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Based on observation, interview, and record review, the facility's Governing Body failed to:


A. ensure safe and effective provision of dialysis services.

1. ensure the chlorine checks were conducted every 4 hours on the portable reverse osmosis (RO) water treatment systems.

2. ensure the security of the dialysis water room products in the acute dialysis unit.

3. ensure the pick-up tubes (wands) were fitting securely to the acid and bicarbonate jugs that were being used to dialyze the patients during a dialysis treatment to prevent bacterial contamination and evaporation. Also, the facility failed to have a disinfection log for the acid and bicarbonate wands.

4. obtain and verify the Hepatitis B status of the dialysis patient prior to dialyzing the patient. This deficient practice had the likelihood to expose patents and staff to Hepatitis-B.

5. ensure that 3 of the dialysis machines (#2, #3, and #5) for the months of May, June, and July 2019 were disinfected every 7 days and bleach clearance checked prior to the next patient use.

6. ensure the independent device was functioning to perform the conductivity for checking the dialysis machine.

7. ensure the informed consent for the dialysis treatment was signed by the patient or designee and physician for 3 (#12, #13, and #15) of 5 hemodialysis patients.

8. ensure that staff members were not removing greater than 13 ml/kg/hr of fluid on 3 (#13, #14, and #15) of 5 patient treatment sheets reviewed.

9. ensure dialysis staff were wearing gowns, face shields, eye wear, or masks for personal protective equipment (PPE) to prevent exposure of spurting or splattering of blood during the initiation and termination of dialysis treatment.

10. ensure dialysis staff were maintaining a clean and sanitary environment for the acute dialysis patient.

11. ensure the dialysis Quality Assurance Performance Improvement (QAPI) program was developed, implemented, maintained and evaluated with focus indicators to improve the outcomes of the acute dialysis unit.

It was determined that the deficient practices at the Acute End-Stage Renal Disease unit posed an Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, impairment and/or subsequent death.

Refer to tag A0144


B. include all departments and outpatient services in the Quality program. Outpatient services, Dialysis, Physical Therapy, Laundry/Linen, and plant operations were not reflected in the quality program.

Refer to tag A0273


C. ensure the medical staff followed the Medical Staff bylaws, Rules and Regulations.

1. Medical staff failed to complete medical records within the defined time limits (30 days).

2. Failed to suspend, in accordance with their Rules and Regulations, those physicians who did not complete their documentation within the 30 days time period

Refer to tag A0347


D. develop a plan for identifying, reporting and investigating (potential) infections within the facility for 4 months, April, May, June, and July 2019, in 2 (Intensive Care Unit, Kitchen) of 4 services areas, Intensive Care unit, Kitchen, and Physical Therapy.

Refer to tag A0749

It was determined that the deficient practices at the Acute End-Stage Renal Disease unit posed an Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, impairment and/or subsequent death.


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

A. ensure the chlorine checks were conducted every 4 hours on the portable reverse osmosis (RO) water treatment systems.


B. ensure the security of the dialysis water room products in the acute dialysis unit.


C. ensure the pick-up tubes (wands) were fitting securely to the acid and bicarbonate jugs that were being used to dialyze the patients during a dialysis treatment to prevent bacterial contamination and evaporation. Also, the facility failed to have a disinfection log for the acid and bicarbonate wands.

D. to obtain and verify the Hepatitis B status of the dialysis patient prior to dialyzing the patient. This deficient practice had the likelihood to expose patents and staff to Hepatitis-B.

E. ensure that 3 of the dialysis machines (#2, #3, and #5) for the months of May, June, and July 2019 were disinfected every 7 days and bleach clearance checked prior to the next patient use.


F. ensure the independent device was functioning to perform the conductivity for checking the dialysis machine.

G. ensure the informed consent for the dialysis treatment was signed by the patient or designee and physician for 3 (#12, #13, and #15) of 5 hemodialysis patients.

H. to ensure that staff members were not removing greater than 13 ml/kg/hr of fluid on 3 (#13, #14, and #15) of 5 patient treatment sheets reviewed.

I. ensure dialysis staff were wearing gowns, face shields, eye wear, or masks for personal protective equipment (PPE) to prevent exposure of spurting or splattering of blood during the initiation and termination of dialysis treatment.

J. ensure dialysis staff were maintaining a clean and sanitary environment for the acute dialysis patient.

K. ensure the dialysis Quality Assurance Performance Improvement (QAPI) program was developed, implemented, maintained and evaluated with focus indicators to improve the outcomes of the acute dialysis unit.


Cross Refer to Tag: A 0144

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


A. ensure the chlorine checks were conducted every 4 hours on the portable reverse osmosis (RO) water treatment systems.

B. ensure the security of the dialysis water room products in the acute dialysis unit.

C. ensure the pick-up tubes (wands) were fitting securely to the acid and bicarbonate jugs that were being used to dialyze the patients during a dialysis treatment to prevent bacterial contamination and evaporation. Also, the facility failed to have a disinfection log for the acid and bicarbonate wands.

D. to obtain and verify the Hepatitis B status of the dialysis patient prior to dialyzing the patient. This deficient practice had the likelihood to expose patents and staff to Hepatitis-B.

E. ensure that 3 of the dialysis machines (#2, #3, and #5) for the months of May, June, and July 2019 were disinfected every 7 days and bleach clearance checked prior to the next patient use.

F. ensure the independent device was functioning to perform the conductivity for checking the dialysis machine.

G. ensure the informed consent for the dialysis treatment was signed by the patient or designee and physician for 3 (#12, #13, and #15) of 5 hemodialysis patients.

H. to ensure that staff members were not removing greater than 13 ml/kg/hr of fluid on 3 (#13, #14, and #15) of 5 patient treatment sheets reviewed.

I. ensure dialysis staff were wearing gowns, face shields, eye wear, or masks for personal protective equipment (PPE) to prevent exposure of spurting or splattering of blood during the initiation and termination of dialysis treatment.

J. ensure dialysis staff were maintaining a clean and sanitary environment for the acute dialysis patient.

K. ensure the dialysis Quality Assurance Performance Improvement (QAPI) program was developed, implemented, maintained and evaluated with focus indicators to improve the outcomes of the acute dialysis unit.



It was determined that the deficient practices at the Acute End-Stage Renal Disease unit posed an Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, impairment and/or subsequent death.



Findings included:

A. A review of the log titled, "Daily Log for Osmonic 23G Machine" for the month of May, June, and July 2019 revealed the following:

A review of the log revealed the chlorine check was only done at the beginning of the dialysis day and not done again. Patients were being dialyzed for greater than the four-hour chlorine check parameter. There were no other chlorine checks performed.

An interview with Staff #22 on 07/22/19 at 11:00 AM confirmed that chlorine checks were not being checked every 4 hours per the acute dialysis parameters. Also, the parameters were not being followed by Staff #22.


B. During a tour of the facility on 07/22/19 at 10:30 AM, observed the water room was not secured from the hospital staff.

An interview with Staff #22 on 07/22/19 at 10:30 AM confirmed the water room entrance was not locked.

C. During a tour of the facility on 07/22/19 at 10:30 AM, observed a patient receiving a dialysis treatment. The pick-up tubes (wands) were hanging out of the acid and bicarbonate jugs. There was no secure connection from the pick-up tube to the opening of the acid or bicarbonate jug. This deficient practice allowed for cross contamination, acid spills, and bacterial growth in the bicarbonate jug. Acid concentrate is not susceptible to bacteria contamination, but every effort should be made to keep the system closed to prevent nonbacterial contamination and evaporation per the ANSI/AAMI standards. Also, the facility failed to ensure that the cleaning and disinfection of acid and bicarb wands were being completed and logged with date and time of cleaning and disinfection.

A review of the policy titled, "Testing of Water to be Used for Hemodialysis Treatments" revealed:

"D. Hemodialysis machines are heat disinfect daily. The surface will be cleaned with Microkill Plus (red top saniwipes) and the clamp, scissor-clamps, and solution wands will be cleaned with 1:100 solution of 5.25% bleached after each use."

In an interview with Staff #22 on 7/22/2019 at 10:30 AM stated," I just rinse the wands at the end of the day and place them on the machine for the next day. I did not know we needed to keep a log." Also, Staff #22 confirmed the wands did not fit the dialysate solution securely.

D. A review of Patient #11's record revealed there was no Hepatitis-B verification status completed prior to initiating dialysis.

In June 2019, the Regulatory compliance of the facility had developed a plan of correction action plan. The facility had realized there was no documentation in the record for the patients Hepatitis-B status prior to patient being dialyzed. The action plan failed, and the Patient #11 was dialyzed without knowing the Hepatitis-B status.

An interview with Staff #6 on 07/22/2019 at 1:30 PM confirmed the above findings.

E. A review of the "Care of the Machines Bleaching" log revealed:

1. Machine #2 in the month of May 2019 was bleached on 5/20/2019 and not bleached again until 5/31/2019, 11 days later. In the month of July, Machine #2 was bleached on 7/01/2019 and not bleached again until 7/10/2019, 9 days later.

2. Machine #3 in the month of June 2019 was bleached on 6/24/2019 and not bleached again until 7/03/2019, 9 days later. In the month of July 2019, Machine #3 was bleached on 7/10/2019 and not bleached again until 7/18/2019, 8 days later.

3. Machine #5 in the month of June 2019 was bleached on 6/03/2019 and not bleached again until 6/12/2019, 9 days later. Machine #5 was bleached on 6/24/2019 and not bleached again until 7/03/2019, 9 days later. In the month of July 2019 Machine #5 was bleached on7/10/2019 and not again until 7/18/2019, 8 days later.

A review of the policy titled, "Testing of Water to be Used for Hemodialysis Treatments" revealed:

"A. Hemodialysis machines will be cleaned with a solution of bleach (5.25% sodium hypochlorite) per manufacturer's directions at least weekly, following any patient treatments those days. This is the "CHEMICAL/RINSE" procedure."

An interview with Staff #22 on 07/22/2019 at 2:00 PM confirmed the above findings.

F. During a tour of the facility on 07/22/19 at 10:30 AM, observed during the dialysis treatment an independent device (Mesa) was used by Staff #23. Staff #23 was asked does this device do conductivity to verify the dialysis machine conductivity. Staff #23 stated, "This device only checks the PH of the machine." The acute dialysis unit did not have an independent device to check the conductivity of the dialysis machine.

G. A review of Patient #12's hospital record for 5/22/2019 revealed no current informed consent for inpatient hemodialysis.

A review of Patient #13's hospital record for 5/01/2019 revealed no current informed consent for inpatient hemodialysis.

A review of Patient #15's hospital record for 7/11/2019 revealed no current informed consent for inpatient hemodialysis.

In an interview on 7/22/2019 in the afternoon with Staff #2, Staff #22 and Staff #23 confirmed there was no current informed consent for hemodialysis on the above patients and were unaware that a new informed consent must be signed with each hospitalization before hemodialysis can be performed.

H. A review of Patients #13's treatment sheet revealed the facility staff was pulling greater than 13 ml/kg/hr.
A review of treatment sheet for Patient #13 dated 5/01/2019 revealed, facility staff removed 16.66 ml/kg/hr of fluid.

A review of Patient #14's treatment sheet revealed the facility staff was pulling greater than 13ml/kg/hr.
A review of treatment sheet for Patient #14 dated 7/20/2019 revealed, facility staff removed 19.44ml/kg/hr of fluid.

A review of Patient #15's treatment sheet revealed the facility staff was pulling greater than 13ml/kg/hr.
A review of treatment sheet for Patient #15 dated 7/11/2019 revealed, facility staff removed 20.63ml/kg/hr of fluid.

In a review of orders for Patients #13, #14 and #15 there were no orders from the MD to remove more than 13ml/kg/hr of fluid.

In an interview with Staff #6 on 7/22/2019 at 3:00 PM the above findings were confirmed.

I. Observed during a dialysis treatment on 07/22/19 at 10:30 AM, Staff #23 was not wearing complete PPE (Personal Protective Equipment) attire. Staff #23 had a blue gown on, but the back was open, and the tie tails were not tied. Also, Staff #23 was not wearing any type of eye/face protection.


J. During a tour of the acute dialysis unit and the dialysis storage area on the afternoon of 07/22/19 observed the following infection control issues:

Dialysis Equipment:

During a tour of the facility on 07/22/19 at 10:30 AM, observed during the dialysis treatment that Machine #5 (which is a H series) was rusty and leaking water from the back of the machine. The staff were using a towel to catch the water running from the back of the machine. Also, observed that Staff #23 had difficult time getting the machine to start the dialysis treatment. It took over an hour before the actual dialysis treatment started. The process was witnessed by the Dialysis Medical Director.


Storage room for Acute Dialysis unit:


1. Observed 3 plastic containers hanging on the wall labeled "Dilute Bleach" with tubing hanging from the containers. Surveyor asked the contract Bio-Med staff and Staff #22 how long these containers have been hanging here. They both stated, "We have no idea."

2. There were brown stains noted on the wall that appeared to be water stains. The wall had numerous missing plaster.

3. Observed the floor of the storage area to have discolored floor tile with a black substance stuck to the floor. The entire floor in the storage room was discolored with unclean appearance.

4. The wall base was pulling apart from the wall with dust and dirt in the crack of the wall base.

5. There were 3 sets of metal shelves in the store room with patient supplies on the shelves. The bottom shelf was low to the floor and there was no way to keep the dust and wet mopping from splashing on the supplies. The surveyor looked under the lowest shelf and observed trash, dead insects, and dirt under the shelves.

6. There was portable (RO) water system machine in the storage room that had sign on it that read "This machine is not approved to be used on a patient." The Bio-med technician stated, "The machine is so old we cannot get parts for it to fix it, it needs to be scrapped."

7. The shelves holding the patient supplies were shared with used machine parts and tools. The shelves were cluttered and disorganized. The metal shelves were rusted and dirty.

8. There was a large plastic container labeled bicarbonate with a wand inside it. Surveyor asked Staff #21 and #22 when was the container last used and disinfected. The staff could not answer when the container had been disinfected and used on a patient.

9. Observed a large yellowish discolored plastic container sitting on a shelf with fluid in it. Staff #21 and #22 could not tell the surveyor how long it had been sitting there or what the solution was.

10. On one of the rusted metal shelves that was stocked with peritoneal dialysis supplies observed dust and dirt particles on the plastic covering. One of the bags of fluids was almost touching the floor. These peritoneal dialysis supplies were being stored on the bottom shelf of the rusted metal shelf.

11. There was a metal bucket sitting on the floor of the storage room and it was filled with trash.

12. There was a metal rolling cart in the storage room and on it was four opened containers of different dialysis solutions. The open containers were labeled with patient names, but all the patients were no longer in the hospital. Also, observed a towel hanging from the metal cart. Unknown if towel was dirty or clean.

13. Observed a plastic basket full of some type of filter and the white paper covering was water stained. Staff reported we don't use those anymore.

14. The locking mechanism of the storage room was not working properly. Staff #22 placed her key in the door and could not get her key out of the door.

An interview with Staff #21 and #22 on 07/22/19 at 2:30 PM confirmed the above findings during the tour of the facility.


K. A review of the QAPI (Quality Assurance Performance Improvement) meeting minutes for 2019 did not address the dialysis issues. There was no documentation of dialysis noted in the QAPI meetings. Staff #22 who works at the acute dialysis unit full time was asked if she was involved in the quality meetings. Staff #22 stated, "No, the only documents I provide are the water culture reports."

An interview with Staff #6 on 07/22/19 at 2:00 PM confirmed the QAPI meetings did not address issues found in the dialysis department.

Based on observation, interview, and record review, the facility failed to include all departments and outpatient services in the Quality program. Outpatient services, Dialysis, Physical Therapy, Environmental services, Laundry/Linen, and plant operations were not reflected in the quality program.


Refer to tag A0273

Based on observation, interview, and record review, the facility failed to include all departments and outpatient services in the Quality program. Outpatient services, Dialysis, Physical Therapy, Environmental services, and Laundry/Linen were not reflected in the quality program from January through July 2019, 6 months.


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


Findings included:

1. On 7/25/2019 in the morning, an interview with the Quality Director, staff #4, confirmed all departments and services areas were not reflected in the Quality program.

On 7/24/2019 accompanied by the Quality Director, staff #4, the facility's RHC (rural Health Clinic) was toured. The Quality Director and Director of Outpatient Services, staff #43, and Laboratory Director were present to observe and confirmed excessive infection control risks in the laboratory.


The RHC 's did not participate in the Quality program.


2. On 7/24/2019 in the morning a tour of the Physical Therapy Department revealed a clean and orderly program, however, an interview with the Director of the program confirmed the department followed no Quality specific guideline and had no process improvement other than tracking cancellations and scheduling.

Physical Therapy did not participate in the Quality program.


3. On 7/22/2019 during a tour and observation of the Dialysis program and the services it provided, Immediate Jeopardy was found. The facility staff failed to check the Chlorine levels, every 4 hours as required for safety of the patient use solution.

After interview and attempts to review the documentation collected for the quality program it was determined the Dialysis services were not participating in the Quality program and had no process improvement or data collection that was submitted for quality review.

4. Environmental services tracked no data that reflected monitoring of sanitation within the facility, or was submitted to the Quality program and had no definitive process improvement.

5. Linen and Laundry tracked no specific data. This services was a contracted service. There was no data reflecting a process improvement.

Observation of the room (closet) dedicated to the collection of soiled linen prior to pick up was in need on deep cleaning, and repair.

Based on document review and interview, the facility failed to ensure that 22 (#10, #20, #26, #27, #28,
#29, #30, #31, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, and #56) of 49
Providers completed all documentation and authenticated medical records according to the Medical Staff Rules and Regulations and facility policy. Also, the facility failed to follow their own policy and enforce the Med Staff Rules and Regulations.


This deficient practice had the likelihood to cause harm to all patients.


Findings include:


Review of document titled, "Deficiency Statistics Summary by Physician Report" revealed the following:


There were 8 (#19, #20, #26, #31, #43, #50, #52, and #53) of 49 Providers had medical records that were incomplete and delinquent greater than 31 days.


There were 6 (#19, #46, #48, #49, #43, #51, and #56) of 49 Providers had medical records that were incomplete and delinquent greater than 46 days.


There were 5 (#19, #20, #48, #51, and #56) of 49 Providers had medical records that were incomplete and delinquent greater than 61 days.


There were 11 (#19, #20, #30, #43, #44, #45, #46, #47, #49, #53. and #55) of 49 Providers had medical records that were incomplete and delinquent greater than 90 days.


A review of the documentation provided by Staff #17 revealed a letter that was sent to Staff #19 regarding all incomplete and delinquent medical records on June 20, 2019.


A review of documentation provided by Staff #17 revealed a letter that was sent to Staff #20 regarding all incomplete and delinquent medical records on June 20, 2019.

Staff #1, #3, and #17 confirmed the above findings.


A review of Policy titled, "HIM, Delinquent Medical Records" revealed the following::

" ...Procedure:

5. A chart which is not completed within thirty (30) days of discharge will trigger suspension of the staff member's privileges and the staff member will be notified in writing ..."



A review of the document titled, "NAVARRO REGIONAL HOSPITAL MEDICAL STAFF RULES & REGULATIONS" revealed the following:

" ...ARTICLE II MEDICAL RECORDS 2.16

Suspension. A chart which is not completed within thirty (30) days of discharge will trigger suspension of the responsible physician privileges ..."


An interview was conducted on 7/22/2019 after 9:00 AM with Staff #17 in the HIM Department. Staff #17 was asked how the department tracked delinquent medical records. Staff #17 stated,"They have less than 5% delinquent medical records. We send letters to the providers twice a month and follow up with the physicians. The delinquent percentage was discussed in our daily flash huddle meetings.


On 7/23/2019 after 1:00 PM Staff #1, #3, and #17 confirmed the above findings.

Based on record review and interview, the facility failed to ensure that all entries in the patient medical record were legible, complete, dated, timed, and authenticated in 5 (Patient #'s 24, 27, 30, 31, and 41) of 15 records reviewed.

During review of patient medical records on July 24, 2019 after 10:00 AM the following observations were made


PATIENT #24
The facility document titled, "Leaving Against Medical Advice" was signed, dated and timed by the patient. It was also signed by the witness but not dated and timed.


PATIENT #27
The patient presented to the ER on 6/12/2019 at 10:59 am with suicidal and homicidal ideations. The patient was triaged, medically screened by the physician and a transfer to inpatient mental health facility discussed with behavioral health consultant. On 6/12/2019 at 10:22 pm. Nursing documentation showed the patient wanted to leave the hospital to go home and feed her dogs and informed the patient sitter and nurse of this. The patient was educated on the risks of leaving and verbalized understanding. There is no documentation to show that an "Leaving Against Medical Advice Form" was initiated for the patient. The patient left the facility and was documented as an elopement. Documentation further shows the police were notified by hospital staff.


Review of the facility policy from the Emergency Services Policy and Procedure Manual titled "Patient Leaves Against Medical Advice" with a last reviewed date of August 2014 Section II C - "After explanation of potential risks and consequences, if the patient refused to wait for the physician, or if the patient talks to the physician and stills desires to leave 'against medical advice', request that the patient sign the AMA form and give copy to the patient." Section II E - "If the patient refuses to sign the form, complete the form except for the patient's signature, write across the signature area that the patient refuses to sign and have a second witness sign the form." Section II I-"All patients who leave after triage (LWOT) or after physical exam (AMA) should be entered into the EMR (electronic medical record) patient daily log. All patients who leave prior to triage will be on the EMR "Left from Presentation" log.

The facility failed to follow its own policy.


PATIENT # 30
The facility document titled, "Memorandum of Transfer" was incomplete. Under section A - the discharge time was left blank., also under Section A titled "Transfer Support" the time contacted and "ETA" sections were left blank.

Review of the facility policy titled "Transfer of Patients from Navarro Regional Hospital (NRH) to another Hospital," with the last review/revised date of 10/2015, under section titled "Procedure" part 6 states, "Supervisor will complete Section A of the "Memorandum of Transfer" (MOT) and obtain physician signature."

The facility failed to follow its own policy.


PATIENT #31
The facility document titled, "Transfusion of Blood and Blood Components Consent Form" was signed by the patient but was not dated or timed. Without the date and time on the consent form, it is unable to be determined if the patient signed the consent before or after the blood was administered.


PATIENT #41
The facility document titled, "Contrast Media Patient Education" was signed by the patient but was not dated and timed.

A second facility document titled "Contrast Media Patient Education" was signed by the patient representative and dated, but not timed.




An interview with Staff # 6 conducted on July 24, 2019 after 1:00 p.m. revealed that consent forms and MOT's are not reviewed for completeness prior to be scanned into the medical record system. Staff # 6 confirmed the above findings.

Based on observation and interview, the Facility failed to ensure that the dumpster was secured to prevent scavenging by animals or humans.

Findings included:

On a tour of the Facility in the morning on 7/23/2019, the dumpster outside of the back loading dock was noted to have fencing on 3 sides but no gate to secure the dumpster when not in use. On further inspection of the dumpster area, trash and debris were behind the dumpster and a large amount of space was noted that could allow for animals or humans to hide and scavenge in the dumpster.

In an interview with Staff #43 on 7/23/2019 at 10:00 AM the above findings were confirmed.

Based on observation and interview, the facility failed to ensure that 2 of 101 fire extinguishers in the facility were secured in a cabinet or to the wall to prevent the fire extinguisher from falling onto employees or visitors.

Finding included:

During a tour of the facility in the morning of 7/23/2019, 2 fire extinguishers, one in the hallway at the back entrance from the loading dock and one in the Radiology area hallway were observed to be sitting in the designated cabinet for fire extinguishers. The Plexi glass cover was missing on both cabinets and the fire extinguishers were not mounted to the wall which would allow them to be easily knocked over and fall out of the cabinet which could injure anyone near the area of the fire extinguisher.

In an interview with Staff #43 on 7/23/2019 at 10:30 AM the above findings were confirmed.

Based on observation, interview and record review the facility failed to

A. maintains a sanitary environment to avoid sources and transmission of infections and communicable diseases in 9 (Intensive Care Unit, kitchen, central supply area, clean and dirty laundry rooms, main laboratory, radiology department, emergency department and medical surgical unit.) of 13 areas of the hospital, Intensive Care Unit, kitchen, Physical Therapy, central supply area, clean and dirty laundry rooms, main laboratory, radiology department, emergency department, medical surgical unit, and outpatient radiology.) .

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


Findings included.


Intensive Care Unit (ICU):

On 7/22/2019 during the initial tour of the facility, the ICU was toured and a patient in a private room was observed on a ventilator. On the outside of the door of the room, was an "Isolation" sign, and the Personal Protective Equipment (PPE) Kit. The door was fully open. For a nurse to obtain the PPE it would be necessary for the nurse to enter the room prior to donning the PPE. The isolation order for the patient was contact isolation.


Kitchen:

1. Cobb webs collected behind the ice machine.
2. Heavy build up of oils below, between and behind heavy cooking appliances.
3. One bag of frozen breaded okra was observed open to the air in the freezer.
4. Four (4) gallon bottles of condiments (dressings) were expired.
5. Heavy rust visible on fryer vents.

The above observations were confirmed by the Dietary manager.

The dietary manager also confirmed there was no log of documentation for when the oil in the fryer was changes and the fryer cleaned.


B. develop a plan for identifying, reporting and investigating (potential) infections within the facility for 4 months, April, May, June, and July 2019, in 9 (Intensive Care Unit, kitchen, central supply area, clean and dirty laundry rooms, main laboratory, radiology department, emergency department and medical surgical unit.) of 13 areas of the hospital, Intensive Care Unit, kitchen, Physical Therapy, central supply area, clean and dirty laundry rooms, main laboratory, radiology department, emergency department, medical surgical unit, pediatric health clinic and outpatient radiology.) .

Refer to tag A 0749




40989

An observation tour of the Radiology Department was conducted on 7/23/2019 after 9:00 AM with Staff #8 and the following was observed.

In the Tomography (Cat Scan) Room the cabinet holding the clean linen was missing part of the covering on the lower inner edge of the exposing the porous surface. This surveyor tried to open the locked cabinet that contained IV Catheters and the laminate covering on the face of the cabinet fell into this surveyor's hands exposing the porous surface underneath. The porous surface cannot be properly sanitized to prevent the spread of infectious disease.

An interview was conducted with Staff #8 on 7/23/2109 after 9:00 AM. Staff #8 was asked if the cabinet had been broken for very long. Staff #8 replied, "We have asked for new cabinets for a long time. These cabinets are extremely old, and they are all in need of repair or replacement."


Staff #8 confirmed the findings.


41831

On July 22, 2019 between 10:30 am and 12:00 pm the following infection control issues were found in the Emergency Room.


Clean Supply Room - A plastic bin containing various weights, tube gauze applicators and a cast saw. Upon closer inspection, the traction weights were found to have chipped paint, and rusted areas. Rust cannot be sanitized. The cast saw was found to have dirt and dust on the saw blade. A fall mat was uncovered stacked next to covered fall mats. When Staff # 15, ER Director was asked if the mat was clean or dirty, she stated she was unsure as their procedure in the ER is to cover all clean, reusable supplies with a plastic bag. The mat was removed from the area.


Clean Utility Room - 2 out of 2 Work Station on Wheels (WOW) were found in the clean utility room. Both WOWs were dusty and uncovered, the bottom cover on one WOW was dusty and splattered with an unknown brown substance. There was also an IV pump in the clean utility area sitting on a WOW. Staff 15 was unable to determine if the IV pump had been cleaned prior to being placed in the clean utility room.


Pediatric Crash Cart - Pediatric AED pad 1 out of 2 sets expired on 7/8/2019 and were on the crash cart available for use. A package containing a disposable curved (MacIntosh) laryngoscope blade used for intubation was found that manufacture seal had been broken and the blades were open to air and available for use on the crash cart. A Laryngeal Mask Airway was found to be expired on 6/2019 and available for use on the crash cart. An Infant Feeding Tube expired 05/2019 and was available for use on the crash cart. A sterile package in a wire basket on the wall next to the suction and oxygen in the trauma room was found to have blood on the outer package. All expired, open or soiled items were removed and replaced at the time of observation.

Patient Exam Room in ER - The counter with the sink in patient exam room was found to have laminate edging that was loose or coming off showing the exposed wood. This is unable to be sanitized.
Nurses station in ER - Laminate countertops have worn corners with exposed wood, cracked and chipped laminate on the edges.

Staff #15 Confirmed all findings in the ER.



On July 23, 2019 between 1:15 pm and 2:30 pm the following infection control issues were found on 2nd floor Medical Surgical Unit.

Patient bathroom in room 23 - The shower curtain rod in the patient bathroom was rusted. Rust cannot be sanitized. A plumbing fitting at the back of the toilet in the patient bathroom was found loose from the wall with a screw hanging, damage dry wall was exposed, and a mesh tape was noted underneath. This area cannot be sanitized.

Patient room 23- A bedside commode found in a clean patient room was covered with a plastic bag indicating it to be cleaned, per staff # 3, CNO. Underneath the bedside commode was an unknown brown substance near the bucket. Rusty bolts were found on the underside. Rust cannot be sanitized. The rubber cap on the leg bottom of the bedside commode was noted an unknown brown substance on these rubber caps.

Staff # 3, CNO confirmed all findings.






40990


Central Supply Area

On observation in the central supply storage area on 7/23/2019 at 9:15 AM, multiple cardboard boxes were observed on shelves sitting above open supplies such as gauze, tape and 4X4's that were being taken directly to patient care areas for patient use.

"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAM1 ST46-Section 5.2 Receiving items)."
In an interview with Staff #42 and #43 on 7/23/2019 at 9:30 AM the above findings were confirmed.

Dirty and Clean Laundry

On observation in the clean and dirty laundry storage areas on 7/23/2019 at 10:15 AM, clean pediatric hospital gowns were lying on a cart uncovered and not wrapped in plastic which were available for use in the patient care area. Also, in the dirty laundry room the walls were heavily damaged with exposed sheetrock and chipped paint, the floor was also dirty with dirt and debris along the wall, and floor tiles were cracked and broken.

In an interview with Staff #43 on 7/23/2019 at 10:30 AM the above findings were confirmed.

Main Laboratory

On observation in the main laboratory on 7/23/2019 at 9:45 AM, 3 of 5 of the stainless-steel sinks that were observed in the laboratory area were heavily rusted and the caulking around the sink was peeling or missing. Also, the sink in the pathology lab had a broken flange at the point where the faucet connected to the sink.

In an interview with Staff #43 on 7/23/2019 at 10:00 AM confirmed the above findings.

Based on observation,interview and record review the facility failed to develop a plan for identifying, reporting and investigating (potential) infections within the facility for 4 months, April, May, June, and July 2019, in 10 (Intensive Care Unit, Kitchen, Central Supply, Clean/dirty linen rooms, Main hospital Laboratory, Radiology, Emergency Department, Medical Surgical unit) of 13 services areas, Intensive Care unit, Kitchen and Physical Therapy.

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

Findings included.

On 7/22/2019 a review of the written "Infection Control Plan 2019" was conducted.

Found under the title (III Purpose, The purpose of the Navarro Regional Hospital Infection Control Plan is to use surveillance methodologies, prevention and control activities based on current guidelines and recommendations to identify, control, and minimize the spread of communicable and transmittable infections within the hospital while providing an optimum level of patient care. It is a comprehensive hospital-wide, interdisciplinary program for patients (inpatients and outpatient), healthcare workers, and visitors.)

The IC officer was asked for the program as well as the plan. She felt the program and plan were written together in the "Navarro Regional Hospital Infection Control Plan".

Further review of the IC Plan 2019 identified the following departments as participants in the IC plan.
Nursing
Dietary
Central Sterile
Environmental Services
Radiology,
Laboratory
Pharmacy
Respiratory Care
Facilities
Dialysis.

It was noted that Physical Therapy was not listed nor were the two outpatient Rural Health clinics (adult and Pediatric) or the out-patient Radiology service. The listing of "Environmental services failed to clarify if that included, the physical plant, emergency preparedness, waste management, linen/laundry services or housekeeping.

Further in the body of the IC Plan for 2019, found under (c. IC Responsibilities:
iii. Monitor the patient care staff work practices and their compliance with OSHA, CDC, state and local guidelines and regulations as they had (sic) been directed.)

Observed on 7/22/2019 during the initial tour of the facility, the ICU was toured and a patient in a private room was observed on a ventilator. On the outside of the door of the room, was an "isolation" sign, and the Personal Protective Equipment (PPE) Kit. The door was fully open. For a nurse to obtain the PPE it would be necessary for the nurse to enter the room prior to donning the PPE. The isolation order for the patient was contact isolation.

Further review of the IC Plan for 2019, found under (c. IC responsibilities
iv. Conducts hazardous surveillance rounds on a regular basis and reports findings to the director of the unit or department for corrective action if deemed necessary.)

On 7/24/2019 the IC office was asked how often environmental rounds were conducted she replied on a monthly basis. When asked if she had rounded in the kitchen she replied yes, she was aware of the build up of oils, under, between, and behind the heavy cooking appliances.

Kitchen:

1. Cobb webs collected behind the ice machine.
2. Heavy build up of oils below, between and behind heavy cooking appliances.
3. One bag of frozen breaded okra was observed open to the air in the freezer.
4. Four (4) gallon bottles of condiments (dressings) were expired.
5. Heavy rust visible on fryer vents.

The above observations were confirmed by the Dietary manager.

The dietary manager also confirmed there was no log of documentation for when the oil in the fryer was changes and the fryer cleaned.

The IC preventionist explained the kitchen was planning a remodeling to occur sometime in the future, no plan of action for immediate cleaning of the oil build up had been addressed in the IC program.


Further review of the IC Plan 2019, found at (VIII. Monitoring and evaluation of the IC Plan.
a. If a problem has been identified the IC Preventionist will consult with departments affected along with the Quality Department to develop a plan of action. Action plans will include conclusions, recommendations and action taken, with follow-up and re-evaluation noted. Assessment of all corrective action will be conducted following implementation. Conclusions will be developed after corrective actions have been in place long enough to result change. Follow-up will continue on a specific period of time to ensure resolution.)


Further discussion with the IC officer explained what she provided as the "IC Plan" was infarct the "IC Program". She, the facility, had no method (plan) documented explaining how the IC program would be carried out, who was responsible to carry the plan out other than the IC officer, how specifically would the plan be documented, when, specifically would it be reviewed, how would corrections be implemented, and addendums or additions to the plan be recorded, carried out and evaluated.

The facility could not provide documentation the present IC Plan for 2019 had been acted upon other than a risk analysis of diseases identified within the facility. The Infection documentation identified only nursing patient care related issues (Methicillin-resistant Staphylococcus Aureus, hand hygiene, Catheter Acquired Urinary Tract Infection, Surgical Site Infections, Central Line Associated Bloodstream Infections, ICU Ventilator Acquired Pneumonia.) No other department infection control risks were identified.

There were no evidence rounding was being carried out. There was no evidence IC problems in the kitchen, lab or ICU had been identified and acted upon.