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Based on observation, document review and interview, the facility failed to ensure sharps disposal containers located in patient rooms were designed to prevent access to contaminated sharps in 25 of 25 patient rooms.
This deficient practice had the likelihood to cause harm to patients, staff and visitors.
On 8/3/2016, at approximately 10:30 a.m., a tour was conducted of the facility's open patient rooms on the Medical/Surgical floor. A sharps disposal container was mounted on the wall opposite of the patient's bed. The sharps container was located close to the horizontal center of the wall 54 ½ inches from the floor (measured to the top opening of the container). The container was mounted to the wall in a locked mounting device with an opening at the top that allowed access to the container opening. The opening on the top of the container allowed full view and access to the contaminated sharps inside the container. The opening was circular shaped and measured approximately 1 1/2 to 1/3/4 inches in diameter.
Staff #18 confirmed the observations.
A review of the facility's policy titled, "Safety Management Plan", dated 6/2016, revealed the following information:
"The Safety Management Plan describes the programs used to manage a safety program to reduce the risk of injury for patients, staff and visitors for 'the facility' ....The program is applied to all locations where patients are treated and/or employees perform work function, including hospital and clinic.
OBJECTIVES
The Objectives for the Safety Program are developed from information gathered during routine and special risk assessment activities, annual evaluation of the previous year's program activities, performance measures and environmental tours."
A review of the recommendations from the National Institute for Occupational Safety and Health (NIOSH) document titled, "Selecting, Evaluating, and Using Sharps Disposal Containers", revealed the following information:
"The selection of a sharps container should be based on a site-specific hazard analysis. Employers should select the appropriate container design after assessing the hazards associated with use of sharps containers (e.g., considering the size and types of contaminated sharps the employer expects to dispose of). Generally, when containers having small opening(s) on the lid are selected for use, the employer has based such a selection on a determination that the configuration of the opening(s) would accommodate the largest sharp being used in the particular workstation/location. In situations where the small opening on the lid of the container is of sufficient size to accommodate all sharps requiring disposal, there should be no need for the entire lid to be opened. If the employer is finding the need to open the entire lid, perhaps further evaluation is needed to assure that the container selected is suitable to accommodate sharps of all types and sizes that require disposal. It is likely that a container of a different size, type or design configuration would be more appropriate in the specific situation of use."
A review of the facility's service agreement for regulated medical waste revealed the following information:
" ...5. Liability for Equipment. Customer shall have the care, custody and control of containers and other equipment placed at Customer's premises which is owned by 'vendor' and accepts responsibility and liability for the equipment and its contents except when it is being physically handled by employees of 'vendor'. Customer agrees to defend, indemnify and hold harmless 'vendor' from and against any and all claims for loss or damage to property, or personal injury or death, resulting from or arising in any manner out of Customer's use, operation or possession of any containers and other equipment furnished under this Agreement. Any damage to such property and equipment, other than normal wear and tear, will be charged to the Customer, and payable to 'vendor' as additional service cost."
An interview was conducted on 8/3/2016, at approximately 10:45 a.m., with staff #18 during the tour of the patient rooms. Staff #18 confirmed the sharps containers were the same design in all patient rooms. Staff #18 agreed the open sharps container in the patient rooms was a potential safety hazard since patients and visitors were allowed in the rooms without staff supervision. Staff #18 also agreed the sharps container opening was large enough for a child or small adult's hand to fit inside, allowing access to contaminated sharps.
An interview was conducted on 8/3/2016, at approximately 1:15 p.m., with staff #8 (Plant Operations and Safety Officer). Staff #8 informed surveyors the regulated medical waste vendor was in charge of selecting, placing and exchanging all sharps containers in the facility. Staff #8 confirmed the sharps containers provided by the vendor were the same design throughout the facility.

Based on observation and interview, the facility failed to separate contaminated waste from clean products and protect patients, staff and visitors from potential risk of exposure to contaminated waste.
This deficient practice had the likelihood to cause harm to patients, staff and visitors.
A tour of the facility's outside storage building was conducted on 8/2/2016, at approximately 1:30 p.m., with staff #8 (Plant Operations and Safety Officer). The building was constructed of sheet metal and wood with a concrete floor. Upon entering the building, surveyors encountered an insect flying out of the building. The storage building housed a large metal storage shelving unit loaded with large sharps containers. Multiple containers were closed and full of contaminated sharps. Open "clean" sharps containers were stored on the same shelving unit. Multiple contaminated sharps containers were touching the "clean" sharps containers. In addition, surveyors observed multiple "clean" sharps containers stored on the concrete floor with the tops open, allowing inside access to potential pests.
A review of the facility's policy titled, "Safety Management Plan", dated 6/2016, revealed the following information:
"The Safety Management Plan describes the programs used to manage a safety program to reduce the risk of injury for patients, staff and visitors for 'the facility' ....The program is applied to all locations where patients are treated and/or employees perform work function, including hospital and clinic.
OBJECTIVES
The Objectives for the Safety Program are developed from information gathered during routine and special risk assessment activities, annual evaluation of the previous year's program activities, performance measures and environmental tours."
No other policies related to the deficient practice was provided.
An interview was conducted on 8/2/2016, at approximately 2:30 p.m, with staff #8. Staff #8 confirmed the above findings.

Based on record review and interview, the facility's Governing Body failed to ensure the policy "Security Management Plan", dated 6/2016, was initiated and appropriately followed so as to provide quality care in a safe environment.
A review of the policy "Security Management Plan", dated 6/2016, revealed the following information:
"The Security Management Plan describes the methods of providing security for people, equipment, and other material through risk assessment and management for 'the facility' ... The Objectives for the Security Program are developed from information gathered during routine and special risk assessment activities, annual evaluation of the previous year's program activities, performance measures and environmental tours. The Objectives for this Plan are:
Respond to emergencies and requests for assistance in the Emergency Department in a more timely fashion.
Plant Operations staff will make themselves available at all times during normal work hours.
911 should be called after hours ...
The Security Officer, in collaboration with the committee, is responsible for monitoring all aspects of the Security Program ...."
An interview was conducted on 8/4/2016, at approximately 10:00 a.m. with staff #8 (Plant Operations and Safety Officer). Staff #8 confirmed the facility had not initiated or followed the policy, "Security Management Plan". Staff #8 also stated the facility did not have a Security Officer on staff.

Based on interview and record review the facility failed to implement their infection control policy by failing to ensure timely vaccinations on 1 of 1 employees (Staff #15).

This deficient practice had the likelihood to cause harm in all patients.

Findings include:

Review of personnel files revealed the following:

Staff #15's date of hire was 04/05/2013. According to a "Hepatitis B Vaccination Record" dated 06/22/2016, Staff #15 had an immunity titer of less than 5 (meaning not having the required immunity). According to documentation on the form a series of Hepatitis vaccinations was not started until 08/02/2016.
During an interview on 08/03/2016 after 4:00 p.m., Staff #10 confirmed the vaccinations were started late.
Review of a facility policy named "Immunizations" dated 03/2016 revealed the following:

"Purpose: To protect employees/patients from communicable disease. Immunization is the administration of antigens to stimulate the development of specific antibodies and eventual resistance to the disease. All applicants (employees, volunteers, Physicians, and allied health professionals) will be evaluated through Employee Health prior to working at or for TMC Bonham in any capacity....
Recommended Immunizations and /or testing:
C. Hepatitis B....
2. The vaccination scheduled consists of three (3) intramuscular injections, the second and third administered 1 and 6 months, respectively after the first.
3. One to 2 months after completion of the 3 dose vaccination series the employees will be tested for antibody to hepatitis B surface antigen(anti-HBs).
For non-responders: Persons who do not respond to the primary series will be offered additional doses of the vaccine total of 6. Persons who receive additional doses of vaccine will have HBsAB level repeated after each additional dose to determine if antibody protection has been achieved. Primary non-responders to vaccination who are HbsAG-negative will be considered susceptible to HBV infection and will be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG Ag-prophylaxis for any know or probable parenteral exposure to HbsAg-positive blood."

Based on interview and record review the facility failed to ensure accurate and acceptable documentation of medication administration on 1 of 2 sampled patients on anticoagulant therapy (Patient #2).
This deficient practice had the likelihood to cause harm in all patients on anticoagulant therapy.

Findings include:

Review of the emergency department record on Patient #2 revealed he was a 76 year old male admitted on 07/21/2016 with diagnoses of pneumonia, hyperkalemia and dehydration.
Review of a chest x-ray dated 07/21/2016 revealed Patient #2 had the following:
" 1. Right basal atelectasis and/or infiltrate with small pleural effusion ... "

Review of physician orders dated 07/22/2016, 9:52 a.m. revealed an order to "Initiate Heparin weight based protocol."

Review of the Heparin protocol order form dated 07/22/2016 at 12:30 p.m. revealed the following:
Heparin Loading Dose (Bolus) 5000 units/ml - 10:47 a.m. was written in on the form.
______<100 lbs.------------3000 units
______100 - 149 lbs.------4000 units
______150-200 lbs.--------5000 units (This category was checked) There was documentation in the section that "*2 nurses must initial." Staff #' s 27 and 28 initialed the area.
______> 200 lbs.------------6000 units

There was no documentation in the section of who wrote the time 10:47 a.m. on the form, what it meant or any indication as to which nurse administered the loading dose of medication.

"B. Heparin Solution-25,000 units/500 ml (50 units/ml) in D5W"

C. Heparin Maintenance Infusion
______<100 lbs.---------800 units (16 cc/hr)
______100 - 150 lbs.---900 units(18 cc/hr)
______>150 lbs.--------1000 units(20 cc/hr) units (This category was checked) There was documentation in the section that "*2 nurses must initial." Staff #'s 27 and 28 signed in the area. There was also documentation of a start time of 1:30 p.m.
There was no documentation in the section of who wrote the time 1:30 p.m. on the form, what it meant or any indication as to which nurse started the Heparin infusion.

Review of medication administration records revealed that Staff #28 gave the bolus at 10:47 a.m. and Staff #27 documented administration of an infusion rate of 1000 units /hr (20 cc/hr) at 1:29 p.m..

Review of the "Heparin Flow Sheet" revealed documentation of an initial rate change being made on 07/22/2016 at 11:05 a.m.. There was no documentation as to what the rate change was at 11:05 a.m..
The next entry on the flow sheet was timed for 7:48 p.m. (over 8 hours later) when the PTT (Partial thromboplastin time -blood test that measures the time it takes your blood to clot) was elevated over 100 and staff stopped the Heparin for 1 hour as per the protocol.

There was no documentation of bolus that was given at 10:47 a.m. by Staff #28 and no documentation of the infusion administration at 1:29 p.m. by Staff #27 on the form.
Review of medication administration records revealed no documentation of administration of Heparin between 10:47 a.m. and 1:29 p.m. as listed on the "Heparin Flow Sheet."
The Heparin monitoring tool and medication administration record were not consistent.

During an interview on 08/03/2016 after 11:00 a.m., Staff #5 confirmed not being able to tell which nurse gave the medication by looking at the order sheet and the Heparin flow sheet. Staff #5 confirmed the discrepancies written on the Heparin flow sheet.

Review of a facility policy named "Administration of Drugs" dated 06/01/2015 revealed the following:

"II. PURPOSE
Individuals who prepare, dispense and administer drugs shall do so only upon the prescription order of a practitioner who has been granted clinical privileges and is legally authorized to prescribe/order drugs. Prescription orders may be written or given verbally and reduced to writing. These activities are performed to be in compliance with maintaining an accurate and current medical record."

Based on interview and record review the facility failed to ensure verbal orders were authenticated by the physician timely in 1 of 27 sampled patients (Patient # 2).

This deficient practice had the likelihood to cause harm in all patients.

Findings include:

Review of the emergency department record on Patient #2 revealed he was a 76 year old male admitted on 07/21/2016 with diagnoses of pneumonia, hyperkalemia and dehydration.

Review of physician orders dated 07/22/2016. 9:52 a.m. revealed an order to "Initiate Heparin weight based protocol."
Review of the "HEPARIN ORDER SHEET" which listed the protocol revealed it was signed as a verbal order taken by nursing on 07/22/2015.

Review of facility "RESTRAINT ORDERS" revealed the following:
On 07/22/2016 at 1:00 p.m. a telephone order was written by nursing for bilateral soft wrist restraints.
On 07/23/2016 at 7:00 a.m. a telephone order was written by nursing for bilateral soft wrist restraints.

All of the order forms were authenticated by the physician over a week later on 08/01/2016.

During an interview on 08/03/2016 after 11:00 a.m., Staff #5 confirmed the order forms were signed late by the physician.

According to the Medical Staff Rules and Regulations dated 07/27/2016 the following was revealed:
"VIII. Physicians orders
A. All orders should be recorded on the patient's clinical chart, timed dated and signed by the staff member in charge of the case. This may be accomplished in any of the following ways:
1. Entered into the electronic health record or written personally and dated, timed and authenticated by the appropriate staff member.
2. Dictated verbally by the staff member in person or over the telephone, and dated, timed and authenticated within 96 hours by the prescriber or another practitioner who is responsible for the care of the patient and has been credentialed by the medical staff and granted privileges which are consistent within the written orders. Orders for restraints will be signed/dated/timed within 24 hours ...."

Based on medical record review and interview the facility failed to care plan the diagnosis and interventions for which 1 of 1 patient (Patient #19) was admitted for hospital services.


This deficient practice had the likelihood to cause harm for all patients.


Findings include:

On morning of 8/4/2016 the medical record for patient (Pt/pt) #19 was reviewed and revealed she was 87 years old, and was admitted for a fractured hip. The nursing staff had not care planned the fractured hip but had care planned the problem of "Pain". The nursing indications addressed pain management with medications for the reduction and control of pain. The nursing care plan did not address that fact that the patient's family had opted not to have the fracture repaired. This would have increased the likelihood of pain upon position changes required for daily tasks such as repositioning for meal intake, dressing, and incontinent care.

The nursing staff also failed to enter into the care planning process the Occupational Therapy (OT) evaluation for pt #19, once she was transferred to the swing bed unit.


When staff #5 was questioned regarding the absence of the nurses care planning the fracture, which caused the pain and need for the OT evaluation, she indicated the entire chart was the care plan.