HospitalInspections.org

Based on review of documentation and interview, the facility failed to protect and promote each patient's rights, as evidence by the following findings:

1. The facility failed to ensure that each patient, or the patient's parent, guardian or legally authorized representative, had the right to participate in the development and implementation of his or her plan of care. Cross refer to A0130.

2. The facility ensure care in a safe setting on their dialysis units as evidence by failing to ensure that policies were implemented, components of the water system were tabled with function and parameters. Also chemical analysis and water cultures were not being performed per policy or regulatory standards. Cross refer to A0144.

3. The facility failed ensure that seclusions were discontinued at the earliest possible time. Cross refer to A0154.

Based on review of documentation and staff interviews, the facility failed to ensure that each patient, or the patient's parent, guardian or legally authorized representative, had the right to participate in the development and implementation of his or her plan of care, according to the facility policy, as 7 of 12 patient records [Patients #B2-B7 and #B9] indicated either no, late or early patient involvement in the treatment planning process.

Findings were:

a. A review of patient records at the South Texas Behavioral Health Center revealed the facility could provide no documented evidence of the patient or patient's parent having been involved in the treatment planning process for 7 of 12 patient records reviewed [Patients #B2-B7 and #B9]. In addition, the date, time and location of the treatment plan meeting for each of these patients was unclear as the treatment team's signatures were either not dated, or spread over several days, implying no treatment team meeting actually took place.
For example:
· A review of the Master Treatment Plan of Patient #B2 revealed an area entitled Patient Involvement with Master Treatment Plan. The plan was not signed by the patient or parent/guardian. The patient was 15 years old. In addition, there was no documented evidence that the patient or parent had declined involvement.
· Patient #B3 was admitted to the facility on 6/19/15. A review of his treatment plan revealed a psychiatrist signed the plan on 6/21/15 at 2:30 p.m., a nurse on 6/20/15 at 5:25 p.m., and a pharmacist on 6/22/15 at 1:00 p.m. Patient #B3 signed the plan on 6/21/15, no time noted.
· Patient #B7 was admitted to the facility on 7/9/15. A review of his treatment plan revealed a psychiatrist signed the plan on 7/12/15 at 6:00 p.m., a social worker on 7/11/15 at 2:41 p.m., and a pharmacist on 7/13/15 at 9:26 a.m. The patient signed the treatment plan on 7/11/15, no time noted.

Facility policy #BCH.2225 entitled Interdisciplinary Treatment Team - STBHC, last revised 5/1/14, included the following:
"It is the policy of South Texas Behavioral Health Center (STBHC) to complete an interdisciplinary plan for treatment for every patient ...The patient is included in the process as evidenced by the patient's (and/or the family's) signature on the treatment plan ...
a. The Clinical Therapist will review the treatment plan with the patient and obtain the patient's signature or document appropriately if the patient is unable or unwilling to participate.
b. The Clinical Therapist, upon obtaining permission from the patient, will review the treatment plan with the patient's family or supportive person ..."

b. The above findings were confirmed in an interview with the facility Administrator and Director of Nursing, as well as other administrative staff on the afternoon of 9/15/15 in the South Texas Behavioral Center meeting room.

Based on interviews and observation, the facility failed to ensure as safe setting as dispensers for alcohol-based hand rubs were installed in an unsafe manner and liquid soap was dispensed over a copier machine.


Findings included:

a. During a tour of the McAllen Heart Hospital the morning of 9/17/15, the following was observed:
· Dispensers for alcohol-based hand sanitizer were observed installed over and adjacent to electrical outlets and switches in patient hallways. The dispensers contained alcohol-based hand rub, which is flammable, creating a fire hazard. The above was confirmed in an interview during a tour of the facility with Staff #M73 on 9/17/15.

b. During a tour of the McAllen Heart Hospital the morning of 9/17/15,the following was observed:
· In the PACU, there was an unfinished partial sheet of sheetrock mounted over a window. A liquid soap dispenser was mounted on the sheetrock directly over a copier machine, next to a handwashing sink. This presents a risk of electrical shock if the liquid were to drip or spill onto or into the copier.
· Dispensers for alcohol-based hand sanitizer were observed installed over and adjacent to electrical outlets and switches and elevator control buttons in the patient hallways and in offices. The dispensers contained alcohol-based hand rub, which is flammable, creating a fire hazard. The above was confirmed in an interview during a tour of the facility with Staff #H3 on 9/17/15.


30250

Based on review of documentation and interview, the facility failed to ensure care in a safe setting on their dialysis units as evidence by failing to ensure that policies were implemented, components of the water system were tabled with function and parameters. Also chemical analysis and water cultures were not being performed per policy or regulatory standards.

Findings included:
a. Facility based system wide policy HD.1065 entitled, "Dialysate Water-Chlorine Testing/Opening of the System" stated in part,
"Documentation:
A. Daily reverse osmosis water disinfection logbook.
B. Individual machine disinfection log sheet.
Daily disinfection logs of each machine must reflect date and negative results for chlorine before patients are place on the machines."
The above policy did not provide detailed instructions for performing the chlorine tests, including how long the test strip should be exposed to the sample water, per manufacturer's recommendations. It is unknown if employees at the facility are exposing in the test strips for the recommended amount of time for an accurate test result. The policy also does not contain expected test results or what actions to take if the chlorine levels are out of range. This presents a potential risk of break through chlorine not being identified or addressed, putting patient safety at risk.

b. At Edinburg Regional Medical Center the following findings were made:
- The Machine Disinfection Logs for each individual dialysis machine did not contain documentation of negative chlorine results, per facility based policy.
- The Hemodialysis R.O. Machine Log Sheet had a cell labeled "Total" with the letters "CL" handwritten into this cell. This appeared to document the test results for total chlorine. The values indicated on this form for 2015 were within acceptable range levels.

Facility based policy HD.2085 entitled, "Phoenix Meter Protocol" stated in part,
"Procedure:
A. START-UP OF METER (AM)....
3. Check conductivity by using Conductivity Standard Solution (Range: 12.8-15 mS/cm).
4. Check pH by using Standard Buffer Solution (Range pH 6.5-7.8).
7. Document in Phoenix Meter Log. "


c. At Edinburg Regional Medical Center the following findings were made:
- No Phoenix Meter Logbook was present to document testing and calibration of the Phoenix meter prior to use on a patient machine, per facility based policy.
The above findings were verified in an interview with staff member E2 on 09/16/15.

d. During a tour of the water treatment rooms at Edinburg Regional Medical Center (ERMC) and McAllen Medical Center (MMC) on 09/16/15 and 09/17/15 the following observation was made:
- Each major water system component was not labeled in a manner that identified the device; describes its function, how performance was verified and actions to take in the event performance was not within an acceptable range.
- At MMC the area where the primary carbon tank is stored was surveyed. 2 large unlabeled tanks were observed. Staff member E46 stated these were carbon tanks that supplies water to the dialysis area and laboratory area. The tanks were not labeled to identify contents or which area the water is directed (dialysis versus laboratory). 3 sample ports labeled "chlorine" were observed. Staff member E46 was unable to identify which port is associated with the carbon tank that supplies the dialysis unit. Without being able to identify which port was associated to the two tanks, the facility cannot ensure that the proper tank is being tested for chlorine. Staff member E46 stated that staff members test for chlorine before each shift and test each port.

e. The lack of proper labeling of components of the water system at these locations was verified with staff member E2, E3, E46 and E47.

f. Facility system wide policy HD.1060, entitled "Analysis of Dialysis Water" stated in part, "C. Chemical contaminant analysis will be done every 6 months."

g. Review of the chemical analysis (AAMI) lab results at Edinburg Regional Medical Center (ERMC) and McAllen (MMC) Medical Center revealed the following:
- Both facilities are conducting chemical analysis annually, not every 6 months per policy and regulation.
- In an interview on 09/16/15, staff member E2 at ERMC verified this analysis done annually not every six months.
- In an interview on 09/16/15, staff member E46 at MMC verified this analysis was done annually not every six months


g. Review of the water culture results at Edinburg Regional Medical Center (ERMC) revealed the following:
- This facility was not conducting tests on hemodialysis machines quarterly for bacterial growth and the presence of endotoxins. This testing was being performed every 6 months per interview on 09/16/15 with staff member E2 at ERMC verified this analysis done annually not every six months.

Based on review of documentation and interview, facility failed ensure that seclusions were discontinued at the earliest possible time.


Findings included:

a. Facility based policy PC.1110 entitled "Restraints and Seclusion" stated in part,
"N. Discontinuance/release of restraint:
1. Violent/Self-Destructive:
a. Based on an individual patient assessment determining that the patient does not pose a threat to himself/herself or others, an RN trained in the use of violent/self-destructive may remove the restraints."

At South Texas Behavioral Center, patient B12 was placed in seclusion on 05/15/15 at 11:15 AM. The "Behavioral Management Seclusion/Restraint Observation Record" indicated that the patient was displaying calm behavior indicated as a number 6 for "resting/quiet" for 11:30 and 11:45 AM. The patient was not released from seclusion until 11:45 AM after displaying calm behavior for over 15 minutes.

Nursing notes support that the patient was displaying quiet behavior during this period of time.
- At 11:23 stated, "Patient remains in seclusion, no distress". but was not discontinued the earliest possible time."
- At 11:38 stated, "Patient remains in seclusion, not in distress. Appears to be calming down."
- At 11:45 stated, "Patient is calm, seclusion ended".

The patient was displaying calm behavior with no violent or self-destructive behavior exhibited. The seclusion was not discontinued at the earliest possible time.

b. In an interview on 09/15/15 staff member B2 verified this patient should have been released from seclusion at the earlier possible time after displaying calm/quiet behavior.

Based on review of documents and interview, the facility failed to ensure that a medical history and physical examination was completed and documented and placed in the patient's medical record within 24 hours after admission.

Findings included:

a. Review of the medical record for 1 out of 16 patients (Patient #M1) at the McAllen Medical Center revealed no documented evidence of a history and physical examination.

b. Review of the STHS Medical Staff General Policies stated, in part, "2.2 Admission History Guidelines, Physical Examination Guidelines, and Treatment Plan Guidelines. 2.2(a) Timing and Other Requirements. A physician, oral maxillofacial surgeon, or other qualified licensed independent practitioner...must complete a physical examination and medical history ("H&P") for each patient no more that thirty (30) days before or within twenty-four (24) hours after the patient's admission or registration ..."

c. The above findings were confirmed in an interview the afternoon of 9/17/15 in the facility conference room with Staff #M4 and Staff #M79.

Based on review of documentation and interview, the facility failed to ensure that patient medical records contained information necessary to monitor the patient's condition.

Finding included:

a. Facility based policy for South Texas behavior Health Center BHC.2500 entitled, "Patient Observation" stated in part,
"3. Mental Health Technician ....
c. Observe each patient on a 15 minute interval and/or according to precaution level and document location and behavior on the Observation Record."

b. Review of the Patient Observation Records revealed:
- Patient B3 was on observation precautions for aggression and elopement. On 06/23/15 the form was not completed for over a half hour (1300 and 1315 were blank).
- Patient B6 was on observation precautions for aggression, elopement, and suicide. On 06/21/15 the form was not completed for over a half hour (0100 and 0115 were blank).

c. The above findings were verified in an interview with staff member E2 on 09/16/15.

Based on observation, review of documentation and interviews with facility staff, the facility failed to ensure outdated medications were unavailable for patient care use as expired medications were found in patient care areas and in a pharmacy department. This was not consistent with facility policy and potentially could have resulted in patients receiving unsafe or ineffective medications.
The findings were:
a. The facility policy entitled "Handling and Expiration Dating" MM.2209 dated 07/01/15 reflected in part "III. Oral liquids, topicals and metered dose inhalers: The manufacturer's expiration date will be used as the official expiration date for commercially available oral liquids, topical products and metered dose inhalers once opened, unless shorter dating is stated by the manufacturer."
During a tour of the patient units at South Texas Behavioral Health Center on the morning of 09/15/15, the following expired topical medications were observed in patient care areas available for use in patient care.
1. Found in the geriatric unit utility room: PVP Prep solution, povidone iodine 10%, 4 oz. bottle, 2 expired 10/14.
2. Found in the geriatric unit laundry room: Hebiclens 4% solution, 8 oz. bottle, 10 expired 5/14.
b. In an interview during the tour with director, Staff B15 on 09/15/15 at approximately 11:00 am, Staff B15 acknowledged that the above listed topical medications were expired.
c. During a tour of the pharmacy department at McAllen Heart Hospital on 09/17/15 at approximately 10:30 a.m. with Staff H24 (Director of Pharmacy), two boxes of unopened Fentanyl Citrate Injections 1000 mcg/20 mL per ampule (50 total ampules) were identified to be expired since 06/01/15 and stored in an area of current narcotic use medications.
c. Review of facility policy MM.2215 (Inspections: Medication Areas) last revised 09/11/15 reflected in part:
· Pharmacist(s) in Charge or qualified designee shall conduct monthly inspections of all medication areas (e.g., nursing-care units, emergency drug containers, and other areas where drugs are dispensed, administered or stored).
· Outdated or otherwise unusable drugs are identified, removed from stock and stored to prevent their distribution and administration
d. Interview with Staff H24 on 09/17/15 at approximately 10:35 a.m. confirmed two unopened boxes of of Fentanyl Citrate Injection medications (50 total ampules) were expired and indicated she would dispose of the expired narcotics as required by facility policy and state/federal regulations.
During the Exit Conference on 09/17/17, the facility was given an opportunity to ask questions and provide additional information regarding the deficient practice findings. No additional information was provided at that time.




29934



The facility policy entitled "Handling and Expiration Dating" MM.2209 dated 07/01/15 reflected in part "III. Oral liquids, topicals and metered dose inhalers: The manufacturer's expiration date will be used as the official expiration date for commercially available oral liquids, topical products and metered dose inhalers once opened, unless shorter dating is stated by the manufacturer."
a. During a tour of the patient units at South Texas Behavioral Health Center on the morning of 09/15/15, the following expired topical medications were observed in patient care areas available for use in patient care.
1. Found in the geriatric unit utility room: PVP Prep solution, povidone iodine 10%, 4 oz. bottle, 2 expired 10/14.
2. Found in the geriatric unit laundry room: Hibiclens 4% solution, 8 oz. bottle, 10 expired 5/14.
b. In an interview during the tour with director, Staff B15 on 09/15/15 at approximately 11:00 am, Staff B15 acknowledged that the above listed topical medications were expired.
c. During the Exit Conference on 09/17/17, the facility was given an opportunity to ask questions and provide additional information regarding the deficient practice findings. No additional information was provided at that time.

Based on observation, review of documentation and interviews with facility staff, the facility failed to check food temperatures according to facility policy and to properly check sanitizer as expired test strips were being used. This was not consistent with facility policy and potentially could have resulted in food being served to patients that was at an unsafe temperature and sanitizer testing to be inaccurate.
The findings were:
a. The facility policy entitled "HACCP Food Safety Program" #DIET.0123 dated 9/1/14 reflected in part "5. Maintain temperature records for all patient and cafeteria meals served." The facility policy entitled "Testing of Sanitizer Solution for Pots and Pans" #DIET.0157 dated 5/1/10 reflected in part "3. Add enough sanitizing solution to sink 3 to have 'Hydrion Papers QT10' read 200 ppm."
During a tour of the dietary department at South Texas Behavioral Health Center on the morning of 9/15/15, the food temperature logs were reviewed. There were no temperature checks done for the following meals: 7/6/15 lunch; 7/7/15 lunch; 7/25/15 dinner; 8/3/15 dinner; 8/29/15 dinner; and 9/12/15 lunch.
During the tour of the dietary department, the dish washing area was observed. The QAC QR test strips the staff used to test the sanitizer concentration were observed to have expired 3/15.
b. In an interview with the dietary director, staff #B14 during the tour on 9/15/15 at approximately 9:30 am, staff #B14 acknowledged that the temperature checks were not done for the meals as listed above and that the sanitizer test strips were expired.

Based on observation, review of documentation and interviews with facility staff, the facility failed to maintain a sanitary environment as two washing machines used to wash patient clothing at South Texas Behavioral Health Center were not properly maintained which made it impossible to properly clean the machines between patient uses according to facility policy. A vinyl covered couch in an activity room had holes in the vinyl covering exposing the fabric below which made properly cleaning impossible.
The findings were:
a. The facility policy entitled "Laundry Equipment and Cleaning" BHC.2250 dated 2/1/14 reflected in part "Staff cleans washer and dryer with hospital approved cleaner between usage."
During a tour of the geriatric unit on the morning of 9/15/15, the washing machine in the laundry room was observed to have the paint peeling on the metal ring under the lid that was above the tub which made proper cleaning impossible and could cause paint chips to fall in the tub with the laundry.
b. In an interview during the tour with director, staff #B15 on 9/15/15 at approximately 11:10 am, staff #B15 acknowledged that the paint was peeling as noted above.
c. During a tour of the pediatric unit on the afternoon of 9/15/15, the washing machine in the laundry room was observed to have a large amount of rust around the inner edges of the lid and was crusted with hardened soap scum. The rust made proper cleaning of the inner lid impossible. A couch in the quiet activity room was observed to have a 1-1/2" in diameter hole in the vinyl cover on the middle of the back cushion of the couch. The left arm of the couch had multiple ¼" holes in the vinyl cover. The holes exposed the fabric below the vinyl and made proper cleaning impossible.
In an interview during the tour with the nursing director, staff #B17 on 9/15/15 at approximately 3:00 pm, staff #B17 acknowledged the rust on the washing machine lid and the holes in the couch vinyl cover as noted above.

Based on interview, observation and review of documentation, the facility failed to provide a sanitary environment to prevent cross contamination..

Findings included:

a. During a tour of the McAllen Medical Center the morning of 9/17/15, accompanied by Staff #M73, the following was observed:
· There was a rusted can opener in the drawer with patient supplies in the storage room for baby formula and breast milk in the NICU. This presents a risk for cross contamination.
· In NICU Pod 1, the patient supply shelves were in need of cleaning as there was a powdery black substance on the shelves next to items such as small bore extension sets, trach supplies, and gastro supplies which were available for patient use. This presents a risk for cross contamination.

b. During a tour of the McAllen Heart Hospital the morning of 9/16/15, accompanied by Staff #H3, the following was observed:
· In the PACU, there was an unfinished partial sheet of sheetrock mounted over a window. The sheetrock, a porous material, was directly above the handwashing sink. This presents a risk for contamination, as the sheetrock was porous and could not be properly disinfected, and the sheetrock could become wet and present an environment for bacterial growth.
· Seasonal decorations were stored in the dirty utility room in the PACU which contained contaminated items. Staff #H3 confirmed that these decorations were used on the unit during the holiday season, which presents a risk for cross contamination.


32870

a. On a tour of the emergency department of Edinburg Regional Medical Center on the morning of 9/16/15 with the Interim Clinical Director the following items were noted:

· Triage room #1 had broken, chipped laminate above the bed and broken areas of flooring. The flooring base board gaped away from the wall in the corner of the room. The permeable wood beneath the laminate was exposed making thorough cleaning impossible. In addition, dust was present on high horizontal surfaces.
· In a small patient nourishment room there were two shelving units each holding clean patient linen. The shelving unit closest to the door, was covered only in open mesh making it possible for liquids or other contaminates to reach the linen.
· A housekeeping closet contained a bucket of standing water with rags lying in the water.
· The director stated trauma room #1 had been cleaned and was available for patient use. There was debris on the floor under the bed, including cellophane wrappers and paper. In addition, the floor appeared visibly soiled in areas.

b. On a tour of the emergency department of Edinburg Children ' s Hospital on the morning of 9/17/15 with the Interim Clinical Director the following items were noted:
· The patient restroom had an approximate ¼ " gap between the wall and the edge of the flooring around the entire floor perimeter. In addition, there were 4 chips in the plaster on the wall. These items made thorough cleaning of the restroom impossible.

Facility policy #EVS.1100 Environmental Sanitation, last revised 3/1/11, included the following:
" 1. The Environmental Services Department provides a clean environment for patient care in order to prevent and minimize the potential for transmission of infection between patients and staff via the inanimate environment ...
h. Store buckets dry when not in use ... "

Based on a review of facility documentation and staff interview, the facility failed to follow its own discharge planning process which required each patient to be discharged with a discharge plan for 4 of 6 patient records reviewed (Patients #E15, #E17-E19).

Findings were:

a. Patient records were reviewed for patients re-admitted within 30 days of a prior admission at the Edinbug Regional Medical Center. In 4 of the 6 patient records at reviewed (Patients #E15, #E17-E19), the facility could provide no documented evidence of the patient having received a discharge planning assessment or of the patient having a discharge plan. Thus, staff members responsible for discharge planning activities were not following the hospital's discharge planning policies and procedures, and not facilitating the provision of each patient's follow-up care. This issue was not evident at the rest of the facilities in South Texas Health System when medical records were reviewed.

b. In an interview with staff #E1, Lead Case Management, on the morning of 9/16/15 in the facility conference room, she stated it was the policy of the facility that all inpatients were provided a discharge plan. In review of three patient records (Patients #E17-E19) during the interview, she stated the records contained no evidence of discharge planning activity beyond an initial one-sentence statement made by an RN on the date of admission which indicated the patient could potentially be discharged home.

c. In a subsequent interview with Staff #E1, Lead Case Manager, on the morning of 9/17/15 in the facility conference room, each of the patient charts reviewed the preceding day were again reviewed and the previous findings re-confirmed. In addition, an additional three patient charts were reviewed (Patients #E14-E16). Of these three charts, she stated the record of Patient #E15 had no evidence of discharge planning activity beyond an initial one-sentence statement made by an RN on the date of admission which indicated the patient could potentially be discharged home.

Facility policy NSG.0500 entitled Discharge Planning for Acute Care Patients, last revised 12/1/14, included the following:
"It is the policy of the Nursing and Case Management Department to facilitate the discharge planning process for all acute care patients ...Discharge planning seeks to provide those services that will enable the patient to become as independent as possible ...
C. The Case Management/Social Service assessment is completed at a minimum 48 hours in advance of patient's discharge by the Case Manager/Social Worker ...
IV. Documentation: The discharge planning assessment and arrangements are documented in the discharge section of the electronic medical record...Clear documentation of the patient's informed choice/options given and that patient is in agreement with plan is necessary in the discharge planning area of the medical record ..."

d. All findings were confirmed in an exit conference with senior hospital system staff on the afternoon of 9/17/15 in the conference room of the main hospital campus.