HospitalInspections.org

Based on a tour of the facility, staff interviews, and review of facility documentation, it was determined that the Governing Body failed to adequately oversee the conduct of the hospital.


Findings were:


The governing body failed to ensure that their Patient's Rights were protected when:

" patient written complaints were not addressed per hospital policy. See Tag A118

" patients were not allowed to actively participate in the development and implementation of their Plan of Care. See Tag

" patients were not provided written information about their psychoactive medications. See Tag A130

" failed to provide patient care in safe setting when surveyors observed multiple ligature risks at the DePaul Center. See Tag A144

" failed to protect patient health information from the public. See Tag A147

" failed to ensure that staff were properly trained to apply restraints to the psychiatric patients they serve. See Tag A196



The governing body failed to ensure that accepted infection control practices were used in the hospital when:

" they failed to ensure the Infection Control Officer had the appropriate qualifications to perform the job. See Tag A748

" the surveyors observed multiple incidents were staff did not perform appropriate infection control measures when providing patient care. See Tag A749

" the hospital and DePaul Center kitchens were observed to be unkempt and in disrepair. See Tag A748

" the hospital surgical services improperly used flash sterilization for their surgical instruments. See Tag A712



The governing body failed to ensure that the Food and Dietetic Services were provided in a safe manner:

" the DePaul Center kitchen/dining area was in need of cleaning of dirt, debris, insects and grease in the food preparation and plating areas. See Tag A620

" Sanitizing solutions did not contain the minimum amount of sanitizer to be effective. See Tag A620

" dried food was observed on cooking utensils. See Tag A620

" observations of improperly stored food. See Tag A620




In interviews during the week of 4/3/17 through 4/6/17 with hospital administration and patient care staff (see specific citations) the above findings were acknowledged.

Based on document review, policy review, and staff interview, the hospital governing body failed to ensure their contracted provider followed their contract agreement, followed state and federal rules and regulations, and their own policies in the care of hemodialysis patients.


Findings were:


Review of Acute Dialysis Services Agreement dated 1/15/08 states in part:

* The services shall be performed by non-physician employees or contractors of Provider, all of whom shall be duly licensed and qualified nurses or qualified technicians trained in extracorporeal therapy including acute dialysis treatments, as applicable to the particular services prescribed and in accordance with relevant state licensure requirements (the Provider Staff).

* Provider shall provide policies, procedures, and techniques pertaining to the methods by which the services are rendered at Hospital pursuant to this Agreement.

* All Provider Staff performing services at Hospital will have a current competency record including primary source verification of licensure....competency record of each Provider staff providing services hereunder....current CPR card, .... competency exam verification, ....annual dialysis evaluation verification, ...current job description.

* Provider and Provider staff providing services to Hospital under this Agreement shall perform all Provider's duties and obligations as set forth herein in accordance with all applicable federal and state laws and regulations, applicable Hospital policies, bylaws, rules, and regulations.


Review of Fresenius Medical Care Policies and Procedures state:

* Nursing Supervision of the FMS Inpatient Services Program Procedure states "An FMS registered nurse will directly supervise all care provided by a Licensed Practical Nurse or Inpatient Services Patient Care Technicians in accordance with the guidelines specified in the Nursing Supervision of the FMS Inpatient Services Program Policy."

* Nursing Supervision of the FMS Inpatient Services Program Policy states "Responsibility: FMS Inpatient Services Staff (based on job description, license certification, State and/or Federal regulations). Direct Supervision: for purposes of inpatient dialysis services provided under this policy requires the RN to be on-site (though not necessarily physically present) where the patient care is being performed, and the FMS RN must be able to be available to respond. Direct supervision requires that the FMS RN be in close physical proximity to the PCT or LVN, such as being in rooms that are across the hall or are adjacent. The American Nurses Association and the National Council of State Boards of Nursing define delegation as a nurse directing another person to perform a nursing task(s) or activities that are delegable defined by the State Nurse Practice Act. If services are provided in Intensive Care Unit, then an Inpatient RN can supervise....None. Patient Care Technicians may be used to set up hemodialysis equipment for treatment in the centralized inpatient treatment area, intensive care, and individualized patient hospital room.

* FMS Inpatient Services Emergent On Call Procedure states "The contracted hospital will be responsible for notifying the on call FMS Inpatient Services nurse regarding the need for any emergent dialysis treatments. All emergent inpatient services and procedures will be performed in appropriate settings by skilled staff."

* FMS Inpatient Services Emergent On Call Policy states "It is the policy of FMS Inpatient Services to provide emergent treatments in accordance with the contractual agreement between the FMS Inpatient Services program and the contracted "hospital". At least one FMS Inpatient Services Registered Nurse will be on call at all times. ONLY registered nurses may take call for FMS Inpatient Services after hour's emergent treatments."

* Initiation of Treatment Using a Central Venous Catheter.... states "The task of connecting and disconnecting the central venous catheter to the dialysis machine, the monitoring during dialysis treatment, and the technical aspects of the dressing change procedure may be performed by both nurses and patient care technicians in some states. However, in certain states, patient care technicians are prohibited from these tasks....... Tasks completed by Patient Care Technicians (PCT) within FMCNA must be in accordance with State laws and regulations. Delegation of tasks to PCTs cannot occur until it is determined that State permits delegation of a particular function..."

* Termination of Treatment Using a Central Venous Catheter.... states "The task of connecting and disconnecting the central venous catheter to the dialysis machine, the monitoring during dialysis treatment, and the technical aspects of the dressing change procedure may be performed by both nurses and patient care technicians in some states. However, in certain states, patient care technicians are prohibited from these tasks....... Tasks completed by Patient Care Technicians (PCT) within FMCNA must be in accordance with State laws and regulations. Delegation of tasks to PCTs cannot occur until it is determined that State permits delegation of a particular function..."

* FMS Inpatient Service General Policy Statement states "FMS Inpatient Services will adhere to all FMS policies and procedures."


Texas Administrative Code is as follows:

TAC 117.65
DIALYSIS TECHNICIANS.

Prohibited Acts:

Performance of the following acts by any dialysis technician who is not a licensed vocational nurse is prohibited:

(1) initiation of patient education;

(2) alteration of ordered treatment, including shortening of the treatment time.

(3) initiation or discontinuation of dialysis via a central catheter, manipulation of a central catheter, or dressing changes for a central catheter;

(4) administration of any medications other than normal saline, heparin, lidocaine, or oxygen, which may only be administered in the course of a routine dialysis treatment;

(5) administration of blood or blood products;

(6) performance of nonaccess site arterial puncture;

(7) acceptance of physician orders;

(8) provision of hemodialysis treatment to pediatric patients less than 35 kilograms;

(9) alteration of the level of electrolytes in dialysate through the use of additive(s) ("spiking"); and

(10) initiation or discontinuation of dialysis via an implantable port.


TAC 117.46 (f)(1)(B)
Qualifications of Staff.

(B) Any staff member assigned responsibilities in the technical area shall pass a written competency examination, demonstrate skills related to the required level of responsibility, and be certified by the facility's medical director as competent to perform their assigned duties. Current certification by a national board in dialysis technology may substitute for the written test.


TAC 117.63 (f)
DIALYSIS TECHNICIANS.

Competency Evaluation.
(f) If a dialysis technician other than a licensed vocational nurse is to cannulate a dialysis access, administer normal saline, heparin, lidocaine, or oxygen, the medical director shall verify and document competency of the dialysis technician to perform these tasks and delegate authority to the technician in accordance with Occupations Code, Chapter 157.


Review of On Call schedule for December 1, 2016-April 2017 revealed the contracted dialysis provider used patient care technicians for call for acute dialysis treatments outside of the normal operating hours of the inpatient dialysis program.


Review of personnel file for contracted dialysis staff acute coordinator reveals the following:

* Acute Coordinator: Education: Graduate of an accredited School of Nursing (R.N.)
* Signed by staff #23 who is an LVN.


Review of personnel files for contracted dialysis staff reveals the following deficiencies:

* Staff #16, #18, #19, #20, #21, #22, #23, #25, and #26 have no review by the medical director to certify their training in technical duties related to water and dialysis skills.

* Staff #16, #18, #19, #20, #21, #22, #23, and #25 have no color blindness testing in their file and they perform water testing.

* Staff #16, #19, #21, and #22 are patient care technicians and have no delegation by the medical director to perform cannulation of the dialysis access and administer dialysis related medications, i.e. normal saline and oxygen.


In an interview with staff #19 in the dialysis inpatient room on 4/3/17, she stated she was a dialysis technician. She further stated she took call about every 5 weeks. She stated when she is on call she does not have a dialysis RN on call with her. She stated the dialysis technicians are the staff on call for inpatient dialysis services outside of the normal operating hours. She stated she dialyzed patients in the ICU and in isolation rooms by herself with no dialysis trained RN in the room or on the unit with her. She further stated she does what she can in assessing the patient and relies on the floor nurses to do assessments and give medication to the patients. She stated she gives normal saline boluses to the patients when needed during treatment. She further stated she did initiation and termination and CVC dressing changes on the dialysis patients with central venous catheters.


In an interview with staff #27 outside the inpatient dialysis room on 4/3/17 he stated FMC follows their policies in regard to caring for inpatient dialysis patients. He stated they do have technicians on call as they do not have enough registered nurses in the area. He stated they do have a medical director for their inpatient program and he was not aware the state of Texas regulations did not permit patient care technicians to perform care of central venous catheters during dialysis treatments. He further stated he was not aware the medical director had to delegate authority to the patient care technicians to give normal saline to patients and to cannulate their access. He further stated he was not aware the medical director had to approve the training and competency of the staff performing technical duties in the water room.


In an interview with the CEO and the CNO on 4/4/17 in the office of the CEO he stated he was not aware the provider for inpatient dialysis services was not following their own policies and procedures in providing dialysis care to the patients at the hospital.


In an interview with the CNO on 4/4/17 she stated the only thing the dialysis provider presents for their Quality Assurance program is the water cultures. She further stated the dialysis provider nor the hospital do any audit activities in regard to infection control or compliance with rules and regulation in staffing needs in the inpatient dialysis program.

Based on review of documentation, tour of the facility, and staff interviews, it was determined that the facility did not protect the rights of it's patients when they:


" Failed to respond to a written patient complaint where the patient said they didn't feel safe in the hospital. See Tag A118

" Failed to allow patients and/or their legally authorized representative to participate in the development of their Comprehensive Interdisciplinary Treatment Plan. See Tag AA130

" Failed to provide the patients written information on their psychiatric medications leaving the patient unable to make an informed decision about their care. See Tag A131

" Failed to provide care in a safe setting when the patient call system did not meet regulatory requirements. See Tag A144

" Failed to ensure that the De Paul Psychiatric Unit had no ligature risks, the fire extinguishers had their service checks completed and failed to ensure that patient records were secured and kept confidential. See Tag A147

" Failed to ensure that all staff working with psychiatric patients were appropriately trained to do restraints on the patients. See Tag A196

.

In interviews during tours of the facility on 4/3/17 and 4/4/17 with the Clinical Informatics Coordinator, the LMSW for the DePaul Center and the Nurse Manager of the DePaul Center, the above findings were confirmed.

Based on review of records and interview, the facility failed to respond to a written patient complaint that the patient did not feel safe at the hospital. There was no nursing assessment documented based on the patient's expressed need.


Findings included:


Review of the medical record for Patient #A5 revealed a document entitled, "DePaul Center Letter to the Administrator". Patient #A5 documented at 520 on 4/3/17, "I no longer feel safe here. I am having panic attacks & arguing with the nurse over my med's. I must go outside!! I must have fresh air or I will get aggressive. Please discharge me now!"


The documented response at 4/3/17 at 1741 of the Physician Assistant to the above statement to Patient #A5 was "I will commit her tomorrow. I told her that this morning. She needs to stay a few days."


An interview was conducted with Staff #A37 the morning of 4/5/17 in the DePaul Center Adult patient unit. A request was made for the response to the statement by Patient A#5 that "I no longer feel safe here." Staff #A37 reviewed the medical record and stated that there was no nursing documentation that of any assessment or response to the patient's written complaint that she did not feel safe. There was no documented evidence in the medical record that the complaint was addressed.


Facility policy, "Complaint/Grievance process" stated, in part, "Complaint: A concern voiced by a Complainant about service, care, or treatment that can be resolved quickly by the staff ...Patient Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient ... regarding the care (when the complaint is not resolved at the time of the complaint by staff present) ..."Staff present" includes any hospital staff present at the time of the compliant (sic) who can quickly be at the patient's location to resolve the complaint ... Procedure: 1. Complaints that occur within a department should be referred to the Director of that department for immediate resolution ..."


Staff #A37 stated that the physician met with the patient the next morning on 4/4/17 at 7:35 am, however there was no intervention between the documentation on 4/3/17 at 1720 until the patient was seen by the physician the following morning (approximately 15 hours later). Staff #A37 confirmed that the complaint, "I no longer feel safe here" was not addressed "quickly" and was not addressed by nursing staff.

Based on a review of documentation and interviews, the facility failed to ensure that a patient or legally authorized representative had the right to participate actively in the development and periodic review of an individualized treatment plan. Staff interview revealed that a patient and/or legally authorized representative were not provided the opportunity to participate in meetings with their multidisciplinary team to provide input into the development of the comprehensive interdisciplinary treatment plan. Interview and facility policy revealed that the treatment plan was developed without the patient and presented to the patient for signature after development. The facility policy failed to ensure that the treatment plan was reviewed with the patient. The patient or representative did not actually have the benefit of providing input to the multidisciplinary treatment team, consisting of medical, nursing, social work, activity therapy, and any other disciplines as indicated. This is a restriction of the patient right to participate in their own treatment planning and could cause potential inadequate identification and care of patient's needs.


Findings included:


In an interview with Staff #A37 Nurse Manager the morning of 4/5/17 at the DePaul Center, she was asked by the survey team when the interdisciplinary treatment plan for patients was completed. Staff #A37 stated, "The social worker does the treatment plan." When asked if the patient treatment plan was an interdisciplinary treatment plan, Staff #A37 stated that "I only chart to the nursing care plan." When asked if the patient was involved in creating the treatment plan with the treatment team, Staff #A37 stated that the social worker was responsible for the treatment team and the treatment plan, that the nurses only enter the nursing care plan in the medical record."


In an interview with Staff #A34 Social Worker the morning of 4/5/17 at the DePaul Center, he stated that the initial Treatment Plan has 3 sections, nursing, physician, and psychosocial which are completed by each discipline, nursing, physician, and social workers. Staff #A34 stated that the Interdisciplinary treatment plan also is completed by each discipline, nursing, physicians, and social workers and is subsequently reviewed once a week by the treatment team. Staff #A34 stated that the treatment plan is revised or updated as needed each week when reviewed by the treatment team. When asked if the patient or the patient's legally authorized representative attends the treatment team meetings, Staff #A34 stated, "No, the patient doesn't attend, the social worker reviews the treatment plan with the patient after the meeting."


Facility policy, "Interdisciplinary Plan of Care" provided to the survey team the morning of 4/5/17 on the DePaul unit, stated, in part, "The Interdisciplinary Plan of Care is develop based on information gathered through ongoing assessment of the patient ...A. Nursing staff utilize the physician orders and Nursing Assess on admission to identified patient problems/needs. Goals ...and appropriate interventions to be addressed by Nursing ...B.A member of the Activity Therapy staff should complete an assessment ...and identify appropriate problems/needs, goals ...These are then entered onto the Care Plan ...C. The assigned Case Manager ...1. Reviews admission data and completes a Psychosocial assessment within 72 hours of admission to identify patient problems/needs, goals ...These are then entered onto the Care Plan ...4. The Case Manager should print the Care Plan and hold primary responsibility for ensuring that all parties including the patient, case manager, nurse and psychiatrist sign the form 5. If the patient is unable to unwilling to review and/or sign the Care Plan, the Case Manager should document the reasons for the lack of a patient signature, obtain all of the other signatures and file the original Care Plan in the chart. A continuing effort should be made to obtain the patient's signature and these efforts should be documented in the electronic medical record ...3. Interdisciplinary Care Plan Review: A. In Care Plan Review Sessions or upon consultation with the patient's physician, the Case Manager completes an Interdisciplinary Care Plan Review form."


Review of the facility policy revealed no documented evidence that the patient was involved in or allowed to participate actively in the development and periodic review of an individualized treatment plan. The facility policy merely stated that the Case Manager should ensure that the patient sign the form or document why the patient did not sign the form. The facility treatment plan policy did not require or mention that any staff member would involve the patient in planning their own treatment, that the patient would be allowed to participate actively in the development and periodic review of an individualized treatment plan, or even that the treatment plan would be discussed with the patient, merely that the patient's signature should be obtained.


There was no documented evidence provided to the survey team in the medical record for Patients A1, A2, A3, A4, A5, and A6 that the patient, parent, guardian, conservator, or any other person was notified of the date, time, and location of each meeting so that he or she could participate in the development and periodic review of an individualized treatment plan. There was no documented evidence that the patient and treatment team collaboratively developed the patient's treatment plan or that the patient contributed to the formulation of the treatment plan.


The above findings were confirmed in an interview with Staff #A#37 and #A32 the morning of 4/5/17 in the DePaul Center Adult Unit.

Based on review of records and staff interview, the facility failed to ensure that patients received written information on psychotropic medications before administration and that medication consent forms were complete. This presents a risk that patients or their legally authorized representative will not be knowledgeable and able to provide informed consent.


Findings included:


Review of the medical record for Patient #A4 revealed a "Consent to Treatment with Psychoactive Medication" form for Saphris, signed by the patient on 3/28/17. The space on the consent for "I have read a complete explanation of the psychoactive medication ..." was left blank and incomplete. The question on the form, "Info Sheet given to patient?" was left blank.


Review of the medical record for Patient #A4 revealed a "Consent to Treatment with Psychoactive Medication" form for Librium, Ambien, Catapres, and Phenergan signed by the patient on 4/2/17. The patient signed a "Consent to Treatment with Psychoactive Medication" form for Vistaril, however, the consent form was not dated. The question on the form, "Info Sheet given to patient?" was left blank.


Review of the medical record for Patient #A5 revealed a "Consent to Treatment with Psychoactive Medication" form for Zyprexa signed by the patient on 4/3/17. The question on the form, "Info Sheet given to patient?" was left blank.


There was no documented evidence provided to the surveyor to indicate the above patients received information about the above medications.


The above findings were confirmed in an interview with Staff #A#37 the morning of 4/5/17 in the DePaul Center Adult Unit.

Based on observation and interview, the facility failed to ensure that patients received care in a safe settings.


Findings included:


During a tour of the MRI Center the afternoon of 4/3/17 accompanied by Staff #A1, in 2 out of 4 patient dressing rooms, the patient call light pull cord was not extended to within six inches of the floor, rendering it ineffective or out of reach for a patient experiencing a fall on the floor to summon help in an emergency. This was confirmed during the tour by Staff #A1.


During a tour of the Woodway Radiology Center the afternoon of 4/4/17 accompanied by Staff #A20, in the patient holding room, the patient call light pull cord was observed knotted and not extended to within six inches of the floor, rendering it ineffective or out of reach for a patient experiencing a fall on the floor to summon help in an emergency. This was confirmed during the tour by Staff #A20


During a tour of the Woodway Rehabilitative Services facility the afternoon of 4/4/17 accompanied by Staff #A21, the following was observed: in two patient restrooms and in the men's pool dressing room, the patient call light pull cords were observed knotted and not extended to within six inches of the floor, rendering it ineffective or out of reach for a patient experiencing a fall on the floor to summon help in an emergency. This was confirmed during the tour by Staff #A21.


During a tour of the Providence DePaul inpatient psychiatric facility the morning of 4/4/17 accompanied by Staff #23, the following was observed:

a. In Adult unit patient room 122, there was a substantial diameter screw imbedded in the window frame far enough to present a ligature risk. The protruding screw also presented a risk for injury.

b. In the Adult unit patient bathroom, there was a plastic bag liner in the trash can, which could be used for suffocation in a suicide attempt.

c. In the ICU nurses station, the fire extinguisher had a tag, but there was no date indicated for the last service or check. There was no means to determine when the extinguisher was last serviced. This could likely have resulted in the fire extinguisher not functioning properly in the event of an emergency.

d. In the Seclusion room, the faucet in the bathroom was a ligature risk as it could be used as an anchor point for hanging as the faucet head projected out from the faucet base.

e. In the hallway outside the seclusion room, there were 2 door closer's at the top of the doors which were metal and extended out perpendicularly from the top of the doors, providing an anchor point or ligature risk. Most internal doors on the patient rooms and internal doors within the patient care units each consisted of 3 large metal hinges per door, which projected out from the door approximately 1 inch, providing an anchor point or ligature risk. There was also a door in this area in need of repair as the door hinge was broken off, though hinge parts remained attached to the door.

f. In the outside area for patients, there were 2 garden hoses attached to a spigot approximately waist high, easily accessible to a patient which could be used as a weapon or for self-injurious behavior, including hanging.

g. In the outside patio area for patients, there were 2 walls built of decorative cinder blocks creating 2 walls, reaching from the ground level to the roof. There were openings in the cinder blocks which were large enough for a foothold. These walls could be climbed by a patient wishing to reach the roof of the facility. This presents a safety risk that patients could climb or attempt to climb the wall and fall or jump from the wall or the roof. In an interview with Staff #A32, he stated that "That's never happened here before. They always have staff with them."

h. In the outside area for patients, there were at least 4 wooden fence boards which were broken and not secured to the fence. Some of the broken fence boards had jagged or sharp edges. There were nails protruding from the fence. The fence and gates were in need of repair and present a safety risk to patients and staff.

i. In the outside area for patients, there were old, rotted railroad ties which appeared to have been a raised garden bed some time past. There were pieces of rusted rebar, approximately 18 inches in length lying in this area, which could be used as a weapon or an instrument for self-injury by a patient. Staff #A32 stated, "Staff are always with patients; that's never happened here before."


The above findings were confirmed during the tour by Staff #A23 and Staff A32.

Based on observation and interview, it was determined that the DePaul Center failed to ensure that patient identifying information was secure and safeguarded from potentially unauthorized use.


Findings were:


Paperwork with identifying patient information was potentially accessible by staff who did not have a need to access such information.


In a large storage room located on the hallway adjacent to the kitchen, the surveyors observed that the floor was stained and dirty in appearance and in addition, this room contained several large cardboard boxes which contained old paperwork to include old employee personnel information, and old unit daily census reconciliation forms. These old daily census forms were found to contain patient names. In interview with staff member #A32 on the morning of 4/04/2017 it was confirmed that these old census forms contained identifying patient information and that that housekeeping staff have access to his room.


In the maintenance hallway, there were two large trashcan style wheeled bins with lockable covers, each of the covers had a slot where confidential waste paperwork could be inserted. These bins were for paperwork which was to be later shredded. Each of the covers were found to be unsecured even though each had a lock. An examination of the contents of each of these bins revealed patient identifying information. In an interview with #A30 on the morning of 4/04/2017 the surveyors were informed that these bins should have been locked. Staff #A30 also commented in the same interview that identifying patient information was contained in the unsecured bins and that the hallway area was accessed by housekeeping and or maintenance staff.

Based on review of documentation and interview, it was determined that the hospital failed to ensure that part time security staff (licensed peace officers) who frequently participate in the restraint of psychiatric patients at the hospital's DePaul Center are trained in CPI (Crisis Prevention Institute) which is used by the direct care staff for intervention with combative or aggressive patients.


Findings included:


A review of a document entitled: "Monthly Restraints for January 2016-March 2017" revealed that security staff was present for 17 out of 27 restraints in 2016 (January- 2, February-3, March- 2, May-2, July-1, August-1, September-1, October- 2, November-1, and December-2). For 2017 security staff was present for 10 out of 12 restraints (February- 6, March- 4).


A review the hospital training transcripts found in the personnel files for 5 of 5 (hospital part time staff members: A24, A25, A26, A27 and A28) revealed no documentation of any CPI training. In an interview with hospital staff member #A38 it was confirmed that there was no documentation available for review by the surveyors indicating that the part time staff documentation of CPI training.


In an interview in the DePaul Center conference room on the morning of 4/05/2017 when the survey team asked why security staff is frequently called to assist in the restraint of patients, staff member #A37 responded that: "for a show of force." Also present during this interview was hospital staff member # A30.


A review of Restraint and Seclusion Checklist used by staff revealed that the first line of the document stated: "Code A or Security summoned by clinically privileged RN, Supervisor or DON only."


Review of the Providence "Behavioral Restraint and Seclusion" training provided to the survey team the afternoon of 4/5/17 in the facility conference room by Staff #A35 stated, in part, "Initiation of Restraints - Restraints are a last resort; try all other interventions first. Security is to be summoned by clinically privileged RN, Supervisor, or DON only."


Review of the medical record for Patient #A1, a 77 year old, female patient with psychosis, revealed that she was restrained from 3/1/17 at 0754 until 3/1/17 at 0925. The objective behaviors noted stated, "Assaulted a Providence Security Officer." The physician documented in the Face to Face Assessment that the patient "Attacked police officer on unit." Nurse documentation Late Entry on 3/1/17 at 0745 stated, in part, "Patient was sitting in the day area eating breakfast. During this time the patient became extremely agitated and began cursing, yelling, and screaming delusional thoughts about being a pirate ...The patient ...immediately became verbally aggressive and began threatening staff members. A verbal order was received from Dr. [name] for Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg IM NOW. [Name], RN, NOS [Nurse Supervisor Office] and Security notified. Upon securities (sic) arrival the patient continued to curse, scream, yell and threaten staff members." Social work note on 3/1/17 at 0754 stated, in part, "Involved in restraint: [list of names including 2 security officers]."


Review of the medical record for Patient #A2, a 38 year old, male patient revealed that he was restrained on 2/19/17 from 0823 until 0900. The objective behaviors noted stated, "Threatening gestures to psychiatrist, staff, and security." Review of physician note, Restraint/Seclusion Face To Face Assessment on 2/19/17 stated, "2. Assessment patient's reaction to the restraint/seclusion: "Pt. had staff/security assist [with] same." Nursing progress note for the incident stated, in part, "Patient had upset the milieu and physician ordered an emergency dose of Geodon 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg. IM. Security was notified to assist and arrived on the unit at 08:12. Officer [name] and Sergent (sic) [name] arrived to assist. Attempts made again to talk with patient to calm him however he resisted and began making threats to Waco PD officers. Patient made a threatening gesture to police officers and at that time the officer put patient in a personal hold restraint at 08:23."


Review of the medical record for Patient #A3 a 43 year old, male patient revealed that he was restrained on 3/27/17 at approximately 0525. The nursing progress note stated, in part, "Pt began yelling, screaming, and pacing the unit. Verbal intervention was not effective. Security was notified and MD was notified for medication orders ...Security arrived at 0523 ...Pt threatened security, bowing up at them with clinched fists. Security physically restrained patient and placed him in the restraint chair at 0525."


The above findings were confirmed in an interview the afternoon of 4/5/17 with Staff #A37 and A30 in the facility conference room.

Based on observation and interview, the facility failed to ensure that there was a process for accounting controlled substances, i.e. scheduled medications, between nursing shifts or staff changes, when brought in by a patient. Consequently, the facility did not maintain a current record of scheduled drugs when these medications were brought to the facility by an admitted patient. This lack of a policy or procedure and lack of monitoring process of controlled substances brought in by patients presents a risk for diversion of controlled substances. This practice were not consistent with current guidelines and standards of practice.


Findings included:


During a tour of the Providence DePaul inpatient psychiatric facility the morning of 4/4/17 accompanied by Staff #A14 and A30, the following was observed:


Staff #A39, LVN, was asked how a patient's personal medications brought to the facility were handled. Staff #A39 stated that the medications were secured in a bag, then placed in a vault which was locked. The cabinet with actual plastic bags of medication were observed by the survey team. Staff #A39 confirmed that sometimes controlled substances are brought in by patients and placed in the plastic bag, and in the medication room cabinet. Per Staff #A39, the controlled substances are counted by 2 nurses when placed in the bag, but are not accounted for until the controlled substances are removed when the patient is discharged, which could be days or a week or more. Staff #A39 confirmed that the medication nurse on each shift has access to the cabinet, and therefore has access to any controlled substances that may have been brought in by a patient. As these controlled substances are not counted or otherwise secured, and are accessible to multiple staff during the patient's stay, this lack of accountability presents a risk for diversion of controlled substances. This also presents a risk that the facility would not be able to identify a person if diversion would occur, as multiple staff had access to the controlled substances. The above findings were confirmed with Staff #A30 and Staff #A14 during the tour the morning of 4/14/17.


In an interview with Staff #A30 the morning of 4/14/17, Staff A14 confirmed there was no requirement that controlled substances are to be counted or accounted for when the shift changes or when control of the cabinet/medication nurse responsibility changes either at shift change or during shift change.


In an interview conducted the morning of 4/14/17 with Staff #A14 stated that there was no policy or procedure for accountability of controlled substances which were brought into the facility by patients admitted to the facility. Staff #A14 confirmed the above risk of diversion and lack of accountability.

Based on document review, policy review, and staff interview, the facility failed to ensure their contracted provider followed their contract agreement, followed state and federal rules and regulations, and their own policies in the care of hemodialysis patients.


Findings were:


Review of Acute Dialysis Services Agreement dated 1/15/08 states in part:

* The services shall be performed by non-physician employees or contractors of Provider, all of whom shall be duly licensed and qualified nurses or qualified technicians trained in extracorporeal therapy including acute dialysis treatments, as applicable to the particular services prescribed and in accordance with relevant state licensure requirements (the Provider Staff).

* Provider shall provide policies, procedures, and techniques pertaining to the methods by which the services are rendered at Hospital pursuant to this Agreement.

* All Provider Staff performing services at Hospital will have a current competency record including primary source verification of licensure....competency record of each Provider staff providing services hereunder....current CPR card, .... competency exam verification, ....annual dialysis evaluation verification, ...current job description.

* Provider and Provider staff providing services to Hospital under this Agreement shall perform all Provider's duties and obligations as set forth herein in accordance with all applicable federal and state laws and regulations, applicable Hospital policies, bylaws, rules, and regulations.


Review of Fresenius Medical Care Policies and Procedures state:

* Nursing Supervision of the FMS Inpatient Services Program Procedure states "An FMS registered nurse will directly supervise all care provided by a Licensed Practical Nurse or Inpatient Services Patient Care Technicians in accordance with the guidelines specified in the Nursing Supervision of the FMS Inpatient Services Program Policy."

* Nursing Supervision of the FMS Inpatient Services Program Policy states "Responsibility: FMS Inpatient Services Staff (based on job description, license certification, State and/or Federal regulations). Direct Supervision: for purposes of inpatient dialysis services provided under this policy requires the RN to be on-site (though not necessarily physically present) where the patient care is being performed, and the FMS RN must be able to be available to respond. Direct supervision requires that the FMS RN be in close physical proximity to the PCT or LVN, such as being in rooms that are across the hall or are adjacent. The American Nurses Association and the National Council of State Boards of Nursing define delegation as a nurse directing another person to perform a nursing task(s) or activities that are delegable defined by the State Nurse Practice Act. If services are provided in Intensive Care Unit, then an Inpatient RN can supervise....None. Patient Care Technicians may be used to set up hemodialysis equipment for treatment in the centralized inpatient treatment area, intensive care, and individualized patient hospital room.

* FMS Inpatient Services Emergent On Call Procedure states "The contracted hospital will be responsible for notifying the on call FMS Inpatient Services nurse regarding the need for any emergent dialysis treatments. All emergent inpatient services and procedures will be performed in appropriate settings by skilled staff."

* FMS Inpatient Services Emergent On Call Policy states "It is the policy of FMS Inpatient Services to provide emergent treatments in accordance with the contractual agreement between the FMS Inpatient Services program and the contracted "hospital". At least one FMS Inpatient Services Registered Nurse will be on call at all times. ONLY registered nurses may take call for FMS Inpatient Services after hour's emergent treatments."

* Initiation of Treatment Using a Central Venous Catheter.... states "The task of connecting and disconnecting the central venous catheter to the dialysis machine, the monitoring during dialysis treatment, and the technical aspects of the dressing change procedure may be performed by both nurses and patient care technicians in some states. However, in certain states, patient care technicians are prohibited from these tasks....... Tasks completed by Patient Care Technicians (PCT) within FMCNA must be in accordance with State laws and regulations. Delegation of tasks to PCTs cannot occur until it is determined that State permits delegation of a particular function..."

* Termination of Treatment Using a Central Venous Catheter.... states "The task of connecting and disconnecting the central venous catheter to the dialysis machine, the monitoring during dialysis treatment, and the technical aspects of the dressing change procedure may be performed by both nurses and patient care technicians in some states. However, in certain states, patient care technicians are prohibited from these tasks....... Tasks completed by Patient Care Technicians (PCT) within FMCNA must be in accordance with State laws and regulations. Delegation os tasks to PCTs cannot occur until it is determined that State permits delegation of a particular function..."

* FMS Inpatient Service General Policy Statement states "FMS Inpatient Services will adhere to all FMS policies and procedures."


Texas Administrative Code is as follows:
TAC 117.65
DIALYSIS TECHNICIANS.

Prohibited Acts:

Performance of the following acts by any dialysis technician who is not a licensed vocational nurse is prohibited:

(1) initiation of patient education;

(2) alteration of ordered treatment, including shortening of the treatment time.

(3) initiation or discontinuation of dialysis via a central catheter, manipulation of a central catheter, or dressing changes for a central catheter;

(4) administration of any medications other than normal saline, heparin, lidocaine, or oxygen, which may only be administered in the course of a routine dialysis treatment;

(5) administration of blood or blood products;

(6) performance of nonaccess site arterial puncture;

(7) acceptance of physician orders;

(8) provision of hemodialysis treatment to pediatric patients less than 35 kilograms;

(9) alteration of the level of electrolytes in dialysate through the use of additive(s) ("spiking"); and

(10) initiation or discontinuation of dialysis via an implantable port.


TAC 117.46 (f)(1)(B)
Qualifications of Staff.

(B) Any staff member assigned responsibilities in the technical area shall pass a written competency examination, demonstrate skills related to the required level of responsibility, and be certified by the facility's medical director as competent to perform their assigned duties. Current certification by a national board in dialysis technology may substitute for the written test.


TAC 117.63 (f)
DIALYSIS TECHNICIANS.

Competency Evaluation.

(f) If a dialysis technician other than a licensed vocational nurse is to cannulate a dialysis access, administer normal saline, heparin, lidocaine, or oxygen, the medical director shall verify and document competency of the dialysis technician to perform these tasks and delegate authority to the technician in accordance with Occupations Code, Chapter 157.


Review of On Call schedule for December 1, 2016-April 2017 revealed the contracted dialysis provider used patient care technicians for call for acute dialysis treatments outside of the normal operating hours of the inpatient dialysis program.


Review of personnel file for contracted dialysis staff acute coordinator reveals the following:

* Acute Coordinator: Education: Graduate of an accredited School of Nursing (R.N.)

* Signed by staff #23 who is an LVN.


Review of personnel files for contracted dialysis staff reveals the following deficiencies:

* Staff #16, #18, #19, #20, #21, #22, #23, #25, and #26 have no review by the medical director to certify their training in technical duties related to water and dialysis skills.

* Staff #16, #18, #19, #20, #21, #22, #23, and #25 have no color blindness testing in their file and they perform water testing.

* Staff #16, #19, #21, and #22 are patient care technicians and have no delegation by the medical director to perform cannulation of the dialysis access and administer dialysis related medications, i.e. normal saline and oxygen.


In an interview with staff #19, she stated she was a dialysis technician. She further stated she took call about every 5 weeks. She stated when she is on call she does not have a dialysis RN on call with her. She stated she dialyzed patients in the ICU and in isolation rooms by herself with no dialysis trained RN in the room or on the unit with her. She further stated she does what she can in assessing the patient and relies on the floor nurses to do assessments and give medication to the patients. She stated she gives normal saline boluses to the patients when needed during treatment. She further stated she did initiation and termination and CVC dressing changes on the dialysis patients with central venous catheters.


In an interview with staff #27 he stated FMC follows their policies in regard to caring for inpatient dialysis patients. He stated they do have technicians on call as they do not have enough registered nurses in the area. He stated they do have a medical director for their inpatient program and he was not aware the state of texas regulations did not permit patient care technicians to perform care of central venous catheters during dialysis treatments. He further stated he was not aware the medical director had to delegate authority to the patient care technicians to give normal saline to patients and to cannulate their access. He further stated he was not aware the medical director had to approve the training and competency of the staff performing technical duties in the water room.

Based on review of documentation and interviews, the facility failed to ensure that patients were assessed and facility protocols were followed. There was no nursing assessment or physician notification when a patient had abnormal vital signs in accordance with nursing standards of practice. The facility policy failed to address abnormal vital signs or the response to abnormal vital signs. This lack of response or assessment presents a risk for an adverse patient event. The facility also failed to respond to a written patient complaint that the patient did not feel safe at the hospital. There was no nursing assessment documented based on the patient's expressed need.


Findings included:


Facility policy, "De Paul Center Nursing Policy Subject: Vital Signs and Weights" stated, in part, "Temperature, pulse, respirations, blood pressure and pain are assessed BID at 0600 and 1800 unless ordered otherwise by physician."


Review of the "Orders for Alcohol Detoxification" stated, in part, "Vital Signs on admission q 2 hours x 24 hours, then q 4 hours x 24 hours, then q shirt. Call physician if pulse is greater than 110, diastolic BP is greater than 120 mmHg, or systolic BP is greater than 180 mmHg."


Review of the "Orders for Opiate Detoxification" stated, in part, "Vital Signs on admission q 2 hours x 24 hours, then q 4 hours x 24 hours, then q shirt. Call physician if pulse is greater than 110, diastolic BP is greater than 120 mmHg, or systolic BP is greater than 180 mmHg."


The above findings were confirmed in an interview with Staff #A#37 the morning of 4/4/17 in the DePaul Center Adult Unit.


Review of the medical record for Patient #A4 revealed a blood pressure of 189/94 on 4/3/17 at 0430. There was no documented evidence that the RN assessed the patient. There was no documented evidence in the medical record that the MD was notified of the elevated blood pressure.


Review of the medical record for Patient #A1 revealed that she was to have vital signs taken twice daily, or once each 12 hour shift. On 2/25/17 at 0400, the blood pressure for Patient #A1 was 205/87. There was documentation that the patient refused further vital signs. There was no documentation of an assessment of Patient #A1 and no documentation that the physician was notified of the elevated blood pressure of 205/87. The resident physician noted the elevated blood pressure at 1446 on 2/25/17, greater than 12 hours later.


There were no documented vital signs for Patient #A1 on the pm shift for 3/3/17. There were no documented vital signs for Patient #A1 for 7 consecutive shifts:
evening shift of 3/4/17, day and evening shift of 3/5/17, day and evening shift of 3/6/17, day and evening shift of 3/7/17. There was no documentation that the patient refused or other reason why the vital signs were not taken.



Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,

"(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:

(A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;

(B) Implement measures to promote a safe environment for clients and others ...

(D) Accurately and completely report and document:

(i) the client's status including signs and symptoms;

(ii) nursing care rendered;

(iii) physician, dentist or podiatrist orders ...

(v) client response(s); and

(vi) contacts with other health care team members concerning significant events regarding client's status;"


The above findings were confirmed in an interview with Staff #A#37 the afternoon of 4/5/17 in the DePaul Center Adult Unit.


Review of the medical record for Patient #A5 revealed a document entitled, "DePaul Center Letter to the Administrator". Patient #A5 documented at 520 on 4/3/17, "I no longer feel safe here. I am having panic attacks & arguing with the nurse over my meds. I must go outside!! I must have fresh air or I will get aggressive. Please discharge me now!"


The documented response at 4/3/17 at 1741 of the Physician Assistant to the above statement to Patient #A5 was "I will commit her tomorrow. I told her that this morning. She needs to stay a few days."


An interview was conducted with Staff #A37 the morning of 4/5/17 in the DePaul Center Adult patient unit. A request was made for the response to the statement by Patient A#5 that "I no longer feel safe here." Staff #A37 reviewed the medical record and stated that there was no nursing documentation that of any assessment or response to the patient's written complaint that she did not feel safe. There was no documented evidence in the medical record that the complaint was addressed.


Facility policy, "Complaint/Grievance process" stated, in part, "Complaint: A concern voiced by a Complainant about service, care, or treatment that can be resolved quickly by the staff ...Patient Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient ... regarding the care (when the complaint is not resolved at the time of the complaint by staff present) ..."Staff present" includes any hospital staff present at the time of the compliant (sic) who can quickly be at the patient's location to resolve the complaint ... Procedure: 1. Complaints that occur within a department should be referred to the Director of that department for immediate resolution ..."


Staff #A37 stated that the physician met with the patient the next morning on 4/4/17 at 7:35 am, however there was no intervention between the documentation on 4/3/17 at 1720 until the patient was seen by the physician the following morning (approximately 15 hours later). Staff #A37 confirmed that the complaint, "I no longer feel safe here" was not addressed "quickly" and was not addressed by nursing staff.

Based on document review, policy review, and staff interview, the hospital failed to ensure their contracted provider followed their contract agreement, followed state and federal rules and regulations, and their own policies in the care of hemodialysis patients.


Findings were:


Review of Acute Dialysis Services Agreement dated 1/15/08 states in part:

* The services shall be performed by non-physician employees or contractors of Provider, all of whom shall be duly licensed and qualified nurses or qualified technicians trained in extracorporeal therapy including acute dialysis treatments, as applicable to the particular services prescribed and in accordance with relevant state licensure requirements (the Provider Staff).

* Provider shall provide policies, procedures, and techniques pertaining to the methods by which the services are rendered at Hospital pursuant to this Agreement.

* All Provider Staff performing services at Hospital will have a current competency record including primary source verification of licensure....competency record of each Provider staff providing services hereunder....current CPR card, .... competency exam verification, ....annual dialysis evaluation verification, ...current job description.

* Provider and Provider staff providing services to Hospital under this Agreement shall perform all Provider's duties and obligations as set forth herein in accordance with all applicable federal and state laws and regulations, applicable Hospital policies, bylaws, rules, and regulations.


Review of Fresenius Medical Care Policies and Procedures state:

* Nursing Supervision of the FMS Inpatient Services Program Procedure states "An FMS registered nurse will directly supervise all care provided by a Licensed Practical Nurse or Inpatient Services Patient Care Technicians in accordance with the guidelines specified in the Nursing Supervision of the FMS Inpatient Services Program Policy."

* Nursing Supervision of the FMS Inpatient Services Program Policy states "Responsibility: FMS Inpatient Services Staff (based on job description, license certification, State and/or Federal regulations). Direct Supervision: for purposes of inpatient dialysis services provided under this policy requires the RN to be on-site (though not necessarily physically present) where the patient care is being performed, and the FMS RN must be able to be available to respond. Direct supervision requires that the FMS RN be in close physical proximity to the PCT or LVN, such as being in rooms that are across the hall or are adjacent. The American Nurses Association and the National Council of State Boards of Nursing define delegation as a nurse directing another person to perform a nursing task(s) or activities that are delegable defined by the State Nurse Practice Act. If services are provided in Intensive Care Unit, then an Inpatient RN can supervise....None. Patient Care Technicians may be used to set up hemodialysis equipment for treatment in the centralized inpatient treatment area, intensive care, and individualized patient hospital room.

* FMS Inpatient Services Emergent On Call Procedure states "The contracted hospital will be responsible for notifying the on call FMS Inpatient Services nurse regarding the need for any emergent dialysis treatments. All emergent inpatient services and procedures will be performed in appropriate settings by skilled staff."

* FMS Inpatient Services Emergent On Call Policy states "It is the policy of FMS Inpatient Services to provide emergent treatments in accordance with the contractual agreement between the FMS Inpatient Services program and the contracted "hospital". At least one FMS Inpatient Services Registered Nurse will be on call at all times. ONLY registered nurses may take call for FMS Inpatient Services after hour's emergent treatments."

* Initiation of Treatment Using a Central Venous Catheter.... states "The task of connecting and disconnecting the central venous catheter to the dialysis machine, the monitoring during dialysis treatment, and the technical aspects of the dressing change procedure may be performed by both nurses and patient care technicians in some states. However, in certain states, patient care technicians are prohibited from these tasks....... Tasks completed by Patient Care Technicians (PCT) within FMCNA must be in accordance with State laws and regulations. Delegation of tasks to PCTs cannot occur until it is determined that State permits delegation of a particular function..."

* Termination of Treatment Using a Central Venous Catheter.... states "The task of connecting and disconnecting the central venous catheter to the dialysis machine, the monitoring during dialysis treatment, and the technical aspects of the dressing change procedure may be performed by both nurses and patient care technicians in some states. However, in certain states, patient care technicians are prohibited from these tasks....... Tasks completed by Patient Care Technicians (PCT) within FMCNA must be in accordance with State laws and regulations. Delegation os tasks to PCTs cannot occur until it is determined that State permits delegation of a particular function..."

* FMS Inpatient Service General Policy Statement states "FMS Inpatient Services will adhere to all FMS policies and procedures."


Texas Administrative Code is as follows:
TAC 117.65
DIALYSIS TECHNICIANS.

Prohibited Acts:

Performance of the following acts by any dialysis technician who is not a licensed vocational nurse is prohibited:

(1) initiation of patient education;

(2) alteration of ordered treatment, including shortening of the treatment time.

(3) initiation or discontinuation of dialysis via a central catheter, manipulation of a central catheter, or dressing changes for a central catheter;

(4) administration of any medications other than normal saline, heparin, lidocaine, or oxygen, which may only be administered in the course of a routine dialysis treatment;

(5) administration of blood or blood products;

(6) performance of nonaccess site arterial puncture;

(7) acceptance of physician orders;

(8) provision of hemodialysis treatment to pediatric patients less than 35 kilograms;

(9) alteration of the level of electrolytes in dialysate through the use of additive(s) ("spiking"); and

(10) initiation or discontinuation of dialysis via an implantable port.


TAC 117.46 (f)(1)(B)
Qualifications of Staff.

(B) Any staff member assigned responsibilities in the technical area shall pass a written competency examination, demonstrate skills related to the required level of responsibility, and be certified by the facility's medical director as competent to perform their assigned duties. Current certification by a national board in dialysis technology may substitute for the written test.


TAC 117.63 (f)
DIALYSIS TECHNICIANS.

Competency Evaluation.

(f) If a dialysis technician other than a licensed vocational nurse is to cannulate a dialysis access, administer normal saline, heparin, lidocaine, or oxygen, the medical director shall verify and document competency of the dialysis technician to perform these tasks and delegate authority to the technician in accordance with Occupations Code, Chapter 157.


Review of On Call schedule for December 1, 2016-April 2017 revealed the contracted dialysis provider used patient care technicians for call for acute dialysis treatments outside of the normal operating hours of the inpatient dialysis program.


Review of personnel file for contracted dialysis staff acute coordinator reveals the following:

* Acute Coordinator: Education: Graduate of an accredited School of Nursing (R.N.)

* Signed by staff #23 who is an LVN.


Review of personnel files for contracted dialysis staff reveals the following deficiencies:

* Staff #16, #18, #19, #20, #21, #22, #23, #25, and #26 have no review by the medical director to certify their training in technical duties related to water and dialysis skills.

* Staff #16, #18, #19, #20, #21, #22, #23, and #25 have no color blindness testing in their file and they perform water testing.

* Staff #16, #19, #21, and #22 are patient care technicians and have no delegation by the medical director to perform cannulation of the dialysis access and administer dialysis related medications, i.e. normal saline and oxygen.


In an interview with staff #19 in the dialysis inpatient room on 4/3/17, she stated she was a dialysis technician. She further stated she took call about every 5 weeks. She stated when she is on call she does not have a dialysis RN on call with her. She stated the dialysis technicians are the staff on call for inpatient dialysis services outside of the normal operating hours. She stated she dialyzed patients in the ICU and in isolation rooms by herself with no dialysis trained RN in the room or on the unit with her. She further stated she does what she can in assessing the patient and relies on the floor nurses to do assessments and give medication to the patients. She stated she gives normal saline boluses to the patients when needed during treatment. She further stated she did initiation and termination and CVC dressing changes on the dialysis patients with central venous catheters.


In an interview with staff #27 outside the inpatient dialysis room on 4/3/17, he stated FMC follows their policies in regard to caring for inpatient dialysis patients. He stated they do have technicians on call as they do not have enough registered nurses in the area. He stated they do have a medical director for their inpatient program and he was not aware the state of texas regulations did not permit patient care technicians to perform care of central venous catheters during dialysis treatments. He further stated he was not aware the medical director had to delegate authority to the patient care technicians to give normal saline to patients and to cannulate their access. He further stated he was not aware the medical director had to approve the training and competency of the staff performing technical duties in the water room.


In an interview with the CEO and the CNO on 4/4/17 in the office of the CEO he stated he was not aware the provider for inpatient dialysis services was not following their own policies and procedures in providing dialysis care to the patients at the hospital.

Based on review of records and staff interview, the facility failed to ensure that a discharge summary was completed on all patients.


Findings included:


Review of the closed medical record for Patient #A1 revealed no documented evidence of a Discharge Summary.


The above findings was confirmed in an interview the afternoon of 4/5/17 in the facility conference room by Staff #A23.

Based on observation and interview, the facility failed to ensure that there was a process for accounting controlled substances, i.e. scheduled medications, between shifts or staff changes when brought in by a patient. Consequently, the facility did not maintain a current record of scheduled drugs when these medications were brought to the facility by patients. This lack of a policy or procedure and lack of monitoring process to these controlled substances presents a risk for diversion of controlled substances. This practice were not consistent with current guidelines.


Findings included:


During a tour of the Providence DePaul inpatient psychiatric facility the morning of 4/4/17 accompanied by Staff #A14 and A30, the following was observed:

Staff #A39, LVN, was asked how a patient's personal medications brought to the facility were handled. Staff #A39 stated that the medications were secured in a bag, then placed in a vault which was locked. The cabinet with actual plastic bags of medication were observed by the survey team. Staff #A39 confirmed that sometimes controlled substances are brought in by the patient and placed in the plastic bag and in the medication room cabinet. Per Staff #A39, the controlled substances are counted by 2 nurses when placed in the bag, but are not accounted for until the controlled substances are removed when the patient is discharged, which could be days or a week or more. Staff #A39 confirmed that the medication nurse on each shift has access to the cabinet, and therefore has access to any controlled substances that may have been brought in by a patient. As these controlled substances are not counted or otherwise secured, and are accessible to multiple staff during the patient's stay, this lack of accountability presents a risk for diversion of controlled substances. This also presents a risk that the facility would not be able to identify a person if diversion would occur, as multiple staff had access to the controlled substances. The above findings were confirmed with Staff #A30 and Staff #A14 during the tour the morning of 4/14/17.


In an interview with Staff #A30 the morning of 4/14/17, Staff A14 confirmed there was no requirement that controlled substances are to be counted or accounted for when the shift changes or when control of the cabinet/medication nurse responsibility changes either at shift change or during shift change.


In an interview conducted the morning of 4/14/17 with Staff #A14 stated that there was no policy or procedure for accountability of controlled substances which were brought into the facility by patients admitted to the facility. Staff #A14 confirmed the above risk of diversion and lack of accountability.

Based on observation and interview, it was determined that the facility failed to ensure that expired supplies were removed and not available for use by staff.


Findings were:

Expired supplies were found and available for use by staff.


During a tour of the Providence MRI Center on the afternoon of 4/03/2017 expired supplies were found in the center's crash cart to include:

" 2 each BD Insyte Autoguard 18 Ga 1.16 in (1.3x30mm) needles with an expiration date of 2017-03

" 2 each BD Insyte Autoguard 16 Ga 1.16 in (1.7x30mm) needles with an expiration date of 2016-05.


In an interview on the afternoon of 4/03/2017 with staff member #A4 on the afternoon of 4/03/2017 the above findings were confirmed.


A tour of the DePaul Center on the morning of 4/04/2017 revealed the following:

" On the ICP2 unit the emergency cart contained expired supplies to include: one each IV bag of 500ml 0.9% Sodium Chloride, expiration date was Oct 2016.

" 10 each disposable Betadine Solution Swabsticks with expiration date of 06 2016.

" 2 each BD Insyte Autoguard 22 Ga 1.00 in (0.9x25mm) needles with an expiration date of 2015-04.

" 2 each BD Insyte Autoguard 18 Ga 1.16 in (1.3x30mm) needles with an expiration date of 2015-01.

" 3 each BD Insyte Autoguard 20 Ga 1.16 in (1.1x30mm) needles with and expiration date of 2015-09.


During a tour of the MRI Center the afternoon of 4/3/17 accompanied by Staff #A-1,

the following was observed:

a. There were 6 expired green top lab tubes, expiration date 12/2016.

b. 2 each BD Insyte Autoguard 18 Ga 1.16 in (1.3x30mm) needles with an expiration date of 2017-03
.
c. 2 each BD Insyte Autoguard 16 Ga 1.16 in (1.7x30mm) needles with an expiration date of 2016-05.

d. There was a 100 ml bag of D5W in the crash cart which expired 1/Mar/2017.


In an interview on the afternoon of 4/03/2017 with Staff #A-4 the above findings were confirmed.


In an interview with staff members #A4 and #A6 on the morning of 4/04/2017 the above findings were confirmed.

Based on observation and interview the facility failed to maintain sanitary conditions in the kitchen located in the main building and the kitchen located in it's outpatient services when:

" The main kitchen located in the hospital and the kitchen area at the De Paul Center had dirt, debris, insects and grease on the floors, food preparation and food plating areas.
" Dried food observed on clean cooking utensils.
" Improperly stored food items.
" Improper mixing and monitoring of sanitizing solutions.
" Expired foods available for patient consumption.

Cross refer to 482.28 Food and Dietetic Services, A 620

In interviews with the RN/Manager of the DePaul Center and the Dietary Director on 4/3/17 and 4/5/17, the above findings were confirmed.

Based on observation, review of documentation, and interviews, the hospital failed to ensure that dietary services were provided in accordance with recognized dietary standards, as the DePaul Center kitchen/dining room was observed to have dirt, debris, insects, and grease in the food prep and plating area; the sanitizing solution did not contain the minimum concentration of sanitizer to to be effective; there was dried food on kitchen cooking utensils, food was stored improperly, and routine cleaning and checklists were not completed. The kitchen was not maintained in a clean and sanitary manner in accordance with facility policy and food service standards. This presents a risk for a food-borne illness or other cross contamination preparing food in an unsanitary environment.


Findings included:


The kitchen/serving area was not maintained in a clean or sanitary manner. During a tour of on the morning of 4/04/2017 the following were observed:


The reddish colored floor tile behind steam table area was dirty and stained in appearance. There was dirt, debris, and spills on the floor in the serving area. There was a layer of grease on the floor underneath the kitchen fixtures.
4 of the five steam pans in the steam table had visible pieces of food matter in the water of the steam pan areas. In one of the steam pans were what appeared to be small pieces of green beans. There was a grease residue on the surface. 5 of the 5 steam pan covers had what appeared to be a visible residue on the cover.


The area directly behind the steam table which appeared to be an old griddle type cooktop was a significant accumulation of grease and crumbs as if food had been stored or prepared in that area. The lower portion of this cook top area was supported by a stainless steel framework which have multiple areas of staining. The surveyor used a food handler glove and was able to remove some of the stains by rubbing glove on the stainless steel. The wall mounted light switch which controlled the light in the range vent hood over this cook top area was greasy to the touch and was visibly soiled. There was a large fryer which was very greasy, with old food debris and dirty grease pooled around and on top of it.


There was a significant accumulation of what appeared to be bread crumbs observed in the stainless steel bread storage drawer located immediately adjacent to the steam table area.


In the actual kitchen/food prep area, the floor tiles by the baseboard area were noted to be dirty and stained, and there was what appeared to be a wadded up napkin and other debris on the floor under the food prep area.


In the bottom of a stainless steel sliding drawer located in the food prep area, there was a sticky food residue noted with what appeared to be small pieces of food which had become stuck in the residue. In this drawer were multiple food serving utensils to include: large kitchen knives, tongs, spatulas and serving spoons. These utensils were not arranged any kind of organized manner but instead all intermingled in the drawer. At least three of these serving utensils were noted to have dried food residue on them. Review of the hospital dietary manual which was provided to the surveyors for review contained policy #F017, entitled: "Storage of Pots, Dishes, Flatware, Utensils." This policy stated: "Pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pests, or other means."


In a walk in dry storage area, there was what appeared to be a dead cricket on the floor and what appeared to be the leg of cricket also visible on the floor.


The ceiling mounted air vents in the kitchen area were dirty with visible dust and an area with flaking chipped paint was observed immediately adjacent to one of the vents. Also noted was dust clinging to the ceiling next to one of the vents. This accumulation of dust presented the opportunity for contamination of patient food as the dust could become airborne and land on patient food. When the surveyor entered the kitchen area at the beginning of the tour, there were approximately 30 individual salads sitting uncovered on the food prep area. (Later these salads were noted to have been moved into the walk in cooler and were observed to not be covered). In an interview with staff member #A33, on the morning of 4/04/2017 it was confirmed that the salads in the walk in cooler should have been covered.


In the hallway immediately adjacent to the kitchen area visible light was observed under the full width of an exterior door. This presented the possibility that insects or small rodents could potentially gain access to the facility.


In an interview on the morning of 4/04/2017 with staff member #A4 and A33 the above findings were confirmed.


In an interview the morning of 4/4/17 with Staff #A30 and Staff #A6 and Staff #A14, all stated that there had been no cooking in the kitchen for "several years" but that the food was prepared in the kitchen then sent to the units. Staff #A6 stated that she had been at the hospital for "many years." Staff #A6 stated that the kitchen probably hadn't been cleaned "in a long time" but couldn't remember the last time the kitchen had been used for cooking, and explained that food was brought into the kitchen and set up for the patients in the kitchen.


In an interview the morning of 4/4/17 with Staff #A18, Food Service Worker, she stated that she used the area, including the griddle and the food prep area and the steam table to plate the food for the patient on the DePaul Center unit. She confirmed that the utensils mentioned above were used in preparation of plates of food for the patients. Staff #A18 confirmed that the kitchen and food prep area were in need of cleaning.


In an interview the morning of 4/5/17 with Staff #A18, Food Service Worker, she was asked by the survey team for the sanitizing solution used for sanitizing food contact and food preparation surfaces. Staff #A18 revealed a red, unlabeled bucket approximately 1/2 full of a clear liquid. There was no label on the bucket to indicate the contents, or the date and time the solution was last prepared; Staff #A18 confirmed that the bucket was not labeled. When the surveyor asked Staff #A18 to test the solution with a test strip to determine the concentration of the solution, Staff #A18 obtained a test strip from another area of the kitchen and dipped it into the solution. Staff #A18 stated that the strip should be dipped into the solution for "about 2-3 seconds." Review of the strip label revealed the strip should be submerged in the solution for 10 seconds. After approximately 15 seconds (by observation), Staff #A18 removed the strip from the solution and the solution still did not read 150 ppm (minimum range). The sanitizing solution did not contain the minimum concentration of sanitizer to be effective. When asked for a log indicating the frequency of changing the sanitizing solution and testing the concentration of the solution, Staff #A18 stated that a log was not maintained and there was no documented evidence provided to the surveyor to indicate that sanitizing solutions were being tested and regularly changed.


Review of the hospital dietary manual which was provided to the surveyors for review contained a 3 page "Basic Sanitation Checklist" form. This form contained multiple areas of inspection to include: "Dining Room, Production Area, Storage Areas, DishRoom." In the Production Area section specific areas included: "1. General appearance, free of clutter, clean, orderly and odor free?" "2. Utensils are clean and neatly organized? Soiled utensils in proper location?" "4. Floors ae clean and free of litter? Baseboards and kick plates are clean and polished?" "6. Battery of cooking equipment - area behind and under is free of food, grease and dust?" Review of facility policy #F015, entitled: "Sanitation Inspection and Checklist" stated: "A basic sanitation inspection is conducted at least once per month to assure that established procedures are being followed and that sanitation standards are being met. Review of a seven page "Cleaning Checklist" which was also found in the hospital dietary policy and procedure manual revealed multiple areas to check on a daily, weekly, monthly time frame and there was an area where an individual's initials could be documented and as well as an area labeled manager. The last page of the checklist was entitled: "Kitchen." Items on this page to check in the kitchen area included: "Kitchen walls, doors, ceiling, & lighting cleaned." Clean counter tops, legs, drawers, & shelving." "Clean stove tops." "Sweep and mop kitchen floor including all pass through areas." "All utensils cleaned & stored properly." On the morning of 4/05/2017 in the DePaul Center conference room the surveyor asked staff #A33 if there was documentation that this cleaning checklist found in the dietary policy and procedure manual had been done. Staff member #A33 confirmed that that there was no documentation that it had been done for the DePaul Center.


In an interview the afternoon of 4/5/17 in the facility conference room with Staff #A36, Infection Control, she stated that she was aware of the grease, debris, old food and dirty state of the kitchen and that the kitchen was being used for patient food preparation despite the need for cleaning. Staff #A36 stated that the kitchen was "Gross." Staff #A36 stated that quarterly Environment of Care Rounds are made at DePaul which include a tour of the kitchen and that she had documented the need for the kitchen to be cleaned and reported it. Staff #A36 provided the survey team with the documents from the "Environmental Tours" which included items in the checklist for the kitchen area at DePaul, the most recent documented tour conducted on 9/4/2016. Staff #A36 stated that the Director of the DePaul Unit, the Quality Assurance Manager, and other hospital staff were participants in the quarterly environmental tour.
In an interview the afternoon of 4/5/17 in the facility conference room with Staff #A30, Manager of DePaul Center, she confirmed that she participated in the DePaul quarterly environmental tour and was aware of the condition and need for cleaning in the kitchen, however stated that she was not present for the tour conducted the most recent quarter.


During a tour of the Providence DePaul inpatient psychiatric facility the morning of 4/4/17 accompanied by Staff #23, there were 3 cans of Glucerna Chocolate, 8 ounces, available for patient use in the refrigerator which expired 4/1/2017. This was confirmed by Staff #A-14 the morning of 4/4/17.





28422

Based on observation, review of documentation, and interviews with staff, the facility failed to employ a full-time employee who was responsible for daily management of the dietary services.


Findings were:


During a tour of the dietary department on 4-5-17, the following observations were made:


-Dried bits of food were present on the blade and the blade guard of the meat slicer in the grill area. Food residue encourages rodents, which can carry bacteria and disease.

-Three french fries were on the floor to the right of the fryer in the grill area.

-One cucumber slice was on the floor to the left of the fryer in the grill area.

-A binful of raw turkey meat, a tray of cut vegetables, a tray of raw chicken breasts, and a tray of raw lamb patties were found uncovered in the refrigerator drawer located under the grill. Allowing food to remain uncovered can result in debris falling into the food and contaminating it.

-In the dry goods pantry, food items were not marked with a received date to ensure a first-in/first-out rotation. These food items included two 7lb 6oz cans of sliced strawberry topping, six 5lb boxes of yellow cake mix, four 7lb boxes of fudge brownie mix and seven 5lb boxes of white cake mix, to name a few.

-Under the wire shelving units in the dry goods pantry, debris including a water bottle, a bottle of teriyaki sauce, individual, serving-sized tubs of peanut butter, food crumbs, an open package of cookies, mayonnaise/mustard packets and dried pasta.

-The walk-in freezer contained such frozen items as scone dough, cookie dough, potato puffs, vegetables and meats, all contained in their original, outside shipping box. Outside shipping boxes carry dirt and bacterial debris into the facility.

-Standing water approximately 1/4" deep was present on the floor of the dirty dish room and had no means by which to properly drain. Standing water can serve as a bacterial breeding ground.

-A strong, foul odor was noted in the dish room and a stagnant, slimy substance was noted in the corner of the room near the dishwasher.

-3 of 3 air vents in the dishwashing area contained chipped paint and were coated with dust. Chipped paint prohibits a surface from being properly cleaned and the dust on the vents carries bacteria, which can cause disease.

-Metal serving trays and bowls were observed stored in the kitchen area inverted and stacked on top of each other. It was observed approximately 25 metal containers and bowls had visible water trapped and were moist to touch, due to being stacked while wet. This moisture presents a risk for bacterial contamination.

-In the dishwashing area, approximately 50 plastic bowl and 70 plastic drinking cups were observed inverted and stacked on top of each other. These items had visible water trapped and were moist to touch, due to being stacked while wet. This moisture presents a risk for bacterial contamination.

-It was observed that metal serving bowls were being placed upside down on the flat metal surface above the dishwashing sink. This prevented the items to air dry or completely finish drying prior to being stacked for storage. In an interview, a kitchen staff member confirmed this is standard practice in the kitchen area. Failing to allow the above dishware to air dry or dry completely before storage increases the risk for moisture accumulation, providing growth medium for bacteria.

-In the grill area, the red bucket containing sanitizer solution was tested by kitchen staff member at 2:00 PM. The test strip results revealed that the sanitizer strength was at 0-100 ppm which is below the manufacture recommended strength of 200-400 ppm.

-In the coffee shop area, the red bucket containing sanitizer solution was tested by kitchen staff member at 2:40 PM. The test strip results revealed that the sanitizer strength was at 0-100 ppm which is below the manufacture recommended strength of 200-400ppm.

-This surveyor located a Sanitizer Solution Concentration Log which was blank. In an interview on 04/05/17, staff member #D20 confirmed the facility staff were not completing the Sanitizer Solution Concentration Log per facility policy.

-2 refrigerators containing 21 trays of individual serving of salads, pies, fruit, and jello were observed to have no dates indicating when the items were prepared or discard dates noted.

-In the coffee shop area, an open jug of milk and a carton of creamer were observed with no date indicating when opened.

-A drawer was found to contain cake decorating items including measuring cups, frosting tips, and slicer's. Debris was noted on these utensils and throughout the drawer.

-In the thaw fridge, the following expired items were noted: a containers of sliced tomatoes, diced tomatoes, and chopped eggs were observed with a label noted they were opened on 04/01/17 with a discard date of 04/03/17 documented. A container of sliced strawberries had no label noted.

-In the entrée cook station, the paper towel dispenser was noted with a sticky substance present, indicating ineffective cleaning and a potential for cross contamination.


During a tour of the dietary area on 04/06/17 the following observations were made:

-In the dish washing area, bowls and cups were not being air dried completely prior to being stacked.

In the main kitchen area, it was observed approximately 6 metal containers and bowls had visible water trapped and were moist to touch, due to being stacked while wet. This moisture continued to present a risk for bacterial contamination.

-In the main kitchen area the red bucket containing sanitizer solution was tested by kitchen staff member at 2:00 PM. The test strip results revealed that the sanitizer strength was at 200 ppm which is at the manufacture recommended strength of 200-400 ppm.


Facility based policy #B006 titled "Production, Purchasing, Storage" states, in part:

"Policies:
-All food.non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.

Dry Storage:

-Date and rotate items; first in, first out (FIFO).

Refrigerated Storage:

-Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date."


Facility based policy #F001 titled "Sanitation and Infection Control" states, in part:

"Policies:
Proper sanitation and infection control practices are observed in all phases of food production and service."


Facility based policy #F017 entitled, "Storage of Pots, Dishes, Flatware, Utensils" stated in part,

"Pots, dishes, and flatware are stored in such a way to prevent contamination by splash, dust, pests. Or other means.

PROCEDURES:

Dish Handlers, Trayline Area Employees
o Air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet."


Facility based policy #F018 entitled, "Sanitizing Food Contact Surfaces" stated in part,

"PROCEDURES:

Sanitize food contact surfaces after they have been thoroughly washed and rinsed.

Follow the instructions on the test strips package for temperature of solution when tested and process must be followed...

Use one of the following products:

"Oasis 146 Multi-Quat Sanitizer, at concentration of 200-400 ppm, and a minimum temperature of 75 [[degrees] F...

Complete Sanitizer Solution Concentration Log once a day for sanitizer being dispensed from unit to fill red buckets.

If the concentration of the sanitizing solution does not meet the standard listed above, the solution is mixed manually; each a batch is tested and recorded."



The above findings were confirmed in interview on 04/05/16 and 04/06/17 with staff members #D17 and #D20.

Based on observation, review of documentation, and interviews with facility staff, the facility failed to maintain supplies to ensure an acceptable level of safety and quality as expired medical supplies were found available for use in patient care areas. This potentially could have resulted in unsafe or ineffective medical supplies being used in patient care.


The findings were:


Based on observation and interview, it was determined that the facility failed to ensure that expired supplies were removed and not available for use by staff.


Findings were:


Expired supplies were found and available for use by staff. During a tour of the Providence MRI Center on the afternoon of 4/03/2017 expired supplies were found in the center ' s crash cart to include:

2 each BD Insyte Autoguard 18 Ga 1.16 in (1.3x30mm) needles with an expiration date of 2017-03

2 each BD Insyte Autoguard 16 Ga 1.16 in (1.7x30mm) needles with an expiration date of 2016-05.

There were 6 expired green top lab tubes, expiration date 12/2016.


In an interview on the afternoon of 4/03/2017 with staff member #A4 on the afternoon of 4/03/2017 the above findings were confirmed.


A tour of the DePaul Center on the morning of 4/04/2017 revealed the following:

On the ICP2 unit the emergency cart contained expired supplies to include: one each IV bag of 500ml 0.9% Sodium Chloride, expiration date was Oct 2016.

10 each disposable Betadine Solution Swabsticks with expiration date of 06 2016.

2 each BD Insyte Autoguard 22 Ga 1.00 in (0.9x25mm) needles with an expiration date of 2015-04.

2 each BD Insyte Autoguard 18 Ga 1.16 in (1.3x30mm) needles with an expiration date of 2015-01.

3 each BD Insyte Autoguard 20 Ga 1.16 in (1.1x30mm) needles with and expiration date of 2015-09.
In an interview with staff members #A4 and #A6 on the morning of 4/04/2017 the above findings were confirmed.

Based on observation, review of documentation and interview the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases when they:

" Failed to ensure that the Infection Control Officer had the required qualifications for the position as set forth by the hospital.

" Failed to properly insulate facility doors allowing bugs to enter the facility.

" Allowed multiple areas in the hospital to have dirty floors and dust buildup on the windows and air vents.

" Incorrect hand hygiene practices.

Cross refer to:
A 0712 Flash Sterilization
A 0734 Preventative Maintenance
A 0748 Infection Control Officer
A 0749 Infection Control Program

In interviews with the Infection Prevention Nurse, the OR Manager and the Chief Medical Officer on 4/3/17 and 4/4/17 the above findings were confirmed.

Based on review of documentation and interview, it was determined that the Infection Control Officer did not have the qualifications determined by the hospital for the position.


Findings were:


Job Description entitled "Infection Prevention Practitioner" dated 10/9/16 described job qualifications as follows:

"Certified Certification specializing in Infection Control credentialed from the Certification Board of Infection Control and Epidemiology, Inc. (CBIC) obtained prior to hire date or job transfer date. CICC required within two years of hire.

"Licensed Clinical Registered Nurse credentialed from the Board of Nursing. Licensed RN in the state of Texas required.

"Education: Bachelors of Science in Nursing required. MSN preferred."


In an interview with staff member #E9 on 4/5/17, it was acknowledged that she did not have Certification specializing in Infection Control nor a Bachelor's of Science in Nursing.

Based on observation and interview, the facility failed to ensure a sanitary environment to avoid sources and transmission of infections and communicable diseases.


Findings included:


During a tour of the MRI Center the afternoon of 4/3/17 accompanied by Staff #A1, the following were observed:

a. There was a mop standing in approximately 2 inches of water in the mop bucket of a cleaning cart in the housekeeping area. Mops should be placed in a position that allows them to air-dry without soiling walls, equipment, or supplies as standing dirty water presents a risk for the growth of bacteria.

b. There was a layer of raised dust on high horizontal surfaces, including the suction canister, the crash cart, and the respiratory and cardiac emergency boxes.

c. There was a 100 ml bag of D5W in the crash cart which expired 1/Mar/2017.


In an interview on the afternoon of 4/03/2017 with Staff #A1 the above findings were confirmed.


During a tour of the Woodway Radiology Center the afternoon of 4/4/17 accompanied by Staff #A20 in the patient holding area, the exam table had a puncture in the vinyl covering and the pillow had two holes in the outer covering which exposed the porous material underneath and made proper disinfection impossible; a potential source of infection. These findings were confirmed during the tour with Staff #A20.


During a tour of the Woodway Rehabilitative Services facility the afternoon of 4/4/17 accompanied by Staff #21, 2 out of 4 high/low tables had punctures in the vinyl coverings which exposed the porous material underneath and made proper disinfection impossible; a potential source of infection. These findings were confirmed during the tour by Staff #21.


During a tour of the Providence DePaul inpatient psychiatric facility the morning of 4/4/17 accompanied by Staff #A14, the following was observed:

a. There were 2 size XL patient gowns available for patient use stored uncovered in the Adult unit storage room. This potentially could have caused these clean linens to be contaminated from airborne dust or infectious agents.

b. There was a bag of more than 25 vacutainer holder/lab drawing devices in a clear plastic bag stored on the floor in the Adult unit storage room. Next to the bag on the floor was a plastic bin with more vacutainer holders. These items are used in direct patient care and storing patient care items on the floor presents a risk for contamination by dirt, dust, or insects, or during cleaning of the floors.

c. There were 3 external shipping boxes (dirty corrugated boxes) in the Adult Unit Storage room on the shelving unit next to supplies such as 02 nasal cannulas which were available for patient use. Storing patient use items in contact with a contaminated external shipping box/container, makes cross contamination likely. "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material, serve as generators of and reservoirs for dust." (AAMI ST46-Section 5.2 Receiving items).

d. In the Adult Unit Nourishment room, there were water damaged ceiling tiles and the floors were in need of cleaning, especially in the area around and behind the refrigerator as there were drips, what appeared to be old food debris, and raised dirt.

e. In the Adult Unit Laundry room, the floors were in need of cleaning as there was spilled laundry soap, dust and debris around the washing machine and dryer.

f. In the Adult Unit, the back external door had a 1 inch opening around the lock and sunlight from the outside was visible from the inside of the building. This could allow the entrance of dust and pests, creating a risk for cross contamination.

g. In the external door near the seclusion room in the ICU, there was an extended hinge which had dust and spider webs adhered and hanging on the top of the door and the hinge and there was sunlight from the outside visible on the bottom and right side of the door from inside the building. The lack of weather stripping or seals prevents a risk for contamination from the weather and the entry of insects and other environmental contaminants such as dust and debris.

h. In a large storage room located on the hallway adjacent to the kitchen the surveyors observed that the floor was stained and dirty in appearance, with copious amounts of dust, dirt, and debris on the floor. The housekeeping equipment was kept in this room and was rolled in and out of this room across the contaminated floor into the patient care area, therefore presenting a risk for cross contamination.

i. In the seclusion room and Patient room 122, there was raised dust and debris in the window sill. The screen underneath the window above the window sill was in need of cleaning as there was raised dust and dirt in the window.

These findings were confirmed during the tour by Staff #A14.


Based on observation, review of documentation, and interviews, the hospital failed to ensure that dietary services were provided in accordance with recognized dietary standards, as the DePaul Center kitchen/dining room was oberved to have dirt, debris, insects, and grease in the food prep and plating area; the sanitizing solution did not contain the minimum concentration of sanitizer to be effective; there was dried food on kitchen cooking utensils, food was stored improperly, and routine cleaning and checklists were not completed. The kitchen was not maintained in a clean and sanitary manner in accordance with facility policy and food service standards. This presents a risk for a food-borne illness or other cross contamination preparing food in an unsanitary environment.


The kitchen/serving area was not maintained in a clean or sanitary manner. During a tour of on the morning of 4/04/2017 the following was observed:

The reddish colored floor tile behind steam table area was dirty and stained. There was dirt, debris, and spills on the floor in the serving area. There was a layer of grease on the floor underneath the kitchen fixtures. 4 of the five steam pans in the steam table had visible pieces of food matter in the water of the steam pan areas. In one of the steam pans were what appeared to be small pieces of green beans. There was a grease residue on the surface. 5 of the 5 steam pan covers had what appeared to be a visible residue on the cover.


The area directly behind the steam table which appeared to be an old griddle type cooktop was a significant accumulation of grease and crumbs on it as if food had been stored or prepared in that area. The lower portion of this cook top area was supported by a stainless steel framework which have multiple areas of staining. The surveyor used a food handler glove and was able to remove some of the stains by rubbing glove on the stainless steel. The wall mounted light switch which controlled the light in the range vent hood over this cook top area was greasy to the touch and was visibly soiled. There was a large fryer which was very greasy, with old food debris and dirty grease pooled around and on top of it. There was a significant accumulation of bread crumbs observed in the stainless steel bread storage drawer located immediately adjacent to the steam table area.


In the actual kitchen/food prep area, the floor tiles by the baseboard area were noted to be dirty and stained, and there was what appeared to be a wadded up napkin and other debris on the floor under the food prep area.


In the bottom of a stainless steel sliding drawer located in the food prep area, there was a sticky food residue noted with what appeared to be small pieces of food which had become stuck in the residue. In this drawer were multiple food serving utensils to include: large kitchen knives, tongs, spatulas and serving spoons. These utensils were not arranged any kind of organized manner but instead all intermingled in the drawer. At least three of these serving utensils were noted to have dried food residue on them. Review of the hospital dietary manual which was provided to the surveyors for review contained policy #F017, entitled: "Storage of Pots, Dishes, Flatware, Utensils." This policy stated: "Pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pests, or other means."


In a walk in dry storage area, there was what appeared to be a dead cricket on the floor and what appeared to be the leg of cricket also visible on the floor.


The ceiling mounted air vents in the kitchen area were dirty with visible dust and an area with flaking chipped paint was observed immediately adjacent to one of the vents. Also noted was dust clinging to the ceiling next to one of the vents. This accumulation of dust presented the opportunity for contamination of patient food as the dust could potentially become airborne and land on patient food. When the surveyor entered the kitchen area at the beginning of the tour, there were approximately 30 individual salads sitting uncovered on the food prep area. (Later these salads were noted to have been moved into the walk in cooler and were observed to not be covered). In an interview with staff member #A33, on the morning of 4/04/2017 it was confirmed that the salads in the walk in cooler should have been covered.


In the hallway immediately adjacent to the kitchen area visible light was observed under the full width of an exterior door. This presented the possibility that insects or small rodents could potentially gain access to the facility.


In an interview on the morning of 4/04/2017 with staff member #A4 and A33 the above findings were confirmed.


In an interview the morning of 4/4/17 with Staff #A30, Staff #A6, and Staff #A14, all stated that there had been no cooking in the kitchen for "several years" but that the food was prepared in the kitchen then sent to the units. Staff #A6 stated that she had been at the hospital for "many years." Staff #A6 stated that the kitchen probably hadn't been cleaned "in a long time" but couldn't remember the last time the kitchen had been used for cooking, and explained that food was brought into the kitchen and set up for the patients in the kitchen.


In an interview the morning of 4/4/17 with Staff #A18, Food Service Worker, she stated that she used the area, including the griddle and the food prep area and the steam table to plate the food for the patient on the DePaul Center unit. She confirmed that the utensils mentioned above were used in preparation of plates of food for the patients. Staff #A18 confirmed that the kitchen and food prep area were in need of cleaning.


In an interview the morning of 4/5/17 with Staff #A18, Food Service Worker, she was asked by the survey team for the sanitizing solution used for sanitizing food contact and food preparation surfaces. Staff #A18 revealed a red, unlabeled bucket approximately 1/2 full of a clear liquid. There was no label on the bucket to indicate the contents, or the date and time the solution was last prepared; Staff #A18 confirmed that the bucket was not labeled.


When the surveyor asked Staff #A18 to test the solution with a test strip to determine the concentration of the solution, Staff #A18 obtained a test strip from another area of the kitchen and dipped it into the solution. Staff #A18 stated that the strip should be dipped into the solution for "about 2-3 seconds." Review of the strip label revealed the strip should be submerged in the solution for 10 seconds. After approximately 15 seconds (by observation), Staff #A18 removed the strip from the solution and the solution still did not read 150 ppm (minimum range). The sanitizing solution did not contain the minimum concentration of sanitizer to be effective. When asked for a log indicating the frequency of changing the sanitizing solution and testing the concentration of the solution, Staff #A18 stated that a log was not maintained and there was no documented evidence provided to the surveyor to indicate that sanitizing solutions were being tested and regularly changed.


Review of the hospital dietary manual which was provided to the surveyors for review contained a 3 page "Basic Sanitation Checklist" form. This form contained multiple areas of inspection to include: "Dining Room, Production Area, Storage Areas, DishRoom." In the Production Area section specific areas included: "1. General appearance, free of clutter, clean, orderly and odor free?" "2. Utensils are clean and neatly organized? Soiled utensils in proper location?" "4. Floors ae clean and free of litter? Baseboards and kick plates are clean and polished?" "6. Battery of cooking equipment - area behind and under is free of food, grease and dust?" Review of facility policy #F015, entitled: "Sanitation Inspection and Checklist" stated: "A basic sanitation inspection is conducted at least once per month to assure that established procedures are being followed and that sanitation standards are being met.


Review of a seven page "Cleaning Checklist" which was also found in the hospital dietary policy and procedure manual revealed multiple areas to check on a daily, weekly, monthly time frame and there was an area where an individual's initials could be documented and as well as an area labeled manager. The last page of the checklist was entitled: "Kitchen." Items on this page to check in the kitchen area included: "Kitchen walls, doors, ceiling, & lighting cleaned." Clean counter tops, legs, drawers, & shelving." "Clean stove tops." "Sweep and mop kitchen floor including all pass through areas." "All utensils cleaned & stored properly." On the morning of 4/05/2017 in the DePaul Center conference room the surveyor asked staff #A33 if there was documentation that this cleaning checklist found in the dietary policy and procedure manual had been done. Staff member #A33 confirmed that that there was no documentation that it had been done for the DePaul Center.


In an interview the afternoon of 4/5/17 in the facility conference room with Staff #A36, Infection Control, she stated that she was aware of the grease, debris, old food and dirty state of the kitchen and that the kitchen was being used for patient food preparation despite the need for cleaning. Staff #A36 stated that the kitchen was "Gross." Staff #A36 stated that quarterly Environment of Care Rounds are made at DePaul which include a tour of the kitchen and that she had documented the need for the kitchen to be cleaned and reported it. Staff #A36 provided the survey team with the documents from the "Environmental Tours" which included items in the checklist for the kitchen area at DePaul, the most recent documented tour conducted on 9/4/2016. Staff #A36 stated that the Director of the DePaul Unit, the Quality Assurance Manager, and other hospital staff were participants in the quarterly environmental tour.


In an interview the afternoon of 4/5/17 in the facility conference room with Staff #A30, Manager of DePaul Center, she confirmed that she participated in the DePaul quarterly environmental tour and was aware of the condition and need for cleaning in the kitchen, however stated that she was not present for the tour conducted the most recent quarter.


During a tour of the Providence DePaul inpatient psychiatric facility the morning of 4/4/17 accompanied by Staff #23, the following was observed:

a. There were 3 cans of Glucerna Chocolate, 8 ounces, available for patient use in the refrigerator which expired 4/1/2017. This was confirmed by Staff #A-14 the morning of 4/4/17.


28421



Based on documentation and interview, it was determined that the facility's Infection Control Committee failed to ensure that nursing staff practiced appropriate hand hygiene.


Findings were:


Facility Policy entitled "Standard and Transmission Based Precautions" stated in part "Hands must be cleansed with soap and water OR alcohol-based hand rubs following any direct contact with a patient's skin, mucous membranes, body fluids, and any contaminated patient care-items.


"Cleanse hands between tasks and procedures on the same patient to prevent cross contamination of different body sites."


"Patient Safety/Quality Council Minutes" dated May 19, 2016 stated in part "Hand Hygiene Compliance goal is a rate of >/= 90%; the current rate is 77.73%. This was the result of a sharp decline in the number of units/departments reporting hand hygiene observations. The quality management department provided observations to help provide an increased sample size. It was determined due to observation process differences the compliance rate dropped dramatically. Action Plan: Discussions are scheduled to gain access to video for unbiased observation collection."


"Clinical Excellence Committee/Quality" dated July 2016 scored hand hygiene compliance hospital wide at 95.65%.


"Infection Control Committee Charter's" purpose was stated as "The Infection Control Committee shall bring together clinical, administrative and epidemiological expertise to participate in and direct the Infection Control activities of Providence Health Center."


"Infection Control Committee" meeting minutes dated February 17, 2016 stated "Hand Hygiene: The compliance for 4th quarter 2015 is 96.23%. (Staff) noted there has been an increase of the receipt of hand hygiene surveillance forms into Infection Control. Action Plan: Monitoring will continue."


"Infection Control Committee" meeting minutes dated August 17, 2016 stated "Hand Hygiene: The compliance for 2nd quarter 2016 is 85.85%. (Staff) noted the Quality Department has developed a plan to review video surveillance and remove this responsibility from unit staff. This will begin as soon as the logistic issues can be resolved. Action Plan: Monitoring will continue."


"Infection Control Committee" meeting minutes dated November 16, 2016 stated "Hand Hygiene: The compliance rate for 3rd quarter 2016 is 59.16%. (Staff) explained that the Quality Department implemented the process on 8/26/2016 to review video observations for hand hygiene compliance. (Staff) noted, although this has resulted in increased observations, those observations being on camera have resulted in a steep decline of compliance. (Staff) assured the committee that an action plan is being developed to aid all departments in meeting the goal of 90% hand hygiene compliance house wide. Action Plan: Monitoring will continue."


"Infection Control Committee" meeting minutes dated February 15, 2017 stated "Hand Hygiene: The compliance rate for 4th quarter is 41.28%. (Staff) reminded the committee that the Quality Department implemented the process on 8/23/2016 to review video observations for hand hygiene compliance. (Staff) noted, this has resulted in increased observations, and those observations, being on camera, have resulted in a steep decline of compliance. (Staff) assured the committee that an action plan is being implemented to aid in all departments in meeting the goal of 90% hand hygiene compliance house wide. Action Plan: Monitoring will continue."


In an interview with staff member E9 (Infection Prevention Nurse) on 4/5/17, it was acknowledged that during the past 6 months, hospital acquiescence with hand hygiene has declined with no documented action plan to improve compliance.




28422



Based on observation, review of documentation, and interviews with staff, the infection control officer failed to develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.


Findings were:


During a tour of the dietary department on 4-5-17, the following observations were made:

-Dried bits of food were present on the blade and the blade guard of the meat slicer in the grill area. Food residue encourages rodents, which can carry bacteria and disease.

-Three french fries were on the floor to the right of the fryer in the grill area.

-One cucumber slice was on the floor to the left of the fryer in the grill area.

-A binful of raw turkey meat, a tray of cut vegetables, a tray of raw chicken breasts, and a tray of raw lamb patties were found uncovered in the refrigerator drawer located under the grill. Allowing food to remain uncovered can result in debris falling into the food and contaminating it.

-Under the wire shelving units in the dry goods pantry, debris including a water bottle, a bottle of teriyaki sauce, individual serving-sized tubs of peanut butter, food crumbs, an open package of cookies, mayonnaise/mustard packets, and dried pasta was noted.

-The walk-in freezer contained such frozen items as scone dough, cookie dough, potato puffs, vegetables, and meats, all contained in their original outside shipping box. Outside shipping boxes carry dirt and bacterial debris into the facility.

-Standing water approximately 1/4" deep was present on the floor of the dirty dish room and had no means by which to properly drain. Standing water can serve as a bacterial breeding ground.

-A strong, foul odor was noted in the dish room and a stagnant, slimy substance was noted in the corner of the room near the dishwasher.

-3 of 3 air vents in the dishwashing area contained chipped paint and were coated with dust. Chipped paint prohibits a surface from being properly cleaned and the dust on the vents carries bacteria, which can cause disease.

-Metal serving trays and bowls were observed stored in the kitchen area inverted and stacked on top of each other. It was observed approximately 25 metal containers and bowls had visible water trapped and were moist to touch, due to being stacked while wet. This moisture presents a risk for bacterial contamination.

-In the dishwashing area, approximately 50 plastic bowl and 70 plastic drinking cups were observed inverted and stacked on top of each other. These items had visible water trapped and were moist to touch, due to being stacked while wet. This moisture presents a risk for bacterial contamination.

-It was observed that metal serving bowls were being placed upside down on the flat metal surface above the dishwashing sink. This prevented the items to air dry or completely finish drying prior to being stacked for storage. In an interview, a kitchen staff member confirmed this is standard practice in the kitchen area. Failing to allow the above dishware to air dry or dry completely before storage increases the risk for moisture accumulation, providing growth medium for bacteria.

-In the grill area, the red bucket containing sanitizer solution was tested by kitchen staff member at 2:00 PM. The test strip results revealed that the sanitizer strength was at 0-100 ppm which is below the manufacture recommended strength of 200-400 ppm.

-In the coffee shop area, the red bucket containing sanitizer solution was tested by kitchen staff member at 2:40 PM. The test strip results revealed that the sanitizer strength was at 0-100 ppm which is below the manufacture recommended strength of 200-400ppm.

-A surveyor located a Sanitizer Solution Concentration Log which was blank. In an interview on 04/05/17, staff member #D20 confirmed the facility staff were not completing the Sanitizer Solution Concentration Log per facility policy.

-2 refrigerators containing 21 trays of individual serving of salads, pies, fruit, and jello were observed to have no dates indicating when the items were prepared or discard dates noted.

-In the coffee shop area, an open jug of milk and a carton of creamer were observed with no date indicating when opened.

-A drawer was found to contain cake decorating items including measuring cups, frosting tips, and slicer's. Debris was noted on these utensils and throughout the drawer.

-In the thaw fridge the following expired items were noted: a containers of sliced tomatoes, diced tomatoes, and chopped eggs were observed with a label noted they were opened on 04/01/17 with a discard date of 04/03/17 documented. A container of sliced strawberries had no label noted.

-In the entrée cook station the paper towel dispenser was noted with a sticky substance present, indicating ineffective cleaning and a potential for cross contamination.


During a tour of the dietary area on 04/06/17 the following observations were made:

-In the dish washing area, bowls and cups were being air dried completely prior to being stacked. In the main kitchen area, it was observed approximately 6 metal containers and bowls had visible water trapped and were moist to touch, due to being when stacked while wet. This moisture continued to present a risk for bacterial contamination.

-In the main kitchen area, the red bucket containing sanitizer solution was tested by kitchen staff member at 2:00 PM. The test strip results revealed that the sanitizer strength was at 200 ppm which is at the manufacture recommended strength of 200-400 ppm.


Facility based policy #B006 titled "Production, Purchasing, Storage" states, in part:

"Policies:

-All food.non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.


Dry Storage:

-Date and rotate items; first in, first out (FIFO).

Refrigerated Storage:

-Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date."


Facility based policy #F001 titled "Sanitation and Infection Control" states, in part:

"Policies:

Proper sanitation and infection control practices are observed in all phases of food production and service."



Facility based policy #F017 entitled, "Storage of Pots, Dishes, Flatware, Utensils" stated in part,

"Pots, dishes, and flatware are stored in such a way to prevent contamination by splash, dust, pests. Or other means.

PROCEDURES:

Dish Handlers, Trayline Area Employees

o Air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet."


Facility based policy #F018 entitled, "Sanitizing Food Contact Surfaces" stated in part,

"PROCEDURES:

Sanitize food contact surfaces after they have been thoroughly washed and rinsed.

Follow the instructions on the test strips package for temperature of solution when tested and process must be followed...

Use one of the following products:

"Oasis 146 Multi-Quat Sanitizer, at concentration of 200-400 ppm, and a minimum temperature of 75 [[degrees] F...

Complete Sanitizer Solution Concentration Log once a day for sanitizer being dispensed from unit to fill red buckets.

If the concentration of the sanitizing solution does not meet the standard listed above, the solution is mixed manually; each a batch is tested and recorded."


The above findings were confirmed in interview on 04/05/16 and 04/06/17 with staff members #D17 and #D20.




32870



Based on a review of facility documentation and staff interviews, the facility failed to implement and enforce its policy related to "flash sterilization" and to perform routine preventive maintenance as recommended by the manufacturers on the sterilizers and scope washer in the sterile processing department.


Facility policy entitled Sterilization, last reviewed 11/16, included the following:

"FLASH STERILIZATION

1. Flash sterilization is limited to urgently needed medical devices and instruments when patient care requirements preclude the use of other methods of sterilization.

2. Unwrapped / Non-Porous ..."


A review of the "Flash Sterilization Log Quarterly Report 2016" revealed a category entitled "Patients Receiving Flashed Items" for "reason insufficient items." The quarterly findings were as follows:

2015 - 2nd Quarter - #7 cases - "Insufficient facility owned instrument/sets identified - Eye inst trays, Ortho Major ...Neuro Basic inst ..."

2015 - 3rd Quarter - #24 cases - "Insufficient facility owned instrument/sets identified - All insufficient items have been replaced, drill batteries ..."

2015 - 4th Quarter - #26 cases - "Insufficient facility owned instrument/sets identified: Eye insts/Neuro Basic inst ..."

2016 - 1st Quarter - #14 cases - "Insufficient facility owned instrument/sets identified: Eye inst trays, Ortho Major, Drill batteries trays/Neuro Basic inst."

2016 - 2nd Quarter - #16 cases - "Insufficient facility owned instrument/sets identified: ..." Sets not identified.

2016 - 3rd Quarter - #11 cases - "Insufficient facility owned instrument/sets identified ..." Sets not identified.

2016 - 4th Quarter -- #12 cases - "Insufficient facility owned instrument/sets identified: ..." Sets not identified.


A summary of the cases "flash sterilized" in the first quarter of 2017 was not available. However, review of the number of cases for each month included the following: 4 cases in March for "Insufficient OR Inst"; 3 cases in February for "Insufficient OR Inst"; 7 cases in January 2017 for "Insufficient OR Inst."


Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008, published by the CDC, and available at http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf, includes the following: "Flash sterilization should not be used for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time ..."


A position statement on Immediate Use Steam Sterilization endorsed by the Association of perioperative Registered Nurses, Association of Professionals in Infection Control and Epidemiology, as well as a number of other surgical services professional organizations, and available at http://www.apic.org/Resource_/TinyMceFileManager/


Position_Statements/Immediate_Use_Steam_Sterilization_022011.pdf, includes the following:

""Immediate Use" is broadly defined as the shortest possible time between a sterilized item's removal from the sterilizer and its aseptic transfer to the sterile field ...A sterilized item intended for immediate use is not stored for future use, nor held from one case to another ...Instrument inventories should be sufficient to meet anticipated surgical volume and permit the time to complete all critical elements of reprocessing ..."


A statement by the American Society of Cataract & Refractive Surgery, prepared on February 16, 2007, and available at http://eo2.commpartners.com/users/apic/downloads/
RecPracticesCleaningSterilizingIntraocular.pdf included the following:
"c. Flash sterilization is designed to manage unanticipated, urgent needs for instruments. Flash sterilization should not be used to save time or as a substitute for sufficient instrument inventory ..."


The above findings were confirmed in an interview with the Staff #E9, the Infection Control Coordinator on the afternoon of 4/5/17 in the facility meeting room. She stated they were working on decreasing the number of "items flashed."


A review of the Belimed Operating Instructions Steam Sterilizer MST-V manual included the following:

"7.2 Maintenance

Besides the daily and weekly maintenance tasks, three maintenance levels are defined ...Regular maintenance of the sterilizer is important in order to avoid malfunctions ...


Weekly maintenance

A maintenance routine must be performed every week. In the scope of this maintenance routine, the operator must perform the tasks described below. No maintenance message is displayed for the weekly maintenance routine ...

Cleaning the following elements:

Drainage screen in the chamber floor

Chamber

Front surfaces of sterilizer ...

Visual inspection:

When the door is open, the door seal must lie completely in the seal frame all around the circumference

Check the door seal for damages

Leakproofness of the system:

Visual inspection of the piping system in the servicing space (water, air or steam escaping)

Water level of steam generator:

Check water level. The water level must be visible in the sight glass

Emptying the steam generator:

The steam generator can only be emptied by person with "ZSVA Leader" user authorization ..."


A review of the Olympus Operation Manual for the OER-Pro endoscope reprocessor revealed the following:

"Chapter 7 - Routine Maintenance

To ensure safe operation of the device, it should be cleaned and inspected regularly ..."


A listing of weekly maintenance tasks included:

"Cleaning the alcohol tank ...

Checking cassette cutters (when using concentrated disinfectant solution) ...

Cleaning the disinfectant bottle drawer (when using concentrated disinfectant solution) ...

Replacing the disinfectant solution ...

Cleaning the mesh filter in the water supply hose connector ...

Replacing the fuse ...

Disinfecting

Based on review of documentation and interview, it was determined that the facility did not employ enough respiratory staff to meet the needs of its patient population.

Findings were:

Facility policy entitled "Normal Therapy Schedule" stated in part "Therapy can be given up to 30 minutes before or 60 minutes after scheduled time. If therapy is one hour late, it should be documented on the "Missed Therapy Log" as late treatment and charted in WIZARD. If therapy is over two hours late, it is a missed treatment, it should be documented on the "Missed Therapy Log" as a missed treatment and charted in WIZARD. If late/missed due to unavailability of respiratory therapist, then an ERS report must be completed."

Facility policy entitled "Staffing Plan" stated in part "Typically, minimum patient care staffing will be as follows:
Day shift: 5-6 Technicians/Therapists/Assistants
1 Supervisor (Monday-Friday)
1 Department Educator
1 Department Director (Monday-Friday)
Night shift: 4-5 Technicians/Therapists/Assistants ...
Each shift will be staffed with a minimum of three credentialed technicians or therapists."

During the past 6 months, the following respiratory treatments were missed:
" March 2017: 83 treatments were missed
" February 2017: 71 treatments were missed
" January 2017: 54 treatments were missed
" December 2016: 18 treatments were missed
" November 2016: 15 treatments were missed
" October 2016: 19 treatments were missed

In an interview with staff member E1 (Respiratory Therapy Supervisor) on 4/4/17, it was acknowledged that the above respiratory therapy sessions were missed. Staff member E1 stated that two of her therapists were out on leave. She said respiratory therapy treatments could not be delegated to nursing staff and that when there was a call for a therapist in the Emergency Department, the therapist attended to the patient in the ED-prioritizing care. At times, the patients having routine scheduled treatments were not seen because of the lack of respiratory care staff.