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Based on record review and interview, the facility failed to ensure the patient grievance process was followed and contact was made with the complainants within 7 business days in 5 (patients #36, #38, #39, #40 and #41) out of 6 (patients #36, #37, #38, #39, #40 and #41) grievances reviewed.
A review of 5 (patients #36, #38, #39, #40 and #41) out of 6 (patients #36, #37, #38, #39, #40 and #41) written "Complaint Records" revealed the facility did not make contact with the complainants within 7 business days to acknowledge receipt of the grievances.
A review of the facility's policy titled, "Complaint and Resolution Process" revealed the following information:
" ...The patient, a family member or the responsible party will be contacted within 7 business days of the concern, complaint or grievance received in writing to document the contact, to acknowledge receipt of the concern, complaint or grievance and/or answer the complaint.
An interview with staff #6 and #39, confirmed the above findings.

Based on record review, document review and interview, the facility failed to ensure the patient grievance process was followed and a final written response was sent to the complainant within 30 business days in 1 (patient #40) of 6 (patients #36, #37, #38, #39, #40 and #41) grievances reviewed.
Review of patient #40's Complaint Record revealed the written grievance was received by the facility on 02/25/2016. The final resolution letter was sent to the complainant 51 business days later on 05/06/2016.
A review of the facility's policy titled, "Complaint and Resolution Process" revealed the following information:
" ...The final written response must be sent to the complainant within 30 business days."
An interview with staff #6 and #39, confirmed the above findings.

Based on record review and interview the Chief Nursing Officer failed to:

A. ensure all nursing staff had current competencies and were qualified by education to perform invasive procedures. These findings had the likelihood to cause harm to all patients receiving care at the facility by failure to ensure staff were competent. Citing 5 (#11, #12, #13, #21 and #22) of 6 (#11, #12, #13, #14, #21 and #22) personnel records for staff working on the hemodialysis unit.

B. provide clear lines of authority and responsibility for staffing of the Observation Unit.


A. Findings:

Review of the facility policy Competency Assessment #200.141, 3. "Competency will be assessed annually by: a. Performance evaluation. b. Completion of unit specific self-assessment and manager/peer validation. c. Continued licensure, registration or certification. d. Annual fit testing. e. Learner paced modules and post-test, as appropriate. f. Return demonstration."

Review of staff #11's personnel record revealed the competencies were last evaluated in May 2014.

Review of staff #13's personnel record revealed the competencies were last evaluated in May 2014. In addition, staff # 13 was an unlicensed technician and was allowed to cannulate AV Fistulas and AV Grafts; there was no evidence of training by the facility. An interview with staff # 10 on 05/17/2016 at 4:30 p.m. confirmed there was no policy approved by the Chief Nursing Officer and Governing Body of the Hospital to allow unlicensed technicians to cannulate accesses.

Review of staff #11's personnel record revealed there were no documented competencies in the personnel file. In addition staff #11 was an unlicensed technician and was allowed to cannulate AV Fistulas and AV Grafts; there was no evidence of training by the facility. An interview with staff #10 on 05/17/2016 at 10:30 a.m. confirmed there was no policy approved by the Chief Nursing Officer and Governing Body of the Hospital to allow unlicensed technicians to cannulate accesses. There also was no evidence staff #11 had taken CPR.

Review of staff #21's personnel record revealed the competencies were last evaluated in June of 2013. In addition the CPR expired in February 2016.

Review of staff #22's personnel record revealed the competencies were last evaluated in October 2013. In addition the CPR expired in February 2016.

Interview with staff # 10 on 05/17/2016 at 4:30 p.m. confirmed the above findings.





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B. Findings.

Review of Emergency Department staffing records showed that nurses from the Emergency Department were assigned on a regular basis to staff a unit of the hospital, the Observation Unit, which is not part of the Emergency Department.

An interview with Staff #66 was conducted on the morning of 5-16-2016 in the Emergency Department. Staff #66 stated there was an Observation Unit that had been created for patients whose treatment in the Emergency Department was completed and were admitted to the hospital in Observation Status. The Observation Unit was started November 1, 2015. The Unit is run by another director from the hospital and staffed during the daytime shift with hospital staff.

During the night shift, 7:00 PM to 7:00 AM, the Emergency Department is required to staff the Observation Unit with two nurses. Staff #66 stated she is responsible for the employees on night shift. At night, a minimum of two staff members were provided. Should a problem arise on the night shift, her employees should notify both her and the Observation Unit director, depending on what the problem was. Staff #66 stated that the Observation Unit director had authority over the unit.

Review of the hospital organizational chart showed that the Observation Unit does not appear on the organization chart. Review of Emergency Department Staffing Matrix does not specify dedicated nurse staffing for a hospital Observation Unit.

Based on record review and interview the facility staff failed to ensure that they had a procedure in place to ensure hospital nursing personnel had a current and valid license. These findings had the likelihood for an unlicensed nurse to obtain employment and care for patients. Citing 3 (#12, #21 and #22) of 3 (#12, #21 and #22) Registered Nurse files reviewed from the hemodialysis unit.

Findings:

Review of the Texas Board of Nursing website Texas Nursing Bulletin Volume 39, No 3 dated July 2008 stated "After September 1, 2008 Nurses and employers should go to the agency website at www.bon.state.tx.us and verify licenses on line. The verification, once printed, will resemble a license and will allow the nurse to have the documente laminated for the purpose of carrying the license with them."

Review of nursing personnel records for staff # 12, #21 and #22 the facility had only verified the nurse's licensure status at the Texas State Board of Nursing web site by searching the nurse's name. The site was not searched by either license number or Social Security Number and date of birth, in order to verify that the nurse working was the same licensed nurse found on the board site. When the site was searched for a nurse by name only, a list of nurses with that name is all that is available to the person running the verification. In order to obtain the correct nurse's license, the site must be searched by either the license number or social security and date of birth.

Review of personnel record for staff #12 who worked in the dialysis unit revealed there was a list from the board of nursing web site that contained 6 Registered Nurses by her same name. In addition the licenses were expired for all 6 nurses listed. There was no way to tell which of the nurses was working at the facility.

Review of personnel record for staff #21 revealed the copy of the board form ran by name only did not contain a license number. The record also indicated the license listed under this name expired in 01/31/2013. There was no evidence the facility had searched using the above process in order to be sure this was the correct nurse and the license was current.

Review of personnel record for staff #22 revealed the copy of the board form ran by name only did not contain a license number. The record also indicated the license under this name had expired in 10/31/2013. There was no evidence the facility had searched using the above process in order to be sure this was the correct nurse and the license was current.

An interview with staff #10 on 05/18/2016 at 14:30 p.m. confirmed the above findings.

Based on interview and record review the facility failed to ensure the right to make an informed decision was provided regarding care in 1 of 1 sampled patients (Patient #14).

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

Findings include:

Review of the clinical record of Patient #14 revealed he was a 69 year old male who presented to the Emergency Department on 05/14/2016 at 4:00 a.m.. Patient #14 presented with diagnoses which included gastrointestinal bleeding and altered mental status.
Review of the clinical record revealed Patient #14 received blood transfusions and had a bedside EGD (esophagogastroduodenoscopy) while in the hospital.
Review of the clinical record revealed a consent for treatment which was not signed by the patient or patient representative. There was a consent for anesthesia, flexmoid sigmoidoscopy, esophagogastroduodenoscopy, and blood transfusion which had the documentation "medical necessary" in the section designated for the patient/other responsible person's signature.
Review of Patient #14's record revealed a phone number and name of a responsible person listed. There was no documentation on the consents or in the record showing there were attempts made to notify the responsible party to obtain consent prior to treatment.
Staff #83 confirmed the problems with the consents.

Review of the facility policy named "Informed Consent, Policies On" revealed the following:

"Consent will be obtained in writing prior to performing surgical procedures, nonsurgical invasive, diagnostic and /or therapeutic procedures, intravenous injection of contrast material, central line insertions (unless in conjunction with anesthesia) and all procedures in which anesthesia or sedation is used.
Exceptions: In emergency treatment, when the individual's welfare or safety is at risk and substitute consent from authorized individual cannot be obtained the treating physician must document in the progress notes the medical necessity of the treatment or procedure.
9. If a patient is comatose, incapacitated, or otherwise mentally or physically incapable of communication, an adult surrogate, who has decision making capacity and is available after a reasonably diligent inquiry may give consent."

Based on record review and interview, the facility failed to:

A. ensure staff performed conductivity readings with an independent device before each dialysis treatment and compare them to the dialysis machine reading. Citing 1 (#5) out of 5 (#4, #5, #12, #43 and # 44) medical records reviewed.

B. ensure staff corrected an abnormal conductivity between the phoenix meter and the dialysis machine citing 1 (#5) of 5 (#4, #5, #12, #43 and # 44) medical records reviewed.

C. ensure staff maintained evidence of monthly logs for all phoenix meters, when in service or noting they are out of service. Citing 1 of 2 phoenix meters.

D. ensure staff conducted the second level calibration of the phoenix meter at least monthly for 2 (03773K and P35315) of 2 (03773K and P35315) phoenix meters. The staff also failed to maintain all the logs for 1 (P35315) of 2 (03773K and P35315) phoenix meters.

E. ensure the staff changed the dialysate filters on the dialysis machines at least every 90 days. Citing 4 (OKOS-162237, OKOS-162328, OKOS-162271 and OKOS-162316) of 7 (OKOS-162237, OKOS-162328, OKOS-162271, OKOS-162316, OKOS-162342, OKOS-162337, OKOS-162342) dialysis machine records reviewed.

F. conduct weekly culture and endotoxin until they had 4 weekly consecutive negative tests when replacing the membranes in the main water system (RO). Citing replacement of membranes for 1 of 1 main RO's.

G. ensure they had documented evidence of the Hepatitis B immunizations for all clinical staff; by having proof of their Hepatitis B antibody conversion, non-responder status, or have administered the immunization. Citing 13 staff employee health files reviewed (#7, #8, #10, #11, #19, #20, #43, #47, #50, #51, #52, #53, and #54) of 18 staff (#7, #8, #10, #11, #12, #13, #14, #19, #20, #21, #22, #43, #47, #50, #51, #52, #53, and #54) employee health records reviewed.

H. ensure the Hospital Quality Improvement Committee reviewed the contracted dialysis service including the operation of the water system, dialysis equipment maintenance, phoenix meter logs, chlorine logs and all other daily operation of the dialysis unit. The minutes must document compliance, plan of action when they identify corrective action taken. In addition there was no evidence the reports of culture and endotoxin (LAL) reports were trended over time through the hospital's Quality Improvement meeting. Citing 9 (August 2015- April 2016) of 9 months (August 2015- April 2016) Dialysis Quality Improvement Meeting minutes requested.

I. ensure the staff kept the floor of the water room clean.

These findings had the likelihood to cause harm to all patients by exposing them to unsafe dialysate, increased risk of infection by failure to maintain the water room in a clean manner and failure to conduct the appropriate cultures.

J. ensure STAT/one time orders for chemical restraints were administered only one time. The facility also failed to ensure the one time order was not written or used as a PRN (as needed) medication, with a possibility of the patient receiving multiple doses of psychotropic medications, that could cause serious harm or potential death in 1 (#54) of 3 (#54-56) charts reviewed.

K. ensure the behavioral unit was free of safety hazards that could be used to cause harm to patients.



Findings:

A. Review of medical record #5 revealed the staff failed to notice the conductivity variance was greater than 0.3mS/cm between the dialysis machine and the handheld meter. The FMC-CS policy # IS-I600-028C2 dated 05-Nov-2013, "3.The conductivity on the dialysis machine must be within 0.3 mS/cm of the reading taken with the handheld conductivity meter or dialysis treatment(s) may NOT be initiated. " (Sic) The staff failed to follow their own policy.

B. Review of medical record #5 revealed the staff failed to compare the conductivity between the machine and the independent device on 05/11/2015. The conductivity of the phoenix meter was the only reading documented.

C.- D. Review of the phoenix meter logs revealed the staff failed to conduct the monthly second level calibration of meters 03773K and P35315 for the month of December 2015. In addition there were no logs for meter P35315 for the months of January and February. In an interview with staff #57 on 05/18/2015 at 2:30 p.m. he confirmed there were no logs for this meter for January and February that indicated if the meter was in service or out of service.

E. Review of the maintenance record for dialysis machines OKOS-162237, OKOS-162328, OKOS-162271 and OKOS-162316 revealed the staff failed to change the dialysate filter every ninety days.

Machine OKOS-162237 dialysate filter was changed in January, April, and July but the staff failed to change the filter in October 2015.

Machine OKOS-162328 dialysate filter was changed in February, May and August but the staff failed to change the filter in November 2015.

Machine OKOS-162271 dialysate filter was changed in January, April, and July but the staff failed to change the filter in October 2015.

Machine OKOS-162316 dialysate filter was changed in February, May and August but the staff failed to change the filter in November 2015.

F. Review of the maintenance and disinfection records revealed the staff failed to collect weekly cultures and endotoxins until they achieved 4 consecutive negative cultures when the membranes were changed on December 20, 2015. Review of the water cultures revealed they did not collect water cultures and endotoxins until the monthly cultures were due on 1/20/2016.

An interview with staff # 57 and 58 on 05/18/2016 at 12:30 p.m. confirmed findings in A-F.

G. Review of employee health files for staff #7, #8, #10, #11, #19, #20, #43, #47, #50, #51, #52, #53, and #54 revealed there was no evidence of Hepatitis B immunizations or evidence of Hepatitis B antibody conversion or non-responder status. An interview with staff # 10 on 05/17/20016 at 3:30 p.m., confirmed the findings in the personnel records.

H. August 2015 through April 2016 Quality Improvement Meeting minutes for the dialysis unit were requested numerous times from staff #'s 6, 10 and 56 on May 16-18, 2016. The minutes of the meetings were never provided. Staff # 56 stated several times she could find the minutes from early 2015 and 2014 but could not find August 2015-April 2016 minute book. Staff # 10 provided 2 tables of data dated March and April 2016 of reporting but there was no evidence the committee reviewed the reports and made recommendations for corrective action if indicated. An interview with staff # 10 confirmed they did not have the minutes for the dialysis Quality Improvement Meetings.

An interview with staff # 10 on 05/18/2016 at 4:30 p.m. confirmed the above findings in G and H.

I. During a tour of the dialysis water room on 05/17/2016 at 10:00 a.m., the water room floor was noted to be dirty with what looked like a black substance over the entire floor. An interview with staff # 58 on 5/17/2016 at 10:00 a.m. confirmed the water room condition.









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J. Review of patient #54 ' s medical record revealed the patient was psychotic and had episodes of aggressive behaviors. Patient #54 was placed on Zyprexa (antipsychotic medication) and Ativan (benzodiazepine) by mouth as part of her medication regimen. Patient #54 had been aggressive and volatile with staff and patients. The physician was called and the nurse wrote the restraint medication order as Zyprexa 10mg IM and Ativan 1 mg IM every 8 hours PRN (as needed) for psychotic agitation on the paper physician orders, a section of the restraint and seclusion form. The nurse then transcribed the order to the computer as written. The computer documentation read the same. However the start date to administer the medication was 5/1/16 at 10:58 and the stop date was 5/1/16 at 11:01 AM. The order was discontinued as a one-time order.
Another order was written for patient #54 on 5/3/16 Zyprexa 10mg IM and Ativan 2 mg IM every 8 hours PRN (as needed) for agitation. The start date was 5/3/16 at 7:15 and stopped at 5/3/16 at 8:18AM. The order was discontinued in the computer as a one-time order but did

Based on record review and interview the Chief Nursing Officer failed to:

A. ensure all nursing staff had current competencies and were qualified by education to perform invasive procedures. These findings had the likelihood to cause harm to all patients receiving care at the facility by failure to ensure staff were competent. Citing 5 (#11, #12, #13, #21 and #22) of 6 (#11, #12, #13, #14, #21 and #22) personnel records for staff working on the hemodialysis unit.

B. provide clear lines of authority and responsibility for staffing of the Observation Unit.


A. Findings:

Review of the facility policy Competency Assessment #200.141, 3. "Competency will be assessed annually by: a. Performance evaluation. b. Completion of unit specific self-assessment and manager/peer validation. c. Continued licensure, registration or certification. d. Annual fit testing. e. Learner paced modules and post-test, as appropriate. f. Return demonstration."

Review of staff #11's personnel record revealed the competencies were last evaluated in May 2014.

Review of staff #13's personnel record revealed the competencies were last evaluated in May 2014. In addition, staff # 13 was an unlicensed technician and was allowed to cannulate AV Fistulas and AV Grafts; there was no evidence of training by the facility. An interview with staff # 10 on 05/17/2016 at 4:30 p.m. confirmed there was no policy approved by the Chief Nursing Officer and Governing Body of the Hospital to allow unlicensed technicians to cannulate accesses.

Review of staff #11's personnel record revealed there were no documented competencies in the personnel file. In addition staff #11 was an unlicensed technician and was allowed to cannulate AV Fistulas and AV Grafts; there was no evidence of training by the facility. An interview with staff #10 on 05/17/2016 at 10:30 a.m. confirmed there was no policy approved by the Chief Nursing Officer and Governing Body of the Hospital to allow unlicensed technicians to cannulate accesses. There also was no evidence staff #11 had taken CPR.

Review of staff #21's personnel record revealed the competencies were last evaluated in June of 2013. In addition the CPR expired in February 2016.

Review of staff #22's personnel record revealed the competencies were last evaluated in October 2013. In addition the CPR expired in February 2016.

Interview with staff # 10 on 05/17/2016 at 4:30 p.m. confirmed the above findings.





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B. Findings.

Review of Emergency Department staffing records showed that nurses from the Emergency Department were assigned on a regular basis to staff a unit of the hospital, the Observation Unit, which is not part of the Emergency Department.

An interview with Staff #66 was conducted on the morning of 5-16-2016 in the Emergency Department. Staff #66 stated there was an Observation Unit that had been created for patients whose treatment in the Emergency Department was completed and were admitted to the hospital in Observation Status. The Observation Unit was started November 1, 2015. The Unit is run by another director from the hospital and staffed during the daytime shift with hospital staff.

During the night shift, 7:00 PM to 7:00 AM, the Emergency Department is required to staff the Observation Unit with two nurses. Staff #66 stated she is responsible for the employees on night shift. At night, a minimum of two staff members were provided. Should a problem arise on the night shift, her employees should notify both her and the Observation Unit director, depending on what the problem was. Staff #66 stated that the Observation Unit director had authority over the unit.

Review of the hospital organizational chart showed that the Observation Unit does not appear on the organization chart. Review of Emergency Department Staffing Matrix does not specify dedicated nurse staffing for a hospital Observation Unit.

Based on observation and review of policy, nursing staff failed to administer medication using procedures specified by hospital policy in 1 (Patient #16) of 1 patient observed.
This deficient practice had the likelihood to cause harm to all patients.

Findings include:

On the morning of 5-17-2016, Staff #72 was observed while administering medication to Patient #16 via the feeding tube. During the process, Staff #72 was observed to stop the feeding, disconnect the feeding tube from the feeding pump, administer the medication into the feeding tube, use water to flush the medication through the feeding tube, reconnect the feeding to the feeding pump, then resume the feedings.

During interview, Staff #72 verbalized the steps she had taken. Staff #72, then provided a copy of the policy titled "Enteral Feeding/Medication, Policy Code 200.063". The section titled "Medication Administration" listed step number 3 as, "Flush tubing before and after medication administration with 20-30 ml's of water." Staff #72 acknowledged that she had missed the step in the procedure requiring her to flush the tubing prior to administering the medication into the tube.

Based on interview and record review the facility failed to ensure 1 of 1 sampled patients receiving blood transfusions received continuous monitoring (Patient #14).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of the clinical record of Patient #14 revealed he was a 69 year old male who presented to the Emergency Department on 05/14/2016 at 4:00 a.m.. Patient #14 presented with diagnoses which included gastrointestinal bleed and altered mental status.
Review of lab results at 4:24 a.m. revealed Patient #14 had a low hemoglobin of 7.3 (reference ranges being 14-18) and a hematocrit of 23.7 (reference ranges being 38.0-54.0). Patient #14 had a Partial thromboplastin time (PTT) greater than 500 ( reference ranges being 22.4-37.2). The PTT being a test to check the blood's clotting ability.
A physician order was written at 5:16 a.m. for two units of leuko reduced red blood cells STAT (immediately).
Review of the transfusion records for both units revealed they were signed off by the lab technician at 5:23 a.m. on 05/14/2016.
The following instructions were documented on the transfusion forms:
"Prior to starting this transfusion, an RN and one other licensed personnel have completed all clerical checks including verifying the patient name, account number, and sample number on this slip with the patient's armbands at bedside and all information given."
There were two places for signatures of staff that were not completed.
The pre-transfusion vital signs, 15 minute transfusion vital signs, post-transfusion vital signs, transfusion start time, transfusion stop time, amount transfused and if the patient was observed during transfusions were not completed on the forms.

Review of the record revealed Patient #14 received another unit of blood during a bedside procedure in the intensive care unit on 05/14/2016. According to the transfusion form the blood was started at 6:11 p.m. and stopped at 6:20 p.m.. The pre-transfusion vital signs, 15 minute transfusion vital signs, and post-transfusion vital signs category were left blank. There was documentation on the transfusion record referring you to the anesthesia record. There was a set of vital signs performed before the procedure, but they were not timed. There were vital signs taken during the procedure, but they did not include a temperature.
Staff #83 confirmed the missing documentation.