HospitalInspections.org

Based on observation, review of documentation, and interviews with facility staff, the facility failed to ensure that contracted services were provided in accordance with hospital policies and applicable standards as the contracted MRI trailer was observed to have several maintenance issues that potentially could impact patient safety. This was not in accordance with the contract between the facility and the MRI vendor.

The findings were:

The contract entitled "Service Organization of the Big Country Exclusive Magnetic Resonance Imaging Contract" dated 9/24/14 reflected in part "Numed will provide routine maintenance and service on equipment furnished by Numed."

During a tour of the MRI trailer on the morning of 5/10/16, the following observations were made. The fire extinguisher in the MRI trailer had not been checked in accordance with hospital policy. An exit light in the MRI trailer designed to be illuminated was not lit. An emergency exit light in the MRI trailer did not light when the test button was depressed. An oxygen cylinder was observed standing on the floor in the MRI trailer unsecured in any way. In an interview with the MRI tech, staff #18 during the tour on the morning of 5/10/16, agreed with the above listed observations. In an interview with the CEO, staff #29 in the conference room on 5/10/16 at approximately 11 am, staff #29 stated he would be sure that Numed took care of the above listed maintenance issues.

Cross-refer to:
CFR 482.41(a), A0701, Maintenance of Physical Plant
CFR 482.41(c)(2), A0724, Facilities, Supplies, Equipment Maintenance

Based on observation the facility failed to provide protection of medical records from destruction. During a tour of the facility on the morning of 5/10/16 accompanied by staff # 16 and staff # 5, 10 boxes of medical records were observed on the floor. This potentially could have caused destruction of the records in the event of a flood or plumbing problem.

Findings were:

During a tour of the facility on the morning of 5/10/16 accompanied by staff # 16 health information manager, and staff # 5 CNO, 3 boxes of medical records were observed on the floor in medical storage room # 1.

During a tour of the cardiac rehab lab on the morning of 5/10/16 accompanied by staff # 5 CNO, 7 boxes of medical records were observed at the desk.

Review of policy secure filing of medical records stated, "The Health Information Department is responsible for safeguarding both the record and its informational content against loss, defacement and tampering."

In an interview with staff # 5 CNO during a tour of the cardiac rehab lab on the morning of 5/10/16, staff # 5 agreed with the findings.

In an interview with staff # 16 health information manager during the tour on 5/10/16, staff # 16 agreed with the findings.

Based on observation, review of documentation, and interviews with facility staff, the facility failed to properly secure medications as intravenous contrast agents were stored in an unlocked cabinet in the CT room which had a door that was not lockable and was standing open to a corridor with general hospital traffic. This was not consistent with hospital policies regarding securing medications and potentially could have resulted in unauthorized access to medications.

The findings were:

The facility policy entitled "Medication Administration" #733-13.02 dated 7/15 reflected in part "The medication cart should be locked whenever unattended, unless stored beyond the reach of the general public, or in plain view of the nursing staff."

During a tour of the facility on the morning of 5/10/16, vials of intravenous contrast agents were found stored in an unlocked cabinet in the CT room. The door to the CT room was standing open to a corridor with general hospital traffic which included patients and visitors. In an interview with staff #10 during the tour on the morning of 5/10/16, staff #10 agreed that the vials of intravenous contrast agents were being stored unsecured. Staff #10 was asked if the CT room was always attended by a staff member and staff #10 stated it was not.

Based on observation, review of documentation and interviews with facility staff, the facility failed to maintain proper safety precautions against radiation hazards as protective lead aprons were not checked annually in accordance with state regulation. This potentially could have resulted in radiation leaks in protective lead aprons.

The findings were:

The Texas Administrative Code at 25 TAC 289.227 (i)(4)(B) reflected in part "Protective devices, including aprons, gloves, and shields shall be checked annually for defects such as holes, cracks, and tears. These checks may be performed by the registrant by visual or tactile means, or x-ray imaging. If a defect is found, protective devices shall be replaced or removed from service until repaired. A record of this test shall be made and maintained by the registrant in accordance with subsection (s)(1) of this section for inspection by the agency." Subsection (s)(1) specifies the time interval for keeping records is 3 years.

During a tour of the facility on the morning of 5/10/16, a record of lead apron checks was requested from the radiology manager, staff #10. The documentation of lead apron checks reflected the last time the aprons were checked was 3/19/14. In an interview with staff #10 during the tour on the morning of 5/10/16, staff #10 agreed that the last time the lead aprons were checked was 3/19/14.

Based on observation, review of documentation, and interviews with facility staff, the facility failed to maintain the hospital environment in a manner that assured the safety of patients as fire drills had not been conducted in accordance with hospital policy since October 2015. The flooring of the corridor with general hospital traffic between the surgery and sterile processing departments had numerous large depressions in the tile which constituted a tripping hazard. An exit light designed to be illuminated was not lit in the MRI trailer. An emergency exit light in the MRI trailer did not light when the test button was depressed. These findings potentially could impact the safety of patients.

The findings were:

The facility policy entitled "Life Safety Plan" reflected in part "Fire Drills will be conducted as a minimum, once per quarter per shift. Each fire drill will be evaluated by members of the Safety Committee. All departments will respond to any fire drill. All fire drills will be documented and actions taken to correct discrepancies."

Facility documentation was reviewed on 5/10/16, and the records of fire drills reflected that drills had been conducted as follows. 5/21/15 at 4:15 pm, 6/26/15 at 11:30 pm, 7/15/15 at 9:00 am, 8/25/15 at 3:30 pm, 9/17/15 at 7:45 am, 10/29/15 at 2:50 pm, 11/18/15 at 8:03 am, 1/19/16 at 7:40 am, 2/1/16 at 8:01 am. There were no drills documented in December 2015, March 2016 or April 2016. There was no drill conducted on the evening and night shifts the fourth quarter of 2015 or the first quarter of 2016. In an interview with the CNO, staff #5 in the conference room on 5/10/16, staff #5 agreed that the fire drills had been conducted as listed above.

During a tour of the facility on the afternoon of 5/9/16, the flooring of the corridor between the surgery and sterile processing departments was observed to have at least 4 areas where the floor tile was cracked and depressed approximately ½". The areas of depressed floor tiles ranged in size from 3" in diameter to one that was 4" x 12". The corridor was trafficked by staff, patients and visitors. In an interview with staff #29 during the tour on 5/9/16, staff #29 stated they have had problems with the flooring in this area. Staff #29 showed the surveyor an area in the same corridor with different colored floor file and stated the old tile had to be removed and the concrete underneath repaired to fix the depressed areas. Staff #29 agreed there were depressed areas in the flooring as described above.

In a tour of the facility on the morning of 5/10/16, the exit light in the MRI trailer which was designed to be illuminated was not lit. The emergency exit light in the MRI trailer did not light when the test button was pushed. In an interview with the MRI tech, staff #18 during the tour on the morning of 5/10/16, agreed that the exit light was not lit and that the emergency exit light did not light when the test button was pushed.

Based on observation, review of documentation and interviews with facility staff, the facility failed to maintain equipment to ensure an acceptable level of safety as 3 fire extinguishers had not had an annual inspection by a certified, licensed contractor in accordance with facility policy. A suction machine in the CT room had no evidence of a biomedical inspection. These findings could potentially result in the equipment not working properly when used. An oxygen cylinder in the MRI trailer was unsecured which could have been unsafe if it tipped over.

The findings were:

The facility policy entitled "Life Safety Plan" reflected in part "Fire alarm systems and portable fire extinguishers will be inspected, tested and maintained in accordance with the Life Safety Code and applicable city ordinance. They will be checked and certified annually by a certified, licensed contractor, additionally all portable fire extinguishers will be inspected on a monthly basis."

The facility policy entitled "Medical Equipment Management Plan" reflected in part "Department managers will maintain an equipment inventory which identifies all departmental equipment ...All inventoried equipment is monitored and inspected at least annually dependent upon the type of equipment and any historical information regarding its service history."

The facility policy entitled "Medical Gas Safety Procedures" #740-7.03 dated 4/16 reflected in part "All medical gas cylinders are to be kept and stored in the proper rack or cylinder holder at all times."

During a tour of the facility on the morning of 5/10/16, the fire extinguishers located in the hallway near the administration office and in the hallway near purchasing were observed to have tags attached which reflected the last inspection done by the fire extinguisher company was done 12/14. In an interview with staff #29 during the tour on the morning of 5/10/16, staff #29 agreed the tags on the above mentioned extinguishers reflected the last inspection was done 12/14.

During a tour of the facility on the morning of 5/10/16, the fire extinguisher located in the MRI trailer was observed not to have an inspection tag attached. An oxygen cylinder was observed standing on the floor unsecured in any way and was not in a rack or holder. In an interview with staff #18 during the tour on the morning of 5/10/16, staff #18 stated that the fire extinguisher had been installed in February 2015 and had not been inspected since then. Staff #18 agreed that the oxygen cylinder was unsecured.

During a tour of the facility on the morning of 5/10/16, a Laerdal suction machine was observed in the CT room that had no biomedical inspection sticker affixed. In an interview with staff #10 during the tour on the morning of 5/10/16, staff #10 agreed there was no biomedical inspection sticker on the suction machine. In an interview with staff #5 in the conference room on 5/11/16, staff #5 stated the equipment management inventory for the radiology department had been checked and the Laerdal suction machine was not on the inventory.

Based on observation, and an interview with staff # 27 Swing Bed Coordinator, the facility failed to provide activities under the direction of a qualified activity director.

Findings were

Review of policy Patient Activity Program Policy stated, "14. The Administrator has appointed a qualified Activity Director who will function to assist with planning, development, and implementation of the Activity program."

In an interview with staff # 27 at the facility on the morning of 5/11/16, staff # 27 stated the swing bed program did not have an activity director.

Based on observation, review of facility documentation and an interview with staff # 27 swing bed coordinator on the morning of 5/11/16; the facility failed to provide discharge planning for 3 of 5 swing bed patients. Discharge planning was not established with the patient, family, and team members providing patient care for the swing bed patients.

Findings were:

Review of Coordinated discharge planning procedures 2. stated, "Establish discharge planning goals with patient and family as well as the primary contributors."

Review of swing bed medical records (swing bed discharge planning team review forms) for patients # 15-19 revealed no documentation from family, patient or other team members providing care to the swing bed patients.

In an interview with staff # 27 swing bed coordinator at the facility on the morning of 5/11/16, staff # 27 agreed with the findings.

Base on review of facility documentation, and an interview with staff #5 Chief Nursing Officer, the facility failed to have dental services available for emergencies for the swing bed patients.

Findings were:

Review of swing bed patient policy, Dental Services stated,"The swing bed program assists patients in obtaining regular and emergency dental care."

In an interview with staff #5 CNO at the facility on the morning of 5/11/16, staff # 5 CNO, stated an agreement with a local dentist had not been signed by the dentist.