HospitalInspections.org

Based on observation, interview, and record review, the facility failed to store pharmaceuticals safely.

Findings include:

An observation, on 9/15/20, during a tour of the facility's Emergency Room, revealed (5) one-liter saline solution bags in a warming cabinet.
The bags did not have a date as to when they had been placed in the warmer. All of the bags were warm to the touch.

On the morning of 9/15/20, during an interview in the ER, Staff #2 reported, the fluids needed to be dated when they placed in the warmer.

Review of the facility provided policy, IV Warmer (undated) reflected, "IV'S in the warmer will be kept at 103-120 degrees F and changed out every 7 days. Bags taken out of the warmer are still available for use with the regular floor stock. The bags will be marked with the 'date in' on the bag."

Based on a review of facility documentation and staff interviews, the facility failed to ensure that errors in the administration of drugs were reported and monitored. Thus, it was unknown whether or how many patients at the hospital might have received the incorrect medication, the incorrect dose, or received a dose at the incorrect time.

Findings were:

In an interview with Staff #1, CEO, and Staff #2, chief nursing officer (CNO), on the afternoon of 9/15/20 in the hospital meeting room, surveyor requested a listing of reported medication errors. Staff #2 stated, "There aren't any listed since April 2019." She acknowledged and agreed with surveyor remark that this didn't seem realistic. She stated, "It doesn't seem realistic to me either."

No policy was available for surveyor review related to tracking medication errors.

In an interview with Staff #1, hospital CEO, on the morning of 9/16/20, he stated that the former CNO had been responsible for quality and infection control. "She had some minutes, but she had to leave the position suddenly, and I don't know where she put the minutes." He added, "I've been through 4 CNOs in the last 2 years. The last one was probably doing this, but I don't know where she would have kept the information."

The facility's infection control program failed to provide evidence of an active program when it failed to follow prevention and control guidelines.

- The facility failed to provide evidence of tracking and trending of infections.
- The facility's Transvaginal Probe was not being sanitized correctly, placing patients at risk of infections
- Patient care items were being stored under the hand sinks, placing the items at risk of being contaminated by leaking pipes.
- The sink in the Laboratory's blood bank had a large amount of scale build-up, making it uncleanable.
- Intravenous fluids were being stored warm with no expiration date.
- No evidence was available of infection control meeting minutes or other discussion and monitoring of infection control issues.
- Infection control policies had not been revised since 2007.

Cross refer to: 1206, 1208, and 1016.

Based on a review of facility documentation, observation and staff interviews, the facility failed to ensure a functioning infection prevention and control program which included surveillance and prevention of infection control issues, as well as ensuring a clean and sanitary environment, in order to avoid sources and transmission of infection and communicable diseases.

Findings were:

Facility policy #1003 entitled "Infection Control," effective date 3/8/07 (no revisions), included the following:
"Culberson Hospital represented by the medical and administrative staff, along with the Governing Body, recognizes the need to formalize the infection control efforts. The goal of the Infection Control Program is to reduce the risk of acquisition and transmission of healthcare associated infections (HAIs). To accomplish this goal effectively requires and integrated process involving a collaborative effort by all programs and services throughout the facility. The Governing Body of Culberson Hospital directs that an Infection Control Program be established ...
The Infection Control Program at this hospital incorporates the following in a continuing cycle: ...
* Prevention:
- Implementation of methods to prevent transmission of infectious agents and to reduce risks for
device-related and procedure-related infections
* Control:
- Evaluation and management of outbreaks ...

PROGRAM DESCRIPTION ...
"Departmental policies and procedures for infection control will be reviewed and/or revised as an ongoing practice ..."

The above policy gave guidance for developing and implementing an infection control program. In an interview with Staff #2, Chief Nursing Officer (CNO), on the morning of 9/16/20 in the hospital meeting room, she stated, "We've got a policy about a program, but no infection control program. We're trying to get a real infection control program from the corporate office." She also stated she had been assigned the role of hospital infection control coordinator though she had no specialized training in infection control. She could not state that infection control training was planned for her.

In an interview with Staff #1, hospital CEO, on the morning of 9/16/20, he stated, "We're all involved in infection control. It's a hospital-wide thing." He added that the former CNO had been responsible for quality and infection control. "She had some [meeting] minutes, but she had to leave the position suddenly, and I don't know where she put the minutes." Thus, the facility could provide no evidence of having implemented a program which thoroughly monitored and addressed infection control issues in the hospital. This was the case even, and especially, during the covid-19 pandemic. The CEO stated that the number of covid-19 cases was high in Van Horn on the date of survey. He stated, "We've just had word this morning that they're closing the school. All the staff are trying to figure out what to do with their kids - they're leaving and coming back this morning." The infection control policies included nothing to address the special circumstances regarding the current covid-19 pandemic. No infection control policies could be located which had been effective and/or revised since 2007.

Based on observation, interview, and record review, the facility failed to provide a sanitary environment when:
a.) The facility's Transvaginal Probe was not being sanitized correctly, placing patients at risk of infections
b.) Patient care items were being stored under the hand sinks, placing the items at risk of being contaminated by leaking pipes.
c.) The sink in the Laboratory's blood bank had a large amount of scale build-up, making it uncleanable.

Findings Include:

A review of the facility provided policy, Infection Control Plan (EFFECTIVE: 03-08-07) reflected, " ...
Prevention: implementation of methods to prevent transmission of infectious agents and
to reduce risks for device-related and procedure-related infections. The program intends to provide a safe environment consistent with nationally recognized infection control precautions and is based on recommendations from the Center for Disease Control, National healthcare-associated infections (HAls)
Surveillance System, Association of Practitioners in infection Control, and the Occupational Safety and Health Administration.

a.) An observation, on 9/15/20, during a tour of the facility's Radiology Department, revealed a transvaginal probe resting in the ultrasound machine's holder.

On 9/15/20, during an interview, when asked how the probe is cleaned, Staff #17, Radiology Technician, reported the sonographer cleans the probe with a Disinfectant Spray.

A review of the facility provided Protex Disinfectants Spray instruction for use reflected, " ...is an effective one-step fungicide ...This product is not to be used as a terminal sterilant/high-level disinfectant on any surface or instrument that (1) is introduced directly into the human body, either into or in contacted with the bloodstream or normal sterile areas of the body, or (2) contacts intact mucous membranes but which does not ordinarily penetrate the blood barrier or otherwise enter normally sterile areas of the body..."

Review of the facility provided Operation Manual for the facility's Diagnostic Ultrasound System Xario XG reflected, " ...To ensure the prevention of infection, confirm the effectiveness of each chemical for cleaning, disinfection, effectiveness or sterilization based on the criteria ...After cleaning, rinse the transducer thoroughly with purified water to remove all chemical residues ....Chemical residues on the transducer may be harmful to the human body..." The operation Manual provided a list of approved disinfectants, Protex Disinfectant Spray was not included.
On 9/15/20, during an interview, Staff #2, CNO, confirmed the finding.

b.) An observation, on 9/15/20, during a tour of the facility's Pharmacy Department, revealed two large bags of clean adult briefs, three boxes of clean soap towelettes, and multiple miscellaneous types of equipment being stored under the staff handwashing sink.

An observation, on 9/15/20, during a tour of the Patient's Nourishment room, revealed a large pooling of dark brown liquid leaking from the sinks drain pipe.


c.) An observation, on 9/15/20, during a tour of the facility's Blood Bank, revealed a two-bowel sink; one of the sinks had a large ring of scale built up around the bowel.
Two bright red specks were noted in the sink.

On 9/15/20, during an interview, Staff #2, CNO, confirmed the findings.

Based on the interview and record review, the facility failed to serve the Dietitian approved menus to meet the patient's nutritional needs.

Findings include:

A review of the facility provided menu for 9/15/20 revealed the lunch menu included Spinach Salad and Banana Nut Dessert.

During an interview on the afternoon of 9/15/2020, Staff #19, Cook, reported she didn't have the items for the menu. She would be serving a tossed salad and fruit instead.
When asked for the substitution log, Staff #19 was not able to provide one.

On the afternoon of 9/15/2020, during an interview, Staff #18, Head Cook, reported due to their location, the facility is unable to purchase some of the items on the menu. Staff #18 confirmed the substitutions had not been documented for the Dietitian to review. Staff #18 confirmed the cook would not know what had been substituted the day before, to avoid repetition, and whether the substitution was an appropriate substitution of equal nutritional value.

Review of the facility provided document Menu (undated) reflected, Menu
POLICY:
Menus will be planned by the qualified dietitian for all patients
PROCEDURE:
1. The daily menus will be planned, ...Texas Diet Manual and Medicare regulations.
2. Ten day [sic] cycle menus will be used with seasonal or daily changes made by the dietitian, as a
guide ...
5. Menu substitutes will be recorded and reviewed by the dietitian.
6. Specific modifications from prescribed [sic] diet due to allergy or food preference will be recorded
and substitutions will be made by the dietitian or dietary employee.

On 9/15/20, during an interview, Staff #2, CNO, reported she oversees the Dietary Department. Staff #2 confirmed the findings.