HospitalInspections.org

Based on a review of facility documents and policies, observation, and staff interview, the governing body failed to ensure hospital policy was implemented to ensure requirements were met as medical staff appointments were not conducted, medical staff and nursing staff licensure was not verified, contracted services were not provided in a safe manner, patient rights were not protected related to grievances and safe settings, food was not prepared in a sanitary environment, the physical plant was not maintained in a safe manner, and the facility failed to provide a sanitary environment to avoid sources and transmissions of infections.


Findings were:

Record review and interview revealed that the facility failed to ensure that members of the current medical staff were appointed by the Governing Body.
Cross refer A0046

Record review and interview revealed that criteria for selection including individual character, competence, training, experience, and judgment were not determined.
Cross refer A0050

Record review and interview revealed that contracted services were not evaluated, contracts were not reviewed, and training, licensure, and competency was not assessed for contracted agency nursing personnel.
Cross refer A0084

Review of facility documents, policies and records, facility tour, and staff interviews revealed the facility failed to protect and promote each patient ' s rights, as grievance time frames were not provided and written decisions were not provided to patients, food was not prepared in a sanitary environment, and the physical plant was not maintained in a safe manner.
Cross refer A0115

Review of records and interview revealed that the facility failed to follow its policy and procedure for Quality Assurance and Performance Improvement.
Cross refer A0273

Review of facility policies and staff interviews revealed the facility failed to ensure that a patient had nursing personnel assigned based on the competence of the nursing staff.
Cross refer A0386

Review of documentation, observation, and interviews with facility staff revealed the facility failed to maintain the hospital environment in a safe manner for the wellbeing of the patients.
Cross refer A0701

Review of documentation, observation, and interviews with facility staff revealed the facility failed to provide a sanitary environment to avoid sources and transmissions of infections.
Cross refer A0747

Based on record review and interview, it was determined that the facility failed to ensure that members of the current medical staff were appointed by the Governing Body.

Findings were:

Review of Medical Staff credentialing files on 11/28/12 revealed that staff #17 ' s (physician) appointment from the board expired on 11/22/12.

The above findings were confirmed in an interview with the Director of Nursing on 11/28/12.

Based on record review and interview, it was determined that the facility failed to ensure that members of the current medical staff maintained licensure necessary for the providing patient care.

Findings were:

Review of Medical Staff credentialing files on 11/28/12 revealed the following:
? Personnel #13 (Physician Assistant) had a Texas Department of Public Safety license that expired on 10/31/12.
? Personnel #14 (Physician Assistant) had a Texas Department of Public Safety license that expired on 7/31/12.
? Personnel #15 (Physician) had a Drug Enforcement Agency license that expired on 8/31/12.
? Personnel #16 (Physician) had a Texas Department of Public Safety license that expired on 5/31/12.
? Personnel #17 (Physician) had a Texas Department of Public Safety license that expired on 7/3/12.

The above findings were confirmed in an interview with the Director of Nursing on 11/28/12.

Based on a review of facility policies, facility documents and staff interviews, the governing body failed to ensure that contracted services were evaluated and provided in a safe and effective manner and contracts were not reviewed and training, licensure, and competency was not assessed for contracted agency nursing personnel.

Findings were:

Review of 3 out of 5 contracts on 11/28/12 revealed no documented evidence that the contracts for the following entities were reviewed annually per policy.
? Pest control (effective 9/2/11)
? Hazardous waste (effective 4/22/09)
? Agency nursing service (effective 11/8/08).
Review of facility policy entitled, " Evaluation of Contract Services " last revision date 9/1/2011 revealed the following:
" Contract services are evaluated on, at minimum, an annual basis to assure the quality of services is maintained according to BCA Permian Basin patient care standards ...
5. Personnel utilizing the service will be asked to complete an annual Written Evaluation of Contracted Clinical Service prior to the contract anniversary ...
5.2 A copy of the Written Evaluation will be placed in the contract file "

Review of facility policy entitled, " Nursing Agency Personnel " last revision date 8/22/2011 revealed the following:
" The agency shall provide documentation of proof of the following:
1.1 Licensure
1.2 CPR certification
1.3 Current TB test
1.4 Patient Rights
1.5 Abused, Neglect, Exploitation
1.6 Infection Control and Universal Precautions
1.7 Age-specific Competencies
1.8 Fire and Safety Training.
2. Records The orientation checklist, proof of licensure and certifications and all other items listed in " 1 " above shall be filed in the Nursing Department files and copies will be filed in the Human Resources files.
3. Facility Specific Orientation:
3.1 Agency personnel shall review the Agency Orientation Packet and sign. "

In an interview with the Human Resources Director and the Director of Nursing the afternoon of 11/29/12 in the conference room, both individuals confirmed that 8 registered nurses, Staff # 19 - 26, and 3 licensed vocational nurses, Staff # 27, 28, and 29, and 34 nursing assistants, from various nursing staffing agencies had working in the facility from 9/15/12 to 11/29/12, yet there were no records and no personnel file available of provided for any of these agency staff. There was no documented evidence provided of an orientation checklist or proof of licensure and certification. There was no documented evidence that any of the nursing assistants had completed any training, including CPR, Patient rights, Abuse/Neglect/Exploitation, Fire and Safety, or were competent or qualified to care for patients at this hospital.

Based on a review of facility documents, policies and records, facility tour, and staff interviews, the facility failed to protect and promote each patient ' s rights, as grievance time frames were not provided and written decisions were not provided to patients, food was not prepared in a sanitary environment, and the physical plant was not maintained in a safe manner.

Findings were:

Based on a review of facility policies and staff interviews, the facility failed to ensure that time frames were specified for review of a grievance and the provision of a response for patients.
Cross refer A0122

Based on a review of facility documentation and staff interviews, the facility failed to ensure that patients were provided written notice of grievance decisions, including steps taken, results, and date of completion.
Cross refer A0123

Based on a review of facility documentation and policies, tour of the facility, and staff interviews, the facility failed to provide care in a safe setting, as food was not prepared in a sanitary environment to avoid sources and transmission of infections, and the physical plant was not maintained in a safe manner.
Cross refer A0144

Based on a review of facility policies and staff interviews, the facility failed to ensure that time frames were specified for review of a grievance and the provision of a response for patients.

Findings were:

Review of facility policy entitled, " Consumer Complaint " last revision 8/11/12, revealed no documented evidence of specified time frames for review of a grievance and the provision of a response to the patient.

Review of the " Patient Handbook " revealed no documented evidence of specified time frames for review of a grievance and the provision of a response to the patient.

In an interview at 3:15 pm on 11/18/12 in the conference room with Staff #5, Patient Advocate, she confirmed that the policy did not include specified time frames for review of a grievance and the provision of a response to the patient.

Review of the file of patient complaints from 8/20/12 to 10/17/12 revealed 21 out of 21 complaints/grievances received did not receive a written notice of the hospital ' s decision and there was no indication of a written response provided and the date of completion of a response.

The above was confirmed in an interview with the Director of Nursing the afternoon of 11/29/12 in the conference room.

Based on a review of facility documentation and staff interviews, the facility failed to ensure that patients were provided written notice of grievance decisions, including steps taken, results, and date of completion.

Findings were:

In an interview in the conference room the afternoon of 11/28/12 with the Risk Manager, Staff #2, he stated that the Patient Advocate takes complaints and forwards the complaints to him. He stated that by the time he receives the complaint/grievance, the patient has usually been discharged and so nothing happens with the grievance. When asked if there is any further communication with the patient or person making the complaint/grievance, he stated that since the patient has usually been discharged, there is no communication. When asked if any written notice is provided to the patient or person filing the grievance/complaint, he stated that there was none that he was aware of.

Review of the file of patient complaints from 8/20/12 to 10/17/12 revealed 21 out of 21 complaints/grievances received did not receive a written notice of the hospital ' s decision, the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

In an interview at 3:15 pm on 11/18/12 in the conference room with Staff #5, Patient Advocate, she confirmed that written notices are not provided to the patient as above.

Based on a review of facility documentation and policies, tour of the facility, and staff interviews, it was determined that the facility failed to follow its policy regarding accountability of patient's belongings for 7 of 20 patient records reviewed, food was not prepared in a sanitary environment to avoid sources and transmission of infections, and the physical plant was not maintained in a safe manner.

Findings were:
Review of patient charts on 11/28/12 revealed that the facility failed to provide appropriate accountability of patient's personal belongings for patients #3, #6, #7, #8, #9, #14, and #18. Mental Health Assistants (MHA) failed to properly record and obtain proper signatures of patients indicating they received all their belongings upon discharge from the facility.
BCA policy# 1400.6 "Medical Records Documentation Requirements" paragraph 27.3 states: "The MHA will return all belongings at the time of discharge and obtain the patient's signature indicating he/she has received the belonging and dates of the return."

During a tour of the dietary department at the facility on the afternoon of 11/27/12, the surveyors accompanied by staff # 2, 3, and 4 observed the following;
1. The entrance floor to the dining room where the patients ate their meals was observed to have dust, grayish blackish particles in the floor corners, baseboards, and the cells of the glass windows forming the walls on the left side of the dining area. The glass windows were dirty, smudgy and greasy to the touch.
2. The corridor where patients drop off dirty trays was dirty, including raised brown and black dirt and raised grey dust on the floor, most prominently in the corners, and dried drips of various colors on the walls.
3. The door seal to freezer #3 was torn and worn approximately 4 feet, allowing for inconsistent temperatures of food.
4. There was a thick layer of dust on high and low horizontal surfaces in the entire kitchen/food preparation area.
5. There was debris that appeared to be food on the floor of refrigerator #2.
6. There was dust, food-like debris, and dried drips of various colors on the top and outside of the flour, rice and sugar bins.
7. There was an 8 ounce can of ThickenUp with a handwritten " Opened 9-1-11 " ; the use by date printed on the can was July 22, 2012.
8. 12 ounce jar of " Gumbo Seasoning was greasy and sticky on the outside of the container.
9. On the shelf underneath the food preparation area, was a tray with dust, dirt, dried food, and old cheese.
10. There was a bottle of " Coco powder " labeled " opened 4-30-11 " with a use by date of May 20, 2012.
11. There was a one gallon container of " Red Hot Wing Sauce " that had been opened and was available for use in food preparation labeled, " Best by Jul 13, 2012 " which had dirty dried drips and was covered with a thick layer of greasy dust.
12. There was a dead moth on the shelf with the spices above the food preparation area. There was dried food debris and a layer of greasy dust on the shelf, too.
13. There were 22 jars of spices, 6 ounces on the shelf above the food preparation area that were covered with a thick layer of greasy dust.
14. There was a food thermometer that had dried food on the probe and drips and dried food on the glass top.
15. There was a jar of " Grillmates Pepper " in the utensils drawer.
16. In a drawer in the food preparation area the following was observed:
a. 2 meat cleavers with multiple areas of different colored food-like substances
b. An electric knife with dried drips and foodlike substance adhered.
c. A hand-held paper hole puncher that was greasy.
d. 2 food graters that had dried food-like substance adhered.
e. A pair of tongs with a dried food-like substance adhered.
17. There was a first aid box on the wall over the food preparation area that was covered in greasy dust and there was brown and black dirt inside the first aid box.
18. There was dirt, debris, and food-like substance in the bottom of the utensils drawer.
19. On the shelf underneath the food preparation area the following one gallon containers were observed opened, with no label to indicate date opened, covered with greasy dust:
a. Gourmet red wine vinegar
b. Hickory Seasoning liquid smoke
c. Teriyaki sauce
d. Soy sauce
20. The floor underneath stoves and appliances were covered with a thick, black, greasy substance, which indicated a lack of cleaning for some time.
21. In the knife stand, there were 4 knives with dried food. There was another knife in the stand which had not been cleaned, as it was covered with an oil-like substance and multiple food particles that were not dried on both surfaces.
22. The floor in the dish washer area was observed to have white clumped residue on the baseboards, corners, pipes leading from the dishwasher to the faucets under the dishwasher, and around the drain in the center of the floor. The floors contained greasy, slippery areas with yellowish white residue. Yellowish, greasy, brownish particle buildup was observed on the tile backsplash behind the clean sink.
23. Dust was present on top of all of the refrigerators and freezers in the kitchen.
24. A gap of light was present between double doors leading out to the loading dock, allowing the entrance of dust and pests.
25. There was a hole in the wall behind the ice machine, allowing an entry point for pests.
26. The fan and vent on top of the ice machine was covered in a thick, dirty grayish-brown dust.
27. The middle drawer of a stainless steel food preparation table had small pieces of food under a tray containing clean ice-cream scoops.
28. A food warmer " Auto-Shamm " had dried crusted food inside of it on the racks.
29. Dust was observed hanging from all of the celling air vents in the in the kitchen and patient dining area.
30. A dirty food tong was located in an area among clean food tongs.
31. Two food containers labeled " Caramel Topping " and Chocolate Flavored Syrup " , both indicated that they should be " Refrigerated After Opening " ; both of these food containers were not stored in a refrigerator.
32. An oily substance was present on 2 clean food pans.
33. Dirt, yellow greasy, white powdery and blackish residue was observed on all baseboards and floor corners in the kitchen/dining area.
34. Dust was observed hanging from the artificial greenery hanging in the patients dining area over the food serving area.
35. There was dirt and debris on the floor in the corners of the dry food storage room.
36. There was no weather stripping under the external door in the kitchen area to the loading dock, as daylight from the outside was visible from inside the building.
Review of " Dietary Department Infection Control Overview " page 291 stated, " Infection control within the dietary department shall be monitored to promote food safety and prevent foodborne illness. Cleaning is the removal of food, soil and other types of debris from a surface. Two factors that are essential elements of cleaning and sanitizing programs are as follows; Establish clear procedures that address all the types of food equipment used including clean-in place systems and effectively training employees. "

During a tour of the facility on the afternoon of 11/27/12 torn carpet, peeling paint, dirty air celling vents, and generalized unsafe areas throughout the physical environment of the facility.
In the Intake area, the wooden baseboard was broken and loose and part of the baseboard was missing.
1 6 double doors leading into the " Central Court Yard " had gaps of light around the doors, indicating worn or non-existent weather stripping, allowing the entrance of dust and pests.
2 A couch in the " Library " had 3 tears in a vinyl seat cushion, making the couch impossible to completely clean.
3 Dust was present on high horizontal surfaces in the " Central Supply " area.
4 A lab supply closet had 131 blue-top lab tubes that expired in April 2012 and August 2012, and 10 " Urine Specimen Collection Kits " that expired in July 2012.
5 The " Central Court Yard " had holes in the bricks near the ground by the door near units 1 and 2, and by the door near units 3 and 4; both of the holes were approximately 1 foot by 6 inches in size, this could allow the entry of pests into the facility.
6 The ceiling air-vent cover was missing in the " Patient Luggage Closet " .
7 Floors in shower stalls on Unit 4, rooms 410, 408, 407, and 405 had white powdery residue in the corners.
8 Peeling paint was observed around the celling lights in unit 4.
9 5 two gallons of paint was located in the closet in the patients library.
10 Tile on the shower floor Unit 2, room 204 had about a 12 inch crack allowing entry for pests, and potential for patient to injury during showers.
11 Unit 2, room 206 shower door was rusty and the baseboards in the bathroom contained white powdery residue.
12 Dust was present on high horizontal surfaces in the " Central Supply " area.
13 A lab supply closet had 131 blue-top lab tubes that expired in April 2012 and August 2012, and 10 " Urine Specimen Collection Kits " that expired in July 2012.
14 In the Geriatric Room, there were the following expired items:
15 40 ml anaerobic culture solution: quantity of 1 expired 11/2011, quantity of 2 expired 2/2012
16 40 ml aerobic culture solution: quantity of 3 expired 8/2012.
17 4 red top lab tubes expired 7/2012
18 4 blue top lab tubes expired 4/2012
19 purple top lab tubes expired 9/2011
20 14 microtainer lab tubes expired 11/2011
21 In the Geriatric room the seam between the internal wall and the external wall was separated and a cold air was felt by the surveyor flowing into the room. This was confirmed by Staff # 3 on 11/27/12.
22 In the Geriatric room, the baseboards were broken and/or missing; the front of a drawer was missing, and there were patient games and supplies stored on the floor.
23 Exam room located between the adult and geriatric units contained the following:
24 41 expired Gen Probes that expired 12/31/2009- 05/31/12.\
25 0.9% Sodium Chloride irrigation 1000ml expired 7/2012, quantity of 2
26 Magnesium Citrate Solution 10 ounces, expired 7/2012
27 The " Central Court Yard " had holes in the bricks near the ground by the door near units 1 and 2, and by the door near units 3 and 4; both of the holes were approximately 1 foot by 6 inches in size, this could allow the entry of pests into the facility.
28 The ceiling air-vent cover was missing in the " Patient Luggage Closet " .
29 In the Adolescent Recreation Yard, there were 4 nails exposed and trim falling off the building with nails exposed. There was also a hole in-between the building and the roof, approximately 12 inches x 12 inches.
30 In the Central Supply room, there were 3 unsecured oxygen tanks.
31 In the main corridor throughout the building, there was frayed carpet, holes in the carpet, and raised carpet, which created a tripping hazard.
Review of documentation Environment Of Care page 2 stated, " The safety management program functions to maintain a safe environment for patients, personnel and visitors through compliance with regulations, procedures, and standards set forth by OSHA, JCAHO, National Fire Code, the Midland County Fire Marshall ' s Office and Standard Building Codes. "
Review of documentation Environment of Care page 1 of 5 stated, " Dust must be kept to a minimum in the facility environment. "

During the tour of the facility on the afternoon of 11/27/12 with staff # 2, 3, and 4 the findings were confirmed.

Based on review of records and interview, it was determined that the facility failed to follow its policy and procedure for Quality Assurance and Performance Improvement.

Findings were:

According to BCA ' s " Performance Improvement Plan 2012 " , the following " Important Aspects of Care " are " monitored due to their high risk, high volume or problem prone nature:
? Patient Falls
? Medication Errors
? Restraint/Seclusion
? Medical Transfers
? Patient Denials
? Infections
? Elopements
? Abuse Allegations"

Based on review of the BCA Permian Basin Performance Improvement (PI) committee meeting minutes on 11/28/12, the facility failed to discuss the following items in the 2012 June, July, August, September, and October meetings:
1. Medical transfers
2. Patient denials
3. Elopements
4. Abuse allegations
Review of the BCA Permian Basin Performance Improvement (PI) committee meeting minutes on 11/28/12, revealed that the facility failed to implement follow-up actions and reevaluation of outcomes for the proposed improvements. On the meeting held on 06/21/12 at 3:00PM, the document stated that the Social Services Director would report information in July for social services to include abuse allegations. No discussion regarding Abuse allegations were mentioned on the 07/19/12 meeting.

BCA ' s " Performance Improvement Plan 2012 " stated the following under the heading " Process " , " 4. Data used to improve performance, practice and process (Acting). a. Upon undesirable trends or patterns in performance being identified, an analysis will occur. If the action does not achieve the desired improvement, new actions shall be planned and tested. "

Review of BCA ' s Performance Measures on patients leaving against medical advice (AMA) revealed that the minutes on 06/21/12 failed to address an increase in acute adolescent unit AMA discharges from 4% in April to 23% in May 2012. There was no evidence in the PI meeting minutes of any action taken to identify issues contributing to the increased number of AMA discharges.

The above findings were confirmed in an interview with the Director of Nursing on 11/29/12.

Based on record review and interview, it was determined that the facility failed to complete a history and physical within 24 hours of admission for 1 of 20 patients.

Findings were:

Review of patient #19 ' s record on 11/28/12 revealed that the patient was admitted on 9/28/12; however the patient did not have a history and physical completed until 10/01/12, which was greater than 24 hours after admission.

The facility ' s " Medical Staff Rules and Regulations " stated the following on page 5; " A complete medical history and physical examination (H&P) as described in the Texas Administrative Code, #482.61(a), shall be recorded within twenty-four (24) hours of inpatient admission. "

The above findings were confirmed in an interview with the Director of Nursing on 11/29/12.

Based on a review of facility policies and staff interviews, the facility failed to ensure that a patient had nursing personnel assigned based on verified competence and licensure of the nursing staff and the identified needs of the patient.

Findings were:

Review of facility policy entitled, " Nursing Agency Personnel " last revision date 8/22/2011 revealed the following:
" The agency shall provide documentation of proof of the following:
1.1 Licensure
1.2 CPR certification
1.3 Current TB test
1.4 Patient Rights
1.5 Abused, Neglect, Exploitation
1.6 Infection Control and Universal Precautions
1.7 Age-specific Competencies
1.8 Fire and Safety Training.
2. Records
The orientation checklist, proof of licensure and certifications and all other items listed in " 1 " above shall be filed in the Nursing Department files and copies will be filed in the Human Resources files.
3. Facility Specific Orientation:
3.1 Agency personnel shall review the Agency Orientation Packet and sign. "

In an interview with the Human Resources Director and the Director of Nursing the afternoon of 11/29/12 in the conference room, both individuals confirmed that 34 nursing assistants from various nursing staffing agencies had working in the facility from 9/15/12 to 11/29/12, yet there were no records and no personnel file for any of these staff. There was no documented evidence provided of an orientation checklist or proof of licensure and certification. There was no documented evidence that any of the nursing assistants had completed any training, including CPR, Patient rights, Abuse/Neglect/Exploitation, Fire and Safety, or were competent or qualified to care for patients at this hospital.

Based on a review of facility policies and staff interviews, the facility failed to ensure that a patient had nursing personnel assigned based on the verified competence of the nursing staff and the needs of the patient.

Findings were:


Review of facility policy entitled, " Nursing Agency Personnel " last revision date 8/22/2011 revealed the following:
" The agency shall provide documentation of proof of the following:
1.1 Licensure
1.2 CPR certification
1.3 Current TB test
1.4 Patient Rights
1.5 Abused, Neglect, Exploitation
1.6 Infection Control and Universal Precautions
1.7 Age-specific Competencies
1.8 Fire and Safety Training.
2. Records The orientation checklist, proof of licensure and certifications and all other items listed in " 1 " above shall be filed in the Nursing Department files and copies will be filed in the Human Resources files.
3. Facility Specific Orientation:
3.1 Agency personnel shall review the Agency Orientation Packet and sign. "

In an interview with the Human Resources Director and the Director of Nursing the afternoon of 11/29/12 in the conference room, both individuals confirmed that 8 registered nurses, Staff # 19 - 26, and 3 licensed vocational nurses, Staff # 27, 28, and 29, from various nursing staffing agencies had working in the facility from 9/15/12 to 11/29/12, yet there were no records and no personnel file available of provided for any of these agency staff. There was no documented evidence provided of an orientation checklist or proof of licensure and certification. There was no documented evidence that any of the nursing assistants had completed any training, including CPR, Patient rights, Abuse/Neglect/Exploitation, Fire and Safety, or were competent or qualified to care for patients at this hospital.

Review of nursing staff personnel folders revealed 9 out of 10 nursing staff no documented evidence of a completed annual pharmacology exam, including Staff # 2, 30, 31, 32, 33, 34, 35, 36, and 38.

Review of facility policy entitled " Pharmacology Exam for RN ' s & LVN ' s stated, in part, " All licensed nursing personnel ...must achieve a minimum score of 80% on the pharmacology exam administered during orientation and annually thereafter. "

Review of nursing staff personnel folders revealed that 2 out of 10 nursing staff, and RN and an LVN, Staff # 30 and 36 had expired CPR certification.

Review of facility policy entitled, " Orientation " effective date 1/1/2007 stated, in part, " At a minimum, the facility Orientation Program will include ...CPR and first aid certification requirements. "

The above findings were confirmed in an interview the afternoon of 11/29/12 in the conference room with the Director of Nursing.

Based on record review and interview, it was determined that the facility failed to provide proper documentation regarding treatment plans for 7 of 10 patients.; additionally, the facility failed to provide adequate monitoring of patients who were on precaution orders as evidenced by 20 of 20 charts being non-compliant with proper documentation, and the facility failed to ensure that records were completed within time frames specified in Medical Staff Rules and Regulations.

Findings were:
Review of patient records on 11/28/2012 revealed the following:
? Patient #1: Admission date 10/01/12. The Treatment plan was missing the physician's signature and date.
? Patient #2: Admission date 10/03/12. The Treatment plan was missing the patient ' s goals.
? Patient #4: Admission date 10/26/12. The Treatment plan was missing the physician's signature and date.
? Patient#6: Admission date 11/01/12. The Treatment plan was missing the physician's signature and date.
? Patient#7: Admission date 10/01/12. The Treatment plan was missing the physician's signature and date.
? Patient#10: Admission date 11/19/12. The Treatment plan was missing the physician's signature and date, no diagnosis recorded, and no patient participation was noted.
? Patient #20: Admission date 6/5/12. The treatment plan was missing the physician ' s signature and date.

The Facility failed to comply with BCA Permian Basin policy # 1400.6 " Medical Records Documentation Requirements " which states on paragraph 10: " All members of the treatment team must sign and date the Master Treatment Plan " .

The staff failed to identify the type of precautions and the level of observation required for patients on the Precautions Observation Checklist:
? The Precautions Observation Checklist had areas where precaution levels would be recorded for each patient; however these were left blank for patients 1 through 20.
? Additionally, patient #11 had no staff initials on 10/3/12 at 7:00 PM and 7:15 PM, and on 10/4/12 at 7:00 PM;
? Patient #16 had no staff initials on 10/13/12 at 7:00 PM and 7:15 PM, on 10/14/12 at 7:00 PM, on 10/18/12 at 7:00 PM, and on 10/19/12 at 7:00 PM and 7:15 PM;
? Patient #17 had no staff initials on 11/2/12 at 7:00 PM, 7:15 PM, 7:30 PM, and 7:45 PM.

The Facility failed to comply with BCA Permian Basin policy # 1400.6 " Medical Records Documentation Requirements " which states on paragraph 19, " Nursing Staff (MHAs) are responsible for the Precautions Observation Checklist. 19.1 Documentation must include: 19.11 Patient identifying information. 19.12 Date 19.13 Initials of codes placed in appropriate time slot with staff initials. "
The above findings were confirmed in an interview with the Director of Nursing on 11/28/12.
Review of the Medical Staff Rules and Regulations for BCA Permian Basin stated, in part, " Deficient items include any authorization not completed within established time periods and/or under 30 days post discharge. "

In an interview with the Director of Medical Records on 11/28/12 in the conference room, she stated that the medical record delinquency rate was 72% in September 2012, with 113 discharges and 86 delinquent charts. On 11/29/12, the Director of Medical Records stated that she completed the medical record delinquency rate for October 2012 and that the medical record delinquency rate for October 2012 was 22%, with 144 discharges, and 32 delinquent charts.

Based on record review and interview, it was determined that the facility failed to follow its policies concerning informed consent for 1 of 20 patient records reviewed.

Findings were:

Review of 10 patient ' s charts on 11/28/12, revealed that the facility failed to obtain informed consent for administering medications for patient #3. Patient #3 received Risperidone 1mg tab and Aricept 5mg tab on 10/17/2012; 10/18/2012 and 10/19/2012 without evidence of a signed consent. This surveyor observed a consent page with the above medications and observed that no patient signature was present.

BCA ' s policy #304 stated the following, " under no circumstances other than an emergency, are nurses to give psychotropic medications without consent of patient or guardian. "

The above findings were confirmed in an interview with the Director of Nursing on 11/29/12.

Based on record review and interview, it was determined that the facility failed to document patient vital signs per facility policy for 3 of 20 patients.

Findings were:

Facility policy #383 " Vital Signs/Weight " stated the following; " Vital signs consist of blood pressure, temperature, pulse, and respirations. Vitals signs are recorded on vital sign sheet. They may also, as appropriate, be recorded on assessment sheets, and in the body of the interdisciplinary treatment notes ...1.1 Vital signs are taken on every patient at the time of admission, then daily. "

Patient records reviewed on 11/28/12 revealed the following:
? Patient #12, admitted on 10/9/12 and discharged on10/15/12, did not have vital signs documented on 10/10/12, 10/11/12, or 10/12/12.
? Patient #15, admitted on 10/5/2 and discharged on 10/11/12, did not have vital signs documented on 10/7/12
? Patient #18, admitted on 10/22/12 and discharged on 10/30/12, did not have vital signs documented on 10/23/12 or 10/24/12.

The above findings were confirmed in an interview with the Director of Nursing on 11/29/12.

Based on record review and interview, it was determined that the facility failed to ensure that discharge summaries were completed within 30 days following patient discharge for 4 of 20 patients.

Findings were:

Patient records reviewed on 11/28/12 revealed the following:
? Patient #11 was discharged on 10/9/12, the discharge summary was signed over 30 days later on 11/26/12.
? Patient #14 was discharged on 10/11/12, the discharge summary was signed over 30 days later on 11/26/12.
? Patient #15 was discharged on 10/11/12, the discharge summary was signed over 30 days later on 11/26/12.
? Patient #19 was discharged on 10/10/12, the discharge summary was signed over 30 days later on 11/26/12.

Facility policy #1400.6 " Medical Records Documentation Requirements " stated the following; " 3.2 The attending physician must sign the discharge summary ...3.22 Discharge summary must be signed by 30 days of discharge. "

The above findings were confirmed in an interview with the Director of Nursing on 11/29/12.

Based on observation, review of documentation, and an interview with the dietary director on the morning of 11/28/12 the dietary department fail to be staffed to ensure that the needs of the patients are met in accordance with the physicians ' orders and acceptable practice.

Findings were:

The facility dietary department was staffed with 3 employees on 11/28/12 and 2 employees on 11/29/12.
During a tour of the dietary department at the facility on the afternoon of 11/27/12 the surveyor observed staff # 10 dry the dishwasher clean table with a dish towel, then remove cooking utensils from the dishwasher, dry the utensils with the same dish towel, and then place the utensils in a draw. The surveyor asked staff # 10 had she been trained in dish-washing procedures, staff # 10 stated " not yet this is my second day on the job. "
Review of dietary policy page 307 stated, " Dish Machine Practices procedure two employees shall be assigned to run the dish machine when dishes are machine washed. One employee shall be responsible for handling soiled dishes, and the other shall be responsible for handling the clean, sanitized wares. "
Review of Dietary policy, page 356 Safety Rules and Guidelines stated, " 4. The orientation of new employees shall include safe techniques during daily work routines.
Review of Dietary Orientation of Dietary employees page 452 stated, " Dietary employees shall receive adequate orientation to the facility, the dietary department and job specific training. "
Review of staff # 10 personnel file did not contain an application for employment, dietary orientation training. The file contained a Drug Screen Compliance Form.
In an in-person interview with the dietary director staff # 8, on the morning of 11/29/12 in the kitchen/dining area, staff # 8 stated staff # 10 was late the first day, did not show up the 3rd day and was late yesterday. Staff # 8 stated, " There are only 2 employees working in the kitchen, staff # 10 will not be coming back. " Staff #8 stated he comes in around 5 am, cooks breakfast and lunch leaves around 1:30 pm; staff # 9 comes in at 11:00 am cooks dinner.

Based on observation, review of documentation and interviews with facility staff the facility failed to maintain the hospital environment in a safe manner for the wellbeing of the patients.

Findings were:

During a tour of the facility on the afternoon of 11/27/12 torn carpet, peeling paint, dirty air celling vents, and generalized unsafe areas throughout the physical environment of the facility.

? In the Intake area, the wooden baseboard was broken and loose and part of the baseboard was missing.
? 6 double doors leading into the " Central Court Yard " had gaps of light around the doors, indicating worn or non-existent weather stripping, allowing the entrance of dust and pests.
? A couch in the " Library " had 3 tears in a vinyl seat cushion, making the couch impossible to completely clean.
? Dust was present on high horizontal surfaces in the " Central Supply " area.
? A lab supply closet had 131 blue-top lab tubes that expired in April 2012 and August 2012, and 10 " Urine Specimen Collection Kits " that expired in July 2012.
? The " Central Court Yard " had holes in the bricks near the ground by the door near units 1 and 2, and by the door near units 3 and 4; both of the holes were approximately 1 foot by 6 inches in size, this could allow the entry of pests into the facility.
? The ceiling air-vent cover was missing in the " Patient Luggage Closet " .
? Floors in shower stalls on Unit 4, rooms 410, 408, 407, and 405 had white powdery residue in the corners.
? Peeling paint was observed around the celling lights in unit 4.
? 5 two gallons of paint was located in the closet in the patients library.
? Tile on the shower floor Unit 2, room 204 had about a 12 inch crack allowing entry for pests, and potential for patient to injury during showers.
? Unit 2, room 206 shower door was rusty and the baseboards in the bathroom contained white powdery residue.
? A couch in the " Library " had 3 tears in a vinyl seat cushion, making the couch impossible to completely clean.
? Dust was present on high horizontal surfaces in the " Central Supply " area.
? A lab supply closet had 131 blue-top lab tubes that expired in April 2012 and August 2012, and 10 " Urine Specimen Collection Kits " that expired in July 2012.
? In the Geriatric Room, there were the following expired items:
? 40 ml anaerobic culture solution: quantity of 1 expired 11/2011, quantity of 2 expired 2/2012
? 40 ml aerobic culture solution: quantity of 3 expired 8/2012.
? 4 red top lab tubes expired 7/2012
? 4 blue top lab tubes expired 4/2012
? 3 purple top lab tubes expired 9/2011
? 14 microtainer lab tubes expired 11/2011
? In the Geriatric room the seam between the internal wall and the external wall was separated and a cold air was felt by the surveyor flowing into the room. This was confirmed by Staff # 3 on 11/27/12.
? In the Geriatric room, the baseboards were broken and/or missing; the front of a drawer was missing, and there were patient games and supplies stored on the floor.
? The Exam room located between the adult and geriatric units contained the following:
? 41 expired Gen Probes that expired 12/31/2009- 05/31/12.\
? 0.9% Sodium Chloride irrigation 1000ml expired 7/2012, quantity of 2
? Magnesium Citrate Solution 10 ounces, expired 7/2012
? The " Central Court Yard " had holes in the bricks near the ground by the door near units 1 and 2, and by the door near units 3 and 4; both of the holes were approximately 1 foot by 6 inches in size, this could allow the entry of pests into the facility.
? The ceiling air-vent cover was missing in the " Patient Luggage Closet " .
? In the Adolescent Recreation Yard, there were 4 nails exposed and trim falling off the building with nails exposed. There was also a hole in-between the building and the roof, approximately 12 inches x 12 inches.
? In the Central Supply room, there were 3 unsecured oxygen tanks.
? In the main corridor throughout the building, there was frayed carpet, holes in the carpet, and raised carpet, which created a tripping hazard.

Review of documentation Environment Of Care page 2 stated, " The safety management program functions to maintain a safe environment for patients, personnel and visitors through compliance with regulations, procedures, and standards set forth by OSHA, JCAHO, National Fire Code, the Midland County Fire Marshall ' s Office and Standard Building Codes. "
Review of documentation Environment of Care page 1 of 5 stated, " Dust must be kept to a minimum in the facility environment. "

During the tour of the facility on the afternoon of 11/27/12 with staff # 2, 3, and 4 the findings were confirmed.

Based on observation, review of documentation and interviews with facility staff the facility failed to provide a sanitary environment to avoid sources and transmissions of infections.

Findings were:

During a tour of the dietary department at the facility on the afternoon of 11/27/12, the surveyors accompanied by staff # 2, 3, and 4 observed the following;
? The entrance floor to the dining room where the patients ate their meals was observed to have dust, grayish blackish particles in the floor corners, baseboards, and the cells of the glass windows forming the walls on the left side of the dining area. The glass windows were dirty, smudgy and greasy to the touch.
? The corridor where patients drop off dirty trays was dirty, including raised brown and black dirt and raised grey dust on the floor, most prominently in the corners, and dried drips of various colors on the walls.
? The door seal to freezer #3 was torn and worn approximately 4 feet, allowing for inconsistent temperatures of food.
? There was a thick layer of dust on high and low horizontal surfaces in the entire kitchen/food preparation area.
? There was debris that appeared to be food on the floor of refrigerator #2.
? There was dust, food-like debris, and dried drips of various colors on the top and outside of the flour, rice and sugar bins.
? There was an 8 ounce can of ThickenUp with a handwritten " Opened 9-1-11 " ; the use by date printed on the can was July 22, 2012.
? 12 ounce jar of " Gumbo Seasoning was greasy and sticky on the outside of the container.
? On the shelf underneath the food preparation area, was a tray with dust, dirt, dried food, and old cheese.
? There was a bottle of " Coco powder " labeled " opened 4-30-11 " with a use by date of May 20, 2012.
? There was a one gallon container of " Red Hot Wing Sauce " that had been opened and was available for use in food preparation labeled, " Best by Jul 13, 2012 " which had dirty dried drips and was covered with a thick layer of greasy dust.
? There was a dead moth on the shelf with the spices above the food preparation area. There was dried food debris and a layer of greasy dust on the shelf, too.
? There were 22 jars of spices, 6 ounces on the shelf above the food preparation area that were covered with a thick layer of greasy dust.
? There was a food thermometer that had dried food on the probe and drips and dried food on the glass top.
? There was a jar of " Grillmates Pepper " in the utensils drawer.
? In a drawer in the food preparation area the following was observed: meat cleavers with multiple areas of different colored food-like substances, an electric knife with dried drips and foodlike substance adhered, a hand-held paper hole puncher that was greasy, food graters that had dried food-like substance adhered, a pair of tongs with a dried food-like substance adhered.
? There was a first aid box on the wall over the food preparation area that was covered in greasy dust and there was brown and black dirt inside the first aid box.
? There was dirt, debris, and food-like substance in the bottom of the utensils drawer.
? On the shelf underneath the food preparation area the following one gallon containers were observed opened, with no label to indicate date opened, covered with greasy dust: Gourmet red wine vinegar, Hickory Seasoning liquid smoke, Teriyaki sauce, Soy sauce
? The floor underneath stoves and appliances were covered with a thick, black, greasy substance, which indicated a lack of cleaning for some time.
? In the knife stand, there were 4 knives with dried food. There was another knife in the stand which had not been cleaned, as it was covered with an oil-like substance and multiple food particles that were not dried on both surfaces.
? The floor in the dish washer area was observed to have white clumped residue on the baseboards, corners, pipes leading from the dishwasher to the faucets under the dishwasher, and around the drain in the center of the floor. The floors contained greasy, slippery areas with yellowish white residue. Yellowish, greasy, brownish particle buildup was observed on the tile backsplash behind the clean sink.
? Dust was present on top of all of the refrigerators and freezers in the kitchen.
? A gap of light was present between double doors leading out to the loading dock, allowing the entrance of dust and pests.
? There was a hole in the wall behind the ice machine, allowing an entry point for pests.
? The fan and vent on top of the ice machine was covered in a thick, dirty grayish-brown dust.
? The middle drawer of a stainless steel food preparation table had small pieces of food under a tray containing clean ice-cream scoops.
? A food warmer " Auto-Shamm " had dried crusted food inside of it on the racks.
? Dust was observed hanging from all of the celling air vents in the in the kitchen and patient dining area.
? A dirty food tong was located in an area among clean food tongs.
? Two food containers labeled " Caramel Topping " and Chocolate Flavored Syrup " , both indicated that they should be " Refrigerated After Opening " ; both of these food containers were not stored in a refrigerator.
? An oily substance was present on 2 clean food pans.
? Dirt, yellow greasy, white powdery and blackish residue was observed on all baseboards and floor corners in the kitchen/dining area.
? Dust was observed hanging from the artificial greenery hanging in the patients dining area over the food serving area.
? There was dirt and debris on the floor in the corners of the dry food storage room.
? There was no weather stripping under the external door in the kitchen area to the loading dock, as daylight from the outside was visible from inside the building.
Review of " Dietary Department Infection Control Overview " page 291 stated, " Infection control within the dietary department shall be monitored to promote food safety and prevent foodborne illness. Cleaning is the removal of food, soil and other types of debris from a surface. Two factors that are essential elements of cleaning and sanitizing programs are as follows; Establish clear procedures that address all the types of food equipment used including clean-in place systems and effectively training employees. "
The findings were confirmed on the afternoon of 11/27/12 during the tour of the dietary department by staff # 2, 3, and 4.

? In the Seclusion Room on Unit 4, there were 6 dead bugs in the light fixture and the base of the toilet was dirty.
? There were 5 holes in the wall in the Unit 3 Day Room, providing an entry for dirt, dust, or insects.
? In the Unit 3 patient hygiene closet, there was a case of adult diapers stored on the floor, creating a risk for contamination.
? In the patient day room, there was old red tape marking out a zone around the nurses station. The tape was partially disintegrated, sticky, peeling, and was dirty and black, as the tape could not be disinfected.
? In Unit 3, there was no weather stripping under the external door, as daylight from the outside was visible from inside the building.
? In the Central Supply room, there was a box of exercise equipment stored on the floor, creating a risk for contamination.
? In the " Extra Storage " room, there was a dead lizard, 2 dead scorpions, and a moth on the floor.
? In the Seclusion Room on Unit 1, the base of the toilet was dirty.
? In the Unit 1 kitchen, the refrigerator had pink drips and spills inside and there were coffee grounds on the cabinet.
The following observations were made during a tour of the Adult/Geriatric area on 11/27/12:
? Large amounts of dust were present on 4 air-vents located on the wall.
? Large amounts of dust were present on high horizontal surfaces in the medication preparation area.
? The cabinet under a sink in the nurses station was very dirty and warped from water exposure; specimen cups and paper towels were stored in the cabinet.

In the Adolescent Unit, review of the " Refrigerator Temperature Log for Patient Nutrition - FOOD " had temperatures above the " acceptable Refrigerator Range for FOOD " on 11/25/12 and 11/27/12. There was no documentation of action taken. The freezer was out of range on 11/20/12, 11/21/12 and there was no documentation of action taken. The form stated, " If temperature is ABOVE or BELOW the shaded area, take action and document below. "

Review of the Refrigerator/Freezer Temperature Log for the Adolescent Unit for November 2012 for specimens revealed that the temperature was not logged on 16 days between 11/1/12 and 11/27/12. There were 3 dates that the temperature was out of range for the dates documented. The form stated, " Maintenance called for any refrigerator/freezer temperatures out of range for 3 consecutive days " and a code of " 4. Maintenance Called " was to be entered in the " Action " column. There was no documented evidence that maintenance was called.

During a tour of the facility on 11/27/12, the Director of Nursing was asked when and how patient clothes washers and dryers were cleaned after patient use. The Director of Nursing stated that the patient clothes washers and dryers were disinfected only once a day and confirmed this was true even if more than one patient used the clothes washers and dryers in one day.

Review of facility policy entitled " Washer/Dryer Policy " last revision 9/2012 stated, in part, " 4. Staff will add 1/2 cup of Clorox and 1/2 cup of water and run cycle with no clothes after each use. "

The above findings were confirmed by the Physical Plant Director and Clinical Director during a tour of the facility the afternoon of 11/27/12.