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Based on observation, review of documentation, and interviews with facility staff, the facility failed to ensure that equipment and supplies commonly used in life saving procedures were readily available for treating emergency cases.

The findings were:

The facility policy titled, " Department: EMERGENCY, Crash Car Checklist For ER," states, "The Emergency Room crash cart will be used for any code initiated in the Emergency Room. The crash cart is to remain locked at all times to indicate readiness to respond to emergency needs. Each shift, a short checklist is completed to indicate readiness."

The facility policy titled, " Department: MEDSURG, Crash Cart Checklist," states, "Crash carts should be checked at the beginning of each shift for; supplies located on the top of the crash cart; oxygen content of the tank located on the side of the crash cart; seals are intact; test the defibrillator and assure electrode patches and conductive gel is available. Documentation of the Crash Cart and Defibrillator check is to be done on the checklist kept with each Crash Cart."

On a tour of the facility on the afternoon of 8/8/16, the following were observed:

The crash cart in ER Treatment Room #1:
- The adult defibrillator pads were missing
- The wrench used to open the oxygen tank was missing
- The crash cart log documentation showed that the crash cart was not checked:
o 8/7/16 night shift
o 8/6/16 night shift
o 8/5/16 night shift
o 8/4/16 night shift
o 7/27/16 day and night shift
o 7/26/16 night shift
o 7/19/16 day shift
o 7/18/16 day and night shift
o 7/5/16 day shift
o 7/4/16 day shift
o 6/28/16 night shift

The crash cart in the Medical Surgical unit:
- The crash cart log documentation showed that the crash cart was not checked:
o 8/7/16 night shift
o 7/27/16 night shift
o 7/9/16 night shift
o 7/8/16 night shift
o 7/3/16 day shift

In an interview with Staff #1 and #4 on the afternoon of 8/8/16, both staff members acknowledged the findings above.

Based on observation, interview and record review the facility failed to properly store pharmaceuticals according to the manufacturer's recommendations when pharmaceuticals were being improperly stored and placed in unmonitored warming cabinets in the Radiology and Operating Room (OR) departments.

Findings Include:

Review of the Package Insert and Label Information reflected,
VISIPAQUE Injection in all presentations may be stored in a contrast media warmer for up to one month at 37°C (98.6°Fahrenheit).
ISOVUE store at 20-25 degrees Celsius (68-77 degrees Fahrenheit). There were no directions for storing the medication in a media warmer.

An observation made on 8/8/16 in the afternoon, during a tour of the facility's Radiology Department, revealed injectable radiopaque contrast medium used in the Computed tomography (CT) studies, (8) eight bottles of Isovue 300 mg(milligram), (6) six bottles of Visipaque 320 mg, and (9) nine bottles of Isovue 370 mg, were being stored in the Radiology Department's contrast media warmer. The medications did not have a date when placed in the warmer and the warmer's temperatures were not being monitored and recorded.

During an interview on 8/8/16 at 4:00 p.m. in the CT room, Staff #6 Radiology Technician stated, "We don't date when we place the contrast in the warmer. We turn the dial to 2." When asked what the temperature was, Staff #6 stated, "We don't keep it very warm." When asked was the facility monitoring the temperatures Staff #6 stated, "No."

An observation made during a tour of the facility's OR Department revealed (1) one bag of Glycine liquid and (11) bags of Lactated Ringer and Normal Saline liquids, administered intravenously, in the OR's warmer. The fluids did not have a date when placed in the warmer and the warmer temperatures were not being recorded.

During an interview on 8/9/16 at 11:20 a.m., in the facility's operating room, Staff #25, OR Manager stated, "We are supposed to date when we put the solutions in the warmer." When asked if the facility is monitoring the temperatures of the warmer, Staff #25 stated, "No."

Review of the facility provided document Medication Delivery (dated 8/4/12) reflected, "...we recommend the use of controlled temperature warming cabinets ...IV solutions ...can be warmed in their plastic overpounches [sic] to temperatures not exceeding 40 degrees Celsius (104 degrees Fahrenheit), and for a period of no longer than 14 days ....Once the containers have been in the warming cabinet for their maximum time period, the containers should be removed...and identified as having been warmed ..."

Based on record review and interview the Governing Body failed to ensure policies and procedures were followed and enforced when

A. A patient requiring airborne isolation precautions was incorrectly placed on droplet precautions.

B. The staff failed to monitor their Emergency Crash Carts to ensure that equipment and supplies commonly used in life saving procedures were readily available for treating emergency cases.

The findings were:

A. An observation during a tour on 8/8/16 at 2:30 p.m. of the facility's nursing unit revealed Patient #2 was in a room with a sign on the door showing droplet precautions. Staff # 17, RN (registered nurse) stated, "Patient #2 is on droplet precautions for Shingles (varicella zoster a painful, blistering contagious rash) .... You need to wear a gown, gloves and a mask." The N-95 particulate respirator mask was not available on the isolation station outside the room.

Review of Patient #2's medical record reflected a diagnosis of Shingles. Further review revealed there was no physician's order for isolation precautions.

Review of the facility provided document "GUIDELINES FOR ISOLATION PRECAUTIONS (dated 3/8/07) reflected Airborne Infection Isolation ...these precautions are intended to reduce the risk of airborne transmission of important and virulent infectious agent such as ...Varicella Zoster ....This category requires a single patient room equipped with negative air flow, increased air exchanges per hour and air exhausted directly to the outside or circulated through....filtration ...All persons entering the room must wear a ... approved N-95 mask (particulate respirators).

During an interview on 8/9/16 at 2:00 p.m., on the inpatient unit, Staff #17, RN stated, "Patient #2 needed to be on airborne precautions. We moved her to a room with negative pressure." When asked did the physician order the type of precautions to be initiated, Staff # 17,RN stated, "No, we just put her on the Droplet precautions. When asked how the nursing staff determined what type of precautions were needed, Staff #17 stated," We looked it up ...we must have misinterpreted the information ....Staff #28 (Infection Control nurse) had told us you just can't touch it."

During an interview on 8/9/16 at 2:30 p.m. Staff #27, DO stated, "I didn't tell them what type of precautions to put her on ...I left it up to the facility."


B. The facility policy titled, " Department: EMERGENCY, Crash Car Checklist For ER," states, "The Emergency Room crash cart will be used for any code initiated in the Emergency Room. The crash cart is to remain locked at all times to indicate readiness to respond to emergency needs. Each shift, a short checklist is completed to indicate readiness."

The facility policy titled, " Department: MEDSURG, Crash Cart Checklist," states, "Crash carts should be checked at the beginning of each shift for; supplies located on the top of the crash cart; oxygen content of the tank located on the side of the crash cart; seals are intact; test the defibrillator and assure electrode patches and conductive gel is available. Documentation of the Crash Cart and Defibrillator check is to be done on the checklist kept with each Crash Cart."

On a tour of the facility on the afternoon of 8/8/16, the following were observed:

The crash cart in ER Treatment Room #1:
- The adult defibrillator pads were missing
- The wrench used to open the oxygen tank was missing
- The crash cart log documentation showed that the crash cart was not checked:
o 8/7/16 night shift
o 8/6/16 night shift
o 8/5/16 night shift
o 8/4/16 night shift
o 7/27/16 day and night shift
o 7/26/16 night shift
o 7/19/16 day shift
o 7/18/16 day and night shift
o 7/5/16 day shift
o 7/4/16 day shift
o 6/28/16 night shift

The crash cart in the Medical Surgical unit:
- The crash cart log documentation showed that the crash cart was not checked:
o 8/7/16 night shift
o 7/27/16 night shift
o 7/9/16 night shift
o 7/8/16 night shift
o 7/3/16 day shift

In an interview with Staff #1 and #4 on the afternoon of 8/8/16, both staff members acknowledged the findings above.

Based on observation, interview and record review the facility failed to provide Surgical Services in a safe manner when:

- The facility did not monitor or track the use of immediate-use sterilization equipment.

- The sterile processing staff did not receive initial and on-going training in sterilization processes and procedures.

- The facility's Endoscope was not being cleaned in a sanitary environment.

- The facility was not tracking post-surgical patients for possible infections.

- The operating room had a 5 inch by 6 inch opening in the wall with exposed electrical wires.

Observations made on 8/9/16 at 11:30 a.m. in the facility's Surgical Department operating room revealed a laminated paper taped to the wall. The tape was discolored and not cleanable; once removed, a large 5 inch by 6 inch opening in the wall was discovered creating a possible breach in the sanitary environment.

Further observation revealed the endoscope was being cleaned in an unsanitary room, located in the operating room's sterile core. The room's ceiling vent was covered in dust. The back of the Autoclave Sterilizer extended into the room, it was not enclosed. The internal pipes, gauges and wiring were exposed. The Autoclave's insulation had been covered with a foil tape that was peeling off and not cleanable. The foil tape was covered in a layer of dust and debris. The facility's Autoclave Sterilizer was draining into a raised pipe coming out of the floor; the drain was located approximately 4 inches from the wall. The steam created by the Autoclave had caused the paint to peel off the wall. The steam had created three (3) 6 by 6 puddles of standing water. The paint had peeled off the floor where the water was standing. The puddled water had collected brown debris in the floor's crevices.

During an interview on 8/9/16 at 1:50 a.m. in the facility's operating room, Staff #25, OR manager stated, "We covered the Autoclave's insulation with the tape ...I try to clean it myself, I don't want anyone else to get burned...it's too hot... we did the best we could ....the water is coming from the Autoclave, we even put this thing here (dehumidifier) to try to fix the problem....it doesn't work."

Staff #25, OR manager stated, "I was shown how to use the Sterilizer 15 years ago by the person before me, I haven't recieved any additional training... when someone new is hired we train each other...We don't track the flashed items, I wasn't aware we needed to keep a log..." Staff #25, OR manager confirmed the physical findings in the OR.

During an interview on 8/9/16 in the facility's classroom, Staff #4, Risk Manager confirmed the facility was not tracking post-operative out-patients for possible infections.

Based on observation, interview and record review the facility failed to provide an ongoing program of activities directed by a qualified professional and designed to meet the psychosocial well-being of each swing bed patient.

Findings include:

Review of Patient #2's Physician's Swing Bed History and Physical dated 8/9/16 reflected an 85 year old female admitted for weakness and advanced osteoarthritis.

Review of Patient #2's Swing Bed Assessment Form dated 7/22/16 reflected, " ...making self: understood ...decision-making ability: independent ...Oriented to: person, place, time, situation ...Short term memory: Good, Long term memory: Good ...
Activity Pursuit Patterns reflected Music, Religious Activities, Watching TV, Talking/Conversing and help others volunteer were marked as current interest."

During an interview on 8/8/16 at 2:30 p.m. on the patient swing bed unit, when asked if she attends activities Patient #2 stated, "All I do is watch TV ...when I first got here I was able to go out of my room, I used to like to sit in the sun ....I got Shingles ...I can't go outside and now no one comes to visit me ..."

Review of the facility provided document Job Description Indigent Care Coordinator reflected " ...Serves as the Swing Bed Activities Coordinator ...Job Qualifications ...C. Licensure, Registry or Certification: None required, E: One year in a business office environment and one year word processing experience ....formulates activity plan ...Visits patients twice weekly to carry out activity plan ..."

During an interview on 8/9/16 at 2:00 p.m., on the inpatient unit, when asked if the nurses know what the patient's activity choices are, Staff #17, RN stated," ...We don ' t provide activities, someone else does it..."

During an interview on 8/9/16 in the facility classroom Staff #1, Human Resources Manager stated, "Staff #11 is the activity director ...she isn't certified...we should document when we provide activities ..."

Based on observation, interview and record review the facility failed to encourage patients to participate in care planning, including encouraging attendance at care planning conferences if they so desire and revised as the resident's status changes for (1) of (2) two patients reviewed in Swing Beds. (Patient #2)

Findings include:

Review of Patient #2's Physician's Swing Bed History and Physical dated 8/9/16 reflected an 85 year old female admitted for weakness and advanced osteoarthritis.

Review of Patient #2's Swing Bed Assessment Form dated 7/22/16 reflected, " ...making self: understood ...decision-making ability: independent ...Oriented to: person, place, time, situation ...Short term memory: Good, Long term memory: Good ...Social/Activity Care Plan reflected, " ...Hx arthritis has minimal feeling to hands ...excited to do therapy ...will monitor for further needs ...no problem identified or need of referral at this time ..."

Observation on /8/16 at 2:30 p.m. on the patient swing bed unit revealed Patient #2 lying in bed attempting to eat out of a Styrofoam bowl. The Patient #2 was having difficulty grasping the plastic spoon. The food had been chopped up into small pea sized bites. Patient #2 was not wearing dentures.

During an interview on 8/8/16 at 2:30 p.m. on the patient swing bed unit, Patient #2 stated, "I have trouble with my hands ...they hurt from my arthritis ...I can't feed myself ...the nurses used to help me but therapy told them to let me do more ... I prefer to eat with my dentures in, I can't put my dentures in by myself...no one helps me...I got Shingles, now I am given this plastic spoon...look I can't hold it, how can I feed myself ." When asked if she participated in her care plan to discuss her needs, Patient #2 stated, "No."

Review of Patient #2's Care Plan did not reflect an activity plan had been formulated and the patients need for assistance with feeding and or an occupational therapy evaluation had not been documented.

During an interview on 8/9/16 at on the nursing unit, Staff #4, DO stated, "Patient #2 could use OT (occupational therapy) treatments ...we only offer PT (physical therapy) here."

During an interview on 8/9/16 in the afternoon, in the classroom, Staff #4, Swing Bed Coordinator confirmed the patient's activity plan was not included in the care plan and Patient #2 was not invited to attend the care plan to discuss her needs.

Review of the facility provided document PATIENT RIGHTS AND RESPONSIBILITIES (undated) reflected, "The right to a reasonable response their request and needs ...Texas Administrative Code Title 25, Chapter 133 Hospital licencing [sic] Rules, Patient Bill of Rights ....the right to participate in the development and implementation of his or her plan of care ...including the acceptance or refusal of treatment, and being involved in care planning and treatment..."