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Based on interview and record review facility staff failed to develop comprehensive emergency preparedness plans to include provision for pharmaceuticals, equipment and supplies during situations where patients, visitors and staff were relocated to the designated shelter area (basement of the building). The facility census was 12 patients.

Findings included:

1. Record review of the facility Emergency Operations Plan, Severe Weather, last revised 01/06 directed, in part, the following:
-General instructions include do not use the elevator.
-Tornado Evacuation Procedures, Ambulatory Patients: Instructed where to take shelter.
All patients capable of traveling to the basement via the stairs should be moved to the lower level, using the nearest stairway.
-The Emergency Room nurse will direct urgent care ambulatory patients to the lower level.
-Med Surg Licensed Practical Nurse (LPN) will accompany ambulatory patients to the lower level and will monitor those patients.
-Obstetrical nurses will give the babies to the mothers and accompany or direct ambulatory mothers to the lower level.
-Visitors/outpatients will be directed to appropriate areas. The lower level for ambulatory patients via the nearest stairway.
-All other staff will access the lower level by the nearest stairway.

During an interview on 07/06/10 at approximately 4:30 P.M. the Chief Nursing Officer (CNO), Staff A stated the following:
-During a tornado warning, anyone who can walk would be directed to go to the basement.
-If patients were moved to the basement there currently were no facilities, equipment or supplies for telemetry, or suction.
-If patients were moved to the basement there currently were no emergency pharmaceuticals and/or supplies (as found on a multi-drawer locked cabinet on wheels stocked with medications, intravenous fluids and supplies commonly called a crash cart).
-The CNO, Staff A stated he/she wrote the Emergency Operations Plan, Severe Weather and did not consider the need for equipment and supplies such as a crash cart.

Based on interview and record review the facility failed to have a system in place for identifying, reporting, investigating, controlling infection. The facility identified infections after they occurred through lab and chart review. The surgical site follow-up occurred only when the physician's office reported it to the infection control nurse. The facility failed to do hospital wide surveillance for hand hygiene nor was any other hospital, infection control surveillance conducted. The facility failed to do any pre-screening of patients for possible infections and to provide more comprehensive education specific to other infection control procedures. The census was 12 patients.

Findings include:



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1. During an interview on 07/07/10 at 10:10 A.M. the Infection Control Nurse stated the following:
-He/she did not hold Infection Control Practitioner advanced credentialing such as certification as an Infection Control Practitioner (CIC) or a member of the Association of Infection Control practitioners (APIC's stated primary responsibility is infection prevention, control and hospital epidemiology in healthcare settings).
-He/she was a full time staff member however divided on duty time into infection control, utilization review and employee healthy duties.
-He/she estimated about fifteen to seventeen hours per week were devoted to infection control for the facility.
-One of the facility infection control monitors done recently was hand hygiene observations.
-He/she did not do the observations of hand hygiene and had relinquished the hand hygiene monitoring to the house supervisors and staff persons on the Environment of Care Committee.
-All areas of the facility were monitored for hand hygiene compliance except the surgical department.
-He/she tracked reported Surgical Site Infections (SSI) however, knew there could be some SSI that were not reported.
-He/she tracked inpatient infections based on retrospective review of preliminary reports provided by the facility Lab.
-Lab results provided preliminary results and actual results could take two to five days depending upon the micro-organism.
-He/she monitored Urinary Tract Infection (UTI) after discharge of a patient, only if he/she was made aware of those discharged patient's reports of infection like symptoms.
-He/she had not advocated for admission screening for infections such as MRSA, (Methicillin-resistant Staphylococcus aureus bacteria are resistant to many antibiotics and cannot be treated with antibiotics such as methicillin.) or C. Diff. (Clostridium difficile, a bacterium that causes symptoms ranging from diarrhea to life-threatening inflammation of the colon. Illness from C. difficile most commonly affects older adults in hospitals or in long term care facilities).
-He/she depended upon patient reports of diarrhea on admission and presumed the physician's would order appropriate isolation for the patient if c. diff was suspected.
-He/she developed a new signage program in which color coded isolation signs would be posted on the room doors of infectious patients however he/she did not plan to monitor staff to see if they heeded the precautions outlined on the signs.
-The Infection Control Nurse performed surveillance by retrospectively reviewing lab culture results, Emergency Department medical records and inpatient medical records for developing infections.

2. Record review on 07/07/10 at approximately 11:00 A. M. of infection control education showed:
-A sign, with a STOP sign on it and explanation as to when staff should wash their hands.
-A power point presentation titled, "Hand Hygiene Life Saver" that covered hand washing, hand sanitizer, when to use it, and when to put on gloves.

3. Record review on 07/07/10 at approximately 11:00 A.M. of infection control monitoring program showed:
- A schedule for May 2010 for supervisors that conducted hand hygiene(washing hand with soap and water or cleaning hands with sanitizer foam or gel) surveillance. The Infection Control Officer scheduled supervisors on Mondays, Wednesdays, and Fridays to complete this task.

- A worksheet titled, "Noscomial Infection Worksheet" to complete with patient information , invasive procedures, vital signs, nurses notes, infection information, significant labs, cultures, and x-rays, antibiotics ordered, and Dr. notes.

-A completed form of each:
-hospital departments
-number of staff witnessed during patient care
-number of staff witnessed
-number of staff who performed hand hygiene at appropriate times
-number of staff who failed to perform hand hygiene at appropriate times

-A bar graph that showed each units hand hygiene surveillance from November 2009 through April 2010.

Based on interview and record review the facility failed to use medication policy of giving medication 30 minutes before or 30 minutes after the scheduled time.

Findings Include:

1. Review of facility policy titled "Medication Administration Schedules" Procedure # TXGN-141, Index: Scheduling Medication and effective date: 12/06 revealed "Medication must be administered within one hour of the time order was written." "Nursing will have one hour before and to one hour after time medication is scheduled to complete med pass."
2. In an Interview on 07/06/10 at 3:30 P.M. Staff A, Chief Nursing Officer said that the medication time frame was 30 minutes before and after. After viewing the medication policy stated one hour before and after he verified this was the current policy.
3. In an interview on 07/07/10 at 9:25 A.M. Staff B, Medical/Surgical Director said that the medication time frame was 30 minutes before and 30 minutes after.
4. In an interview on 07/07/10 at 9:30 A.M. Staff B, Medical/Surgical Director said that the previous answer was wrong and handed this surveyor the policy that was effective 12/06. Staff B verified this was the current policy for medication time frame to give medication one hour before or one hour after the scheduled time of the medication.