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Based on observation, interview, and record review, the Governing Body failed to ensure quality medical services were provided in a safe and effective manner that permitted the hospital to comply with all applicable rules and standards. The Governing Body allowed paramedics to function outside their scope of practice while providing patient care in an acute care hospital setting, citing 2 of 2 paramedic personnel (Personnel 20 & 21) who worked in the emergency department (ED) on 11/06/18.

Findings included:

A review of the ED record of Patient #4 reflected..."0930 ED IV (intravenous) Crew. Number of attempts: 2...Personnel #21 (paramedic) and...both unsuccessful..." the entry was electronically signed by Personnel #21 (Paramedic).

During a tour of the ED on 11/06/18 at 0945 Personnel #20 (paramedic) was assigned the role of Podium Medic.
Personnel #20's (paramedic) job description reflected "Job Title: Advanced Care Technician (Paramedic) Effective date 11/13/16, to provide care to patients at (hospital name) under the direction of the medical director. To perform support functions related to unit operations. To support and supplement the health care team in designated areas of the hospital...Essential Job Functions. Performs the following procedure with written order and supervision of a licensed physician: Administration of medication limited to: Antipyretics, Topical admixtures...PO (by mouth) miscellaneous medications...IV solutions without additives...Assists the RN (Registered Nurse) with IM (intramuscular) administration when dose must be divided. Obtain IO access in critical patient. Insertion of urethral bladder catheter, nasogastric catheter; wound cleansing and irritation. Application of sterile dressings and application and monitoring of oxygen...Performs the following procedures as ordered by physician and/or delegated by a registered nurse: Peripheral venipuncture, suture and staple removal, otic irrigations, enemas, immobilization of patients for procedures. Recognizes and reports appropriately basic arrhythmias. Can apply extremity splints, elastic bandages, fit and adjust crutches, and provide proper crutch walking technique. Collection, reporting and documentation of data (excluding initial and discharge)...Patient transport: Accompanies/monitors patients between emergency services and clinical areas. Accompanies/monitors patients during diagnostic/therapeutic procedures outside emergency services as deemed appropriate by the registered nurse...Screening: Demonstrates utilization of triage principles and/or problem solving abilities. Recognizes deviations from normal or baseline and reports changes to R.N. Uses professional judgment in the performance of job duties. Uses the nursing department chain of command for hospital related problems..."

The Bylaws of the Professional Staff of the hospital adopted October 2018 did not clarify or describe
EMT-Paramedics' duties and responsibilities were in the hospital setting.

The Podium Medic Initial Training undated and unreferenced reflected "Systematic & comprehensive approach to the initial assessment...Triage System...Level I (which is blue in color)...see patient immediately. Level II (which is red in color)...within 15 minutes. Level III (which is yellow in color)...within 30 minutes. Level IV (which is green in color)...Within 60 minutes. Level V (which is white in color)...Within 120 minutes..."

During a tour of the ED on 11/06/18 at 0945 Personnel #15 was asked what tasks the paramedics were allowed to perform in the ED. Personnel #15 stated the Paramedics can start an IV, insert a Foley catheter, place a nasogastric tube, draw labs, and fill the role of a Podium Medic. The Podium Medic was the first person that a patient would see. The medic would perform a quick assessment and then assign the patient a color based on their condition to let the triage nurse know which patient needed to be seen first.

Patient #4's medical record was reviewed on 11/06/18 in the ED. Patient #4's record reflected "0930 ED IV (intravenous) Crew. Number of attempts: 2...Personnel #21 (paramedic) and...both unsuccessful..." the entry was electronically signed by Personnel #21 (Paramedic). At 1005 Personnel #15 confirmed Personnel #20 had attempted to start an IV on Patient #4.

TITLE 22 EXAMING BOARDS, PART 9 TEXAS MEDICAL BOARD, CHAPTER 197 EMERGENCY MEDICAL SERVICE RULE 197.7 Physician Supervision of Emergency Medical Technician-Paramedic or Licensed Paramedic Care Provided in a Health Care Facility Setting (provide Advanced Life Support in the Facility)...Advanced life Support-Health care provided to sustain life in an emergency, life-threatening situation ...Direct Supervision-Supervision by a licensed physician who is present in the same area or an area adjacent to the area where an emergency medical technician-paramedic or licensed paramedic performs a procedure and who is immediately available to provide assistance and direction during performance of the procedure...a person who is certified as and EMT-P or a LP, is acting under the delegation and direct supervision of a licensed physician, and is authorized to provide advanced life support by a health care facility, may in accordance with HHSC rules provide advanced life support in the facility's emergency or urgent care clinical setting, including a hospital emergency room and a freestanding emergency care facility...The supervising physician may use protocols, which may include standing delegation orders. Such instructions may not be used in lieu of communication with the supervising physician or of obtaining the physician's physical assistance and direction during the performance of a procedure...The physician who delegates to and directly supervises advanced life support in a healthcare facility as authorized in this sections remains professionally and legally responsible for the patient care provided by the EMT-P or LP...The physician who delegates to and directly supervises an EMT-P or LP meets all requirements under the law related to creating and maintaining a medical record documenting the patient encounter...adopted to be effective April 3, 2016, 41 TexReg 2315.

The TX BON (Texas Board of Nursing) delegation rules view EMTs, Paramedics, or other similarly trained staff as "unlicensed assistive personnel" (UAP) when working in acute care settings, such as the ED.
https://www.bon.state.tx.us/faq_delegation.asp#t7-Paramedics/EMTs in the Emergency Department (ED)...Can a RN delegate starting a peripheral IV saline lock to an EMT/Paramedic in the Emergency Department (ED)? Some of the "techs" in our ED are "licensed paramedics" who also work for EMS. What other kinds of tasks can be delegated to Emergency Medical Technicians (EMTs)/Paramedics in the ED setting...The rules governing EMTs and Paramedics are located in Title 25, Texas Administrative Code, Section 157.2. This rule limits the scope of practice of EMTs/Paramedics to performing duties in the "pre-hospital and inter-facility transport" settings...Therefore, whether certified or licensed, the BON delegation rules view EMTs, Paramedics, or similarly trained staff as "unlicensed assistive personnel" (UAP) when working in acute care settings, such as the ED... The BON's delegation rule 224 is not prescriptive to specific procedures or tasks that may or may not be delegated. Rule 224 permits an RN to delegate starting a peripheral IV saline lock to an unlicensed person providing all of the delegation criteria are met...other laws outside of the BON's jurisdiction may prohibit performance of certain tasks by unlicensed personnel, even if a physician is willing to delegate a task."

TITLE 22 EXAMING BOARDS, PART 11 THEXAS BOARD OF NURSING, CHAPTER 224 DELECATION OF NURSING TASKS BY REGISTERED PROFESSIONAL NURSES TO UNLICENSED PERSONNEL FOR CLIENTS WITH ACUTE CONDITIONS OR IN ACUTE ENVIRONMENTS...Rule 224.8, "Delegation of Tasks...Discretionary Delegation Tasks...the following are nursing tasks that are not usually within the scope of sound professional nursing judgment to delegate...sterile procedures-those procedures involving a wound or an anatomical site which could potentially become infected...non-sterile procedures, such as dressing or cleansing penetrating wounds and deep burns...invasive procedures-inserting tubes in a body cavity or instilling or inserting substances into an indwelling tube; and care of broken skin other than minor abrasions or cuts generally classified as requiring only first aid treatment...Nursing Tasks Prohibited from Delegation By way of example, and not in limitation, the following are nursing tasks that are not within the scope of sound professional nursing judgment to delegate...physical. Psychological, and social assessments which requires professional nursing judgment, intervention, referral, or follow-up...formulation of the nursing care plan and evaluation of the client's response to the care rendered...the responsibility and accountability for client health teaching and health counseling (discharge instructions) which promotes client education and involves the client's significant others in accomplishing health goals; and administration of medications, including intravenous fluids, except by medication aides as permitted under 224.9 of this title (relating to the Medication Aide Permit Holder)..." and Rule 224.5, "RN Accountability for Delegated Tasks. The RN nurse administrator of the RN who is responsible for nursing services in settings that utilize RN delegation in clients with acute care conditions or acute care environments shall be responsible for knowing the requirements of this rule and for taking reasonable steps to assure that registered nurse delegation is implemented and conducted in compliance with the Texas Nursing Practice Act and this chapter..."

Based on observation, interview, and record review, the hospital staff failed to ensure patient's safety, citing 1 of 1 patient (Patient #34) in that, a syringe with blood and a vacutainer with a needle were placed on top of the bedside table next to Patient #34 on 11/05/18. This practice promoted high risk for blood exposure, cross-contamination, and needlestick exposure to patients and staff.

Findings included:

During a tour of the hospital's Intensive Care Unit (ICU) on 11/05/18 at 3:30 PM, the surveyor observed a Registered Nurse (RN) (Personnel #59) accessed Patient #34's central venous catheter (CVC) ports and aspirated blood from the port using a vacutainer and a syringe. Personnel #59 placed the syringe with blood and the vacutainer with a needle on top of the bedside table next to Patient #34 while Personnel #59 talked to Patient #34 and prepared Patient #34 for his treatment.

A review of the hospital's Bloodborne Pathogen Exposure Control Plan Policy and Procedure dated July 2018 reflected "...purpose...to prevent occupational exposure...Procedure...D. Handling of Contaminated Sharps...1. Sharps will be disposed of in sharps containers...E. Handling of Specimen...2. All procedures involving blood...a manner as to minimize splashing, spraying...3. Specimens of blood and body substances...are to be placed in a container to prevent leakage during...handling..."

This finding was confirmed in an interview with Personnel #59 on 11/05/18 at 3:40 PM.

Based on interview and record review, the physician did not complete a medical history and physical with 24 hours of admission, in that 1 of 3 patients (Patient #7) medical record did not have evidence that a medical history and physical exam was completed within 24 hours of admission.

Findings included:

Patient #7 was admitted through the emergency department to the behavioral health unit on 10/29/18 for suicidal ideation. The history and physical dated 10/30/18 at 8:29 AM in the medical record did not have a review of body systems and/or a physical examination. It stated "Completed in the emergency department on 10/29 and reviewed in the electronic medical record. This was completed by Dr..."

During an interview on 11/06/18 at 10:45 AM, Personnel #22 was informed of the findings and verified the findings. Personnel #23 stated because most of their patients were admitted through the emergency department they just referenced the emergency room physicians record as their medical history and physical, they do not complete a medical history and physical once they are admitted to the behavioral health unit.

Based on observation, interview, and record review, the hospital failed to make expired medication unavailable for patient use, in that on 11/05/18 one (1) of five (5) anesthesia carts inspected in the radiology area contained expired medication. This was not consistent with facility policy and potentially could have caused unsafe or ineffective medication to be used in patient care.

Findings included:

During a tour of the radiology area on the afternoon of 11/05/18, medication: Suprane 240 ml bottle (expired 08/18) was found in the CT (computed tomography) anesthesia cart.

In an interview with the anesthesia tech supervisor, Personnel #54 during the tour on 11/5/18 at approximately 2:40 PM, Personnel #54 agreed the above listed medication was expired.

The hospital policy entitled "Medication Storage" #PS173 dated 09/18 reflected in part "Expired, damaged, and/or contaminated medications in the medical center campus will be returned to the pharmacy."

Based on observation, interview, and record review, the hospital failed to provide adequate laboratory services as expired lab tubes available for patient use were found in 1 of 4 inspected phlebotomy carts on 11/05/18. This was not consistent with facility policy and potentially could have resulted in a specimen collected in an expired tube and to have to be re-drawn.

Findings included:

During a tour of the main lab on the afternoon of 11/5/18, the phlebotomy carts were inspected and one was found to contain 2 red top lab tubes in a drawer with the expiration date of 09/30/18. In an interview with phlebotomist, Personnel #53 and lab manager, Personnel #49 during the tour on 11/5/18 at approximately 12:05 PM, both Personnel #49 and #53 agreed that the two red top tubes were expired.

The hospital policy entitled "Specimen Center Material Acquisition and Management" dated 05/18 reflected in part "The laboratory performs an expired tube audit on all nursing units, OP/main lab storerooms and phlebotomy carts each month."

Based on observation, interview, and record review, the hospital failed to ensure the dietary department was in compliance with their established policies and procedures. The following was observed.

1) Twelve of 25 Full Hotel pans, and 2 of 24 muffin pans were stored wet and were stacked upon one another.
2) A dust mop and a dust pan were stored in the clean dry storage room.
3) Three of 3 used wet mops were observed leaning against a wall and pipes.
4) One of 7 walk-in refrigerators had plastic curtains that were in disrepair hanging from the doorway.
5) Control Monitor Temperatures for the high temperature warewashing machine, reflected 2 of 10 final rinse temperatures for breakfast dishes did not meet the minimum temperature requirements.

Findings included:

During a tour of the facility's kitchen at 11:00 AM on 11/06/18 the following was observed. Personnel #1, #31, #32, #33. #34, and #35 were present and verbally confirmed the findings below:

1) Pans on storage racks near the warewashing machine, were observed with dripping water and/or had water drops observed on the outside of the pans. The pans were separated and counted. Twelve of 25 Full Hotel pans, and 2 of 24 muffin pans were stored wet and were stacked upon one another.

The hospital's Food Contact Surfaces policy, dated 9/2017 reflected on page 2, "...All food contact surfaces are cleaned and sanitized daily after each use. This includes food prep tables and all food preparation equipment such as knives and slicers. Cooking and serving pans and utensils are to be stacked in manner that allows air drying..."

2) A used dust mop and a used dust pan were stored in the clean dry storage room. When discovered, staff removed them from the room.

The hospital's Infection Control Hospital Approved Agents and Practice policy dated 8/2003, reflected on page 1, "...Staff is trained and expected to maintain sanitation of cleaning equipment to avoid contamination. Staff should not leave mops, brooms, dustpans, or other cleaning equipment in an area other than the designated storage area of the kitchen..."

3) Three of 3 used wet mops were observed leaning against a wall and pipes with the handles resting in an enclosed drainage area. Adjacent to the area was a place to hang mops.

The hospital's Infection Control Hospital Approved Agents and Practice policy dated 8/2003, reflected on page 1, "...Staff is trained and expected to maintain sanitation of cleaning equipment to avoid contamination. Staff should not leave mops, brooms, dustpans, or other cleaning equipment in an area other than the designated storage area of the kitchen. Dirty mop heads should be stored in designated area..."

4) One of 7 walk-in refrigerators was observed to have plastic curtains that were in disrepair and hanging from the doorway. There were several tears in the curtains. Dirty duct tape was observed on one of the tears, in an attempt to repair it.

The hospital's Sanitizing and Maintenance of Equipment policy dated 8/2014 reflected on page 1, "...During the cleaning process, Food and Nutrition Services staff will check for any necessary repairs to the equipment. If the equipment is in need of repair, staff will contact a supervisor for communication to Facility Services..."

5) A review of the Control Monitor Temperatures for the high temperature warewashing machine, reflected during October, 21-27, 2018 the final rinse temperature for the breakfast dishes on October 23, was 178 degrees Fahrenheit. There was no documentation of corrective actions taken. A review of the temperatures for November, 4-6, 2018 reflected the final rinse temperature for the breakfast dishes on November 4, was 178 degrees Fahrenheit. There was no documentation of corrective actions taken.

The hospital's Dishwashing policy dated July, 2003 reflected the following on page 1, "...Dish machine temperatures are to be monitored and documented on the temperature log at least 3 times daily via the temperature gauge on the machine with the wash temperature reading 160 degrees or higher and the rinse temperature reading 180 degrees or higher. Should the temperatures be out of range, the diet aide will run a pan through the machine with a temperature strip attached and note on the action on the log. Should the inaccurate temperature continue, a supervisor should be notified to call maintenance with this also documented on the temperature log..."

Based on observation, interview, and record review, the hospital failed to properly maintain medical supplies as expired medical supplies were available for patient use in 2 of 5 anesthesia carts inspected in the radiology area on 11/05/18. This was not consistent with facility policy and potentially could have resulted in unsafe medical supplies being used in patient care.

Findings included:

During a tour of the radiology area on the afternoon of 11/05/18, the following expired supplies were found in anesthesia carts:

1) Found in the CT (computed tomography) anesthesia cart: IV catheter, 14-gauge x 1-1/4", 3 expired 3/18 and 2 expired 5/18; IV catheter, 18-gauge x 1-1/4", 3 expired 1/18 and 4 expired 9/18; blood collection set, 3 expired 7/18; arterial blood sampler, 2 expired 10/18 and 1 expired 7/18; and Microcuff endotracheal tube, 3 mm, expired 7/18.

2) Found in MRI (magnetic resonance imaging) induction room #5 anesthesia cart: IV catheter, 18-gauge x 1-1/4", 4 expired 9/18; oral tracheal tube, 7 mm, expired 10/17; and oral tracheal tube, 3.5 mm, expired 6/17.

In an interview with anesthesia tech supervisor, Personnel #54 during the tour on 11/05/18 at approximately 2:40 PM, Personnel #54 agreed the above listed medical supplies were expired.

The facility form entitled "DSC/DRC/MRI Expired Checklist" for September and October 2018 reflected that the anesthesia carts were checked as follows: "September 2018: Location: CT, Date: 9/7/18, October 2018: blank" and "September 2018: Location: MRI Scanner 1: Date: 9/4/18, October 2018: Date: 10/3/18."

The facility form "Environmental Safety Tour" reflected in part "Patient Care Specific Issues...39. Storage rooms...no expired supplies on hand."

The hospital policy entitled "General Infection Prevention and Control Policy" #IN01 dated 08/18 reflected in part "Staff are to check the item for package integrity and/or expiration date prior to use. Items with expiration dates are not to be used if the expiration date has passed."

Based on observation, interview, and record review, the hospital's infection control officer failed to identify infection control issues and/or implement policies governing infection control in that, the following was observed on 11/06/18 while following a tracer patient, Patient #1 in the operating room (OR):

1) 2 of 2 physicians (Physician #8 and #12) did not perform appropriate hand hygiene after taking off the gloves;

2) 1 of 2 physicians (Physician #8) did not properly wear the mask;

3) 1 of 3 healthcare providers (Personnel #14) did not completely restrained the hair; and

4) 1 of 1 physician (Physician #13) was observed carrying a black backpack on the shoulder and rolled a personal computer bag and in the restricted area.

Findings included:

1) On 11/06/18 a tracer patient, Patient #1 was followed to DSOR #1. At 8:49 AM, Physician #12 was observed starting an IV (intravenous) access on Patient #1 with gloves on. After completion of the IV start, Physician #12 took off the gloves and continued to provide direct patient care. Physician #12 did not perform hand hygiene after taking off the gloves. Then Physician #12 went to the computer and entered some data. At 8:53 AM, Physician #8 was observed taking off the gloves, and subsequently put on sterile gloves. Physician #8 did not perform hand hygiene after taking off the gloves and/or prior to putting on the sterile gloves. Physician #8 then wrapped Patient #1's head with a blue cloth.

2) At 8:53 AM, Physician #8 was observed wearing a mask that was tied losely that allowed venting.

3) At 8:55 AM, Personnel #14 was observed wearing a cloth bouffant that did not completely restrain the hair. Thick long strands of hair on the right side of the head was showing out of the cloth bouffant.

4) During a tour in the main surgical area, Physician #13 was observed carrying a black backpack on the shoulder and rolled a personal computer bag in the restricted area of surgery.

All the above observations were confirmed by Personnel #10 who was with the surveyor throughout the tour.

Hospital policy IN-15 "Hand Hygiene" issued 04/2017 required "III. Indications for hand hygiene...F. After removing gloves."

Hospital policy SS-003 "Attire: Surgical Services" issued 06/2017 required "B. Hair Covering: 1. Persons entering semi-restricted and restricted areas of surgery...should have maximal hair coverage...C. Mask...3. Masks should cover the nose and mouth completely...to prevent venting."

Hospital policy IN-01 "General Infection Prevention and Control Policy" issued 08/2018 required "VII Miscellaneous...I. Personal items such as...backpacks...briefcases should be restricted from sensitive areas such as operating room..."