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Based on observation, interview and record review, the facility failed to ensure staff who provide nursing and emergency services in the hospital competency were assessed and meet the facility's policy and procedure for the provision of care in 5 of 8 staff personnel files reviewed Staff A, F, C, N and Staff I

Findings:

Review of the Facility's current Policy and Procedure on Nursing Competency, revised 04/27/2012 direct staff as follows:" All nursing staff at Palacios Community Medical Center will be required to express competency in their specific nursing location when hired and annually at the in-service /performance review."


Review on 07/20/2016 of the Registered Nurse (F's) personnel and training record revealed she was hired to the facility as a registered nurse on 06/20/201. Review of the record revealed no evidence of a skill competency completed on Registered Nurse ( F).


Interview on 07/20/2016 at 10:30 a.m with the Facility's Chief Nurse Officer (L) revealed an annual competency was not done on Registered Nurse (F)




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Observation on 7/20/2016 at the facility at 10:20 am revealed a kitchen that was set up for food preparation for in-patients.


During an interview on 7/20/2016 at 10:25 am with Staff ( #D) Food Service Manager she stated the Nurses' Aides prepare patient meals in the facility and are required to have food handler's permits.

During an interview on 7/20/2015 at 11:10 am with Staff (# C) , Nurses' Aide she stated she prepares breakfast and lunch for patients, serve the meals and wash the dishes.

According to Staff (#C) she did obtain a food handlers permit 'some time ago'

During an interview with Staff (L) Chief Nursing Officer, she stated all personnel that prepare meals for the patients are required to have a current food handlers permit. She stated the permits were good for five(5) years


Review of the food handlers permits for Staffs ( C and N) , Nurses' Aides who prepare patient meals at the facility revealed the permits were issued in April 27,2011 and expired since 4/27/2016.

Review of the Facility's Dietary Policy dated 8/1/2014 revealed the following information:

"Palacios Community Medical Center's Dietary personnel will possess a food handler's certificate.

All employees working in the dietary department shall possess at minimum a food handler's certification.

This certification will be renewed upon expiration. All new hires will be expected to complete the certification . The Food Manager will be responsible for assuring this certification is current."



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Physician Assistant (I) was observed providing patient care services in the facility during the course of the survey 7/18/2016-7/20/2016.

Record review of employee files on 7/20/2016 at 10:00 revealed Physician Assistant (I) did not have evidence of current Advanced Cardiac Life Support (ACLS) on file with the hospital.

Interview with the facility's Chief NUrsing Officer (L) on 7/20/2016 at 11:05 revealed that it was a requirement that the Physician Assistants do have current ACLS.

Based on observation, interview and record review, the facility failed to operationalize it's policy and procedure to ensure clean/sterile supplies were not stored directly on floor; nursing staff wear gloves and wash hands in between handling blood product and clean supplies; sharp containers were emptied when full and expired supplies were not available for use in the facility and medical equipment were stored in a clean manner in 5 areas of the hospital observed


Findings:
Observation on 07/18/2016 at 10:50 a.m. during tour of the facility's main trauma room revealed the suction canisters attached to the suction machine had an accumulation of dust.

Observation on 07/18/2016 at 10:50 a.m. during tour of the facility's main trauma room revealed the following expired supplies were observed intermingled with supplies available for use in the facility:
Three bags 1000 mls Intravenous fluid of 5% Dextrose Saline, Lot number C950980, expired March 2016.
One bottle 1000 mls Normal saline, Lot # 17-603-4B-01 and Sterile water 1000 mls Lot # TSE908 were opened. There was no indication when the bottles were opened.

Observation on 07/18/2016 at 11:10 a.m. revealed boxes of gauze sponges, non- woven sponges, secondary medication set, nasal Cannula, mouth wash and powder free gloves were observed stored directly on the floor in the central supply area.

On 07/18/2016 at 11:10 a.m. the Facility's Chief Nursing Officer (L) was notified of the observation of medical supplies stored in boxes directly on the floor.


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Observation on 7/18/2016 at 11:50 am in the Emergency Room Suite 2 revealed four (4) unwrapped laryngoscopes in the crash cart ready for emergency use.

During an interview on 07/18/2016 at 12:10 p.m with Staff (L) Chief Nursing Officer, she was not able to tell if the laryngoscopes were clean or dirty. She stated the laryngoscopes should be sterilized after use, but there was no evidence that the laryngoscopes were sterilized.


Observation on 7/19/2016 at 1:50 pm in the Laboratory revealed Staff (# M), Laboratory Technician was observed handling tubes of specimens.

The Staff removed her gloves and did not wash or sanitize her hands. Staff (# M) retrieved a unit of blood from the blood storage refrigerator without wearing gloves.

Staff (# M) replaced the blood in the refrigerator and proceeded to handle paper records on a desk. The staff did not wash her hands.


During an interview on 7/19/2016 at 2:05 pm with Staff (# M) regarding glove use and handwashing she stated she usually wear gloves when handling blood products or specimens and should have washed her hands.

Review of the facility's Handwashing/Decontamination Policy that was presented during the survey revealed the following information:

"The purpose of handwashing/cleansing is to remove dirt, organic material and transient microorganisms from the hands so as to decrease the risk of cross contamination.
Personnel are expected to wash hands a the following times:

Before and after direct contact with a patient's blood, body fluids, mucous membranes, non-intact skin, glove use and objects which are likely to be contaminated".



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Tour of the facility on 7/18/2016 at 10:35 A.M. revealed sharps receptacle in exam room one (1) and the lab draw room were above the fill level, not allowing for proper sharps disposal.

On 7/18/2016 at 10:36 A.M.the facility's Chief NUrsing Officer (L) was in agreement that the sharp containers were above the fill line, not allowing for proper sharps disposal.

Tour of the facility's central sterile supply area on 7/18/2016 at 11:15 A.M. revealed one box of ten (10) Cautery Low Adjust-A-Temp, Lot # 0312C expired 3/2016.

The facility's Chief Nursing Officer (L) stated that the new stock had come in and the expired items had not been removed.