HospitalInspections.org

45707


Based on interview and record review, the hospital's QAPI program (Quality Assessment and Performance Improvement) failed to identify that a Patient Safety Program (PSP) policy was required by State regulations per 25 Texas Administrative Code 133.48(a)(2). The PSP must be approved by the Governing Body and made available for review by the Department.

Findings included:

On 04/19/22 at 10:15 AM, Personnel #6 was requested to provide the hospital's Patient Safety Program. After clarification, Personnel #6 replied the hospital did not have this policy.

Based on observation, interview, and record review, the hospital's A) anesthesia room was found to have 1 of 1 medication unsecured, and B) 2 of 3 (Labor/Delivery unit and Wound Care clinic) mobile medication carts were not checked daily as required.

Findings included:

A. During a tour of the anesthesia room on 04/18/22 at 11:35 AM, a one mL vial of Phenylephrine HCL injection was found in the cabinet drawer of the anesthesia room. Personnel #10 was present during this tour and was asked why the medication was left unsecured. Personnel #10 replied she was not aware the medication was left in the drawer.

B. 1. During a tour on 04/19/22 at 1:05 PM, the mobile medication cart in Labor and Delivery unit was not checked daily as required. It was not checked on 04/2022 and 03/2022 either day shift and/or night shift. The following dates that were not checked for ready to use were:
2022 April 4, 12, 13, 15, 17, and
2022 March 31, 29, 22, 21, 17, 16

Personnel # 11 was present during the tour and confirmed the findings. Personnel #11 stated the crash cart should have been checked daily.

2. During a tour on 04/20/22 at 2:00 PM, the mobile medication cart in the Wound Care Clinic was not checked daily as required and the cart's plastic lock was not in place. The cart log was last signed and dated 04/15/22.
Personnel #18 was present during the tour and confirmed the findings. Personnel #18 stated the cart should have been checked daily and the cart's plastic lock should have been present.

Hospital Policy and Procedures:
"Use and Storage of Stock Drugs..." last revised on 04/2020 required "Purpose: That the drugs needed for surgery patient will be readily available for the patient but secured from unauthorized use."

"Crash Cart Check..." last revised on 10/2022 required "Policy: 1. Crash cart will be checked every shift by nursing serviced and monthly by pharmacy."

Based on observation, interview, and record review, the hospital did not ensure that equipment in 2 of 2 units (Labor & Delivery and Medical Surgical) were clean and sanitary to avoid sources and transmission of infection.

Findings included:

During a tour of the Labor and Delivery unit on 04/19/22 at 1:38 PM, the clean room behind the nurses' station was observed to have 3 gift bags with contents, 2 personal purses, and a container of fresh fruit (grapefruit and grapes). The small refrigerator contained a medication "NPH 100 3 mL/100 units/mL" that belonged to a patient who was previously discharged. Personnel #11 who was present during the tour confirmed the findings. Personnel #11 was asked what the refrigerator was for. Personnel #11 replied it was to store breast milk only.

During a tour in the medical-surgical unit on 04/19/22 at 1:30 PM, medical equipment on a rack was observed in the hallway. Personnel #6 was asked if she could identify which equipment on the rack was clean or used/dirty. Personnel #6 replied she could not. Both Personnel #6 and #12 were informed and confirmed the findings. A policy and procedure was requested and both personnel stated they did not have this particular policy.

Policy and Procedure "Neonate: Formula Preparation and storage" last revised on 11/2019 required "Breast milk and formula refrigerators are to be used solely for breast milk and formula."



44975

Based on observation, interview, and record review, the hospital's 2 of 2 operating rooms (ORs) OR #1 and OR #2 had moderate dust particles on the frames of the ventilation exhaust system and sterilization policies and procedures were not adhered to.

Findings included:

During a tour of the Surgery Department on 04/18/22 at 11:25 AM, OR #1 and OR #2 were observed to have 2 ventilation exhaust systems in each room. The ventilation frames were covered with moderate dust particles. Personnel #10 who was present during the tour confirmed the findings.

On 04/18/22 at 11:42 AM, the tour proceeded to the sterile supply room. The following 20 of 29 sterile instrument tips were sterilized in a closed position. The greatest bioburden were located at the tip of the instruments, hence these instrument must be open during the sterilization process.
Babcock Allis - 2
Iris Tenots - 2
Hemostats -8
Needle Holders - 8

Personnel #10 who was present during the tour confirmed the finding.

On 04/18/22 at 11:48 AM the tour proceeded to where the sterilizers were located. The hospital had 2 steam sterilizers (sterilizer #1 & 2). Review of the log for April 2022 indicated no biological indicators were logged. Personnel #10 who was present during the tour stated the technician did not document the results of the biological indicators. The following dates in April 2022 did not have biological indicator results:
Sterilizer #1: 2022 April 4, 7, 8, 11, 13, 15, and 18
Sterilizer #2: 2022 April 1, 5, 6, 7, 8, 11, and 15

Hospital Policies and Procedures:
1. Cleaning of the Operative Room and PACU Procedure last revised 04/2020 page 1-2 required "EACH DAY BEFORE USING THE or: Surgery Nurses: 1. Clean all furnishings...g. open surfaces...AT THE END OF THE DAY: HOUSEKEEPING...4. Clean outside of air vents..."

2. Care of Surgical Instruments and Equipment last revised on 10/2019 page 3 required "General Instructions...1...c. Instruments with hinges should be opened and those with removable parts should be disassembled when placed in trays designed for sterilization..."