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Based on observation and interview, it was determined that the facility failed to remove expired supplies in the Emergency Department from Emergency Carts and failed to perform daily checks on emergency carts.

Findings were:

Tour of the Emergency Department on 05/19/2015 revealed the following expired supplies:

ER Room Crash Cart: Easy Cap II C02 Detector, X 4 that expired 11/2014,
Cricothyroidotomy Catheter set expired on 04/2015, X 3 Pedi Yellow top blood laboratory tubes expired 3/2015.

Policy/Procedure, Equipment and Supplies in part states: "Maintaining Supplies- Materials Management maintains the supply inventory, replacing stock according to use (from patient charges) or by daily count. Materials Management counts and replaces non-chargeable supplies daily, Monday through Friday. All ED personnel have been oriented to Materials Management for the purpose of obtaining supplies during off-hours, should the need arise. Expiration dates on sterile supplies are checked by materials management on a monthly basis, but it is the responsibility of every employee working in the ED to notify Materials Management of any Supplies that are out of date and nearing the expiration date.
The above deficits were confirmed by the Emergency Manager on the morning during the tour of the Emergency Room, on May 19, 2015.

In addition the facility failed to maintain the accountability checklist of the Crash Cart.

· February 2015, the Crash Cart was not checked a total of 16 times on the PM shift on the following dates: 2/4, 2/5, 2/6, 2/7, 2/8, 2/12, 2/13, 2/15, 2/16, 2/17, 2/18, 2/19, 2/23, 2/24, 2/27, 2/27.
· March 2015, the Crash Cart was not checked a total of 11 times on the PM shift on the following dates: 3/4, 3/5, 3/14, 3/15, 3/18, 3/19, 3/22, 3/23, 3/24, 3/26, 3/31.
· April 2015, the Crash Cart was not checked a total of 14 times on the PM shift on the following dates: 4/4, 4/5, 4/6, 4/9, 4/10, 4/15, 4/18, 4/22, 4/23, 4/25, 4/26, 4/27, 4/28, 4/30.
· May 2015, the Crash Cart was not checked 3 times on the PM shift on the following dates: 5/10, 5/15, 5/16.

Crash Carts Policy/Procedure stated in part; Procedure # 3. "The crash cart will be checked each shift by nursing staff assigned to that unit who will sign the checklist provided. If department is closed, crash cart will not be checked until department reopens. Upon opening department, this will be one of the first tasks. Refer to individual Crash Cart Checklist."
In an interview with Staff # 6 Emergency Room Manager, acknowledged that the accountability of the crash cart was not done as per hospital policies.

The above findings were confirmed in an interview with the Chief Executive Officer and the Chief Operating Officer in an interview on the afternoon of 5/20/2015 in the facility conference room.

Based on a facility tour, review of documentation and staff interviews, the hospital failed to ensure that the hospital premises were clean, orderly and properly maintained.

Findings were:

During a tour of the labor and delivery area on 05/19/15, the following infection control issues were noted:

In the food storage area 18 external shipping boxes of Similac formula were observed stored on shelves. The external shipping boxes pose a hazard of introducing dirt, debris, pest, and otter contaminates into the area used for the storage of formula.

In the triage room, dust was observed on high horizontal surfaces, indicating ineffective cleaning of these areas.

In a pateint bathroom, rust was observed on the metal showerhead cord. Rust prevents effective cleaning of surfaces.

In the area near the Pyxis, 3 pieces of duct tape were observed ion the floor, creating a box shape. Tape prevents effective cleaning of the floor in this area.



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In the Radiology Department:
· The clean utility room contained shelves of uncovered patient linen along with other patient care supplies.
· The soiled utility room had what appeared to be the carcass of a dead insect.
· In an imaging room, there was an approximate 12 " x12 " area of raised tile flooring behind the CT scanner under which subfloor could be seen. This made cleaning difficult and posed a safety hazard.
· Dust was found on high horizontal surfaces in the CT scan room and in the ultrasound room.

In the OR Suite:
· In OR #1, there was an iPhone taped to the wall to provide music. The tape made cleaning difficult. There were several 2 " x3 " chips in the plaster of the OR wall which also made cleaning difficult.
· In OR #2, there were small chips in the wall plaster.
· In a patient restroom, a call light ended approximately 2 feet above the floor which made patient access difficult.

In the day surgery area, there was dust on high horizontal surfaces.

In the facility glycol circulating closet, there was a dead bug and soiled towel lying on the floor under equipment.

On a tour of the facility Affordable Care Clinic area on the morning of 5/20/15 with Staff #2, a thick layer of dark dust was observed on high horizontal surfaces. In the soiled utility closet, a mop bucket contained several inches of water in which a wet mop rested.

Facility policy entitled Standard Cleaning Procedures, no effective date, stated in part:
"Procedure:...High Dusting:
Proceed around the room tilting the high duster in the corners and dusting all horizontal surfaces (i.e., pictures, lights, cubicle curtain tracks, overbed lights, etc.) from the ceiling down to shoulder height..."

Facility policy entitled Cart and Equipment Daily Care, no effective date, stated in part:
"Procedure:
1. Remove all soiled rags, wet mops, and dust mops...
2. Empty soiled solution from mop bucket, rinse bucket and wringer with Clorox bleach solution..."

Facility policy entitled Standard Cleaning Procedure High Dusting, no effective date, stated in part:
"High dusting will be done in such a way as to minimize the release of dust particles in the air...
2. High dust all ledges and surfaces not reachable by normal damp wiping..."

The above findings were confirmed during the tours of the facility and in an interview with the facility Chief Executive Officer and Chief Operating Officer on the afternoon of 5/20/15 in the facility conference room.

Based on a facility tour, review of documentation and staff interviews, the hospital failed to ensure that refrigerators housing patient food items were maintained at an appropriate temperature.

Findings were:

A tour of the facility on the morning of 5/19/15 included the day surgery area of the hospital. A refrigerator containing items identified by Staff #2, Chief Operating Officer, as patient food items had a Refrigerator Temperature Log which had intermittent entries. For example, no temperature readings were documented for the May 2015 dates of: 5/1, 5/2, 5/3, 5/5, 5/7, 5/8, 5/9, 5/10, 5/12, 5/13, 5/15, 5/16, and 5/17.

On a tour of the Affordable Care Clinic area of the hospital on the afternoon of 5/20/15, a refrigerator in a small nourishment area was identified by Staff #2 as containing patient food items. It was also identified as shared by the clinic and the emergency department. The facility could provide no documented evidence of monitoring the refrigerator temperatures.

Facility policy entitled Patient Food Refrigerators/Freezers, last revised '13, stated in part:
"PURPOSE: ...To assure that refrigerators and freezers are clean, contents properly stored, and the temperature monitored ...5. Patient refrigerator/freezer temperatures are recorded by nursing or department personnel daily. An electronic thermometer with alarm may be used in lieu of daily recording..."

The above findings were confirmed with Staff #2 during the facility tours. They were again acknowledged in an interview with the Chief Executive Officer and Chief Operating Officer on the afternoon of 5/20/15 in the facility conference room.

Based on observation, interview, and record review, the facility failed to ensure a system for identifying, and controlling infections and communicable diseases. In the food and dietetic services department the following items were observed:
1. Food intended for patient use was not properly stored, labeled, and dated.
2. Adequate hand washing facilities were not available for use.
3. Chemicals removed from the original packaging are appropriately labeled.
4. Hair was not restrained while in food production areas.
In addition, hospital staff tuberculosis skin testing was not performed annually according to the facility policy.

Findings were:

Observations during the facility's kitchen tour on 5/18/15 from 9:05 AM to 10:15 AM revealed:

The hand washing sink in the dish room and the bakery sink did not have a functioning soap dispenser, and two hand washing sinks in the food production area did not have a functioning hand towel dispenser. Staff #5, the kitchen supervisor, stated the dispensers run on batteries and was not aware the batteries needed replacing.

There were multiple frozen meats and vegetables in the freezer removed from the original packaging that were not labeled or dated to ensure rotation. A package of corned beef in a plastic bag was observed to have white edges, indicative of freezer burn. The freezer floor contained food debris under the shelves.

In the refrigerated pass through there was a large pan of desserts that was not label or dated. The main walk-in refrigerator contained unlabeled grated cheese, corn, green salad, one opened container of liquid eggs did not contain an opened date, and the refrigerator did not contain an internal thermometer.

The floor drains in the salad production area and in the food tray line were black with food residue.

There was three dietary staff in the food production area wearing hair restraints that did not adequately cover their bangs.

In the main kitchen, two unlabeled plastic spray bottles contained an unidentified liquid. Staff #5, the kitchen supervisor, stated the facility had labels for all the chemicals used in the kitchen. She confirmed the bottles needed to be labeled.

Review of the facility provided Dress Code Personal Appearance Policy (revised 3/1/11) reflected: Food and Nutrition 6. Bouffant cap or hairnet provided by the hospital will be worn to cover hair.

Review of the facility provided Infection Control-Food and Nutrition Services- Cleaning and Sanitizing-Freezer (dated 10/20/08) reflected: Employees will clean ...walk-in freezer in the following manner: 6. Sweep walk-in freezer floor with broom.

During an interview on 5/20/15 in the dining room, staff #4 , the Dietician, stated there was not a specific policy for hand washing or the labeling and dating of food items and that she did not document her kitchen inspections. The Dietician confirmed the above findings during the Dietary tour.

In accordance with the Texas Food Establishment Rules:

§229.164(o) (5) (B) ... "refrigerated, ready-to-eat, potentially hazardous food prepared and packaged by a food processing plant shall be clearly marked using calendar dates, days of the week, color-coded marks, or other effective means, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in subparagraph (A) of this paragraph:

(i) the day the original container is opened in the food
establishment shall be counted as Day 1; and

(ii) the day or date marked by the food establishment may not
exceed a manufacturer ' s use-by date if the manufacturer determined the use-by date based on food safety.

§229.164 (r) Labeling.

(1) Food labels.

(A) Food packaged in a food establishment, shall be labeled as specified in
law, including 21 Code of Federal Regulations (CFR) 101, Food Labeling, 9 CFR 317, Labeling, Marking Devices, and Containers, and 9 CFR 381, Subpart N, Labeling and Containers.


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Review of employee records on the afternoon of 5/19/15 revealed the that five out of twenty employees did not have a have a current TB Skin Test as per hospital policy.

Staff # 6, last TB Skin Test was read on 4/30/14.
Staff # 29, last TB Skin Test was read on 3/31/14.
Staff # 9, did not have a TB Skin Test on file, skin test was administered on 5/19/15. Staff # 11 did not have a TB Skin Test on file; skin test was administered on 5/19/15.
Staff # 19 did not have a TB Skin Test on file; skin test was administered on 5/19/15

These deficits were confirmed by the Infection Control nurse on 5/19/15 and she acknowledged that TB Skin Test was done annually as per hospital policy.

All the above findings were confirmed with the Chief Executive Officer and Chief Operating Officer in an interview on the afternoon of 5/20/2015 in the facility conference room.