HospitalInspections.org

Based on observation, documentation review, and interviews with facility staff, the facility failed ensure that patients received care in safe settings.
Findings were:
During a tour of Hyperbaric Therapy Room, located in the wound care clinic on the morning of 07/25/12. Hyperbaric therapy staff # 43 stated, "the only safety checks performed for the hyperbaric chamber were the pre and post daily checks."
When staff # 43 was asked by the surveyor, "Are weekly and monthly safety checks for the hyperbaric chamber performed?"
Staff # 43 stated, "the pre and post safety checks are documented in the patient progress notes."
No documentation of weekly or monthly safety checks was offered to the surveyor for review.

Review of facility documentation Hyperbaric Safety and Infection Control, reference # 2036. Page 2 of 3 stated, "The Medical Director will also review/sign the safety checklist at least once a month. The checklist will be maintained in a binder marked HBO Safety Checklist located in the HBO unit."

A. Based on observation, review of documentation and interviews with facility staff, the facility failed to maintain equipment to ensure an acceptable level of safety and quality in violation of facility policy as the facility failed to properly maintain 1 of 1 dish washing machines.
B. Based on observation, and interview, the facility did not maintain supplies for an acceptable level of safety and quality in two (2) patient care areas of the Emergency department (ED).

The findings were:
The facility form entitled "Critical Control Dish Machine Temperature Log" reflected "Rinse, min 180 degrees, max 200 degrees." The Texas Food Establishment Rules with an effective date of 3/15/06 reflected in part "in a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 90 degrees Celsius (194 degrees Fahrenheit) or less than: (i) for a stationary rack, single temperature machine, 74 degrees Celsius (165 degrees Fahrenheit); or (ii) for all other machines, 82 degrees Celsius (180 degrees Fahrenheit)."

During a tour of the Dietary Department on the afternoon of 7/23/12 in the company of personnel # 31 , the Dish Machine Temperature Log was reviewed for the months of Feb 2012 - July 2012. The temperature of the rinse water was recorded as below 180 degrees Fahrenheit 13 of 87 times in Feb 2012; 21 of 93 times in March 2012; 23 of 93 times in April 2012; 21 of 90 times in May 2012; 21 of 90 times in June 2012; and 19 of 68 times in July 2012. The Dish Machine Temperature Log had a column entitled "Corrective Action" to the right of the column where the temperatures were recorded. In each case where the temperature was below the required range of 180 - 200 degrees Fahrenheit, the Corrective Action column was blank. The dish machine was observed to be the type where racks of dishes moved on a conveyor through the machine, that is, it was not a stationary rack type of machine.

Personnel # 31 was interviewed on 7/24/12 at 3:40 PM and asked what the facility policy was on the temperature of the dish machine rinse water. He provided the Texas Food Establishment Rules dated 3/15/06 and stated the facility used these rules as the facility policy for the dish machine water temperatures. The Texas Food Establishment Rules dated 3/15/06 reflected the fresh hot water rinse temperature should be 180 degrees Fahrenheit. When asked what staff should do when the temperature was below the required range, personnel # 31 stated that the staff member should report it to the Dietary supervisor who should report it to Facilities Management. When asked if there was documentation that the low rinse water temperatures were reported to Facilities Management, he stated that there was no documentation that the low rinse water temperatures were reported or that corrective action was done.


20676


On 7/23/12 from 2:40 PM until 4:30 PM, during the tour of the Emergency Department (ED) the surveyor observed the following expired equipment in patient care areas available for patient use.
In examination room # 20:
4 packages of cotton tipped swabs expired 06/12
4 blood collection tubes expired 06/12.

In trauma room #1 crash cart:
multilumen Central Venous Catheter expired 04/12.
2 packages of intravenous tubing that expired 01/11
2 butterfly IV start kits that expired on 05/12
2 butterfly IV start kits expired on 06/12.

An interview was conducted on 7/23/12 at 4:30 PM with Personnel #11 who verified the above expired supplies were available for patient use in these ED patient areas.

Based on observation, review of documentation, and interviews with staff # 21, # 44, and # 1; the facility failed to ensure that the wound care clinic manager met the qualifications specified by the medical staff.

Findings were:
Review of the Wound Care Clinic Manager staff # 44 personnel file, revealed the Hyperbaric Oxygen Certification for staff #44 expired on 01/31/12.

Review of facilities Wound Care Manager Qualifications and Licenses stated, Hyperbaric Respiratory Therapist, licensing and certifications, stated "must have CPR and HBO certifications."

In an in-person interview conducted with staff # 21, #44 and # 1, on the morning of 07/26/12 at the facility it was confirmed that the Hyperbaric Therapy Certification for staff # 44 expired on 01/31/12.