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Based on observation and an interview with staff, the facility failed to ensure that necessary equipment was usable and ready for an emergency.

During a tour of the emergency department on 2-1-17, the following items were found in the Broselow cart:
· 7 oxygen delivery modules
· 7 intraosseous modules
· 7 intubation modules

All above items listed had expired but were still available for patient use. In an interview with staff #6, staff #6 confirmed that the items had expired but had not been removed from the cart.

The above was confirmed in an interview with the Chief Executive Officer and other administrative staff on the afternoon of 2-1-17.

Based on observation, the facility did not have a preventive maintenance program to ensure that the premises were kept clean and orderly.

Findings were:

During a tour of the cardiac rehabilitation unit on 1-31-17, the sealed surface of the flooring had worn away, allowing bacteria to collect and preventing proper cleaning.

The above was confirmed in an interview with the Chief Executive Officer and other administrative staff on 2-1-17.

Based on observation, a review of documentation, a review of clinical records and interviews with staff, the governing body failed to assume full legal responsibility for determining, implementing, and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment.



Findings were:

During a review of dietitian consultation reports for 2016, the facility did not receive 8 hours of consultation services from a licensed dietitian for the following months:
· May 2016 - 5 hours of consultation received
· October 2016 - 7 hours of consultation received

Facility dietary policy titled "Consultant Dietitian Role" states, in part:
"Procedure:
1. The consultant will visit a minimum of 8 hours per month..."

During a tour of the dry goods pantry on 1-31-17, the following items were found:
· 9 plastic cups of thickened water
· 18 plastic cups of thickened tea
· 6 plastic cups of thickened apple juice
· 7 plastic cups of thickened orange juice

None of the above items listed had been marked with the date of their receipt into the facility.

Facility dietary policy titled "Receiving System" states, in part:
"Procedure:
...
6. All foods shall be dated with the date of delivery and stored to provide for first-in, first-out usage."

Facility dietary policy titled "Safety Policies and Procedures" states, in part:

"Procedure:
...
2. Stock is rotated so that older items are used first . Products are dated to assure that a first-in, first-out procedure is followed."

In an interview with staff #18 on 1-31-17, staff #18 confirmed that the items listed had not been dated with the date they had been received into the facility.

· No temperature log was being maintained for 1 of 4 freezers present and in use.

Facility dietary policy titled "Food Preparation" states, in part:
"Procedure:
...
16. All refrigerators and freezers will have working thermometers and temperatures will be documented daily..."

In an interview with staff #18 on 1-31-17, staff #18 confirmed that no temperature log was being maintained for 1 of the 4 freezers present and in use.

· Hard, dried residue was stuck to the blade of the can opener.
· 2 of 2 ovens contained a moderate amount of residue on the insides of the oven doors and on the floors of the ovens.

Facility dietary policy titled "Cleaning Schedule and Procedures for Dietary Department" states, in part:
"Daily:
...
6. Wash can opener after each meal, if used. Run through dish machine. Be sure blade is clean.
Weekly:
...
2. Thoroughly clean ovens."

In an interview with staff #18 on 1-31-17, staff #18 stated that the can opener had been used to prepare the lunch meal (approximately 1 hour prior) but had not been cleaned since it's recent use. Staff #18 also stated, when asked, that the dietary staff "tries" to clean the ovens weekly but was unable to state when the ovens had last been cleaned or provide a cleaning log for the ovens.

During a review of clinical records for 6 patients seen in the emergency department in 2016 (patients #11 through #16), 2 of the 6 patients (patients #11 & #16) had received initial assessments from a licensed individual working outside the scope of their practice.

For patient #11, the "assessment" portion of the record had been completed by staff #15 (a licensed vocational nurse). The assessment had been cosigned by staff #10 (a registered nurse).

For patient #16, the "assessment" portion of the record had been completed by staff #16 (a licensed vocational nurse). The assessment had been cosigned by staff #11 (a registered nurse).

Per the Texas Board of Nursing, "The question of an RN co-signing after an LVN most often arises in situations when an attempt is made to expand the LVN's scope of practice by holding the RN responsible for expanded tasks performed by the LVN. The RN co-signing for something that is beyond the LVN's scope of practice does not legitimize the LVN's actions. A nurse never functions "under the license" of another nurse. Therefore, if a patient requires a comprehensive assessment performed by an RN, the assignment (or a portion thereof) may not be given to an LVN. If such an assignment is inadvertently given to an LVN, he/she is responsible for notifying the nurse who made the assignment that it is beyond his/her scope of practice to perform the assigned task. Each nurse has a duty to maintain client safety [217.11(1)(B)] that includes communication with appropriate personnel."

Facility job description for "Registered Nurse, Charge" states, in part:
"Essential Duties and Responsibilities:
· Complete comprehensive assessment of inpatients upon admission and change in condition."

· Facility job description for "Licensed Vocational Nurse" states, in part:
"Essential Duties and Responsibilities:
· Conducts focused assessments (following initial comprehensive assessments completed by the registered nurse)."

During the review of 6 clinical records for patients seen in the emergency department in 2016, 1 of the 6 patients (patient #12) had suffered an animal bite. The clinical record contained no documentation that any law enforcement agency had been notified of the event.

Facility policy titled "Reporting Animal Bites" states, in part:
"Policy:
All animal bites are to be reported to the local law enforcement."





30250

Facility based policy entitled, "Use of Restraint" stated in part,
"2. Orders for Restraint or Seclusion.
a. The use of restraint or seclusion must be in accordance with a written order by a physician or Licensed independent Practitioner who is authorized to order restraint or seclusion under Texas law. A standing or PRN order cannot be used to authorize restraint or seclusion....
c. Each order for restraint for seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or other may only be renewed in accordance with the following limits up to a total of 24 hours:
(1) 4 hours for individuals adults age 18 and older;
(3) 2 hours for children and adolescents 9-17 years of age; or
(4) 1 hour for children 9 years of age.

3. Assessment of Restrained or Secluded Patient...

a. When a restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1 hour after the initiation of the intervention by a physician or other LIP or by a registered nurse or physician assistant who has been trained in accordance with Section 5 below...The individual conducting the evaluation must evaluate:
1. The patient's immediate situation;
2. The patient's reaction to the intervention;
3. The patient's medical and behavioral condition; and
4. The need to continue or terminate the restraint or seclusion."


Review of the medical record of patient #16 revealed documented incidents of violent behavior that jeopardized the immediate physical safety of staff members, the patient himself, and other patients. However, the order for the patient's restraints was inappropriately maintained as an ongoing PRN order for medical restraints, rather than obtaining an order for behavioral restraint.

On 12/21/16, Patient # 16 was brought to the facility emergency room related to altered mental status. The Nursing Assessment stated the patient arrived via EMS and was " confused AMS X 2 nights " .

The Emergency Department Nursing Assessment documented the following:
At 0903 "...Pt swinging arms, biting at staff."
At 0940 Haldol 10 mg and Benadryl 50 mg were administered intramuscularly.
At 1015 "Pt cont to be combative. [Physician] at bedside...Pt climbing over rails hitting @ wife and staff and biting." Haldol 5 mg was administered intramuscularly.
At 1140 "Pt very combative hit nurse in nose. Order received Haldol 5 mg IM X 1 given..."
At 1205 "Pt still combative, biting, swinging, at staff/ Pulling at IV, climbing out of bed. Order received-wrist restraints and ankle restraints applied..."
At 1300 "Pt resting with eyes closed. Restraints released. Pt again became combative-reapplied..."

The "Emergency Department Order Sheet" for this patient included, "5. Restraints" at 1150.
Physician Order's dated 12/21/16 at 1230 included an order for "Restraints PRN protocol". These were the only 2 restraint orders present in the medical record.

The "Restraint Flowsheet" for Patient #16 dated 12/21/16 at 1205 documented that the patient was in soft restraints (wrist and ankle) from 1200 on 12/21/16 through 12/22/16 at 0500.

Nursing documentation included:
On 12/21/16 at 1345 stated in part, "Will leave restraints off at this time."
On 12/21/16 at 1615 stated in part, "Soft wrist restraints applied per orders."
On 12/21/16 at 1720 stated in part, "Pt in wrist and ankle restraints with continuously one on one monitoring."
On 12/21/16 at 1800, "Pt still continues to pull at restraints..."
On 12/21/16 at 1930 stated in part, "Pt resting in bed, continues to move about at time, wrist and ankle restraints in place..."
On 12/21/16 at 2023 stated in part, "Pt continues to move in bed but less agitated at the present..."
On 12/21/16 at 2149, "Pt continues to rest, continues to be thirsty and asking for fluids, pt restless in, assisted to reposition, see restraint flowsheet for details of restraints."
On 12/22/16 at 0201 stated in part, "...attempted to take restraints off while patient was sleeping, pt slipped over onto stomach attempting to get out of bed, squeezing staff hands, and raising hand to hit staff, pt placed back in soft restraints to bilateral legs and arms."
On 12/22/16 at 0500 stated, "Wrist restraints left off for approximately 30 minutes pt remains aggressive [sic], squeezing and twisting staffs arms, scratching at anything he comes into contact with, pt is redirected and he repeats over and over 'not hurt you' and 'I need drink' Pt remains a one on one continues to be monitored closely..."
On 12/22/16 at 0600 stated in part, "Pt has no restraints on at this time..."


The above documentation described violent behavior that jeopardized the immediate physical safety of the patient and staff members. These restraints were ordered and documented as non-violent restraints, the patient was in restraint on and off for 17 hours per documentation. Behavioral restraints can only be ordered for an amount of time not to exceed 4 hours, with a renewals required after each 4 hour period of time. A behavioral restraint also cannot be ordered PRN or as a standing order.

This incident of violent restraint also contained no documentation of a face-to-face evaluation within 1 hour after the initiation of:
1. The patient's immediate situation;
2. The patient's reaction to the intervention;
3. The patient's medical and behavioral condition; and
4. The need to continue or terminate the restraint or seclusion.

The lack of documentation the above assessments of the patient within one hour of the behavioral restraint interventions, indicates the facility did not follow policy or regulatory requirements.

Based on the above findings, the facility failed to obtain appropriate orders and document required elements (including 1 hour face to face evaluation) for violent/behavioral restraints. This patient demonstrated violent/ aggressive behaviors that jeopardized the immediate physical safety of staff, the subsequent restraint episodes did not have appropriate orders or renewals in place. Separate restraint events were treated as a continuous 17 hour restraint episode.

The above findings were confirmed in an interview staff member # 6 on 01/30/17.

Based on a review of documentation and interview, the facility failed to ensure that all verbal orders in the medical records were complete by not ensuring they were dated, timed, and authenticated by the prescriber.

Findings included:

Facility based policy entitled, " Verbal and Written Medication Orders by the Physician" stated in part,
"Verbal order:
· Only verbal orders by the physican will be take. Verbal orders of medication shall be received and recorded by the licensed nurse...The prescriber shall co-sign the order within 24 hours."

The "Rules and Regulations of the Medical Staff of Coleman County Medical Center" stated in part,
"PHYSICAN DELEGATED/TELEPHONE ORDERS...
30. All orders for treatemnt shall be in writing except in emergencies, or situation where the qualified person is not on facility site and is covering from a separate location. The attending physican shall sign and date such orders on his/her next visit, but in no event, later than forty-eight (48) hours from the time of the order."

Review of surgical records revealed 4 of 4 surgical patients (#17, 18, 19, and 20) had verbal orders documented in (October, November, and December 2016) that were initialed or signed by the prescribing physican. The verbal orders were not dated or timed with 24 hours per policy.

The above findings were confirmed on 02/01/17 in an interview with staff member #12.

Based on review of medical records and interview, the facility failed to ensure that a qualified practitioner, examined each patient before surgery to evaluate the risk of anesthesia.

Findings included:

Facility based policy entitled "Completion of Surgical or GI Patient's Chart" stated in part, "Pre-anesthesia evaluation of the patient must be completed prior to the administration of the pre-operative medication."

Review of surgical records revealed 4 of 4 surgical patients (#17, 18, 19, and 20) had Pre-Operative Anesthesia Assessments that were dated the same date of the procedure by the anesthesia staff. The form was not timed, thus it cannot be established the evaluation was completed before surgery. With no time present, it cannot be determined the consent was properly obtained prior to the administration of pre-operative medication, per policy. Or that the form was completed within 48 hours prior to surgery per regulations.

The above findings were confirmed on 02/01/17 with staff member # 12.