HospitalInspections.org

Based on observation, interview and record review the Hospital failed to ensure a safe setting. The following were noted at Ben Taub Hospital:
1) Intravenous fluids were pre-spiked in the surgery suite area and kept greater than 24 hours against hospital policy
2) An anesthesia provider was scrolling on her cell phone while providing anesthesia to a patient
3) The surgery department failed to keep cooled saline in the event of Malignant Hyperthermia per policy

Findings include:

INTRAVENOUS FLUIDS
Observation 7/9/13 at 1:30 p.m. in the surgery suite area revealed the following:
Operating room #11 had two intravenous fluids of one liter Normal Saline pre-spiked. The tubing was dated 7/7/13 at 12 p.m. Further observation revealed a liter of Ringers Lactate intravenous solution pre-spiked outside the anesthesia work room. The date on the tubing was 7/7/13 at 12 p.m.
(pre-spiked is when the intravenous (IV) solution bag has been attached to tubing, breaking the seal on the IV)

Interview with an anesthesia technician (ID# 11) revealed he prepares intravenous fluids in advance in the event of an emergency case. The technician stated that he keeps the fluids for three days once they have been spiked with the tubing and then discards the solutions.

The Director of Accreditation (ID# 4) confirmed that the standard of practice is to discard any intravenous solutions in 24 hours that have been pre-spiked.

Record review of a policy titled "Medication Use Policy 565.40" (no date) stated "All irrigation containers and Intravenous (IV) solutions will be dated when opened and discarded within twenty-four (24) hours after opening."

MALIGNANT HYPERTHERMIA
Observation 7/9/13 at 1:30 p.m. in the surgery suite area revealed the hospital did not have cooled saline solution immediately available in the event of Malignant Hyperthermia.

A surgical nurse (ID# 20) acknowledged 7/9/13 at 2 p.m. that the surgery area did not keep cooled saline readily available in the event of Malignant Hyperthermia. The nurse stated that if cooled saline were needed they would have to cool it in the ice machine.

Record review of a policy titled "Malignant Hyperthermia" and dated 11/2007 stated "The malignant hyperthermia kit shall contain, but is not limited to:....11) Normal Saline 0.9% for injection IV Bag (kept cold in Operating Room Satellite Pharmacy refrigerator)"

ANESTHESIA
Observation 7/9/13 at 2:05 p.m. in Operating Room #8 revealed a surgical case in progress with several medical staff around the operating room table. The surveyor was observing the case through a window in the door and noticed a staff member sitting at the anesthesia machine and scrolling on her cell phone. Surgical nurse ID# 20 confirmed at this time that the staff member sitting at the anesthesia machine and scrolling on her cell phone was the anesthesia provider for the case (ID# 46). The surgical nurse acknowledged that medical staff should not be using cell phones during surgical cases.

The facility failed to enforce its Medical Staff Bylaws related to completion of a medical History and Physical examination within 24 hours of admission for four (4) of 22 sampled patients at the LBJ Hospital location (Patient ID# ' s: 57, 60, 62, 65).

Findings include:

Record review on 07-11-13 of the clinical records of Patient ID #s 57, 60, 62, and 65 revealed the following:

Patient ID # 65: admitted on 07-05-13 with diagnoses of neck pain and seizures. As of 07-11-13, there was no History & Physical (H&P) examination recorded in the patient record. Staff ID # 56 was unable to locate an H &P in Patient ID# 65 ' s record.

Patient ID # 57: admitted on 07-06-13 with diagnoses of abdominal pain and small bowl construction. Further review revealed an H & P exam was dictated 4 days later on 07-10-13. Patient ID # 57 had surgery on 07-07-13.

Patient ID # 60 : admitted on 07-09-13 with diagnosis of fracture of right calcaneus. H & P recorded by 2nd year resident physician on 07-09-13 at 6:09 a.m. As of 07-11-13, there was no documented agreement of the H & P by the attending physician located in the record. Staff ID # 56 was unable to locate H & P documentation by the attending physician.

Patient ID # 62: admitted on 07-04-13 with diagnosis of vomiting. H & P recorded by surgical resident physician on 07-05-13 at 1904. As of 07-11-13, there was no documented agreement of the H & P by the attending physician located in the record. Staff ID # 56 was unable to locate H & P documentation by the attending physician.

Interview on 07-11-13 at 2:00 p.m. with Medical Records Staff ID # 68 she stated the expectation was the attending physician " write an addendum to the resident ' s H & P within the 24 hour timeframe. "

Interview on 07-12-13 at 1:15 p.m. with the Director of Accreditation (Staff ID # 4), she acknowledged a patient ' s H & P was not authenticated until the attending physician had made an " agreement addendum " after the resident ' s H& P. Staff ID # 4 went on to say the expectation was addendum would be documented within the 24 hour H & P timeframe.

Record review on 07-11-13 of the Medical Staff Bylaws/Rules & Regulations, dated 2009, read: " ...Inpatient: a complete history and physical examination shall, in all cases, be written and placed in the record within twenty-four (24) hours after admission of the patient ...:[In case of emergency surgery ...the H & P shall be recorded immediately after the emergency surgery has been completed] ...The attending physician will document agreement with a complete history and physical examination on all new patients admitted and/or assigned to him/her.. " .

Based on review of documentation and interviews with staff, the facility failed to ensure that medical records were accurately written for 6 of 66 patients whose records were reviewed, as the patient records did not contain documentation of triage assessments conducted by a staff paramedic.

Findings were:

A review of the emergency triage log for Quentin Meese Hospital, which is a Harris County System facility, revealed that 6 patients evaluated and treated by the staff paramedic during July 2013 in the facility triage room did not have documentation of their treatment entered into their medical records. The PARAMEDIC PATIENT CONTACT LOG described the encounters with the patients; however, there was no documentation in the electronic medical records by the paramedic who performed the evaluations.

Patients who were listed on the Quentin Meese triage log for July 2013 included the following:
Patient #1 had been directed to the triage room during a visit to a clinic on the campus. Following an assessment by the paramedic assigned to the triage room, the patient was transported to Ben Taub Hospital by the Houston Fire Department. There was no documentation of the incident into the patient's medical record by the paramedic who assessed the patient. Patients #2 and #3 were assessed by the triage paramedic during visits to the outpatient physical therapy clinic on the campus. Following the assessment and intervention by the triage paramedic, the patients were stabilized and each patient refused transport to the hospital. The patients went home with family members. There was no documentation of the incidents into the patients' medical records by the paramedic who assessed the patients. Patient #4 was also assessed by the triage paramedic; this patient requested to be transported to another nearby hospital not affiliated with the Harris County System. There was no medical record account of the patient's assessment prior to the ambulance transport to the other facility. Patient #5 presented to the triage room on 7/3/13 complaining of abdominal pain. The patient was assessed by the paramedic and transported to the veteran's hospital; however, this assessment was not found in the patient's medical record. Finally, Patient #6 presented to the triage room at Quentin Meese and was assessed by the paramedic for complaints of chest pain. This patient was transported to Ben Taub Hospital; however, there was no entry into the medical record by the paramedic who performed the assessment.

An in-person interview was conducted with Staff #1, the Director of Nursing of Quentin Meese Hospital; Staff #47, a Health Information Management (HIM) Manager; and Staff #48, HIM analyst, the afternoon of 7/10/13 in a facility conference room. These staff members confirmed that paramedics do not have access to the electronic medical record system and do not enter clinical information into the patient records. Staff #1 also acknowledged that these 6 patients had assessments conducted by the paramedic which were not documented in their electronic medical records, and that the PARAMEDIC PATIENT CONTACT LOG is not part of the medical record of these patients.

Based on observation, record review and interview the facility failed to have systems in place to ensure kitchen equipment, walls, and sinks were clean and in good repair; The facility failed to store and prepare food in a manner to prevent the potential for contamination and failed to ensure outdated foods were not available for use. Citing two (2) random observations at LBJ, Quentin Mease Hospital and the Smith Clinic.

Findings:

LBJ

Observation on 7/9/2013 between 8:45 am and 9:25 am revealed uncovered containers of chicken salad were placed approximately a foot from a hand washing sink where staff were constantly washing their hands. This had the potential for contamination from splash during hand washing procedures.

Kitchen equipment including food carts, clean dish storage cart, dishwashing conveyor belt, and bases of refrigerator, walls and hand washing sinks had a heavy buildup of dust, food particles, rust and black grease. Multiple food service utility carts were in a state disrepair.

During an interview on 7/9/2013 at 10:20 am with Staff (57) Food Service Manager, he stated Staff cleaned the hand washing sinks but was not able to say how often the sinks were cleaned. He acknowledged that some of the kitchen equipment were in disrepair and would be disposed of.

Review of the facility's policy/procedure for Nutritional Services presented to the Surveyor documented the following information:

'The Nutrition and food services department should maintain and clean work areas, storage areas, and equipment for handling of supplies in accordance with state and local health department standards.

All surfaces including wall, shelves and refrigerators are cleaned weekly. All food carts are cleaned after each meal.''




12000

Observation 7/8/13 at 2:30 p.m. in the emergency department of Ben Taub Hospital revealed five (5) ham and cheese sandwiches in a refrigerator for patient use in a supply room. The sandwiches were not dated.


21021

A tour of the Smith Clinic, an outpatient clinic of the Harris System, was conducted the afternoon of 7/9/13 in the company of the Nurse Director of Ambulatory Services, Staff #50. In the speech therapy treatment rooms in the outpatient therapy area, outdated food items utilized by the speech therapist during patient therapy were found in cabinets and available for patient use. In one treatment room, 4 containers of Gerber baby food were found with a "best if used by" date of 4/1/13. Two instant oatmeal packages also utilized during speech therapy sessions were found with an expiration date of 10/2012. in the 2nd treatment room, 2 cases of Gerber baby food were found with a "best if used by" date of 4/10/2013. These findings were acknowledged by Staff #50 during the tour of the therapy clinic the afternoon of 7/9/13.

Based on observation, interview, and record review, the facility failed to enforce it's infection control policies for cleaning equipment, proper storing and handling of linen, hand washing protocol and maintaining a sanitary patient environment. This failed practice had the potential for the spread of infection which could adversely affect all patients. Citing four (4) of four (4) locations visited.( LBJ, Quentin Mease, Ben Taub and Smith Clinic)

Findings:

Observation on 7/10/2013 between the hours of 9:30 am and 10:30 am in the Rehabilitation wound care room revealed Staff (60)Physical Therapist completed cleaning a foot wound for Patient (#54), she changed her gloves did not wash her hands, donned clean gloves and proceeded to apply clean dressing to the patient ' s wound.
Staff (#60) changed her gloves four (4)times during the wound care procedure and did not wash her hands after the glove changes.

Staff (# 69) Rehabilitation Technician did not clean a wound care table used during a prior dressing change before setting clean supplies for dressing change for Patient (#53).

Staff (#69) removed a blood stained dressing from the patient ' s right foot she discarded the dressing removed one hand of glove went into the clean supply cupboard to retrieve clean supplies and did not wash her hands.

Staff (# 60)Physical Therapist, used gloved hands to examined the foot and wounds of Patient (#53), she cleaned the wounds removed her soiled gloves donned clean gloves and did not wash her hands,she proceeded to use a scalpel to debride the wound.

Review of wound care procedure seen on staff (#60) orientation performance check list revealed hand washing was not included in the procedure.

Review of the facility's wound care policy # 4001(g) states that: 'Gloves will be changed and hands cleaned after removal of soiled dressings, between treatment of multiple wound sites and after any glove contamination."

During an interview on 7/10/2013 at 11:40 am with the Director of Rehabilitation (#59) she stated cleaning equipment after use was the expectation on the unit. She stated hand washing was discussed in unit meetings but nothing was documented. The Staff stated she could not recall having an infection control inspection by the Infection Control team and that the wound care check list would be revised.

Observation on 7/10/2013 between the hours of at 10:40 am and 11:55 am on the Intermediate Medical Unit (IMU) and the Pediatric Unit revealed rooms that housed four patients had fabric curtains separating each bed cubicle. These partition curtains were permanently drawn and had to be moved aside for persons to enter or exit each cubicle this made the curtains a frequently touched area of the patient cubicle.

Staff on both units interviewed regarding the cleaning protocol for the partition curtains gave information that the curtains were changed when visibly soiled on the Pedi Unit and monthly and when visibly soiled on the IMU. There was no system in place to track the changing of curtains on the units .The staff on both units stated the partition curtains were not changed when patients were discharged from the cubicles. Every item in the cubicles were sanitized after discharge except for the partition curtains.

During an interview on 7/11/2013 at 1:45 pm with the Infection Control Director she stated partition curtains were cleaned when visibly soiled and when a patient is discharged from the Isolation room and not the regular patient cubicles.

During an interview on 7/11/2013 at 2:30 pm with the Director of Environmental Services she stated the curtains in the Quads (4 room cubicles) were not changed or cleaned after patient discharge unless they were visibly soiled.
According to the Director the housekeeping staff followed the cleaning protocols for the Hospital which did not include changing the partition curtains after a patient was discharged.






12000


ENDOSCOPE SUITE
Observation 7/9/13 at 9:25 a.m. in the Endoscope suite at Ben Taub Hospital revealed the following:

In the pre-operative area heavy dust / lint build-up was observed on top of the wall mounted cardiac monitors and red biohazard containers in Holding Room #'s 2, 3, 4, and 5.

In procedure room # 3 heavy dust was observed on top of two Sony monitor screens.

In the fluoroscopy procedure room heavy dust was observed on top of the fluoroscopy machine.

SURGICAL AREA
Observation 7/9/13 at 10:30 a.m. in the pre-operative surgical area at Ben Taub Hospital revealed heavy dust / lint build-up on top of the wall mounted cardiac monitors in bed #'s 1, 2, 7, 8, 9, 10, and 11. Heavy dust was also observed in the post-operative area on top of a Pyxis medication dispensing machine.

QUENTIN MEASE HOSPITAL
Observation 7/10/13 at 10 a.m. of Quentin Mease Hospital revealed the following:
-Lactation room in the basement had a blue vinyl recliner and five (5) white spots were noted on the vinyl

-The Respiratory therapy supply room contained clean Bipap Machines with plastic covering the machines. One Bipap machine had a one inch piece of bacon on the base of the machine. The base of the Bipap Machine was also covered with dust and lint.

-Room 220 was clean and ready to receive a patient. The over-bed table was stained and sticky. A trash can was observed with trash inside.

The Nursing Director of Quentin Mease hospital (ID# 1) acknowledged that environmental services are responsible for cleaning the lactation room and that respiratory therapy is responsible for cleaning the respiratory equipment prior to placing the equipment in the clean storage room.

Record review of a policy titled "Patient Care Equipment: Handling, disposal and / or disinfection" dated June 2005 stated " Policy: Reusable patient care equipment will be thoroughly cleaned by assigned personnel and disinfected between each patient's use..."


21021

A tour of the Smith Clinic, an outpatient clinic of the Harris System, was conducted the afternoon of 7/9/13 in the company of the Nurse Director of Ambulatory Services, Staff #50. In a treatment room in the outpatient radiology area, visible dust was noted on the overhead examination light and other high horizontal surfaces. Visible dust was also noted on horizontal surfaces in a treatment room located in the infusion area, and also in a treatment room located in the endocrine clinic. These findings were acknowledged by Staff #50 during the tour of the clinic the afternoon of 7/9/13.




23032

Re-use / no cleaning of disposable blood pressure cuffs

Observation in the Emergency Room (ER) at LBJ Hospital on 07-09-13 at 11:05 a.m. revealed Patient Care Technician (PCT) # 55 used a disposable blood pressure cuff on a patient in ER treatment room 35. PCT # 55 left ER treatment room # 35 and proceeded to use the same disposable blood pressure cuff on the patient in ER treatment room 36. PCT # 55 failed to clean the blood pressure cuff between patients.

Interview on 07-09-13 immediately after the observation, PCT # 55 stated that often the disposable cuffs had to be re-used between patients if " we don ' t have the correct size. " PCT# 55 acknowledged ER staff did not clean the disposable blood pressure cuffs between patients.

Record review on 07-11-13 of facility policy titled " Patient Care Equipment: Handling, Disposal and/or Disinfection, " dated June 2005, read: " ...2 Reusable patient care equipment will be thoroughly cleaned by assigned personnel; and disinfected between each patients use. 3. Singe use items will be discarded unless a disinfection process and reuse has been approved by the Infection Control Committee... "

Failure to properly change anesthesia supplies/ between cases /sanitize hands:

Observation at LBJ Hospital on 07-10-13 at 9: 30 a.m. revealed Anesthesia Assistant (Staff ID # 61) preparing the anesthesia cart and supplies between surgical cases in OR # 4 .

Anesthesia Assistant ID # 61 gathered the used respiratory supplies from the prior surgical case. After he disposed of the used supplies, Staff ID # 61 failed to sanitize his hands prior to changing gloves. He then wiped down the laryngoscope with disinfectant wipes and placed it into a " sterile " blue towel. This same blue towel (which covered the laryngoscope and endotracheal tube ) was used in the prior case and then for the next case (Patient ID # 58).

Interview on 07-10-13 with MD Chief of Anesthesia (ID # 64) immediately after the OR # 4 set-up, he stated the blue towel containing anesthesia supplies should have been changed between cases. He went on to say that set up and use of anesthesia supplies was an on-going QA initiative. Interview at this same time with OR Director ID # 63, she stated the anesthesia assistant should have sanitized his hands between glove changes.

Unsanitary Storage of Endoscopes

Observation at LBJ Hospital on 07-09-13 at 1:15 p.m. in the Endoscopy Unit revealed a closed storage cabinet that contained various types of endoscopes , hanging vertically. Several human-like hairs and dirt were observed on the bottom shelf of the cabinet, directly below the end of the vertically hanging scopes. There was no towel located at the bottom of the cabinet directly below the end of the scopes.

Interview with GI Tech # 75 at the time of observation she stated she was unaware the bottom of the scope cabinet was dirty; unsure of when it was last cleaned.

Interview with Nursing Director ID # 53 at the time of observation, he acknowledged the cabinet needed cleaning.

Review of facility policy titled " Endoscopy Laboratory/Clinic Infection Control P/P, " dated April 2005, read: " ...8. Endoscopes are stored in a manner that will protect the endoscopes while minimizing the potential for accumulation of residual moisture.. "

Improper storage of linen:

Observation at LBJ Hospital on 07-10-13 at 2:15 p.m. in the Endoscopy Area revealed two(2) patient holding rooms. In patient holding room # 1 there was a patient on a stretcher waiting for a endoscopy procedure. At the end of his stretcher, there was a table that contained a stack of six (6) uncovered blankets. A stack of " clean " patient gowns was stored directly on top of a soiled linen hamper in this patient holding room.

Interview on 07-10-13 at the time of observation with RN (Staff ID # 56) , she stated it was not acceptable to store clean linen uncovered or on top of a soiled linen hamper.

Observation at LBJ Hospital in Day Surgery Unit on 7-09-13 at 1:05 p.m. revealed an uncovered linen cart that was open to family/visitor traffic entering from the outside hallway. Interview at the time of observation with RN # 52, she acknowledged the linen cart should be kept covered at all times.

Review of facility policy titled " Material Management Infection Control Guidelines,: dated June 2005 read: " ...Linen/ Laundry: ... 4. Carts (linen) are covered when not in use ...7. Linen is stored in covered, clean storage carts or areas and/or cabinets. "

Dirty ice machines: 4-A, 4 B, and ICU

Observation on 07-09-13 during initial tour of LBJ Hospital from 9:45 a.m. -12 :00 p.m. revealed ice machines (3) with water mineral build-up , stains, and dust/dirt in the side vents on Units 4-A, 4-B, and MICU.

Interview with RN # 75 at the time of observation on 4-B she stated she was unsure of how often the ice machines were cleaned. She went on to say that nursing would clean as needed but housekeeping cleaned them too. RN # 75 was unaware of any ice machine cleaning logs.

Review of facility policy titled " Nutrition Services: Infection Control procedures, dated May 2006, read: " V11. Equipment ...D. Ice machines are cleaned and routine maintenance provided ... "

Miscellaneous issues:

Observation at the Endoscopy Unit at LBJ Hospital on 07-10-13 at 2:15 p.m. revealed a crash cart that had dirt/dust on the top; and an oxygen cylinder with oxygen tubing wrapped around the tank. RN # 56 acknowledged at the time of observation, the oxygen tubing could have been used and should have been discarded.

Observation on 07-09-13 during initial tour of LBJ Hospital from 9:45 a.m.-12:00 p.m. revealed dirty " roller bases"of several vital sign machines/monitors located on 4-A, 4-B, and ER; on 07-12-13, the same observation was made on Unit 2-B.

Observation on 07-09-13 at 10:45 a.m. of the Treatment Room (4-B) at LBJ Hospital revealed a portable patient privacy screen that was stained and dirty. Additional observation at this time included a table that contained an ultrasound probe and related equipment. The top of the table had dust and dirt. Interview at the time of observation with unit Director ID # 65, she acknowledged the treatment room was not used often and the cleaning was overlooked.




32043


During the tour of the Psychiatric Unit on 7/8/13 at 3:00pm with Staff ID# 39, and Staff ID# 38 Charge Nurse (CN) of the unit revealed the following:

Soiled towels were found on the floor of patient ' s bathrooms HCHD 4.219 and HCHD 4.213. CN stated that the linen were used by patients during shower and should have been removed by the techs after shower. On the floor of HCHD 4.213 was a folded bed spread with a brown dusty stain on it, CN was observed bent down and dusted the stain with her hand. CN continued with the tour without washing her hands or using hand sanitizer; she handled the keys opening doors.

Observed in the seclusion area restroom upon opening the door were several drain flies, commode was dirty and the water in commode appears to have been stagnant for a long time, no foul odor noted. CN stated that housekeeping cleans the unit daily. She explained that the drain flies had been an ongoing off/on problem and whenever they are noticed, she called housekeeping that came to exterminate the flies. Staff stated that she was unsure of the cause of the problem and had not reported it to management.

Based on observation, interview and record review the Hospital failed to ensure a safe setting. The following were noted at Ben Taub Hospital:
1) Intravenous fluids were pre-spiked in the surgery suite area and kept greater than 24 hours against hospital policy
2) An anesthesia provider was scrolling on her cell phone while providing anesthesia to a patient
3) The surgery department failed to keep cooled saline in the event of Malignant Hyperthermia per policy

Findings include:

INTRAVENOUS FLUIDS
Observation 7/9/13 at 1:30 p.m. in the surgery suite area revealed the following:
Operating room #11 had two intravenous fluids of one liter Normal Saline pre-spiked. The tubing was dated 7/7/13 at 12 p.m. Further observation revealed a liter of Ringers Lactate intravenous solution pre-spiked outside the anesthesia work room. The date on the tubing was 7/7/13 at 12 p.m.
(pre-spiked is when the intravenous (IV) solution bag has been attached to tubing, breaking the seal on the IV)

Interview with an anesthesia technician (ID# 11) revealed he prepares intravenous fluids in advance in the event of an emergency case. The technician stated that he keeps the fluids for three days once they have been spiked with the tubing and then discards the solutions.

The Director of Accreditation (ID# 4) confirmed that the standard of practice is to discard any intravenous solutions in 24 hours that have been pre-spiked.

Record review of a policy titled "Medication Use Policy 565.40" (no date) stated "All irrigation containers and Intravenous (IV) solutions will be dated when opened and discarded within twenty-four (24) hours after opening."

MALIGNANT HYPERTHERMIA
Observation 7/9/13 at 1:30 p.m. in the surgery suite area revealed the hospital did not have cooled saline solution immediately available in the event of Malignant Hyperthermia.

A surgical nurse (ID# 20) acknowledged 7/9/13 at 2 p.m. that the surgery area did not keep cooled saline readily available in the event of Malignant Hyperthermia. The nurse stated that if cooled saline were needed they would have to cool it in the ice machine.

Record review of a policy titled "Malignant Hyperthermia" and dated 11/2007 stated "The malignant hyperthermia kit shall contain, but is not limited to:....11) Normal Saline 0.9% for injection IV Bag (kept cold in Operating Room Satellite Pharmacy refrigerator)"

ANESTHESIA
Observation 7/9/13 at 2:05 p.m. in Operating Room #8 revealed a surgical case in progress with several medical staff around the operating room table. The surveyor was observing the case through a window in the door and noticed a staff member sitting at the anesthesia machine and scrolling on her cell phone. Surgical nurse ID# 20 confirmed at this time that the staff member sitting at the anesthesia machine and scrolling on her cell phone was the anesthesia provider for the case (ID# 46). The surgical nurse acknowledged that medical staff should not be using cell phones during surgical cases.

The facility failed to enforce its Medical Staff Bylaws related to completion of a medical History and Physical examination within 24 hours of admission for four (4) of 22 sampled patients at the LBJ Hospital location (Patient ID# ' s: 57, 60, 62, 65).

Findings include:

Record review on 07-11-13 of the clinical records of Patient ID #s 57, 60, 62, and 65 revealed the following:

Patient ID # 65: admitted on 07-05-13 with diagnoses of neck pain and seizures. As of 07-11-13, there was no History & Physical (H&P) examination recorded in the patient record. Staff ID # 56 was unable to locate an H &P in Patient ID# 65 ' s record.

Patient ID # 57: admitted on 07-06-13 with diagnoses of abdominal pain and small bowl construction. Further review revealed an H & P exam was dictated 4 days later on 07-10-13. Patient ID # 57 had surgery on 07-07-13.

Patient ID # 60 : admitted on 07-09-13 with diagnosis of fracture of right calcaneus. H & P recorded by 2nd year resident physician on 07-09-13 at 6:09 a.m. As of 07-11-13, there was no documented agreement of the H & P by the attending physician located in the record. Staff ID # 56 was unable to locate H & P documentation by the attending physician.

Patient ID # 62: admitted on 07-04-13 with diagnosis of vomiting. H & P recorded by surgical resident physician on 07-05-13 at 1904. As of 07-11-13, there was no documented agreement of the H & P by the attending physician located in the record. Staff ID # 56 was unable to locate H & P documentation by the attending physician.

Interview on 07-11-13 at 2:00 p.m. with Medical Records Staff ID # 68 she stated the expectation was the attending physician " write an addendum to the resident ' s H & P within the 24 hour timeframe. "

Interview on 07-12-13 at 1:15 p.m. with the Director of Accreditation (Staff ID # 4), she acknowledged a patient ' s H & P was not authenticated until the attending physician had made an " agreement addendum " after the resident ' s H& P. Staff ID # 4 went on to say the expectation was addendum would be documented within the 24 hour H & P timeframe.

Record review on 07-11-13 of the Medical Staff Bylaws/Rules & Regulations, dated 2009, read: " ...Inpatient: a complete history and physical examination shall, in all cases, be written and placed in the record within twenty-four (24) hours after admission of the patient ...:[In case of emergency surgery ...the H & P shall be recorded immediately after the emergency surgery has been completed] ...The attending physician will document agreement with a complete history and physical examination on all new patients admitted and/or assigned to him/her.. " .

Based on review of documentation and interviews with staff, the facility failed to ensure that medical records were accurately written for 6 of 66 patients whose records were reviewed, as the patient records did not contain documentation of triage assessments conducted by a staff paramedic.

Findings were:

A review of the emergency triage log for Quentin Meese Hospital, which is a Harris County System facility, revealed that 6 patients evaluated and treated by the staff paramedic during July 2013 in the facility triage room did not have documentation of their treatment entered into their medical records. The PARAMEDIC PATIENT CONTACT LOG described the encounters with the patients; however, there was no documentation in the electronic medical records by the paramedic who performed the evaluations.

Patients who were listed on the Quentin Meese triage log for July 2013 included the following:
Patient #1 had been directed to the triage room during a visit to a clinic on the campus. Following an assessment by the paramedic assigned to the triage room, the patient was transported to Ben Taub Hospital by the Houston Fire Department. There was no documentation of the incident into the patient's medical record by the paramedic who assessed the patient. Patients #2 and #3 were assessed by the triage paramedic during visits to the outpatient physical therapy clinic on the campus. Following the assessment and intervention by the triage paramedic, the patients were stabilized and each patient refused transport to the hospital. The patients went home with family members. There was no documentation of the incidents into the patients' medical records by the paramedic who assessed the patients. Patient #4 was also assessed by the triage paramedic; this patient requested to be transported to another nearby hospital not affiliated with the Harris County System. There was no medical record account of the patient's assessment prior to the ambulance transport to the other facility. Patient #5 presented to the triage room on 7/3/13 complaining of abdominal pain. The patient was assessed by the paramedic and transported to the veteran's hospital; however, this assessment was not found in the patient's medical record. Finally, Patient #6 presented to the triage room at Quentin Meese and was assessed by the paramedic for complaints of chest pain. This patient was transported to Ben Taub Hospital; however, there was no entry into the medical record by the paramedic who performed the assessment.

An in-person interview was conducted with Staff #1, the Director of Nursing of Quentin Meese Hospital; Staff #47, a Health Information Management (HIM) Manager; and Staff #48, HIM analyst, the afternoon of 7/10/13 in a facility conference room. These staff members confirmed that paramedics do not have access to the electronic medical record system and do not enter clinical information into the patient records. Staff #1 also acknowledged that these 6 patients had assessments conducted by the paramedic which were not documented in their electronic medical records, and that the PARAMEDIC PATIENT CONTACT LOG is not part of the medical record of these patients.

Based on observation, record review and interview the facility failed to have systems in place to ensure kitchen equipment, walls, and sinks were clean and in good repair; The facility failed to store and prepare food in a manner to prevent the potential for contamination and failed to ensure outdated foods were not available for use. Citing two (2) random observations at LBJ, Quentin Mease Hospital and the Smith Clinic.

Findings:

LBJ

Observation on 7/9/2013 between 8:45 am and 9:25 am revealed uncovered containers of chicken salad were placed approximately a foot from a hand washing sink where staff were constantly washing their hands. This had the potential for contamination from splash during hand washing procedures.

Kitchen equipment including food carts, clean dish storage cart, dishwashing conveyor belt, and bases of refrigerator, walls and hand washing sinks had a heavy buildup of dust, food particles, rust and black grease. Multiple food service utility carts were in a state disrepair.

During an interview on 7/9/2013 at 10:20 am with Staff (57) Food Service Manager, he stated Staff cleaned the hand washing sinks but was not able to say how often the sinks were cleaned. He acknowledged that some of the kitchen equipment were in disrepair and would be disposed of.

Review of the facility's policy/procedure for Nutritional Services presented to the Surveyor documented the following information:

'The Nutrition and food services department should maintain and clean work areas, storage areas, and equipment for handling of supplies in accordance with state and local health department standards.

All surfaces including wall, shelves and refrigerators are cleaned weekly. All food carts are cleaned after each meal.''




12000

Observation 7/8/13 at 2:30 p.m. in the emergency department of Ben Taub Hospital revealed five (5) ham and cheese sandwiches in a refrigerator for patient use in a supply room. The sandwiches were not dated.


21021

A tour of the Smith Clinic, an outpatient clinic of the Harris System, was conducted the afternoon of 7/9/13 in the company of the Nurse Director of Ambulatory Services, Staff #50. In the speech therapy treatment rooms in the outpatient therapy area, outdated food items utilized by the speech therapist during patient therapy were found in cabinets and available for patient use. In one treatment room, 4 containers of Gerber baby food were found with a "best if used by" date of 4/1/13. Two instant oatmeal packages also utilized during speech therapy sessions were found with an expiration date of 10/2012. in the 2nd treatment room, 2 cases of Gerber baby food were found with a "best if used by" date of 4/10/2013. These findings were acknowledged by Staff #50 during the tour of the therapy clinic the afternoon of 7/9/13.

Based on observation, interview, and record review, the facility failed to enforce it's infection control policies for cleaning equipment, proper storing and handling of linen, hand washing protocol and maintaining a sanitary patient environment. This failed practice had the potential for the spread of infection which could adversely affect all patients. Citing four (4) of four (4) locations visited.( LBJ, Quentin Mease, Ben Taub and Smith Clinic)

Findings:

Observation on 7/10/2013 between the hours of 9:30 am and 10:30 am in the Rehabilitation wound care room revealed Staff (60)Physical Therapist completed cleaning a foot wound for Patient (#54), she changed her gloves did not wash her hands, donned clean gloves and proceeded to apply clean dressing to the patient ' s wound.
Staff (#60) changed her gloves four (4)times during the wound care procedure and did not wash her hands after the glove changes.

Staff (# 69) Rehabilitation Technician did not clean a wound care table used during a prior dressing change before setting clean supplies for dressing change for Patient (#53).

Staff (#69) removed a blood stained dressing from the patient ' s right foot she discarded the dressing removed one hand of glove went into the clean supply cupboard to retrieve clean supplies and did not wash her hands.

Staff (# 60)Physical Therapist, used gloved hands to examined the foot and wounds of Patient (#53), she cleaned the wounds removed her soiled gloves donned clean gloves and did not wash her hands,she proceeded to use a scalpel to debride the wound.

Review of wound care procedure seen on staff (#60) orientation performance check list revealed hand washing was not included in the procedure.

Review of the facility's wound care policy # 4001(g) states that: 'Gloves will be changed and hands cleaned after removal of soiled dressings, between treatment of multiple wound sites and after any glove contamination."

During an interview on 7/10/2013 at 11:40 am with the Director of Rehabilitation (#59) she stated cleaning equipment after use was the expectation on the unit. She stated hand washing was discussed in unit meetings but nothing was documented. The Staff stated she could not recall having an infection control inspection by the Infection Control team and that the wound care check list would be revised.

Observation on 7/10/2013 between the hours of at 10:40 am and 11:55 am on the Intermediate Medical Unit (IMU) and the Pediatric Unit revealed rooms that housed four patients had fabric curtains separating each bed cubicle. These partition curtains were permanently drawn and had to be moved aside for persons to enter or exit each cubicle this made the curtains a frequently touched area of the patient cubicle.

Staff on both units interviewed regarding the cleaning protocol for the partition curtains gave information that the curtains were changed when visibly soiled on the Pedi Unit and monthly and when visibly soiled on the IMU. There was no system in place to track the changing of curtains on the units .The staff on both units stated the partition curtains were not changed when patients were discharged from the cubicles. Every item in the cubicles were sanitized after discharge except for the partition curtains.

During an interview on 7/11/2013 at 1:45 pm with the Infection Control Director she stated partition curtains were cleaned when visibly soiled and when a patient is discharged from the Isolation room and not the regular patient cubicles.

During an interview on 7/11/2013 at 2:30 pm with the Director of Environmental Services she stated the curtains in the Quads (4 room cubicles) were not changed or cleaned after patient discharge unless they were visibly soiled.
According to the Director the housekeeping staff followed the cleaning protocols for the Hospital which did not include changing the partition curtains after a patient was discharged.






12000


ENDOSCOPE SUITE
Observation 7/9/13 at 9:25 a.m. in the Endoscope suite at Ben Taub Hospital revealed the following:

In the pre-operative area heavy dust / lint build-up was observed on top of the wall mounted cardiac monitors and red biohazard containers in Holding Room #'s 2, 3, 4, and 5.

In procedure room # 3 heavy dust was observed on top of two Sony monitor screens.

In the fluoroscopy procedure room heavy dust was observed on top of the fluoroscopy machine.

SURGICAL AREA
Observation 7/9/13 at 10:30 a.m. in the pre-operative surgical area at Ben Taub Hospital revealed heavy dust / lint build-up on top of the wall mounted cardiac monitors in bed #'s 1, 2, 7, 8, 9, 10, and 11. Heavy dust was also observed in the post-operative area on top of a Pyxis medication dispensing machine.

QUENTIN MEASE HOSPITAL
Observation 7/10/13 at 10 a.m. of Quentin Mease Hospital revealed the following:
-Lactation room in the basement had a blue vinyl recliner and five (5) white spots were noted on the vinyl

-The Respiratory therapy supply room contained clean Bipap Machines with plastic covering the machines. One Bipap machine had a one inch piece of bacon on the base of the machine. The base of the Bipap Machine was also covered with dust and lint.

-Room 220 was clean and ready to receive a patient. The over-bed table was stained and sticky. A trash can was observed with trash inside.

The Nursing Director of Quentin Mease hospital (ID# 1) acknowledged that environmental services are responsible for cleaning the lactation room and that respiratory therapy is responsible for cleaning the respiratory equipment prior to placing the equipment in the clean storage room.

Record review of a policy titled "Patient Care Equipment: Handling, disposal and / or disinfection" dated June 2005 stated " Policy: Reusable patient care equipment will be thoroughly cleaned by assigned personnel and disinfected between each patient's use..."


21021

A tour of the Smith Clinic, an outpatient clinic of the Harris System, was conducted the afternoon of 7/9/13 in the company of the Nurse Director of Ambulatory Services, Staff #50. In a treatment room in the outpatient radiology area, visible dust was noted on the overhead examination light and other high horizontal surfaces. Visible dust was also noted on horizontal surfaces in a treatment room located in the infusion area, and also in a treatment room located in the endocrine clinic. These findings were acknowledged by Staff #50 during the tour of the clinic the afternoon of 7/9/13.




23032

Re-use / no cleaning of disposable blood pressure cuffs

Observation in the Emergency Room (ER) at LBJ Hospital on 07-09-13 at 11:05 a.m. revealed Patient Care Technician (PCT) # 55 used a disposable blood pressure cuff on a patient in ER treatment room 35. PCT # 55 left ER treatment room # 35 and proceeded to use the same disposable blood pressure cuff on the patient in ER treatment room 36. PCT # 55 failed to clean the blood pressure cuff between patients.

Interview on 07-09-13 immediately after the observation, PCT # 55 stated that often the disposable cuffs had to be re-used between patients if " we don ' t have the correct size. " PCT# 55 acknowledged ER staff did not clean the disposable blood pressure cuffs between patients.

Record review on 07-11-13 of facility policy titled " Patient Care Equipment: Handling, Disposal and/or Disinfection, " dated June 2005, read: " ...2 Reusable patient care equipment will be thoroughly cleaned by assigned personnel; and disinfected between each patients use. 3. Singe use items will be discarded unless a disinfection process and reuse has been approved by the Infection Control Committee... "

Failure to properly change anesthesia supplies/ between cases /sanitize hands:

Observation at LBJ Hospital on 07-10-13 at 9: 30 a.m. revealed Anesthesia Assistant (Staff ID # 61) preparing the anesthesia cart and supplies between surgical cases in OR # 4 .

Anesthesia Assistant ID # 61 gathered the used respiratory supplies from the prior surgical case. After he disposed of the used supplies, Staff ID # 61 failed to sanitize his hands prior to changing gloves. He then wiped down the laryngoscope with disinfectant wipes and placed it into a " sterile " blue towel. This same blue towel (which covered the laryngoscope and endotracheal tube ) was used in the prior case and then for the next case (Patient ID # 58).

Interview on 07-10-13 with MD Chief of Anesthesia (ID # 64) immediately after the OR # 4 set-up, he stated the blue towel containing anesthesia supplies should have been changed between cases. He went on to say that set up and use of anesthesia supplies was an on-going QA initiative. Interview at this same time with OR Director ID # 63, she stated the anesthesia assistant should have sanitized his hands between glove changes.

Unsanitary Storage of Endoscopes

Observation at LBJ Hospital on 07-09-13 at 1:15 p.m. in the Endoscopy Unit revealed a closed storage cabinet that contained various types of endoscopes , hanging vertically. Several human-like hairs and dirt were observed on the bottom shelf of the cabinet, directly below the end of the vertically hanging scopes. There was no towel located at the bottom of the cabinet directly below the end of the scopes.

Interview with GI Tech # 75 at the time of observation she stated she was unaware the bottom of the scope cabinet was dirty; unsure of when it was last cleaned.

Interview with Nursing Director ID # 53 at the time of observation, he acknowledged the cabinet needed cleaning.

Review of facility policy titled " Endoscopy Laboratory/Clinic Infection Control P/P, " dated April 2005, read: " ...8. Endoscopes are stored in a manner that will protect the endoscopes while minimizing the potential for accumulation of residual moisture.. "

Improper storage of linen:

Observation at LBJ Hospital on 07-10-13 at 2:15 p.m. in the Endoscopy Area revealed two(2) patient holding rooms. In patient holding room # 1 there was a patient on a stretcher waiting for a endoscopy procedure. At the end of his stretcher, there was a table that contained a stack of six (6) uncovered blankets. A stack of " clean " patient gowns was stored directly on top of a soiled linen hamper in this patient holding room.

Interview on 07-10-13 at the time of observation with RN (Staff ID # 56) , she stated it was not acceptable to store clean linen uncovered or on top of a soiled linen hamper.

Observation at LBJ Hospital in Day Surgery Unit on 7-09-13 at 1:05 p.m. revealed an uncovered linen cart that was open to family/visitor traffic entering from the outside hallway. Interview at the time of observation with RN # 52, she acknowledged the linen cart should be kept covered at all times.

Review of facility policy titled " Material Management Infection Control Guidelines,: dated June 2005 read: " ...Linen/ Laundry: ... 4. Carts (linen) are covered when not in use ...7. Linen is stored in covered, clean storage carts or areas and/or cabinets. "

Dirty ice machines: 4-A, 4 B, and ICU

Observation on 07-09-13 during initial tour of LBJ Hospital from 9:45 a.m. -12 :00 p.m. revealed ice machines (3) with water mineral build-up , stains, and dust/dirt in the side vents on Units 4-A, 4-B, and MICU.

Interview with RN # 75 at the time of observation on 4-B she stated she was unsure of how often the ice machines were cleaned. She went on to say that nursing would clean as needed but housekeeping cleaned them too. RN # 75 was unaware of any ice machine cleaning logs.

Review of facility policy titled " Nutrition Services: Infection Control procedures, dated May 2006, read: " V11. Equipment ...D. Ice machines are cleaned and routine maintenance provided ... "

Miscellaneous issues:

Observation at the Endoscopy Unit at LBJ Hospital on 07-10-13 at 2:15 p.m. revealed a crash cart that had dirt/dust on the top; and an oxygen cylinder with oxygen tubing wrapped around the tank. RN # 56 acknowledged at the time of observation, the oxygen tubing could have been used and should have been discarded.

Observation on 07-09-13 during initial tour of LBJ Hospital from 9:45 a.m.-12:00 p.m. revealed dirty " roller bases"of several vital sign machines/monitors located on 4-A, 4-B, and ER; on 07-12-13, the same observation was made on Unit 2-B.

Observation on 07-09-13 at 10:45 a.m. of the Treatment Room (4-B) at LBJ Hospital revealed a portable patient privacy screen that was stained and dirty. Additional observation at this time included a table that contained an ultrasound probe and related equipment. The top of the table had dust and dirt. Interview at the time of observation with unit Director ID # 65, she acknowledged the treatment room was not used often and the cleaning was overlooked.




32043


During the tour of the Psychiatric Unit on 7/8/13 at 3:00pm with Staff ID# 39, and Staff ID# 38 Charge Nurse (CN) of the unit revealed the following:

Soiled towels were found on the floor of patient ' s bathrooms HCHD 4.219 and HCHD 4.213. CN stated that the linen were used by patients during shower and should have been removed by the techs after shower. On the floor of HCHD 4.213 was a folded bed spread with a brown dusty stain on it, CN was observed bent down and dusted the stain with her hand. CN continued with the tour without washing her hands or using hand sanitizer; she handled the keys opening doors.

Observed in the seclusion area restroom upon opening the door were several drain flies, commode was dirty and the water in commode appears to have been stagnant for a long time, no foul odor noted. CN stated that housekeeping cleans the unit daily. She explained that the drain flies had been an ongoing off/on problem and whenever they are noticed, she called housekeeping that came to exterminate the flies. Staff stated that she was unsure of the cause of the problem and had not reported it to management.