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Based on record review and interview the hospital failed to ensure that personnel were licensed and met other applicable standards that are required by State or local laws in 7 of 7 (ID#55, 63, 68, 71, 73, 76, 87) personnel files reviewed.

Findings Include:

Record review of facility 2021 Personnel Policy and Employee Handbook
stated the official personnel record will usually contain the following information:
4. Application and supporting data
6. Orientation and training records
7. Licensure/certification/registration information

Record review on 07/28/2022 of the seven (7) personnel files revealed, all seven files (ID#55, 63, 68, 71, 73, 76, 87) were incomplete.

Four (4) licensed personnel (ID# 68, 71, 73, 76) did not have a license verification completed (lab director, respiratory director, pharmacist, or the Licensed vocational nurse) in their file.

The Director of the kitchen (ID#55) had the wrong job description. The job description stated the director should be a licensed dietitian with a bachelor's degree in food and nutrition or home economics.

The Director of the kitchen (#ID 55) verified that he was not a licensed dietitian.

The case manager did not have a job description in the personnel file.

No background checks were completed on the seven (ID#55, 63, 68, 71, 73, 76, 87)employee files reviewed

Five out of seven employee files (ID#55, 68, 71, 73, 76) did not have annual competencies or current training noted in their personnel file.

Record review of the job description for nursing supervisor over surgical services (ID# 87) stated ACLS was required. The ACLS card was noted to be expired in the personnel file.

Interview on 07/28/2022 at 1242 with nurse (ID#87) who verified that her ACLS card was indeed expired.

The personnel files were verified on 07/28/2022 at 1300 by human resources assistant (ID#83).

Based on interview and record review, the Governing Body failed to ensure the Medical Staff bylaws, rules, and regulations were implemented and enforced.

A. Medical staff failed to have signed and approved delineation of privileges (IDs 70, 90 and 92) ;

B. Allied Health Practitioners, Certified Registered Nurse Anesthetists (CRNA) credential files failed to have licensure verification (IDs 85 and 86).

Findings include:

Record review of Medical Staff Bylaws (not dated) showed the following information:

Article IX: Clinical Privileges

9.1 Clinical Privileges Restriction

a. Every practitioner practicing at this Hospital by virtue of Medical Staff Membership or otherwise, shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to the Practitioner by the Board.

Article X: Allied Health Professionals ("AHP")

10.1 Qualifications of AHPs. Every AHP who applies for or is providing services in the Hospital must, at the time of initial an, if approved, continuously thereafter, demonstrate the following qualifications:

a. current license, registration, certification or such other credential, if any, as may be required by Texas law for the provision of the services being requested.

Observation on 7/26/2022 showed physician (ID 70) practicing as the facility emergency medicine doctor.

Record review of credential file for Emergency Room physician (ID 70) showed Core Emergency Medicine delineation of privileges with no chief of staff signature or chairman of the board signature.

Record review of credential file for physician (ID 90) showed Core Gynecology delineation of privileges with no chief of staff signature or chairman of the board signature.

Review of medical record for patient (ID 49) showed operative report for 4/25/22 signed by physician (ID 90) for Abdominal Supracervical hysterectomy, bilateral salpingectomies and lysis of adhesions.

Review of medical record for patient (ID 48) showed operative report for 7/11/2022 signed by physician (ID 90) for an unspecified procedure for uterine fibroids, menorrhagia, chronic blood loss anemia, pelvic adhesive disease and dyspareunia.

Review of medical record for patient (ID 29) showed operative report for 7/7/22 signed by physician (ID 90) for hysteroscopy, D & C, endometrial ablation with NovaSure.

Review of medical record for patient (ID 47) showed operative report for 7/18/22 signed by physician (ID 90) for Vaginal hysterectomy, morcellation of uterus, bilateral salpingectomies, removal of bilateral hulka clamps (2 on each side), obtryx sling, and cystoscopy.

Review of medical record for patient (ID 46) showed operative report for 7/25/22 signed by physician (ID 90) for Vaginal hysterectomy, bilateral salpingectomies.

Review of medical record for patient (ID 45) showed operative report for 7/28/22 signed by physician (ID 90) for hysteroscopy, D & C, endometrial ablation with NovaSure.



Record review of credential file for physician (ID 92) showed Core Hospitalist delineation of privileges with signature from chief of staff dated 7/27/22 (after survey team entrance)and no signature or chairman of the board.


interview with DON (ID 52) on 7/28/2022 at 12:45, she confirmed the above findings.

Interview with Medical Director, Chief of Staff (ID 62) on 7/28/2022 at 1:00 PM, he stated that it was discovered yesterday that priceless for staff (ID 92) had no signed delineation of privileges (DOP) so he signed it then.


Review of credential file for CRNA (ID 85) showed current licensure verification performed on 7/27/2022 at 1655 (after survey team entrance).

Review of medical records for patients (IDs 42, 43 and 44) for date of service 7/27/2022 showed CRNA (ID 85) as the anesthesia provider.

Review of credential file for CRNA (ID 86) showed current licensure verification performed on 7/27/2022 at 1656 (after survey team entrance).

Review of medical records for patients (IDs 38, 39, 40 and 41) for date of service 7/19/2022 showed CRNA (ID 85) as the anesthesia provider.

Based on observation, review of facility records and staff interviews, the failed to ensure:
1. The pharmacist supervised and coordinated all of the activities of the pharmacy as evidenced by lack of enforcement and tracking of incomplete prn medication orders in 4 of 49 charts reviewed (ID#s 13, 26, 28 and 31)
2. regular pharmacy and therapeutics committee meetings/activities
3. proper storage of supplies in pharmacy.

Findings include:

1. Incomplete prn medication orders

Record review of El Campo Memorial Hospital Policy "Specific Instructions for use on PRN orders" (no date) provided by staff pharmacy director ID #54 stated "1. PRN medication orders will have an indication documented in the medical record. The clinician entering the order in the EMR will define the indication for prn use during order entry." It further stated, "2. When multiple medications are ordered for the same indication, the physician will indicate parameters for administration of each medication within the order using a pain scale. a. Hospital has defined the following pain scale: i. Mild pain 1-4, ii. Moderate pain 5-7, iii. Severe pain 8-10." The policy stated "5. PRN orders missing pain scale parameters will be clarified with the physician. 6. Documentation of these clarifications will be recorded. A monthly report of these clarifications will be provided to the hospital and presented at P&T."

Record review of El Campo Memorial Hospital Medical, Medical Staff Rules and Regulations, approved 01/26/2022 by the governing body, stated "7. The practitioner's orders must be written clearly, legibly and completely. Orders that are illegible or improperly written will not be carried out until rewritten or understood by the nurse."

Record review of 10 current inpatient medical records, revealed that 4/10 current inpatients had prn medications which lacked clear, specific indicators:
Patient ID #31 Order for "Ketorolac 30 mg IV push Q 6 hrs prn" by staff physician ID #89.
Patient ID #13 Order for "Acetaminophen 325 mg tabs - 2 tablet oral prn Q 6 hrs for pain or fever" by staff physician ID #89.
Patient ID #26 Order for "Hydrocodone/APAP 5-325 mg oral prn Q 6 hrs for breakthrough pain" by staff physician ID #89.
Patient ID #28 Order for "Ibuprofen 200 mg tablets - 3 tablets oral prn Q 6 hrs" by staff physician ID #89.

Interview 7/28/2022 11:45 a.m. with staff pharmacist Staff ID #54 revealed that she was aware of issues with "physicians not using prn indicators" when entering medication orders. She reported she had tried to address this, however had no evidence of training, education or monitoring. She stated that the computer order entry system did not require prn indicators to be entered with the order for the clinician.


2. Inactive Pharmacy and Therapeutics committee.


Record review of Pharmacy & Therapeutics committee meeting minutes with director of pharmacy staff ID #54 revealed P&T committee meeting minutes for dates: 4/15/21, 8/12/21, 12/29/21, 7/14/22.

Record review of Mid Coast Health System "P&T Committee" policy, last revised 4/2022, stated it was the pharmacy goals "to provide services that meet patient needs, to provide services that met accepted ethical and professional practice standards, to provide services that meet all legal requirements, to improve the quality of pharmacy services."

Record review of El Campo Memorial Hospital policy "Specific Instructions for use on PRN orders" (no date) provided by director of pharmacy staff ID #54 stated "6. Documentation of these clarifications (referring to PRN orders) will be recorded. A monthly report of the clarifications will be provided to the hospital and presented to P&T."

Interview 7/27/2022 11:25 a.m. with director of pharmacy staff ID #54 revealed that the facility has only had 1 Pharmacy and Therapeutics committee meeting from 1/1/2022 until 7/27/2022. She reported they are supposed to be held quarterly. She reported awareness that prn indicators with medication ordering is an issue however it has not been specifically tracked. She stated that clinical pharmacy responsibilities, lack of pharmacy staffing, and employee Covid-19 infection rate contributed to inability to complete these duties.

Interview 7/27/2022 2:20 p.m. with director of quality staff ID #53 revealed Pharmacy & Therapeutics committee was expected to meet quarterly. She confirmed awareness that they were not current this calendar year.


3. Improper storage of dirty supplies with clean supplies in the pharmacy.

Observation 7/27/2022 11:20 a.m. during pharmacy tour with director of pharmacy staff ID # 54 and DHHS Surveyor revealed a room with locked key access on the right side of pharmacy where narcotic lock boxes were located. This room contained a rolling cart with an unused drug destroyer container sitting on the bottom shelf next to a drug destroyer container with dried seepage and evidence of prior use.

Interview 7/27/2022 11:20 a.m. with staff pharmacist ID #54 at the time of observation revealed "I know these don't belong here, but we are very limited on storage space." She stated there was no institutional policy regarding storage of clean supplies versus dirty supplies specific to pharmacy.

Based upon observation, interview with staff and record review, it was determined that the facility failed to ensure that only authorized personnel had access to the pharmacy.

Findings Include:
Record review of "After Hours - Sign Out Log" pharmacy sheet dated "7/28" at 07:30 a.m., "Patient name" patient ID #45 label affixed, "Drug Removed" was illegible, "Dose ordered" was illegible, Quantity "1", Licensed personnel signature" was illegible.

Observation during a tour of the pharmacy 7/28/22at 11:00 a.m. with director of pharmacy Staff ID # 54, showed two (2) video cameras are noted in the pharmacy facing different angles. There was no security alarm noted.

During a video review of pharmacy entry door camera footage with IT Director Staff ID # 88 from July 28, 2022 at 07:29 a.m., it was observed that 2 females in scrubs (identified by Director of Nursing as Staff ID # 81 ("day shift charge nurse") and day surgery registered nurse staff ID #58) entered the pharmacy and went to the far left to remove a medication. One of the employees appeared to be writing on the log sheet which was placed on front pharmacy counter.

Interview with director of pharmacy staff ID #54 on 7/28/22 at 11:45 a.m. she was asked about who had accessed the pharmacy and what medication had been removed 7/28/22 07:30 a.m. per the log sheet. She stated, "I don't know, I can't read what they wrote." She stated the pharmacy tech would call day surgery to follow-up. She was asked who has access to the pharmacy and she pointed to a typed list of 15 names on the entry wall which was labeled "Charge Nurse After Hours Authorization," with "Day Shift" and "Night Shift" and was dated "07/07/2022." She stated that all the people on the list were approved for after-hours pharmacy access. She stated she did not have a signature list of those employees with access. She stated she would "write the door entry code on a piece of paper, place in an envelope and it would be passed shift to shift between charge nurses." She stated she had no method for knowing who exactly had received the code. She stated the process was that the door code was changed quarterly per policy. She validated that the current "After Hours Sign Out Log" only had the place for 1 staff signature and did not reflect who had entered the pharmacy. The pharmacist confirmed there was no policy and procedure governing the charge nurse practice of removing drugs or biologics from the pharmacy when pharmacy staff were not in house. She confirmed that she does not get notified of when someone enters pharmacy and had not been

Interview with director of nursing Staff ID #52 on 7/28/22 12:30 p.m., she stated that "only 2 charge nurses on day shift and 2 nurses on night shift have the code". When asked to review the typed sheet in pharmacy labeled "Charge Nurse After Hours Authorization," she stated that list was "incorrect and that all those employees on the list should not have or need codes". She confirmed that RN Staff ID # 58 was not listed on afterhours list. She stated that the pharmacy did not have a security alarm and stated the policy was "incorrect." She stated she has been requesting the pharmacy have staff in-house for longer hours, to minimize needs for non-pharmacy personnel to enter the pharmacy.

Record review of Mid Coast Health System "Pharmacy Security" policy last revised 02/2022 revealed "7. The pharmacy is equipt with an alarm system which is unarmed upon entering the pharmacy and armed upon leaving the pharmacy after normal hours."

Record review of the El Campo Memorial Hospital Director of Pharmacy job description revised 07/2010 stated that the "pharmacist in charge is responsible for all drug storage and drug preparation." It stated that the pharmacist "directs and coordinates purchasing, receiving, pricing, storing, and dispensing all hospital pharmaceuticals."

Based on observation, record review and interview the facility failed to ensure that staff documented the correct temperature for the dishwasher in the kitchen and the blanket warmer in the ED.

Findings Include:

Observation of the dishwasher temperature on 07/26/2022 at 1100 during the washing cycle revealed a wash temperature of 160 degrees.

Record review of the dishwashing temperature log revealed documentation by the staff for July 2022 as a temperature of 190 for wash and a rinse temp of 180. The manufacturing instructions of the ECOLAB dishwasher stated the water temperature should be 120-180.

When questioned about the correct documentation of the dishwasher temperature of 160 the Director of the Kitchen (ID#55) stated the water pressure is low and keeps the water temperature at 160.

Record review of the facility policy "ICU Refrigerator and Blanket Warmer Checks", revised 11/2021, stated if there are any variations in temperature or function of the refrigerator and /or blanket warmer, plant operations is to be notified.

Record review on 07/26/2022 at 1410 of the blanket warmer temperature record stated the range of the blanket warmer should be 126F-134 F. Observation of the ED blanket warmer log for June and July revealed documentation from 115-120, with missing documentation on June 23 and 26th, and July 19 and 22nd.

Interview with staff nurse (ID # 63) about the documentation on the temperature log, and why no one notified anyone about the temperature for the warmer, since the record states it should be 126F-134F. She stated "I have never seen the temperature at 126, maybe it's the old warmer".

Based on observation, interview, and record review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections.

Findings included:

Record review of the policy and procedures manual: Cleaning Instructions: Floors, Tables and Chairs dated 2019, stated,
1. Sweep and clean kitchen floors after each meal. Sanitize at least once daily. Move major appliances at least once a month (as appropriate) in order to facilitate cleaning behind and underneath them.

Observation of the kitchen on 07/26/2022 between 0930-1100 revealed dirt and food on the floor under the frier, in the corners, in the freezer floor, under the sinks, and the prep areas.
The fan in the dishwashing area mounded on the wall, had heavy visible dust and dirt.

Interview on 07/26/2022 at 1100 with the Director of the Kitchen (ID#55) who verified the floors needed to be sweep and cleaned, and the fan need to be removed.

Policy and procedure for the kitchen, dated 2019, stated, when a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food.

Observation of food and sauces in the kitchen on 07/26/2022 at 1050 revealed the following:
Browning sauce, 128 fluid ounces (oz). opened 06/11/2022
Worcestershire sauce, 1 gallon (gal), opened 06/11/2022
Red hot sandwich sauce, 128 fluid oz. opened 06/21/2022
Cocktail sauce seafood, 8 pounds (lbs) opened 08/11/2022
Ranch dressing, 1 gallon, no opening date
Sweet bay-mango sauce, no opening date
Bom-Bom sauce, no opening date
Diced ham, 5 lb bag, opened 06/30/2022

Interview with the Director of the kitchen (ID#55) on 07/26/2022 at 1100 who stated that once an item is opened, they have 30 days from the date the item is opened to use it or thrown out

Observation of the Sentrack room on 07/26/2022 at 1340 revealed a separate air-conditioned building that housed both food, lab supplies, disaster supplies, used and broken equipment.
Five large cans green beans
Seven large cans of pulled chicken
Six cases of water
Two cases of dry milk
Five cases of shoe covers
Four boxes of protective coveralls
Boxes of food were noted on the floor.
Lab supplies

The dirty supplies were mixed with the clean supplies and near food.

Interview on 07/26/2022 at 1340 with the CNO (ID#52) who vertified that the clean and dirty supplies should not be stored together.

Observation on 07/26/2022 at 1410 revealed holes on the walls in ED#1 at the head of the bed, and the opposite wall where equipment was removed from the wall. Walls across from bed 5, had chipped plaster, including the walls where the respiratory and EKG equipment was stored.
Cleaning supplies were also found under the sink in room #1, including a biohazard box, and trash bags.

Interview on 07/26/2022 at 1410 with CNO (ID# 52), who stated that they do not have any bumpers on the wall, and nothing should be under the sink.

Return visit to the ED on 07/27/2022, at 1045 revealed expired supplies in room two (2) in the Broselow/Hinkle bag. The expired supplies were as follows:
Yellow IV Delivery, expired
One (1) on 03/31/20 and three (3) on 04/30/20,
Yellow Intubation module, two (2) expired 04/30/20
White Intubation, expired on
Two (2) expired on 04/30/20
Three (3) expired on 04/31/20.
Blue Intubation module expired:
One (1) 3/2020
One (1) 06/30/21.
Orange Intubation module expired:
One (1) expired on 07/2018 and open
One (1) expired on 03/20
Green IV delivery kit
One (1) expired on 06/20/21
One (1) expired on 06/30/21
Green Intubation kit
One (1) 03/31/2020
Pink Intubation kit:
One (1) expired on 03/2018, open
Oxygen Delivery kit:
One (1) expired on 06/20
IV delivery kit
Two (2) 04/30/21
Purple Oxygen Delivery, Lot 7813360
One (1) Expired on 04/2019
Two (2) Intubation Model kits
Oxygen tackle Box:
Two (2) mental handles did not fit the straight plastic blades
Oxygen Nellor detector: Pediatric colorimetric C02 revealed: three (3) expired items, 08/2017, 05/28/2019, 02/14/20.
One (1) 6.5 endotracheal, expired 08/2017.
Intubation Stylet-Mallinckrodt, lot 1419286JZX- 09/2019
Oral/nasal tracheal tube cuffless 2.5, lot 15h0706JZX expired 08/26/20
One (1) Lubricating jelly expired 07/01/22

Interview with the 07/27/2022 at 1050 with staff nurse in the ED (ID# 84) vertified the supplies were expired.


37490

Based on observation, interview, and record review, the facility failed to implement an effective infection prevention program. The facility failed to :

1. ensure dirty suction canisters were removed from the operating room
2. ensure expired items were available for use in the surgical services department.
3. ensure sterile items were stored in an area where temperature and humidity were monitored

Findings include:

Observation on 7/26/2022 at 11:30 in operating room (OR) #1 showed a suction canister contained bloody fluid form a previous surgery.

Interview with OR supervisor (ID 58) at the time of observation, when asked if the room was clean and ready for a procedure she stated "yes." When shown the suction canister containing bloody fluid from a previous surgery, she stated that it should have been removed when the room was cleaned.

Record review of facility policy titled "cleaning of specific areas," dated 2/2022 did not have the operating room specific procedure provided.


Observation in the post anesthesia care unit (PACU) on 5/26/2022 at 11:15 in the malignant hyperthermia cart showed the following:
-1 liter sterile water x 2 wit expiration date of 6/2022
-2 vaccutainer blood collection tubes with expiration date of 6/30/2022
-1 vaccutainer blood collection tube with expiration date of 3/31/2022

Interview with OR supervisor (ID 58) at the time of observation confirmed the above findings and stated that the contents are checked monthly for expired items.

Record review of facility policy titled Malignant Hyperthermia, dated 5/2022 showed the following:
4. Cart Maintenance
1. OR nursing and pharmacy departments are jointly responsible for daily checks of the following;
-replace missing or expired items


Observation on 7/26/2022 at 11:25 in the OR Equipment storage room showed sterile supplies including surgery packs, drapes and arm positioners.

Interview with OR Supervisor (ID 58) at the time of observation stated that overstock of supplies were stored in the room. When asked if the room's temperature and humidity were monitored, she was not sure.

Interview with maintenance staff (ID 61) on 7/26/22 at 11:30 stated that the room's temperature and humidity were not monitored.

Record review of AORN GUIDELINES FOR PERIOPERATIVE PRACTICE - 2022 EDITION, showed the following: Sterile storage room temperature shall be max 75 degrees F and relative humidity should be mac 60%.