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Based on observation and staff interviews, the facility failed to maintain clean and orderly premises and failed to ensure proper maintenance of the hospital.

Findings were:

Facility policy entitled Custodial and Maintenance Staff Safety Manual, no effective date, included the following:
"It is the policy of Cochran Memorial Hospital to provide and maintain safe, healthful working conditions, and to promote continuing safety awareness at all levels ..."

During a tour of the facility on the morning of 7/6/16 with the director of nursing, the following observations were made:

Entrance Hallway:
· The tile flooring was cracked from wall to wall in two areas of the hallway, approximately 10' across. The floor at the cracks was uneven, making thorough cleaning impossible and posing a fall risk to patients and staff.
· There were numerous chips in the tile flooring.
· A hall chair had a tear in the vinyl cover, making it impossible to clean properly
· The hallway patient bathroom did not have an emergency call light.
Emergency Room (ER):
· A black storage cart was dirty and had a thick layer of dust.
· A large drum light above the examining bed had a thick layer of dust.
· There were dirty adhesive marks on the bottom shelves from old tape making it impossible to clean properly.
· Tape was used to post documents/forms on the walls throughout the ER, making cleaning difficult.
Emergency Room Bathroom:
· There was no emergency call light in the patient bathroom.
· Soiled linen was stored in the patient bathroom.
· Two bedside commodes were stored in the patient bathroom, making it a small, cramped, not easily negotiable space.
· Wall tile was cracked and chipped. One especially large chip had sharp edges.
· A sink faucet was rusty and had a large ring of corrosion buildup around the faucet opening, making it impossible to clean properly.
The bathroom door had a locking mechanism that locked from the inside of the bathroom only, posing a threat for a patient to be locked inside the bathroom with staff unable to reach the patient in an emergency situation.
X Ray Room
· Floor tiles had large black stains, and was chipped and dirty. There were large indentations and broken tiles making it impossible to clean.
· The IV pole had paper taped around the top section making it impossible to clean, and posing a risk for infection.
· The Patient Bathroom did not have an emergency call light.
· Wall-floor trim section missing.
Lab Re-Agent Storage Room
· There was an approximate 8" x 4" hole in the wall around pipes connecting the unused autoclave allowing entry of pests, dirt and debris.
· The pipes connecting the large autoclave had a thick layer of dust.
· The floor had debris and visible dirt.
Laboratory
· The work counter top was dirty and in areas, had a thick layer of dust.
· Floor tiles were chipped and stained throughout.
· The sink faucet had a buildup of rust and corrosion at the spout.
· Rust and dust particles were visible all over bottom sink shelf.
· Two gallon containers of one of each of hydrochloric acid and lab detergent were stored under the sink. Items stored under sinks are at risk for contamination by moisture, mold and pests.
· In the refrigerator area, there was an approximate 24" x 24" hole in the ceiling leading directly to the crawl space above. This allowed entry for dirt and pests.
· There was broken laminate on the chair in which patients sat to have their blood drawn. The area missing laminate was a spot likely to be touched by patients and the exposed permeable area made cleaning impossible.
Medical Supply Room
· Approximately 5 ceiling tiles above clean patient supplies had old water stains.
· Medical Supplies were stored in old cardboard boxes. Cardboard boxes attract pests and contain dirt and dust.
West Hallway Exit Doors
· There was an approximate ¼" gap between the two external doors through which outside light was visible. This allowed entry for pests and dust.
Medication Room
· A jar of applesauce was found in the medication refrigerator with no date of when it was opened. There were medications in the refrigerator as well.
Nursing Unit Exit Doors
· Visible external light was apparent underneath the entire width of the doors.
Patient Rooms
· Rooms 117 and 118 had loose vinyl wall covering behind the commode, making cleaning difficult. The bathroom floors had visible debris.
· There was no patient call light cord in Room 117. Room 118 had a call chord which ended approximately 24" from the floor, making it too short to reach from the floor.

In an interview with the administrator/lab manager during a tour of the lab on the morning of 7/6/16, he stated, "I probably don't clean in here as often as I should. It does seem to be dusty."

All the above findings were confirmed with the director of nursing during the tour of the hospital on the morning of 7/6/16.

Based on record review and staff interviews, the governing body failed to ensure medical staff privileges were present and current for 4 of 4 medical staff records reviewed. These findings had the potential to impact all patients at the hospital by having a member of the medical staff with unassigned privileges perform patient care.

Findings were:

The Cochran Memorial Hospital Medical Staff By-Laws included the following:
"Each member of the Medical Staff must attest to or provide documentation that he has no physical or mental limitations which would impair his/her ability to render quality patient care, at the time of initial application, during the pending of his appointment, and upon each annual reapplication for Medical Staff membership and clinical privileges ...
4. On receipt of the report of credentials department, the Medical Staff shall recommend to the Board of Directors that the application be accepted, deferred, or rejected. If accepted, the Medical Staff shall also define the type and scope of privileges the physician or mid level is authorized ...
Active Medical Staff Privileges
i) Members of the Active Medical Staff shall be composed of qualified physicians of general medicine and specialty fields, physician assistants, and nurse practitioners ... "

A review of the credentialing file of staff #17, the hospital medical director, revealed he last requested privileges in 2001. The list of privileges had not been updated or modified from that time. His 2016 appointment letter stated he had been granted privileges as requested.

A review of the credentialing file for two nurse practitioners, staff #18 and #20, and for a physician's assistant, staff #19, revealed no listing of hospital privileges at all, despite each of their 2016 appointment letters stating they had been granted privileges as requested.

The individual identified by the director of nursing as being responsible for credentialing, staff #22, was interviewed on the afternoon of 7/6/16 in the facility conference room. She stated, "I just inherited this position. Someone suddenly quit and I was just handed this job about a year ago." When asked for the title of her position, she stated, "I'm a bookkeeper. "

In an interview with the facility administrator on the afternoon of 7/6/16 in the conference room, he stated "I didn't realize that about the privileges. We'll correct that. "

Based on a tour of the facility, review of facility policies, and staff interview, the facility failed to ensure that drugs were stored in accordance with accepted professional principles, and that outdated, mislabeled, or otherwise unusable drugs were not available for patient use.


Findings were:


"United States Pharmacopeia General Chapter 797 recommends the following for multi-dose vials of sterile pharmaceuticals: "If a multi dose has been opened or accessed (e.g. needle punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. If a multi dose vial has not been opened or accessed, it should be discarded according to the manufacturer's expiration date."
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Facility Policy entitled, "Section 21-M", stated, "All multiple dose vials will be good until the documented expiration date on the vial. When the time period for the vial has expired, the medication will be destroyed and the vial disposed. Insulin vials shall be included in this policy."
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During a tour of the facility on the morning of 07/06/2016, the following were available for immediate patient use:

In the pharmacy refrigerator:
· Multi-dose vial of insulin did not have the date it was opened.
· Multi-dose vial of Intradermal Purified Protein Derivative (tuberculin skin test) did not have the date it was opened.
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The above findings were confirmed on 07/06/2016 by the Director of Nursing (DON) and staff #10. The DON stated that the facility did not have a policy indicating a 28 day expiration date for multi-dose vial medications.

Based on a review of facility documentation, observation and staff interview, the facility failed to maintain and implement current health care policies related to infection control.

Findings were:

A review of the hospital's infection control policies revealed a cover page which included the following:
"This is to certify that the following Policy and Procedures have been reviewed, approved and adopted by Administration, Medical Staff and the Board of Directors ..." The page included signatures of the president of the board of directors, facility administrator, chief of staff and director of nursing. Each signature was dated in May 2016.

Facility policy entitled Infection Control Policy and Procedure Review included the following:
"1. Cochran Memorial Hospital Policy and Procedures are reviewed at least every three years ..."

Facility policy entitled Infection Control Program, included the following:
"Environmental surveillance is an integral part of preventing, containing and controlling infections. Certain equipment will be monitored on a routine basis (i.e., steam autoclaves, ethylene oxide sterilizers, and dialysis water) ..."

Facility policy entitled Post-Discharge Infection Identification included the following:
"3. Monthly mail-out to physicians whose patients were followed as part of the targeted surgical wound surveillance program requesting information on the presence of infections on postoperative visits to the physician's office ..."

Facility policy entitled Infection Control Committee included the following:
"The Infection Control Committee will be the multi-disciplinary committee that is responsible for the surveillance and prevention activities of Cochran Memorial Hospital Infection Control program ..."

During a tour of the facility on the morning of 7/6/16 with the director of nursing, two dirty and rusty autoclaves were found in the lab reagent storage room. The director of nursing stated the autoclaves had not been used in years. "Everything we use is disposable - one-time use. We should probably get rid of these."

During a subsequent interview with the director of nursing on the morning of 7/6/16 in the facility conference room, she stated the hospital did not perform dialysis. When asked if the facility performed any surgeries, she stated, "No we don't." She stated surgeries had been performed at the hospital many years ago. She also stated the infection control committee did not exist. "The infection control nurse reports her indicators to the quality committee. It's more of a combined meeting, and she's just basically reporting to it."

Facility policy entitled Reportable Diseases and Conditions, effective date 5/18/16, included the following:
"1. When a patient is determined/suspected to have a communicable disease and/or reportable condition, it is reported to the Infection Control Person and/or the Texas Department of Health as applicable ...
4. Cochran Memorial Hospital will cooperate with Health Authorities in providing patient information necessary in investigating and follow up of communicable diseases as outlined in Texas Law ..."

During the tour of the facility on the morning of 7/6/16, a list of Texas Notifiable Conditions was found in the emergency department supply area. The list included revised date of December 2010 and expiration date of December 2012. The director of nursing stated, "I think I have a current list posted in the [rural health] clinic, but not in here."

These outdated policies were reviewed in an interview with the administrator and director of nursing on the afternoon of 7/6/16 in the facility conference room.

Based on a review of facility documentation and staff interviews, the facility failed to ensure that inpatient medical records were complete and accurately documented as the facility had a medical record delinquency rate of 57% from April 2015 through April 2016.

Findings were:

The Cochran Memorial Hospital Medical Staff Rules and Regulations included the following:
"f.) The medical record needs to be completed within thirty (30) days of discharge ...
8. The attending Physician, Physician Assistant or Nurse Practitioner shall complete the medical record of a discharged patient within thirty (30) days following that patient's discharge from the hospital. Failure to complete a medical record within the prescribed time frame shall result in the attending provider having admission privileges restricted to only emergency admissions ..."

A review of facility medical record audits from April 2015 through April 2016 performed by staff #4, the facility quality assurance coordinator, revealed only 6 of 14 inpatient medical records were considered complete according to hospital policies.

In an interview with staff #4 on the afternoon of 7/6/16 in the facility conference room, she stated the facility had a number of incomplete inpatient charts. She said missing documentation included progress notes, history and physical examination results and discharge summaries.

The medical records for patients #15 and #21 were reviewed to corroborate her findings. The record for patient #15 was missing a history and physical. The record for patient #21 was complete, as noted by staff #4.

These findings were reviewed in an interview with the facility administrator and other administrative staff on the afternoon of 7/6/16 in the facility conference room.