HospitalInspections.org

Based on review of records and interview, the facility failed to ensure that the patient and/or their representative were advised of their rights provided by the Informed Message from Medicare (IM Letter) for 1 (Patient #22) out 4 patients reviewed.

Findings included:

Review of Patient #22's chart showed that he was a Medicare and Medicaid recipient. The patient's niece was listed as the patient's next of kin. The chart stated that the patient had a history of Mental Retardation, Autism, and Early Dementia. The patient was noted to be confused upon admission and unable to sign his IM Letter. On 8/9/2021 the IM Letter was documented "Pt unable to sign." On the line with instructions "Please sign below to indicate you received and understand this notice", two staff members signed and dated where "Signature of Patient or Representative" should have been. No evidence was found that the patient's next of kin was provided with the information necessary to exercise the patient's rights.

Prior to discharge, the patient remained confused and unable to follow instructions for care of his surgical site. He had to be restrained to prevent him from pulling off his colostomy bag, pulling out his intravenous (IV) catheter for medication administration, and/or injuring his healing surgical site. Despite his inability to understand what he needed to do to care for himself, two staff members signed the second IM Letter delivered prior to discharge as "Reviewed verbally with patient". No evidence was provided that his Next of Kin was advised of the patient's rights afforded to patients who were Medicare recipients.

Review of Policy Title: Important Message from Medicare (IMM) Letters / Notifying Medicare Beneficiaries of their Discharge Right to Appeal, Number CM.004, Created 12/2/2021 was as follows:

"Patient Representatives
Christus Health will make every effort to have all IMM notices acknowledged by the Medicare beneficiary. When the beneficiary is unable to provide signature of acknowledgment of understanding, a patient representative may receive the information and provide acknowledgement. The delivery should be in person, but may be made by phone with appropriate documentation of how and to whom the notification was made. Telephone notification should be followed with the document being mailed or faced to the representative the same day. If a representative cannot be reached, the document can be mailed via certified mail and the date and signature of receipt or (sic) will serve as the notification date."

On 3-15-2022, an interview was conducted with Staff #27. Staff #27 confirmed that the patient would have been unable to understand and exercise his rights as provided in the IM Letter and that the IM Letter should have been provided to his Next of Kin.

Based on observation, document review, and interview the facility failed to provide a secure location that protected a patient's personal belongings in 1 (Patient #23) of 3 patients records reviewed. The facility also failed to follow their own policy and secure patients' personal belongings.

Findings include:

A tour of the Emergency Department was conducted on 3/14/2022 at 1:50 PM with Staff #29. Outside the 4 patient rooms that were specifically designed and used for psychiatric patients was a large brown cabinet that was partially opened. This cabinet was next to the nursing documentation area. Inside the unlocked cabinet were 2 (two) backpacks with a sticker for Patient #23 applied to the outside. A purse was inside a clear plastic bag with a sticker applied to the outside of the bag identifying Patient #23. Inside the 2 backpacks were personal belongings for Patient #23. Clothes, shoes, hygiene products, a watch, and 3 medication bottles. This surveyor nor Staff #29 looked into the patients purse.

An interview was conducted with Staff #29 on 3/14/2022 at 2:45 PM. Staff #29 was asked if the cabinet was always unlocked. Staff #29 stated the cabinet should always be locked anytime patient belongings were inside. Staff #29 was asked where Patient #23 was at this time. Staff #29 stated that Patient #23 was admitted to the Emergency Room on 3/11/2022 and transferred for inpatient psychiatric care on 3/12/2022 and she would find out where she was transferred to and ensure that her belongings were returned to her. Staff #29 called the hospital security department and had the belongings picked up by Staff #32 and secured until the patient belongings were returned to Patient #23. There was no inventory of Patient #23's belongings completed between Staff #29 and Staff #32 when the belongings were removed from the Emergency Room by Staff #32.

Staff #29 stated, "We know we have a problem with patient belongings, and we are trying to work on that."

An interview was conducted with Staff #32 on the morning of 3/15/2022. Staff #32 was asked to explain the process of securing a patients belongings. Staff #32 stated, "The hospital department calls us and tells us that they have patient belongings or valuables that they need to be picked up and secured until the patient is discharged. We then go to the department and do an inventory with a nurse or other staff and bring the valuables back here and log them in the book, lock them in a safe, and the key goes to the patients medical record." Staff #32 was asked how a patients home medications were secured. Staff #32 replied, "We do not keep any medications in the security office. They go straight to the pharmacy." Staff #32 was asked if she was aware that Patient #23's belongings were in an unlocked cabinet in the Emergency Room. Staff #32 stated, "No, I was not aware but if the department does not call us then we have no idea that it was there."



A review of the facility policy titled; "Standards of Care for the Behavioral Health Patient in the Emergency Department" Adopted 3/2021 with a review date of 3/2021 was as follows:

" ...PURPOSE: To provide guidelines for the care ad management of individuals with emergent behavioral health needs at CHRISTUS Southeast Texas Emergency Department in an environment of safety, with appropriate levels of observation, while arrangements for behavioral health treatment are being made.

GUIDELINES:
...
6. All patient belongings shall be searched by staff when admitted to the ED. The search is completed to eliminate contraband from the patient room and to ensure a safe environment. Belongings are to be sent hoe with family members if feasible. Otherwise, all medications are to be locked in the Pharmacy until the patient is released. All valuable items (i.e., phones, money, credit cards, etc.) are to be safeguarded by security until patient is released. All other personal items shall be placed in a patient belonging bag, LABELED, and locked in the cabinet. Documentation of location of belongings shall be noted in the electronic medical record and reported during hand-off instances.

Contraband includes but is not limited to the following items:

Firearms
Knives and blades
Tobacco and/or vaping products
Matches and lighters
Belts, robes, ties, drawstrings, shoelaces
Cellular telephones, charging devices, earphone/buds, or other
electronic equipment
Medications
Illegal substances ..."





A review of the facility policy titled, "ARMED SECURITY PATIENT VALUABLES AND PROPERTY POLICY; CO.SEC.010" with a last approved date of 04/20/2021 was as follows:

" ...PROCEDURE:

When Security Officers are called to pick-up valuables, the officer will obtain a patients valuable envelope, in numerical sequence, and go to the location of the patient. While the valuables are being logged on the inventory of Personal Effects Form Security, patient, and patient's nurse will witness the transaction.

1. The Security Officer and the nurse will sign the Inventory of Personal Effects form after the items have been placed in the envelope and the envelope has been sealed. The envelope will be sealed in the presence of the nurse and security officer.

2. The Inventory of Personal Effects Form has three parts: the white copy will be placed in the patient's chart, the pink copy will go inside the valuables envelope along with the items and the yellow copy will be placed in the valuable book, which is kept in the Security storage areas ..."


On the morning of 3/15/2022 Staff #29 confirmed there was no documentation of Patient #23's personal belongings in the medical record.


Staff #29 and Staff #32 confirmed the above findings.

Based on record review and interview, nursing staff failed to complete the assessment of wounds for 1 (#15) of 5 (#18, #27, #28, and #29) patient's medical records that were reviewed. Also, the nursing staff was not consistent in the documentation of wound assessments. The facility failed to follow the facility's policy on "Pressure Injury Prevention and Management"

This deficient practice had the likelihood to cause the patient's skin integrity to deteriorate.

Findings included:

Patient #15 was a 63-year-old male, significant past medical history of seizures on Dilantin, chronic quadriplegic secondary to C-spine injury in 1990 from a motor vehicle accident with indwelling Foley, and recently at the hospital and discharged with a UTI. Patient #15 was admitted on 08/13/2021 with constipation and presenting with altered mental status. Patient was found at 3 PM at home on 08/13/2021 unresponsive on the ground and EMS was called. Patient had no complaints although he was not alert X 3 not answering questions or following commands appropriately.

A review of Patient #15's initial assessment in the Emergency room on 08/13/2021 at 22:44 (10:44 PM) revealed no skin assessment.

A review of Patient #15's admission assessment to ICU (Intensive Care Unit) on 08/15/2021 at 15:45 (3:45 PM) revealed a written statement of "Skin Assessment label" "Left lower Scrotum Lesion" and Coccyx possible previous injury that is healed. Patient was placed on specialty bed. Further skin assessment reveals edematous scrotum with small pink lesion on left side and patient has what appears to be where a previous pressure injury was (no location of the injury documented). Nursing staff scored skin assessment as 9 points. A score of 9 indicates high risk for developing a pressure injury. There was no documentation on the facility's forms titled, "Skin Algorithm/gram" or the form "pressure ulcer present on admission."

There were no photographs taken on admission to ICU and no assessment as far as size of the wounds was found in the nurses note.

A review of wound assessments for Patients #18, #27, #28, and #29 revealed the forms for "Skin Algorithm/gram" and "pressure ulcer present on admission" were present in the medical record. Pictures of the wounds were available in the medical record.

An interview with Staff RN #23 on 03/15/2022 at 8:30 AM conducted in the ICU department was asked how wounds are assessed and documented. RN #23 reported that the Braden QD scale risk assessment tools are used. A review of the chart revealed the "Skin Algorithm/gram" and "pressure ulcer present on admission" were completed. Pictures were taken of the wounds.

An interview with Staff RN #19 on 03/14/2021 at 4:00 PM confirmed the documentation of the wound assessment was inconsistent on the patient #15 compared to the patients #18, #27, #28, and #29 and the "Pressure Injury Prevention and Management" policy was not completely followed.


A review of the facility's policy, titled "Pressure Injury Prevention and Management" dated 7/21 revealed the following:

"I. KEY WORDS: Pressure Injury, Braden Scale, Braden QD Scale

II. OBJECTIVE: To establish guidelines in an effort to prevent and assist in the management of pressure injuries; to establish guidelines for the systematic assessment of patients for risk of pressure injury development and the identification of the specific factors placing them at risk for development of a pressure injury; provide guidelines for preventive interventions based upon the risk assessment; provide guidelines for the initial response to an identified pressure injury; and outline procedures for documentation and communication procedures.

III. GUIDELINE STATEMENT: CHRISTUS Health and its affiliated entities will implement basic and universal pressure injury prevention guidelines for all patients consistent with the understanding that prevention is a goal but not all pressure ulcers can be prevented depending on the circumstances. Patients and residents of CHRISTUS Health and affiliated entities and facilities will be assessed for pressure injuries and risk for pressure injury development upon admission, transfer, change in status, and periodically thereafter. The re-assessment schedule is determined by the individuals risk category, circumstances related to clinical care being provided and the care location (e.g., hospital in-patient, long-term care resident, etc.). A multidisciplinary team may institute interventions in an effort to reduce the risk factors associated with soft tissue injury and pressure injury development. At times, skin breakdown is inevitable due to the circumstances related to the clinical care being provided. Patients who develop a pressure injury will be appropriately managed and the specific situation will be investigated for possible practice or procedural changes. This multi-factorial pressure injury prevention program, including procedures for the staging and management of pressure injuries, is supported by evidence-based practice and interdisciplinary involvement but care is individualized to each patient situation such that not all elements of this prevention program may be available to all patients.
NOTE: This guideline reflects evidence-based practices derived from contemporary literature review. Individual patient assessment and other clinical situations may influence specific courses of action.

IV. DEFINITIONS:
A. Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Not all pressure injuries are preventable despite rigorous efforts to avoid them.
B. Medical Device Related Pressure Iniury: Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. Not all medical device related pressure injuries are preventable despite rigorous efforts to avoid them.
C. Mucosal Membrane Pressure Injury: Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue these ulcers cannot be staged.
D. Braden Scale: A tool designed to facilitate pressure injury risk assessment in the adult population. The tool consists of six subscales that evaluate a patient's sensory perception, activity level, mobility, nutritional status, and the skin's exposure to moisture, friction, and shear forces. Lower total scores of 18 or less are associated with a higher risk of developing pressure injuries.
F. Braden QD Scale: This version of the Braden Scale Risk Assessment is modified for use with neonates and up to 21 years of age. The tool consists of five subscales and identifies risk for both immobility and device-related pressure injury.
F. Pressure Injury Stages: Based on recommendations defined by the National Pressure Ulcer Advisory Council (NPUAP):
*Deep Tissue Pressure Injury (DTPI): Intact or nonintact skin with localized area of nonblanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister.
*Stage I Pressure Injury (non-blanchable erythema of intact skin): Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin.
* Stage II Pressure Injury (partial-thickness skin loss with exposed dermis): Partial thickness
loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister.
* Stage III Pressure Injury (full-thickness skin loss): Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible.
* Stage IV Pressure Injury (full-thickness skin and tissue loss): Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur.
* Unstageable Pressure Injury (obscured full-thickness skin and tissue loss): Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
G. Eschar: A dry, black/brown leathery necrotic tissue
H. Undermining: Tissue destruction underlying intact skin along wound margins
I. Tunneling/Sinus Tracts: Pathways that can extend in any direction from the wound surface

V. PROCESS:
1. Depending on the circumstances on admission, in most circumstances, a Registered Nurse (RN) will complete a skin assessment at the time of the admission assessment with dressings removed. The RN, with documented competency/education in using the Braden or Braden QD Scale Risk Assessment Tools, will also perform a pressure injury risk assessment using the appropriate Pressure injury Risk Assessment Tool.
2. The Braden Scale (Attachment A) is used for adult patients and for women admitted to perinatal services.
3. The Braden QD Scale (Attachment B) is used for neonates and pediatric patients and may be used for patients up to 21 years of age.
4. To the extent possible, the Braden/Braden QD Scale is completed on every admission/readmission.
The skin and the pressure injury risk should be re-assessed on a frequency determined by patient condition and setting, as follows:
a. Hospital in-patients receive a daily re-assessment; ICU patients whose condition is unstable should be reassessed every shift.
b. Rehab patients are assessed on admission. A skin assessment is performed each day.

A. FOR ADULT PATIENTS:
1. The risk assessment for each Braden sub-scale will be documented according to current documentation procedures. Level of risk for developing a pressure injury is identified according to score. A lower score equals higher risk.
Braden Category Score
Not at Risk More than 18
Mild Risk 15 to 18
Moderate Risk 13 to 14
High Risk 10 to 12
Very High Risk 9 or lower

2. Level of risk categories will be used to determine how aggressive prevention measures should be and to evaluate their effectiveness. Re-assessment scores will also be used to determine when more aggressive preventive measures are no longer appropriate or necessary. When any one subcategory scores a one (1) on the Braden Scale, specifically address an intervention to reduce that risk in the plan of care."

Based on observation, interview, and record review, the facility failed to ensure the facilities and equipment were maintained in a manner to promote patient safety in the emergency department.

This deficient practice had the likelihood to cause harm to all patients.


During an observation tour on 03/14/2022 and 03/15/2022 the following was observed:

Emergency Department Trauma Bay:

* Belmont Rapid Blood Infuser E30182 - Last PM date on sticker - 10-21. Date due: 1-2022.

* Doppler Flow Detector E70209 - Last PM date on sticker - 1-20. Date due: 01-2021

* Thermoscientific Chart Recorder E29480 - Last PM date not readable on sticker. Date due not readable.

*Welch Allyn Vital sign monitor E41830 - Last PM date on sticker 01-20. Date due: 01-2021.


A review of the facility's Preventative maintenance log revealed the following:

* Belmont Rapid Blood Infuser - E30182 - not found on log.

* Doppler Flow Detector E70209 - completed on 01/01/2022 and close on 02/04/2022.

*Thermoscientific Chart Recorder E29480 - completed 01/01/2022 and closed on 02/04/2022

*Welch Allyn Vital Sign Monitor E41830 - completed 01/26/2021 and closed 01/28/2021.


A review of the facility's policy titled, "Environment of Care Compliance: Medical Equipment Testing - Scheduled Service (PM& ES)," dated December 2020 revealed:

"Purpose: This policy describes the process by which each piece of equipment is tested and documented at intervals determined by manufacture recommendations, risk levels and current Facility experience.
Policy: To ensure that there is written equipment testing procedures for each piece/type of fixed or portable medical equipment the Medical Equipment Management Program encompasses in the inventory.
Scheduled Service is broken down into (3) distinct categories:
Planned Maintenance includes a complete external inspection, cleaning, lubrication, calibration verification, environmental, and operational check of the medical equipment.
Performance Verification includes an external visual inspection, calibration verification, environmental, and operational check of medical equipment.
Electrical Safety Tests ensures that the medical equipment contains no electrical hazards to operators or patients.
Procedure:
1. The HTS Department will develop written Inspection and/or Electrical Safety Procedures for every piece/type of fixed or portable medical equipment in the Alternate Equipment Management Program.
2. Inspection Procedures will be established by using the manufacturer's literature, regulatory agency performance standards (ANSI/AAMI EQ56, ANSI/AAMI EQ89, NIOSH, NFPA-99:2012, etc.), general experience, and industry experience.
3. Medical equipment subject to federal or state law or Medicare Conditions of Participation including Medical Lasers and Imaging/Radiologic Equipment (therapeutic and diagnostic) will be maintained according to manufacturer recommendations. New Medical Equipment will be maintained according to manufacturer recommendations unless maintenance history supports the use of alternative equipment maintenance management (AEM) strategies. Available AEM-E Equipment will have a completion rate of 100% for each month. Should the rate of completion fall below 100%, the Unit Director will analyze the results to determine the cause and make/report on recommendations to achieve established target rate.
4. An inspection schedule will be developed to show the months when scheduled inspections are to be performed. The PM schedule is maintained within the CMMS; and available upon request.
5. PM work orders are auto generated at least two weeks prior to the first of the next month.
6. All medical equipment found to be "in use" at the time of scheduled inspection will be deferred and brought to the attention of the Department Head or Assignee and a schedule will be established to service that medical equipment.
7. Inspection results documentation will be entered into the Computerized Maintenance Management System (CMMS) medical equipment service history.
8. All Available Non-High Risk AEM Equipment will be tested according to determined intervals in a timely manner. Maintenance activities and frequencies for Non-High Risk AEM Equipment will be completed at 100%. Scheduled maintenance will be conducted on 100% of available Non-High Risk AEM Equipment for each month. Should the rate of completion fall below 100%, the Unit Director will analyze the results to determine the cause and make/report on recommendations to achieve established target rate.
9. Available High-Risk Equipment will have a PM completion rate of 100% for each month. Should the rate of completion fall below 100%, the Unit Director will analyze the results to determine the cause and make/report on recommendations to achieve established target rate.
10. It will be the responsibility of the Facility's Department Head or designated contact to locate and notify the HTS Department when the medical equipment is available for service or report medical equipment which was removed from service.
11. It will be the responsibility of the Facility's Department Head or designated contact for the quality control testing and user testing on all sterilizers.
12. It will be the responsibility of the Facility's Department Head or designated contact for the dialysis equipment cleaning, disinfection, and testing for compliance with biological and chemical standards for the dialysis water supply.
13. It will be the responsibility of the Facility's Department Head or designated contact to ensure all required medical physicist QC, dose, and performance testing is conducted in accordance with regulatory standards.
14. It will be the responsibility of the Facility's Department Head or designated contact to ensure compliance with construction, equipment, administration, and user maintenance related to Hyperbaric Facilities in accordance with NFPA 99 -2012 Chapter 14.
15. Equipment listed for use in oxygen-enriched atmospheres will be inspected in conjunction with the established PM schedule to ensure the devices are clearly and permanently labeled in accordance with NFPA 99 -2012 Chapter 11.5.3.1.
16. Items that could not be located from the scheduled inspection process will be logged into the CMMS utilizing the "UTL" (unable to locate) designation. The work order will remain open. After 2 consecutive PM cycles, if the asset has not been located, the asset may be de-activated. "UTL" and equipment "In Use" looked for "on time" (time of scheduled inspection) will be excluded from MEMP PM reporting requirements. Equipment sent out for vendor repair "VS" and not physically in the facility during scheduled maintenance will be excluded from the MEMP PM reporting requirements.
The overall PM completion rate shall be documented and reported with HR, AEM-E, & AEM completion rates for each month. UTL, IU, and VS devices shall be reconciled. Refer to QMP-7.5.3-WI01 for more details.
UTL, IU, and vs shall be monitored combined at< 5% of total PM's generated. Should the UTL, IU, and vs rate exceed S%, the Unit Director will analyze the results to determine the cause and make/report on recommendations to achieve established target rate.

17. A UTUIU report is to be run monthly to assist in the completion of the PM work orders and presented to Facility's designated contact, Department Head, and Environment of Care Committee.
18. The Asset will remain in the UTL status until the medical equipment is either located and reactivated or deemed 10st and deactivated.
19. If medical equipment listed as UTL is located the work order will be completed and closed per established procedures.
20. If the Asset has been located after deactivation, reactivate device per established procedures.
21. Upon completion of the inspection, the Facility's designated contact will receive a Maintenance Status Report. Additional efforts will be made to locate equipment not found during the inspection.
22. All efforts will be made to locate or resolve equipment issues before the end of the service period."


A review of the facility's policy titled, "Environment of Care Compliance: Documentation," dated December 2020 revealed:

"Labels and Tagging:
1. Inspection lables denote the date inspected and the date due for the next inspection. Dates are noted in the format of mm/yy.

2. Inspection labels are used when conducting perodic inspection on equipment or systems.

3. The following are types of inspection labels:

* Periodic Inspection Label: This label appears on all medical equipment that has been inspected."

An interview with Staff # 49 and Staff # 50 was conducted on 03/15/2022 at 10:00 AM. Staff # 49 was asked the facility process for preventative maintenance (PM's) for equipment in the ED. Staff # 49 reported the facility was up to date on all (PM's). Staff # 49 presented this surveyor with the PM Log. Staff # 49 was asked about the PM labels on the equipment in the ER. Staff # 49 and # 50 reported they use the log to determine when PM's are due and current. Staff # 49 was then asked how staff in the ED were to know if the equipment was in good working order if the PM labels are not current on the equipment. Staff # 49 stated "I'm not sure."

An interview with Staff # 8 on 03/15/2022 at 10:30 AM, confirmed all the above findings

Based on observation, interview, and record review, the facility failed to provide a clean and sanitary environment and have an active program for preventing infections. This deficient practice was found in 3 of 3 departments (Emergency, 6 Neuro, and 2nd floor Telemetry.)

On 3/14/22 at 4:20PM a tour was conducted of the 2 nd floor Telemetry unit with Staff # 9 (RN). The following was observed:
2nd Floor Telemetry-

There was clutter down both sides of the hallway blocking egress in some areas and dirty patient trays and trash next to clean linen and patient equipment.

Computer WOWs (workstations on wheels) were lined up outside the nurse's station along with a linen cart. The wow's were visibly soiled with hair, dust and debris. The linen cart had a Styrofoam drink pitcher laid on its side on top of the cart. There was no evidence to show if the pitcher was clean or dirty.

An oxygen tank (E-cylinder) was found sitting in the hallway unsecured.

The crash cart was sitting in the hallway. It was visibly soiled on the top and bottom with dust. A dirty blue cart was sitting next to the crash cart with dirty used patient food trays, uncovered, on top.

In the hallway a second dirty cart was sitting next to a full patient trash can. Dirty food trays were on the bottom of the cart and a bag of dirty laundry was sitting on the top.

A spillage of liquids was found on the ground in the hallway. Two paper napkins had been laid on top of the spillage but was never cleaned up.

A stretcher was found in the hallway heavily soiled with rust, dirt, dust and hair. The stretcher was missing paint, and the rails of the bed were soiled. Staff # 51 confirmed the stretcher was the only one transport had available at the time to transport.

A confused patient was found wandering the hallway rummaging through the old patient food trays. Staff #9 confirmed the findings, and a floor nurse took the patient back to her room. The wainscot on the side of the wall was coming lose and exposing sheetrock.

An Active Compression System (machine that goes on a patient's legs and enhances the circulation of blood in the deep veins of the legs) was found hanging, in the hallway, on the hallway rail. The cuffs of the machine were laying on the floor outside of an isolation room. There was no evidence of where it came from, if it had been on an isolation patient, or if it was clean or dirty.

A bedside commode chair was found outside the patient's room in the hallway. The chair was visibly soiled on the outside. When the commode chair was lifted it was soiled with feces on the inside.

Towards the end of the hallway a large trash can, a full linen cart and a transport food warmer with patient trays on top were found sitting side by side. Sitting outside of room 2135 was 2-containers for biohazard waste, a fan, and a large trash can.

At the end of the hall was a 5-shelf metal cabinet with double doors. The cabinet was not locked. The surveyor opened the cabinet, and it was full of patient supplies. Inside the cabinet the supplies were all mixed up and scattered. There was respiratory equipment and IV pumps sitting on top of the supplies. There was no identification if the equipment was clean or dirty.

The trash disposal room was inside a room with exposed wires and cables. Dirty gloves were thrown all in the wires and cables. Full trash bags and boxes were piled up by the trash chute. The floor was covered in debris and dirt.

An interview was conducted with Staff #51 (LVN) on 3/14/22 at 4:20PM. Staff #51 stated that the large patient trash cans were out in the hallways because there was no room for the staff to discard their PPE in the patient room and these rooms did not have an anteroom. Staff #51 stated that the staff come out of an isolation room with their PPE on, go across the hall to the trash can and DOFF (remove PPE) there. Staff #51 stated she could gel her hands from the dispenser in the hallway or had to go to the nurse's station. Staff #9 and Staff #51 both stated they were to use the CDC guidelines when donning (putting on) and doffing(removing) PPE. The CDC recommends that you are to remove PPE at doorway or in anteroom. Staff #51 stated that there were small trash cans in the patient rooms, but they were always full. Staff #51 stated the cans get full out here too but house keeping eventually picks it up. Staff #51 confirmed that the hallways were cluttered with equipment, food trays, and linen. Staff #51 stated that there were places to put these items, but they had not had time to clean the items. Staff #51 stated the trash bins were off the hall and so was the laundry chutes.



10135

6 Neuro


During an observation on 03/15/2022 after 8:50 a.m., the following was noted:

A nurse's workstation on wheels (WOW) was found parked in an Alcove in front of the clean storage room. The WOW had a plastic bag draped over it which was an indicator that it was clean. When the plastic bag was removed the base of the WOW was found soiled with dried spills and the wheels had a build-up of dried debris. The tray on the equipment was soiled with brown stains.

Two oxygen concentrators were found in the Alcove on top of a shredder. There was no indication as to if the concentrators were clean or soiled.
They were not tagged as being clean or in a plastic bag.

Inside the clean supply room were full, partial and empty oxygen canisters. The soiled oxygen tanks were stored in the room with clean patient supplies.

Patient supplies were stored on top of the supply shelves in close proximity to the ceiling and underneath the air vent. The clean supply cart was found to be rusted, soiled with debris.

An open fifty count sterile packet of BBL Culture Swabs was found on the shelf with an expiration date of 01/31/2022.

Some of the supplies on the shelves were open and just thrown on top of each other. A cardboard box of supplies was found lying on a shelf on top of other patient supplies.

A Dina Map (mobile vital sign machine) was stored in the hallway with a plastic bag over it. When the plastic bag was removed the white base of the equipment was found to be soiled with brown and black buildup. The wheels of the equipment were soiled and had strings twisted around them.

The clean equipment storage room had seven pieces of patient use monitors (WOWs, Dina maps, and blood pressure monitors) stored in the room which were covered with plastic bags. When the bags were removed the equipment was found to be soiled with dust, dried brown stains and had a build-up of dirt on the wheels. One of the dinamapps had temperature probe covers stored in it. The bin was soiled with spills.


Room #609B was identified as being a clean room by Staff #2 (Infection control coordinator). A Dina map was found in the room. The storage bin was found to have a thermometer in it with a pair of used gloves thrown in the bin.
The mattress was raised on the patient's bed and the frame underneath was soiled with a build-up of debris.
A green recliner was soiled with a dry brown substance. The leather covering on the recliner had two tears. In this condition there was no way the recliner could be sanitized.

Staff #2 confirmed the observations.




Neuro Intensive care unit

An unidentified staff member was observed to leave out of an isolation room with her PPE still on. The staff member closed the door and stepped into the hallway. When she turned around and saw she was being observed the staff member stepped back into the room and removed her PPE, placed it in the trash can that was near the door.

Staff #2 (infection control coordinator) confirmed the observation and said the unidentified staff member was supposed to remove her PPE inside the door and discard it.

Review of the facility's environmental rounding sheets from October 07, 2021 to February 10, 2022 revealed documentation of identification of dirt buildup, rusted equipment, problems with PPE, problems with supply storage and repairs and cleaning concerns with floors, walls and ceiling.

During an interview on 03/15/2022 after 10:30 a.m., Staff #2 (Infection control coordinator) said they were performing weekly environment/infection control rounding until the first part of February. They stopped to focus on the Joint Commission citations.





Review of a facility's policy named "INFECTION CONTROL:INPATIENT EQUIPMENT CARE" dated 06/2019 revealed the following:

"POLICY:
Patient care equipment used in such a manner as to provide quality care with the least risk of infection. Standard precautions used at all times and Personal Protective Equipment will be worn whenever indicated.
Jasper Memorial Health (wrong hospital name)- Equipment cleaned at point of use with a hospital-approved disinfectant according to manufacturer's recommendation and stored in a clean equipment room.

"...Personal Protective Equipment...
2.PPE will be disposed of properly when task is completed ...
Portable Vital Sign Monitors
1.Portable vital sign monitors are to be cleaned using sanicloth, bleach wipes, or hospital approved germicidal ..."

Review of a facility's policy named "SYSTEM SUPPLY CHAIN PROCEDURE" dated September 2021 revealed some of the following:
"...1.All stock locations must be maintained in proper order with the emphasis on cleanliness ...
4. To maintain sterility, supplies must never be placed on the floor or on damp surfaces. Bins and shelves must be cleaned on a regular basis ...
5. Any contaminated or expired product must be adjusted out to the inventory system and sent to Materials Management for proper disposal or return to the manufacturer for credit..."



40989

EMERGENCY ROOM

During a tour of the Emergency Room on 3/14/2022 at 2:00 PM with Staff #29 the following was observed:

1. CLEAN AREA

This was an area designated in the ER for clean patient equipment. A sign applied to the wall outside this area read, "CLEAN AREA No Dirty Equipment No Patient Specimens." The area was behind a curtain. Behind the curtain the following was observed:
A. Two of four IV poles, three patient warming units, and three IV Pumps, were not identified as clean.
B. The telehealth monitor for Psychiatry and Neurology were not identified as clean. A basket attached to the pole that was identified as "CSETX St E ED Psych Cart 2" was noted to have a dried brown colored liquid in the bottom that resembled old, dried blood. Directly under the monitor dirt and dust was noted.

2. EXAM ROOM 4 TRAUMA ROOM A & B

A. A locked refrigerator was used to store blood products for patient use. At the bottom of the outside was a filter that was heavily covered with lint. On the inside of the refrigerator were two shelves. On the top shelf next to the blood products trash was identified. In the bottom shelf pooled water was identified.

B. Inside the red cabinet used to store IV fluids for burn patients was noted to have dirt and dust.

C. In the open cabinets above the countertop a 50 ml (milliliters) of 1% Lidocaine and two 30 ml bottles of 2% Lidocaine with Epinephrine was open and not dated with an expiration date. Staff #29 could not confirm how long the medication had been opened.

3. SOILED UTILITY

Inside the soiled utility room on the wall above the three biohazard bins, was a dried brown liquid that had run down.

An interview was conducted with Staff #29 at 2:45 PM on 3/14/2022. Staff #29 was asked if clean and dirty equipment was placed in the Clean Area on a regular basis. Staff #29 stated, "The staff knows that the labels have to be placed on the equipment once the equipment was cleaned before it can be stored in that area." Staff #29 was asked who was responsible for the filter changes on the blood refrigerator. Staff #29 replied, "It is either the lab or the Plan Operations Department."

Review of a facility's policy named "INFECTION CONTROL:INPATIENT EQUIPMENT CARE" dated 06/2019 revealed the following:

" ...POLICY:
Patient care equipment used in such a manner as to provide quality care with the least risk of infection. Standard precautions used at all times and Personal Protective Equipment will be worn whenever indicated.

Jasper Memorial Health (wrong hospital name)- Equipment cleaned at point of use with a hospital-approved disinfectant according to manufacturer's recommendation and stored in a clean equipment room.

PROCEDURE:
...
Portable Vital Sign Monitors
1. Portable vital sign monitors are to be cleaned using sanicloth, bleach wipes, or hospital approved germicidals.
...
IV Poles
1. IV pumps will be returned to Central Supply for cleaning.
2. Extra IV poles will be cleaned with sanicloths or hospital grade disinfectant between patients ..."


Staff #29 confirmed no patient equipment goes to Central Supply for cleaning that is used in the ER. the findings. After multiple requests for a policy related to outpatient/ER patient care equipment none was presented for review.

Staff #29 confirmed the above findings.