HospitalInspections.org

Based on observation and staff interviews, the hospital staff failed to maintain a clean and orderly premises and ensure proper maintenance of the hospital in Laboratory and Radiology Department.

Findings:
During a tour of the hospital on 8/26/25 the following observations were made:

Laboratory Department:
Observation of the laboratory department on the afternoon of 8/26/25, reflected the following:
1-Sink one: located to the left of the entry into the lab area had a drain that contained residual from a lab testing machine, personal coffee cups and other supplies were placed on the counter. The sink counter held the lab centrifuge which is considered dirty. Under the sink the cabinet had supplies and yellow brown colored substance on the bottom of the cabinet.
2- Sink two: located to the right of the entry into the lab area contained a drain from lab testing machines and under the cabinet there were supplies and yellow brown colored substance on the bottom of the cabinet. There were printers in the countertops with no defined separation of clean and dirty. a slide with blood smear was resting on the counter between the sink and printers.
3- Sink three located in the adjacent room to the lab area labeled supply room had drains from the nearby lab testing machine and supplies under the cabinet.

During an interview 8/27/25 with Staff # 18, Lab Director, he confirmed there was no sink that was clearly labeled as clean
or dirty and confirmed the above findings.

Radiology Department:
1. A thick layer of dust on the lateral surface of the CT scan machine .
2. Oxygen tubing that was attached to the oxygen regulator and hanging down. There was no indication of weather the
tubing was clean or dirty.
3. A white crystallized substance was observed on the floor on the control pedals and on lateral surfaces near the CT scan table.
4. A used tourniquet and opened alcohol prep were observed on the table with the clean supplies for IV starts.

Staff #1 verified these findings.

Based on interviews and record reviews, the facility failed to ensure the prevention and control of HAI's, including auditing of adherence to infection prevention and control policies and procedures by CAH personnel when the staff did not follow the manufacture's recommendations for cleaning the glucometer between patient use with no auditing to verify adherence to policy and procedure..

Findings :

Review of the facility Policy #3887, Title: POC Blood Glucose Monitoring, Capillary, Current Effective Date 2/1/2024 reflected the following:
" ... PROCEDURE: ... Clean the glucometer after each use following the manufacturer's directions ..."
Review of the Nova Biomedical Corporation Nova Stat Strip Glucometer Manual at www.novabiomedical.com (LPN_65965_StatStrip_2.0_Glu_IFU_EN.pdf) reflected the following:
" ...Acceptable Cleaning and Disinfecting Materials
Nova Biomedical recommends the use of Clorox Healthcare® Bleach Germicidal Wipes, EPA Registration #67619-12, or any disinfectant product with EPA Registration #67619- 12, and Super Sani Disposable Wipes (Sani Wipes) EPA Registration #9480-4 may be used ...
1. Clean the Meter.
- Remove a fresh germicidal wipe from the canister.
- Wipe the external surface of the meter thoroughly with a fresh germicidal disinfecting bleach wipe. Discard the used wipe into an appropriate biohazard container.
2. Disinfect the Meter.
- Using a new, fresh germicidal bleach wipe, thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally followed by 3 times vertically avoiding the bar code scanner and electrical connector.
- Gently wipe the surface area of the test strip port making sure that no fluid enters the port. Figure 5.3 Wiping the Surface of the Meter 3. Observe surface contact time.
- Ensure the meter surface stays wet for 1 minute (Clorox Wipes) or for 2 minutes (Super Sani Wipes) then allow to air dry for an additional 1 minute ..."

During an interview, on the afternoon of 8/26/25, Staff #14, LVN, reported that he cleans the glucometer with an "alcohol wipe after each use".

During an interview on the afternoon of 3/26/25, Staff #2 reported that she thought the manufacture's recommendations were to wipe the glucometer with alcohol after use. In an interview with the Director of Infection, Staff # 2 it was acknowledged this was not being audited for adherence.

Based on review of records and interview, the facility failed to develop a facility wide antibiotic stewardship program that demonstrated coordination among all components of the CAH responsible or antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, nursing services, and pharmacy services.

Findings:

During an interview, on the morning of 8/27/25, Staff #2, Infection Prevention Nurse, CNO, reported that she does not have Infection Prevention/Antibiotic Stewardship Committee meetings. When asked if she met with the pharmacist to review his reports related to antibiotic Stewardship, she reported that she does not meet with the pharmacist or receive a copy of his reports.

During an interview, on the morning of 8/28/25, Staff #1, CEO, reported that she reports the pharmacy and infection control reports from her dashboard (program for QAPI the facility uses for collecting the data) so the pharmacist and infection preventionist do not need to have a meeting.

No documents were provided related to coordination of the components of the infection prevention and control program and the pharmacy services.

Based on review of facility-based documentation and interview, the facility QAPI (Quality and Performance Improvement) program did not consistently use objective measures to evaluate its organizational processes, functions and services. The Patient Safety Program monthly findings were not monitored and evaluated by the Quality Improvement Committee to promote patient safety.

Findings:
Facility policy titled Patient Safety Program (PSP) initiated 10/31/2024 in part stated,
"...PURPOSE: This policy is our commitment to those we serve by promoting a safe environment of care for the
patients of our Hospital. Additionally, the policy assists in demonstrating compliance with Texas
Administrative Code requiring a written Patient Safety Program...
POLICY:
· Situations or events felt to be unsafe will be reported utilizing the Incident Reporting process.
· At minimum medication errors, falls, and failures to maintain a safe environment will be reported and considered a patient safety event.
· Annual patient safety education will be conducted.
· Patient safety events will be monitored and evaluated by the Quality Improvement Committee...
PROCEDURE:
I. Patient Safety Philosophy
A. It is the goal of this program to maintain a culture that works toward recognizing safety challenges and
implementing viable solutions rather than harboring a culture of blame,shame and punishment.
B. The Patient Safety Program is fulfilled in part by:
1. Safety huddles
2. Tracking and trending incidents/events...
II. Program elements:
A. Reporting and Evaluation of Events
1. All events or incidents will be reported utilizing the incident form and/or reporting system.
2. Incidents will be maintained in a confidential manner.
3. The Risk Manager will provide a summary report; details will only be shared with those having
a need to know, for review by the Quality Committee.
4. When data is presented to the Quality Committee it will be discussed and evaluated to determine
action. ..
E. Responsibilities of the Quality Committee
1. Review, discuss and make recommendations on the summary reports provided by
the Risk Manager.
2. Assign responsibility to a responsible individual to ensure and report on actions
taken to prevent future such incidents..."

Review of monthly QAPI and Safety meeting minutes held in August 21, 2025, July 16, 2025, June 19,2025 & May 29,2025 revealed the following:

On the afternoon of 8/26/25 this surveyor reviewed the QAPI and Safety meeting minutes with the Director of Risk and Quality, Staff # 2, and the facility could not provide documentation of the patient safety audits used to monitor and evaluate each department is reviewed by the Quality Improvement Committee.

In an interview 8/26/25 with the Patient Safety Officer, Staff #4, it was shared, he was just recently appointed and had not received training. Each facility department directors were responsible for performing monthly safety worksheets and sending to him to submit during the Safety meetings and QAPI. He did not review them for trends, just reported what was sent, as it was not a known responsibility. It was acknowledged when reviewing the 2025 monthly audits there were missing worksheets.

In an interview on 08/27/25, with staff member #1 (CEO) confirmed the Patient Safety Program (PSP) did not provide accurate data and did not follow facility policy and procedure.