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Based on review of records and interview, it was determined that the facility failed to ensure that it ' s staff are licensed, certified, or registered in accordance with applicable Federal, State, and local laws and regulations.

Findings were:

Facility policy entitled " Credentialing Contractual Related Services " stated in part, " Credentialing will be done in accordance with state law requirements, professional standards, and according to the requirements of the medical staff. "

Facility policy entitled " Credentialing Quality Assurance " stated in part " QA credentialing will be done in accordance with Federal and State laws, Professional standards and the requirements of medical staff. "

Review of physician employee files on 11/2/11 revealed the following:

? Staff member # 6 (MD) ' s Controlled Substance Registration Certificate (Federal Drug Enforcement Administration) expired 9/30/11. The Texas Controlled Substances Registration Certificate expired on 3/31/11
? Staff member # 7 (MD) ' s Controlled Substance Registration Certificate (Federal Drug Enforcement Administration) expired 10/31/11
? Staff member # 8 (MD) ' s Texas Controlled Substances Registration Certificate expired on 6/30/11
? Staff member # 10 (MD) ' s Controlled Substance Registration Certificate (Federal Drug Enforcement Administration) expired 6/30/11.
? Staff member # 12 (MD) ' s Controlled Substance Registration Certificate (Federal Drug Enforcement Administration) expired 6/30/11.
? Staff member # 13 (MD) ' s Texas Controlled Substances Registration Certificate expired 7/31/11.
? Staff member # 14 (MD) ' s Texas Controlled Substances Registration Certificate expired 9/30/11.
? Staff member # 15 (MD) ' s Texas Controlled Substances Registration Certificate expired 10/31/11.
? Staff member # 17 (MD) ' s Controlled Substance Registration Certificate (Federal Drug Enforcement Administration) expired 6/30/11.
? Staff member # 18 (MD) ' s Full Physician Permit expired 8/31/11
? Staff member # 19 (MD) ' s Full Physician Permit expired 5/31/11. His Controlled Substance Registration Certificate (Federal Drug Enforcement Administration) expired 6/30/11.
? Staff member # 20 (MD) ' s Full Physician Permit expired 5/31/11. His Texas Controlled Substances Registration Certificate expired 5/31/10.
? Staff member # 21 (MD) ' s Controlled Substance Registration Certificate (Federal Drug Enforcement Administration) expired 6/30/11. His Texas Controlled Substances Registration Certificate expired 1/31/11.
? Staff member # 22 (MD) ' s Texas Controlled Substances Registration Certificate expired 7/31/11.
? Staff member # 23 (MD) ' s Full Physician Permit expired 11/30/10. His Texas Controlled Substances Registration Certificate expired 7/31/11.
? Staff member # 24 (MD) ' s Full Physician Permit expired 8/31/10. His Texas Controlled Substances Registration Certificate expired 7/31/11 and his Controlled Substance Registration Certificate (Federal Drug Enforcement Administration) expired 8/31/11.

In an interview with the hospital ' s Administrative Assistant on 11/2/11, the lack of documented evidence of current certification for the above physicians was confirmed.

Based on observation and interview, it was determined that the facility failed to ensure that the facility was maintained to ensure a safe and sanitary environment.

Findings were:

Tour of the facility on 11/3/11 revealed the following:

? Ceiling tiles throughout the hospital were stained and water damaged demonstrating the failure to effectivley clean these areas
? A nonfunctional drinking fountain was noted adjacent to the nurses ' station. This fountain was attached to a wall that had sheetrock that was warped and bubbled preventing effective cleaning
? The patient rooms observed had cracks and damage to their sheet rock walls with chipped plaster preventing effective cleaning
? The floor in the facility had many areas that had swollen and discolored tiles. In places, the linoleum tiles had glue seeping up between the tiles. In several spots, the tile was chipped or missing, preventing effective cleaning.
? The lab area had limited workspace as the countertops were crowded with equipment and computer cables, demonstrating the failure to effectivley clean these areas

In an interview with the Director of Nurses on 11/3/11, the above maintenance issues were confirmed.

Based on observation and interview, it was determined that the facility failed to ensure that the hospital practiced appropriate infection control.

Findings were:

Tour of the facility on 11/3/11 found the following infection control issues:


? In the Emergency Room, a 1/2 inch tear was noted on the vinyl covering on one of 2 beds, making disinfection impossible and cross contamination likely
? In the Emergency Room, 20 pairs of scissors and hemostats were found in the closed position, making disinfection impossible.

In an interview with the Director of Nurses on 11/3/11, the above infection control issues were acknowledged.

Based on review of documentation and interview, it was determined that the facility failed to provide timely nutritional assessments on its patients.

Findings were:

Facility policy entitled " Dietary Services for Swing bed " stated in part " The Dietary Manager will visit each Swing bed patient within 48 hours of admission. Thereafter, the manager will visit each patient once a week to consult with them in regard to any personal preferences, quality and quantity of food received, or anything the patient may wish to discuss related to their diet. "

Review of the medical record of Swing bed patient # 13 (admitted 8/6/11, died 8/10/11) revealed an incomplete Admission Nutritional Assessment form dated 8/28/11. This form was outside of the 48 hour time limit for nutritional assessment as stated in facility policy.

In an interview with the Registered Dietician on 11/2/11, it was admitted that the Admission Nutritional Assessment was not completed on patient # 13 until 2 weeks after his death. She stated, " I usually complete the assessment the day the patient was admitted but I was out sick at the time. "