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Based on records review and interviews, the facility failed to ensure that all patients received their patient's right including information regarding whom to contact within the facility to file a grievance. Citing 6 (#1, #4, #5, #7, #9 and #22) of 12 inpatient medical records reviewed on the medical unit. This deficient practice has the potential for patient complaints and grievance to not have appropriate follow up.

Findings:

Review of patient medical record #1, #4, #5, #7, #9 and #22 revealed no evidence that these patients received a copy of "Patient Rights and Responsibilities" that informed them who to contact within the facility to file a grievance. The facility had a blank on the form to initial if they received a copy of the patient ' s rights including how to file a grievance and information concerning advanced directive.

During an interview on 05/09/2013 at 2:15 p.m. in the conference room of the facility, staff # 29 confirmed there was no evidence the facility provided the above required information.

Based on records review and interviews, the facility failed to ensure that all patients received their patient's right including information regarding their right to receive information on advanced directives. Citing 6 (#1, #4, #5, #7, #9 and #22) of 12 inpatient medical records reviewed on the medical unit. This deficient practice has the potential for patient complaints and grievance to not have appropriate follow up.

Findings:

See Tag 118 for details

Based on observation, interview and record review the facility failed to develop and keep a current plan addressing skin breakdown in 1 (#23) of 33 charts reviewed.
This deficient practice had the potential to affect all 10 patients in the Intensive Care Unit (ICU).
Findings include:
During an observation on 05/08/13 at 2:05 p.m., Patient #23 was found to have a closed dark red pressure sore to the coccyx, left flank with red excoriation, and an open Stage III pressure sore to the left heel. Staff #42 removed a dressing off the left heel, cleansed the pressure sore with normal saline and applied a clean dressing.
Review of the policy "Skin Integrity, Management of " dated 04/13/13 revealed the following:
"The Physician and /or Physical Therapist should be consulted on Stage II, Stage III, Stage IV,or Suspected Deep Tissue Injury."
Review of physician orders revealed Patient #23 was a 77 year old male admitted to ICU on 05/06/13 with a diagnosis of right lower lobe pneumonia.
Review of an "ICU Assessment" dated 05/06/13 revealed Patient #3 had a 2 x 2.5cm Stage III ulcer to the left heel, two small 1.5 x 1.5 centimeter (cm) on coccyx, 1 x .50 cm red spot on the coccyx, and excoriated skin on the left abdomen. Treatments were provided to the skin breakdown.
Review of the admit physician orders dated 05/06/13 revealed treatment orders for the left flank, but there were no orders for the coccyx and left heel.
Review of the "Patient Care Management Profile" initiated 05/06/13 revealed no care plan addressing how often skin treatments were to be performed.
During an interview on 05/08/13 at 12:15 p.m., Staff #42 reported they were cleansing the left heel with saline soaked gauze and covering it with a sterile dressing. She could not find a physician order for the treatment. Staff #42 reported they were not using a skin treatment protocol.
During an interview on 05/08/13 at 2:27 p.m., Staff #29 confirmed there was no care plan or documentation of treatments provided. She confirmed the first physician order received for treatment was just written for the left heel on 05/08/13 at 12:30 p.m.

Based on record review and interview the facility failed to ensure that non-employee nurses (agency) were provided job descriptions, that licensure, work history and background checks were reviewed and competences, including CPR, were validated by the hospital staff. Citing 6 (30, 31, 32, 33, 34 and 35) out of 6 (30, 31, 32, 33, 34, and 35) agency nurses personnel records reviewed. These deficient practices have the potential to cause harm to all patients receiving care within the hospital by failure to ensure nurses were qualified to work at the facility.

Findings:

Review of agency personnel records for nurses #30, 31, 32, 33, 34, and 35 on 05/08/2013, revealed they did not contain evidence of a signed job description and application. Nurses # 32, 33, 34 and 35 did not have evidence of a background check.

Review of agency staff record # 30, 31, 33, and 34 did not have evidence that hospital staff had validated their competencies. Staff # 30, 32, and 25 did not have evidence of CPR training.

Interview with staff # 29 on 05/08/2013 at 2013 confirmed the facility did not have evidence of the above findings.

Based on interview and record review the facility failed to ensure physician progress notes were timed in 4 (#4, #6, #9 and #26) of 33 charts reviewed.
This deficient practice had the potential to affect all in-patients and patients presenting to the hospital.
Findings include:

Review of the following charts revealed physician progress notes that were not timed:
*Patient #4, progress notes dated 05/06 and 05/07/13;
*Patient #6, progress notes dated 05/03, 05/04, 05/05, and 05/06/13;
*Patient #9, progress notes dated 04/29, 04/30, 05/01, 05/02, 05/03, 05/04, 05/05, 05/06, and 05/07;
*Patient #26, progress notes dated 05/08/13.
During interviews on 05/07/13 at 2:55 p.m., Staff #41 and 05/08/13 at 10:00 a.m. Staff #29 confirmed the physician progress notes were not timed.

Based on interview and record review the facility failed to ensure physician orders were timed in 7 ( #4, #6, #7, #8, #9, #23 and #26) of 33 charts reviewed.
This deficient practice had the potential to affect all in-patients and patients presenting to the hospital.
Findings include:
Review of the following charts revealed physician orders were not timed:
*Patient #4, orders dated 05/06 and 05/07/13;
*Patient #6, orders dated 05/03/13;
*Patient #7, orders dated 05/02 and 05/04/13;
*Patient #8, orders dated 05/05 and 05/06/13;
*Patient #9, orders dated 04/29, 04/30, 05/02, 05/03, 05/04, and 05/06/13;
*Patient #23, orders dated 05/06, 05/07, and 05/08;
*Patient #26, orders dated 05/08/13.
During interviews on 05/07/13 at 2:55 p.m., Staff #41 and 05/08/13 at 10:00 a.m. Staff #29 confirmed the physician orders were not timed.

Based on observation and interview the facility failed to ensure anesthesia carts containing drugs and biological's were stored in a secure area and locked to prevent unmonitored access by unauthorized individuals.

During a tour of the surgical department on 05/07/2013 at 1:30 PM with staff #25 the following was observed:

The anesthesia cart in the cystoscopy room contained medication and supplies for anesthesia staff to sedate patients during surgery. The cart was unlocked and medication was being stored on top. The door to the cystoscopy room was also unlocked and surgical cases for this one room had been completed per the operating room schedule for 05/07/2013.

The anesthesia cart in the obstetrics room contained medication and supplies for anesthesia staff to sedate patients during surgery. The cart was unlocked and medication was being stored on top. There were no surgical cases scheduled for the obstetrics room per the operating room schedule for 05/07/2013.

Review of American Society of Anesthesiologist (ASA) "Statement on Security of Medications in the Operating Room" (Approved by the ASA Executive Committee in October 2003, and reaffirmed by the ASA House of Delegates on October 17, 2012 revealed the following:

"Preamble: A secure environment of care is needed for medication safety. Medication safety includes the security of oral, sublingual, parenteral, and inhaled drugs used for elective and emergency patient care. A secure are ensures the integrity of anesthesia machines as well as other equipment and materials. Security of medications in the operating room suite is essential for patient safety.

Recommended Policies:

1. Access to operating room suites must be strictly limited to authorized persons.
2. All schedule 3 and 4 narcotic medications must be kept locked enclosed area when not under the direct control of an anesthesia professional.
3. Anesthesia professional must have immediate access to drugs required for emergency patient care. Procedures designed to prevent unauthorized access to such suite.
4. Anesthesia carts and anesthesia machines may remain unlocked, and non-controlled medications may be left in or on top of unlocked anesthesia carts or anesthesia machines immediately prior to, during, and immediately following surgical cases in an operating room, so long as there are authorized operating room personnel in the OR."


An interview with staff #25 on 05/07/2013 at 1:30 PM confirmed the findings of the anesthesia carts unlocked.

Based on observation and interview, the facility failed to:
A. ensure medication carts, pills crushers, linen rooms were kept sanitary, and the biohazard waste was stored in secure area on (Dietary Department, Emergency Department (ED), MedSurg (MS) I, MedSurg (MS) II, Obstetrics (OB), and Intermediate Care (IMC) ) of 7 units.
During an observation on 05/07/13 the following was found:
*At 8:53 a.m. a pill crusher on Medical- Surgical unit II had a buildup of dried spills and debri.
*At 9:08 a.m. inside drawers and the outside of two medication carts on Medical-Surgical unit II were heavily soiled and with a buildup of dried spills. The clear tape used to hold the identification numbers on the drawers had a buildup of brown substance. Medications were stored in the drawers.
*At 9:37 a.m. the inside drawers and the outside of the medication cart on the Intermediate care unit was soiled with dried spills. Medications were stored in the drawers.
*At 9:52 a.m. the intravenous antibiotics were found stored in open plastic bins in the medication room on Medical-surgical unit I. The plastic bins were soiled with dried spills.
* At 10:01 a.m. inside drawers and the outside of a medication cart on Medical-Surgical unit I was heavily soiled and with a buildup of dried spills. Medications were stored in the drawers.
* At 10:30 a.m., two boxes of normal saline irrigation were stored on the floor in Room #220.
*At 11:02 a.m., Staff #38 (RN) nurse was sitting at the nurses' station with a patient's respiratory inhalers in a plastic zip up bag. During an interview she reported this was her own personal bag. After she administers the inhalers she places them back into the bag.
*At 11:05 a.m. the clean linen cart on the Obstetrics unit (OB) had the covering pulled back and was stored in a room with used intravenous pumps, boxes, beds and carts.
*At 12:42 p.m. two large biohazard containers were stored in the open nursing station on the OB unit. One contained used intravenous bags, tubing and gloves and the other container was filled with medication vials and sharps to the top.
The medication cart on the OB unit had a buildup of dried spills on the inside drawers.


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B. provide sanitary storage for scope irrigation tubing in the gastroenterology lab (GI).

During a tour of the GI lab on 05/08/2013 at approximately 2:00 PM with staff #37, observed irrigation tubing that connects to the scopes hanging on the oxygen outlet on the wall in the procedure room. Questioned staff #37 was the irrigation tubing clean? Staff #37 stated "yes." The tubing was within the splatter reach of a patient having a procedure, which could potentially cause a risk for infection.

An interview with staff #37 on 05/08/2013 at 2:30 PM confirmed the clean scope irrigation tubing was hanging on the oxygen outlet in the procedure room, while a procedure was being performed.


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C. ensure storage of supplies to protect from cross contamination.
While touring the facility on 5/6/2013 at 2:00 pm and on 5/10/2013 at 10:00 am the following observations were made.
* Wire racks used for storage of non-perishable food items, paper good, and/or cooking utensils in the dietary department were stored on the bottom shelf of wire racks without a barrier to protect from possible contamination.
*Wire racks used for storage of sterile and/or non-sterile patient care supplies in the emergency department storage area were stored on the bottom shelf of wire racks without a barrier to protect from possible contamination.

* Wire racks used for storage of sterile items used for patient care in the surgical suite storage area were stored on the bottom shelf of wire racks without a barrier to protect from possible contamination.

Interview with staff # 23, #25, and #28 confirmed the findings on 5/10/2013 at 10:20 am.


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D. ensure that non-employee nurses (agency) were required to provide proof of immunizations as required by hospital policy. Citing 4 (30, 33, 34 and 35) out of 6 (30, 31, 32, 33, 34, and 35) agency nurses personnel records reviewed. These deficient practices have the potential to cause harm to all non-immune patients' staff at in the hospital by failure to ensure nurses were immunized as required.

Review of facility policy titled "Protect Patients from Exposure to Vaccine preventable Diseases" requires staff to provide evidence of immunizations for 2. Measles, 3. Mumps, Rubella 5. Varicella (a highly infectious disease cause by a varicella-zoster virus) 6. Pertussis. Responsibility A. 1. Verify documentation of vaccination or immunity, 2. Provide exemptions forms, and 3. Provide evidence of immunity or vaccination to Employee Health Nurse." In addition the hospital policy requires proof of hepatitis B, on hire 2 step TB skin test, and annual influenza.

Review of agency nurse employee files #30 on 05/09/2013, revealed there was no evidence of any of the required immunizations.

Review of agency nurse employee files #33 on 05/09/2013, revealed there was no evidence of any of the required immunizations except hepatitis B (a virus that affects the liver).

Review of agency nurse employee files #34 on 05/09/2013, revealed there was no evidence of any of the required immunizations.

Review of agency nurse employee files #35 on 05/09/2013, revealed there was no evidence of any of the required immunizations except the 2012 influenza (flu) vaccine and the Tuberculosis (TB) vaccine.

During an interview on 05/10/2013 at 10:15 a.m. in the conference room of the facility staff # 28 confirmed there was no evidence the facility provided the above required information.

Based on record review and interview the surgeon failed to have a completed history and physical examination with update prior to the patient having surgery in 2 (#10 and #11) of 9 (#10, #11, #12, #13, #14, #17, #18, #25, and #26) surgical records.

Findings include:

Review of the record titled "East Texas Medical Center Athens Medical Staff Rules and Regulations" Section 2. Medical Records, Subsection 3. Revealed;
"For surgical patients, the H&P shall be completed prior to any operative or other high-risk procedures or any procedure requiring anesthesia services."

Review of #10 surgical record forms titled "History & Physical/Short Stay" revealed surgeon #8 wrote "see H&P" (history and physical). On this form (page 2) is a section that says "This section is to be completed if the H&P was done prior to the day of surgery" this section was blank. The clinic note from the surgeon office of the history and physical is dated 04/22/2013. The record revealed no documentation if the patient had been reassessed for changes in the patient's medical status prior to surgery.

Review of #11 surgical record forms titled "History & Physical/Short Stay" revealed surgeon #39 had no documentation of any history and physical. On this form (page 2) is a section that says "This section is to be completed if the H&P was done prior to the day of surgery" this section was blank. The clinic note from the surgeon's office which was being used as the history and physical is dated 03/18/2013 greater than 30 days prior to the surgery date. The record revealed no documentation if the patient had been reassessed for changes in the patient's medical status prior to surgery.

An interview with staff #25 on 05/07/2013 at 3:30 PM confirmed the history and physical were not completed by surgeons #8 and #39 prior to the patient having surgery.

Based on record review and interview the surgical department failed to have an operating room register that was complete.

A review of records revealed the surgical services department did not have a complete register that contained patient's name, patient's identification number, date of operation, inclusive or total time of operation, name of surgeon and any assistant, nursing personnel (scrub and circulating), type of anesthesia used and name of person administering it, pre and post-op diagnosis, and age of patient.

An interview with staff #25 on 05/07/2013 at 3:30 PM confirmed the operating room register was not complete.

Based on record review and interview the surgeon failed to have a completed operative report and signed immediately following surgery in 7 (#11, #12, #13, #14, #17, #18, and
#25) of 9 (#10, #11, #12, #13, #14, #17, #18, #25, and #26) surgical records.

Findings include:

Review of the record titled "East Texas Medical Center Athens Medical Staff Rules and Regulations" Section 2. Medical Records, Subsection 5. Revealed;

"A post procedure note shall be written in the medical record immediately after surgery or other high risk procedures and shall contain a description of the findings, the technical procedures used, the specimens removed, the postoperative diagnosis, estimated blood loss and the name of the primary surgeon and any assistants. The report shall be authenticated by the surgeon and filed in the medical record as soon as possible after surgery or other high risk procedures and before the patient is transferred to the next level of care."

Review of patient #11's surgical record revealed no operative report completed by surgeon #39.

Review of #12, #13, #14, #17, #18, and #25 surgical record revealed no operative report completed by surgeon #40.

An interview with staff #25 on 05/07/2013 at 3:30 PM confirmed the operative report was not completed by surgeons #39 and #40 immediately following surgery.