HospitalInspections.org

Based on interview and record reviews, the facility's QAPI (Quality Assurance Performance Improvement) program failed to ensure all patient care services and other services affecting patient health and safety were evaluated.

Findings included:

Review of all 2019 QAPI minutes (on October 2019, August 2019, July 2019, May 2019), and other related documents revealed the following areas have been evaluated: laboratory/transfusion, imaging, rehab services, nursing, health information, pharmacy, safety, infection control. The hospital did not ensure all patient care services were evaluated. For example, hospital did not evaluate services such as contracted services, dietary services, and EVS (Environmental Services).

Review of QAPI plan, with last reviewed dated of 7/11/19, stated in part, "Purpose ... Services that will be evaluated as part of the Quality Assurance Program will include: medical records, laboratory, radiology, nursing, pharmacy, infection control, health information, physical therapy." This plan did not ensure all patient care services and other services affecting patient health and safety were evaluated.

In an interview on 2/26/20, at 1:30 p.m., Staff #3 confirmed the above findings and agreed that services such as contracted services, dietary services, and EVS affect patient care services.

Based on review of facility documents, credentialing files and staff interview, the governing body failed to implement and monitor policies governing the hospital's operation.

Findings included:

Facility-based Medical Staff Bylaws, Article VI titled "The Medical Staff Application, Appointment, Reappointment and Clinical Privileging Process" stated in part, "6.9 Reappointment Process.
6.9.1 Term. All reappointments shall be for a period not to exceed two (2) years."
Article VII titled "Clinical Privileges" stated in part, "7.1.1 The Board of Directors shall determine the clinical privileges granted to Members in accordance with the application procedure ... for the granting of clinical privileges set forth in these Bylaws. Every Practitioner practicing in this hospital by virtue of Medical Staff membership or otherwise shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to the Practitioner by the Board.
7.1.2 Every initial application for staff appointment and application for reappointment must contain a request for the specific clinical privileges desired by the Applicant ..."
Article IX titled "Clinical Services" stated in part, "9.4 Credentialing. The Chief of Staff also plays an active role in determining appropriate criteria for the awarding of clinical privileges and makes recommendations to the Medical Executive Committee regarding such on all individuals requesting privileges and for reappointment. The Medical Executive Committee then makes their recommendations to the Governing Body for the final approval."

Review of the credentialing file for staff #17 revealed the last appointment was for 1/18/18 through 1/17/19 with a status of "provisional." The medical staff stated in part, "Recommends reappointment with all requested privileges" which was signed by the chief of medical staff on 1/15/18 and approved by the Board on 1/24/18. Form titled "Medical Staff Clinical Privileges Request Form" was last requested on 7/18/17 with no documentation on the form if the privileges were approved or by whom.

Review of the credentialing file for staff #18 revealed the last appointment was for 3/24/18 through 3/23/19 with a status of "Active." The medical staff stated in part, "Recommends reappointment with all requested privileges" which was signed by the chief executive officer on 3/24/17 and approved by the Board on 3/27/17. Form titled "Medical Staff Clinical Privileges Request Form" was last requested on 8/8/15 with no documentation on the form if the privileges were approved or by whom.

Two of two physicians on the medical staff were not current on their appointment period and privileges.

The above was verified in an interview with staff #6 on the morning of 2/25/20.

Based on review of facility documents, observations, and staff interview, the facility failed to ensure nutritional needs of inpatients were met in accordance with recognized dietary practices as the facility failed to:
A. ensure compliance with accepted standards of practice and Chapter 228 of the Texas Administrative Code (relating to Retail Food)
B. have a current therapeutic diet manual
C. ensure the qualified dietician worked at least once per month for not less than eight hours.


Findings included:

A. Texas Administrative Code [TAC] rule §228.61 stated in part, "Food shall be safe, unadulterated, and, as specified in §228.78(b) of this title, honestly presented."

TAC rule 228.63 stated in part, "(a) Temperature. (1) Except as specified in paragraph (2) of this subsection, refrigerated, time/temperature controlled for safety (TCS) food shall be at a temperature of 5 degrees Celsius (41 degrees Fahrenheit) or below when received."

Review of TFER (Texas Food Establishment Rules, October 2015) reflected the following under section §228.81:
"Contaminated Food, Disposition. Discarding or reconditioning unsafe, adulterated, contaminated food ... (1) A food that is unsafe, adulterated, or not honestly presented as specified under §228.61 of this title shall be reconditioned according to an approved procedure or discarded."

In an article published by Spectrum Health in July, 2014 it was stated "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."

Facility-based policy titled "Food Supplies Purchasing" stated in part, "4. All delivered items should be properly stored in accordance with State and County codes and standards: ...dd. All refrigeration units must be maintained at 38 to 45 degrees F ...
16. All empty boxes, crates and other packaging are disposed of immediately to eliminate potential harboring places for vermin.
...20. Rotate stock so that older items are used first. Date products to ensure the use of RFirst [sic] In-First Out procedures.
21. Outdated and recalled nutrition products will not be provided to patients. Expiration dates will be checked daily, prior to use ..."

Facility-based policy titled "Purchasing and Storage" stated in part, "7. Fruits and vegetables, dairy products, meat and poultry will be stored at 38°F - 45°F.
...9. There will be a thermometer in each refrigerator ... to be sure proper temperature is maintained. These will be checked daily and co-effective action taken if temperature is not within the accepted stated range.
10. Food, whether raw or prepared, if removed from the container or package in which it was obtained, shall be stored in a clean, covered, labeled and dated container ... Container covers shall be impervious and non-absorbent."

Facility-based policy titled "Food Storage" stated in part, "B. Perishable Storage (Cold and Frozen): ...3. The temperature of all cool storage facilities should be checked and logged on the appropriate form daily ...
II. Storage of Food Items
A. Dry Storage:
1. Containers of corrosion-resistant material, NSF approved for food storage, so fabricated that residue may be completely removed by normal cleaning methods and with tight-fitting lids must be used for bulk materials, such as flour, sugar, mixes, dry legumes, pasta, etc. Store scoops for these items in a separate holder."

Facility-based policy titled "Infection Control" for the Food and Nutrition Department stated in part, "E. Care of equipment: ...All working surfaces, utensils, and equipment are cleansed thoroughly and sanitized after each period of use."

The following was observed during the tour of the kitchen on the afternoon of 2/25/20:
*Waffle maker with dirt build-up that scrapped off with a pen, indicating it was not thoroughly cleansed and sanitized after each use.
*Scoops for bulk sugar, flour, and rice were stored in their bins and not separated
*External shipping boxes stored in the freezer
*Many bags in the freezer such as steak fingers and other meats that were previously cooked with no expiration date
*Previously opened frozen bags of vegetables and fruits with no open or expiration date
*All herbs and spices, such as onion powder, salt, and pepper that were opened and in use without an open or expiration date
*In the dry goods storage, several opened items, such as vegetable oil, soy sauce, and white chocolate, with no open or expiration date
*Next to the office area, a shelf of individual packets of items such as salad dressings, peanut butter, and syrup with no expiration dates
*Next to the office area, a refrigerator with vegetables and fruits that was not monitored for correct temperature range.

In an interview with the dietary director during the tour, they verified the above findings.


B. TAC rule §133.41 stated in part, "(i) Menus shall provide a sufficient variety of foods served in adequate amounts at each meal according to the guidance provided in the Recommended Dietary Allowances (RDA), as published by the Food and Nutrition Board, Commission on Life Sciences, National Research Council, Tenth edition, 1989, which may be obtained by writing the National Academies Press, 500 Fifth Street, NW Lockbox 285, Washington, D.C. 20055, telephone (888) 624-8373 ...
(C) A current therapeutic diet manual approved by the dietitian and medical staff shall be readily available to all medical, nursing, and food service personnel. The therapeutic manual shall:
(i) be revised as needed, not to exceed 5 years;
(ii) be appropriate for the diets routinely ordered in the hospital;
(iii) have standards in compliance with the RDA;
(iv) contain specific diets which are not in compliance with RDA; and
(v) be used as a guide for ordering and serving diets."

Facility-based policy and procedure titled "Leadership: The Role of Consulting Dietician" stated in part, "Approving the diet manual ..."

In an interview with staff #7 on the afternoon of 2/25/20, when asked for the therapeutic diet manual, they stated, "We only have these," and provided a binder with menus that stated in part, "Fall/Winter 2012-2013" that included days of the week with menus and substitutions for portions, cardiac/low fat/low chol/NAS [no added salt]; diabetic and 1800 Calorie diets. The binder included updated menus for Fall & Winder 2019-2020. When asked what variety of menu was provided to the patients, staff #7 stated, "We only have three weeks of menus. We are on week two this week."

In an interview with staff #3 on the afternoon of 2/25/20 when asked if there was a new therapeutic diet manual, they stated, "Don't get me started on that ... the patients get bored of the food pretty quickly, it doesn't seem like there's much variety."

The above was confirmed in an interview with administrative staff the afternoon of 2/26/20.

C. Review of the dietitian consultant's reports for 2018 and 2019 revealed "hours of consultation" consistently typed as "8+ hours."

In an interview with staff #7 on the afternoon of 2/25/20, when asked if the consultant dietician reviews records and performs staff in-services, staff #7 stated, "Yes, she does." When asked if the dietician updates the therapeutic manual, she stated, "We are in the process of getting new menus, but right now we only have three-weeks." When asked if the dietician spends at least eight hours a month on facility services, staff #7 stated, "She's here once a month about 5-6 hours."

When asked staff #1 if they were sure the dietician was only in-house once a month, they stated "Yes."

The above was verified in an interview with administrative staff on the afternoon of 2/26/20.

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) patient care equipment/furnishings were found to be dirty
2) hospital did not have an effective procedure/practice for C-diff (bacteria that requires specific spore-killing disinfectant) disinfection

Findings included:

1) Tour of the hospital with Staff #1 on 2/25/20, from 11:00 a.m. to 12:30 p.m., revealed the following observations:
-Materials Management Room: white refrigerator with various debris and hair inside.
-CT (Computed Tomography) Room: 1 of 2 patient bathroom had a chair made of cloth material with dirt and stains in various locations.

The above findings were confirmed with Staff #1 on 2/25/20 afternoon. Evidence of cleaning/cleaning schedule was unavailable.

In an interview on 2/25/20, at 11:40 a.m., Staff #6 stated the refrigerator was used as a back-up for storing pharmacy medications. When asked about how often the refrigerator was cleaned and who would be responsible, she stated, "we don't have a set schedule and I guess I am responsible."

Tour of the hospital with Staff #3 on 2/25/20, from 1:30 p.m. to 2:00 p.m., revealed the following observations:
-Isolation Room #110: teal colored couch/sofa made of cloth material with dirt and stains in various locations.

The above finding was confirmed with Staff #3 on 2/25/20, at 2:00 p.m. She stated, "we know about the issue and will replace it."

Review of hospital policy titled Environmental Services Policy, IC-45, with issued date of 1/20, stated in part, " ... apply effective and efficient cleaning methods and schedules to maintain a clean and healthy environment ..."

2) Tour of the hospital ED (Emergency Department) and inpatient units with Staff #1 on 2/25/20, from 11:00 a.m. to 12:30 p.m., revealed only "CaviWipes1" were available as disposable wipes. This product had no indication that it can kill C-diff/spores.

In an interview on 2/25/20, at 11:26 a.m., Staff #1 was asked about what cleaning agents/products were used after caring for patients with C-diff. He stated hospital used the Clorox bleach wipes. When asked to locate the bleach wipes, Staff #1 was unable to locate any in the ED/inpatient units. He was able to find 2 containers of "Clorox Disinfecting Wipes" in the EVS (Environmental Services) closet located away from the ED/inpatient units. Upon inspection of the "Clorox Disinfecting Wipes," it was revealed the product specifically indicated "Bleach-Free," and no indication that it can kill C-diff/spores.

Review of hospital policy titled Cleaning and Disinfecting Patient Care Equipment, IC-23, with issued date of Nov 19, reflected no specific instructions for cleaning equipment after coming in contact with patients with C-diff.

Review of hospital policy titled Environmental Services Policy, IC-45, with issued date of 1/20, stated in part, "B. Cleaning Products: ... 2.c. When selecting disinfectant or other cleaning products, factors to consider include its use, efficacy ..."