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Based on observation and interviews, the hospital did not ensure that all patient care equipment was safely maintained, in that, expired equipment was available for patient use in 3 of 4 patient care areas.

During a tour of the hospital the afternoon of 06/22/10 with a registered nurse who also works in the hospital's Emergency Department (ED), (Personnel # 23), the surveyor noted the following expired equipment was available for patient use in the following areas:
ED Crash Cart:
4- needles, 14 gauge, expired 05/00.
1- endotracheal tube, 4.0, expired 03/07.
Medical/Surgical Crash Cart:
2-Cardiac electrode packages, expired 06/20/10.
1- butterfly needle, 19 gauge, expired 08/02.
2-butterfly needles, 23 gauge, expired 03/06.
Radiology:
2-X-ray cassette bags, large, expired 12/05.
8-butterfly needles, 23 gauge, expired 11/07.

In an interview the afternoon of 06/22/10 with Personnel # 23, he confirmed the above expired equipment had been available for patient use in those 3 patient care areas.

Based on observations and interviews, the hospital did not ensure that drugs and biologicals were appropriately stored in 3 of 3 patient care areas.

1) During a tour of the unlocked Respiratory Therapy office and patient supply storage area the afternoon of 06/21/10, the surveyor observed unsecured drugs kept in the Respiratory Director's (Personnel #12) desk drawer which included:
6- Xopenex 1.25 milligrams
16-Xopenex 0.63 milligrams
24-Xopenex 0.31 milligrams
25-Sodium Chloride 3 milliliter vials
7-Budesonide Inhalation suspension 0.25 milligrams
31-Budesonide inhalation suspension 0.5 milligrams
10- Duo Neb 3 milliliters
5-Pulmicort Respules 0.25 milligrams
36-Ipratropium Bromide inhalant solution 0.5 milligrams
5-Racepinephrine inhalant solution 0.5 milligrams
1-Decadron 4 milligram vial
In an interview the afternoon of 06/21/10 with the Respiratory Director (Personnel #12), he was asked if the Respiratory Therapy office and patient supply storage area was normally unlocked. He confirmed that the above drugs and biologicals had been kept in an unlocked drawer in his unlocked office.

2) During a tour of the hospital Emergency Department (ED) the afternoon of 06/22/10, the surveyor observed the following unsecured drugs in open cabinets with no doors in the ED:
3-Xylocaine 1%, 50 milliliter bottles
2-Xylocaine 2%, 50 milliliter bottles
2-Heplock flush, 10 milliliters
2-Sodium Chloride, 30 milliliter bottles
2-Sterile Water, 10 milliliter bottles
Also observed in the unlocked Eye Tray in the ED:
1-tube of Gentamycin eye ointment
1-Tropicamide opthalmic solution
1-Maxitrol ointment
3-Tetracaine 1/2 %, 2 milliliters
1-Gentamycin ointment, 3.5 gram tube
1-Tobramycin 3 % opthalmic solution
In an interview the afternoon of 06/22/10 with an ED nurse (Personnel #23), he was asked if the above drugs and biologicals are routinely unsecured, and he said "yes."

3) On a tour of the Medical/Surgical unit's area where drugs that are refrigerated are kept, the surveyor observed the following medications had been stored in an unlocked refrigerator:
1-Humalog 10 milliliter insulin bottle
1-Humulin R U-100 10 milliliter bottle
1-Novolog U-100 10 milliliter bottle
1-Influenza vaccine 5 milliliter bottle
In an interview the afternoon of 06/22/10 with a registered nurse (RN) who works on the Medical/Surgical unit (Personnel #23), he was asked if the above drugs were routinely kept in an unsecured refrigerator, and he said "yes."

The pharmacy "Monthly Inspections of Nursing Stations," policy, undated, noted that:
-"The pharmacist will be responsible for recorded periodic inspections of the nursing stations floor stock inventories and patient medication storage areas at least monthly."
This policy does not address appropriately stored drugs and biologicals. The only pharmacy policy that addresses the security of drugs refers to controlled substances only.

Based on review of records and interview, the hospital's medical records were not complete in that the medical record entries for 15 of 15 patients (Patients #4, 5, 7 through 9, 11, 12, 16, 19 through 24, and 30) discharged between 01/01/10 and 05/21/10 were not timed, dated, and/or authenticated as required by 25 Texas Administrative Code (TAC) 133.41 (j)(5).

25 TAC 133.41 (j)(5): Medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.

Findings:
"History - Physical Examination" signatures were not timed and dated for the following:
1) Patient #4 - Transcribed 02/05/10
2) Patient #5 - Transcribed 01/15/10
3) Patient #7 - Transcribed 01/08/10
4) Patient #8 - Transcribed 03/10/10
5) Patient #11 - Transcribed 03/12/10
6) Patient #12 - Transcribed 04/12/10
7) Patient #19 - Transcribed 04/22/10
8) Patient #20 - Transcribed 05/10/10
9) Patient #23 - Transcribed 01/04/10
10) Patient #30 - Transcribed 05/15/10
11) Patient #21 - Transcribed 01/25/10

"Discharge Summary" signatures were not timed and dated for the following:
1) Patient #4 - Transcribed 02/11/10
2) Patient #5 - Transcribed 01/20/10
3) Patient #7 - Transcribed 01/14/10
4) Patient #8 - Transcribed 03/15/10
5) Patient #9 - Transcribed 01/12/10
6) Patient #12 - Transcribed 04/12/10
7) Patient #16 - Transcribed 05/07/10
8) Patient #19 - Transcribed 04/29/10
9) Patient #24 - Transcribed 05/06/10
10) Patient #30 - Transcribed 05/18/10
11) Patient #21 - Transcribed 02/05/10

"24/7 Radiology Final Report" electronic signatures were not timed and dated for the following:
1) Patient #4 - Approved 02/05/10
2) Patient #5 - Approved 01/15/10
3) Patient #7 - Approved 01/10/10
4) Patient #11 - Approved 03/13/10

"Physician's Orders" physician signatures were not timed and dated for the following:
1) Patient #4 - Verbal orders 02/04/10
2) Patient #5 - Verbal orders 01/18/10
3) Patient #7 - Verbal orders 01/08/10
4) Patient #8 - Verbal orders 03/09/10
5) Patient #11 - Verbal orders 03/15/10
6) Patient #12 - Verbal orders 04/10/10
7) Patient #19 - Verbal orders 04/21/10
8) Patient #20 - Verbal orders 05/07/10
9) Patient #22 - Verbal orders 02/15/10
10) Patient #30 - Verbal orders 05/17/10

"Dietary Nutritional Assessment Form" signatures were not timed for the following:
1) Patient #5 - Dated 01/19/10
2) Patient #21 - Dated 01/25/10

"Respiratory Care Initial Patient Assessment" signature was not timed for the following:
1) Patient #5 - Assessment Date 01/15/10
2) Patient #21 - Assessment Date 01/25/10

"Respiratory Care Initial Patient Assessment" was not signed and dated for the following:
1) Patient #7 - Assessment Date 01/11/10

"Physical Therapy" signatures were not timed for the following:
1) Patient #7 - Dated 01/10/10 and 01/12/10
2) Patient #24 - Dated 04/28/10, 04/29/10, 04/30/10, 05/01/10

"Speech Language Pathology Plan of Treatment" and/or "Speech Therapy ...Progress Notes" signatures were not timed for the following:
1) Patient #7 - Plan dated 01/08/10, Progress notes dated 01/11/10

Laboratory information reports including "Routine Urinalysis" signatures were not timed for the following:
1) Patient #5 - Dated 01/14/10
2) Patient #11 - Dated 03/12/10
3) Patient #19 - Dated 04/21/10
4) Patient #22 - Dated 02/15/10
5) Patient #23 - Dated 01/02/10

"Initial Nursing Assessment/Admission Survey" was not signed, timed, and dated for the following:
1) Patient #7 - Admission 01/08/09
2) Patient #8 - Admission 03/09/10
3) Patient #30 - Admission 05/15/10

During an interview the morning of 06/24/10, the Director of Nursing (Personnel #2) reviewed the medical records for Patients #2 through 5, 7 through 9, 11, 12, 16, 19 through 24, and 25. Personnel #2 was in agreement that dates, times, and/or signatures were missing.

The Medical Staff's "Rules & Regulations" approved 12/08/05 noted "All entries in the medical record must be legible and complete and must be authenticated and dated promptly by the person who is responsible for ordering, providing, or evaluating the service furnished..." Time was not included in the "Rules and Regulations."

The "Health Information Management Department" policy reviewed and approved 12/15/09 noted "All entries into the medical record shall be authenticated by the author by placing his/her signature and the date. Time was not included in the hospital's policy.

Based on observation, review of records, and interview, the pharmacy did not follow their policy to ensure that outdated drugs and biologicals were not available for patient use.

During a tour of the Medical/Surgical Unit the afternoon of 06/22/10, the surveyor observed the following outdated medications and biologicals in the open room where these items are kept:
5-Dextrose 5% water (D5W), 1000 milliliters, expired 05/10.
3-Dextrose 5% water (D5W), 1000 milliliters, expired 11/09.
7-Lactated Ringers (LR), 10000 milliliters, expired 05/10.
2-Benadryl, 50 milligrams, expired 04/09.
2-Epinephrine, 1 milligram vials, expired 01/10.
2-Atropine 0.4 milligrams, expired 02/09.
1- Tuberculin vaccine, 1 milliliter, expired 05/10.
1-Neomycin/Polymixin B Sulfate injection, 20 milliliter, expired 04/10.
2-Gabapentin (250 milligrams/5 milliliters), 750 milligrams, expired 04/03/09.

The pharmacy "Outdated Drugs," policy, undated, noted the following:
-"It is the responsibility of the pharmacy to make sure that all medication used in the hospital are in date and of acceptable quality."
-"The pharmacy will remove all medications which will expire by the end of or before the end of the current month. "Out of date" checks will be made near the end of the preceding month so as to be sure that the outdated drugs will not be available for use."

In an interview the afternoon of 06/22/10 with a registered nurse (RN) who works on the Medical/Surgical unit (Personnel #23), he confirmed that the above drugs and biologicals were available for patient use.

Based on review of records and interview, the hospital failed to maintain the medical records for patients hospitalized between 01/01/10 and 06/16/10 in that the physician did not date, time, and authenticate/sign medical orders that were verbally given to the nurse for 2 of 3 patients (Patient #3 and 13) according to their own policy.

Findings:
1) Patient #3 was admitted to the hospital on 06/14/10 with hyperkalemia and acute chronic renal failure. Admit orders that included a normal saline "IV...CBC...Meclizine..." were taken verbally by a nurse at 06/14/10 13:45. On 06/14/10 18:40, the physician gave verbal orders to the nurse that included "Clonidine." On 06/16/10 08:30, the physician gave verbal orders that included "Discharge home." As of 06/21/10, the physician's 06/14/10 and 06/16/10 verbal orders were not signed and dated.

2) Patient #13 was admitted to the hospital on 05/31/10 with diagnoses that included seizures and aspiration pneumonia. On 05/31/10 12:20, the physician gave a verbal order to discontinue "NTG" to the nurse. On 05/31/10 16:30, the physician gave verbal orders to the nurse that included to change Patient #13's vital signs and "neuro's" to every two hours. As of 06/21/10, the physician's 05/31/10 verbal orders were not signed and dated.

During the morning of 06/24/10, the Director of Nurses (Personnel #2) was shown the verbal orders for Patient #3 and #13. Personnel #2 said that the physician did not sign all of the verbal orders.

The "Verbal and Written Orders Policy" effective 03/01/10 noted, "The prescribing practitioner must date, time and authenticate the verbal order within 24 hours or if the ordering Physician is not available within the 24 hours, it is acceptable for the covering Physician to authenticate the order for the ordering Physician."

Based on review of records and interviews, the hospital did not develop a comprehensive care plan that had been prepared by an interdisciplinary team that included the resident's attending physician, for 3 of 3 Swing Bed residents (Patients # 1, 2 & 25).

Medical Records for 3 reviewed Swing Bed residents noted the following:

Patient #25: The "Multi-Disciplinary Resident Plan of Care (Swing Bed)" form initiated by the Swing Bed Coordinator (Personnel # 19), a registered nurse (RN), included areas for various disciplines to document their evaluation of the resident. However, this form did not contain a comprehensive "plan of care," or include participation by Patient #25's attending physician into the care planning process by the interdisciplinary team.

Patient #1: The "Multi-Disciplinary Resident Plan of Care (Swing Bed)" form initiated by the Swing Bed Coordinator (Personnel # 19), a registered nurse (RN), included areas for various disciplines to document their evaluation of the resident. However, this form did not contain a comprehensive "plan of care," or include participation by Patient #1's attending physician into the care planning process by the interdisciplinary team.

Patient #2: The "Multi-Disciplinary Resident Plan of Care (Swing Bed)" form initiated by the Swing Bed Coordinator (Personnel # 19), a registered nurse (RN), included areas for various disciplines to document their evaluation of the resident. However, this form did not contain a comprehensive "plan of care," or include participation by Patient #2's attending physician into the care planning process by the interdisciplinary team.

In interviews held separately on 06/22/10 with the Swing Bed Coordinator (Personnel # 19), the Activity Director (Personnel # 20), and the Physical Therapist (Personnel # 21), when asked if the hospital had an interdisciplinary team that included the attending physician, they each said "no." When asked if an interdisciplinary team met regularly to develop a comprehensive care plan for each Swing Bed resident, they each said "no."

Based on review of records and interview, the hospital did not ensure residents maintained acceptable nutritional status, in that, 2 of 3 Swing Bed residents (Patients # 1 & 25) had no dietary evaluation as part of their comprehensive assessment.

Medical Records for 2 Swing Bed residents noted the following:
Patient #25: Admitted 06/11/10 with diagnosis of Right Total Knee Arthroplasty. He was ordered a regular diet as tolerated. After knee replacement surgery he had peripheral edema and was ordered Maxzide and Lasix, both diuretics to be taken daily. He was also receiving Surfak, a laxative, twice a day. Daily weights were ordered. No nutritional evaluation was in the record, and there was no dietary input documented in this Swing Bed resident's comprehensive assessment.

Patient #1 Admitted 05/26/10 with a diagnosis of New Onset Congestive Heart Failure (CHF), Hypertension, and Gastroesophageal Reflux Disease (GERD). She was ordered a
Low Sodium diet, with Ensure supplement as needed. On 05/29/10 the physician ordered to "Grind all meat." The "Dietary Nutritional Assessment Form," and the "Dietary Progress Notes" were blank. No nutritional evaluation was in the record, and there was no dietary input documented in this Swing Bed resident's comprehensive assessment.

The hospital "Swing Bed Dietary" policy, undated, noted that the procedure followed by Dietary for Swing Bed residents included:
1) "History- Take a diet history (included on Nutritional Assessment Form)."
2) "Care Plan- Include the diet ordered...Special problems/plan of action...Evaluate after 24 hours and once a week thereafter."
3) "Progress Notes- Confirm diet ordered on admitting to Swing Bed and all changes thereafter...Include a daily percentage of food eaten...Diet instruction...Document any changes in patients eating habits."

In an interview the morning of 06/22/10 with the Swing Bed Coordinator (Personnel # 19), she was asked if the Swing Bed residents routinely received dietary evaluations as part of their comprehensive assessment. She stated a space for dietary evaluation is on the
"Multi-Disciplinary Resident Plan of Care (Swing Bed)" form and confirmed that there were no dietary evaluations in the medical records of Patients #1 & # 25.