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Based on observation and interview, the facility failed to:

A. perform a daily check on the defibrillators to ensure the recording time and clocks in the room of the Emergency Department (ED) carts #1 and #2, were calibrated to the correct time.

B. have appropriate equipment to intubate a patient in the inpatient crash cart #3.

C. secure 3 of 3 patient medical supply rooms that were found unlocked and unsupervised.

On 7/29/19 Staff #3 turned on the defibrillator for crash cart #1 in the ED. Staff #3 was asked to run a test strip for the EKG. The time was 3:24 PM. The time on the defibrillator stated it was 3:20 PM and the clock on the wall was 3:19 PM. There was no consistency in any of the time pieces. Staff #3 ran a test strip for crash cart #2. The time was 3:10 PM, the strip showed 3:06 PM, and the clock time was 3:15 PM. It is imperative that all the times are the same during a code. The recorder of the code must keep up with the time medications were administered and the events of the code to prevent patient harm or death. Staff #3 confirmed the times with the surveyor.

On 7/30/19 a check was done on a crash cart #3 in the hallway of the inpatient area. Staff #3 broke the cart seal and opened the cart. Observation of the cart revealed there was no handles to fit the blades to assist the physician when intubating a patient's airway.

The laryngoscope is a device designed to assist in the visualization of the trachea during intubation. It consists of two parts: a handle and battery holder and a blade. The handle is usually made of metal (although some are made of plastic) and contains batteries that are used to operate the light bulb found in the blade. Failure to have a working laryngoscope could delay the patient in receiving lifesaving oxygen and possible death could occur. Staff #3 confirmed there was no handle for the blades.

During a tour of the facility on 7/29/19 revealed three patient medical supply rooms were found unlocked. Staff # 3 confirmed there are no locks for the supply room. Medical supplies were accessible to anyone walking in the hallways with no supervision.

Based on review, observation, and interviews, the facility failed to have blood safely secured and a system in place to ensure nursing staff would retrieve the right blood type in an emergency.

On 7/30/19 observation to the medication room revealed medications and blood was stored unsecured. Housekeeping, maintenance and a certified nurse's aide had entered the room unsupervised. Upon entering the room on 7/30/19 at 11:15 AM, surveyor observed an approved blood refrigerated unit was unlocked and held multiple units of blood.

An interview was conducted with Staff #34 on 7/30/19. Staff #34 reported that the lab decided to keep the blood in the nurse's medication room due to the lab was not open 24/7 and blood may need to be administered in an emergency. Staff #34 was shown all the different blood type bags mixed together. 2 units of A+, 4 units of O+, and 2 units of O-. Staff #34 was asked if the nurse needed to pull a unit for an emergency and no type and cross match was done, how could the lab and nurse be sure they retrieved the right blood unit? Staff #34 stated that if a patient had not been typed and cross matched the patient could only receive O- blood. Staff #34 stated the RN would know that. Staff #34 was not concerned that the RN may not know what blood type to retrieve in an emergency and that different types of blood were mixed together in one drawer. An interview was conducted with Staff #26 (RN) concerning the blood storage. Staff #26 was asked what blood type could be administered to any other blood type in an emergent situation. Staff #26 reported that she was unsure and did not know.

Staff #34 stated that the nurses are not allowed to get the blood out for a scheduled transfusion. The lab personnel retrieve the blood and sign off with the nurse but can see where a problem could occur, if the blood was not secured, and the nursing staff had no knowledge on emergency blood.

Review of the policy and procedure "Blood Bank General Policy" stated, "2. Uncrossmatched blood is used only in cases of extreme emergency at the Doctor's Request Only. Group specific blood will be used when available in preference to Group O Rh Negative. The crossmatch will be completed, even in the event the patient expires."

Based on review of documents, observation, and interview, the facility failed to:

A. maintain the building in a manner to assure the safety of patients, staff, and guests in 6 (Room 205, Janitor Room, Work Room/Room 212, Hallway between Medical Records and the Mechanical Room, Room 143 I.C.U. & Recovery/Room 5, and Dietary Department) of 6 areas observed.
Cross Refer to Tag C0221

B. ensure that all essential patient care equipment was maintained in safe operating condition in 1 (Work Room/212) of 6 areas observed. Lead-acid batteries were observed to be charging in a confined area that was also in a patient care area of the hospital.
Cross Refer to Tag C0222

C. ensure that the commercial dumpster was secured to prevent scavenging by animals or humans.
Cross Refer to Tag C0223

D. ensure areas for drug storage were secured and had back-up temperature control for safe storage of medications in 3 of 3 drug storage areas (main pharmacy area, inpatient nursing medication room area, and Emergency Department storage area).
Cross Refer to Tag C0224


40989

Based on observation and interview the facility failed to maintain the building in a manner to assure the safety of patients, staff, and guests in 6 (Room 205, Janitor Room, Work Room/Room 212, Hallway between Medical Records and the Mechanical Room, Room 143 I.C.U. & Recovery/Room 5, and Dietary Department) of 6 areas observed.

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


A tour of the facility was conducted on 7/29/2019 after 12:30 PM with Staff #3 and #7.


Findings include:




ROOM 205

Room 205 was being used to store patient equipment and general supplies, (infant cribs, IV Poles, walkers for ambulation assistance, office supplies, and educational resources used to teach CPR classes). Observed two electrical outlets labeled #6 and #7 being used. Multiple extension cords with surge protectors were stretched across the floor to charge patient equipment creating a fall risk for all staff who enter. The electrical outlets were not covered with a plate and exposing the bare electrical socket and leaving an opening into the sheetrock. This hole was an opening for insects or rodents. The electrical sockets were being used to charge patient equipment. On the adjacent wall it was noted a plastic covering, above where the infant cribs were stored, was not secured to the wall and exposed a hole that was square in shape. This hole created an opening for insects or rodents. Under the hole were multiple holes and chipped paint exposing the sheetrock. Peeling paint was noted on the wall approximately 2 feet lateral from the multiple holes.

Staff #3 confirmed the above findings.



JANITOR ROOM

The door frame leading into the Janitor Room was chipped and missing paint exposing the metal. At the base of the doorframe the tile was noted to be broken and the floor was covered with heavy dirt and dust. Inside the room was coolers, trash liners, lids to waste receptacles, cleaning supplies, Styrofoam cups, and plastic utensils. The wall next to the wooden shelf where the cooler was stored was unfinished, bare wood baseboard. The wall was not painted and exposing the bare sheetrock. The wooden shelf the cooler was stored on was broken and had chipped paint. The base of the wall next to the metal shelf holding the styrofoam cups and plastic utensils was noted to be unpainted with no baseboard exposing the wood surface underneath. The base of the metal door frame was unpainted and exposing the metal.


WORK ROOM/ROOM 212

The lighting in this work room was very dim and flickered on and off. The inside of the light fixture cover was soiled with a dark brown stain. Multiple ceiling tiles were noted to have dark brown stains from a water leak. Above the door the ceiling tile around the vent was noted to have brown/green colored stains. Directly below the ceiling tile, on the floor, was a brown/green colored stain. There were three vents in the ceiling that were heavily soiled with dirt, dust, and debris. There was patient equipment that was used for ambulatory assistance, physical therapy equipment used for patients rehabilitation, and Mass Casualty Oxygen Manifold System also stored in this room. The inside of the light cover was heavily soiled with a greenish/brown stain. Behind the door the floor was covered with dirt, dust, debris, and new set of crutches for patients use. The knobs on the sink were noted to have rust colored stains. The vinyl trim on the doors of the cabinet, under the sink, were peeling away from the surface exposing the porous material underneath.




HALLWAY BETWEEN MEDICAL RECORDS AND MECHANICAL ROOM

At the end of the hallway near the EXIT sign, the ceiling tile was noted to have a large brown stain. Adjacent to that ceiling tile was a metal vent that was visibly soiled with dust and dirt. The metal vent did not completely cover the ceiling tiles and left an opening into the ceiling. This hole had the potential to allow rodents and insects to enter the building.


An interview was conducted with Staff #5 on 7/30/2019 at 3:50 PM. Staff #5 was asked about the ceiling tiles and if there had been a recent water leak. Staff #5 said, "The roof is only about 8-10 years old and it is still under warranty and we have to call them out here all the time. We replace ceiling tiles very frequently. The ceiling tile at the end of my hallway by the exit sign, I just replaced last week and needs to be replaced again already. The roofing company comes and repairs some spots on the roof."





143 I.C.U. & RECOVERY/ROOM 5

An observation was made that this room was labeled with two different room numbers. A hard-plastic sign affixed to the door read, "143 I.C.U. & Recovery." Below this sign was a piece of paper titled, "Room 5." The confusion of room numbers puts all patients, staff, and guests at a risk of cross contamination and the spread of infectious diseases. The thermostat inside the room did not have a cover over the front exposing all the dials and wires.




DIETARY DEPARTMENT

An observation tour of the Dietary Department was conducted on 7/30/2019 at 9:40 AM with Staff #4. Inside the storage room were multiple plastic bins with lids storing food and condiments for patients. The wall behind the shelf was missing paint and exposing the bare sheetrock. The vent was visibly soiled with dirt and dust. Two metal racks storing patient food items were noted to have rust on the legs and missing the top coating exposing the metal surface underneath. Inside the walk-in refrigerator, condensation was noted on the ceiling outside the freezer door. Water was dripping onto the floor just outside the freezer. Inside the freezer door, it was noted that the rubber seal around the door to maintain the adequate temperature was worn down and torn in several places. This could possibly cause the temperature to be out of range and not freeze food at the appropriate temperature placing all patients, staff, and guests at risk for food borne illnesses.


An interview was conducted on 7/30/2019 at 9:40 AM with Staff #4. Staff #4 was asked why there was condensation and water dripping onto the floor in front of the freezer door. Staff #4 stated he had asked for a replacement seal for the freezer several times, but nothing had been done yet. Staff #4 was asked if he could provide documentation where he requested the work order. No documentation was provided for review.


An interview was conducted on 7/30/2019 at 1:30 PM with Staff #11. Staff #11 was asked if she was aware of the seal on the freezer door being worn down and torn in several places. Staff #11 stated yes, she was aware of the problem and that she had discussed it with Staff #4 and the Plant Operations Director. Staff #11 also stated Staff #4 reported the problem on several occasions to the Plant Operations Director. No documentation was provided for review.

Based on observation and interview the facility failed to ensure that all essential patient care equipment was maintained in safe operating condition in 1 (Work Room/212) of 6 areas observed.


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


Findings include:


During a tour of the facility on 7/29/2019 after 3:50 PM with Staff #5 the following was observed in Room 212. The room was being used by Outpatient Therapy as a storage room for patient equipment. The room was small, narrow, and crowded with various therapy equipment being stored, as well as some emergency preparedness equipment that was infrequently used. Beside the sink were two black boxes with a battery charger on top labeled, "Automatic Sealed Lead Acid Battery Charger." Staff #5 was asked what the batteries were used for and why were they being stored in this room. Staff #5 stated, "I am not sure, but I think they go to the Emergency Preparedness stuff." The door was kept closed and locked, as it had access to a public hallway. These conditions prevented good airflow and the potential for the gasses released by the lead acid battery charging process to build up, creating an unsafe condition for patients, staff, and visitors.




A review of the "XENOTRONIX BRAND Model HPX60 Series Automatic Battery Charger User's Manual Rev.1.0 October 17, 2006" revealed:

" ...Page 1

DANGER-

Recharge batteries in well ventilated areas to prevent build-up of explosive gases.

Allow space around unit and adequate air circulation to reduce internal heat buildup. Do not operate in a small enclosed, enclosed spaces ..."


Staff #7 confirmed the batteries were for the Emergency Oxygen Manifold System and being recharged.

Based on observation and interview, the facility failed to ensure that the commercial dumpster was secured to prevent scavenging by animals or humans.



Findings included:


An observation tour was conducted on 7/30/2019 after 10:00 AM with Staff #5. This surveyor observed the commercial dumpster outside on the back lot was overflowing with trash, not covered, or secured. On further inspection of the dumpster area, old equipment (standing scale) was noted beside the commercial dumpster on the ground. The commercial dumpster area was not secure and was left open allowing animals or humans to hide or scavenge in the dumpster.


An interview was conducted on 7/20/2019 after 10:00 AM with Staff #5.
Staff #5 was asked why the dumpster was not closed or secured. Staff #5 said, "They only pick up twice a week and the lid won't close because it is too full."


Staff #5 confirmed the above findings.

Based on observation, review of records, and interview, the facility failed to ensure areas for drug storage were secured and had back-up temperature control for safe storage of medications in 3 of 3 drug storage areas (main pharmacy area, inpatient nursing medication room area, and Emergency Department storage area).


Findings included:

Upon entering the hospital on Monday, 7-29-2019, the room temperature felt uncomfortably warm. Staff #7 advised that the air conditioning had gone out on the previous Friday evening. Staff #7 stated that a chiller unit had been temporarily installed on Sunday afternoon, but was not functioning properly. Staff #7 advised that the air conditioning system was currently being worked on.

On 7-29-2019 a tour of the facility was made. Medication storage was observed to be in the main pharmacy area, an inpatient nursing medication room area, and inside of a cabinet in an Emergency Department treatment room. The temperature in all areas was noted to be uncomfortably warm and humid.

On 7-30-2019 at 9:06, an interview was conducted with Staff #19 while making an inspection of the main pharmacy area. Again, the room temperature was felt to be uncomfortably warm with high humidity. Staff #19 was asked how the temperature and humidity for medication storage areas was monitored. Staff #19 stated, "I've been through a lot of surveys, and I've never been asked that. What do you mean?" Staff #19 was shown an open bottle of Levothyroxine Sodium tablets (thyroid medication) that was in the inventory for dispensing to patients. Staff #19 was shown the information label on the bottle that read:

"Dispense in a tight, light-resistant container as defined the USP (USP - Unites States Pharmacopeia provides standards for medications) using a child-resistant closure.
Keep container tightly closed. Keep this and all medication out of the reach of children.
Store at 20C (68 to 77F).
[See USP Controlled Room Temperature.]
Protect from light and moisture.

Staff #19 was asked if medication room storage temperatures and humidity were monitored and recorded. Staff #19 was asked how she knew that the medications being stored had not been stored above required temperatures since the air conditioning had not been working since the previous Friday. Staff #19 stated she had never monitored for temperature and humidity and that she did not know how high the temperature had reached while the air conditioning system had been out. Staff #19 stated the medication bottles have little containers of material to absorb moisture inside of them. Staff #19 was asked how she knew the container of material to absorb moisture had not reached their capacity for absorption and were still effective. Staff #19 stated she did not know.

Laboratory staff was found to be monitoring the temperature in the Inpatient Nursing Medication Storage Area since they also stored Lab supplies in there. Review of the Temperature Logs showed that the temperature for that area had exceeded the recommended storage temperatures for the IV fluids stored in there from 7-27-2019 through 7-29-2019.

An inspection of the Inpatient Nursing Medication Storage Area on 7-30-2019 was made. A medication refrigerator was observed to have a plastic container inside of it. On top of the plastic container was a puddle of liquid. Staff #19 was asked if there was a problem with leaks. Staff #19 explained the liquid was condensation from the high humidity. Staff #19 stated when the refrigerator door was opened and closed frequently, the high humidity from the warm room condensed on the cool plastic to form the puddle of liquid observed.

The facility had no plan for back-up temperature control for stored medications when the heating and air conditioning systems were inoperable, as they were not aware that they were required to store medications in a controlled environment and had not been monitoring for such.

During the tour of the Emergency department it was observed that medications were being stored in a patient treatment room cabinet. The cabinet was unlocked and found to contain a variety of intravenous (IV) fluids to be administered to patients. The cabinet was found to be unlocked and without a way to lock it. This allowed patients and visitors access to medications while they were in the room without staff present. This room was left open when no patients were using it, allowing all staff of the hospital and the public access to these medications when the area was left unattended. This unsafe condition exposed medications to possible tampering or removal by unauthorized persons.

During a tour of the Inpatient Nursing Medication Storage area, an unsecured drawer was opened and key to the main pharmacy was found laying inside. Staff #19 confirmed that this was the key so that nursing staff could access the pharmacy after hours if needed. The after-hours access was supposed to be controlled with limited access only to staff on the approved authorization list. The Inpatient Nursing Medication Storage area had a code-pad lock on it, preventing the public from entering the room. However, hospital staff other than nursing had access to the room. This included housekeepers, maintenance staff, patient care technicians, and laboratory staff. Everyone who had access to the room also had access to the keys to the main pharmacy.

Review of Sabine County Hospital policy; Subject: Medication Storage; Originated Date: 4/2009; Current Reviewed/Revised Date: (blank); was as follows:

"Purpose:
To provide for the appropriate and safe storage of medications.

Policy:
...
2. Medications will be stored as per manufacturer's recommendations to ensure stability.

3. Medications are secured in accordance to the hospital's policies and law and regulation so that unauthorized persons cannot obtain access to them. Medications will either be locked or under constant observation.

4. Controlled substances are stored to prevent diversion and according to state and federal laws and regulations. See Sabine County Hospital's policy on Controlled Drugs and Controlled Drugs at Nurses Station.

...."


32143

Medication Room-

On 7/31/19 observation of the medication room where medications were stored revealed it was unlocked. Housekeeping, maintenance and a certified nurses aide had entered the room unsupervised. Upon entering the room on 7/31/19 at 11:17 AM the door to the medication refrigerator was open. A drawer labeled Ativan 2mg/ml vials were easily accessible to the surveyor. 14 vials were unsecured in an unsecured medication room.

Ativan is a benzodiazepines class IV scheduled drug. Drugs listed in Schedules II, III, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970 shall be kept locked within a secure area.

Staff #3 confirmed that the room was accessible by anyone in the building and the Ativan was not secured and locked.

Based on review and interview Nursing failed to have sufficient nursing staff available for the Emergency Department(ED) and Inpatient Areas. An Registered Nurse (RN) was not always immediately available to provide care to patients in 2 (Inpatient and ED) of 2 units.

A tour of the facility was conducted on 7/29/19. The tour revealed there was an Emergency Department (ED) on one end of the building and an inpatient /swing bed area on the other end. A large nurses desk was found on the inpatient side. There were two Registered Nurses (RN), 1 Licensed Vocational Nurse (LVN) and 1 Certified Nurse Aide (CNA). There was no nurse in the ED due to no patients at that time.

An interview was conducted on 7/29/19 with Staff #26 (RN),27 (RN), and 32 (LVN). Staff #27 was asked who was assigned to the ED? Staff #27 reported that no one was assigned "officially" to the ED. Staff #27 was asked when a patient presents to the ED who goes to care for the patient. Staff #26 stated that both RN's go to check in the patient. Staff #27 agreed. Staff #32 was asked who was left on the inpatient area to monitor and care for the patients if both RN's go to the ED? Staff #32 reported that she was and a CNA. Staff #32 asked if this is a current occurrence and Staff # 32 stated, "yeah, I guess. I mean we can call if we need somebody." Staff #32 was asked if she was left unsupervised on the floor for any length of time and Staff #32 stated, "yes." Staff #32 was asked if she was ever alone on the unit and she stated, "yes." Staff #32 was asked how would she call for help if she was with a patient in distress? Staff #32 reported that she would have to leave the patient to call for help. Staff #26, 27 and 32 was asked if a patient came in on a code blue and there was no physician or practitioner in the building, who would respond? Staff #26 stated they would all have to respond and take care of the patient to the best of their ability. Staff #27 and 32 confirmed they would all repond if needed.

Review of the Staffing Matrix revealed there was no staffing ratio for each unit. The staffing ratio was for the hospital in general.

An interview was conducted with Staff #3 on 7/29/19. Staff #3 was asked if she was aware that the RN's would go together to the ED leaving only an LVN and possibly a CNA on the floor, monitoring patients, unsupervised by an RN. Staff #3 stated that there were other RN's in the building including herself that could assist if needed. Staff #3 was asked if those RN's were always accessible for "immediate availability?" Staff #3 stated she could not ensure that. Staff #3 was asked if the RN's clock out for lunch at the same time. Staff #3 stated that has been a problem getting the staff to clock in and out for their lunch breaks. Staff #3 was unable to monitor if both RN's were on break at the same time since the staff had not been compliant.

Review of the Staffing Matrix revealed if there was 4 patients in the facility the staffing ration was 2 RN's and 1 LVN. The matrix revealed there would be a 2 RN minimum until the patient ration was over 15.

Based on observation, document review, and interview the facility failed to:

A. ensure pharmacy staff maintained a safe and sanitary environment for storing and repackaging medications. Pharmacy staff failed to monitor storage areas for proper temperature control and excessive humidity; store repackaging materials in a manner that prevented their contamination; and provide a sanitary environment for repackaging and preparing medications.
Cross Refer to Tag C0276

B. maintain a clean and sanitary environment to ensure patient's health, safety and mitigate risks of possible hospital acquired infections, transmissions of infectious diseases, and communicable diseases in 10 (Clean Linen Room, Room 143/I.C.U. & Recovery, Room 181, Room 212, Emergency Room (ER) 1, and Emergency Room 2, bio hazard, Laboratory, Inpatient Area, and Crash Carts) of 10 areas observed. Findings included the facility failed to:

1. maintain a clean and sanitary environment to ensure patient's health, safety and mitigate risks of possible hospital acquired infections in 6 (Clean Linen Room, Room 143/I.C.U. & Recovery, Room 181, Room 212, Emergency Room (ER) 1, and Emergency Room 2) of 6 areas observed.
2. ensure supplies that were readily available for patient use were not expired in 2 (Emergency Room 1 and Emergency Room 2) of 2 areas observed.
3. ensure multi-dose vials were not used for more than one patient and not stored or accessed in the immediate patient treatment area in 1 (Emergency Room 1 and Emergency Room 2) of 2 areas observed.
4. ensure a qualified candidate, by education and training, was appointed as the infection control nurse for the infection prevention and control program.
Cross Refer to Tag C0278


C. maintain a complete list of contracted services with a description of the nature and scope of services provided.
Cross Refer to Tag C0291

D. appropriately evaluate services provided by contract or under arrangement for quality of services that allowed the hospital to comply with all applicable Conditions of Participation (CoP).
Cross Refer to Tag C0292

E.
1. ensure 2 (#13 and #14) of 2 patients that received anesthesia services were provided care in a safe manner by qualified personnel.
2. have a signed patient consent for anesthesia in 1(#13) of 2 (#13 and #14) charts reviewed.
3. have training on conscious/ moderate sedation specific to the hospital or its policy and procedures in 2(#13 and #14) of 2 charts reviewed.
4. have physician orders for the titrated Propofol or IV push. There was no documentation that any physician was present during the procedure, assessment of the patient, or administered moderate sedation by a physician in 2(#13 and #14) of 2 patient charts reviewed.
Cross Refer to Tag C0297

F.
1. have a developed and ongoing care plan in 2 (#8, 13) of 4 (#8,9,13 and 15) patient charts reviewed.
2. have a nursing care plan assessing the patient's nursing care needs (not solely those needs related to the admitting diagnosis) The care plans failed to reveal what changes the patient had, how those changes were addressed, what actions were put into place, and goals for those actions in 2 (#15, #9) of 4 (#8,9,13 and 15) patient charts reviewed.
Cross Refer to Tag C0298


40989

Based on observation, review of records, and interview, the facility failed to ensure pharmacy staff maintained a safe and sanitary environment for storing and repackaging medications. Pharmacy staff failed to monitor storage areas for proper temperature control and excessive humidity; store repackaging materials in a manner that prevented their contamination; and provide a sanitary environment for repackaging and preparing medications.

Finings included:

On the morning of 7-30-2019 a tour of the pharmacy was made. Plastic bins containing medications and supplies were observed to be visibly dusty and soiled.

An area for repackaging medications was located at the back of the pharmacy. A drawer was opened to reveal plastic containers for repackaging bulk medications into individual doses. The plastic containers were not in any protective wrapper and laying loose in the drawer. The individual pockets to place medications in were exposed in way that contaminants from the counter top, dust, dirt, and debris could collect in the individual pockets.

Syringes for repackaging individual liquid doses were observed to be in opened plastic bags in the same drawer as the plastic individual dose containers. Syringes were observed to have spilled out of the bag and lying loose in the drawer. The top lip of the drawer was observed to visibly dirty. The inside of the drawer was observed to visibly dirty with tape and labels stuck to the side and bottom of the drawer.

The medication preparation area was next to a sink. The cabinet door to the under-sink area was visibly soiled with dried spills. The cabinet area under the sink was heavily soiled with black matter. During interview, Staff #19 stated that the area had recently had a leak, but had been cleaned. However, the black matter was observed to be easily picked up with a wet sanitary wiping cloth. On the counter-top, between the sink and preparation area were a portable fire-extinguisher, bottle of hand soap, containers of chemical wipes, plastic cups stacked inside of each other that Staff #19 stated were used to water plants, a small trash can on top of medication disposal boxes, and an opened sharps container that was visibly soiled around the lid with dried spills of unknown substances. These items all presented potential sources of contamination to the medication preparation and packaging area. A broom and dustpan were propped up against the wall in a manner that broom handle was on the floor and the dirty broom head and dustpan were up against the wall at the approximate 4-foot height. This allowed for dust and dirt particles to be stirred up and drift into the medication preparation and packaging area when staff were working in the area.

The temperature was felt to be uncomfortable warm in the pharmacy area with high humidity. The air conditioning system had not been working since the previous Friday. Interview with Staff #19 revealed that the pharmacy staff did not monitor temperature and humidity in any of the medication storage areas. Staff #19 confirmed that she did not know it was required. Staff #19 was shown an open bottle of medication from a medication bin the pharmacy that read, "Store at 20 to 25C (69 to 77F). [See USP Controlled Room Temperature.] Protect from light and moisture." (USP - United States Pharmacopia)

When Staff #19 was asked how she was protecting the open bottle of medication from high humidity, Staff #19 stated the medication had a packet inside of material that protected it from moisture. Some medications were shipped with packets of desiccant (a material that absorbs moisture) in them. However, in high moisture environments, the desiccant material could reach its capacity for absorption and, because it had become saturated, become a source of moisture that could degrade the medication it was placed with. Staff #19 was asked if she was able to tell if the desiccant packet in the medication bottle was still effective or if it had reached it maximum capacity for absorption due to the prolonged high humidity in the pharmacy. Staff #19 stated she was not able to tell if the desiccant packets were still working.

Review of the USP Controlled Room Temperature was as follows:

"Controlled room temperature: The temperature maintained thermostatically that encompasses the usual and customary working environment of 20°-25° (68°-77° F). The following conditions also apply. Mean kinetic temperature not to exceed 25°. Excursions between 15° and 30° (59° and 86° F) that are experienced in pharmacies, hospitals, and warehouses, and during shipping are allowed. Provided the mean kinetic temperature does not exceed 25°, transient spikes up to 40° are permitted as long as they do not exceed 24 h. Spikes above 40° may be permitted only if the manufacturer so instructs. Articles may be labeled for storage at "controlled room temperature" or at "20°-25°", or other wording based on the same mean kinetic temperature [see also Good Storage and Distribution Practices for Drug Products ?1079?, Quality Management System, Environmental Management System, Mean Kinetic Temperature (MKT) Calculation]."

Review of USP 36, General Information / <1079> Good Storage and Shipping Practices reveal the following:

"The MKT is the single calculated temperature at which the total amount of degradation over a particular period is equal to the sum of the individual degradations that would occur at various temperatures. MKT may be considered as an isothermal storage temperature that simulates the non-isothermal effects of storage temperature variation. It is not a simple arithmetic mean.

...

For dispensing sites, such as pharmacies and hospitals, where the use of such instruments may not be feasible, devices such as high-low thermometers capable of indicating weekly high and low temperatures may be employed. The arithmetic mean of the weekly high and low temperatures is then used in the calculation of MKT. MKT is calculated by the following equation (derived from the Arrhenius equation):"

USP 36 stated the following about excursions outside of the temperature range:

"Temperature excursions for brief periods outside of respective storage label conditions may be acceptable provided stability data and scientific/technical justification exists demonstrating that product quality is not affected ..."

Interview was conducted with the consulting pharmacist, Staff #21. Staff #21 confirmed he was responsible for the management of the pharmacy. Staff #21 confirmed that the pharmacy used USP guidelines for managing the pharmacy. Staff #21 confirmed he was not monitoring temperatures in the pharmacy or other medication storage areas in the hospital.

Based on observation, document review, and interview the facility failed to maintain a clean and sanitary environment to ensure patient's health, safety and mitigate risks of possible hospital acquired infections, transmissions of infectious diseases, and communicable diseases in 10 (Clean Linen Room, Room 143/I.C.U. & Recovery, Room 181, Room 212, Emergency Room (ER) 1, and Emergency Room 2, bio hazard, Laboratory, Inpatient Area, and Crash Carts) of 10 areas observed.


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


Findings include:




CLEAN LINEN ROOM

An observation tour with Staff #3 and #7 was conducted on 7/29/2019 at 1:45 PM. Inside the room labeled "CLEAN LINEN" were multiple 5 tier metal framed shelves. The base of each shelf was a solid porous surface that was unpainted or sealed with a coating that could be sanitized. These shelves stored clean linen and laundry for patients. The linen and laundry were noted to be uncovered and exposed to environmental hazards. The cover to the light fixture in the ceiling was noted to have large brown spots next to the surface. Inside this room was a bathroom that had a bathtub. Stored in the bathtub was old metal bed rails covered with dirt, dust, and debris. Under the metal poles there was dirt, dust, debris, and dead insects. There was an open corrugated box placed on top of the metal rails and was noted to have new pillows used for patient care. On the floor next to the bathtub this surveyor observed pieces of wood and metal poles. The floor was covered with heavy dark brown dirt, dust, and debris. This room was not a safe and sanitary location to store clean patient linen and laundry.

Staff #3 confirmed the above findings.



ROOM 143/I.C.U. & RECOVERY/ROOM 5

On 7/31/2019 after 1:30 an observation tour was conducted with Staff #1. Staff #1 was asked if this room was ready for a new patient. Staff #1 said, "Yes." Inside the bathtub was a large brown stain around the drain. On the base of the toilet was a brown spot next to the exposed bolt. The caulking around the base of the toilet next to the floor was soiled with dirt, dust, and debris. The wall behind the toilet was noted to have chipped paint and exposing the bare sheetrock. The porous surface cannot be properly sanitized to ensure patients aren't exposed to infectious diseases. The slide out recliner in the room was noted to have chipped wood on the arm rest. Under the foot rest was heavily soiled with dirt, dust, and debris. Sheets on the bed were noted to have holes in them and the pillow covering was torn completely across the top. Under the handrails of each side of the bed, dust, dirt, and human hair were noted. The metal door frame was missing paint and exposing the metal underneath. The metal surface cannot be properly sanitized to prevent the transmission of diseases.

Staff #1 confirmed the above findings.


ROOM 181

The clean sheets on the bed were noted to have multiple holes. Staff #1 was asked if this room was ready to receive a new patient. Staff #1 replied, "Yes." Under the foot rest on the recliner there was a dry white substance. The foot rest was also visibly noted with heavy dirt and dust. On the wall where the hand sanitizer hung, the wall was unpainted and torn exposing the underlying porous surface. This porous surface could not be properly sanitized to prevent the transmission of infectious diseases. On the bottom of the IV Pole, the coating on the metal was missing and exposing the metal surface. The metal surface cannot be properly sanitized.

Staff #1 confirmed the above findings.


WORK ROOM/ROOM 212

An observation tour was conducted on 7/30/2019 with Staff #5. Room 212 was next to the Physical Therapy Room. The room was filled with patient physical rehab equipment, ambulatory assistive devices, oxygen tank and Mass Casualty Oxygen Manifold System. The counter top was visibly soiled with heavy dust and dirt. Single use patient drapes were noted on the countertop. New hand-held patient weights used for rehabilitation strength were noted in a corrugated box sitting on the floor. There were disposable plates and utensils on the counter top stored in a plastic bag next to the sink. The ceiling tile above the door, around the vent, was noted to have a green/brown stain and directly beneath it, on the floor, there was the same colored stain. Behind the door, the floor was noted to be heavily soiled with dirt, dust, and debris. Lying behind the door, on the floor, was a new pair of crutches still wrapped partially in plastic. The metal waste receptacle was rusted and did not provide a lid to secure the trash. The sink knobs were noted to have a brown colored substance inside the handles. This is the same room that stored the lead acid batteries exposing environmental hazards to all staff and patients. The room was so cluttered it could not be properly sanitized to avoid sources and transmission of infections onto the stored patient equipment readily available for patient use.

Staff #5 confirmed the above findings.



EMERGENCY ROOM #1

An observation tour of the Emergency department was conducted on 8/1/2019 after 12:00 PM with Staff #2. The door to this room was open and accessible from the hallway to all patients and staff. Patient supplies were stored in the unlocked cabinet. There were sutures (sterile needle and thread used to sew a laceration) stored in this cabinet readily available for patient use that were expired. 23 sutures were removed from the cabinet that expired in July 2019. Staff #2 was asked if she was aware the sutures were expired and she replied,"NO." In the adjacent cabinet there was Ammonia Inhalant (a smelling salt used to revive someone suffering a fainting spell) that expired 6/2019. There were test strips used to test a female's water for amniotic fluid (leaking fluid that could indicate active labor in a female patient) stored and ready for patient use that showed an expiration date of 7-15-16. On top of the counter were 4 yellow top and 4 red top blood tubes (used to draw patients' blood) with an expiration date July 2019.


EMERGENCY ROOM #2

An observation tour of the Emergency department was conducted on 8/1/2019 after 12:00 PM with Staff #2. The door to this room was open and accessible from the hallway to all patients and staff. Patient supplies were stored in the unlocked cabinet. There were sutures (sterile needle and thread used to sew a laceration) stored in this cabinet readily available for patient use that were expired. 68 sutures were removed from the cabinet that expired in July 2019. Staff #2 was asked if she was aware the sutures were expired and she replied,"NO." . On top of the counter were 8 yellow top blood tubes (used to draw patients' blood) with an expiration date July 2019. Next to the blood tubes was a multi dose vial of 1% Lidocaine with Epinephrine. Multi dose vials of medication must be discarded if it enters the immediate treatment area and cannot be used for multiple patients.

Staff #2 was asked how often the staff monitor for expired supplies. Staff #2 stated, "We have assigned areas monthly and we look for expired supplies. If items are going to expire that month we usually remove them and have them replaced at that time."

Staff #2 confirmed the above findings.


An interview was conducted with Staff #1 on 7/29/2019 after 2:00 PM. Staff #1 was asked if she had any specific training for infection control monitoring. Staff #1 stated, "No, I don't have specific training, but we went to a seminar about hospital required reporting last week. I am training Staff #2 for the Infection Control Nurse position as I will be leaving to attend school full time." Staff #1 was asked how often infection control rounds were made to ensure the facility maintains a clean and sanitary environment for patient and staff safety. Staff #1 stated, "I make quarterly rounds on the patient units."

A review of the document titled, "PATIENT UNIT INFECTION CONTROL SITE VISIT" revealed there were no rounds made for infection control between 4/16/2018 and 2/4/2019.

The facility failed to have a designated individual that was qualified by education or experience responsible for the infection control program


A review of Staff #1's employee file did not reveal any training or education in Infection Control.


32143

Biohazard Storage

During a tour of the facility on 7/29/19 at 2:35 PM revealed a biohazard room. Inside the room was two wooden pallets on a heavily soiled floor. On top of the pallets were biohazard cardboard boxes with biohazard trash inside the red bags. underneath the pallets was soiled flooring with dried spilled waste.

In the same room a wooden pallet was found by the window with clean biohazard boxes and bags that would be used inside a patients room. The drain in the floor was heavily covered in dirt. A large standing patient weight scale was sitting in the room. The room had blinds on the window covered in dirt, dust and hair.

An interview with housekeeping on 7/29/19 confirmed that the facility was storing clean biohazard boxes and bags in the same room with soiled and contaminated trash.


Laboratory

During a tour of the Laboratory on 7/30/19 at 10:21 revealed a wooden pallet laying on the floor under the desk. The pallet is made of porous wood and is unable to be cleaned. The floor underneath the pallet was heavily soiled with dust and dirt.

A large air conditioning unit was found attached to the wall. The air conditioner was soiled with dust and was blowing across the laboratory testing area.

The work space for laboratory testing was very small with limited work space. The counters were cluttered and soiled with dust.

The sink in the lab was soiled with stains, and hard water build up around the faucets. The calcium and rust build up cannot be properly cleaned.

Metal blood tube holders were found to be heavily rusted.


Crash Carts
2 Crash carts in the ED were found to be heavily soiled with dust, dirt and hair on the top and inside the drawers.
1 Adult crash Cart on the inpatient floor was soiled with dust and hair.


Inpatient Area

The nurses desk was made of wood. The desk had multiple worn areas and exposed wood harbors germs and bacteria. The desk was so high that it impaired the vision of the nurses to properly see the unit and patients.

The ante room attached to the isolation room was found to have multiple bags of biohazard waste sitting on the floor. The bags were opened and some were closed. The opened bags were sitting next to opened clean patient supplies used to gown up before going into an isolation room.

Based on review of records and interview, the facility failed to maintain a complete list of contracted services with a description of the nature and scope of services provided.

Findings included:

The facility provided a list titled, 'Master Contract "Overall" Eval Spreadsheet Sabine County Hospital'. Review of the list showed that it contained a column titled "Contractor" and an evaluation column for 2017, 2018, and 2019. Review of the list for Pharmacy did not include services provided by the consulting pharmacist who managed the hospital's pharmacy. Review of the contracted services did not include a dentist or the organ procurement organization.

Staff #7 was asked to provide a complete list of contractors with the required information. Staff #7 stated that was the only list he had. The list failed to describe the services offered, the individual or entity providing the service, whether the services were offered on- or off-site, any limits on the volume or frequency of the service, or when the services were available.

Based on review of records and interview, the Chief Executive Officer (CEO) failed to appropriately evaluate services provided by contract or under arrangement for quality of services that allowed the hospital to comply with all applicable Conditions of Participation (CoP).

The facility provided a list titled, 'Master Contract "Overall" Eval Spreadsheet Sabine County Hospital'. Review of the list showed that it contained a column titled "Contractor" and an evaluation column for 2017, 2018, and 2019. Review of the list for Pharmacy did not include services provided by the consulting pharmacist who managed the hospital's pharmacy.

The evaluation columns for the contracted services listed stated if the service was Satisfactory, Unsatisfactory, or N/A for the year being evaluated. The CEO was asked for the actual evaluations and the criteria each were being evaluated with. The CEO stated that the evaluations reported on the list (Satisfactory, Unsatisfactory, N/A) was the entire evaluation process. When asked how he determined if a service was satisfactory or not, he replied, "If I'm happy with them, they were satisfactory." The CEO confirmed that objective criteria for quality of services were not developed for any of the contracted services.

Based on record review and interview, the facility failed to:
A. ensure 2 (#13 and #14) of 2 patients that received anesthesia services were provided care in a safe manner by qualified personnel.
B. have a signed patient consent for anesthesia in 1(#13) of 2 (#13 and #14) charts reviewed.
C. have training on conscious/ moderate sedation specific to the hospital or its policy and procedures in 2(#13 and #14) of 2 charts reviewed.
D. have physician orders for the titrated Propofol or IV push. There was no documentation that any physician was present during the procedure, assessment of the patient, or administered moderate sedation by a physician in 2(#13 and #14) of 2 patient charts reviewed.

Patient #13
Review of Patient #13's chart revealed she was a 69-year-old admitted to the ED on 10/3/18 at 9:20 AM. Patient #13 had an anterior dislocation of the left shoulder.
Review of the providers ED notes dated 10/03/18 at 13:45 (1:45 PM) revealed the following:
"Course of Care: Demerol 75 mg with Phenergan 12.5 mg IM given. Sedative drug warning given to patient. Morphine 5mg 1VP given. Sedative drug warning given to patient. We spoke about the likelihood of needing transfer for orthopedic services. She states she would prefer Memorial in Lufkin.
spoke with Dr. ______, orthopedics, via SMS. He has received CT images and X-rays. He now received post reduction films and confirms her outpatient appointment tomorrow AM at his clinic. Pt and I spoke about this and expressed understanding 15:01 and agreement. Patient is stable. Symptoms much better.
1345 Propofol initiated after Pt review for conscious sedation performed and pt agreed to procedure. Dr. ____ (Staff #12) arrive at this time.
Propofol induction performed 1345 and first attempt at reduction performed. Post procedure films obtained and confirmed still dislocated. Second induction performed and Propofol titrated for effect. Second reduction performed with success. Post reduction films obtained and confirmed. Propofol was discontinued at 1432. Norco 5mg PO given. Sedative drug warning given to the patient. Norco 5mg PO given. Sedative drug warning given to the patient."

Review of the chart revealed there was no consent for a conscious sedation procedure signed by the patient or physician. Review of the patients consents to treat had no date or time of signatures.

Review of the Procedural Sedation H&P/T-sheet dated 10-3-19 revealed the Staff #29 (PA) completed the pre-procedure examination at 1345. The post -procedure assessment was also done by Staff #29 revealed he left the "Adverse Events During Sedation" and there was no time documented upon completion.
Review of the flow sheet conscious sedation had no date. The signature in the nurse's notes were not legible nor was the discipline. The note documentation was as follows:
"1357- Propofol 8 mg IVP by Dr. _____ (Staff #12)
1408- Propofol drip @ 12 ml
1410- Propofol 25 IVP by ___ (Staff #29)
1425- Propofol titrated to (illegible)
1430- Propofol titrated to 120ml/hr
1431- Propofol 16 mg IVP by ___ (Staff #29)
1432- Propofol stopped.
1433- Post reduction film completed."

Review of the policy and procedure "Propofol Infusion" stated, "A Bolus of Propofol ONLY to be administered by Physician."

There was only one order written for Propofol dated 10/3/18 at 1345. The order revealed, "Propofol 200mg/20ml Intravenous once." There were no orders for the 8 mg, 25 mg, or 16 mg IV push. There was no physician order for the titrated Propofol. There was no documentation that any physician was present during the procedure, assessed the patient, or administered moderate sedation.

Review of the policy and procedure "Propofol Infusion" stated, "13. Documentation:
b) the patient level of sedation is indicated by the RASS will be recorded with each titration and then at least every two to four hours once stable (and more often as patient's condition warrants) on vital sign flow sheet of the EMR, Nurses Notes under the short name RASS.
c) Richmond Agitation Scale (RASS)."

There was no documentation of the patient's conscious state during the medication administration and during procedure. There was no found documentation of the RASS score.
Review of insert For "Propofol Injectable Emulsion, USP, for INTRAVENOUS ADMINISTRATION" revealed the following:

"WARNINGS
Use of Propofol injectable emulsion has been associated with both fatal and life-threatening anaphylactic and anaphylactoid reactions. For general anesthesia or monitored anesthesia care (MAC) sedation, propofol injectable emulsion should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure. Sedated patients should be continuously monitored, and the facilities for maintenance of a patent airway, providing artificial ventilation, administering supplemental oxygen, and instituting cardiovascular resuscitation must be immediately available. Patients should be continuously monitored for early signs of hypotension, apnea, airway obstruction, and/or oxygen desaturation. These cardiorespiratory effects are more likely to occur following rapid bolus administration, especially in the elderly, debilitated, or ASA PSIII or IV patients ..."

Patient #14
Review of Patient #14's chart revealed she was a 58-year-old female that admitted to the ED on 3/8/19 at 7:55 AM with a right anterior shoulder dislocation. Patient #14 was examined by Staff #31 (PA). Review of the Physician Clinical Report dated 3/8/19 at 1438 stated, "Medications: Versed IV administered by nurse. Patient status during sedation was attended constantly, was cooperative and oriented and responded only to verbal commands. Sedation and procedure performed by me. Intra service time 10-22 minutes." Review of the chart revealed there was no physician order for Versed.

Versed (midazolam) is a drug usually used for pre-anesthesia sedation and for procedural sedation for children. It is a benzodiazepine and a central nervous system depressant.

Review of the nurse's notes dated 3/8/19 at 10:45AM revealed the Staff #26 RN administered Versed 5 mg IV push.

Review of the policy and procedure "conscious sedation" stated, "Inter-procedure:
1. All medication used for conscious sedation shall be titrated to the effect desired as described per physician. The following doses are recommended guidelines and may be modified by the provider according to patient circumstance, judgment, and practice of the individual prescribing provider.

2. The licensed professional registered nurse who manages the care of the patient must demonstrate competency to administer and monitor IV conscious sedation and is required to:
a) Be familiar with proper dosages, administration, adverse reactions, and interventions for adverse reactions and overdose.
b) Know how to recognize an airway obstruction and demonstrate skills in basic life support.
c) Assess total patient care requirements or parameters, including but not limited to respiratory rate, oxygen saturation, blood pressure, cardiac rate, pulse rate and level of consciousness.
d) Have the knowledge and skill to intervene in the event of a complication.
e) Have initial "on-hire" assessment and annual competency evaluation and validation.
f) Be familiar with the attached adult and pediatric drug guidelines."

Review of the conscious sedation policy and procedure had a packet attached of required forms to be used when documenting the conscious sedation as follows:
"The procedural sedation sheet
Sedation care record
Recovery Assessment
Flow sheet
Patient Education conscious sedation for adults." The packet materials were not found in Patient #14's chart.

An interview was conducted with Staff #3 and Staff #26 on 7/30/19. Staff #3 stated the staff nurses had taken an online course on conscious sedation through health streams but did not have any clinical check offs. There was competencies performed on the nurses knowledge in administering or the policy and procedure for administration of a conscious sedation medication. Staff #26 stated she had no training at the facility in administering a conscious sedation medication. Staff #26 stated she had taken an online HealthStream education on conscious sedation but had no training specific to the facility or policy.

Based on record review and interview, Nursing failed to:

a. have a developed and ongoing care plan in 2 (#8, 13) of 4 (#8,9,13 and 15) patient charts reviewed.

b. have a nursing care plan assessing the patient's nursing care needs (not solely those needs related to the admitting diagnosis) The care plans failed to reveal what changes the patient had, how those changes were addressed, what actions were put into place, and goals for those actions in 2 (#15, #9) of 4 (#8,9,13 and 15) patient charts reviewed.

Review of Patient #15's chart revealed he was admitted on 3/26/19 with pneumonia and required blood transfusions. Review of the chart revealed a care plan dated 3/26/19 that addressed chest pain, coughing, fatigue, fever, shortness of breath and wheezing. There were no goals for any interventions documented. The patient received blood transfusions. The transfusions were never addressed in the care plan.

Review of Patient #9's chart revealed she was admitted on 7/9/19 to swing bed status. The care plan revealed it was initiated on 7/2/19, 7 days prior to the admission. Patient #9 had a previous admission on 7/2/19 due to Anemia and received blood transfusions and was discharged on 7/8/19. The patient was readmitted to swing bed status on 7/9/19 but the care plan was not restarted and reevaluated to address her new medical issues that brought her to the ED. A new care plan was not initiated.

Based on review of records and interview, the facility failed to ensure records were accurately documented by the staff providing services in 1 of 1 patient records (Patient #7) reviewed in which the patient was provided care during computer down-time. False information was added to the Electronic Medical Record (EMR) by staff not present during patient care in order to facilitate billing of the third party payer for services and supplies.

Findings included:

During review of Patient #7's record on 8-2-2019, it was noted that part of the documentation was hand written on a treatment sheet (T-sheet) form. The record also contained the same information in the computerized Electronic Medical Record (EMR).

Upon review of the EMR as compared to the T-sheet, it was noted that Staff #23 was the Emergency Room (ER) nurse on duty on 7-10-2019 when Patient #7 arrived to the ER. Staff #23 documented that patient care began at 2214 (10:14 PM care time) when the patient arrived by ambulance. The EMR noted that this entry was entered into the computer system by Staff #23 at 2239 (10:39 PM documentation time).

At 22:30 (10:30 PM care time) 7-10-2019, a patient care entry was documented the next day at 11:35 AM on 7-11-2019 (documentation time) by Staff #1. Records indicated that Patient #7 had expired on 7-11-2019 at 0137 (1:37 AM). The note read as follows:

"22:30 07/10/2019 Site #2 started via IV in the right wrist with an 20g angiocath; one attempt. Saline lock flushed with 10ml saline (Per ___ ___ [Staff #24's name written in chart] - system down- help charting - see scanned in documents). -11:53 7/11/19 ____ ____ [Staff #1's name written in chart]" When compared to the T-sheet, no documentation was found stating the "Saline lock flushed with 10 ml saline."

Other notes entered into the EMR by Staff #1 after the patient had expired included:

"22:40 07/10/2019 Site #3 started via IV in the right antecubital space with an 18g angiocath; one attempt. Saline lock flushed with 10 ml saline (started per ___ ___ [Staff #24's name written in chart]). -11:55 7/11/19 ___ ___ [Staff #1's name written in chart]" When compared to the T-sheet, no documentation was found stating the "Saline lock flushed with 10 ml saline."

"22:50 07/10/19 Started bag #2 1000 ml IV Fluids IV NS; at 1000 ml/hr via site #2 via IV pump. Allergies verified and confirmed 5 rights. IV patency established. IV site checked; no pain, redness, or swelling. IV flushed thoroughly pre- and post-medication administration. Information reviewed with family. - 12:07 7/11/19 ___ ___ [Staff #1's name written in chart]" When compared to the T-sheet, no documentation was found stating that the second bag of IV fluid was connect to site #2 or that an IV pump was used. No documentation was found on the T-sheet that said, "Allergies verified and confirmed 5 rights. IV patency established. IV site checked; no pain, redness, or swelling. IV flushed thoroughly pre- and post-medication administration. Information reviewed with family."

"22:50 07/10/2019 Started bag #3 1000 ml IV Fluids IV NS: at 1000 ml/hr via site #1. Allergies verified and confirmed 5 rights. IV patency established. IV site checked: no pain, redness, or swelling. IV flushed thoroughly pre- and post-medication administration. Information reviewed with family. - 12:09 7/11/19 ___ ___ [Staff #1's name written in chart]" When compared to the T-sheet and previous EMR records, it was found that the T-sheet did not specify what IV site bag #3 of IV fluids had been connected to. Staff #23 had documented in the EMR that the bag #1 of IV fluids had been connected to site #1 at 22:46 and the T-sheet indicated that the fluid was not stopped until 23:00. Therefore, bag #3 could not have been connected to site #1 as documented by Staff #1. Further review of the T-sheet showed no documentation that a pump was used or that "Allergies verified and confirmed 5 rights. IV patency established. IV site checked: no pain, redness, or swelling. IV flushed thoroughly pre- and post-medication administration. Information reviewed with family." as documented by Staff #1.

"23:00 07/10/2019 IV Fluids IV NS via IV site #1 Discontinued: bag #1 completed upon arrival. Total amount infused 1000 mL. IV flushed thoroughly (per ___ ___ [Staff #23's name written in chart]- system down- see chart sheet). -12:05 7/11/19 ___ ___ [Staff #1's name written in chart]" Review of the T-sheet (chart sheet) showed no documentation by Staff #23 of "bag #1 completed upon arrival" or "IV flushed thoroughly".

Staff #1 documented the following:
"23:57 07/10/2019 Started 4 ml of Levophed (Norepinephine Bitartrate) Drip IV in bag #2 1000 ml; at 2mcg/min via site #3 via IV pump. Allergies verified. IV patency established. IV site checked: no pain, redness, or swelling. IV flushed thoroughly pre- and post-medication administration. (per ___ ___ [Staff # 24's name written in chart]. -11:57 7/11/19 ___ ___ [Staff #1's name written in chart]" Review of the T-sheet showed no documentation of Staff #24 documenting any of the above care. Review of the Cardiopulmonary Resuscitation (CPR) Record showed that Staff #23 had documented starting a new IV site at 2348 (11:48 PM patient care time) to the left AC (antecubital - inside bend of the arm opposite of the elbow area). Staff #23 documented that this was site #3 when a site #3 had been previously documented earlier in the evening as being place to the right AC by Staff #24. The CPR Record showed that Staff #1 had incorrectly documented the site of Levophed administration. The CPR record documented that the Levophed was connected to the site #3 in the left AC which was started by Staff #23 and not site #3 in the right AC that was start by Staff #24. The CPR record also did not contain an entry by Staff #23 that "Allergies verified. IV patency established. IV site checked: no pain, redness, or swelling. IV flushed thoroughly pre- and post-medication administration."

Staff #1 documented the following in the EMR at 0000 on 7/11/2019 (patient care time of midnight going from 7-10-2019 over into 7-11-2019):
"00:00 07/11/19. 16 fr Foley catheter placed in ED. Reason for indwelling catheter: critical need to monitor intake and output and patient's decreased level of consciousness. During procedure hand hygiene observed and sterile equipment and aseptic technique used. Return of less than 50 mL cloudy urine; attached to bedside drainage bag positioned below the bladder and secured with tape. She tolerated procedure well (minimal output). -12:18 7/11/19 ___ ___ [Staff #1's name written in chart]."

Review of the T-sheet and CPR Sheet showed that the only thing documented by Staff #1 above and also documented on the T-sheet and CPR Sheet was that a Foley catheter (a tube placed in the bladder to drain urine) was placed at 0000. Neither the T-sheet or CPR sheet documented the size of the Foley (16 fr [French] is the size of the Foley tube); the reason for placement; technique of placement (hand hygiene / sterile equipment / aseptic technique); the amount of urine output (50 milliliters and minimal output); the color of the urine (cloudy); positioning of the Foley (attached to bedside drainage bag positioned below the bladder), how it was secured (with tape); or how the patient tolerated the procedure.

Other inconsistencies with documentation by Staff #1 were noted. Staff #1 was interviewed on 8-2-2019 at 9:23 AM. Staff #1 confirmed that she worked during the day time and was not present when Patient #7 had been brought to the emergency department. Staff #1 confirmed that she had not been called in from home to assist with the care of Patient #7 and was not present in the hospital during the times of patient care. Staff #1 was asked why she documented patient care in the EMR on 7-11-2019 after the patient had expired. Staff #1 explained that the hospital could not send a bill to the patient's insurance company for medications and supplies unless a nurse documented the care associated with it (i.e.: medication administration start and stop times) and supplies used. Staff #1 stated she had made a note at the beginning of the chart that the EMR was down and she was just helping put the information from the paper ER records into the EMR.

Staff #1 was asked about the discrepancies between what she documented and what was written on the paper record, such as using 10 milliliters (ml) of normal saline to flush an IV site or using an IV pump. Staff #1 was asked how she knew that these inconsistencies she documented had actually occurred since she wasn't there. Staff #1 stated, "That's what we always do". Staff #1 explained that IV sites are always flushed with 10 ml of normal saline and that IV fluids are always run through a pump. When asked how she knew that procedures hadn't been varied because this patient was in critical condition and coding, Staff #1 confirmed that she did not know. Staff #1 stated she was just trying to help out with getting the documentation into the EMR so the hospital could bill for services.

Based on document review and interview the facility failed to ensure all medical record entries were signed, dated, and timed in 5 (Patient #8, #9, #10, #11, and #12) of 5 medical records reviewed.


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


Findings Include:



PATIENT #8

A review of Patient #8's medical record revealed the document titled, " ...Admission Medication Reconciliation and Physician Order Form, Medications at Admission/Entry ...", was signed and dated. Staff #29 failed to document the time for the orders.



PATIENT #9

A review of Patient #9's medical record revealed a verbal order was taken by Staff #30 to discharge Patient #9 from the Swing Bed Unit and Admit to Acute Care on 7/1/2019 at 8:00 AM. Staff #12 and Staff #14 signed the verbal order but did not document the date or time of their signature.



PATIENT #10

A review of Patient #10's medical record revealed a verbal order for wound care evaluation and treatment was taken by Staff #27 on 4/24/2019. Staff #27 failed to time the verbal order. Further review of the order dated 4/24/2019 revealed Staff #12 signed and dated the verbal order on 5/3/2019 but failed to document the time. On 4/26/2019 Staff #31 documented a verbal order at 10:30 AM for Physical Therapy Evaluation. Staff #12 signed and dated the verbal order on 5/3/2019 but failed to document the time.


PATIENT #11

A review of Patient #11's medical record revealed a verbal order was taken by Staff #30 to discharge Patient #11 was documented on 6/20/2019 at 9:50 AM. Further review of the record revealed Staff #12 and Staff #14 signed the verbal order but failed to document the date or time.




PATIENT #12

A review of Patient #12's medical record revealed the document titled, " ...Admission Medication Reconciliation and Physician Order Form, Medications at Admission/Entry ...", was not signed, dated, or timed by Staff #12.



Staff #6 confirmed the above findings.


An interview was conducted on 7/30/2019 with Staff #6 at 2:40 PM. Staff #6 was asked how she monitored records for completeness and delinquencies. Staff #6 stated she runs routine reports to see if there are delinquent medical records. Staff #6 was asked if there were delinquent medical records. Staff #6 said, "No".

An interview was conducted with Staff #1, #6, and #7 on 7/31/2019 after 2:00 PM. Staff #1 was asked why the verbal orders taken by the nursing staff were not being signed in a timely manner. Staff #1 stated the facility does track these written orders and they are scanned into the medical record and the medical records department runs reports to see if there are any delinquent records. Staff #6 stated, "I do not have access to that part of the electronic record and I don't know why. I can't see the clinical side of this program and I have talked about that with Staff #7 and so that does not show up on any of my reports." Staff #7 said he was aware that Staff # 6 did not have access to the clinical side of the electronic record and did not know why."


Staff #1, #6, and #7 confirmed the above findings.

Based on review of records and interview, the facility failed to either carry out or arrange for an annual review of its total program, including all services, the number of patients served, the volume of services, and policies.

Findings included:

An interview with Staff #10 and Staff #7 was conducted on the morning of 8-1-2019. Review of the Quality Department Policy manual provided at the beginning of survey did not include a Quality Plan or Annual Review. Staff #10 stated she had the 2019 Quality Plan in her policy binder. When asked for the annual review of the hospital's total programs, neither Staff #10 or Staff #7 could speak to an annual review. When the requirements for an annual review were explained, both confirmed that an annual review had never taken place.

Staff #7 stated that all policies were reviewed annually. As evidence, a signature sheet with a statement saying policies were reviewed was located in the front of each manual, signed by the department heads, CEO, and Medical Director. However, policies were found to be outdated in many departments and covered services not provided, such as nursing policies for managing a Labor and Delivery unit and Surgery Services. During a previous interview with Staff #3, Staff #3 confirmed that each policy in the manual was not reviewed in its entirety. Policies were reviewed as necessary and when changes were needed.

Policy headings were found to be incomplete with missing policy numbers, approval dates, and signatures. Because the signature sheets did not contain a complete list of policy numbers and titles with approval dates that had been reviewed, the potential was present for staff members to make unauthorized changes to policies without submitting them through the appropriate committees for approval. The facility had not been able to provide complete manuals as evidenced by the manual provided at the beginning of the survey for the Quality Department containing different policies than the Quality Director's manual. Surveyors were unable to follow policies through the approval process to determine of the policies provided were the actual policies that had been approved by the Governing Body.

Based on review of records and interview, the CEO failed to take appropriate action to correct reported problems identified by the Dietary Department through the Quality Assurance Process Improvement (QA/PI) program for 4 of 4 quarters that it was reported.

Review of the QA/PI meeting minutes for the month of April 23, 2019 was made. The minutes reflect that temperature logs being monitored were "slightly below for 4/4 Quarters. Problem: Coolant leak in part of freezer. This is sporadic occurrence that can only be identified the next day." The minutes reflect that the CEO stated it would continue to be monitored internally. Staff #10 was asked what was being done about it. Staff #10 stated that currently, the coolant was being replaced when the temperature was found to be out of range due to low coolant.

Staff #7 was asked why he had not taken action. The leak had not been repaired and/or the freezer had not been replaced. This placed frozen foods at risk for potential spoilage. Staff #7 stated the hospital had the money to correct the problem, but "I'm just cheap." Staff #7 confirmed it was cheaper to have the coolant serviced when the temperature was found to be out of range for safe storage of food than correcting the problem, despite the risk of potential spoilage or contamination of patient food.

Based on record review and interview, the facility failed to:

A. provide information that Staff # 17 was licensed as an Activity Director (AD)

B. provide a list of activities and schedule for the swing bed patient

C. provide an activities assessment or documentation of the Activities Director involvement with activities in 1(#8) of 2 (8 and 9) charts reviewed.

An interview was conducted with Staff #17 on 8/1/19. Staff #17 stated that she was the activities director and the swing bed coordinator. Staff #17 was asked if she was a Licensed Activities Director and she stated, "yes." The surveyor asked multiple times for Staff #17's proof of licensure but was not provided with the information.

A request was made (multiple times) for a list of activities offered to the patients and an activities calendar. The information was not provided.

Review of Patient # 8's chart revealed the patient did not have a comprehensive assessment. The patient was documented as given activities materials by the nurses. There was no documentation of the AD involvement.

Review of Patient #9's chart revealed a comprehensive assessment was performed but no documentation of AD involvement with activities.

Based on record review and interview, the facility failed to have a Dental Contract for routine and emergency dental services to meet the needs of each resident.

An interview was conducted with Staff #7 on 7/30/19 in the afternoon. Staff #7 reported the facility did not have a current contract with a Dentist.

Based on document review and interview the facility failed to maintain an updated and comprehensive Emergency Preparedness Plan (EPP) based on an all-hazards approach.


Cross Refer to Tag E0004


Cross Refer to Tag E0006

Based on document review and interview the facility failed to have an updated Emergency Preparedness Plan (EPP) that was based on facility and community-based risk assessments or a Hazard Vulnerability Assessment (HVA).


This deficient practice had the likelihood to cause harm to all patients and staff if the EPP was to be activated.


Findings include:


A review of the document titled, "EMERGENCY OPERATION PLAN POLICY AND PROCEDURE MANUAL SABINE COUNTY HOSPITAL" revealed the EPP was last updated and approved in January 2018.



A telephone interview was conducted on 8/01/2019 at 10:40 AM with Staff #8. Staff #8 was asked when the last EPP and HVA were updated and approved. Staff #8 stated, "We had to make some changes with the Emergency Management Team on the HVA and we are still waiting for the approval from them." Staff #8 was asked if the last approval date of January 2018 was correct. Staff #8 said, "Yes, I guess that is all we have."

Based on document review and interview the facility failed to have an updated Emergency Preparedness Plan (EPP) that was based on facility and community-based risk assessments using an all-hazards approach.


This deficient practice had the likelihood to cause harm to all patients and staff if the EPP was activated.


Findings include:



A review of the document titled, "EMERGENCY OPERATION PLAN POLICY AND PROCEDURE MANUAL SABINE COUNTY HOSPITAL" revealed the EPP was last updated and approved in January 2018. The document further revealed the Hazard and Venerability Assessment Tool was last updated in January 2018 and did not include all required elements.


A telephone interview was conducted on 8/01/2019 at 10:40 AM with Staff #8. Staff #8 was asked when the last EPP and HVA were updated and approved. Staff #8 stated, "We had to make some changes with the Emergency Management Team on the HVA and we are still waiting for the approval from them." Staff #8 was asked if the last approval date of January 2018 correct. Staff #8 said, "Yes, I guess that is all we have."