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Based on observation, interview and record review the Hospital failed to ensure the hospital environment was maintained for the safety of patients in operating room suite area.
(Operating Room #'s 1, 2, 3, 4, 5, 6, 7, and 8).

Findings include:

Based on interview 8/12/11 at 9:40 a.m. with the Director of OR (ID# 55) revealed they currently use only 6 operating rooms (Operating Room #'s 1, 2, 3, 4, 5, and 6) Operating room # 's 7 and # 8 were out of service due to air condition problems. She stated OR # 8 was currently used for storage. The surveyor was unable to view OR # 4 due to surgery in progress.

OPERATING ROOM # 1
Surveyor on August 12, 2011 at 10:00 AM along with OR Director and Director of Maintenance observed equipment in OR # 1. Return air vent was located behind equipment. Rust was observed on wheel brackets of IV pole.

OPERATING ROOM #2
Surveyor on August 12, 2011 at 10:10 AM along with OR Director and Director of Maintenance observed equipment in OR # 2. Surgical table mattress was observed with tears and worn areas. IV pole was observed to have rust on wheel brackets and bottom panel.

OPERATING ROOM #3
Surveyor on August 12, 2011 at 10:00 AM along with OR Director (ID# 55) and Director of Maintenance (ID# 53) observed equipment in OR # 3 to have surface rust on the wall return air vent and surface rust on metal soiled linen container. OR mattress pads were found to have multiple cracks and worn areas on edges and the top surface that were too many to count. Cracks were approximately ? inch along edges of mattress. A blanket warmer was observed in the OR room positioned in front of a return air vent blocking the flow of air.

OPERATING ROOM# 4
Surveyor on August 12, 2011 at 10:15 AM along with OR Director observed stretcher in OR hallway across from room # 4 to have multiple cracks on top surface and edges approximately ? inch in length. Visible rust was also observed the entire length of the right side rail.

Surveyor on the morning of August 12, 2011 along with OR Director and Director of Maintenance observed hand wash area across from OR #4 to have sheetrock that was moist and wet (mushy in appearance) and with flaking paint that could not be cleaned.

OPERATING ROOM # 5
Surveyor on August 12, 2011 at 9:50 AM along with OR Director (ID# 55) observed operating table in OR # 5 with multiple chipped paint areas that were too many to count on the bottom of the OR table with visible rust in paint chip areas approximately 1-1 ? inches by ? inches in size. X-ray lead aprons were found to be hanging over the smoke exhaust return vent blocking air flow. Air conditioner/humidity controls were observed by surveyor, OR Director and Director of Maintenance to have exposed wires with no covers. Director of Maintenance, (ID# 53) stated these were old controls that were no longer used and needed to be removed.

OPERATING ROOM #6
Surveyor on August 12, 2011 at 9:40 AM along with OR Director (ID# 55)
observed equipment in OR # 6 to have an accumulation of visible rust on the IV pole. Rust was observed on the surface of the bottom panel of the IV pole and also an accumulation of visible rust on each wheel bracket. Areas of sheetrock patch work were observed on the wall that had not been painted (exposed sheet rock).

OPERATING ROOM #7
Surveyor on morning of August 12, 2011 along with OR Director and Director of Maintenance observed a ceiling area in OR #7 with raw sheetrock exposed (not painted). It was observed that approximately a 4 foot by 3 foot area had been taped and floated. The maintenance director (ID# 53) stated the damage was the result of a water leak which had been repaired and they were in the process of doing repairs to ceiling. OR Director stated OR #7 was closed due to AC service for about the past 2-3 months.

OPERATING ROOM # 8
Surveyor on August 12, 2011 at 9:30 AM along with OR Director observed OR #8 to have 4 stretchers with pads, operation surgical instruments, surgical supplies, tables,
X-ray equipment and other equipment stored in the room. OR Director stated that OR # 8 was used only for storage. The air conditioning did not work in the room. OR Director stated the air condition had been out for 3-4 months.

Surveyor on the morning of August 12, 2011 along with OR Director and Director of Maintenance observed multiple areas in the operating rooms and hallways where carts had rubbed against walls causing damage leaving sheetrock exposed and unable to be cleaned.

Surveyor on the morning of August 12, 2011 along with OR Director and Director of Maintenance observed areas of damage to all operating room doors
(#'s 1, 2, 3, 4, 5, 6, 7, 8) where particle board was exposed due to carts and equipment hitting doors resulting in chipped Formica.

Surveyor on the morning of August 12, 2011 along with OR Director observed outside of OR # 2 scrub sink area one box of 30 count Providone-Iodine BD EZ Scrub pads with expiration date 2010 - November.

Surveyor on the morning of August 12, 2011 along with OR Director observed outside of OR # 4 scrub sink area one box of 30 count Providone-Iodine BD EZ Scrub pads with expiration date 2010 - February.

Record review of "Surgery Specialty Hospitals" of America Infection Control plan revised 1/2008 revealed the policy states the Purpose: " The Infection Control Program assists in providing a high level of patient care by reducing the risk of nosocomial infections to patients (both inpatients and outpatients), health care providers and visitors. This is accomplished through surveillance, prevention, control of potential infections and continuous review and evaluation of Infection Control practices. Responsibilities: The assurance of a safe hospital environment, which provides quality care and the necessary resources to prevent and control infections, is the responsibility of the governing Board through the hospital administration team."

Interview with Director of Maintenance (ID# 53) on the morning of August 12, 2011 revealed the facility failed to document and maintain logs of dates for HVAC filter changes in the operating rooms.

Review of the facility ' s policy/procedure on "Maintenance and Inspection: Heating, Air Conditioning and Ventilation (HVAC) System" dated 2009 stated "Procedure: Change all in-line filters quarterly and HEPA filters as needed."

Record review of a Performance Improvement Worksheet dated 2011 revealed on 6/28/11 the infection control nurse identified "Operating Room #3 and Operating Room #4 vents rusty." No action has been taken to date (8/12/11).

Complaint Intake: TX00148458

Based on observation, interview, and record review the hospital failed to ensure a physician was on duty in the emergency treatment area at all times.

Findings Include:

Observation 8/12/11 at 8:30 a.m. revealed a physician was not present in the Emergency Department. The Administrator at this time called the physician (ID# 51) scheduled that day and was told by the physician she was in the pre-operative area doing a History and Physical on a patient. The physician assigned to the emergency department is also the Medical Director of the emergency room.

Observation 8/12/11 at 8:35 a.m. in the pre-operative area revealed the emergency room physician assigned to the emergency room (ID# 51) was not in the pre-operative area doing a History and Physical. On 8/12/11 at 8:37 a.m. the emergency room physician was observed coming from the professional building attached to the hospital.

The emergency room physician (ID# 51) acknowledged 8/12/11 at 8:37 a.m. that she has a physician practice in the professional building and sees patients in her office while being simultaneously assigned to cover the emergency room of the hospital. The emergency room physician further stated that it was her understanding that the physician covering the emergency room could be on call as long as they could respond within 30 minutes.

Record review of a contract titled " Medical Services Agreement " dated August 1st, 1999 between the hospital and physician ID# 51 stated " The M.D. agrees to provide patient care services as defined in Attachment A which is incorporated herein ... " Attachment A stated " Hospital Physicians Coverage: Provide on site coverage 24 hours per day, 7 days per week for in and outpatient medical care. "

During the exit conference 8/12/11 at 2:45 p.m. the Medical Director of the emergency room (ID# 51) stated that it is possible that emergency room physicians may at times leave the hospital to go pick up meals since the hospital does not have a cafeteria.

Record review of the " Governing Board Bylaws " dated 02/2009 stated " Scope of Services: 24-hour Emergency Services. "