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Based on observation, review of documentation, and interview with staff, it was determined that the facility failed to have an effective Governing Body legally responsible for the conduct of the facility as an institution. The Governing Body failed to ensure that the environment was maintained to ensure patient safety as respiratory supplies were being stored in the dirty utility room of the Emergency Department and instruments were not being properly sterilized and were available for patient use. Life saving equipment in the Nursery was not properly maintained. Drugs and biologicals were not stored appropriately. Patient supplies were expired and available for patient use. Informed consents were not properly executed prior to surgery, and physician orders were not dated and timed. Personnel files were incomplete and the facility failed to follow company policy.

Findings were:

1. During a tour conducted on August 22, 2011 of the Emergency Department at 2:50pm, the survey team found bagged respiratory supplies, on a peg board on the right wall of the dirty utility room. The dirty utility room was used to clean instruments. On the left side of the counter was a battery charger with batteries charging and cleaned instruments on the same counter. On the right side of the floor just below the sink used to scrub the instruments, was a donated box of toys. All of the supplies were available for patient use.

2. During a tour conducted on August 22-24, 2011, the survey team found significant amount of "sterile instruments" which were improperly sterilized which were available for patient use.

3. The red two piece tool box in the Nursery, referred by Staff #8 as "the crash cart" , had a jammed third drawer labeled "IV supplies" . The drawer failed to open and the attempts were made by the surveyor, Staff #8, and Staff #1. The first drawer stored the intubation supplies opened but did not have a handle.

4. Drugs and biologicals were not properly stored according to policy and procedure.

5. During a tour conducted on August 22-24, 2011 on the nursing units, the survey team found expired medications and supplies available for patient use.

6. Review of patient records and interview with staff, physician orders were not dated and timed.

7. Review of surgical patient records 4 of 5, the informed consent was not properly executed as either the consent for blood products in the event of an emergency was not marked and/or the date and/or time the patient signed the consent was missing.

8. Review of personnel records and interview with staff on August 23, 2011, one of five licensed vocational nurses and 1 of 6 physicians did not contain any evidence of a current CPR certification; 9 of 28 employee records did not contain any evidence that the employee received a position description; and 3 of 28 personnel records did not contain evidence that the employee received an annual performance evaluation.

Review of Corporate Policy #106 entitled, "Position Descriptions" revealed, "Upon hire, employees will receive a copy of the Position Description applicable to the job which they are to perform. At this time, the HR Coordinator will review the Position Description with the employee and will have the employee sign."
Review of Corporate Policy #142 entitled, "Performance Management" revealed, "All employees will receive and participate in a performance evaluation annually." The above was confirmed in interview with Staff #1.



CROSS REFER:
Tag A0144 Patient Rights: Care in Safe Setting, 42 CFR 482.13(c)(2)
Tag A0404 Administration of Drugs, 42 CFR 482.23(c)
Tag A0454 Orders Dated and Signed, 42 CFR 482.24(c)(1)(i)-(ii)
Tag A0501 Pharmacist Supervision of Services, 42 CFR 482.25(b)(1)
Tag A0724 Facilities, Supplies and Equipment Maintenance, 42 CFR 482.41 (c)(2)
Tag A0747 Infection Control, 42 CFR 482.42
Tag A0955 Informed Consents, 42 CFR 482.51(b)(2)

Based on observation, review of documentation, and interview with staff, it was determined that the facility failed to properly maintain life saving equipment in the Nursery which was available for patient use. The facility staff failed to check the crash cart daily for safe working condition.

Findings were:

During a tour on August 23, 2011 of the Nursery at 2:45pm, the surveyor attempted to open the red two piece tool box, referred by Staff #8 as "the crash cart" . The third drawer was jammed which was labeled "IV supplies" . The drawer failed to open during multiple attempts made by the surveyor, Staff #8, and Staff #1. The first drawer of "the crash cart" stored the intubation supplies opened but did not have a handle.

Corporate Policy/Procedure entitled, "Crash Carts" stated, "Purpose: To assure that the drugs and equipment are available when needed." Further review of this policy revealed, "Procedure: 1. The supervisor/charge nurse will be responsible for performing a routine check of equipment on the crash cart at the beginning of each shift. 4. Equipment will be cleaned if necessary and check for working order."

Corporate Policy entitled, "Cardio-Pulmonary Resuscitation on Infant and Children" stated, "Purpose: To establish protocol for the methods employed by physicians, nurses and ancillary personnel with specific training to restore cardiac, circulatory, ventilatory and metabolic function of the infant or child who suffers sudden and unexpected clinical death." Further review of the policy stated, "Essential steps 9. Start IV of 250cc's D5W as a "keep open"."

The above was confirmed in an interview on August 23, 2011 by Staff #1.

Based on observation, review of documentation, and interview with staff, it was determined that the facility failed to administer drugs and biologicals with accepted standards of practice. The surveyors found approximately 112 medications were the sterility had been compromised and were available for patient use.

Findings were:

During a tour of the facility on August 22-24, 2011, approximately 112 medications were found which the sterility had been compromised and were available for patient use.

For example:

1. Tracheotomy kit - Lidocaine 30ml expired 11/2008
2. Chest tube tray- 1% Lidocaine 10ml expired 1/2008, handwritten open vial 06/1/2006
3. Calcium Chloride 100mg/ml expired 07/2011
4. Sodium Bicarbonate 1mEq/ml expired 06/2011
5. Lidocaine 10mg/ml 5ml expired 04/01/2011
6. 2% Lidocaine/Epinephine 20 ml opened not dated
7. Lidocaine Jelly 2% 30 ml expired 02/2011

The above was confirmed in an interview on August 23, 2011 by Staff #1.

Based on observation, review of documentation, and interview with staff, it was determined that the facility failed ensure that all patient orders were signed, dated, and/or timed as 18 of 30 charts reviewed had incomplete entries.

Findings were:

During a review of patient medical records on August 24, 2011, eighteen of thirty patient clinical records revealed incomplete entries. Patient orders either were missing the signature of the provider, date, and/or time.
For example:

1. Patient #16 was missing the physician signature and date on the "Venous Thromboembolic Prophylaxis Order" form.

2. Patient #17 was missing the physician signature and date on the "Venous Thromboembolic Prophylaxis Order" form. Physician order was not dated or timed 08/02/2011. The Registered Nurse noted the order on 08/02/2011 at 0910.

3. Patient #24 was missing the physician time on the "Physicians orders for Patient Discomfort" form. Also revealed in the clinical record was a telephone order dated 08/07/2011 at 0030 which had not been authenticated within the 48 hours and was not flagged for the practitioner to complete.

4. Patient #25 was missing the date and time on the "Covenant Health System- Levelland Physician Discharge Orders" form. Further review revealed a time missing on an order dated 07/29/2011 and on 07/26/2011, a telephone order which had not been authenticated as well as a patient name/label was not on the page in the patient's clinical record. The clinical record was not flagged for the practitioner to complete.

5. Patient #26 was missing the time on the physician order dated 07/23/2011. Further review also revealed on the "Venous Thromboembolic Prophylaxis Order" form the physician signature and date was missing.


The above was confirmed in an interview on August 23, 2011 by Staff #1.

Based on observation, review of documentation, and interview with staff, it was determined that the facility failed to follow its own policies and procedures as approximately 112 medications were found which the sterility had been compromised and were available for patient use.

Findings were:

During a tour of the facility on August 22-24, 2011, approximately 112 medications were found by the surveyors, which the sterility had been compromised and were available for patient use.

For example:

1. Tracheotomy kit - Lidocaine 30ml expired 11/2008
2. Chest tube tray- 1% Lidocaine 10ml expired 1/2008, handwritten open vial 06/1/2006
3. Calcium Chloride 100mg/ml expired 07/2011
4. Sodium Bicarbonate 1mEq/ml expired 06/2011
5. Lidocaine 10mg/ml 5ml expired 04/01/2011
6. 2% Lidocaine/Epinephine 20 ml opened not dated
7. Lidocaine Jelly 2% 30 ml expired 02/2011


Corporate Policy entitled, "Department of Pharmaceutical Services, Job Description: Staff Pharmacist" stated, "VII: Duties and Responsibilities, M. Identifies, quarantines, and replaces or supervises identification, quarantine, and replacement of outdated and unusable medications. P. Supervises drug storage and preparation areas within the pharmacy and throughout the hospital. Q. Conducts monthly inspections of all nursing units and areas of the hospital where medications are dispensed, administered, or stored. R. Develops and enforces policies and procedures relating to the safe and effective use drugs in the hospital."

Corporate Policy entitled, "Department of Pharmaceutical Services, Routine Distribution of Inpatient Medications" stated, "I. Policy: A. All medications dispensed to or administered to an inpatient of Methodist Hospital, Levelland ... following all federal, state and local laws and regulations, and all policies and procedures of this facility."

Corporate Policy entitled, " Department of Pharmaceutical Services, Administrative & Operational" stated, "6. Drugs a. Outdated drugs are removed from dispensing stock and are quarantined together until such drugs are disposed of."


The above was confirmed in an interview on August 23, 2011 by Staff #1.

Based on observation and interview with staff, it was determined that the facility failed to ensure the safety of patients as approximately 204 patient supplies were available for patient use.

Findings were:

During a tour of the facility on August 22-24, the surveyors found approximately 204 patient supplies expired and available for patient use.

For example:

1. Neonatal Speci-Cath Kit expired 5/2003

2. Pedi Lumbar Puncture Tray x2 expired 9/2009

3. Adult Lumbar Puncture Tray x2 expired 3/2011

4. Portex Pro-Vent Arterial Blood Sampling Kit x4 expired 11/2007 and x1 in 1/2010

5. Sterile Gloves - Small x 94 expired 12/2006

Corporate Policy entitled, "Outdated Hospital Processed Supplies" stated, "5. Rotation of supplies is important to insure (sic) that "old" supplies are used prior to "new" supplies."

The above was confirmed in an interview on August 22-23, 2011 by Staff #1.

Based on observation, review of documentation, and interview with staff, the facility failed to ensure a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Findings were:

Observation in the Emergency Department during a tour of the hospital on 8-22-11 revealed 9 forceps, hemostats and scissors that had been sterilized and stored in the closed position and those with lock boxes were in the locked position. Observation in the Nursery during a tour on 8-23-11 revealed 6 hemostats and scissors that had been sterilized and stored in the closed position and those with lock boxes in the locked position. Observation in the surgical suite revealed 14 hemostats and scissors that had been sterilized and stored in the closed position and those with lock boxes were in the locked position. When one package of the scissors was opened, the interior of the closed surface was reddish-brown in appearance. It could not be determined that these surfaces were appropriately cleaned. When instruments are closed, the sterilizing agent cannot penetrate all surfaces to ensure complete sterilization of all surfaces of the instruments. Review of hospital policy "Assembling of Instrument Sets" revealed "8. All jointed instruments are opened or unlocked and disassembled where possible." The above was confirmed with Staff #1 and #9.

Observation in the emergency department during a tour of the hospital on 8-22-11 revealed a wrapped egg crate pad on the floor in the supply room, available for patient use. The base of the cabinets under the sinks in ED rooms 2, 3, and 4 were covered in visible, raised dust and brown and black dirt and debris and the laminate was peeling. Observation of a stool in the ED room 2 available for patient use revealed several tears, ranging from 2 to 4 inches, and 7 holes approximately ? inch, and a large 1 x ? inch hole in the vinyl covering, which could not be properly disinfected. There was a 6 x 2 inch hole in the sheetrock in the hallway between the patient lobby and the emergency department which could allow the entry of dirt particles, rodents, and insects. The floor in the hallways could not be properly disinfected as there were 8 floor tiles that were chipped with missing pieces. In ED room 3, double-sided tape which could not be disinfected was used to attach emergency medications to a tray; black particles, ink marks, and spilled content were observed on the tape next to the medications. In ED room 4 a layer of white dust and small clumps of dust were observed on horizontal surfaces. This was confirmed in interview on 8-22-11 with Staff #1 and #2. Review of hospital policy entitled, " Infection Control Housekeeping Services" revealed "Patient Rooms: All upward facing horizontal surfaces shall be damp cleaned daily."

Observation on 8-22-11 in the emergency department in a room labeled "Dirty Utility" was an open cardboard box on the floor containing small stuffed animal toys next to the sink used to wash dirty surgical instruments prior to sterilizing. There were two medical device battery chargers plugged in on the counter next to the same sink containing two batteries which were used for medical devices used in the ED. On the wall adjacent to the sink and counter used for washing dirty surgical instruments was a peg board on which were hung the respiratory supplies for patients in the ED. There were greater than 35 supplies, consisting of oxygen masks, tubing, suction, nebulizer and other equipment. It could not be determined that the stuffed animal toys, batteries, and respiratory supplies available for patient use were not exposed to infectious airborne agents dispersed while the dirty instruments were being washed . The above was confirmed in interview with Staff #1, 2 and 5 on 8-22-11. Review of the job description entitled, "Respiratory Care, Inc. Department Manager Job Description" revealed "2. Assure necessary equipment is available and in clean, operable condition and ready for immediate use."

Observation in the radiology department revealed ultrasound gel available for patient use stored on the floor in the storage room. In x-ray room 2, a 4 x 2 foot area on two walls that joined in the corner of the room was moisture damaged and was stained. The floor and the baseboard at the corner were dirty, with black particles and stains. Observation in the CT room revealed a bucket on the floor of the cabinet beneath the sink under the pipe which contained approximately 3 ounces of a reddish-brown, rust-colored liquid. The above was confirmed in interview with Staff #1 and #6. Based on interview with Staff #1 and #6 on 8-23-11, the bucket was in place to catch water from leaking pipes.

Observation in the radiology department, the medical/surgical floor, the nursery, the laundry, the operating room, and the emergency department revealed exposed unwrapped linen and pillows on shelves and carts available for patient use and it could not be determined that the linen was protected from contamination. Observation in the medical/surgical unit hallway and the clean linen area of the laundry revealed staff transporting uncovered linen on a cart in red bags labeled with the universal biohazard symbol and the words " BIOHAZARD " directly on top of clean folded linen. Interview with Staff #1 and #2 confirmed in interview on 8-23-11 that clean linen was transported in red biohazard bags and that dirty linen was also transported in red biohazard bags, and the bags used to transport clean and dirty linen were not differentiated by color or the biohazard label. Review of hospital policy entitled, "Infection Control Housekeeping Services" revealed "Clean linen supplies shall be distributed daily in a covered clean linen cart designated for this purpose ...Clean linen shall remain wrapped until needed and/or cart covers lowered and zipped when carts are not in use. There shall be no contact between soiled and processed linen. Separate carts shall be used for transport ...Separate containers shall be used for transporting soiled and clean linen." The above was confirmed with Staff #1 and Staff #2.

Observation in the boiler room during a hospital tour on 8-23-11 revealed a bent and partially removed 4 x 1 foot vent cover in the cinder block wall, and a missing drain cover in the floor, which could allow entry of dirt particles, rodents, and insects. Observation in the hospital storage room with equipment available for patient use revealed dust on horizontal surfaces, water damaged ceiling tiles, a dirty brown/black substance on the ceiling air return grill, an uncovered egg crate mattress on a hospital bed, 3 portable toilets with a reddish-brown substance on the legs. This was confirmed in interview on 8-23-11 with Staff #1 and #2. Review of hospital policy entitled, "General Cleaning and Sanitation" revealed "All patient and non-patient rooms shall be thoroughly cleaned and/or disinfected, keeping in mind Standard Precautions and infection control." The above was confirmed with Staff #1 and Staff #2 on 8-23-11.

Observation in the physical therapy department during a tour of the hospital on 8-23-11 revealed an in-wall air conditioner unit next to the patient table which contained dirty brown dust, debris, paper trash. This was confirmed in interview with Staff #1 and 3.

Observation in the Clean Room in nursing station #1 during a tour of the hospital revealed that the floor and shelf in the cabinet under the sink was warped and peeling and was covered in a black and grey dusty substance, spill marks, and peeling paint. There was a 2 x 1 foot square opening in the sheetrock which had a piece of ill-fitting sheetrock screwed in, leaving a gap which could allow entry of dirt particles, rodents, and insects. There was a pipe extending through the floor which was not sealed, leaving a ? - 1 inch gap in the floor which could allow entry of dirt particles, rodents, and insects. There was a raised area of brown and black dust, dirt, and debris in a corner of the room on the floor. Observation in nursing station #2 during a tour of the hospital on 8-23-11 revealed the plywood floor of the cabinet under the sink in the dirty utility room was warped, broken and stained. There was a layer of dust on the horizontal surfaces of the crash cart. There was a dirty air vent with a spider web containing dead bugs hanging down from the vent in the Station 2 patient care hallway. This was confirmed in interview on 8-23-11 with Staff #1 and #2.

Observation in the ultrasound room during a tour of the hospital on 8-23-11 revealed cracks and torn areas and worn seams covered with tape on the patient examination table. The worn areas, cracks, tears, and use of clear tape prevent the mattresses from being properly disinfected after patient use. This was confirmed in interview with Staff #1.

Based on observation, review of documentation, and interview with staff, it was determined that the facility failed to properly complete an informed consent prior to the admission into Surgery as 4 of 5 consents were incomplete.

Findings were:

1. Patient #5 did not mark the "I (we) (do) (do not) consent to the use of blood and blood products as deemed necessary." The patient also did not date and time the consent form. The physician failed to time the consent form.

2. Patient #21 did not mark the "I (we) (do) (do not) consent to the use of blood and blood products as deemed necessary." The patient also did not date and time the consent form. The Registered Nurse failed to sign as the "Witness to Signature of Patient or Representative."

3. Patient #27 did not mark the "I (we) (do) (do not) consent to the use of blood and blood products as deemed necessary." The patient also did not date and time the consent form. The physician failed to time the consent form.

4. Patient #29 did not mark the "I (we) (do) (do not) consent to the use of blood and blood products as deemed necessary. " The patient also did not date and time the consent form.


The above was confirmed in an interview on August 24, 2011 by Staff #1.