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Based on record review and interview, the facility failed to provide a written response to all grievances. 1 of 2 grievances recorded in 2011 had only a telephone call, with no follow-up written response.

Findings include:

Review of the 2011 complaint log revealed 1 of 2 grievances had only a telephone call, with no follow-up written response.

In an interview on 3/30/11 in staff #1's office, staff #1 confirmed that some grievances were handled over the telephone, with no written response to the complainant.

Based on record review and interview, the facility failed to incorporate all departments in the Performance Improvement program. The Anesthesia and the Accounting/Payroll Departments were not included in the Performance Improvement program.


Findings include:

Review of the Performance Improvement (PI) Minutes for January 2010 until March 2011 revealed no evidence that the contracted Anesthesia Department participated in the PI program (A program set up by the hospital to ensure and monitor all departments for the quality of care being provided. This is done by identifying area needing improvements and make recommendations for improvements.). This review also revealed no evidence that the Accounting/Payroll Department participated in the PI program.

Review of the facilities Policy and Procedure, Title: Quality of Contract Services revealed that " Contract service providers are required to participate in the Performance Improvement program. Ongoing monitoring and data collection are a part of the hospital PI program and are necessary for each contractor to evaluate the quality of their services. Contractors will report these activities through the P.I. Committee or Physician Quality Improvement Committee and then the information is reported to the Medical Executive Committee. "

Review of the " Patient Care Services Organizational Chart, " revealed Accounting/Payroll to be an organized department that reports to the Chief Financial Officer.

Interviews Cheif Nurseing Officer (CNO) and Staff #52 in the Administrative Conference Room on 03/30/2011 at 10:25 AM confirmed that neither the contracted Anesthesia Department nor the Accounting/Payroll Department was participating in the Performance Improvement program.

Based on record review and interview the facility failed to monitor and ensure frequency of reporting by its departments to the Performance Improvement.

Review of the Performance Improvement Plan revealed in III: Authority and Accountability: Leaders report indicators data and team reports at least Quarterly of the Performance Improvement Committee, Physician quality Improvement Committee and Medical Executive Committee.


Review of the Performance Improvement (PI) Minutes for January 2010 until May 2010 revealed no evidence that the Ambulatory Services, Pre-op Holding area had reported their PI indicators (indicators is a way to measure a high risk area or area needing improvemt.)

Review of the Performance Improvement (PI) Minutes for December 2010 until March 2011 revealed no evidence that the Pharmacy Department reported their PI indicators.

Interview with Staff # 45 in his office on 03/30/2011 at 3:30 PM confirmed that Ambulatory Services, Pre-op Holding had not reported to PI for the months of January, February, March, April and May.

Interview with Staff #44 outside of his office on 03/30/ 11 at 10 AM confirmed no reporting of the PI indicators for the months of December, January, February and March.

Based on interview and document review the facility did not meet the requirements for contracted dietary services based on 3 of 3 request for Registered Dietary consultation reports.


On 3/28/2011 at 9:00 AM in the dietary department an interview with the Dietary Supervisor revealed the facility had contracted a Registered Dietician (RD). The Dietary Supervisor indicated the RD came when a patient related dietary evaluation was needed. The dietary supervisor confirmed the RD did not meet with her on a regular basis nor did the RD inservice or monitor dietary staff on a regular basis. The facility policy required eight (8) hours of RD consultation time each month for the purpose of observation of dietary staff and services and PRN for patient evaluation.

Documentation for the past 3 months of RD consultation reports was requested of the dietary supervisor who could not produce the Registered Dieticians Consultant reports.
There was no documentation to substantiate the RD had consulted 8 hours each month for the last 3 months.

Based on document review and interview the facility failed to insure staff were competent to perform their duties based on 2 of 2 separate temperature logs.

On 3/29/2011 at 2:00 PM in the dietary department a review of the policy for vegetable cooler temperatures revealed the desired temperature for the vegetable cooler is 33-41 degrees Fahrenheit.
The temperature logs for the vegetable cooler were reviewed. The AM temperatures for the month of February 2011 recorded cooler #1 had only 3 out of 28 days recorded above freezing.(February 2nd-33 degrees, 4th-35 degrees, 10th- 33 degrees) (all other AM temperatures were less than 33 degrees) Cooler #2 had no days out of 28 days recorded above freezing.(All recorded temperatures were below freezing AND the log recorded a temperature for February 29th) The PM temperatures for Cooler #1 had 9 out of 28 days above freezing.(February 4th-36 degrees, 9th-33 degrees, 10th-33 degrees, 14th-35 degrees, 20th-36 degrees, 22nd-33 degrees, 23rd-33 degrees, 24th-34 degrees, 28th-33 degrees)(All other days were recorded below freezing) Cooler #2 had 6 out of 28 days recorded above freezing.( February 3rd-36 degrees, 4th-40 degrees, 6th-34 degrees, 13th-40 degrees, 14th-36 degrees, 20th-33 degrees) Temperature logs for the month of March 2011 revealed cooler #1 & #2 had only 1 out of 29 days recorded above freezing.(The one day recorded above freezing was February 29th, there were only 28 days in the month)
All vegetables in the cooler for March 28,29,30 were observed to be properly stored at a temperature of 43 degrees Fahrenheit.

On 3/29/2011 at 2:00 PM the inaccurate cooler logs were brought to the attention of the dietary supervisor. The Dietary Supervisor was asked if there had been any loss of cooler vegetables related to freezing. She replied "No". The Dietary Supervisor stated "they don't know how to read a thermometer. I'll talk to them today"

On 3/28/2011 at 10:00 AM in the dietary department a review of the facility policy for dishwasher temperature rinse cycle was 180 degrees.
There were 33 out of 93 dish washer rinse cycles documented for February (Feb) with temperatures below 180 degrees. Facility policy #F019 requires rinse cycle temperature to be 180 degrees Fahrenheit.
Feb1st-175 degrees, 4th-175 degrees, 5th-173 degrees breakfast, 179-degrees lunch, 6th-175 degrees, 7th-170 degrees, 8th-175 degrees, 9th-175 degrees,10th-170 degrees, 12th-175 degrees breakfast, 175 degrees lunch, 13th-168 degrees, 14th-175 degrees breakfast, 179 degrees lunch, 16th-170 degrees,18th-177 degrees breakfast, 175 degrees lunch, 19th-177 degrees breakfast, 175 degrees lunch, 21st-170 degrees breakfast,175 degrees lunch, 174 degrees dinner, 24th-179 degrees breakfast,179 degrees lunch,178 degrees dinner, 25th-178-degrees lunch,175 degrees dinner, 26th-179 degrees, 27th-170 degrees, 28-175 degrees.(temperatures are recorded for all three meals Feb 29-30-31).

There were 29 out of 83 dish washer rinse cycles documented for March that were recorded as less than the recommended 180 degrees required for safe dish sanitation as stated in facility policy #F019. March 1st-175 degrees, 2nd-178 degrees, 3rd-174 degrees breakfast, 178 degrees lunch, 4th-177 degrees, 5th-179 degrees lunch, 179 degrees dinner, 6th-178 degrees, 7th-170 degrees breakfast, 178 degrees dinner, 9th-175 degrees lunch, 179 degrees dinner, 10th-175 degrees,12th-179 degrees, 12th-178 degrees, 16th-170 degrees, 7th-175 degrees, 18th-160 degrees,19th-178 degrees lunch, 178 degrees dinner, 21st-179 degrees,22nd-178 degrees,23rd-178 degrees,24th-175 degrees,26th-175 degrees,27th-179 degrees breakfast, 175 degrees dinner, 28th-178 degrees.

On 3/28/2011 at 10:30 AM the dietary supervisor was asked about the dish washer temperatures recorded less than 180 degrees for the rinse cycle and the response was "they have not brought that to my attention" The Dietary Supervisor was asked, what should staff due to insure the proper function of the dish washer, She replied "they should run it again to make sure the temp gets high enough"

An interview with a male dishwasher revealed he was unaware he was required to notify his supervisor when the dish machine did not reach the required 180 degrees. He indicated he did not know he should run the load again to insure the proper temperature. He stated he just made sure he wrote the temperature down.

There was no intervention recorded on the log sheet when the temperature was less that 180 degrees.
There was no record a maintenance service report had been submitted to insure proper function of the dish washer.
The staff did not recognize the low temperature of the rinse cycle as a problem.

Based on record review, observation, and interview, the facility failed to ensure expired items were removed from patient care areas. Nine (9) expired items were found in the ED (Emergency Department) treatment room. The facility failed to ensure the crash cart was equipped and checked for emergency patient care according to the facility's policy. The crash cart was was not checked 6 of 14 days according to the March 2011 checklist.

Findings include:

During inspection of the ED treatment room on 3/29/11, the following expired items were found:
-18 gauge spinal needle (exp. 05/2009)
-20 gauge spinal needle (exp. 01/2008)
-Insyte Autoguard 14 gauge (exp. 06/2008)
-Insyte Autoguard 16 gauge (exp. 06/2006)
-Insyte Autoguard 18 gauge (exp. 07/2008)
-Insyte Autoguard 20 gauge (exp. 09/2009)
-16 gauge angiocath (exp. 07/2010)
-Irrigation tray x 2 (exp. 06/2009)

The Emergency Department Nurse Manager (staff #27) was interviewed and confirmed these items were expired. Staff #27 removed these items from the ED during the inspection.

Review of record titled Texas Spine and Joint Policy and Procedure Manual; Department: Patient Care Services; Subject: Maintenance and Restocking of Crash Carts: The policy is written;
"d. Each department Manager/Charge nurse will be accountable for verification of the following on a 24-hour basis. The exception to this will be the IPCU nursing units,which will check their crash carts every twelve hours. See below for specific items checked:
i. Defibrillator Function checked unplugged.
ii. Defibrillator Function checked plugged.
iii. EKG paper in place and 1 spare roll
iv. Def-pads 1 pkg
v. External pads 1 pkg. with attachable cable (adult and pediatric sizes needed)
vi. EKG electrodes 1 pkg
vii. Code Blue record
viii. Backboard attached
ix. Adult bag-valve mask kit (1), Pediatric bag-valve-mask kit (1).
x. O2 tank with > or= to 500 PSI with key.
xi. Expiration tag in date
xii. Red tag number 1 and red tag number 2 intact and recorded."

On observation tour of the Pre-Holding Surgical area it was observed that the cardiac monitor was not equipped with recording paper to record patient's rhythm in an emergency situation. The Crash Cart/ Defibrillator Checklist for March 2011 had not been checked on March 9,10,11,18,28, and 29.

The Pre-Holding Nurse Manger (staff #45) was interviewed on 3/29/2011 at 12:00 PM and confirmed the EKG paper was missing from the cardiac monitor and the crash cart had not been checked according to the facility's policy.

Based on observation, record review, and interview, the facility failed to assure patient food was maintained at a safe storage temperature. The pre-op/post-op patient nourishment refrigerator was out of range (greater than 40 degrees Fahrenheit) on 107 of 122 days, from October 2010 through March 2011, with no corrective action documented.

Findings include:

During a facility tour on 3/28/11, the pre-op/post-op patient nourishment refrigerator was observed to be warmer than the upper limit (40 degrees Fahrenheit) on 20 of 20 days, with no documentation of corrective action.

Review of "Daily Monitoring Logs" for October 2010 through March 2011 for this refrigerator revealed the following:
-October 2010- out of range on 13 of 20 days
-November 2010- out of range on 19 of 20 days
-December 2010- out of range on 16 of 21 days
-January 2011- out of range on 19 of 21 days
-February 2011- out of range on 20 of 20 days
-March 2011- out of range on 20 of 20 days
-Total- out of range on 107 of 122 days
-No documented corrective action could be found

Review of the policy titled, " Refrigerator Freezer Checks, " revealed the following:
" 1. The temperature in refrigerators containing consumable items in patient care areas must be maintained with a range of 2? 8?C or 36 - 40?F. Freezer temperature must be maintained at least -4 to 14?F or -20 to -10?C. Appropriate measures should be taken if temperatures are out of range, such as adjusting the thermostat, rechecking the temperature and notifying Plant Services Manager and Manager/Supervisor who will then contact the Pharmacy. Corrective action will be recorded on the Corrective Action Procedure and documentation form for the Refrigerator and Freezer. "
" 6. The unit/area manager shall be responsible for assuring that temperature of the refrigerator and freezer are documented at least daily and any necessary corrective measures are accomplished. "

In an interview on 3/29/11 at 9:15am, the Infection Control Nurse confirmed that the Daily Monitoring Logs are received, reviewed, and filed in the Infection Control office at the end of each month.

Based on observation, documentation and interview the facility failed to provide training and support for staff who handled, transported and stored linen in a method that insures infection control..

On 3/28/2011 at 9:30 AM during a tour, a residential carpet cleaning machine with liquid in the canister. was observed to be stored in the linen closet. The canister had tape around it. In the linen closet a large container of clean mop heads was observed stacked above the top of the container and 25 had fallen to the floor behind the door.

On 3/28/2011 at 9:45 staff #66 was interviewed and asked if the carpet cleaning machine was usually kept in the linen store room. Staff #66 replied "no" and removed the machine stating "this one isn't ours, this one must have been brought from home by someone" When asked if the mop heads were usually allowed to stay on the floor he stated "no" and picked them up and stacked them back on top of the already over filled container.

On 3/29/2011 at 11:00 AM in the hallway an interview with staff #65 revealed she delivered the linen. When asked how she delivered the linen staff #65 indicated she collected the soiled linen and put the bags on the cart to take them to the dirty linen bins. Once she had placed the dirty linen in the bin she place the clean linen on her cart and delivered it to the linen carts for the nursing staff. When asked if she put the clean linen on the same cart as the dirty she replied "yes". When asked how she cleaned the cart between the dirty and clean linen she said she used "#23" and sprayed the surface of the cart then immediately wiped it down. Then placed the linen on the cart afterward.

On 3/29/2011 at 11:30 AM in the conference room the housekeeping /laundry supervisor was interviewed regarding the delivery of clean linen to the nursing units. The supervisor indicated the staff use two separate carts. The housekeeping/laundry supervisor was surprised to learn the staff used the same cart to pick up dirty linen and place clean linen on the nursing units. The supervisor state "oh they aren't supposed to do that" The supervisor was requested to provide the policy for linen delivery to the nursing unit and could not locate a policy.

On 3/29/2011 at 1:00 PM the inservice records for the housekeeping staff, who deliver the clean linen was reviewed and no one was found to have training in linen or laundry service past safe handling of contaminated linen for personal exposure. There was no inservice of staff nor policies for staff regarding infection control for linen. The linen laundry service is contracted and there were no policies or procedures for the linen/laundry services once the linen was stacked in the linen closet by the contracting service

Based on record review and interview the facility failed to follow their policy on Administration of Conscious Sedation. There were 5 of 12 Physicians not certified in Advanced Cardiac Life Support per the facility's policy.

Review of record titled Texas Spine and Joint Policy and Procedure Manual; Department: Patient Care Services; Title: Administration of Conscious Sedation revealed
"PURPOSE: To provide standard guidance for non-anesthesia providers in the
administration of conscious sedation.
POLICY: Conscious sedation practices throughout the hospital shall be established and
monitored by the Anesthesia department. The Clinical Managers of each department that
administers conscious sedation will be responsible for ensuring that policies in their respective
departments are in compliance with this policy.
Physicians who order, supervise or initiate conscious sedation will be credentialed for that
procedure by the Governing Board and be familiar with the hospital policies and procedures
dealing with conscious sedation. Documentation of their current privileges and Advanced
Cardiac Life Support certification will be maintained by the Medical Staff office.
Conscious Sedation cases will be defined as those patients who receive medication orally, by
inhalation, intramuscularly, or intravenously that does not result in the loss of the patient's
protective reflexes. Each patient will be treated individually."

Physicians #16, #67, #68, #69, and #70 were not certified in Advanced Cardiac Life Support as required per the facility's policy on Administration of Conscious Sedation.


Interview with the Chief Nursing Officer and Executive Assistant on 3/30/2011 confirmed the Advanced Cardiac Life Support certification required by the facility's policy on Administration of Conscious Sedation was not being followed by all physicians.