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Based on interview, the facility failed to have licensed employees performing care and medical interventions within the facility's Emergency Department. Emergency Medical Services (EMS) personnel who were not employees of the hospital, were called to assist with procedures in the hospital.

During an interview with staff #2 and #3 on 3/27/18 revealed the facility's Emergency Department have called EMS to assist with medical interventions within the ED. Staff #2 stated there have been times when a patient is brought in with a cardiac arrest and they will stay and assist with the code until the patient stabilizes. There have been times when EMS may be called in to assist with issues such as a complicated intubation. Staff #2 or #3 could not recall a specific patient at this time. Staff #3 stated she was not aware that EMS could not come in and assist in the ED if needed. Staff #2 confirmed the EMS personnel were not employees of the hospital.

Based on observation and interview, the facility failed to ensure building electrical equipment and utility connections were maintained in a safe manner in 1 room (Housekeeping Closet) out of 6 rooms toured in the outpatient rehabilitation department.

Findings included:

A tour of the outpatient rehabilitation department was conducted on the afternoon of 3-28-2018. Metal broom/mop handles were observed hanging on a rack on the wall. The closet had a hot water heater and a sink in it.

The closet did not have an enclosed ceiling. Directly overhead was a pair of electrical boxes. The boxes had electrical "Danger" stickers on them, indicating they could be a shock hazard. The bottom of the boxes had multiple holes in them that appeared to be designed for ventilation/cooling.

An electrical junction box was observed on the wall. The cover to the junction box was open, exposing the electrical connections.

These conditions presented a possible electrocution hazard should the hot water heater line break, spraying water or a metal handle come in contact with the open junction box.

Staff #8 and Staff #30 confirmed the observations.

Based on observation, review of documents, and interview, the facility failed to:

A. enforce safe work practices for the prevention of occupational exposure to pathogens in the laboratory setting

B. ensure a sanitary environment in the laboratory setting

Findings were as follows:

A.

On 3-27-2018 at approximately 11:30 AM, a tour of the laboratory was made with Staff #10. Upon entering the lab, Staff #25 was observed to be standing near a desk and eating. The desk had the following sitting on top and in close proximity to work stations with blood samples at them:

an open container of food on it,
an open lunch bag with food items in it,
one drink with a straw in it,
one drink cup without a lid,
one drink cup with the lid rest on top but not complete covered,
one unopened bottle of water,
two blenders for mixing smoothies or shakes, and
a spoon and a knife were laying on top of a napkin next to five small paper packets of sugar

An open shelved storage shelf of clean laboratory supplies was next to and touching the desk. Next to the shelf was a sink, and then another workspace that contained a microscope, slide-stainer, and a test tube rocker with six purple top test tubes with blood samples in them. On top of the slide-stainer, was a stack of papers and a set of keys. Staff #25 confirmed they were her personal keys to her car and home.

Directly behind the desk was the specimen freezer, specimen refrigerator, work table and blood analyzer machine. The work table had a test tube holding rack on it with two blue top test tubes with samples in them. The blood analyzer was in the process of analyzing a sample.

Staff #25 stated she was currently processing samples for testing for the Emergency Department. During the tour, Staff #25 was observed to remove an open test tube of blood from a testing equipment and place it in the test tube holding rack that was behind the desk with open food containers and drinks on them. Staff #25 stated that the desk was considered their break room since they did not have one.

No barriers (physical, such as Plexiglas; or visual, such as tape on the floor marking the lab area vs. break area) between the desk being used as a staff break area, laboratory supplies, work stations that contained blood, potentially hazardous material, and Other Potentially Infectious Material (OPIM) were present. The desk had a label on it that read, "EMPLOYEE NON CLINICAL TABLE NO SPECIMENS/REAGENTS ALLOWED".

Given the observed physical conditions and practices there was a reasonable likelihood of occupational exposure to blood, potentially hazardous material, or OPIM.

Interview was conducted with Staff #10. Staff #10 confirmed the potential for staff exposure to blood, potentially hazardous material, or OPIM.


Review of the Centers for Disease Control and Prevention (CDC) guidelines for safe practices in a laboratory was as follows:

Page 30 Biosafety in Microbiological and Biomedical Laboratories 5th Edition, HHS Publication No. (CDC) 21-1112, Revised December 2009:

"A. Standard Microbiological Practices

1. The laboratory supervisor must enforce the institutional policies that control access to the laboratory.

2. Persons must wash their hands after working with potentially hazardous materials and before leaving the laboratory.

3. Eating, drinking, smoking, handling contact lenses, applying cosmetics, and storing food for human consumption must not be permitted in laboratory areas. Food must be stored outside the laboratory area in cabinets or refrigerators designated and used for this purpose."



Review of recommendations, page 18, OSHA Laboratory Safety Guidance, were as follows:

"Employers must ensure that workers are trained and prohibited from engaging in the following activities:

Mouth pipetting/suctioning of blood or OPIM, 29 CFR 1910.1030(d)(2)(xii);

Eating, drinking, smoking, applying cosmetics or lip balm, or handling contact lenses in work areas where there is a reasonable likelihood of
occupational exposure to blood or OPIM, 29 CFR 1910.1030(d)(2)(ix); and

Storage of food or drink in refrigerators, freezers, shelves, cabinets or on countertops or benchtops where blood or OPIM are present, 29 CFR
1910.1030(d)(2)(x)."

B.

During the tour of laboratory, the following unsanitary conditions were observed:

Electrical cords on the floor behind the lab equipment were taped to the floor with duct tape. The tape was pulled up in areas and heavily soiled with dirt and grime.

The floor behind the test equipment was visibly soiled with dirt, dust, and debris.

The flooring along the front of the test equipment was heavily soiled.

The wall behind the test equipment was patched where plumbing went through the wall. Other areas of the wall were also patched. The patching material was not painted or sealed. This condition could allow potential spills of contaminated infectious material to absorb into the patching material.

The wall by the test equipment had dried splatters of a red-brown color that had not been cleaned off.

The space between the specimen freezer and specimen refrigerator was heavily soiled with dust, dirt, and debris.

Absorbent pads were observed on the floor in front of the refrigerator and freezer. The pads were placed to contain any potential leaks. The pads were observed to be soiled with dust and dirt.

A metal cart for transporting heavy cardboard containers of liquids was observed to be stored by the lab supply cart. The metal cart was observed to be heavily soiled and rusted.

A towel was observed to be on the floor behind the work station containing the slide-stainer. The towel was removed and the floor was observed to be soiled.

The flooring material by the desk was observed to have numerous cracked tiles. The tiles were heavily soiled.

An interview was conducted with Staff #18. Staff #18 stated the lab was stripped and waxed every six months and mopped regularly. Staff #18 stated the flooring was stained from use. A paper towel was dampened with water and rubbed over the area said to be stained. The paper towel was then observed to be visibly soiled with dirt from the floor. Staff #18 stated that housekeeping used microfiber cleaning pads and they must not be picking up the dirt.

Based on observation and interview, the facility failed to implement security procedures to prevent untrained individuals from accessing radiology equipment and their controls in 2 [radiology department and mobile Computed Tomography (CT) trailer] out of 2 areas. Access of untrained individuals to radiation producing equipment and their controls could result in damage to equipment, injury to individuals, or loss of life through inadvertent exposure to radiation produced by the equipment.

Findings included:

On the afternoon of 3-27-2018, entry was made to the mobile CT trailer with Staff #3. The access door to the trailer was unlocked. Upon entering the trailer, it was discovered to be unattended. When asked where the radiology technician (Rad Tech) was, Staff #3 explained that when a CT was not in progress, the Rad Tech was either in the Radiology Department or the Emergency Department. Staff #3 explained that the trailer was only locked at night time.

Staff #5 arrived as the tour was in progress. Staff #5 confirmed that she left the trailer unattended regularly. Staff #5 confirmed that when she left the radiology department, it was also left unsecured. Staff #5 confirmed that both the CT scanner and radiology equipment controls could be accessed by anyone who happened to wander in. Staff #5 stated that the only equipment that was locked so that controls could not be accessed was the portable x-ray machine. It had a key to it and was locked when not in use. Staff #5 stated that there were not keys to the radiology department and that the doors did not lock.

An interview was conducted with Staff #39 on 3-29-2018. Staff #39 confirmed the only time the mobile CT trailer is locked is at night. Staff #39 explained that the overnight Rad Tech was concerned about walking into the trailer, finding someone in there, and potential harm to herself.

Based on review and interview the facility failed to ensure the Licensed Vocational Nurse (LVN) was supervised by a appropriately licensed supervisor in 29 of 34 shifts reviewed.

Review of the staffing schedule from 3/10-3/26/18 revealed 29 of 34 shifts a Licensed Vocational Nurses (LVN) was left alone without a Registered Nurse (RN) supervision, when the RN was off the clock for meals. Review of the schedule revealed there was a House Supervisor (RN) that was within the facility but no evidence he/she was monitoring the LVN.

Review of the Texas Board of Nursing Requirements revealed, "The LVN's scope of practice requires that his or her nursing practice be directed by an appropriately licensed supervisor, e.g. registered nurse, advanced practice registered nurse, physician, physician assistant, podiatrist or dentist [Nursing Practice Act (NPA) Sections 301.002(5), 301.353 and Board Rule 217.11(2)].

The licensed supervisor is responsible for overseeing the LVN's nursing practice and actively engages in a supervisory process that directs guides and influences the LVN's performance of an activity. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity Board Rule 217.11(2)]."

An interview with the DON was conducted on 3/28/18. The DON stated that the House Supervisor has been monitoring the LVN when the RN goes to meals and was "off the clock." The DON confirmed there was no documentation of the House Supervisor directly monitoring the LVN during these times.

Based on medical record review and interview the facility failed to insure the nursing staff assessed and evaluated 3 (#3,#4 and #5) of 5 (#1, and #2 ) patients entrusted to their care.


This deficient practice had the likelihood to effect all patients of the facility.


Findings included:


On the morning of 3/29/2018, in the conference room, the medical records (MR) for patients (Pt/pt) #1 through #5 were reviewed with the assistance of staff #2.


#3:
* No evidence of complaint or grievance process provided for the pt.

#4:
* No evidence of complaint and grievance process provided for the pt.
* No documentation of description of patient's wound. Pt admitted to swing bed services for therapy status post open hip repair. Pictures taken captured surgical ink still very visible on the pt's hip and an uneven partially healed surgical wound bed.

#5:
* No evidence of pt provided complaint and grievance process.
* No assessment of vital signs upon pt exit to Acute Care hospital for testing or return to Swing Bed unit prior to discharge. Pt #5 was admitted to the swing bed unit for antibiotic therapy for a respiratory infection that resulted in her depressed respiratory status.

Based on interview and record review the facility failed to insure the attending physician for 2 (#4 and #5) of 6 patients had authenticated orders in the patients medical record.


This deficient practice had the likelihood to effect all patients of the facility.


Findings included:


On morning of 3/29/2018 in the conference room the medical records (MR) for patients (Pt/pt) #1 through #5 were reviewed. Listed below are the findings.


Pt #4:

* History and physical (H&P) not signed or updated by the admitting physician, (Received from admitting hospital).
* Discharging physician failed to sign hospital discharge orders.
* Physician failed to authenticate verbal order recorded on 2/14/2018. As of 3/29/2018 the order had not yet been authenticated.
*Admission orders of 2/9/2018, had not been authenticated by the admitting physician as of 3/29/2018.

Pt #5:

* No documented update or signature of H&P by admitting physician. H&P Received from admitting hospital.
* Miscommunication between admission, swing bed status and discharge. Pt admitted to acute Critical Access Hospital. Physician order identified, to discharge pt to swing bed status. Pt left with order for outing, had friend drive her to acute hospital for testing, returned to Critical Access hospital for discharge. Event not resolved in the MR.
* Three (3) verbal orders given by staff physician #14 were given on 3/13/2018. On 3/29/2018 these three orders had not been validated by the authorizing physician.
* The Discharge Summary, 3/10/2018, had been dictated but not authenticated by the physician on 3/29/2018

Based on observation and interview, the facility failed to implement or enforce safeguards preventing unauthorized access to Protected Health Information (PHI) for patients. Records were left unsecured in 2 areas [outpatient physical therapy and mobile Computed Tomography (CT) trailer] of three areas observed.

Findings included:

On the morning of 3-27-2018, a tour of the medical records department was conducted, along with an interview with Staff #19. Staff #19 advised that she scanned medical records from the outpatient physical therapy department into the electronic medical record system. Staff #19 stated the physical copies were kept on a shelf for a short period of time and then destroyed. However, another physical copy of the record was kept in the outpatient physical therapy department. Staff #19 stated she was not responsible for those records. At that time, a tour was made of outpatient physical therapy department medical record storage area with Staff #19 and Staff #10. The storage area was located by a reception desk. No staff was present at the desk and the door to the storage room was opened. Records could have been accessed by unauthorized individuals. This observation was confirmed by Staff #19.

On the afternoon of 3-27-2018, entry was made to the mobile CT trailer with Staff #3. The access door to the trailer was unlocked. Upon entering the trailer, it was discovered to be unattended. When asked where the radiology technician (Rad Tech) was, Staff #3 explained that when a CT was not in progress, the Rad Tech was either in the Radiology Department or the Emergency Department. Staff #3 explained that the trailer was only locked at night time. A log book that recorded patient information to include name, account number, physician, and test was found opened on a desk. This information was available to anyone who entered the trailer unlocked and without staff in it.