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Based on a tour of the facility, staff interviews, and review of policies and procedures, the facility failed to ensure that the premises were clean and orderly.

Findings included:

During a tour of the facility on 2/11/2014, deficient areas were observed by the survey team.

In the Radiology department, the following was observed:
? There were 2 water damaged ceiling tiles in the plain film xray room.
? The linen for the radiology department was uncovered, which presents a risk for cross contamination.
? In the single phase plain film xray control room, the base of the wall was water damaged and deteriorated, which increases the risk of mold, mildew, dust, and insect penetration.
? There was a thick layer of dust on the floors, especially in the corners of the room and behind equipment.
? In the patient bathroom, the call light was looped over the call light box, which prevented use of the call light cord for a patient that might have fallen on the floor.
? In two cabinets, there were dust and spills in the supply drawers with supplies available for patient use.
? Under a sink in the X-ray room were three plastic bottles of varying sizes which the Director of Radiology stated he believe to be detergent bottles. One plastic bottle contained a green liquid and was unlabeled and undated. The contents could not be identified by the Director of Radiology.

In the Patient Clean Supply room, the following was observed:
? There were two dirty external shipping boxes with shipping address labels adhered on the shelves next to patient supplies available for patient use, including face masks and sterile gloves.

In the nurses medication room, the following was observed:
? The pill crusher was dirty and in need of cleaning. The handle to the pill crusher had a dirty, sticky tape residue adhered, which could not be disinfected.
? Under the sink, there was a thick layer of dust and old electrical equipment in the dust.

In the newborn nursery, the following was observed:
? There was a thick layer of raised dust on the shelving unit that contained supplies available for patient use, including baby formula.

In the Operating Room Suite, the following was observed:
? There were 2 water stained ceiling tiles in the Labor & Delivery room bathroom.
? In the facility's operating room supply room revealed a crack in the floor about 5 feet in length. Further observations of the operating room supply room doorway revealed duct tape on its threshold.
? In the OR supply room, there were water damaged ceiling tiles above the patient surgical supplies, available for patient use.
? In the OR corridor, there was deteriorated and dirty yellow tape on the floor to demarcate the surgery area; however the sticky deteriorated tape increases the risk of cross contamination and cannot be disinfected.

In the basement Central Supply room, there were external shipping boxes on the shelves with patient supplies, including oxygen masks, available for patient use. There was a layer of dust on high and low horizontal surfaces.

In the Cardiac Rehab room, there were 2 torn areas in the vinyl seat coverings, approximately 1-2 inches on the exercycle. This prevents effective disinfecting between patients.

In the Kitchen area, the following was observed:
? 3 pans available for use in food preparation which had dried food adhered to the interior of the pans.
? There were two flat, open sticky insect traps, which were very dirty and had several dead insects adhered to them.

In the facility's patient snack room revealed the refrigerator where the patient's snack and drinks were stored had several spots of some sort of dried brown and yellow substance on the refrigerator shelves and walls. Further observations of the refrigerator shelves revealed dirt and food particles were present.

In the facility's patient shower room revealed clean bed linens and towels were sitting on shelves above the toilet uncovered and exposed.

In the unit kitchen containing patient and staff food items available for patients on the medical-surgical unit, the bottom shelves of the base cabinets contained visible dirt and dust, and appeared not to have been cleaned in some time. The 2014 temperature log for the refrigerator which contained patient food items had values logged for 1/1/14 through 1/28/14; entries were lacking for 1/29/14 through 2/10/14. A knife and several vases were under the sink, along with a plastic tub resting on a soiled towel. The towel was stained and contained dark flecks which appeared to be dirt. Upon this discovery, the Assistant Director of Nurses agreed that it appeared there had been a water leak under the sink at some time in the past, but was uncertain when.

In the Emergency Department, the following was observed:
? There was an approximate 3" x 4" hole in the shelving under a sink in the Emergency Department through which the raw subfloor could be viewed. The hole was filled with dust and debris. Also under the sink were stored 8 new and empty sharps containers, 2 rolls of toilet tissue and 1 package of paper towels.
? The call light in the patient restroom of the Emergency Department ended approximately 2 feet above the floor possibly making it inaccessible to a fallen patient.
? The call light in the patient restroom of the trauma room of the Emergency Department ended 18" above the floor possibly making it inaccessible to a fallen patient.
? In the trauma room in the Emergency Department, several items were stored under the sink. These included 2 rolls of toilet paper and 1 package of paper towels which were potentially available for patient use.
? The refrigerator temperature log in the Emergency Department was lacking entries for the dates of 1/28/14 and 2/2/14 through 2/6/14. The refrigerator contained medications to be used for patients in the Emergency Department.
? In the area of the Emergency Department housing patient supplies, the floor was generally dirty and there was a thick layer of dust and debris on a key box mounted approximately 4' above the floor.

Review of the Housekeeping policy and procedure manual provided to the surveyors the morning of 1/12/14 revealed the following:
"Services:
The purpose of the Environmental Services is to provide all patients, employees and visitors with a germ-free and safe environment by providing the following services:
1) Cleaning and disinfecting patient and non patient areas according to policy and procedure ...
5) Evaluate and monitor the interior of the hospital for areas or items needing repair (i.e., floor tiles, carpet, paint, etc.) and reporting items to the appropriate department for repair."

The above findings were all confirmed with the Assistant Director of Nursing and the Director of Nursing while on a tour of the facility the morning and afternoon of 2/11/14.

Based on a review of patient records, facility policies and procedures and staff interviews, the facility failed to ensure that policies were implemented as a pre-surgical checklist was not completed for a surgical patient.

Findings included:

Review of 1 out of 4 surgical patient records revealed that the "Surgical Safety Pre-Operative Checklist" was not completed for Patient #3 prior to her procedure on 1/9/14. Patient #3 underwent a tonscillectomy on 1/9/14, yet the Surgical Safety Pre-Operative Checklist in the medical record with her name/label, including such items as

"Before Induction of Anesthesia",
"Before Skin Incision" and "Sign Out (before pt leaves OR)" were all left blank.

Review of facility policy entitled, "Surgical Safety Checklist", stated, in part, "Before surgery ...Before Induction: Surgeon, Circulator and Anesthesia provider will confirm patient identity, full name, date of birth, site and procedure ...
Before skin incision Surgeon, Circulator and Anesthesia provider Confirm all team members and roles, Confirm patient ' s name, procedure, site, side and position ...
Circulator and Scrub tech Sterility is confirmed, Consent matches verbalized procedures ...
Sign Out Name of procedure is recorded, Instruments, sponges, laps, needles, blades correct..."

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: ...
(D) Accurately and completely report and document:
(i) the client ' s status including signs and symptoms;
(ii) nursing care rendered; ...
(v) client response(s); and
(vi) contacts with other health care team members concerning significant events regarding client's status"

In an interview with Staff #6, OR RN the afternoon of 2/11/14 in the facility training room, she confirmed the above findings.

Based on a review of facility documentation and staff interview, the facility failed to ensure that, at a minimum, all patient care staff maintained current CPR certification as specified in Texas Administrative Code Operational Requirements, Hospital Functions and Services 133.41 (c)(3)(E). In addition, the facility failed to provide documented evidence of a grievance process which supplied information regarding the mechanism for the initiation, review, and when possible, resolution of patient complaints concerning the quality of care according to the requirements of Texas Administrative Code Operational Requirements, Patient Rights (a)(1)(E).

Findings were:

A review of the personnel file for Staff #12, an LVN employed by the facility, revealed no documented evidence of current CPR certification. In an interview with the Director of Nursing on the afternoon of 2/10/14 in the facility training room, she admitted the LVN was not currently certified, but was signed up to take a CPR class "soon."

Review of the Coleman County Medical Center Position Description for a Licensed Vocational Nurse, stated in part:
"Qualifications: ...
? Maintain certifications and continuing education requirements needed to perform job ...
Education and/or Experience:
? Current Vocational Nurse licensure
? Basic Life Support (BLS) certificate..."

A review of the facility's patient grievance log for 2013 revealed three patient grievances. They were as follows:
1. Patient L.M. (no other identifier); Date Received 1/11/2013; Date Response Sent 2/12/2013
2. Patient C.P. (no other identifier); Date Received 1/14/2013; Date Response Sent 2/12/2013
3. Patient H.B. (no other identifier); Date Received 2/25/2013; Date Response Sent 3/11/2013

When asked for the facility patient grievance policy, the Director of Nurses supplied the following facility policy entitled Complaints Regarding Privacy Policies and Procedures, last reviewed 03/09/2012. It stated in part:
"POLICY:
Coleman County Medical Center encourages patients and employees to communicate their concerns by allowing them the opportunity to register a complaint ...
B. External Complaints - Complaints made by patients, or any person on their behalf, will be made to the designated contact person as outlined in Coleman County Medical Center's Notice of Privacy Practices. The contact person will investigate the complaint and escalate the complaint to upper management as appropriate. All complaints will be investigated and if the complaint is found to be a violation of Coleman County Medical Center's privacy and security policies, then appropriate action will be taken to insure that the violator is sanctioned according to the violation. If the violation is determined to be a knowing and willful violation of Coleman County Medical Center's privacy and security policies, disciplinary action up to and including involuntary termination maybe [sic] warranted. If the violation is determined not to have been a knowing or willful violation of Coleman County Medical Center's privacy and security policies, then appropriate disciplinary action such as a warning (verbal or written) or formal write-up maybe [sic] warranted..."

No timeline for the facility's response to a patient grievance was included in this policy. Nor was there information included regarding the resolution of a grievance. The policy included no other specifics regarding the process of initiation, review or resolution of patient complaints or grievances.

No further informaton regarding the facility's patient grievance process was available for surveyor review.

The above findings were confirmed in an interview with the Chief Executive Officer and other administrative staff on the morning of 2/12/14 in the facility training room.

Based on record review and interview the facility failed to furnish a discharge summary for 1 of out 3 sampled Swing Bed resident's charts. Specially, the facility failed to develop a discharge summary designed to ensure the resident's needs will be met after discharge from the facility into the community.

This failure has the potential to affect all Swing Bed residents who require post discharge plan of care.

Findings include:

Review of Resident #20's History and Physical Report dated 12/25/2013 read,"Patient is an 83 year old female with fracture of left femoral neck and the left inferior ramus, which occurred on 12/18/2013. The patient was sent to the facility for surgical treatment of this. On 12/21/2013 she had open reduction and internal fixation of the left hip. She was doing well in the hospital and was discharged to Swing Bed on 12/24/2013 here at the facility."

Review of Resident #20's Physician's Order Sheet dated 01/11/2014 read, "Discharge to home. Continue home medications. Follow-up with physician in one week."

Interview on 02/12/2014 at 9:50 AM with Staff #2 revealed that Resident #20's physician did not complete her discharge within 30 days.

Review of the facility's Medical Staff By-laws undated read, "Patients shall be discharged only on written on order of the attending physician. Within forty-eight hours of discharge, the attending physician shall see that the final diagnosis is recorded on the patient's medical record and shall complete the medical records within the thirty days. Medical records shall be completed in their entirety no later than thirty days after the patient is discharged from the hospital. Any member of the Medical Staff who has an incomplete medical chart thirty days after discharge of the patient from the hospital is delinquent in preparation of that chart for the purpose of the Rules and Regulations and the Medical Staff By-laws."