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Based on observation and interview it was determined that the facility failed to ensure that all patient equipment was maintained in safe operating condition.

Findings were:
Medications were able to be removed from the crash cart located in the corner of the emergency department without breaking the red plastic security tab. During a tour of the emergency department on 6/02/2015 the surveyor was able to pull open the top horizontal sliding drawer of the crash cart approximately 2 inches and was able to reach in and remove a prefilled lidocaine syringe. The surveyor was able to do this without breaking the red plastic security tab. In an interview with the Chief Executive Officer on 6/02/2015 it was confirmed that the top horizontal sliding drawer on this particular crash cart was not secure as the surveyor had been able to remove medication.

Based on observation, review of documentation and interview it was determined that the facility failed to ensure that expired medications and laboratory supplies were properly disposed of.

Findings were:
Expired medications and supplies were found on the premises and potentially available for use. During a tour of the nursing medication room on 6/02/2015 a blister package containing 13 individual 1mg Xanax (Alprazolam) tablets was found stored with other controlled medications. The expiration date on the Xanax blister package was listed as 5-2015. During a tour of the hospital laboratory area on 6/02/2015, 11 expired Adult Blood Culture Collection Kits were found on an open shelf area, the expiration date on these blood collection kits was listed as: 3/18/2015. In wall mounted cabinet in the laboratory, 6 each Siemens 500ml Quiklyte Sample Diluent were found with expiration dates of 2014/12/01. Also found in the same cabinet were 3 each Siemens Dimension Clinical Chemistry System Heterogeneous Immunoassay Module Chemistry Wash with expiration dates of 2015-01-16. Review of facility policy entitled: "Procurement, Storage, Controlled Substances, Drug Samples, Formulary, and Out-of-date Medications" stated: "8. Out-of-date medications are not to be used. Such medications will be removed from stock and inventoried twice annually by the Pharmaceutical Return Specialist. These medications are either mailed to the manufacturer or disposed of in the biohazard disposal system. All nursing staff members must observe dates on any medication they administer. Controlled substances are inventoried and sent back to the Dallas office of the Drug Enforcement Administration and records are maintained. Medications that exhibit only a month/year expiration date shall be considered to expire on the last day of the given month/year." In an interview the Director of Nursing on 6/02/2015 it was confirmed that the expired Xanax and expired laboratory supplies were found during the tour of the facility.

Based on observation and interview it was determined that the facility failed to ensure that the premises were clean.
Findings were: Multiple areas in the hospital were found to be in need of housekeeping services. During a tour of the hospital on June 2, 2015 the following was observed: The top of the refrigerator in the kitchen was dusty. When the surveyor ran their hand across the top edge of the refrigerator, visible amounts of particulate dust matter was observed clinging to the surveyors hand and was also seen floating in the air. Under the sink in the kitchen a clear refillable spray bottle was found which contained a yellowish liquid, there was no labeling on the spray bottle to indicate what the contents were. In an unlocked storage area located adjacent to exterior loading dock, multiple dead insects were observed on the floor. In the men's restroom adjacent to the public lobby area there appeared to be dried water stains in the overhead light fixture. In a small room located adjacent to the nurse's station, the top of the ice machine was dusty, when the surveyor their hand across the top edge of the ice machine, visible amounts of particulate dust matter was observed clinging to the surveyors hand and was also seen floating in the air. In the pharmacy there were what appeared to be dead insects visible in the overhead ceiling light. In the physicians dictation room located across from the blood bank area there was dust found on the top of a laboratory storage refrigerator. There was visible dust on the Physio Control LIfePak 12 defibrillator located by the nurse's station. There was visible dust on the screen of the Dynascope DS 7100 blood pressure/pulse monitor in the emergency department. There was visible dust observed on the top of the crash cart in the emergency department. There was dust observed on the Code Master defibrillator located in the emergency department. Dust was observed on the disposable wall mounted suction canister in the emergency department. What appeared to be dust was observed inside a closed box of non-sterile blunt disposable hyfrecator tips which was found on top of the wall mounted hyfrecator in the emergency department. Additionally dust was observed in multiple areas of the inpatient rooms. The above findings were confirmed by the Director of Nursing and the Hospital Administrator during interviews on 6/02/2015. When the Administrator was asked for a copy of the housekeeping policy, it was confirmed in an interview that there was no current approved hospital policy on housekeeping available for review by the surveyor; the Administrator commented that a policy was being developed and showed the surveyor a draft copy. A review of facility document entitled: "QA Meeting for North Runnels Hospital" dated May 20, 2015 revealed the following comment: "(name of staff member) reports all is going well in housekeeping."

Based on interview it was determined that the facility failed to ensure that the midlevel practitioners (nurse practitioner and physician assistant) had participated in a periodic review of the hospital written policies.

Findings were:
No documentation was found by or provided to the surveyor to indicate that the hospital mid level practitioners (nurse practitioner and physician assistant) had participated in a periodic review of the hospital policies and procedures. On 6/03/2015, upon request by the surveyor, the Chief Executive Officer and the Assistant Director of Nursing were unable to provide any documentation indicating that the mid level practitioners had participated in a periodic review of the hospital polices and procedures. In an interview on 6/03/2015 with the Chief Executive Officer and Assistant Director of Nursing it was confirmed that there was no documentation available for review by the surveyor to indicate that the mid level practitioners had participated in a periodic review of hospital policies.

Based on observation, review of documentation and interview it was determined that the facility failed to ensure that the dating of food products found in the hospital kitchen was consistent.

Findings were:
Opened packages of food products in the hospital kitchen area were found to have no dates indicating when the packaging had been opened and other food products were found to have dates which in some cases were several years old. A tour of the hospital kitchen area on 6/02/2015 found that inside the refrigerator there were opened packages of food with no date indicating when the packages had been opened, these included: an opened package of butter (approximately 1/2 pound) found inside a clear bag, a 16 ounce jar of banana peppers, an opened package of Oscar Meyer Smoked White Turkey Meat, an opened package of summer sausage, and an opaque container of orange juice. In the walk in freezer there was an opened bag of hush puppies with no date indicating when the bag had been opened. In a walk in pantry area there as a "Sterilite" container found to contain corn meal, the date on the container was listed as 12-4-13. In the same pantry area other "Sterilite" containers were found to include one with corn starch with a labeled date of 6/14/13, a container of sugar had a labeled date of 10/27/2010. Additionally there two other "Sterilite" containers, one found to be contain flour with no date and one containing a clear sack of bacon bits with no date as when the bacon bits had been opened. Review of facility policy entitled: "Purchasing and Storage" stated: "3. All food supplies will be dated with a marking pen on delivery by the food service employee who put up the supplies. Stock will be rotated to insure that the older stock is used first. First in - First out." "4. All opened containers and all left-over foods will be covered before storage, stored at temperatures below 40 degrees F, and dated with the date it was opened and prepared." "5. Leftover foods will be discarded after 3 days if not used." Review of hospital document entitled: "Monthly Report of Consultant Dietitian" dated: 5-6-2015 stated: "2. Kitchen neat and clean. Food storage looks good." Review of facility documents entitled: "Food Storage Chart- Shelf Life of Food" "Refrigerator/Freezer Storage Chart" and "Staples Or Pantry Items" (note: these documents were provided to the surveyor by the Dietician) indicated corn meal can be stored for 12 months, granulated sugar can be stored for 2 years and that flour can be stored at room temperature for 6 to 8 months at room temperature of 70 degrees. Lunch meat was listed as being able to be stored for 3-5 days in refrigerator at 37-40 degrees. In an interview with the Dietary Supervisor on the morning of 6/02/2014 it was confirmed that there were food products found without dates indicating when they were opened.

Based on review of documentation and interview it was determined that the facility failed to ensure that the appropriateness of diagnosis and treatment furnished by the mid level practitioners at the CAH were evaluated by a member of the CAH staff who is a physician.

Findings were:
Six medical staff peer review forms were found to have not been completed by facility physicians. Review of facility document entitled: "Medical Staff Meeting North Runnels Hospital" dated April 9, 2015 stated: "14) Peer Review: Dr. (name of physician) given three (3) charts to review; Dr. (name of physician) given (3) charts to review." A review of six separate North Runnels Hospital Medical Staff Peer Review forms (for patients #260-15, #247-15, # 265-15, #221-15, #274-15, #248-15) all with the Date Of Review listed as 4-9-15 were found to have not been completed. The area on each of the six forms which stated: "Please Check The Following Areas: 1. Legibility, 2. Chief Complaint, Previous History, Medication History, 3. Diagnosis and Physician Orders, 4. Laboratory/Radiology Orders, 5. Comments" was found to be blank. Also the area on each of these six forms where the reviewing physician was to sign was found to be blank as well. In an interview withe the Chief Executive Officer and the Assistant Director of Nursing on 6/03/2015 it was confirmed that the 6 hospital peer review forms found by the surveyor had not been completed. In the same interview the Chief Executive Officer commented that there currently was not a hospital peer review policy available for the surveyor to review.