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Based on observation and interview it was determined that the hospital failed to ensure that expired supplies were removed and thus not potentially available for use.

Findings were:
Expired supplies were found and thus potentially available for use. During a tour of the laboratory draw area an examination of the contents of a supply drawer revealed 8 each blue top specimen tubes were found, each of the tubes had an expiration date of 2019-08-31. Additionally, 9 each blue top specimen tubes were found, each with an expiration date of 2019-11-30. In an interview on the afternoon of 12/16/2019 with staff members #5 and #12 the finding was confirmed.

In the laboratory area, a wall mounted cabinet was found to contain 20 each 40ml BD Bactec Peds Plus Culture vials. The expiration date on each of the vials was 2019-10 -31. In the glass front reagent refrigerator, a box containing 6 each Beckman Coulter Access aLH calibrators, was found. The expiration date on the 6 calibrators was 2019-11-30. In an interview on the afternoon of 12/16/2019 with staff member #5 the above findings were confirmed.

An examination of the emergency crash cart located in the nursing station area revealed one each inline ATS Blood Bag, 600ml. The expiration date was listed as 2019/10. In an In an interview on the afternoon of 12/16/2019 with staff member #6 the above finding was confirmed.



29934

Based on observation, review of documentation and interviews with facility staff, the facility failed to ensure that supplies and medications used in treating emergency cases were properly maintained as expired supplies were found in the emergency department available for use in patient care which potentially could cause unsafe or ineffective supplies and medication to be used. Crash cart checks were not documented as having been performed on multiple dates. IV solutions were found in the warmer that were not dated as to when they were put in the warmer.

The findings were:

During a tour of the emergency department on the afternoon of 12/16/19, the following expired supplies and medications were found available for use:

1. Found in the adult crash cart: Solumedrol 125 mg vial, expired 11/19; Epinephrine, 1 mg/ml vial, expired 10/19; Zeroform, 4" x 4", expired 9/19; Yankauer suction tip, expired 1019.
2. Found in the ER Omnicell: Xylocaine 1%, 20 ml multiple dose vial, opened, partially used, and not dated when opened.
3. Found in the ER medication refrigerator: Diltiazem HCl injection, 25 mg/5 ml, 12 vials expired 8/19; Humalin R, 100 units/ml, 3 ml vial, opened, partially used and dated 10/29.
4. Found in the pediatric crash cart: Solumedrol 125 mg vial, expired 11/19.
5. Found in the ER clean utility room: Paracentesis tray, expired 7/19; Evacuated container, 1 liter, expired 7/19.
6. Found in the trauma room: Hydrogen peroxide 3%, 8 oz. bottle, 2 expired 10/19; Zeroform, 4" x 4", 2 expired 9/19, 5" x 9", 2 expired 9/19.
7. Found in the ER warmer: three one liter bags of 0.9% Sodium Chloride IV solution, not dated when put in warmer.

The facility form "Cardiac Monitor and Crash Cart Log" was reviewed for the ER Room 3A, ER Pediatric, and Trauma Room crash carts. The form reflected "Check Daily in the AM." The following dates did not have documentation that the crash carts were checked: 11/25/19, 12/2/19, and 12/12-14/19.

In an interview with the director of nursing, staff #4 during the tour on the afternoon of 12/16/19, staff #4 agreed the above listed supplies and medications were expired, that IV solutions were placed in the warmer undated and that crash cart checks were not done as noted above.

The facility policy entitled "Crash Carts: dated 7/18 reflected in part "Guidelines will be provided for securing emergency medications and related emergency items/equipment using a procedure that will assure all supplies are available, in date, accounted for, and in workable condition when needed. Procedure: 1. Crash carts will be checked regularly, at least once a month on the last week of the month or whenever the crash cart has been opened ...b. All medication that have been used or expired shall be restocked and 'in date', all equipment/supplies should be replaced if needed and in good working order prior to cart drawers being locked ...Responsibilities: On the last week of the month, pharmacy will review the crash cart binder for any drugs expiring by the end of the month. On the last working day of the month pharmacy will remove any expired medications and restock with new ones."

The facility policy entitled "Vials - Single/Multiple Dose" dated 5/16 reflected in part "If a multi-dose vial has been opened or accessed (e.g. needle punctured), it should be DATED and DISCARDED WITHIN 28 DAYS unless the manufacturer specifies different (shorter or longer) date for the opened vial."

The facility policy entitled "Inspection of Nurses Station - Monthly" dated 5/16 reflected in part "The Consultant Pharmacist will perform an inspection of the nurses station, emergency room and all other drug storage areas monthly. His inspection will be for neatness, cleanliness and expired medications."

A letter from Baxter Healthcare Corporation to the facility dated 12/4/19 reflected in part "Solutions for injection in Viaflex Plastic Containers with volumes of 150 ml or larger can be warmed in their plastic overwrap to temperatures: 1. Not exceeding 40 degrees C (104 degrees F) for a period of no longer than 14 days if greater than or equal to 3 months expiry remain on the product. Once the IV solutions in Viaflex Plastic Containers have been in the warming cabinet they should be identified as having been warmed and should be used within the 14 day warming period. If not used within the 14 day warming period the product should be discarded. The product should not be subsequently returned to room temperature storage or returned to the warmer."

Based on observation, review of documentation and interviews with facility staff, the facility failed to maintain the physical environment to ensure the safety of patients. The facility failed to maintain patient care equipment in safe operating condition as a piece of equipment was observed that did not have a recent biomedical inspection. An ER stretcher had a hole and cracks in the vinyl covering of the pad which made proper cleaning impossible. Laryngoscope blades were found unwrapped in the crash cart drawers and there was no evidence that they had been high level disinfected. The facility failed to properly store medications as expired medications were found in patient care areas available for use in patient care which potentially could have resulted in unsafe or ineffective medication being used. The facility failed to maintain a clean and orderly environment as instances of inadequate cleaning and improper storage of supplies were observed. Expired supplies were found in pateint care areas available for use.

The findings were:

Cross refer to:
C0222, CFR 485.623(b)(1), Maintenance
C0224, CFR 485.623(b)(3), Maintenance
C0225, CFR 485.623(b)(4), Maintenance

Based on observation and interview it was determined that the hospital failed to ensure that the building was properly maintained.

Findings were:
The building was not properly maintained.

During a tour of the hospital on the afternoon of 12/16/2019 the following observations were noted:
The soiled utility closet (adjacent to the kitchen) had a broken area on the ceiling measuring approximately 10"x3" and there was also an open circular area measuring approximately 8" in diameter. In an interview on the afternoon of 12/16/2019 with staff member #1 the finding was confirmed. Staff member #7 provided the surveyor with a document dated: Dec 17, 2019. This document listed maintenance items including: "Cover holes and paint in Janitors room next to (name of employee) office." "(Working on Est. 12/30/2019)."

In the kitchen area there was peeling paint observed above the microwave oven and there was a open metal pipe protruding from a wall, the pipe had a piece of tinfoil covering the opening, the tinfoil was noted to have a hole in it. In an interview on the afternoon of 12/16/2019 with staff member #2 the findings were confirmed. Staff member #7 provided the surveyor with a document dated: Dec 17, 2019. This document listed maintenance items including: "Kitchen paint pealing (sic)." "(Will paint Kitchen Est. 12/28/2019)."

In the dietary supply room the one of the ceiling mounted fluorescent light fixtures was not working. In an interview on the afternoon of 12/16/2019 with staff member #2 the finding were confirmed.

In patient room #111 (outpatient therapy room) there was chipped laminate on the edge of the counter top. The chipped area was approximately 2"x 1/4". In an interview on the afternoon of 12/16/2019 with staff members #2 and #7 the finding was confirmed.

The floor covering directly next to an exterior door to the "Patient Courtyard" area was cracked and split causing a potential safety and trip hazard for patients and staff. Staff member #7 informed the surveyor that the damaged floor covering was the result of flooding issues. In an interview with staff members #2 and #7 on the afternoon of 12/16/2019 the finding was confirmed. Staff member #7 provided the surveyor with an updated quote for the work on floor, the date of the updated quote was 12-17-19. In another interview with staff member #4 on the morning of 12/18/2019 the finding of the damage floor covering was confirmed.

Based on observation and interviews with facility staff, the facility failed to maintain patient care equipment in safe operating condition as a piece of equipment was observed that did not have a recent biomedical inspection. An ER stretcher had a hole and cracks in the vinyl covering of the pad which made proper cleaning impossible. Laryngoscope blades were found unwrapped in the crash cart drawers and there was no evidence that they had been high level disinfected.

The findings were:

During a tour of the facility on the afternoon of 12/16/19, a Burton ultraviolet exam light was observed in the eye box stored in the ER clean utility room that had a biomedical inspection sticker affixed which reflected the last biomedical inspection was done 6/17. The stretcher in ER cubicle 3A had a ¼" hole and numerous cracks in the vinyl covering of the pad at the foot of the stretcher exposing fabric below.

In the adult and pediatric crash carts, laryngoscope blades were observed unwrapped in plastic bins along the laryngoscope handles.

In an interview with the DON, staff #4 during the tour on the afternoon of 12/16/19, staff #4 acknowledged that the exam light had not had a biomedical inspection since 6/17 and the hole and cracks in the stretcher pad of the stretcher pad. Staff #4 acknowledged that the laryngoscope blades had not been high level disinfected and were unwrapped.

According to the CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC), laryngoscope blades are "semicritical" items, which are defined as, "Items that directly or indirectly contact mucous membranes of the respiratory tract. They should be sterilized or subjected to high-level disinfection before reuse ...After disinfection, proceed with appropriate rinsing, drying, and packaging, taking care not to contaminate the disinfected items in the process."

The facility policy entitled "Management of Clean Equipment" dated 8/18 reflected in part "V. Seni-critical equipment, those touching mucous membranes, such as laryngoscopes, endoscopes. Respiratory care and anesthesia equipment require high level of disinfection, with exposure time of >20 minutes."

Based on observation, review of documentation, and interviews with facility staff, the facility failed to properly store medications as expired medications were found in patient care areas available for use in patient care which potentially could have resulted in unsafe or ineffective medication being used.

The findings were:

During a tour of the facility on the afternoon of 12/16/19, the following expired medications were found available for use:

1. Found in the ER adult crash cart: Solumedrol 125 mg vial, expired 11/19; Epinephrine, 1 mg/ml vial, expired 10/19.
2. Found in the ER Omnicell: Xylocaine 1%, 20 ml multiple dose vial, opened, partially used, and not dated when opened.
3. Found in the ER medication refrigerator: Diltiazem HCl injection, 25 mg/5 ml, 12 vials expired 8/19; Humalin R, 100 units/ml, 3 ml vial, opened, partially used and dated 10/29.
4. Found in the ER pediatric crash cart: Solumedrol 125 mg vial, expired 11/19.
5. Found in the ER trauma room: Hydrogen peroxide 3%, 8 oz. bottle, 2 expired 10/19.

In an interview with the director of nursing, staff #4 during the tour on the afternoon of 12/16/19, staff #4 agreed the above listed medications were expired.

The facility policy entitled "Vials - Single/Multiple Dose" dated 5/16 reflected in part "If a multi-dose vial has been opened or accessed (e.g. needle punctured), it should be DATED and DISCARDED WITHIN 28 DAYS unless the manufacturer specifies different (shorter or longer) date for the opened vial."

The facility policy entitled "Inspection of Nurses Station - Monthly" dated 5/16 reflected in part "The Consultant Pharmacist will perform an inspection of the nurse's station, emergency room and all other drug storage areas monthly. His inspection will be for neatness, cleanliness and expired medications."

The facility policy entitled "Crash Carts: dated 7/18 reflected in part "Guidelines will be provided for securing emergency medications and related emergency items/equipment using a procedure that will assure all supplies are available, in date, accounted for, and in workable condition when needed. Procedure: 1. Crash carts will be checked regularly, at least once a month on the last week of the month or whenever the crash cart has been opened ...b. All medication that have been used or expired shall be restocked and 'in date', all equipment/supplies should be replaced if needed and in good working order prior to cart drawers being locked ...Responsibilities: On the last week of the month, pharmacy will review the crash cart binder for any drugs expiring by the end of the month. On the last working day of the month pharmacy will remove any expired medications and restock with new ones."

Based on observation and interview it was determined that the hospital failed to ensure that a sanitary environment was maintained.

Findings were:
A sanitary environment was not maintained.

The paraffin bath was not clean. During a tour on the afternoon of 12/16/2019, an inspection of the physical therapy area revealed a paraffin bath. The liquid wax in the paraffin bath contained what appeared to be small hairs and unidentifiable matter observed suspended in the wax. In an interview with staff member #8 on the afternoon of 12/16/2019 the above finding was confirmed.

Clean linen was not stored properly. During a tour of the afternoon of 12/16/2019, an inspection of the storage room of the hospital's speciality clinic revealed four bundles of clean linen sitting on the floor. The linen was wrapped in clean plastic type film. In an interview with staff member #4 on the afternoon of 12/16/2019 the surveyor was told that the bundles of clean linen should not have been placed on the floor of the storage room.


29934

Based on observation and interviews with facility staff, the facility failed to maintain a clean and orderly environment as instances of inadequate cleaning and improper storage of supplies were observed. Expired supplies were found in pateint care areas available for use.

The findings were:

During a tour of the facility on the afternoon of 12/16/19, the following observations were made.

In the ER, the stretchers in ER cubicles 3A, 3B and 2A had visible dust on the lower frame when the surveyor ran a finger on the surface of the frame. In the clean utility room in a cabinet under the sink with exposed plumbing pipes, 3 boxes of IV catheters were observed stored in the cabinet under the sink. In an interview with the DON, staff #4 during the tour on the afternoon of 12/16/19, staff #4 acknowledged that the dust on the stretcher frames and that the IV catheters were stored in a cabinet under a sink.

In the CT store room, 4 boxes of injector syringes were observed that were stored directly on the floor. In an interview with the QA coordinator, staff #2 during the tour on the afternoon of 12/16/19, staff #2 acknowledged that the boxes of injector syringes were stored directly on the floor.

The following expired supplies were found in patient care areas available for use:
1. Found in the adult crash cart: Zeroform, 4" x 4", expired 9/19; Yankauer suction tip, expired 1019.
2. Found in the ER clean utility room: Paracentesis tray, expired 7/19; Evacuated container, 1 liter, expired 7/19.
3. Found in the trauma room: Zeroform, 4" x 4", 2 expired 9/19, 5" x 9", 2 expired 9/19.

In an interview with the DON, staff #4 during the tour on the afternoon of 12/16/19, staff #4 acknowledged that the above supplies were expired.

From American Journal of Infection Control, Volume 28, Number 2, April 2000, APIC State-of-the-Art Report: The role of infection control during construction in health care facilities: "Cabinets: Areas beneath sinks should not be considered storage areas due to proximity to sanitary sewer connections and risk of leaks or water damage. Clean or sterile patient items should be not be placed beneath sanitary sewer pipe connections or stored with soiled items; cleaning materials are the only items acceptable to be stored under sinks, from a regulatory aspect."

The facility policy entitled "Management of Clean Equipment" dated 8/18 reflected in part "I. Clean equipment should be stored in clean storage area/room. Items should be stored off the floor."

Expired supplies were found and thus potentially available for use. During a tour of the laboratory draw area an examination of the contents of a supply drawer revealed 8 each blue top specimen tubes were found, each of the tubes had an expiration date of 2019-08-31. Additionally, 9 each blue top specimen tubes were found, each with an expiration date of 2019-11-30. In an interview on the afternoon of 12/16/2019 with staff members #5 and #9 the finding was confirmed.

In the laboratory area, a wall mounted cabinet was found to contain 20 each 40ml BD Bactec Peds Plus Culture vials. The expiration date on each of the vials was 2019-10 -31. In the glass front reagent refrigerator, a box containing 6 each Beckman Coulter Access aLH calibrators, was found. The expiration date on the 6 calibrators was 2019-11-30. In an interview on the afternoon of 12/16/2019 with staff member #5 the above findings were confirmed.

An examination of the emergency crash cart located in the nursing station area revealed one each inline ATS Blood Bag, 600ml. The expiration date was listed as 2019/10. In an interview on the afternoon of 12/16/2019 with staff member #6 the above finding was confirmed.

Based on review of documentation and interviews with facility staff, the facility's governing body failed to appoint, with the advice of the medical staff, the individual practitioners to the medical staff as the reappointment of an active staff physician, a physician's assistant, and a consultant neurologist were not approved by the governing body.

The findings were:

Credential files of 8 members of the medical staff were reviewed on 12/17/19 and 12/18/19. The files of physician, staff #17 and physician assistant, staff #18 and the medical staff committee minutes dated 1/29/19 reflected that staff #17 and #18 were reappointed to the active staff. The file of consultant physician, staff #23 and medical staff committee minutes dated 7/30/19 reflected that staff #23 was reappointed to the consulting medical staff. There was no evidence provided for review that the governing body approved the reappointment of staff #17, #18, and #23.

In an interview with the CFO, staff #1 on the afternoon of 12/17/19 in an office, staff #1 stated that the governing body minutes were checked and there was no documentation of the approval of the reappointment of staff #17 and #18 by the governing body. In another interview with the CFO, staff #1 on the morning of 12/18/19 in an office, staff #1 stated that the governing body minutes were checked and there was no documentation of the approval of the reappointment of staff #23 by the governing body.

The Medical Staff Bylaws dated 6/17 reflected in part "3.1.3 Appointment to the Medical Staff shall confer only such clinical privileges as have been granted by the Board of Directors in accordance with these Bylaws...7.1.1 The Board of Directors shall determine the clinical privileges granted to Members in accordance with the application procedure and based on written criteria established by the Board for granting clinical privileges set forth in these Bylaws. Every Practitioner practicing at this Hospital by virtue of Medical Staff membership or otherwise shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to the Practitioner by the Board pursuant to these Bylaws."

Based on review of documentation and interviews with facility staff, the facility failed to maintain patient records that contained consent forms as 2 of 10 inpatient and swing bed patient records reviewed did not contain consent forms resulting in incomplete records.

The findings were:

Electronic medical records were reviewed with the assistance of the director of nursing, staff #4 on 12/17/19. The medical records of swing bed patient #3 and inpatient #7 did not contain consent forms which included the permit for diagnosis and treatment, release of information and advance directive information. In an interview with staff #4 on the afternoon of 12/18/19, staff #4 confirmed that the above listed patient records did not contain consent forms.

The facility policy entitled "Flow of the Record" dated 6/15 reflected in part "The policy is to show the flow of the patient record and what should be included in patient records. Policy/Procedure: 1. The record begins in the admitting office at the time the patient presents for admission. The following information is entered into the computer, which shall be printed out as the Admissions Cover Sheet ...O. Other pertinent information, Advanced Directive information ...U. Signature sheet for Agreement to Pay, Permit for Diagnosis and Treatment/Assignment of Benefits/Release of Information."

Based on review of documentation and interview it was determined that the hospital failed to ensure that there was documentation of Quality Assurance activities.

Findings were:
The hospital failed to ensure that there was documentation of the previous year's Quality Assurance activities and documentation of some of the current Quality Assurance activities was not available.

1.) On 12/17/2019 when the surveyor asked to review the hospital's policy/procedure for Quality Assurance. Staff member #1 provided a document entitled: ""Process Improvement Plan Sutton County Hospital District Lillian Hudspeth Memorial Hospital." This plan was 9 pages and on the last page the signature dates were listed as 8-11-14 and 7/22/14. The area where the then CEO was to sign was blank. Staff member #1 stated that this was the most current QA plan available for review. Page 5 of the document stated under the "Process Improvement Committee Chairperson" section: "Conduct an annual departmental and organization-wide evaluation of the PI guidelines." In an interview on the morning of 12/18/2019 staff members #1 #2 confirmed that there was no documentation that an annual departmental and organization wide evaluation was done for 2018.

2.) Review of "Process Improvement Committee" meeting minutes for 2019 revealed that some information was not available for review. The "Process Improvement Committee" meeting minutes for January 29, 2019 stated on page two in the Nursing section: "See attached ER documentation and Attached Report." On the morning of 12/18/2019 when the surveyor asked to see the "Attached Report" staff member #2 stated that it was not available.

The "Process Improvement Committee" meeting minutes for September 24, 2019 stated on page one, item #7 "Nursing Report-work in progress." On the morning of 12/18/2019 when the surveyor asked to see the Nursing Report, staff member #2 stated that there was no documentation available for this report.

The "Process Improvement Committee" meeting minutes for October 29, 2019 stated on page one, item #8 "Infection Control Report--work in progress." On the morning of 12/18/2019 when the surveyor asked to see the Infection Control Report, staff member #2 stated that there was no documentation available for this report.

Continued review of the meeting minutes from October 29, 2019 revealed on page two: "16. Dietary- work in progress." "19. Plant Operations- new manager. Work in progress." "20. Housekeeping- new manager. Work in progress." "21. Wellness- work in progress." On the morning of 12/18/2019 when the surveyor asked to see the Dietary, Plant Operations, Housekeeping, and Wellness reports, staff member #2 stated that there was no documentation available for these.

The "Process Improvement Committee" meeting minutes for December 3, 2019 stated on page two, item #8 "Infection Control Report--work in progress." On the morning of 12/18/2019 when the surveyor asked to see the Infection Control Report, staff member #2 stated that there was no documentation available for this report.

Cross refer to:
CFR 485.641(a)(1) Periodic Evaluation
CFR 485.641(a)(1)(ii) Periodic Evaluation
CFR485.641(a)(2) Periodic Evaluation

Based on interview and documentation it was determined that the hospital failed to ensure that there was documentation that there had been a completed evaluation of the the hospital's total program for 2018.

Findings were:
There was no documentation that there had been a completed evaluation of the hospital's total program for 2018. The surveyor was informed in interview on the morning of 12/18/2019 by staff member #2 that: "The QA program is a work in progress." In the same interview staff members #1 and #2 confirmed that there was no documentation of a completed evaluation of the hospitals total program for 2018. On 12/17/2019 when the surveyor asked to review the hospital's policy/procedure for Quality Assurance. Staff member #1 provided a document entitled: ""Process Improvement Plan Sutton County Hospital District Lillian Hudspeth Memorial Hospital." This plan was 9 pages and on the last page the signature dates were listed as 8-11-14 and 7/22/14. The area where the then CEO was to sign was blank. Staff member #1 stated that this was the most current QA plan available for review. Page 5 of the document stated under the "Process Improvement Committee Chairperson" section: "Conduct an annual departmental and organization-wide evaluation of the PI guidelines."

Based on interview and documention it was determined that the hospital failed to ensure that there was documentation that there had been a representative sample of both active and closed clinical records for 2018.

Findings were:
There was no documentation found by or provided to the surveyor that there had been a representative sample of both active and closed clinical records for 2018. The surveyor was informed in interview on the morning of 12/18/2019 by staff member #2 that: "The QA program is a work in progress." In the same interview staff members #1 and #2 confirmed that there was no documentation of a representative sample of both active and closed clinical records for 2018. On 12/17/2019 when the surveyor asked to review the hospital's policy/procedure for Quality Assurance. Staff member #1 provided a document entitled: ""Process Improvement Plan Sutton County Hospital District Lillian Hudspeth Memorial Hospital." This plan was 9 pages and on the last page the signature dates were listed as 8-11-14 and 7/22/14. The area where the then CEO was to sign was blank. Staff member #1 stated that this was the most current QA plan available for review. Page 5 of the document stated under the "Process Improvement Committee Chairperson" section: "Conduct an annual departmental and organization-wide evaluation of the PI guidelines."

Based on interview and documention it was determined that the hospital failed to ensure that there was documentation available to determine if the results of the 2018 evaluation had been used to determine whether the utilization of services, and established policies were followed and if any changes were needed.

Findings were:
There was no documentation available to determine whether the utilization of services, established policies were followed and if any changes were needed following 2018. The surveyor was informed in interview on the morning of 12/18/2019 by staff member #2 that: "The QA program is a work in progress." In the same interview staff members #1 and #2 confirmed that there was no documentation of a completed evaluation of the hospitals total program for 2018. On 12/17/2019 when the surveyor asked to review the hospital's policy/procedure for Quality Assurance. Staff member #1 provided a document entitled: ""Process Improvement Plan Sutton County Hospital District Lillian Hudspeth Memorial Hospital." This plan was 9 pages and on the last page the signature dates were listed as 8-11-14 and 7/22/14. The area where the then CEO was to sign was blank. Staff member #1 stated that this was the most current QA plan available for review. Page 5 of the document stated under the "Process Improvement Committee Chairperson" section: "Conduct an annual departmental and organization-wide evaluation of the PI guidelines."

Based on review of documentation and interview it was determined that the hospital failed to ensure that fire drills were conducted according to policy.

Findings were:
Fire drills were not conducted according to the hospital's own policy. Documentation revealed that fire drills were typically held during the day shift and frequently around midday. Review of the "Sutton County Hospital District Incident Annex I Fire Safety Plan General Policy & Procedure" stated: "Simulated drills will be held at least once a month covering all shifts each quarter." Review of the Fire Drill Record" form revealed in the comments section: "(Note: Fire drills must be held at unexpected times, under varying conditions, evacuation of patients not required)."

Review of hospital the "Fire Drill Record" for January 2019 revealed that the drill was held on 1-9-2019 at 1330 hours.

Note: no documentation of a fire drill was found by or provided to the survey team for February 2019.

Review of hospital the "Fire Drill Record" for March 2019 revealed that the drill was held on 3-21-2019 at 0730 hours.

Review of hospital the "Fire Drill Record" for April 2019 revealed that the drill was held on 4-16-2019 at 1305 hours.

Review of hospital the "Fire Drill Record" for May 2019 revealed that the drill was held on 5-15-2019 at 1331 hours.

Review of hospital the "Fire Drill Record" for June 2019 revealed that the drill was held on 6-17-2019 at 1110 hours.

Review of hospital the "Fire Drill Record" for July 2019 revealed that the drill was held on 7-30-2019 at 1518 hours.

Review of hospital the "Fire Drill Record" for August 2019 revealed that the drill was held on 8-15-2019 at 1245 hours.

Review of hospital the "Fire Drill Record" for September 2019 revealed that there was no date documented as to when in September the drill had occurred or the time, as these areas were blank. Additionally, the area where who had conducted the drill was to be documented was also blank. Other areas on the form were found to be blank as well. A hand-written comment was found on the form stating: "(name of individual here) in Hospital for 3 weeks."

Review of hospital the "Fire Drill Record" for October 2019 revealed that the drill was held on 10-17-2019 at 1100 hours.

Review of hospital the "Fire Drill Record" for November 2019 revealed that the drill was held on 11-27-2019 at 1330 hours.

In an interview with staff member #2 on the morning of 12/17/2019 it was confirmed that the hospital fire drills were not done per hospital policy as there was no documentation of fire drills being conducted for the night shift staff. Staff member #2 added that the hospital utilizes 12 hours shifts which are 7am to 7pm and 7pm to 7am.