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Based on facility tour and staff interview the facility failed to ensure all medications in the crash cart were immediately available for use. 2 of 3 crash carts in the emergency room contained expired meds.

Findings were:

During a tour of the emergency room of the facility on 8/25/14 the crash cart in room #2 and #4 contained an expired vial of Flumazenil. This medication had expired the last day of March 2014.

In an interview with staff #6 she stated the medication is changed out by the pharmacy and the nurses do not check the expiration dates of the medication in the crash cart.

Based on observation and staff interview the facility failed to ensure all emergency rooms were supplied with unexpired equipment and supplies commonly used in life saving procedures. 2 of 5 rooms contained expired equipment and supplies.

Findings were:

During a tour of the facility on 8/25/14 in the emergency room 2 of 5 of the rooms contained expired equipment and supplies.
* Room 2 crash cart contained multiple expired equipment to include 3 nasotracheal tubes, 1 endotracheal tube, 6 angiocaths, 1 central venous catheter insertion kit, and 1 suction kit.
* Room 4(trauma room) had 3 expired endotracheal tubes on the airway board.

Interview with staff #2 and #6 confirmed the supplies were indeed expired. Staff #6 stated the crash cart and supplies are checked for expiration dates monthly and there is no form of documentation for the nurses to fill out on checking supplies and keeping track of expiration dates or the specific contents of the carts.


28043

During the tour of the facility the morning of 8/26/14 accompanied by the Director of Nursing, Staff #2, the following was observed:
· In the nurses station medication room, there were Glucometer control strips which expired 6/12 and glucometer test strips which expired 5/2012.
This was confirmed during the tour by Staff #2 on 8/26/14.

Based on a tour of the facility and staff interviews, the hospital failed to ensure a safe environment as emergency call lights were not provided or were not available for use and sharp metal was in the shower in a patient room.

Findings included:

A tour of the facility was conducted the afternoon of 8/25/14 accompanied by the Director of Nursing, Staff #2, and Assistant Director of Nursing, Staff #3, who observed and confirmed the following:
· The restroom located in the hospital lobby area had no emergency call light cords. If a patient or family member fell in these restrooms, there would be no way to call for help.
· In patient room 101, the isolation room, the call light was tied up approximately 2 feet from the floor, rendering it out of reach for patient experiencing a fall on the floor to summon help. In the shower, the metal coil around the hose of the flexible, hand held shower head was damaged, revealing multiple sharp metal edges.

A tour of the physical therapy area was conducted the morning of 8/26/14 accompanied by the Director of Nursing, Staff #2 and the Physical Therapist, Staff #21 who observed and confirmed the following:
· In the patient bathroom, the call light cord was wrapped around the handicap bar next to the toiled. The cord was pulled by the surveyor and it did not function due to being wrapped around the handicap bar. This presents a risk for patient safety as the call light would be ineffective for a patient experiencing a fall on the floor to summon help in an emergency.

A tour of the dietary and kitchen areas was conducted the morning of 8/26/14 accompanied by the Director of Nursing, Staff #2 and the Kitchen Manager, Staff #14 who observed and confirmed the following:
· During a tour of the kitchen food prep area, at the entrance to the kitchen area, the dispenser for alcohol-based hand rub was observed installed over the electrical light switches on the wall. The dispenser contained alcohol-based hand rub, which is flammable, creating a fire hazard.

Based on a tour of the facility, review of hospital documentation, and staff interviews, the hospital failed to ensure that pharmacy refrigerator temperatures were logged to ensure that medications were maintained according to manufacturer instructions.

Findings included:

A tour of the pharmacy was continued the morning of 8/26/14 accompanied by the Director of Nursing, Staff #2. Observation of the Pharmacy refrigerator revealed the refrigerator contained multiple medications. A review of the Pharmacy Refrigerator Log for 2014 revealed that there was no temperature logged for the following dates:
· January 1, 4, 5, 11, 12, 18, 19, 25, 30, 31
· February 1, 3, 8, 9, 16, 17, 22, 23, 28
· March 1, 2, 8, 9, 15, 16, 17, 22, 23, 29, 30
· April 5, 11, 12, 13, 18, 19, 20, 26, 27
· May 3, 4, 5, 9, 10, 11, 18, 19, 20, 26, 27
· June 1, 6, 7, 8, 17, 18, 24, 25, 26
· July 4, 5, 6, 11, 12, 13, 19, 20, 23, 24, 25, 26, 27, 28
· August 2, 3, 9, 10, 15, 16, 17, 23, 24

In an interview with the Pharmacy Nurse the morning of 8/26/14 in the pharmacy, she stated that the refrigerator temperatures were not monitored when she was not at work. In reviewing the log for the month of July, there were 6 consecutive days that the temperatures were not monitored; the Pharmacy Nurse stated she had taken her vacation during that week. Failure to follow medication storage/temperature standards can result in subpotent medications; without consistent monitoring of the refrigerator temperatures, it could not be determined that the medications were maintained according to manufacturer specifications.

The above findings were confirmed in an interview with Staff #2 during the tour of the pharmacy the morning of 8/26/14.

Based on credentialing file review, governing board and medical staff bylaws, and staff interview the facility failed to ensure physicians on staff at the hospital had delineation of privileges approved and granted by the governing board of the facility as per medical staff and governing board bylaws. 5 of 5 physicians on staff at the facility did not have delineation of privileges approved by the facility in their credentialing file.

Findings were:

Review of credentialing files for physician #1, #2, #3, #4, and #5 on 8/26/14 revealed the practitioner did not request specific privileges per medical staff bylaws and the governing board did not grant specific privileges to physicians on staff at the facility per governing board bylaws.

Facility policy titled "Medical Staff Bylaws" states, in part "Clinical privileges and scopes of practice are delineated for Practitioners and Allied Health Professionals. Appointment to the Medical Staff shall confer on the appointee only such clinical privileges as have been granted by the Board, in accordance with these Bylaws."

Facility policy titled "Governing Board Bylaws" states, in part "Every Practitioner practicing at the Hospital by virtue of Medical Staff Membership shall be entitled to exercise only those clinical privileges specifically granted to him/her by the Board of Directors."

In an interview with staff #20 on 8/26/14 she verified the credentialing files for physicians did not have delineation of privileges requested and approved for 5 of 5 physician files reviewed.

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

A. Ensure an effective program to identify areas for potential transmission of infections. The infection control nurse did not have training, experience or qualifications in infection control; instruments were not sterilized according to acceptable standards of practice presenting a risk to all patients treated at the hospital, and the hospital was in need of cleaning. Cross refer C0278

B. Ensure that dietary services were provided in accordance with recognized dietary standards, as the kitchen manager did not have education or qualifications as a kitchen manager, the sanitizing solution did not contain the minimum concentration of sanitizer to prevent cross-contamination, there was dried food on kitchen utensils, food was stored improperly, and the diet manual was outdated. Cross refer C0279

C. Ensure that physicians on staff at the hospital had delineation of privileges approved and granted by the governing board of the facility as per medical staff and governing board bylaws. 5 of 5 physicians on staff at the facility did not have delineation of privileges approved by the facility in their credentialing file. Cross refer C0241

D. Ensure that nursing care plans were developed with appropriate nursing interventions based on the needs of the patient and per nursing standards of practice. 19 of 19 patients did not have a nursing care plan developed and updated with interventions and goals for the patient based on their nursing assessment in the acute care setting. Cross refer C0298

E. Ensure that all members of the interdisciplinary team participated in the development of the patient plan of care. 2 of 2 patient charts reviewed did not have documentation from all members of the interdisciplinary team on their plan of care. Cross refer C0395

F. Ensure that the hospital developed, implemented and maintained an effective, ongoing, organization-wide, data-driven Patient Safety Program (PSP), in writing, approved by the governing body, and made available for review by the Texas Department of State Health Services. Cross refer C0271

Based on a review of hospital documentation and staff interview, the governing body failed to ensure that the hospital developed, implemented and maintained an effective, ongoing, organization-wide, data-driven Patient Safety Program (PSP), in writing, approved by the governing body, and made available for review by the Texas Department of State Health Services, as specified in 25 Texas Administrative Code Operational Requirements, 133.48(a)(2). In addition, the facility failed to provide documented evidence of staff training of the Patient Safety Program, according to the requirements of 25 Texas Administrative Code Operational Requirements, 133.48(a)(3).

25 TAC 133.48(a)(2) The hospital must develop, implement and maintain an effective, ongoing,
organization-wide, data-driven Patient Safety Program (PSP).
(A) The governing body must ensure that the PSP reflects the complexity
of the hospital's organization and services, including those services furnished under contract or
arrangement, and focuses on the prevention and reduction of medical errors and adverse events.
(B) The PSP must be in writing, approved by the governing body and made available for review by the department. It must include the following components:
(i) the definition of medical errors, adverse events and reportable events;
(ii) the process for internal reporting of medical errors, adverse events and reportable events;
(iii) a list of events and occurrences which staff are required to report internally;
(iv) time frames for internal reporting of medical errors, adverse events and reportable events;
(v) consequences for failing to report events in accordance with hospital policy;
(vi) mechanisms for preservation and collection of event data;
(vii) the process for conducting root cause analysis;
(viii) the process for communicating action plans; and
(ix) the process for feedback to staff regarding the root cause analysis and action plan.

25 TAC 133.48(a)(3) The hospital must provide patient safety education and training to staff who have responsibilities related to the implementation, development, supervision or evaluation of the PSP. Training must include all PSP components as set out in paragraph (2)(B) of this subsection.

Findings included:

In an interview with the Director of Nursing the afternoon of 8/25/14 and on the afternoon of 8/26/14, a request was made by the surveyor to review the hospital Patient Safety Program. The regulation, 25 TAC, Chapter 133.48 was reviewed with the Director of Nursing. The Director of Nursing stated that the facility did not have a Patient Safety Program in writing, approved by the governing body; there was no documented evidence of a Patient Safety Program provided to the surveyor.

Review of the personnel records for 9 out of 9 hospital staff (Staff #2, 3, 4, 5, 6, 13, 14, 17, and 21) revealed no documented evidence of Patient Safety Program training.

The above findings were confirmed in an interview the afternoon of 8/26/14 with Hospital Administrator and the Director of Nursing in the facility conference room.

Based on observation and interview the hospital failed to identify areas for potential transmission of infections. The infection control nurse did not have training or experience in infection control; instruments were not sterilized according to acceptable standards of practice presenting a risk to all patients treated at the hospital, and the hospital was in need of cleaning.

Findings included:

A tour of the facility was conducted the afternoon of 8/25/14 accompanied by the Director of Nursing, Staff #2, and Assistant Director of Nursing, Staff #3.
The following was observed in the Emergency Department (ED) in the clean utility room the afternoon of 8/25/14:
In the clean utility room, there was a counter top sterilizer. An interview was conducted with Staff #6, ED nurse about the use of the sterilizer in the ED clean utility room.
· Staff #6 stated that she and other nurses sterilized instruments.
· Staff #6 stated that she had not been trained in operating the sterilizer.
· When asked, Staff #6 stated that there was no log book for documenting sterilization activities, including chemical and biological indicator test results, and load numbering of instrument packs. For each sterilization cycle, the specific contents of the lot or load, including quantity, department, and description of the items must be recorded and maintained. This information is essential for product identification and traceability in the event of a sterilization recall.
· Staff #6 stated that the sterilizer was a "flash autoclave" so they did not do any testing of the sterilizer.
· When asked if there was any monitoring of mechanical, chemical or biological indicators for sterilization cycles, Staff #6 stated that no monitoring was conducted for any sterilizer loads of instruments.
· When asked if the time, temperature or pressure was monitored or documented for each load, Staff #6 stated that time, temperature and pressure were not monitored for instruments being sterilized. Staff #6 stated that "I put it [the instruments] in and come back later when it's done and take them out."
· When asked if scheduled daily, weekly, monthly, or quarterly maintenance was conducted on the sterilizer according to manufacturer's instructions for use, Staff #6 stated that there was no maintenance conducted excepted for draining the water out of the sterilizer.
· When asked for the operator's manual for the sterilizer, Staff #6 and Staff #2 were unable to provide an operator's manual. A request was made by the surveyors for the operator's manual for the sterilizer two more times on 8/26/14; there was no documented evidence provided to the surveyors of an operator's manual during the survey. On 8/26/14, Staff #2 stated that she was unable to find the operator's manual for the sterilizer which was in use at the hospital.
· There were 8 instrument packs which were available for patient use which had been sterilized at the hospital and it could not be determined that these instruments were appropriately sterilized. The instrument packs for 3 ophthalmic needle holders had marker ink which had bled through the pack so were no longer sterile. Writing on the paper side of the pack could cause damage to the package (which might not be noticeable) and thereby compromise the barrier protection; there were also water stains on the pack. There were 2 packages of cysto dilators which were available for patient use with water stains on the packs. The wet stains indicate the integrity or barrier protection of the package had been compromised and sterility could not be assured.
· There were 4 hinged instruments where were sterilized in the closed or locked position. When instruments are closed, the sterilizing agent cannot penetrate all surfaces to ensure complete sterilization of all surfaces of the instruments.
· There was a roll of indicator tape in the sterilizer area; however there was no tape or indicators in the sterilizer packs containing instruments which were available for patient use. Internal and external indicators had not been used with the packs observed by the surveyors. This was confirmed with Staff #6, #2, and #3 during the tour of the ED.
· In the clean utility room, there were jugs of distilled water on and around the handwashing sink, which made the sink difficult to access. The sink was next to the supply rack where the sterile instruments were stored causing waster to splash on the sterilized instruments. Sterile items or packs that become wet are considered contaminated because moisture brings with it microorganisms from the air and surfaces.

· In the clean utility room, there were two 500 ml IV fluid bags in the blanket warmer which were not dated to indicate when they were placed in the warmer. IV fluids should not be left in the warmer longer than 2 weeks; there was no means to determine how long the IV bags had been in the warmer.
· In the clean utility room, there was a bottle labeled "Enzyme AW Cleaner" which expired on 12/2011 and a bottle labeled "Surgistain cleaner" which expired on 5/2012, both available for use.
· In the clean utility room in the red phlebotomy case, there were 4 grey lab tubes which expired on 7/2014 observed on 8/25/14. The lab tube holder had reddish-brown drips on the case and there was an open, exposed needle in the bottom of the case, presenting a risk for cross-contamination.
· In the Emergency Department room 3, the privacy curtain was in need of cleaning as there were three stained areas.
· In the Emergency Department Trauma room 4 crash cart, there were 7 laryngoscope blades in the crash cart lying on stained paper towels. Laryngoscope blades should be sterilized or high-level disinfected and not lying on stained paper towels.
· In the Emergency Department room 5, there were scrubs and towels prepared for a precipitous delivery which were on a cart uncovered. Uncovered linen increases the risk for cross-contamination.

In the CT room, there was a dirty, corrugated box stored with the supplies available for use with patients. There was an opened, used syringe, partially filled with a clear liquid in the CT room lying on the cart next to the CT scanner. This presents a risk for cross contamination. There was a large, red sharps container on a wheeled cart which did not have a lid to contain the biohazard waste and sharps if it were to tip over. There was waste visible in the container. This presents a risk for cross contamination.

There were water damaged ceiling tiles with water stains in the pharmacy hallway; the presence of water damaged tiles indicated a potential for contamination from the moisture and bacterial particles.

A tour of the facility was continued the morning of 8/26/14 accompanied by the Director of Nursing, Staff #2 and the following was observed in the nursing area:
· In the clean utility room, there was a specialty mattress, available for patient use, which was stored on the floor in a large bag, which presents a risk for cross contamination.
· The west side external door had insufficient door seals or weather stripping, leaving a gap between the doors and the frame with outside light visible seen from inside the building. The lack of weather stripping or seals prevents a risk for contamination from the weather and the entry of insects and other environmental contaminants such as dust and debris.

A tour of the physical therapy area was conducted the morning of 8/26/14 accompanied by the Director of Nursing, Staff #2 and the Physical Therapist, Staff #21 and the following was observed:
· There was linen available for patient use, including towels and gowns stored open and uncovered under the PT tables; this presents a risk for cross contamination.

A tour of the materials management area was conducted the morning of 8/26/14 accompanied by the Director of Nursing, Staff #2 and the following was observed:
· The external doors had insufficient door seals or weather stripping, leaving a gap between the doors and the frame with outside light visible seen from inside the building. The lack of weather stripping or seals prevents a risk for contamination from the weather and the entry of insects and other environmental contaminants such as dust and debris.
· There were multiple dirty, corrugated external shipping boxes stored on the shelves with supplies available for patient use, including opened supplies such as exam gloves, lotion, shampoo, adult diapers, baby bottles, emergency disposable obstetrical kit, laceration trays, and suture removal trays. Storing patient use items in contact with a contaminated external shipping box/container, makes cross contamination likely.

Maintenance records for the sterilizer were provided to the surveyors by Staff #2 the afternoon of 8/26/14, which revealed the following:
· A document entitled, "Maintenance log for Sterilizer Weekly" which stated, "(Do Weekly maintenance every Sunday on 7pm shift) revealed that maintenance was logged between 12-18-08 through 10-22-10. There were weeks and months in which the maintenance was not documented, revealing inconsistent maintenance of the sterilizer. There was no documented evidence provided to the surveyors that sterilizer maintenance was conducted after October 2010.
· This presents a risk for cross contamination as sterilizers should be inspected and cleaned according to the manufacturer ' s written instructions when used to sterilize instruments for use in patient care.
· Despite several requests by the surveyors, there was no documented evidence provided to the surveyors of an operator's manual during the survey.

Facility policy, "Sterilization" states, in part, "PROCEDURE: 1. All items processed will be properly wrapped and processed in such a manner that will provide an effective barrier to microorganisms." There was no policy or documented evidence provided to the surveyors of the hospital's sterilization process.

Review of the job description for the Infection Control Nurse stated, in part, "QUALIFICATIONS/EDUCATION: ...demonstrates an understanding of the principles of epidemiology and infectious disease in the hospital."

In an interview with Staff #5, Infection Control Nurse, the afternoon of 8/26/14, she stated she had only been in the position for a couple of days and she had no experience, training, or qualifications in infection control.

Review of the personnel record for Staff #5, Infection Control Nurse, revealed no evidence of infection control training, experience, or qualifications as an infection control nurse.

In an interview with the Director of Nursing the afternoon of 8/26/14, she stated that "We have had 6 Infection Control Nurses in the past few years. None of them have had any training in Infection Control."

Facility policy, "Trash and Linen" states, in part, "LINEN: Linen should be covered at all times."

The above findings were confirmed in an interview with Staff #2, Director of Nursing the afternoon of 8/26/14 in the facility conference room.

Based on a tour of the dietary and nutrition areas of the hospital, the hospital failed to ensure that dietary services were provided in accordance with recognized dietary standards, as the kitchen manager had no education or training or qualifications as a kitchen manager, the sanitizing solution did not contain the minimum concentration of sanitizer to prevent cross contamination, there was dried food on kitchen utensils, food was stored improperly, and the diet manual was outdated.

Findings included:

A tour of the dietary and kitchen areas was conducted the morning of 8/26/14 accompanied by the Director of Nursing, Staff #2 and the Kitchen Manager, Staff #14 and the following was observed:

During a tour of the kitchen food prep area, the surveyor requested the sanitizer log for the bucket of sanitizing solution. There was no log provided; staff #14 stated that a log was not maintained. The surveyor requested that Staff #14 test the red bucket of sanitizing solution.

When the bucket of sanitizer concentration was tested on request of the surveyor, there was no color change registered on the strip to indicate any concentration of the disinfectant/sanitizer in the liquid, or less than 50 PPM, indicating the sanitizer did not have the proper solution to sanitize or disinfect the food preparation area.

Pathogenic microorganisms can survive and contaminate food products if food-contact surfaces are not properly cleaned and sanitized with a sanitizing agent maintained at the proper level. When asked, Staff #1 stated that a log was not maintained to demonstrate sanitizer solution testing; there was no documented evidence provided to the surveyor to indicate that sanitizing solutions were being tested.

When Staff #14 was asked if she knew how to read the strip to ensure the proper concentration, she stated she did not. This was confirmed during the tour by Staff # 14 and Staff #2. This presents a risk for cross contamination of food preparation surfaces without sufficient sanitizer concentration.
· In the dishwashing room, the Kitchen Manager, Staff #14, was asked for the temperature logs or logs for checking the sanitizer concentration in the automatic dishwashing machine. Staff #14 stated that the temperatures and the concentration of the sanitizer were not monitored or logged to ensure proper sanitizing of dishware.
In the food prep area, the follow items were observed, available for use in patient food preparation:
· One ladle was hung over the food prep area which had dried food adhered to the bowl; another ladle had water spots inside the bowl indicating the ladle was hung up wet.
· There were 2 bowls and 3 pans with dried food adhered to the surface.
· There were 2 metal pie tins and 3 muffin tins with flaking carbon build-up and what appeared to be dried food.
· The measuring cups and measuring spoons had an oily substance and there was dried food adhered to the surface.
· There was dust and debris on the top of the reach-in ice machine door, which presented a risk for the dust and debris to fall into the ice.
· The counter top mixer and bowl were greasy and had dried food adhered to the surfaces.
· The industrial Hobart mixer was in need of cleaning as it was greasy and there were white splatters on the underside over the bowl.
· There were 2 knives with chipped blades and 3 knives with dried food adhered and there was a thick, black, sticky substance on all three knives where the blade shank was attached to the knife handle (the bolster).
· There was a greasy film on the industrial mounted manual can opener.
· The large trash cans in the kitchen had lids attached; however, there was no means to dispose of trash or dispose of paper towels after handwashing except to touch the trash can lid. This creates a risk for contamination of hands.
Review of the refrigerator log sheets in the kitchen for the reach-in refrigerator, the under counter refrigerator, the under counter freezer, the walk-in refrigerator, and the walk-in freezer revealed no indication of the proper temperature ranges for the refrigerators or the freezers; there were no instructions outlining the steps to be taken if the temperature was out of range.
· In the walk-in freezer, there were 2 zip-lock bags containing nuts which were not labeled with a date.
· The weather stripping for the external door had deteriorated; the lack of weather stripping or seals prevents a risk for contamination from the weather and the entry of insects and other environmental contaminants such as dust and debris.
· In a closet in the kitchen, there were clear plastic spray bottles containing liquid. One bottle was labeled "bleach water" and another bottle was labeled "oven cleaner". There was no date on the bottles to indicate the concentration or when the contents had been mixed or expired. When asked if there was Material Safety Data Sheet information for these chemicals, the surveyor was told there was none.
During a tour of the dry food storage room the morning of 8/26/14 accompanied by the Director of Nursing, Staff #2 and the Kitchen Manager, Staff #14, the following was observed:
· There was a thick layer of dust on high and low horizontal surfaces.
· There was a box containing an artificial Christmas tree on top of the shelving above food supplies; there was also a corrugated box of Halloween decorations stored on top of the shelving above food supplies, all available for patient use.
· There was a dented Ensure can in the food supply stock.
· There were multiple containers of bottled water (one gallon and 2.5 gallon containers) which were dusty and appeared to be old. There was no date on the containers, the paper labels were brittle, and the containers, though closed, were not full, indicating leakage or evaporation. When a container was removed from the shelf, it began to leak water onto the floor.

In an interview with Staff #14, Kitchen Manager, when asked if the hospital had a four day supply of food on available, she stated that there was not a four day supply of food available at the hospital.

In an interview with Staff #14, Kitchen Manager, she was asked to provide the hospital's current diet manual in use. Staff #14 provided the Texas Dietetic Association Manual for 2008. The current manual was last revised in 2013; the hospital was using an outdated diet manual.

During a tour of the nurses unit the morning of 8/26/14, the nurses in the unit were asked if they could provide the current dietary manual in use. The nurses stated they did not know if the hospital had a dietary manual. When the surveyor suggested the manual might be with the policies, the Texas Dietetic Association Manual 2008 was observed on the shelf with nursing policies in another room. The Texas Dietetic Association Manual was last revised in 2013.

Review of the personnel record for Staff #14, Kitchen Manager, revealed no documented evidence of training or qualifications as a food service manager. In an interview with Staff #2, Director of Nursing and the HR Director, these findings were confirmed.

Review of the "Consultant Dietitian's Report - Hospital" provided to the surveyors on 8/26/14 revealed the following:
8/14/14: "No noted sanitation or food safety concerns."
7/15/14: "No noted sanitation or food safety concerns."
4/9/14: "No noted sanitation or food safety concerns."
3/13/14: "No noted sanitation or food safety concerns."
2/12/14: "No noted sanitation or food safety concerns."

Facility policy, "Trash and Linen" states, in part, "TRASH: ...**Good handwashing is stressed after handling any trash."

Facility policy, "Dietary Infection Control Policy" states, in part, "PURPOSE: To develop and maintain clean and sanitary work areas, storage areas and equipment for the handling of supplies in accordance with state and local health department standards ...Procedures for preparation and serving of food must be such as to minimize contamination by microorganisms and chemicals that may result in food poisoning ...FOOD SUPPLY AND STORAGE ...10. All openings to the outside should be rodent and insect proof ...EQUIPMENT ...4. Food grinders, choppers, slicers and mixers should be cleaned and sanitized after use ...6. In dishwashing machines, all dishes must be washed at a temperature of at least 140 F. and rinsed at a temperature of at least 140 degrees F."

The above findings were confirmed in an interview the afternoon of 8/26/14 with the Hospital Administrator and Director of Nursing in the hospital conference room.

Based on medical record review, nurse practice standards, and staff interview the facility failed to ensure the nursing care plan was developed with appropriate nursing interventions based on the needs of the patient and per nursing standards of practice. 19 of 19 patients did not have a nursing care plan developed and updated with interventions and goals for the patient based on their nursing assessment in the acute care setting.

Findings were:

Review of medical records for acute care inpatients on 8/26/14 revealed the patients had problem lists developed that were incorporated into the nursing notes for the patient. The problems identified had no documentation of goals for the patient or nursing interventions identified based on the assessment and needs of the patient. Patient #4 and #16 had a diagnosis of acute kidney failure and no mention of this diagnosis was mentioned in the problem list documented in the nursing notes. Patient #10 and #12 had changes in their breathing patterns with additional orders from the physician for oxygen and drug therapy. The new diagnosis and problem was not documented on the problem list and and no goal or interventions to address this need was developed on the plan of care.

Review of the Texas Nurse Practice Act §217.11. Standards of Nursing Practice, states, in part,
"(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ...
(D) Accurately and completely report and document:
(i) the client's status including signs and symptoms;
(ii) nursing care rendered;
(iii) physician, dentist or podiatrist orders;
(iv) administration of medications and treatments;
(v) client response(s); and
(vi) contacts with other health care team members concerning significant events regarding client's status."

In an interview with the director of nursing on 8/26/14 she confirmed the current process in the hospital for patient care did not include a nursing plan of care that established goals for the patient and included documented interventions to provide care for the patient based on assessment or changes in assessment on the patients.

Based on medical record review, policy review, and staff interview all members of the interdisciplinary team did not participate in the development of the patient plan of care. 2 of 2 patient charts reviewed did not have documentation from all members of the interdisciplinary team on their plan of care.

Findings were:

Review of medical records for patient #13 and #21 on 8/26/14 revealed all members of the interdisciplinary team did not participate and document development of the patient plan of care and patient goals. Patient #13 had a blank plan of care in his medical record for the period of time from admission on 6/26/14 until he was changed to palliative care on 7/6/14. Patient #21 was admitted to swing bed on 8/16/14 and had no documentation on the Patient Interdisciplinary Patient Care Plan by Pharmacy or Physical Therapy as of the time of chart review on 8/26/14.

Facility policy titled "Swing Bed-Total Care/Discharge Plan" states, in part "The Plan will be interdisciplinary to ensure the patient is able to receive coordinated care that is required for his/her improvement. Discipline/Responsibility-ALL departments are to coordinate care to resolve the functional identified need. Progress of the functional need will be noted by each department as related to that department's interventions for the specified problem."

In an interview with staff #2 she stated the patients in swing bed program did not have documentation of input from the entire interdisciplinary team in the development of their plan of care.