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1. Based on observation, review of medical records, policy and procedure, and staff interview, the facility failed to assign a competent staff member to monitor the patients on continuous cardiac monitoring / pulse oximetry.

The findings include the following:

a. Based on observation on 1/21/14 from 12:15 to 1:00p.m.in the nurses' station revealed the telemetry monitoring station was located at the nurses station. 3 patients were observed on the telemetry monitor for continuous pulse oximetry. During the observation period multiple audible alarms were observed with no response from staff that were working on paperwork at the nurses station.

b. Review of medical records for (P7) on 1/21/14 at the facility nurse ' s station at approximately 1:15 p.m. revealed the following orders:
continuous pulse oximetry.
O2 sats <90%

c. Review of policy and procedures manuel on 1/21/14 titled Cardiac Monitoring stated:
The continuous pulse oximetry function of the cardiac monitor may be utilized for a patient already on the cardiac monitor. Levels should be documented on the flow sheet no more frequently than every one hour. A patient who requires more frequent monitoring should not be housed on the surgical unit.

d. Staff interview with (S9) on 1/22/14 at 9:24 a.m. at the nurses station revealed that the RN had been employed with the facility for several years. When asked who was assigned to monitor the cardiac monitoring / pulse oximetry station and report alarms and changes in patinets' status the RN stated that the RN assigned to the patient was responsible for the monitoring. (S9) confirmed that the RN assigned to the patient had other duties assigned to him or her and would not be able to continuously monitor the patient's status. (S9) confirmed that the cardiac monitor had been alarming due to out of parameter alarms. (S9) could not show documentation that the RN assigned to the patient addressed the out of parameter alarms.

1. Based on reviews of medical records, policies and procedures, and staff interviews Foundation Surgical Hospital failed to follow accepted and established standards of practice for documenting the administration of as needed medications (PRN).

The findings included:
a. A review of open and closed medical records on 1/22/14 in the post anesthesia care unit and the inpatient surgical unit revealed documentation of the administration of pain medication did not meet acceptable standards of practice and specifically, those adopted by the hospital.

b. Review of hospital policies and procedures Title: Administration of Medications P&P #07.MM02.01.00
12." Miscellaneous: c. PRN medications administered will be qualified by designating the time of administration and parameters, i.e., blood sugar, blood pressure, pain level, nausea and vomiting".

c. Interviews conducted with recovery room personnel and inpatient nursing staff revealed the location and specific document to annotate the effects of pain medications using a pain scale was inconsistent by the nursing staff. At a minimum initial "First Dose Effects" were documented in the post anesthesia care unit but not on the same document by all nurses. Following her own review of electronic and hard copy medical record entries, S 10 acknowledged she could not provide evidence of compliance with the requirements.



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Based on observations, review of policy and procedures, and staff interviews the facility failed to ensure staff adhered to acceptable standards of infection control practices and their own policies and procedures to provide a safe environment for treating post operative surgical patients, including infection control practices to protect the patient from cross-contamination.

Observations with S15, January 14 at 12:35 p.m. in room 105 revealed the following:

a. Upon entering the patients room S15 explained the medications to the surveyor and the reason for administration of the medication. S15 failed to sanitize hands and glove hands after entering the room, S15 proceeded to hang IV solution, give subcutaneous injection and push medication in peripheral IV port. After administration of medication S15 failed to sanitize hands.

b. Review of facility policy titled " Administering Subcutaneous Injection ", P&P # NU 2.065 revealed the following statement: " 5. Wash hands and don gloves. There is a possibility of encountering blood. "

c. Review of facility policy titled " Transmission Based Precautions-Airborne, Droplet and Contact, P&P # IC 3.0.01 revealed the following statements: " 3. Contact transmission is the most frequent means of transmission of nosocomial pathogens. Usually this involves direct contact and physical transfer of organisms by health care personnel who do not wash hands between patient contacts or use appropriate barrier measures (i.e. gloves, gowns). Less frequently, transmission can result from direct contact between patients or from contamination of items in the environment. Contact Precautions: Gloves for all contact with patient or environment

d. Interview with S15 in the hospital hallway at 12:45 p.m. following her own review of the findings revealed that she did not follow policy and procedure for administration of medications. S15 further stated that she usually sanitize hands and wear gloves while administering medications to patients.

Based on review of medical records, facility contracts, Texas State Board of Pharmacy, and staff interview the facility failed to administer compounded drugs in accordance with acceptable standards of principles in that the facility failed to maintain sufficient records to follow the flow of compounded drugs from entry through dispensation.

The findings included:

a. Review of pharmacy records (drug utilization review) on 1/21/14 at approximately 2:16 p.m. in the pharmacy revealed the following:

(Patient # 7) 1/21/14 Morphine PCA administrated with no lot number and or beyond-use-date documented in the patient's medical record

(Patient # 8) 1/21/14 Morphine PCA administrated with no lot number and or beyond-use-date documented in the patient's medical record

b. Review of facility contracts: No written contract with the compounding pharmacy

c. Texas State of Board of Pharmacy Rule 291.133 stated: A pharmacy that provides sterile compounded preparations to practitioners for office use or to another pharmacy shall enter into a written agreement with the practitioner or pharmacy.
The written agreement shall:
(B) require the practitioner or receiving pharmacy to include on a patient's chart, medication order or medication administration record the lot number and beyond-use date of a compounded preparation administered to a patient;

d. Interview conducted with (S4) on 1/21/14 at approximately 2:20 p.m. in the pharmacy confirmed the facility does not document compounded medications lot number and or beyond-use date in the patient's medical record.