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Based on record review and interview the Governing Body failed to ensure medical staff requirements were met for 3 of 8 physicians (Physicians FF, MM, NN) and 1 Advanced Practice Registered Nurse (APRN) (Personnel GG).

The facility failed to ensure:

1. Medical Staff privileges for physicians and Advanced Practice Registered Nurses (APRN) were current.
2. Delineation of Privileges had been approved and or denied.
3. Medical Staff held a current medical license.
4. Medical Staff held a current DEA licensure.
5. Advanced Practice Registered Nurse held a current DEA license.

Findings Included:

Record review of Medical Staff FF, GG, MM, NN credentialing files on 04/03/2024 and 04/10/2024 failed to contain the following:

1. Record review of Physician FF credentialing file did not evidence current medical staff privileges. The last documented Medical Staff/Governing Board approval was dated 1-21-2021 to 12-31-2022.

Record review of Personnel GG credentialing file did not evidence current clinical staff privileges. The last documented Medical Staff/Governing Board approval was 0/17/2019.

2. Record review of Physician FF credentialing file did not evidence a current delineation of privileges. The last documented delineation of privilege was 01/21/2021.

Record review of Personnel GG credentialing file did not evidence a current delineation of privileges. The last documented delineation of privilege was dated 09/18/2018.

3. Record review of Physician FF credentialing file reflected the medical license had expired on 02/28/2022.

Record review of Physician MM credentialing file reflected the medical license had expired on 02/28/2024.

4. Record review of Personnel GG credentialing file did not evidence a DEA license.

Record review of Physician FF credentialing file reflected the DEA license had expired on 03/31/2021.

Record review of Physician NN credentialing file reflected the DEA license had expired on 09/30/2023.

Stephens Memorial Hospital District Bylaws of the Medical Staff, reviewed and revised on 11/16/2015 ..."Qualifications for Membership ...(1) Licensure. A currently valid license and permit issues by the State of Texas to practice medicine, dentistry, or podiatry.(2) DEA/DPS registration. A current and unrestricted DEA and DPS registration to dispense controlled substances ...6.3 Submission of application ...The Hospital CEO will be responsible for seeing that a separate record is maintained for each individual requesting membership and/or clinical privileges. The completed application shall be submitted to the Hospitals Chief Executive officer ...shall be transmitted to the Medical Staff. 6.4 The Credentials Committee shall verify and investigate ...shall then make a recommendation to the Medical Staff regarding Medical Staff appointment and clinical privileges.6.5 Action by Board of Directors ...The Board may accept or reject the recommendations of the Medical Staff ...6.7 Process for Reappointment ... (c) Review and recommendations. The remaining process for review and recommendation or privileges upon reappointment shall follow the process established for initial appointment. 6.9 The National Practitioner Data Bank ...(d) Requests for information. The hospital shall, directly or through an authorized agent, request information from the Data bank concerning a physician, dentist or other health care practitioner as follows ...(1) At the time a physician, dentist, or other health care practitioner applies for membership on a Hospital's Medical Staff or for clinical privileges at the hospital ...(2) ...Every two years concerning any physician, dentist, or other healthcare practitioner who is on the Hospital's Medical Staff or has clinical privileges at the facility.

During an interview with Personnel C on 04/10/2024 at 1:00 PM stated, credentialing is performed by another facility (Hospital B). Personnel C stated Hospital B recredentials our providers and sends all documents to him for placement in the credentialing file. Personnel C was provided the opportunity to retrieve all current credentialing documents. None was provided. Personnel C confirmed the above findings.

It was determined the Conditions of Participation for Nursing Services was not met as evidenced by.

Based on record review and interview the facility failed to provide organized nursing services to ensure safe care to patients. 11 of 11 surgical patients reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11). There was no organized system to ensure all nursing personnel had signed job description delineating their job responsibilities, verification of orientation and competencies, current Basic Life Support (BLS), Advanced Cardiopulmonary Life Support (ACLS) as required by their job description.

1. The facility failed to ensure clinical staff personnel that worked in the hospital had a signed job description delineating their job responsibilities.

2. The facility failed to ensure clinical staff personnel had a documented orientation to job responsibilities and competency verification.

3. The facility failed to ensure clinical staff personnel held a certification in Advanced Cardiac Life Support (ACLS) as required by their job description.

4. The facility failed to ensure clinical staff personnel held a certification in Basic Life Support (BLS) as required by their job description.

Cross Refer Tag 0397

Based on record review and interview, the hospital failed to provide evaluations of clinical activities of non-employee clinical personnel.

1. The facility failed to ensure non-employee clinical personnel that worked in the hospital had a documented personnel file, orientation to the hospital policies and procedures and competencies assessed.

Cross Refer Tag 0398

Based on interview and record review, the hospital failed to ensure the registered nurse and unit nurse assistant assigned to provide direct patient care held current specialized qualifications and competencies as required.

The facility failed to:

1. delineate job responsibilities through signed job descriptions.
2. provide orientation regarding job responsibilities.
3. provide competency verification.
4. ensure certifications in Advanced Cardiopulmonary resuscitation (ACLS) were current.
5. ensure certifications in Basic Life Support (BLS) were current.

Findings Included:

Record review of Personnel files J, F, I, O, Q, W, X, AA, BB, CC, OO, PP on 04/03/2024 and 04/10/2024 failed to contain the following:

1. Record Review of Personnel J employee file did not evidence a signed job description as the Ambulatory Care Services (ACS) Director.

Record Review of Personnel I, W, AA, BB employee file did not evidence a signed job description as an Operating Room Registered Nurse.

Record Review of Personnel X and Personnel CC employee file did not evidence a signed job description as the Ambulatory Care Services Unit Nurse Assistant (UNA).

Record Review of Personnel O, AA, OO employee file did not evidence a signed job description as an Emergency Department Registered Nurse.

Record Review of Personnel Q employee file did not evidence a signed job description as the Medical Surgical Department Director.

2. Record review of Personnel files F, I, J, O, Q, W, X, AA, BB, CC, OO, PP did not evidence a documented orientation to job responsibilities.

3. Record review of Personnel files F, I, J, O, Q, W, X, AA, BB, CC, OO, PP did not evidence a documented competency verification.

4. Record review of Personnel Q and Personnel W employee file did not evidence an Advanced Cardiac Life Support (ACLS) certification as required by their job description.

5. Record review of Personnel I, Q, W, X, BB, CC employee file did not evidence a Basic Life Support (BLS) certification as required by their job description.

Ambulatory Care Service/Operating Room Director Job Description, ...The ASC/OR Director manages and supervises the activities and personnel in the Operating Room and Ambulatory Care Services. Ensures quality care of patients and coordinated the clinical activities with inpatient units and ancillary services ...maintains current ACLS, BLS and PALS certification."

Operating Room Registered Nurse Job Description ..."The ACS/Registered Nurse assists with nursing care for patients in Ambulatory Care Services/OR and Cardiac rehab. The RN works under the direct supervision of CNO and works cooperatively with ancillary, nursing , and other patient care team members. The functions of the RN are carried out according to hospital policy, the hospital mission and vision statement and nursing standards of care ...Employment requirements ...maintains a current card for the successful completion of Basic Cardiac Life support (CPR-Healthcare Provider) and ACLS ..."

Unit Nurse Assistant Job Description ..."License/Certifications Required ...Certification in BLS."

Emergency Room Registered Nurse Job Description ..."Minimum requirements ...maintain Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS) and Trauma Nursing Core Course (TNCC) certification."

Medical Surgical Department Director Job Description ..." Education and experience ...current card for the successful completion of Basic Cardiac Life Support (CPR-Healthcare Provider) ...Advanced Cardiac Life Support (ACLS)."

During an interview with Personnel L on 04/03/2024 at 4:28 PM confirmed the above findings. Personnel L stated she does not track BLS or ACLS certifications.

During an interview with Personnel E on 04/03/2024 at 4:45 PM stated hospital wide and department specific competencies have not been performed for several years. Personnel E stated there is no process for tracking the required certifications such as BLS, ALCS, Pediatric Advanced Life Support (PALS), and Trauma Nursing Core Course (TNCC).

During an interview with Personnel J on 04/03/2024 at 4: 45 PM confirmed competencies have not been performed on staff and confirmed there is no process for tracking BLS and ACLS certifications to ensure they are current.

Based on record review and interview, the hospital failed to provide evaluations of clinical activities of non-employee clinical personnel.
1. Two of two (Personnel DD and Personnel EE), non-employee clinical personnel that worked in the hospital, did not have a documented personnel file, orientation to the hospital policies and procedures and competencies assessed to work as a certified surgical technician (CST).

2. Six out of six agency nursing personnel employed at the hospital (Personnel QQ, RR, SS, TT, UU, VV) did not have a documented orientation to clinical areas or hospital policies nor verified competency of their clinical skills.



Findings included:

1. The facility did not evidence a personnel file on Personnel DD and Personnel EE.

The facility did not evidence the contracted staff was orientated to the surgical service's policy and procedures.

The facility did not evidence a process to ensure certification of the contracted staff was current.

The facility did not evidence a process to evaluate or establish an expectation of the contracted staffs' skill and competencies.

Record review of the facilities staffing sheet dated 02/06/2024 showed Personnel DD had scrubbed 5 surgical cases that day.

Record review of the facilities staffing sheet dated 04/02/2024 showed Personnel EE had scrubbed 11 surgical cases that day.

During an interview on 04/03/2024 at 4:00 PM, Personnel E stated they did not maintain personnel files on employees provided by the staffing company. Personnel E stated there was no documentation on orientation was performed, or competencies had been assessed. Personnel E also stated there was no process to ensure non-employee personnel licensure or certifications were current.

During an interview with Personnel J on 04/03/2024 at 4:00 PM stated the staffing company provides the surgical technologists on day or surgery. Personnel J was unable to provide documentation an orientation was performed, or competencies assessed on non-employee personnel. Personnel J stated she does not have a process in place to ensure licensure or certifications on non-employee personnel were current.

2. Personnel E stated during an interview on 4/10/24 at 1630 that Travel and/or contracted nurses "pretty much work full-time hours" at the hospital.

Record review of hospital staffing sheets provided to the surveyors on 4/10/2024 at 1625 reflected agency Personnel UU worked shifts on six consecutive days at the time of survey, on 04/04/2024, 04/05/2024, 04/06/2024, 04/07/2024, 04/08/2024 and 04/09/20254.

Record review of agency nursing staff files of Personnel QQ, RR, SS, TT, UU, VV was conducted on 04/11/2024 at or around 1110. There was no evidenced or documented orientation to hospital clinical areas or policies nor were the nursing skills competence documented as verified by hospital staff.


Personnel E acknowledged the lack of orientation documentation during an interview on 04/11/24 at 1125 and stated that there was "not a good process for that. New orientation staff are paired with another staff but no, they don't have an orientation checklist." Personnel E stated that agency nursing personnel worked "pretty much" full time hours.

Based on record review and interview the facility failed to ensure that all patient medical record entries were complete, dated, timed, and authenticated by the person responsible for providing care or evaluating the service provided, consistent with hospital policy and procedures for 11 of 11 patient medical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11).

Findings Included:

Record review of patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 dated 04/02/2024 reviewed on 04/03/2024 failed to contain the following:

Record review of patient #2, #3, #5, #7, #11 medical record reflected the Conditions of Admission and Authorization for Medical Treatment form did not evidence a date or time next to the patient and witness signature.

Record review of patient #4, #6, #8, #9, #10 medical record reflected the Conditions of Admission and Authorization for Medical Treatment form did not evidence a time next to the patient and witness signature.

Record review of patient #1, #2,#3,#4,#5,#6,#7,#8,#9,#10,#11 medical chart did not evidence a physician order to admit patients to the Ambulatory Care Services surgical department.

Record review of patient #2 and #3 medical chart reflected the Medication Administration record dated 04/02/2024 did not evidence a date or time next to the physician signature.

Record review of patient #1, #3, #5, #6, #7, #8, #9, #10,#11 medical chart reflected the Medication Administration record dated 04/02/2024 did not evidence a time next to the physician signature.

Record review of patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 anesthesia consent dated 04/02/2024 reflected the anesthesia providers signature was not legible on the consent for anesthesia. The form did not evidence a date/time and printed/typed name for clarity.

Record review of patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 Ophthalmology Anesthesia record dated 04/02/2024 Physical Exam section did not evidence a date next to the CRNA signature.

Record review of patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 Ophthalmology Anesthesia Record dated 04/02/2024, Pre-Anesthesia Note section consisted of; Patient telephoned evening before surgery, Caller identified self as anesthesia provider, Patients medications and NPO discussed, Local anesthesia discussed, Intravenous sedation discussed, Anesthesia plan accepted by patient, Patients questions answered, Other required the anesthesia provider to circle Y (Yes) and N (No). The provider failed to provide clarity as both Y (Yes) and N (No) columns were circled.

Record review of patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 Ophthalmology Anesthesia Record dated 04/02/2024, Pre-Anesthesia Note section did not evidence a date or time the pre-anesthesia assessment was completed.

Record review of patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 Ophthalmology Anesthesia
Record dated 04/02/2024, Post Anesthesia Note section which consisted of; Course of surgery/ anesthesia uneventful, Vital signs stable after surgery, Patient's condition unchanged from pre-op, Anesthesia related complications noted required the anesthesia provider to circle Y (Yes) and N(No). The provider failed to provide clarity as both Y (yes) and N (No) columns were circled.

Record review of patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 Ophthalmology Anesthesia record dated 04/02/2024 Post-Anesthesia Note section did not evidence a time next to the CRNA signature.

Record review of patient #1, #2,#3,#4,#5,#6,#7,#8,#9,#10,#11 medical chart did not evidence a physician order to discharge the patient home once discharge criteria was met.

Record review of patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 phase II recovery record dated 04/02/2024 did not evidence a physician or anesthesia provider assessment indicating patient was stable for discharge.

Record review of patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 phase II recovery record dated 04/02/2024 did not evidence discharge instructions were provided, if patient or responsible adult verbalized understanding and who accompanied the patient at discharge.

Policy and Procedure titled "Postoperative Care", effective date 03/18/2024," C. Criteria for Discharge from Phase II Recovery ... 4. Availability of an appropriate escort/post-discharge caregiver. 5. demonstrated understanding of post-discharge instructions. D. Criteria for Fast Track to Phase II Recovery (Bypassing Phase I Recovery/PACU) Note: Decision to Fast Track a patient should be based on patient need, clinical assessment, and desired outcomes as well availability of staff and resources 1. Meets Phase I Recovery discharge criteria prior to leaving operating room 2. Patient assessment in operating room by anesthetist with clear documentation of readiness for discharge from Phase I Recovery. 3. Agreement from Surgeon and Circulating RN that patient is ready for discharge from Phase I Recovery and may be Fast Tracked to Phase II Recovery.

During an interview with Personnel E and Personnel J on 04/03/2024 at 5:00 PM confirmed the above findings.

Based on observation, record review, and interview, the facility's infection prevention and control program failed to employ methods of effective surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection.

1. The publicly accessible ice machine in the hospital's dining room had an unknown cleaning schedule which potentially fostered an environment of growth of Legionnaire's Disease.

2. A popcorn popper machine in the publicly accessible hospital dining room was left unclean after the last use for at least eight days prior to the survey which potentially encouraged the growth of microorganisms.

3. A ceiling tile in the hospital's public dining room was observed greatly stained with a brown-colored ring that covered close to half of the tile, potentially indicating water leaks, flooding or condensation, with the potential of encouraging mold and attracting pests.

4. A gumball-type candy-vending machine in the hospital's public dining room had small white particles in its casing and had been left with pieces of candy in the dispenser spout for an unknown period of time.

5. Clean kitchen aprons were stored in very close proximity to disinfecting cleaners. Also close by, stored on a cracked, grime- and dark-colored floor, sat additional soiled equipment, brownish-discolored rags, and grime-colored cleaning brooms with bristles extending to all sides. This had the potential of contaminating other areas while being used as cleaning equipment.

6. Multiple food containers in the kitchen's dry goods storage areas had been staff opened for an unidentified and unknown time, potentially exposing patients to spoiled food items.

7. Two cheese items in the hospital's walk-in refrigerator had been opened at an unidentified date and left uncovered which had the potential of food spoilage.

8. A Ziploc bag in the hospital kitchen's walk-in freezer contained a plastic bag with Pre-Thanksgiving 2023, five-months-old Turkey meat sauce.

9. The MRI (Magnetic Resonance Imaging) suite had potentially infectious and sharps material stored on the floor, potentially accessible to all patients, including pediatrics, who came to be tested.

10. Clean linens in the hospital's inpatient hall were publicly accessible to patients and staff with the potential for contamination and were stored on a shelf above three bags of opened and uncovered adult sanitary briefs.




Findings included:

Observation rounds where conducted with Hospital Personnel K, M, and/ or Y on 04/03/2024 between 1315 and 1440. The following observations were made:

1. The public dining room was observed at 1315. An ice machine and dispenser were noted to be accessible to the public. The surveyor inquired regarding the general cleaning procedures of the machine. Maintenance Staff Y stated the ice was "not changed" and was unsure of the cleaning schedule.

Record review of the User Manual for the hospital's Ice machine supplied by hospital staff on 04/03/2024 at 1715 reflected that "Semi-Annually (more often if conditions dictate) cleaning procedure should always include both the ice machine and dispenser...Periodic cleaning of...ice and water dispenser and ice machine system is required to ensure peak performance and delivery of clean, sanitary ice..." (https://www.follettice.com/sites/default/files/2019-07/Iwd_IOSMan_25_50CIHI_SeriesPlus%20After%20K39863_01234624R04.pdf)

The Center for Disease Control (2024) warned that "any system or equipment containing nonsterile water can grow Legionella...sediment and biofilm, temperature, water age, and disinfectant residual are the key factors that affect Legionella growth in devices that use water..."
(https://www.cdc.gov/legionella/downloads/Control-Toolkit-Other.pdf)

During an interview on 04/03/2024 at 1530, Hospital Staff M denied keeping a log of hospital acquired infections.

2. A publicly accessible popcorn popper machine with cart was observed at 1325 with a few popped corn kernels and a yellow scoop left inside. Hospital Staff K stated at that time that the popcorn machine was "mainly used on Payday Fridays....maybe last Tuesday" [8 days ago]. Staff K was asked whether the popcorn had been left in the popper cart since then and stated "yes."

3. A ceiling tile in the publicly accessible dining room was stained with a large brown-colored ring covering as much as half of the ceiling tile as observed at or around 1330. This was witnessed and acknowledged by Hospital Staff Y and Hospital Staff M.

The Centers for Disease Control and Prevention warned that "stains could include discoloration caused by possible water leaks, flooding or condensation... Moisture allows indoor mold to multiply more easily...can cause or worsen health problems...moisture can also attract cockroaches, rodents, and dust mites" (https://www.cdc.gov/niosh/docs/2019-115/pdfs/2019-115.pdf)

4. A blue gumball-type candy machine in the dining room was observed at 1331. Inside its casing, white unidentifiable particles were observed; its spout evidenced small pieces of multicolored candy. Staff M acknowledged the findings at that time.

5. A storage room in the kitchen area contained a stack of black and red aprons on a shelf as observed at 1335. The aprons were identified as clean by Staff K. Nearby on the neighboring shelf at least three bottles labeled "Rapid Multi-Surface Disinfectant Cleaner RTU" and three one-gallon containers labeled "Enza Bioactive Cleaner" were observed. Approximately five feet away from the clean apparel on the floor was a grey bucket with one yellow and one black hose. Across the clean linen shelf was a yellow bucket turned on its side into a hopper-type basin; its wheels were visibly dark discolored. Two originally blue, now brownish discolored rags and a mop were in the immediate vicinity to the yellow bucket. A green broom was observed close by; its bristles extended in all directions and were cased in a grime-discolored, but originally white, plastic cover with dirt particles. The floor underneath the broom and another dark discolored. but originally yellow, broom-type device was cracked in multiple areas and covered with grime and dark material.

6. The kitchen's dry good storage room was observed at 1340. Multiple food containers were observed opened but undated and included three bags of noodles, one bag of almonds, one bag of coconut flakes, a square container of Alfredo Sauce Mix, one bag of dry mashed potatoes. Staff K stated at that time that the containers "should be dated when opened."

7. The kitchen's walk-in refrigerator was observed at 1400 and contained opened and undated foods including one package of cream cheese and one packet of velveteen spread cheese.

During an interview on 04/03/2024 at 1530 Staff M stated that the hospital surveillance activity had identified "opening dates had been an issue before in the kitchen."


8. The kitchen's freezer was observed with plastic bag labeled Turkey Sauce and dated 11/10/2023. Staff K stated at that time "it should have been pulled."

9. The MRI Suite was toured at 1431. Emergency equipment on the wall was labeled "pedi [pediatric use]." Along the wall a large red sharps container labeled "Regulated Medical Waste -Biohazard" was noted to be open, without a lid, and easy to reach into.

10. A hallway closet on the first-floor patient unit was unlocked and accessible to the public as observed at 1440. Linens and bedsheets on the top shelf were identified by Staff M and Staff E as "clean" at that time. Below the clean linen shelf, other unused sanitary equipment was observed and included two urinary hats, two urinals, and two kidney basins with skin moisturizers. The lowest shelf contained three bags of opened sanitary briefs and at least three briefs were observed uncovered. Staff E acknowledged at that time that the public had access to the closet to take hygiene items and linens and potentially contaminate the clean linen items for patient use.

During an interview on 04/03/2024 at 1530 Staff M denied that the hospital had a log for hospital acquired and community acquired. Surveillance was done in form of "mock surveys" that "hit every unit twice a year."


Record review of Hospital Policy Number 02 Infection Control Plan dated 05/22/2019 reflected the purpose of the Infection Control Plan was "...to use surveillance methodologies, prevention, and control activities based on current guidelines and recommendations to identify, control, and minimize the spread of communicable and transmittable infections within the hospital while providing an optimum level of patient care."

Record review of Infection Control Policy Number ADM 09.035 dated 06/24/2021 reflected infection control evaluations in different departments were to be conducted "monthly....findings will be discussed in the monthly Quality Meetings..."