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Based on observation, record review and interview, the hospital failed to meet the requirement to inform patient's of their patient rights because the hospital patient bill of rights was not prominently and conspicuously posted for display in public areas and medical records did not include documentation that the patients received a copy of the hospital bill of rights.

Findings Include:

a. During a tour of the hospital on 07/10/17 beginning at 2:40 p.m. accompanied by S2 and S3, observations revealed the following:

The Hospital Patient Bill of Rights was not posted in the outpatient registration area or waiting area, emergency department waiting room, or obstetric waiting room.

The Hospital Patient Bill of Rights was not posted in Spanish in the Emergency Department Registration and Admission Area.

In an interview on 07/10/17 at 3:40 p.m. in an interview of S3 during the tour, S3 confirmed the above findings.

b. Review of electronic and paper medical records #1, #3, #4 and #5 on 07/11/17 beginning at 1:15 p.m. on the post partum floor revealed that the medical records did not include documentation that the patients or a representative had received a copy of the Hospital Patient Bill of Rights. Review of electronic and paper medical record #2 on 07/11/17 at 1:45 p.m. at the medical surgical floor nurses station revealed that the medical record did not include documentation that the patient had received a copy of the Hospital Patient Bill of Rights. Review of electronic and paper medical record #6 on 07/12/17 at 9:15 a.m. at the medical surgical floor nurses station revealed that the medical record did not include documentation that the patient had received a copy of the Hospital Patient Bill of Rights.

In an interview on 07/12/17 at 9:27 a.m. in the conference room, S3 confirmed the above findings and stated, "They are given their rights but there is not a specific verbage that they sign that they received the Patient Rights."

Based on observation, record review and interview, the hospital failed to meet the requirement to inform patient's of whom to contact to file a grievance to include the phone number and address for filing a grievance with the State agency because this information was not prominently and conspicuously posted for display in public areas. In addition, medical records did not include documentation that the patients received a copy of the hospital bill of rights or contact information for filing a complaint with the state agency.

Findings Include:

a. During a tour of the hospital on 07/10/17 beginning at 2:40 p.m. accompanied by S2 and S3, observations revealed the following:

The contact information for filing a grievance including the phone number and address for the state agency were not posted in the outpatient registration area or waiting area, emergency department waiting room, or obstetric waiting room.

The contact information for filing a grievance with the state agency were not posted in Spanish in the Emergency Department Registration and Admission Area.

In an interview on 07/10/17 at 3:40 p.m. in an interview of S3 during the tour, S3 confirmed the above findings.

b. Review of electronic and paper medical records #1, #3, #4 and #5 on 07/11/17 beginning at 1:15 p.m. on the post partum floor revealed that the medical records did not include documentation that the patients or a representative had received a copy of the contact information for filing a grievance with the state agency. Review of electronic and paper medical record #2 on 07/11/17 at 1:45 p.m. at the medical surgical floor nurses station revealed that the medical record did not include documentation that the patient had received a copy of the contact information for filing a grievance with the state agency. Review of electronic and paper medical record #6 on 07/12/17 at 9:15 a.m. at the medical surgical floor nurses station revealed that the medical record did not include documentation that the patient had received a copy of the contact information for filing a grievance with the state agency.

In an interview on 07/12/17 at 9:27 a.m. in the conference room, S3 confirmed the above findings.

Based on record review and interview, the hospital failed to meet the requirement to specify time frames in the grievance process for the provision of a response because time frames were not specified regarding the provision of a response.

Findings Include:

Review of the hospital's grievance process last revised 5/15, reviewed on 07/12/17 at 12:00 p.m. in the conference room with S3 revealed that the process made no mention of any time frames regarding the provision of a response other than "efforts made toward resolution within 24 hours" and the following in part:

If a grievance cannot be resolved within 24 hours, the grievance will be referred as described below.
" If the grievance is unable to be resolved to either the patient's or Grievance Coordinator's satisfaction the following avenues will be accessed:
" If the unresolved grievance is related to a quality of care concern, the Performance Improvement Physician Advisor will be notified and requested to intervene.
" If the unresolved grievance is related to perceived premature discharge, the Utilization Management Physician Advisor will be notified and requested to intervene ...In instances where discharge is imminent and a determination cannot be rendered in a timely manner, the patient will be allowed to stay in the facility at no charge for an additional 24-hour period.

The patient will be provided with written notice of:
" The name of the Charge Nurse
" The steps taken to investigate and resolve the grievance
" The final result of the grievance
" The date of grievance completion

In an interview on 07/12/17 at 12:15 p.m. in the conference room, S3 confirmed the above findings and stated that time frames could be added.

Based on medical record review and interview the hospital failed to meet the requirement to ensure all medical records were promptly completed because not all physician orders included the date and time the orders were noted by the nurse and not all history and physicals were dated by the physician.

Findings Include:

Review of medical record #4 and #5 at the post partum nurses station on 07/11/17 at 2:40 p.m. revealed that the physician orders dated 07/10/17 did not include the date and time the orders were noted by the nurse.

In an interview at the post partum nurses station on 07/11/17 at 2:52 p.m., S3 and S4 confirmed the above findings.

Review of medical record #2 at the medical surgical nurses station on 07/11/17 at 2:00 p.m. revealed that orders dated 7/1/17 at 8 a.m. and noted by the nurse on 7/1/17 did not include the time the orders were noted.

In an interview on 07/11/17 at 2:00 p.m. at the medical surgical nurses station, S3 confirmed the above findings.

Review of medical record #6 at the medical surgical nurses station on 07/12/17 at 9:20 a.m. revealed that orders dated 7/10/17 at 6? did not include the date and time the nurse noted the orders.

In an interview on 07/12/17 at 9:22 a.m. at the medical surgical nurses station S3 confirmed the above findings.

Based on review of 5 closed records it was observed that all 5 of the records reviewed were not complete 30 days after the patient was discharged.

Findings:

A. In review of 5 closed medical records the following was observed:

1. 4 out of the 5 records reviewed the History and Physical was not placed in the patient record within 24 hours after patients
admittance.
2. 4 out of the 5 records reviewed were either missing authentication with date and time of the physician 30 days
after patient discharge.

B. The Rules and Regulations of The Medical Staff Starr County Memorial Hospital states on page 6

"The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. All entries in the medical record must be dated and authenticated by the practitioner making the entry...."

C. Interviewed Health Information Director at 11:52am on July 12,2017 in the administration conference room. The staff member was aware of these discrepancies and said they are tracking these type of discrepancies and reporting them as part of Quality Assessment and Performance Improvements. Staff could not provide evidence that these discrepancies were within regulations.

Based on review of 5 closed records it was observed that all 5 of the records reviewed were not complete 30 days after the patient was discharged.

Findings:

A. In review of 5 closed medical records the following was observed:

1. 5 out of 5 records reviewed the Discharge Summaries or final progress note for stays under 48 hours were not completed
within 30 days of patient's discharge.
3. 4 out of the 5 records reviewed were either missing authentication with date and time of the physician 30 days
after patient discharge.

B. The Rules and Regulations of The Medical Staff Starr County Memorial Hospital states on page 6

"The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. All entries in the medical record must be dated and authenticated by the practitioner making the entry...."

C. Interviewed Health Information Director at 11:52am on July 12,2017 in the administration conference room. The staff member was aware of these discrepancies and said they are tracking these type of discrepancies and reporting them as part of Quality Assessment and Performance Improvements. Staff could not provide evidence that these discrepancies were within regulations.

Based on observation, policy review and interview, the hospital failed to meet the requirement to maintain facilities, supplies and equipment to ensure an acceptable level of safety and quality because expired supplies were found on crash carts, laryngoscope blades were not stored in individual wrappers, a bio-hazard waste container was not available for disposal of used gowns and gloves in an isolation room, dirty linen was not confined in dirty linen bags and dirty linen bags were not kept off the floor in the soiled linen room.

Findings Include:

a. During a tour of the hospital soiled linen room outside the housekeeping office on 07/10/17 at 3:45 p.m. accompanied by S2 and S3 observations revealed the following:

One red and one blue soiled linen bag on the floor.
A soiled green towel on the floor.
Four red and one blue soiled linen bags hanging off the linen cart.
Soiled linen sticking out of a red soiled linen bag.

In an interview on 07/10/17 at 3:45 p.m. in the soiled linen room, S2 and S#3 confirmed the above findings.

b. During a tour of labor and delivery room #202 on 07/10/17 at 3:31 p.m. accompanied by S2 and S3, observations revealed the following:

2 packages of 3-0 chromic suture "exp. 2014-09"
12 amnioTest "exp. 2016-06"
6 amnioHook "exp. 2016-11"
1 amnioHook "exp 2016-3"

In an interview on 07/10/17 at 3:36 p.m. in labor and delivery room #202, S2 and S3 confirmed the above findings.

c. During an inspection of the crash cart on telemetry station 2 on 07/11/17 at 10:07 a.m. accompanied by S3, observations revealed the following:

Top of Crash Cart - Pediatric Medtronic Physio-Control Quick Combo Electrodes "Use before 11/15"

Drawer 5 contained the following expired items:

Expired Endotracheal tubes:
Size 3.0 x 1 and Size 3.5 x 2 expired 2015-12
Size 4.5 x 2 expired 2015-04
Size 2.0 x 2 and Size 2.5 x 2 expired 2016-05
Size 4.0 x 2 expired 2016-07
Size 5.0 x 2 expired 2016-10
Size 5.5 x 1 expired 2016-12
Size 7.5 x 2, Size 7.0 x 1 and Size 6.5 x 2 expired 2016-05
Size 8.5 x 1 expired 2016-09
Size 6.0 x 2 expired 2017-03
Size 7.0 x 1 expired 2017-04

Expired Medichoice Lubricating Jelly:
2 packets expired Nov 10
2 packets expired Sep 11
2 packets expired Jul 10
2 packets expired Dec 15
7 packets expired Aug 16

Duoderm x 2 expired 2012-09
8 ½ gloves x 2 pair expired 2015-04

Two black zippered containers sitting on a counter that housed a set of 4 macintosh laryngoscope blades and 5 miller laryngoscope blades and the blades were not individually covered.

In an interview on 07/11/17 at 10:48 a.m. in front of the crash cart, S3 confirmed the above findings.

d. During an inspection of crash cart for station 1 on 07/11/17 at 11:04 a.m. accompanied by S3, observations revealed two black zippered containers sitting on top of the crash cart that housed a set of 4 macintosh laryngoscope blades and 5 miller laryngoscope blades and the blades were not individually covered.

In an interview on 07/11/17 at 11:04 a.m. in front of the crash cart, S3 confirmed the above findings.

e. During an inspection of the crash cart for post partum on 07/11/17 at 3:00 p.m. accompanied by S3, observations revealed two black zippered containers sitting on top of the crash cart that housed a set of 4 macintosh laryngoscope blades and 5 miller laryngoscope blades and the blades were not individually covered.

In an interview on 07/11/17 at 3:00 p.m. in front of the crash cart, S3 confirmed the above findings.

f. During a tour of the nursery on 07/11/17 at 3:17 p.m. accompanied by S3 and S6, observation revealed a tackle box on a cart in the nursery identified by S6 as a respiratory box taken care of by respiratory. Inspection of the respiratory box revealed the following expired items available for patient use:

Expired Medichoice Lubricating Jelly:
5 packets expired Aug 16

Expired Endotracheal Tubes:
Size 3.0 x 2 expired 2015-12
Size 3.5 x 1 expired 2014-09

Expired 0.9% Sodium Chloride Inhalation Solution x 2 Expiration 2014-11

In an interview on 07/11/17 at 3:17 p.m. in the nursery, of S3 and S6 confirmed the above findings and S7 was paged to the nursery. In an interview of S7 on 07/11/17 at 3:20 p.m. in the presence of S6, S7 confirmed the above findings and stated, "We don't use the box" and "The box is out of commission."

Review of the hospital policy #3007 entitled, "Emergency Crash Carts, Revised June 2015," on 07/12/17 at 9:00 a.m. in the conference room revealed that it stated in part, "Emergency drugs and supplies, for use in medical emergencies only, shall be immediately available at each patient care unit or service area."

1. Based on reviews of the Operating room log and staff interviews the hospital failed to maintain an operating room register that was complete and up to date.
The Findings included:
a. A review of the Main Operating room register conducted on 07/11/17 at 10:30 a.m. revealed the log was incomplete and did not contain fields to include the Start and Stop times for the surgical procedure, no start or stop of anesthesia and lastly the log did not contain a field to determine the disposition of specimens.
b. Following her own review of the surgical register on 07/11/17 at 1:25 p.m. the clinical director acknowledged the findings and could not provide evidence of compliance.