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Based upon observation, record review, and interview, the facility failed to ensure all patient care services furnished were in accordance with applicable State laws and regulations. Texas Administrative Code (TAC) Chapter 133, Rule 133.42 (a) (1) requires facility policies and procedures to protect patient's rights; and requires patient to be informed of their patient rights in advance of furnishing patient care, and prior to discharge affecting 15 patients reviewed for patient rights (#1-#15). Specifically,

1.) Patient's #3, #4, #5, #7, #8, #9, #10, and #11 had Medicare and their medical records did not contain evidence of a signed copy of the Centers for Medicare and Medicaid Services (CMS) form titled "An Important Message from Medicare about Your Rights;" (CMS-R-193); as required upon admission and prior to discharge.

2.) The facility did not have specific required postings and; policies and procedures for how and where to report allegations of abuse/neglect/exploitation against the facility and/or facility employees to the appropriate state health care regulatory agency that has authority and licenses the facility; Department of State Health Services (DSHS) at (888) 973-0022; and in accordance with the Health and Safety Code §161.132(b). The required State Law posting to notify patients or patient representatives of the statement of duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language with their right to contact the appropriate complaint line number was not posted at entrances/waiting areas (Entrance/Main Lobby, and Entrance/Emergency Room Waiting), and was not posted in the Rehabilitation area.

These deficient practices affected all 15 patients reviewed for patient rights.

Findings included:

1.) Review of the Facility's Policy for Patient Rights effective 11/26/14 revealed in part, "All patients who register for patient care will receive information regarding their rights and responsibilities as a patient."

Review of the notice "An Important Message from Medicare about Your Rights," form (CMS-R-193) provided to this surveyor after request, revealed as a hospital inpatient you have the right to the following:

-Receive Medicare covered services. This includes medically necessary hospital services and services you may need after you are discharged, if ordered by your doctor. You have a right to know about these services, who will pay for them, and where you can get them.

-Be involved in any decisions about your hospital stay, and know who will pay for it.

-Report any concerns you have about the quality of care you receive to the Quality Improvement Organization (QIO) listed.

Review of the CMS website at: https://www.cms.gov/medicare/medicare-general-information/bni/hospitaldischargeappealnotices.html revealed Hospitals were required to deliver the Important Message from Medicare (IM), CMS-R-193 to all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospital inpatients. The IM informs hospitalized inpatient beneficiaries of their hospital discharge appeal rights.

Review of Patient #3, #4, #5, #7, #8, #9, #10, and #11's medical records revealed they had Medicare insurance as their primary and their medical records did not contain evidence of a signed copy of "An Important Message from Medicare about Your Rights;" (CMS-R-193) as required upon admission and prior to discharge.

During an interview on 02/07/17 at 11:45 AM with the Director of the Business Office (DBO) stated the facility had condensed and combined the inpatient admission consent forms and further confirmed the notification for patients with Medicare titled, An Important Message from Medicare about Your Rights; had been missed and not included for hospital inpatients. This specific notification was provided for patients being admitted into the facility's Swing Bed program within the service agreement.


2.) Review of the facility's patient rights and responsibilities on 2/7/17 that is provided to patients upon admission revealed each person who is a patient has the following rights and responsibilities; in part, "7. The right to be free from mental, physical, sexual, and verbal abuse by any staff member."

Further review of the facility's patient rights policy's which included the following:
Patient's Rights, effective 11/26/14;
Patient Grievance, undated; and
Protected Health Information Disclosure to Law Enforcement Without Individual Authorization, revised 02/20/15, revealed no specific procedures provided for how and where to report allegations of abuse/neglect/exploitation against the facility and/or facility employees to the appropriate state health care regulatory agency that has authority and licenses the facility; (DSHS at 888- 973-0022; and in accordance with the Health and Safety Code §161.132(b).

Further requests were made on 2/7/17 to the facility's Chief Executive Officer (CEO) for specific policy and procedures for reporting abuse/neglect/exploitation against the facility and/or facility employees to the appropriate state health care regulatory agency that has authority and licenses the facility; (DSHS at 888- 973-0022; and in accordance with the Health and Safety Code §161.132(b); and the CEO was unable to provide this specific evidence.

Observation on 2/7/17 at 12:09 PM of the facility's main admission lobby/waiting area, and further observations of the Emergency Room Department and Rehabilitation areas during the survey revealed there was not a posting for display readily visible to patients, or patient representatives of the statement of the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language which included the number of the Texas Department of State Health Services (DSHS) patient information and complaint line at (888) 973-0022; in English and Spanish.

During an interview on 2/7/17 at 2:31PM with the Chief Nursing Officer (CNO) confirmed there was not a posting in the facility for display readily visible to patients, or patient representatives of the statement of the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language which included the number of the Texas Department of State Health Services (DSHS) patient information and complaint line at (888) 973-0022; in English and Spanish. The CNO further stated he understood that abuse/neglect/exploitation allegations were to be reported to Human Resources.

Interview on 2/7/17 at 2:40 PM with the CEO confirmed the facility did not have specific policy and procedures for how and where to report allegations of abuse/neglect/exploitation against the facility and/or facility employees to the appropriate state health care regulatory agency that has authority and licenses the facility; Department of State Health Services (DSHS) at (888) 973-0022; and in accordance with the Health and Safety Code §161.132(b).

Health and Safety Code §161.132(b) indicates: b) An employee of or other person associated with an inpatient mental health facility, a treatment facility, or a hospital that provides comprehensive medical rehabilitation services, including a health care professional, who reasonably believes or who knows of information that would reasonably cause a person to believe that the facility or an employee of or health care professional associated with the facility has, is, or will be engaged in conduct that is or might be illegal, unprofessional, or unethical and that relates to the operation of the facility or mental health, chemical dependency, or rehabilitation services provided in the facility shall as soon as possible report the information supporting the belief to the agency that licenses the facility [DSHS] or to the appropriate state health care regulatory agency [DSHS].

Based on observations, interviews, and record reviews, the facility failed to ensure that the premises were clean and orderly.

Findings included:

Observations conducted at the facility on 2/06/17, from 11:00 am to 2:00 pm revealed the following:

Laser Procedure Room:

- Facility Staffs were storing 6 excess patient pillows on the countertop.

Operating Rooms:

- In OR [operating room] #1, there was an open Endotracheal tube being stored on top of the anesthesia cart.

Sterilization Area/ Surgical Instrument Storage:

- Surgical instrument pill packs were not sealed completely. Observation of the packaging revealed bubbling and fissures/open areas in the top seal of the packages.

Ultrasound:

- The Ultrasound machine was missing the plastic knobs for two of the sliding levers. The remaining levers had a thick, white, crusty substance coating the plastic knobs. There was also an accumulation of dust covering the ultrasound machine.

Record review of the facility policy entitled: Infection Prevention and Control Plan, revised 03/2013 revealed in part the following:

-All employees are responsible for maintain a safe and clean work environment.
- Nursing staff are responsible for being familiar with infection prevention and control policies and procedures.

In an interview conducted at the time of discovery, the facility Chief Nursing Officer confirmed the above findings.