluated by the Registered Dietitian.

Patient ID # 40:

H & P dated 8/28/2021, showed : 81 year old male admitted for COVID pneumonia; feedings per G-Tube; Nursing admission assessment in EMR "patient is at nutritional risk." Dietary was notified ; Patient ID # 40 was not evaluated by the Registered Dietitian.

Patient ID # 41:

H & P dated 11/11/2021, showed a 70 year old male patient, admitted for post-COVID-19 pneumonia; ESRD; pressure ulcers both buttocks; feedings per g-tube ; and ventilator-dependent. Nursing admission assessment in EMR "patient is at nutritional risk." Dietary was notified ; Patient ID # 41 was not evaluated by the Registered Dietitian.

Patient ID # 42 :

H & P, dated 06/05/2021 , showed "95 year old female to ER with foul smelling wounds; altered mental status and weight loss;"Nursing admission assessment in EMR "patient is at nutritional risk." Dietary was not notified ; Patient ID # 42 was not evaluated by the Registered Dietitian.

The above findings were verified by Staff C- ADON. She stated these patients were all at high-nutritional risk and should have been evaluated by the Registered Dietitian.

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

a.) ensure that glucometer quality controls were completed daily

b.) ensure that staff working had documented competencies for the glucometer (IDs G, H and I)

Findings include:

Record review of facility policy titled "Glucometer testing," dated 4/2021 showed the following information:

Policy: To ensure patient safety and accurate testing results, the nursing staff will utilize a hospital approved glucometer testing device to obtain blood glucose results from patient bedside testing. Manufacturer guidelines for the appropriate device will be followed for both patient and quality control testing.

Procedure:
1. Quality Testing All glucometers shall be tested with a low and high control solution every night by the 7pm-7am nursing staff. The results will be recorded on the Daily Quality Control Accucheck Log sheet.


Record review during facility tour on 2/28/2022 at 11:00 AM showed the glucometer quality control log for the month of February to be missing entries on the following dates: 2/13-15/2022, 2/17/2022, 2/26-27/2022.

Interview with staff nurse (ID I) at the time of observation, confirmed the above findings and she also went on to say that there were current patients that were receiving blood sugar checks.

Interview with ADON (ID C) on 2/28/2022 at 11:20 AM, she stated that the night shift is to complete the glucometer quality control log and confirmed missing dates on the log sheet.


Observation on 2/28/2022 at 11:15 AM showed current in-patient four (4) nurses working (IDs G, H, I and J).

Record review of staff glucometer competencies showed no documented competencies for nursing staff (IDs G, H and I).

Interview with ADON (ID C) on 2/28/2022 at 11:20 AM, she stated that nurses are to have documented competencies for the glucometer.

Based on record review and interview, the facility failed to ensure emergency crash carts were checked per facility policy in 1 of 2 clinical areas (in-patient unit).

Findings include:

Record review of facility policy titled : Crash Cart/ Defibrillator Checks," dated 4/2021 showed the following information:

Purpose: To assure the highest quality of patient care and safety by assessing for proper functioning of the equipment and the availability of supplies needed during a critical emergency situation.

Procedure:

1. There are two crash cart/ defibrillator units located within this hospital at the present time. One unit is located in the Emergency Department ER Room 2. The second unit is located in the Nursing Department at the Floor Station.

2. The crash cart and defibrillator shall be checked in each department by the RN on both the day and evening shifts.

6. These actions will be recorded on a crash cart/defibrillator check log sheet. The nurse initials will will also be recorded on this Log sheet for verification.

Record review of Crash Cart/ defibrillator check log sheet for the inpatient nursing units showed missing entries for the following dates:

11/6/2021- PM shift 12/6/2021-AM shift 1/17/2022-PM shift
11/9/2021-AM shift 12/7/2021-AM shift 1/31/2022-AM shift
11/10/2021-AM shift 12/15/2021-PM shift
11/17/2021-PM shift 12/20/2021-AM shift
11/18/2021-AM and PM shifts
11/24/2021-AM shift

Interview with ADON (ID C) on 2/28/2022 at 11:20 AM confirmed the above findings and stated that the log sheet is to be completed each day on both the morning and evening shifts.

Based on observation, interview, and record review, the facility failed to provide nursing services for patients at high risk for falls per accepted standards of nursing practice for 6 of 6 sampled patients [ Patient ID# 3, 29, 30, 31, 32, 34 ].

The facility:

-failed to develop a current nursing fall risk assessment policy and system in place to ensure safety of patients at high risk for falls

-failed to ensure complete admission nursing assessments were performed by a registered nurse within 24 hours of admission per institution policy.

-failed to ensure registered nurses implemented and documented fall safety precautions on patients deemed high risk in their computerized electronic screening admission tool.

Findings included:

Review of Texas Administrative Code (TAC) Title 22, Part 11 [Texas Board of Nursing] Chapter 217: Rule 217.11 :" Standards of Nursing Practice" showed: 1(B) Implement measures to promote a safe environment for clients and others.

Patient ID # 3:

Medical record review for Patient (ID #3) showed incomplete documentation of fall risks and fall prevention strategies. Patient (ID 3) is a male patient with history of severe traumatic brain injury resulting in hemiplegia and prior orthopedic hip surgery who was admitted for cellulitis on the second toe. Observation performed on 2/28/22 at 1030am in nurse's station. There was no visible communication on written patient census board noting which patients are identified to have increased fall risk. There is no written communication of fall risks identified on patient's charts found in nurse's station.

Observation in Patient (ID #3) room 2/28/22 at 1040am. The door to patient's room is closed with no staff or family inside the room. There is no communication externally on door signifying fall status or impaired mobility. There is no bed alarm engaged and no visible sign of a camera device in use. Patient has a yellow fall precaution bracelet in place on right wrist.

Interview with Staff registered nurse (ID I) in the nursing station on the unit on 2/28/22 at 1145 AM, she stated there is no specific policy for fall risk identification or implementation of fall risk prevention measures. She went on to say that "I forgot to chart them." When asked what measures she was using for fall prevention, she stated "Bed position low, call light in reach and door open." She stated the "bed alarm was turned off for bathing and we forgot to turn it back on." She stated, "there used to be a green card placed outside the room" as a visual notice to staff but "I haven't seen those in a while." Review of current census and daily report sheet with Staff I shows no mention of fall risk category for patients. She states, "It's up to individual nurses to communicate at shift change."

Patient ID # 31 :

Medical record review for patient (ID 31) showed was a Covid-19+ male with history of diabetes mellitus, hypertension with prior stroke resulting in impaired mobility. He also had anemia & coronary artery disease. On 2/16/22 he sustained a fall in his room when he attempted to self-mobilize from a bedside chair. No fall risk nursing assessment was documented, and no safety precautions were in documented to be in place. He sustained a fall in his room with superficial injuries noted (skin tear on elbow).

Patient ID # 34:

Medical record review for patient (ID 34) showed he was an elderly 353-pound obese male with diabetes mellitus (poorly controlled), mobility impairment and confusion. Fall risk assessment was left blank on nursing risk admission. Patient had greater than three risk factors which would have elevated his fall risk potential per the facility's electronic nursing assessment form.
Interview with Assistant Director of Nursing, Staff C on 3/1/22 at 1045 AM, she stated that it should have been done.

Patient ID#s : 29, 30, 32:

Record review of facility incident reports showed Patient ID # 29, 30, 32 sustained falls in their rooms with minor injuries identified.
Medical record review for patient's (IDs 29, 30, and 32) showed no evidence of fall risk screening, which would identify risk factors to trigger implementation of safety measures.

Interview with Staff C 3/1/22 at 1135 AM verified she was not able to locate completed assessments in the medical records for patients (IDs 29, 30, 31, 32 and 34).

Interview with Staff B 3/1/22 at 1035 confirmed that their facility nursing admission policy states "a full nursing admission assessment should be performed within 24 hours of admission." Staff B acknowledged nursing policy "Admission Assessment Form" which states "an admission assessment will be completed on all admissions by a registered nurse within 24 hours of admission ...". She located a paper form in the nursing policy binder labeled "Risk/Fall Criteria Assessment" which she said is "no longer used here because we use the electronic medical record."
Record review of facility nursing policy binder reveals no current nursing fall assessment policy or guidelines/ protocol for interventions.

Record review of facility policy titled "Admission Assessment Form" dated 10/30/201, failed to include a fall risk screening assessment.
During an interview with Staff B (Director of Nursing) on 3/1/22 at 1035am, she stated that she was unable to locate a current, specific fall prevention policy. She went on to say that the fall risk assessment is a part of the admission assessment. She located a paper form in the nursing policy binder labeled "Risk/Fall Criteria Assessment" which she said is "no longer used here because we use the electronic medical record."

Interview with Staff C (Assistant Director of Nursing) 3/1/22 at 1105 am. Staff C demonstrated the location of the fall assessment screening on the computerized medical record in the "WCH Admission Nursing Assessment" screen on the computer. This computerized assessment included the statement "If 3 or more 'yes' answers - Institute Fall Risk Protocols." The triggers available for assessment included "Age > 65 years old, confused mental status, impaired mobility, impaired vision, history of falls, use of diuretics and use of narcotics or anti-anxiety medications." Staff C stated "there is no nursing or hospital specific 'Fall Risk Protocol' ". She confirmed that "nurses typically place a yellow fall risk armband on those patients deemed to be high risk for falls". She also stated "we attempt to place these patients close to the nurses' station and leave their door open." She also stated that the facility occasionally use "baby cameras" to assist with monitoring and sometimes use "bed alarms when they are not turned off for care."



37322

Based on record review and interview, nursing failed to ensure pain levels were evaluated and document after administration of pain medication in three of three (#5,6,7) patients in the emergency department (ED).

Findings Include:

Record review of the facility policy "Charting -Documentation of Patient Care: Electronic Version (EMR)", revised 09/29/2015 stated 9. Patient responses to nursing intervention should be recorded (example response to pain medication, etc).

Record review on 02/28/2022 at 1122 of three emergency room patients revealed the following: patient (ID#5) was assessed 02/26/22 with a pain level of 8 and was discharged without a pain re-assessment.

Patient (ID#6) was assessed on 02/26/22 with a pain level on of 7 and medicated with Tylenol was discharged without a pain reassessment.

Patient (ID#7), was admitted 02/14/2022 with a pain level 7, medicated with Stadol was also discharged without pain reassessment.

Based on observation, interview, and record review, the facility failed to employ methods for preventing and controlling the transmission of infection within the facility. The facility failed to adhere to current CDC Guidelines for :

-COVID- 19 screening in healthcare facilities.

Findings included:

COVID Screening:

Record review of CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," last updated 09/10/2021, showed :

-Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so that they can be properly managed: 1) a positive viral test for SARS-CoV-2, 2) symptoms of COVID-19, or 3) who meets criteria for quarantine or exclusion from work.
-Visitors meeting any of the 3 above criteria should generally be restricted from entering the facility until they have met criteria to end isolation or quarantine, respectively.
~~~~
Observation on February 28; and March 1 and 2, 2022 showed a desk inside the front door of the facility. Three (3) state surveyors entered this front on the 3 dates named. A staff person at the desk measured the temperature of each of the surveyors each of the 3 days. She failed to ask any questions concerning recent positive COVID test; symptoms of COVID; or meeting criteria to quarantine. Surveyors were allowed entry into facility all 3 days.

Continued observation on these same 3 dates showed multiple visitors entering this front door. Screening staff failed to question any visitors regarding : recent positive COVID test; symptoms of COVID, or meeting criteria to quarantine. These visitors were allowed entry into facility all 3 days.

During an interview with Staff B, Director of Nurses, on 3/02/2022 at 12:15 PM, she stated the facility followed CDC guidelines.

Based on observations, interviews, and record reviews, the facility failed to maintain an effective infection control, prevention, and surveillance measures, including maintaining a clean and sanitary environment to avoid sources and transmission of infection when:

1) Linen, housekeeping and dietary supplies were store improperly together in a room along with trash.
2) Clean linen was stored improperly in a room with torn insulated ductwork and within 18 inches from the ceiling
3) Housekeeping closet had clean supplies stored in a room with a hopper covered in black dirt
4) Extra central supplies were stored in boxes on the floor and within 18 inches of the ceiling
5) Unsanitary conditions and improper food storage /labeling was observed in the kitchen
6) Unsantiary conditions were observed in area immediately adjacent and open to respiratory supply storage (ventilators)
7) Linen was stored improperly - exposed to contamination in the patient care area

Findings include:

Record Review of facility policy titled "Clean/Dirty Linen," not dated showed the following information:

1. Clean linen should be transported and stored in covered containers.

Record review of facility document titled: "Infection Control Plan 2021," showed the following information:

Purpose: To evaluate, assess, and improve the Infection Control Program at Riceland Medical Center including surveillance, prevention, and control of infections.

II. Risk Identification
A. The infection control department will identify risks for the acquisition and transmission of infection agents on an ongoing basis.

IV. Strategy Implementation
3. Environment of Care
a.) At least monthly rounding off all patient care units and at least bi-annual rounding of non-patient care areas. Note: this activity may be performed in conjunction with established EOC rounds, but must be infection control specific.

Interview with ADON (ID C) on 2/28/2022 at 9:30 AM, she stated that there currently was not an infection preventionist for the hospital. she went on to say that the role is being shared amongst herself, the DON (ID B) and risk manager (ID Q).

Observation on 2/28/2022 at 9:40 AM room with sign on the door that stated "Housekeeping and Dietary Supplies" revealed the following:

-a bed made with sheets and blanket
-countertop containing, washcloths x 2, hand sanitizer bottles x 3, handheld squeegee, green microfiber cloth, and cylindrical loch set
-sink with two (2) cardboard boxes on the floor underneath with trash.
-metal rolling cart with an opened box of fluorescent light bulbs and blankets
-rotary floor buffer
-cardboard box on the floor containing 12 oz foam cups
-plastic bag containing linen on the floor
-uncovered linen on top of a covered linen cart
-a bedside table with an open endotracheal tube
-two missing ceiling tiles

Interview with ADON (ID C) at the time of observation, she acknowledged the above findings. She stated that the bed is used by lab personnel and that all linen should be covered.

Interview with maintenance technician (ID DD) at 9:43 AM, he stated that IT had been doing some work in the room and must not have put the ceiling tiles back in place.

Observation on 2/28/2022 at 9:52 AM revealed a linen closet containing some linen wrapped in plastic along with linen with plastic wrapping that was ripped open, exposing the linen. Linen was stacked on the top shelf touching duct work that contained cracked insulation.

Interview with maintenance technician (ID DD) at the time of observation stated that this was the clean linen for the hospital.

Observation on 2/28/2022 at 9:56 AM revealed a housekeeping closet that contained, wet floor signage, shelves containing hand soap and sanitizer refills and disinfectant wipes, a hopper with copious amount of black dirt.
Interview with maintenance technician (ID DD) at the time of observation stated that the housekeeping staff empty the dirty mop water in the hopper and that the wipes and hand soap and sanitizer were not being used.

Observation on 2/28/2022 at 10:02 AM revealed a room with a sign that read "Extra Central Supplies." The room had over fifty (50) cardboard boxes on the floor stacked to approximately 4 inches from the ceiling.

Interview with materials manager (ID AA) at the time of observation stated that these extra supplies that were an overflow from central supply. She stated that boxes were not to be on the floor and should not be within 18 inches from the ceiling.


23032

5) Unsanitary conditions in kitchen and improper food storage:

Cleanliness:

Record review of facility policy titled "Dietary Department-Sanitation,"dated 01/01/2021, showed:
-the Dietary Manager is responsible for supervising sanitation and housekeeping procedures within the department;
-the Dietary Manager-prepares a cleaning schedule and is responsible that the schedule is followed in a satisfactory manner.

Review of "Texas Food Establishment Rules" (TFER), dated October 2015, showed:
-228.123 (b)-cleaned equipment and utensils shall be stored: in a clean, dry location; where they are not exposed to splash, dust, or other contamination; and at least 15 cm (6 inches) above the floor.
-228.186 (a)- the facilities shall be maintained in good repair
-228.173 ( c) (1)- floor and wall junctures shall be covered and closed to no larger than 1 mm [1/32 inch]

Observation in the kitchen on 2/28/2022 between 9:45 AM and 10:15 AM showed :

- a storage closet that contained trays; misc. kitchen supplies; a metal & a plastic bin stored directly on the floor. The closet floor had stains, a thick layer of dust ; debris; dead bug; and cobwebs.

- a large open area [approx. 1 ft x 1 ft ] located under the 3 compartment sink next to the wall. There were several PVC pipes visible in this opening-with an unsealed space ( at least 6 inches) between the pipes, allowing easy entry for pests of many types.

-the entire perimeter of this open area under the sinks had a thick layer of dust , dirt, and a heavy layer of grime all around the edges, on the pipes, and the floor behind the opening.

Interview at the time of observation with Staff E, Dietary Manager, she stated she had not really looked under the sinks and was unaware. She confirmed the findings and said they would be corrected.

Food storage/ labeling:

Review of "Texas Food Establishment Rules" (TFER), dated October 2015, showed:
-228. 75 (F) (1) (A)--establish a date marking system to indicate the date or day by which the food shall be consumed.
228.68 (a) (2)- In-use utensils, between-use storage. During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: in the food with their handles above the top of the food and the container

Record review of facility policy titled" Policy For Food Storage," dated 01/01/2021, showed:"foods are labeled, dated, and used 'first in and first out method' and are rotated as delivered.

Observation on 2/28/2022 between 9:45 and 10:15 AM the kitchen with the Dietary Manager ( ID-E) showed the following :

-Freezers :

a. One( 1) bag of "breaded chicken" the lable read: "Prepared Date: 09/21/2021; Use By: 12/21/21"
b. five (5) zip-type plastic bags of chicken nuggets-unlabeled/ undated.
c. one (1) zip-type plastic bag of pork chops-unlabeled/ undated.
d. one (1) zip-type plastic bag of frozen tilapia. When this bag was removed from freezer, the bag was open-- and a frozen filet fell on the floor.
e. Multiple plastic bags of frozen foods contained labels that were handwritten and placed inside the bags. These labels were not easily visible; and could cause possible contamination of food.

During an interview with Dietary Manager at time of observation, she stated this was done because the labels kept falling off the bags.

-Dry storage issues:

a. plastic bin of flour: scoop was located "buried" in the flour.
b. One (1)-[3.5 pound] opened carton of "potato pearls" ( instant masked potatoes)-carton was not clipped or sealed.
c. One (1) opened bag of brown sugar-not labeled or dated.
d. One (1) zip-type plastic bag that contained an opened bag of "bacon bits." Label read:" Prepared Date -11/28 ( no year ); "Use By" date was left blank.

6) Unsanitary area adjacent to respiratory supply storage:

Observation on 03/02/2022 at 10:30 AM during a facility walk- through with Staff D, Assistant Administrator, showed the following:

-a door labeled with a yellow sign that read:"Respiratory Equipment Storage-Clean Equipment Only." Several patient ventilators covered with plastic were stored inside this room.
- a connected & completely open room was located immediately adjacent to this respiratory storage .
-this open room was undergoing extensive repair and renovation [looked to be an old bathroom and shower]
- "shower"-uncovered shower drain--exposed drain pipe; floor was covered with a thick layer of grime; yellow/ green stains, and debris.
-other portion of this room showed ripped portion of sheet rock--exposing wood chips, dirt, and debris. The floor in this area was also very stained.

The findings were acknowledged by Staff D, Assistant Administrator, who confirmed this area was an infection control issue being open to the respiratory supply storage. Staff D went on to say repairs from the last flooding were still in progress.

7) Improper linen storage :

Observation on 2/28/2022 at 10:40 AM showed Staff R, Ultrasound (US) Tech, in the hallway with the US machine outside room 302.

Continued observation showed a "clean" folded sheet, towels, and washcloths located on the top surface of the US cart. Staff R was observed going into the room to perform a bedside ultrasound.

A short time later, the US Cart was observed outside room 302- down the hallway with the same linen located on the top of the cart.

On 3/2/2022 at 12:15 PM, these findings were discussed and acknowledged by Staff B, Director of Nurses.

Based on record review and interview the facility did not have a complete quality program.

Findings include:

Record review on 03/02/2022 of the 2021 Quality Management Plan revealed no ongoing long-term facility goals for the medical center. The plan was signed and approved by governing body chairman and the Medical Director on 11/30/2021. The signature of the quality director was missing.

Interview on 1145 on 03/02/2022 with the Director of Nurses (ID #B) who validated the facility did not currently have a Quality Director (QA), and should have signed the plan and filled in the goals.

Interview on 1230 on 03/02/2022 with the Risk Manager (ID#Q) who also verified the facility did not have a QA manager and somethings were missed.

Based on record review, observation and interview the facility did not have an EMTALA signage in the emergency department (ED).

Finding Include:

Record review of the facility policy EMTALA revised 04/18/2018, stated signage (are) will be posted in a place of places likely to be noticed by all individuals entering the ED.

Observation of ED on 02/28/2022 at 1400 revealed no EMTALA signs noted in lobby of the ED, or in the three ED rooms.

Interview with the ED staff (ID# N) on 02/28/2022 during observation verified there was no EMTALA signage note

Additional Findings:

Observation record review and interview of the ED on 02/28/2021 at 1330 with staff (ID# M), revealed the facility failed to post a conspicuously signage in the emergency department (ED), stating there were no Doctor of Medicine or Osteopathy present, in the hospital 24 hours day, 7 days per week in the ED.

Record review of the six months on call provider/PA/NP schedule from September 2021 to February 2022 revealed the following:

September: 21 days of 24-hour medical provider coverage out of 30 days (21/30).
October: 14 days of 24-hour medical provider coverage out of 31 days 14/31.
November: 18 days of 24-hour medical provider coverage out of 30 days 18/30.
December: 7 days of 24-hour medical provider coverage out of 31 days 7/31.
January: 1 day of 24-hour medical provider coverage out of 31 days 1/31.
February: 1 day of 24-hour medical provider coverage out of 28 days 1/28.

Interview with staff (ID# M) revealed there was no signage posted, she presented the ED provider schedule for the month of March.