HospitalInspections.org

Based on observation during a tour of the facility with the Nursing Director, the hospital failed to ensure a clean and orderly state as the following was observed.
Findings were:
*In the Physical Therapy rooms on 2/28/2012, a rusty can opener was observed available for use; the treadmill was observed to be covered in dust and whitish and other colored drips were observed down the front of this treadmill. The Hydrocollator had no temperature log and the last documented cleaning was 11/17/11. The Paraffin bath was observed not to be cleaned, wax was over the edges and the lid was stuck.
*In the Supply room - Triple antibiotic ointment 0.9 gram unit dose, quantity of 144, expired 9/11;
*D5 IV 250 ml fluid bags, 4 cases of 36 each observed to be stored on the floor in hallway, which could be contaminated by dirt, dust, or insect, or during cleaning of the floors.

*In the Dietary Department there was no freezer temperature log, no thermometer was observed in the freezer; interview with the cook revealed that the logs were not done, therefore the correct temperature of the food could not be assured.
Ceiling vents were observed to be very dirty and covered with dirt and dust; there were multiple tiles broken and these areas where there was no tile were in need of cleaning; Grease/dust was observed on top of freezers and refrigerators; Debris was observed in a floor drain; Spices had dates indicating that the spices were over one year old not ensuring the quality of these items and two containers were observed to be opened and in need of cleaning; there were chipped areas of the walls in the dishroom; there were small pieces of foam insulation falling out of the ceiling vents in the kitchen - this was over food areas not protecting patient food from contamination..
*The following food items were observed in the storeroom with expired dates and were available for patient use-
Cream of chicken soup, quantity of 43 cans, expired 5/1/11;
Cream of chicken soup, quantity of 11 cans, expired 12/3/10;
White cake mix expired Oct 24, 11;
Apple pie filling expired 1/14/12;
Condensed milk expired 12/20/10;
Peach halves 4 cans expired 9/1/11;
A second brand of peach halves had one lid popped up (indicating the contents were probably spoiled); quantity of 16 cans, expired 3/1/11;
Blueberry pie filling, expired 4/24/10;
Thicken Up, expired 8/23/11 quantity of 9;
Green Chilies expired 10/7/11, quantity of 8;
Sugar free breakfast syrup expired 10/22/11;
3 cans of pears expired 6/10/11;
6 cans of Pear halves undated; one lid had popped up (indicating the contents were probably spoiled);
Large can of solid vegetable shortening expired 2008 - yellowed.
*Dirt was observed under shelves as well as food, trash, debris, dust and a live bait mouse trap.
*In the Pharmacy open ceiling tiles were observed to be opened and one missing, providing a possible entrance for vermin.
*In Radiology -
Gastrographin drips on side of bottle which was not dated when opened
Isovue 300 open appearing as if it had been used for a patient and left out, unsealed (requires storage in the dark).
X-ray positioning boards and foam pieces were able to absorb body fluids and were not cleanable (these had been used for multiple patients
*The following was observed in the Patient Nourishment area:
Carnation Instant Breakfast 8.45 fluid ounces quantity 7, expired 4/17/11
Nutrigrain bars, quantity of 16, expired 10/3/11
Glucerna 1.0 cal 8 fl oz, expired 2/1/2011
Top of ice machine had an accumulation of dust indicating a possibility of dust falling into the ice and contaminating the contents.
*Patient Room #7:
2.5 inch white drip on patient recliner
*Clean linen room:
Under sink: divider curtains, comforters, pads and sheets were stored under the sink.
Pillows were stored on floor, and 4 pillows were observed stored on top of the red, plastic biohazard can.
Ceiling tile torn, not intact and cleanable, providing a possible entrance for vermin.
*Bathing room:
Bedside commode with chipped paint on the seat available for patient use
*Housekeeping room:
2 dirty mops stored in brownish colored water.
*Clean supply room:
Dirty air mattress cover in the clean supply room that had sticky substance and drips on it that were approximately 2 inches in size, available for immediate use on a patient bed.
The above was confirmed in interview on 2/28/2012 by the Chief Nursing Officer.

Based on a review of available documents and staff interviews, the governing body failed to assume full legal responsibility for determining, implementing, and monitoring the CAH ' s total operation and ensuring that policies are administered and implemented.

Findings were:

Review of the "Culberson County Hospital District Board of Directors Meeting" minutes from October and November, 2011 and January 12, 2012 revealed that only topics of a financial nature were covered at the governing body meetings and the governing body failed to request information to assume responsibility for hospital operations. There was no documented evidence that the facility presented or the governing body was provided with or responded to quality assurance data or clinical issues from the medical staff meetings. The governing body failed to ensure that policies were reviewed by the facility on an annual basis. The governing body failed to ensure that the Infection Control Plan was fully implemented.

The above was confirmed in interview with the Chief Executive Officer and Chief Nursing Officer on 2/29/2012.

Based on a tour of the facility, review of facility policies, and staff interview, the facility failed to ensure that drugs were stored in accordance with accepted professional principles, and that outdated, mislabeled, or otherwise unusable drugs were not available for patient use.

Findings were:

During a tour of the facility on 2/28/2012, the following were available for immediate patient use:

In the Supply room, triple antibiotic ointment, 0.9 gram unit, quantity of 144 doses, expired 9/11.

In the Clean Supply Room, Compound Benzoin Tincture 10% swabsticks, quantity of 45. expired 11/2011.

In the Emergency department, Tetracaine Hcl Ophthalmic 0/5%, 15 ml vial was opened and handwritten labeled, 1/5/11; Benzoin Tincture swabs, expired 11/2011; Epistaxis Nasal Pac, quantity of 6, expired 1/2012; Epistaxis Nasal Pac, quantity of 9, expired 10/2011; Quick Trach, quantity of 2, expired 1/2012; and an arterial blood sample kit, expired 10/2011.

In the Emergency Department, Room 3, 24 gauge x ? IV catheters, quantity of 4, expired 6/11.

In the Emergency Department, Room 5, Benzoin tincture swabs, quantity of 2, expired 11/11.

In an interview with the Chief Nursing Officer on 2/28/2012, she stated that nurses write the date on multi-dose medication vials when opened and vials should be discarded 30 days after opening.

United States Pharmacopeia General Chapter 797 recommends the following for multi dose vials of sterile pharmaceuticals: " If a multi dose has been opened or accessed (e.g. needle punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. If a multi dose vial has not been opened or accessed, it should be discarded according to the manufacturer ' s expiration date. "

In the Emergency Department, the following opened multi-dose pour bottles of oral medications were found opened but not labeled with a date:
Lidocaine viscous 2%, quantity of 2, 100 ml; Children ' s ibuprofen, 100 mg/5ml, 4 fl oz.; Infants Acetaminophen drops, quantity of 2, ? fl oz; Children ' s Tylenol 3.38 fl oz, 160 mg/5ml;
Diphenhydramine, 12.5 mg, 4 fl oz; Antacid/anti-gas 12 fl oz; and Diphenhydramine Hcl 473 ml.

In the Emergency Department, the fully stocked Emergency Crash Cart containing emergency medications and supplies was unsecured and the locking mechanism was defective, rendering the cart unable to be secured.

Facility policy, " Storage of Medications and Solutions in Patient Care Areas " Reference #7013 stated " All multi-dose pour bottles of oral liquid medications or elixirs must be dated when opened. These bottles must be discarded in six (6) months or at expiration date ...Record open and discard dates on solution bottles. "

Facility policy " Emergency Crash Carts " Reference #7016 stated " The emergency drug supply will remain inside the cart, sealed, at all times when not in use. "

The above was confirmed in interview on 2/28/2012 by the Chief Nursing Officer.

Based on a review of available documents, facility policies, and staff interviews, the facility failed to ensure a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

Findings were:

The " Infection Control Plan, Reference #1004 " stated, " Each department, in partnership with the medical staff, will be responsible and held accountable for its role in the Infection Control Program ...Specific assignments will be made to committees, departments and individual personnel and, where assigned, the completion of theses assignments will be expected in a timely yet thorough manner ...The program intends to provide a safe environment consistent with nationally recognized infection control precautions and is based on recommendations from the Center for Disease Control, National healthcare associated infections (HAIs) Surveillance System, Association of Practitioner in Infection Control, and the Occupational Safety and Health Administration ...The Infection Control Program is coordinated by the Hospital Administrator, Chief of Staff, Coordinator of Infection Control, and Director of Nursing. All Departments and services are part of the Infection Control Program ...Information from the Infection Control Performance Improvement Program will be reported every quarter to the Culberson Hospital Infection Control Committee. Minutes of these meetings are forwarded to the Medical Executive Committee, administration, Nursing Services and the Performance Improvement Committee, to assist in a timely and thorough implementation of recommended corrective measures and process outcome revisions. The Infection Control Committee/Infection Control Coordinator has the responsibility for infection control activities throughout the facility ...
Monitoring: Monitoring the results of the infection Control Program allows the hospital to determine if the techniques already in place are working well or if changed conditions (internal or external) require new or revised techniques ...Monitoring is achieved through: Committee interaction, especially the Infection Control Committee ...The Infection Control Committee shall consist of representatives from Administration, Nursing, Clinical Laboratory, Performance Improvement, Surgery/Central Supply, Pharmacy and medical staff members ... "

There was no documented evidence that the facility had conducted Infection Control Committee meetings as required during calendar year 2011. Interview with the facility Infection Control Coordinator and Director of Nursing on 2/29/2012 revealed that the Infection Control Committee meetings had not been conducted.

The " Bylaws of the Medical Staff of Culberson Hospital " stated " Professional Activities Committee ...c. Functions: It shall be responsible for staff functions relating to ...infection control ... (4) Infection Control. The Committee shall be responsible for the surveillance of inadvertent Hospital infection potentials, the review and analysis of actual infections, the promotion of a preventive and corrective program designed to minimize infection hazards, and the supervision of infection control in all phases of the Hospital ' s activities. "

Review of Medical Staff Meeting minutes for calendar year 2011 revealed no evidence of a preventive and corrective program and no supervision of infection control in all phases of the hospital ' s activities. In 8 out of 11 Medical Staff meetings for the calendar year 2011, the minutes reflect " nothing new to report " or similar language for infection control reporting.

During a tour of the facility on 2/28/12, the following was observed:

4 cases containing a quantity of 36 IV 250 ml fluid bags were observed in a box on floor in the hallway, which could be contaminated by dirt, dust, or insect, or during cleaning of the floors.

In the Physical Therapy Department, the Paraffin bath had not been recently cleaned and had dried, melted wax on the edges and sides, and the lid was adhered to the top of the bath by the old, dried wax; a rusty, dirty can opener was observed available for patient use, there was dust on high and low horizontal surfaces, the treadmill was observed to be covered in dust and there were approximately 6 various colored long drips (ranging from 2 inches to 8 inches) on the front and base of the treadmill. There was not temperature log for the Hydrocollator and the last documented cleaning occurred on 11/17/11.

In the Dietary department, the physical plant was not maintained to prevent dirt, dust, and access by insects in the patient food preparation, storage and service areas. Cross refer: C0279.

In the Radiology Department, an opened bottle of Gastrographin was observed with drips down the side of the bottle, and x-ray positioning foam triangles were observed available for patient use with tears in the vinyl that could not be cleaned or sanitized between patient use and could provide a source of infections.

The above was confirmed in interview on 2/28/2012 with the Chief Nursing Officer

Based on observation during a tour of the facility with the Nursing Director the hospital failed to ensure all areas used for the storage and preparation of patient food were not in a sanitary condition as the following was observed.

Findings were:

*In the Dietary Department, there was no freezer temperature log and no thermometer was observed in the freezer, an interview with the cook revealed that the temperature logs were not done, therefore the correct temperature of the food could not be assured.

Ceiling vents were observed to be very dirty and covered with dirt and dust, which could contaminate food or food preparation areas;

There were multiple tiles broken and the areas where there was no tile were in need of cleaning;

Grease/dust was observed on top of freezers and refrigerators;

Debris was observed in a floor drain;

Spices had dates indicating that the spices were over one year old not ensuring the quality of these items and two containers were observed to be opened and in need of cleaning;

There were chipped areas of the walls in the dishroom; and

There were small pieces of foam insulation falling out of the ceiling vents in the kitchen - this was over food areas not protecting patient food from contamination.

*The following food items were observed in the storeroom with expired dates and were available for patient use:
Cream of chicken soup, quantity of 43 cans, expired 5/1/11;
Cream of chicken soup, quantity of 11 cans, expired 12/3/10;
White cake mix, 1 box, expired Oct 24, 11;
Apple pie filling, 1 can, expired 1/14/12;
Condensed milk, 1 can, expired 12/20/10;
Peach halves, 4 cans, expired 9/1/11;
A second brand of peach halves, one can had the lid popped up (indicating the contents were spoiled), and 16 cans were expired 3/1/11;
Blueberry pie filling, 1 can, expired 4/24/10;
Thicken Up, quantity of 9, expired 8/23/11;
Green Chilies, quantity of 8, expired 10/7/11 ;
Sugar free breakfast syrup, 1 bottle, expired 10/22/11;
Pears, 3 cans, expired 6/10/11;
Pear halves, 6 cans undated, one lid had popped up (indicating the contents were spoiled);
Large can of solid vegetable shortening expired 2008 - yellowed;

*Dirt was observed under shelves as well as food, trash, debris, dust and a live bait mouse trap.

*The following was observed in the Patient Nourishment area:
Carnation Instant Breakfast 8.45 fluid ounces, quantity of 7, expired 4/17/11;
Nutrigrain bars, quantity of 16, expired 10/3/11;
Glucerna 1.0 cal 8 fl oz, expired 2/1/2011;
The top of ice machine had an accumulation of dust indicating a possibility of dust falling into the ice and contaminating the contents.

The above items were confirmed in interview with the Nursing director during a tour on 2/28/12.

Based on a review of available documentation and staff interview, the facility failed to ensure that policies were reviewed annually.

Findings were:

On 2/29/2012, the facility failed to provide evidence that the following policies had been reviewed at least annually, as indicated by the documented approval dates:

Infection Control Policies and Procedures, Approved 3/31/2010;
Med/Surg Policies and Procedures, Approved 3/31/2010;
Dietary Policy and Procedure Manual, Approved 3/31/2010;
Rehabilitation Services, Approved 4/6/10;
Medical Nutrition Therapy Manual of Texas Dietetic Association, Approved 3/31/2010;
Emergency/Trauma Policies and Procedures, Approved 4/6/2010;
Medical Records Policy and Procedure Manual, Approved 4/6/2010; and
Employee Health Policies and Procedures, Approved 4/6/2010

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on 2/29/2012.

Based on a review of available documentation and interviews, the facility failed to develop, implement and maintain an effective, on-going, hospital-wide, data-driven quality assessment and performance improvement program that involved all hospital departments and services.

Findings were:

Review of the Culberson Hospital QA/PI meeting minutes for calendar year 2011 revealed that although problems were identified through the QAPI program, there was no documented evidence to determine if there was follow up and resolution of identified problems. For example, QAPI reporting from radiology revealed that in 2/2011, 7/2011, 8/2011, and 9/2011, serious problems were identified and reported involving the CT scanner relating to electrical power; in the following months there was no documented monitoring or resolution to the problem.

Review of the Culberson Hospital AQ/PI meeting minutes for the revealed that the following hospital departments consistently reported " Nothing new to address " as indicated below and did not provide updates on currently identified issues or performance improvement projects:
August 2011: 5 of 9 hospital departments reporting, including infection control, radiology, physical therapy, Housekeeping/Central supply, and maintenance.
September 2011: 4 of 8 hospital departments reporting, including infection control, pharmacy, medical records, business office.
October 2011: 4 of 10 hospital departments reporting, including infection control, nursing, housekeeping/central supply and maintenance.
December 2011: 3 of 9 hospital departments reporting, including infection control, nursing, and pharmacy.
January 2012: 3 of 10 hospital departments reporting, including infection control, pharmacy, and nursing.

The above was confirmed in interview on 2/29/2012 with the Chief Nursing Officer.