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Based on observation, record review and interview, the facility failed to have an effective governing body in that:

A) The hospital failed to have an effective discharge planning process in place for one of one patient (Patient #8). Patient #8 was admitted on 01/09/15 with suicidal ideation and a plan to jump off a bridge. On 01/19/15, the day of his discharge, Patient #8 was on suicide precautions. A safe discharge plan was not completed. Patient #8 was discharged and was left at a bus stop with directions to take an approximately 200 mile bus trip (www.bingmaps.com) to his place of residence. Patient #8 was found deceased under a bridge on 01/20/15, within 24 hours of discharge.
Cross refer to A-0806.

B) 5 of 10 Hemodialysis machines available for patient use on 1/28/15 (Hemodialysis Machine #170622, #170777, #168288, #171291 and #177424) did not have historical records of water quality testing (Microbiology: Cultures/bacterial growth and Endotoxins/LAL/presence of toxin released from gram negative organism);
Cross Reference to Tag A-0084.

C) 10 of 10 Hemodialysis machines available for patient use on 1/28/15 (Hemodialysis Machine #163657, #170777, #154979, #155243, #161400, #161524, #170622, #168288, #171291 and #177424) did not have historical records of being heat disinfected and bleached to prevent bacterial growth; and
Cross Reference to Tag A-0084.

D) 3 of 10 Hemodialysis machines available for patient use on 1/28/15 (Hemodialysis Machine #170777, #161524, and #168288) had expired electrical safety testing.
Cross Reference to Tag A-0084 and A-0724.

Based on record review and interview, the hospital failed to reappoint members of the active medical staff, in that 3 of 10 (Physician #84, Physician #85 and Certified Registered Nurse Anesthetist #86) credentialing files reviewed had expired appointments to the medical staff.


Findings:


The credentialing files for Physician #84, Physician #85 and CRNA #86 failed to have current appointments to the medical staff.


Physician #84's last appointment to the medical staff was dated 5/1/2012 through 5/1/2014.


Physician #85's last appointment to the medical staff was dated 10/1/2010 through 10/1/2012.


CRNA (Certified Registered Nurse Anesthetist) #86's last appointment to the medical staff was dated 2/1/2011 through 2/1/2013.


During an interview on 1/29/2015 at 1:00 PM in the conference room, Personnel #17 stated the expired appointments to the medical staff were discovered when the credentialing files were pulled for our review. Personnel #17 stated that there was no excuses, they were expired. When asked if the physicians and CRNA were actively seeing patients, Personnel #17 stated "Yes."

Based on observation, record review and interview, the facility failed to ensure contracted dialysis services were provided in a safe manner for all Hemodialysis patients, in that,

A) 5 of 10 Hemodialysis machines available for patient use on 1/28/15 (Hemodialysis Machine #170622, #170777, #168288, #171291 and #177424) did not have historical records of water quality testing (Microbiology: Cultures/bacterial growth and Endotoxins/LAL/presence of toxin released from gram negative organism);

B) 10 of 10 Hemodialysis machines available for patient use on 1/28/15 (Hemodialysis Machine #163657, #170777, #154979, #155243, #161400, #161524, #170622, #168288, #171291 and #177424) did not have historical records of being heat disinfected and bleached to prevent bacterial growth; and

C) 3 of 10 Hemodialysis machines available for patient use on 1/28/15 (Hemodialysis Machine #170777, #161524, and #168288) had expired electrical safety testing.

Findings Included:

A) During a tour of the fourth floor hemodialysis room with Personnel #9, #31, and #39 (Dialysis contract nurse) on 1/28/15 ending at 4:30 PM, it was observed and witnessed that 2 patients were having treatments. Patient #23 was having treatment on Hemodialysis Machine #163657 and Patient #32 was having treatment on Hemodialysis Machine #170777. The Hemodialysis Machine # 163657 and #170777 did not have historical records of water quality testing. The records for the remaining eight machines, Hemodialysis Machine #154979, #155243, #161400, #161524, #170622, #168288, #171291 and #177424 were reviewed and they did not have historical records of water quality testing.

During an interview in the lobby on 1/28/15 at 3:15 PM, Personnel #9 was asked if the dialysis treatments were provided through a contract and if yes, who the liaison was. Personnel #9 stated, "Yes (they are contracted), I am the hospital liaison for them."

During an interview in the hemodialysis water room on 1/28/15 at 3:45 PM, Personnel #39 was asked where the culture/endotoxin results for the machines were kept. Personnel #39 stated, "In the machine's book." Personnel #39 was asked if she had checked the hemodialysis machine's cultures/endotoxins prior to initiating treatments today. Personnel #39 stated, "I did not." Personnel #39 was informed there were no historical records of the water quality testing in the book for Hemodialysis Machine #163657 and #170777. Personnel #39 looked for herself and stated, "Oh." Personnel #9 called the Hemodialysis Management, Personnel #47, and the surveyor spoke to him.

Personnel #47 was informed that the facility did not have water quality records for the 10 machines available for patient use and was asked for the records to review. Personnel #47 stated, "Those machines are newly installed at that facility and our policy allows for us not to have the history." Personnel #47 was informed of the regulation and was afforded the opportunity to bring all water quality for the 10 hemodialysis machine records and the policies for review.

On 1/29/15 ending at 11:30 AM, the surveyor reviewed the water quality reports brought in by the contractor. Personnel #9 and #47 were present for the review and did not deny the findings.

The Hemodialysis Machine #170622's records did not document August and October 2014 results for cultures and endotoxins.

The Hemodialysis Machine #170777's records did not document August, October, November and December 2014 results for cultures and endotoxins.

The Hemodialysis Machine #168288's records did not document August, September, October, November and December 2014 results for cultures and endotoxins.

The Hemodialysis Machine #171291's records did not document October 2014 results for cultures and endotoxins.

The Hemodialysis Machine #177424's records did not document August, September, October, November and December 2014 results for cultures and endotoxins.

The September 2013, last revised "Dialysate Culture and Dialysate Endotoxin Testing Policy" required, "To confirm that the dialysate used for patient treatments meets or exceeds the current...standards for bacterial contamination...Routine dialysate cultures and dialysate endotoxin specimens are collected monthly..."

B) During a tour of the fourth floor hemodialysis room with Personnel #9, #31, and #39 on 1/28/15 ending at 4:30 PM, it was observed and witnessed that 2 patients were having treatments. Patient #23 was having treatment on Hemodialysis Machine #163657 and Patient #32 was having treatment on Hemodialysis Machine #170777. The Hemodialysis Machine #163657 and #170777 did not have historical records of being heat disinfected and bleached prior to 1/21/15 to prevent bacterial growth. The records for the eight remaining machines, Hemodialysis Machine #154979, #155243, #161400, #161524, #170622, #168288, #171291 and #177424 did not have historical records of being heat disinfected and bleached prior to 1/21/15 to prevent bacterial growth.

During an interview in the hemodialysis water room on 1/28/15 at 3:45 PM, Personnel #39 was asked where the records of the machines being heat disinfected and bleached were kept. Personnel #39 stated, "In the machine's book." Personnel #39 was asked if she had checked the hemodialysis machine's disinfection records prior to initiating treatments today. Personnel #39 stated, "I did not." Personnel #39 was informed there were no historical records of the machines being heat disinfected and bleached prior to 1/21/15 in the book for Hemodialysis Machine #163657 and #170777. Personnel #39 looked for herself and stated, "Oh." Personnel #9 called the Hemodialysis Management, Personnel #47, and the surveyor spoke to him.

Personnel #47 was informed the facility did not have records for the 10 machines available for patient use prior to 1/21/15 being heat disinfected and bleached. Personnel #47 was asked for the records to review. Personnel #47 stated, "Those machines are newly installed at that facility and our policy allows for us not to have the history." Personnel #47 was informed of the regulation and was afforded the opportunity to bring all records prior to 1/21/15 of being heat disinfected and bleached for the 10 hemodialysis machine records and policies for review.

On 1/29/15 ending at 11:30 AM, the surveyor reviewed the reports brought in by the contractor. The reports reviewed for the Hemodialysis Machines #163657, #170777, #154979, #155243, #161400, #161524, #170622, #168288, #171291 and #177424 did not indicate the machines had been heat disinfected and bleached prior to 1/21/15 to prevent bacterial growth. Personnel #9 and #47 were present for the review and did not deny the findings.

C) During a tour of the fourth floor hemodialysis room with Personnel #9, #31, and #39 on 1/28/15 ending at 4:30 PM, it was observed and witnessed that Patient #32 was having treatment on Hemodialysis Machine #170777. Hemodialysis machine #170777, #161524, and #168288 were available for patient use on 1/28/15 and had expired electrical safety testing.

During an interview in the Hemodialysis room on 1/28/15 at 3:30 PM, Personnel #9 was informed of the expired electrical safety testing for Hemodialysis machine #170777, #161524, and #168288. Personnel #9 looked and confirmed they were expired.

The September 2014, last revised "Preventative Maintenance Schedules for Equipment" policy required, "To provide guidance for...maintained in good working condition...equipment will have electrical safety checks performed...at least once per year...documentation will be kept on file...the results of the testing must be recorded..."

On 1/29/15 ending at 11:30 AM, the surveyor reviewed the electrical safety testing that had been completed the evening of 1/28/15 after the surveyor's findings were communicated. Personnel #9 and #47 were present.

Based on observation, record review, and interview, the hospital failed to ensure the director of food and dietetic services was responsible for the daily management of the dietary services in that:


1) Cooked to order items were not being temperature checked for 1 of 10 items (meatloaf) that was not heated to the minimum required safe temperature for serving, and


2) 34 days (November 8, 15, 16, 26, 30; December 20, 31; January 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27) of 89 days the Daily Hot Line Temperature Logs for breakfast, lunch, and dinner from November through January 2015 were missing from the dietary records.


Findings included:


1) The hospital's contracted dietary service's document entitled "HACCP (Hazard Analysis and Critical Control Points)/Food Safety Program" noted, "Cooking of Foods...155 degrees F...for 15 seconds: ground meats...Holding and Serving Foods, Hot Foods...Hot foods must be maintained at a minimum temperature of 140 degrees F or above while holding and serving. Product temperature must be recorded on a specified log at 2 hour intervals during holding and serving..."


During a tour of the dietary department on 1/27/15 at 1130, the cooked to order meatloaf was not heated to the minimum required safe temperature for serving. Personnel #18 was asked to check the temperature of the meatloaf being plated by Personnel #33. The temperature was 134 degrees F (Fahrenheit).


During an interview on 1/27/15 at 1135, Personnel #18 confirmed the internal temperature of the meatloaf was below the minimum correct temperature and had Employee #33 return the meatloaf to the grill for further cooking. The meatloaf internal temperature was rechecked at 175 degrees F, and then plated. Personnel #18 reflected that cook to order items "normally" do not have temperatures checked after cooking. He reflected that "90% of patient food was cooked to order."


(2) The hospital's contracted dietary service's document entitled "Your Request-Room Service Dining standards" noted, "...Each item held on the steam table will have a temperature recorded every two hours. Cook to order items will be spot checked daily and temperatures will be recorded on the HACCP form. Each cook to order item should have minimum of one temperature recorded per day..." HACCP Critical Control Points Daily Temperature Log revealed...Recommended Serving Temperatures**...Meat...145-165 degrees F...** To ensure hot...food at point of consumption..."


34 days of Daily Hot Line Temperatures from November through January 2015 were not available for review. They were as follows:


(a) For January 2015, 27 days (January 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27) of Hot Line Temperature Logs were not produced for review.


(b) For December 2014, 2 days (December 20, 31) of Hot Line Temperature Logs were not produced for review.


(c) For November 2014, 5 days (November 8, 15, 16, 26, 30) of Hot Line Temperature Logs were not produced for review.

Based on observation, record review and interview, the facility failed to ensure the Hemodialysis equipment was maintained at an acceptable level of safety and quality, in that,

3 of 10 Hemodialysis machines available for patient use on 1/28/15 (Hemodialysis Machine #170777, #161524, and #168288) had expired electrical safety testing.

Findings Included:

During a tour of the fourth floor hemodialysis room with Personnel #9, #31, and #39 on 1/28/15 ending at 4:30 PM, it was observed and witnessed that Patient #32 was having treatment on Hemodialysis Machine #170777. Hemodialysis machine #170777, #161524, and #168288 were available for patient use on 1/28/15 and had expired electrical safety testing.

During an interview in the Hemodialysis room on 1/28/15 at 3:30 PM, Personnel #9 was informed of the expired electrical safety testing for Hemodialysis machine #170777, #161524, and #168288. Personnel #9 looked and confirmed they were expired.

The September 2014, last revised "Preventative Maintenance Schedules for Equipment" policy required, "To provide guidance for...maintained in good working condition...equipment will have electrical safety checks performed...at least once per year...documentation will be kept on file...the results of the testing must be recorded..."

On 1/29/15 ending at 11:30 AM, the surveyor reviewed the electrical safety testing that had been completed the evening of 1/28/15 after the surveyor's findings were communicated. Personnel #9 and #47 were present.

Based on record review and interview, the hospital failed to have an effective discharge planning process in place. Patient #8 was admitted on 01/09/15 with suicidal ideation and a plan to jump off a bridge. On 01/19/15, the day of his discharge, Patient #8 was on suicide precautions. A discharge plan was left blank. Patient #8 was discharged and was left at a bus stop with directions to take a two-leg, approximately 200 mile, bus trip (www.bingmaps.com) to his place of residence. Patient #8 was found dead under a bridge on 01/20/15, within 24 hours of discharge.


Based on interviews and documents review, this facility does not have systems or processes in place to ensure effective and safe discharge of patients.


Refer to A 806

Based on record review and interview, the hospital discharge plan failed to include an evaluation of the patient's capacity for self-care for one of one patient (Patient #8). Patient #8 was admitted to inpatient psychiatric hospitalization with suicide plan to jump off a bridge. After ten days of treatment, Patient #8 was discharged on 01/19/15 and was left at a bus stop with directions to take a two-leg, approximately 200 mile, bus trip (www.bingmaps.com) to his place of residence. Patient #8 was on suicide precautions the morning of the day of discharge, 01/19/15. Patient #8 was found dead under a bridge on 01/20/15, within 24 hours of discharge.


Findings Included:


The Physician Discharge Summary noted an admission date of 01/09/15 and a discharge date of 01/19/15. Patient #8 was admitted and treated for Acute Exacerbation of Schizoaffective Disorder. He was suicidal and had planned to jump off a bridge. Discharge diagnoses included provisional Schizophrenia, Paranoid Type, Schizoid Personality, and Compliance Issues.


Patient #8's admission screening dated 01/09/15 at 02:25 noted that the patient was admitted with suicidal ideation. The patient had four previous hospitalizations and denied having followed through with discharge instructions. He was noted to lack insight into his illness. He had cut his wrist twice. He minimized his problems. Patient #8's risk factors included his severe anxiety.


On nine hospital days Nursing noted Patient #8's barriers to learning included the acuity of his illness and his difficulty concentrating.


Patient #8's pre-discharge suicide assessment dated 01/19/15 at 09:15 noted the patient was on suicide precautions. A discharge safety plan to be completed at that time was left blank.


Personnel #51 stated on 01/28/15 at 1500, that Patient #8 was discharged on 01/19/15 with a bus ticket from Sherman, TX to Longview, TX. The patient was to change bus in Dallas, TX. The patient was found dead under a bridge in Dallas, TX bridge.


Personnel #75 stated during an interview on 01/28/15 at 17:00, that Patient #8 was discharged and received detailed instructions to take the bus to Dallas,TX, wait at the terminal for a couple of hours, and take the bus to Longview, TX. Personnel #75 was "concerned that he [Patient #8] would not get off one bus and on the other one."


Personnel #76 stated on 01/29/15 at 11:30 that she took Patient #8 and Patient #36 to the bus stop on 01/19/15 at 1500. Personnel #76 stated she did not watch the patient enter the bus but left before the bus arrived.


Personnel #50 stated on 01/29/15 at 13:00 that an RCA (Root Cause Analysis) was initiated on 01/26/15 and conducted on 01/28/15. The RCA covered social worker notification of the clinical supervisor in case of discharge concerns and alternative modes of transport if needed. Administration drafted a transportation communication document to be reviewed with patients before discharge. Chart audits were planned.


Non-Hospital Personnel #98 was telephone interviewed on 02/03/15 at 11:40 and was asked whether Patient #8 was capable of taking a bus trip. Non-Hospital Personnel #98 stated, "No, he [Patient #8] would get off and not pay attention."


Non-Hospital Personnel #97 stated during a telephone interview on 02/03/15 at 12:45, that Patient #8 was identified by his finger prints on 01/21/15 after he was found dead in Dallas "...under one of those bridges that go over the Trinity River" on 01/20/15. Suicide was suspected.


Non-Hospital Personnel #99 stated on 02/03/15 at 16:30, that Dallas Police Officers found Patient #8 on 01/20/15. Non-Hospital Personnel #99 stated Patient #8 "fell or jumped" off the bridge.


Hospital Policy BHC II.8 dated 07/2013 reflected the purpose to "ensure that a patient is safe to discharge..."