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Based on interview and record review, the Governing Body failed to ensure medical staff requirements were met, in that:

(A) 1 of 6 physicians (Physician #25) did not have a request for clinical privileges that included the types of orthopedic surgeries he would perform in the hospital; and

(B) 1 of 2 non-physicians (Licensed Independent Practitioner and/or Allied Health Professionals) Personnel # 23 did not have a current Texas license to conduct evaluations and treat patients.

Findings included:

(A) Physician #25 credentialed record were reviewed on 07/12/22. Physician #25 performed orthopedic surgeries. Physician #25's privileges did not delineate type of surgeries that were requested and approved by the governing body.

(B) Review of Personnel #23's credentialed file on 07/12/22 indicated she was a Psychiatric Mental Health Nurse Practitioner-Board Certified. The file did not contain a current Advanced Nurse Practitioner (APN) Texas (TX) license. Personnel #23's APN TX license was expired on 04/30/22.

During an interview on 07/12/22 at 3:30 PM, Personnel #27 stated after the credentialing was completed in 2021, she would not follow-up current Texas licensure or DEA certificate. Personnel #27 stated she was not aware that physician privileges must be delineated.

Hospital's Medical Staff Bylaws and Rules and Regulations revised 05/26/22 page 14, 15, 19 required "Article VI Procedure for Appointment and Reappointment...6.2.1. The Medical Staff...shall review...Elements included in this review are: A request for clinical privileges...Article VII Clinical Privileges...7.1.2 ...every application for reappointment must contain a request for the specific clinical privileges desired by the applicant...7.5 Allied Health Professionals (AHP)...7.5.1. Qualifications of AHP...if approved, continuously thereafter, demonstrate the following qualifications: 7.5.1.1 Current license...required by Texas law..."

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Based on interview and record review, the hospital failed to identify that the advisory committee was inactive and responsible for soliciting and receiving input from nurses on the development, ongoing monitoring, and evaluation of the staffing plan per Texas Administrative Code (TAC) Chapter 133.41(o)(2)(H).

Findings included:

In the entrance conference on 07/12/22 at 10:00 AM, the hospital delegated representatives were requested to provide meeting minutes of the nursing advisory committee and/or nursing staffing committee.

The nursing staffing committee meeting minutes provided for review was dated 01/19/2017 at 11:00 AM-12:00 AM.

During an interview on 07/12/2022 at 3:20 PM, Personnel #1 confirmed the above findings and stated there was not a meeting conducted since 01/19/2017.

Based on observation, interview and record review, the hospital failed to ensure all drugs were secured, citing 1of 1 Gastrointestinal suite.

Findings included:

During a tour of the Gastrointestinal suite on 07/13/22 at 11:05 AM, one opened multidose vial of Lidocaine 1% was found not dated and/or labeled with no beyond use date.

During an interview on 07/13/22 at 11:06 AM, Personnel # 31 stated Personnel #28 was responsible for maintaining the Gastrointestinal cart. Personnel #31 stated the unlabeled opened multidose Lidocaine 1% should have been removed, labeled correctly, and properly secured.

Based on observation, interview, and record review, the hospital failed to enforce policies and procedures for preventing and controlling the transmisiion of infection, in that 2 of 3 dietary personnel (Personnel #33 and #34) did not wash or sanitized their hands and did not wear gloves as required.

Findings included:

During a tour in the kitchen on 07/13/22 at 11:05 AM with Personnel #3, Personnel #33 took off her soiled gloves then proceeded to assist in food preparation. Personnel #33 did not sanitize or wash her hands after taking the soiled gloves. Personnel #34 was observed holding an ice scoop without using gloves. Personnel #3 informed Personnel #34 to use gloves when using the ice scoop.

During an interview on 07/13/22 at 12:09 PM, Personnel #3 confirmed the findings.

Policy and Procedure "Handwashing/Hand Hygiene" reviewed 08/26/21 required "5.1 Handwashing shall be done...before and after wearing gloves..."

Based on observation and interview, the hospital failed to ensure surgical care was designed to assure the achievement and maintenance of high standards of medical practice and patient care, citing 1 of 1 tracer patient (Patient # 27) that was not properly identified during the surgical time out.

Findings:

Tracer Patient # 27 was followed to the Operating Room on 07/13/22 at 9:19 AM, it was observed during time-out, Patient # 27 was not properly identified. Personnel #30 did not identify the patient by checking the patient's identification band.

During an interview on 07/13/22 at 9:30 AM Personnel #30 was informed of the above findings. She stated she had verified the correct patient in the Pre-Op room prior to entering the Operating Room.

Policy and Procedure "Universal Protocol" revised 05-19 required "all involved personnel are in the room a "time out" must be called immediately prior to beginning the procedure to validate correct patient, correct site, correct positioning, correct documentation, antibiotic given and implants/equipment available."

Based on observation, interview and record review, the hospital failed to ensure the equipment (defibrillator and suction machine) of 1 of 2 emergency cart in the Post Anesthesia Care Unit was not working properly.

Findings included:

During a tour of the Surgical Department on 07/13/22 at 11:00 AM with Personnel #29, the defibrillator and suction equipment found on top of the emergency cart located in the Post Anesthesia Care Unit were not tested unplugged daily.

During an interview at 11:03 AM, Personnel #29 and Personnel #32 confirmed the findings. They stated they were not aware a daily check of the suction machine was required. They stated the defibrillator was not routinely checked while unplugged.

Policy and Procedure "Crash Cart" revised May 2019 required "Designated Licensed unit personal or trained technician will perform a battery check daily by firing the unplugged unit and ensure daily the suction source is functional and new tubing has been ordered."