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Based on observation, review of documentation, and interviews with facility staff, the facility failed to properly store supplies as expired medical supplies were found in five departments in the facility which could have resulted in potential unsafe or ineffective supplies being used in patient care.

The findings were:

During a tour of the facility on the afternoon of 5/15/17 accompanied by the facility chief executive officer, staff #1 and chief nursing officer, staff #2, expired medical supplies were found available for use in patient care in the following hospital areas:
Laboratory
" 23 red top lab tubes, expired 4/17
" 3 cream top lab tubes, expired 3/16
" 13 green top lab tubes, expired 10/2016
" 15 green top lab tubes, expired 9/2016
" 3 light blue top lab tubes, expired 4/17
" 2 light blue top lab tubes, expired 2/17
" 11 dark blue top lab tubes, expired 2/17
" Thin prep pap test, 6 bottles, expired 5/22/16
" Purell sanitizer 6 -4 oz. bottles, expired 2/17
" Sodium chloride irrigation, 250 ml., 1 opened bottle, expired 10/16
Respiratory Therapy Department
" Bacitracin ointment, 9 packets, expired 11/15
" Zinc ointment, 1 packet, expired 3/11
Radiology Department (respiratory supply box)
" 1 Yankauer suction, expired 11/14
Dietary Department refrigerator
" Glucerna, 1 can, expired 2/1/14
" Gerber sweet potato packages, expired

In an interview with facility chief executive officer, staff #1 and facility chief nursing officer, staff #2 during the tour on the afternoon of 5/15/17, Staff #1 and Staff #2 confirmed the expired medical supplies found in the laboratory and respiratory departments. In an interview with the radiology manager, staff #3 during the tour on the afternoon of 5/15/17, staff #3 agreed that the Yankauer suction was expired. In an interview with the dietary supervisor #38 during the tour on the afternoon of 5/15/17, staff #38 agreed with the expired food items found in the dietary department.

During a tour of the Emergency Department treatment room accompanied by staff LVN, #35 on the morning of 5/16/17, 3 Gen Probe culture containers were observed in the drawer which were expired 10/31/15, 11/30/16, and 4/30/17 available for patient use. In an interview with staff #35 during the tour on the morning of 5/6/17, staff #35 agreed with the findings.

Based on observation, review of documentation, and interviews with facility staff, the facility failed to maintain patient care equipment in safe operating condition as oxygen cylinders were observed that were not secured in any way which were a potential safety hazard if they tipped over. This was not consistent with facility policy.

The findings were:

During a tour of the facility on the afternoon of 5/15/17, three large oxygen cylinders were observed in the gas storage area that were not secured in any way. In an interview with the facilities manager, staff #39 during the tour on the afternoon of 5/15/17, staff #39 agreed that the oxygen cylinders were not secured.

The facility policy entitled "DME Equipment Storage" dated 5/09 reflected in part "Oxygen cylinders will be stored, secured in racks or cylinder stands, in a well-ventilated area, away from flammable products or open flames."

Based on observation, interviews with the staff, and review of documentation the critical access hospital failed to provide a sanitary environment as multiple areas in the facility were not clean and sanitary. The infection control coordinator failed to maintain a log of animal bites and assure that patient's animal bites were reported to the local health department. The policy for reporting animal bites was incomplete as the policy stated report of dog bites and did not state reporting to the infection control coordiinator. The dietary department was not clean. Two dietary staff did not have food handlers certification. There was no documentation available for review of infection control rounds in the dietary department. A LVN failed to wash her hands prior medication administration. Clean patient care supplies were stored under the sink with exposed plumbing. Ice cream bars were stored in the lab refrigerator with a sign stating Lab Specimens Only. 44 surgical instruments were observed that had been processed in the closed and clamped position available for patient use. Cardboard shipping boxes were observed stored in a cabinet with clean patient linens and clean medical supplies which could cause cross contamination from outside dirt on the shipping boxes. Clean patient linens were stored uncovered which could cause contamination from air borne dust and microbes. The facility also failed to store medications in accordance with accepted professional principles as intravenous contrast was stored in a warmer without dating when the contrast was put in the warmer and the warmer temperature was not documented.

The findings were:

Cross refer to:
C0276, CFR 485.635(a)(3)(iv), Patient Care Policies
C0278, CFR 485.635(a)(3)(vi), Patient Care Policies

Based on observation, review of documentation and interviews with facility staff, the facility failed to store medications in accordance with accepted professional principles as intravenous contrast was stored in a warmer without dating when the contrast was put in the warmer and the warmer temperature was not documented. This was not consistent with the manufacturer's product information and could potentially result in microbial growth in the warmed contrast if kept in the warmer beyond the recommended time.

The findings were:

During a tour of the Radiology Department on the afternoon of 5/15/17, a warmer containing seven 100 ml bottles of Visipaque intravenous contrast was observed in the CT room. The bottles of contrast were not dated as to when they were put in the warmer. There was no temperature log for the warmer.

In an interview with the radiology director, staff #3 during the tour on the afternoon of 5/15/17, staff #3 agreed that the bottles of contrast in the warmer were not dated as to when they were put in the warmer and that there was no temperature log for the warmer.

The Visipaque product insert reflected in part "Visipaque injection in all presentations may be stored in a contrast media warmer for up to one month at 37 degrees Celsius."

Based on observation, interviews with the staff, and review of documentation the critical access hospital failed to provide a sanitary environment as multiple areas in the facility were not clean and sanitary. The infection control coordinator failed to maintain a log of animal bites and assure that patient's animal bites were reported to the local health department. The policy for reporting animal bites was incomplete as the policy stated report of dog bites and did not state reporting to the infection control coordiinator. The dietary department was not clean. Two dietary staff did not have food handlers certification. There was no documentation available for review of infection control rounds in the dietary department. LVN failed to wash her hands prior medication administration. Clean patient care supplies were stored under the sink with exposed plumbing. Ice cream bars were stored in the lab refrigerator with a sign stating Lab Specimens Only. 44 surgical instruments were observed in the closed and clamped position available for patient use. Cardboard shipping boxes were observed stored in a cabinet with clean patient linens and clean medical supplies which could cause cross contamination from outside dirt on the shipping boxes. Clean patient linens were stored uncovered which could cause contamination from air borne dust and microbes.

Findings were:

During a tour of the dietary department on the afternoon of 5/15/17 accompanied by staff # 38 dietary supervisor, the following unsanitary conditions were observed: tray of glasses with tea and water uncovered available for patients; multi-cup tea container with tea was uncovered. Utensils were observed in metal drawers with greasy blackish debris appearing to be food particles. 3 black plastic melted serving spoons were observed in the drawer. A bucket with grayish colored water was observed under the manual dishwashing sink for a leaking pipe. In an interview with staff #38 she stated the leak had been reported to the maintenance department.

The handwashing sink where the dietary staff washed their hands contained brownish/blackish stains. Tile baseboards on the wall by the windows in dining area were cracked, exposing the sheet rock which did not connect to the floor exposing an opening for insects or rodents to enter. In an interview with staff #38 during the tour staff # 38 stated a heater was removed and repairs had not been made.

Blackish debris build-up was observed in the floor corners in the dietary department. Assorted food debris was observed on the floors and multiple slippery greasy areas. Multiple metal counter surfaces were observed with food crumbs and sticky to touch with yellowish greasy areas. Containers containing crackers, sugars, various condiments were observed to have spilled condiments, sugars, salt, and blackish debris, greasy to touch. The self-serving refrigerator shelves in the staff food area were dirty to touch. The above instances of inadequate sanitation provided a source of transmission of infections to staff and patients.

In an interview with staff #38 dietary manager on the afternoon of 5/15/17, staff # 38 said the department was cleaned every evening by the dietary staff. During an observation tour of tray preparation at 11:30 am 5/16/17 the dietary department was not clean.

During a tour of the dining area on 5/15/17 accompanied by staff #38 for staff and visitors the ice and water machine contained brownish, rusty colored build-up debris. Cabinet doors under the coffee, ice and water machines were peeling with loose edges protruding. A 4-5 inch broken area in the wall was observed in the staff serving area by the refrigerator. A tour of the food pantry revealed food crumbs, black debris on the floors. The back entry door was dirty with multiple blackish stains, greasy to touch and the bottom door sealant was loose. The floor was dirty with blackish, thick build-up. When the entry door was closed a 2-3 inch opening was observed allowing entry for insects and rodents. Staff #38 stated the wind constantly blows debris whenever the door is open.

During the entrance conference on the afternoon of 5/15/17 the surveyor requested documentation of infection control rounds performed in the dietary department. The surveyor requested documentation of dietary rounds again on 5/16/17 from the infection control coordinator staff #9 and again on the morning of 5/17/17. No documentation was given to the surveyor to review for verification of infection control surveillance in the dietary department.

During a tour of the facility on the afternoon of 5/15/17, a box of clean urine specimen containers were found in the cabinet under the sink with an exposed plumbing pipes in laboratory phlebotomy room. In an interview with the facility lab tech, staff # during the tour on the afternoon of 5/15/17, staff #1 confirmed the clean lab supplies were being stored in the cabinet under a sink with an exposed plumbing pipe.

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."

3 boxes of ice cream bars were observed in a laboratory refrigerator that had a sign which read "Lab Specimens Only." In an interview with facility chief executive officer, staff #1 during the tour on the afternoon of 5/15/17, staff #1 confirmed the food items in the refrigerator.

Review of the facility policy titled "Hansford County Hospital Laboratory Smoking Eating and Drinking in the Laboratory, Date Issued: 09-21-2005" stated in part "Eating, and or drinking, in the Laboratory work area is prohibited. No food or drinks will be stored in Laboratory refrigerators and/or freezers."

Review of dietary staff personnel files revealed 2 of 3 staff did not have food handlers certificates. This caused a potential for staff to handle food in an unsafe technique causing a potential for food-borne illness for patients and staff.

Texas Department of State Health Services September 1, 2016 Required Training Deadline: All employees who work with un-packaged food, food equipment or utensils or food-contact surfaces must be Food Handler Certified by September 1, 2016.

In an interview with staff #30 at the facility on the afternoon of 5/16/17, staff #30 agreed with the findings.

During observation of medication administration on the morning of 5/16/17 staff #35 LVN failed to wash her hands prior to administering medications. Staff # 35 was observe removing a pill from a medication container with her fingers. In an interview with staff #35 during the medication pass staff #35 agreed with the findings.

During a tour of the treatment room in the emergency department at 9:40 am accompanied by staff #35, 44 surgical instruments were observed in closed and clamped positions in sterile packets in a drawer in the ED treatment room available for patient use. In an interview with staff #35 during the tour of the emergency department on 5/16/17, staff # 35 agreed with the findings.

The Centers for Disease Control and Prevention (CDC) article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf, states "Once items are cleaned, dried, and inspected, those requiring sterilization must be wrapped or placed in rigid containers and should be arranged in instrument trays/baskets according to the guidelines provided by the AAMI that hinged instruments and instruments that close should be opened during the process of sterilization."

During a tour of room 103, a clean room ready for patient admission on 5/16/17 in the in-patient area accompanied by staff #35, black debris and hair was observed on the shower floor. In an interview with staff #38 during the tour staff #35 agreed with the findings.

Review of the clinical record of 2 of 2 patients (Patient #7, 22) presenting with an animal bite revealed no documented evidence that the animal bites were reported to the infection control coordinator.

Review of policy Treatment of Dog Bites, date issued 5/28/14 stated all dog bites should be placed on the emergency department record.

According to SUBCHAPTER E. REPORTS AND QUARANTINE Sec. 826.041.REPORTS OF RABIES. (a) A person who knows of an animal bite or scratch to an individual that the person could reasonably foresee as capable of transmitting rabies, or who knows of an animal that the person suspects is rabid, shall report the incident or animal to the local rabies control authority of the county or municipality in which the person lives, in which the animal is located, or in which the exposure occurs.(b) The report must include:(1) the name and address of the victim and of the animal's owner, if known; and (2) any other information that may help in locating the victim or animal.(c) The local rabies control authority shall investigate a report filed under this section. Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989. Amended by Acts 1995, 74th Leg., ch. 44, Sec. 7, eff; May 5, 1995. http://www.statutes.legis.state.tx.us/Docs/HS/htm/HS.826.htm

In an interview with the infection control coordinator at the CAH on the afternoon of 5/16/17, staff # 9 infection control coordinator said she has never reported animal bites.

During a tour of the facility on the afternoon of 5/15/17, a small cabinet was observed in the Radiology Department Ultrasound and Bone Density Room which contained clean patient linens, IV bags and contrast material. The cabinet also contained two cardboard boxes with shipping labels containing medical supplies which could potentially cause cross contamination of the linens and clean medical supplies in the cabinet from dirt brought in from the outside on the cardboard shipping boxes. In an interview with the radiology manager, staff #3 during the tour on the afternoon of 5/15/17, staff #3 agreed that cardboard shipping boxes were in the cabinet with clean linens and medical supplies.

During a tour of the offsite physical therapy department located at 717 W. 7th Street on the afternoon of 5/16/17, clean patient linens were observed that were stored uncovered on open shelves in treatment room #1 and in the traction room which potentially could cause contamination from airborne dust and microbes. In an interview with PT, staff #37 during the tour on the afternoon of 5/16/17, staff #37 agreed that clean patient linens were being stored uncovered on open shelves.

Based on review of documentation and interview with facility staff, the facility failed to ensure that swing bed patients were informed of their right to perform or refuse to perform services for the facility as review of 5 of 5 swing bed electronic medical records (EMRs), did not contain the right to refuse to perform services for the facility.

Findings were:

Review of 5 of 5 (#17, 18, 19, 20, and 21), swing bed patients' (EMRs), did not contain the right to refuse to perform services for the facility. In an interview on the morning of 5/17/17 the findings were confirmed by the chief nursing officer, staff #2 and swing bed coordinator, staff #9. In an interview on the morning of 5/17/17 in the facility conference room, staff #2 stated the facility did not have a separate patient rights document for the swing bed patients.

Review of the facility document titled "HANSFORD COUNTY HOSPITAL SWING BED PROGRAM ACKNOWLEDGEMENT FORM FOR RECEIPT OF PATIENT RIGHTS" stated in part "Upon admission to Hansford County Hospital Swing Bed program, I received, agree and understand the following information: Patient's Bill of Rights and Swing Bed Rights"

Review of the facility policy titled "Patient Rights, Hansford Hospital Swing Bed Department, Date Issued: 02/24/16" stated in part "It is the policy of Hansford Hospital to comply with the following: A. The facility will allow each patient to exercise the rights and pursue the interest described in these policies without restraint, interference, coercion, discrimination, or reprisal." The policy also stated in part "6. Work Activity A. The Swing Bed Program will not require a patient to perform services for the hospital."

Based on review of documentation, and interviews with facility staff, the facility failed to inform swing bed patients of the right to privacy of written communication, as review of 5 of 5 swing bed electronic medical records (EMRs), did not contain the right to privacy of written communication.

Findings were:

Review of 5 of 5 (#17, 18, 19, 20, and 21), swing bed patients' (EMRs), did not contain the right to privacy of written communication, to receive and send mail. In an interview on the morning of 5/17/17 the findings were confirmed by the chief nursing officer, staff #2 and swing bed coordinator, staff #9. In an interview on the morning of 5/17/17 in the facility conference room, staff #2 stated the facility did not have a separate patient rights document for the swing bed patients.

Review of the facility document titled "HANSFORD COUNTY HOSPITAL SWING BED PROGRAM ACKNOWLEDGEMENT FORM FOR RECEIPT OF PATIENT RIGHTS" stated in part "Upon admission to Hansford County Hospital Swing Bed program, I received, agree and understand the following information: Patient's Bill of Rights and Swing Bed Rights"

Review of the facility policy titled "Patient Rights, Hansford Hospital Swing Bed Department, Date Issued: 02/24/16" stated in part "It is the policy of Hansford Hospital to comply with the following: A. The facility will allow each patient to exercise the rights and pursue the interest described in these policies without restraint, interference, coercion, discrimination, or reprisal." The policy also stated in part " 9. Mail A. The hospital will not open or read a patient's incoming or outgoing mail without written permission."

Based on review of documentation, and interview with facility staff, the facility failed to inform swing bed patients of the right to retain personal property as review of 5 of 5 swing bed patient electronic medical records (EMRs), did not contain the right to use personal property.

Findings were:

Review of 5 of 5 (#17, 18, 19, 20, and 21), swing bed patients' EMRs, did not contain the right to retain personal property. In an interview on the morning of 5/17/17 the findings were confirmed by the chief nursing officer, staff #2 and swing bed coordinator, staff #9. In an interview on the morning of 5/17/17 in the facility conference room, staff #2 stated the facility did not have a separate patient rights document for the swing bed patients.

Review of the facility document titled "HANSFORD COUNTY HOSPITAL SWING BED PROGRAM ACKNOWLEDGEMENT FORM FOR RECEIPT OF PATIENT RIGHTS" stated in part "Upon admission to Hansford County Hospital Swing Bed program, I received, agree and understand the following information: Patient's Bill of Rights and Swing Bed Rights"

Review of the facility policy titled "Patient Rights, Hansford Hospital Swing Bed Department, Date Issued: 02/24/16" stated in part "It is the policy of Hansford Hospital to comply with the following: A. The facility will allow each patient to exercise the rights and pursue the interest described in these policies without restraint, interference, coercion, discrimination, or reprisal." The policy also stated in part "8. Property A. The hospital will permit each patient to maintain and use his personal property."

Based on review of documentation, and interview with facility staff, the facility failed to inform swing bed patients of the rights of married couples as review of 5 of 5 swing bed patient electronic medical records (EMRs), did not contain rights of married couples.

Findings were:

Review of 5 of 5 (#17, 18, 19, 20, and 21), swing bed patients' EMRs did not contain the rights of married couples. In an interview on the morning of 5/17/17 the findings were confirmed by the chief nursing officer, staff #2 and swing bed coordinator, staff #9. In an interview on the morning of 5/17/17 in the facility conference room, staff #2 stated the facility did not have a separate patient rights document for the swing bed patients.

Review of the facility document titled "HANSFORD COUNTY HOSPITAL SWING BED PROGRAM ACKNOWLEDGEMENT FORM FOR RECEIPT OF PATIENT RIGHTS" stated in part "Upon admission to Hansford County Hospital Swing Bed program, I received, agree and understand the following information: Patient's Bill of Rights and Swing Bed Rights"

Review of the facility policy titled "Patient Rights, Hansford Hospital Swing Bed Department, Date Issued: 02/24/16" stated in part "It is the policy of Hansford Hospital to comply with the following: A. The facility will allow each patient to exercise the rights and pursue the interest described in these policies without restraint, interference, coercion, discrimination, or reprisal." The policy also stated in part "6. Work Activity A. The Swing Bed Program will not require a patient to perform services for the hospital. 8. Property A. The hospital will permit each patient to maintain and use his personal property. 9. Mail A. The hospital will not open or read a patient's incoming or outgoing mail without written permission."

Based on observation and interviews with the CNO staff #2 the CAH failed to post the rights of patients in a visible, noticeable, and in languages that are served by the population for patients in the emergency department. There was no signs in the entrance, waiting room, or treatment rooms in the emergency department.

Findings were:

During a tour of the emergency department accompanied by staff # 35 on the morning of 5/16/17 there were no signage of patients' rights in visible and language served by the population for the patients in this area. Patients rights was not posted in the entrance area to the emergency department, waiting room, or the treatment rooms. Staff # 35 agreed with the findings during the tour.

In an interview with the CNO staff #2 in the conference room on the morning of 5/16/17, staff#2 stated the patients' rights were posted in the emergency room and all patients were given copies of their rights. 2 surveyors re-visited the emergency department. The patients rights were observed in a glass showcase on the wall in the hall across from one of the treatment rooms in the emergency department. The patients rights were in English on 8 X 11 inch size paper in 12 point font and the bottom 3" of the form was not visible due to the frame of the case. The number for patients to notify the state departments if they had complaints was not visible.