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Based on observation, interviews and record reviews the hospital failed to ensure 1 of 1 RN (Registered Nurse) evaluated and/or ensured nursing care was initiated for 1 of 1 patient (Patient #4) whose B/P (blood pressure) was elevated (189/87).

Findings Included:

Patient #4's history and physical dated 01/22/14 timed at 12:51 PM, reflected, "65 year old with diagnosis of schizophrenia, cognitive disorder, hypertension and nicotine dependence..."

The physician's orders dated 01/20/14 timed at 18:20 PM, reflected, "Lisinopril 10 mg (milligrams) daily..."

The MAR (medication administration record) dated 02/04/13 timed at 08:42 AM, reflected, "(Patient #4) was administered lisinopril 10 mg..."

On 02/04/14 at 1:55 PM, the surveyor and Personnel #34 reviewed Patient #4's vital sign record. The surveyor asked Personnel #34 when Patient #4's blood pressure was taken according to the document. Personnel #34 stated at 07:30 AM. The surveyor informed Personnel #34 that Patient #4's blood pressure was 189/87. Personnel #34 was asked whether Patient #4's blood pressure was taken a second time. Personnel #34 asked Patient #4's nurse Personnel #47 to talk to the surveyor. Personnel #47 stated she was aware Patient #4's blood pressure was elevated in the morning but she did not recheck Patient #4's blood pressure nor reassess Patient #4.

Based on record review and interview, the facility failed to ensure that the nursing care plan was kept current for 2 of 31 patients (Patient #11 and #31) who had a change of condition and/or required medical treatment.

Findings Included:

1) Patient #11 was admitted on 01/10/14 with complaints of left hip pain. Patient #11 had a diagnoses of metastatic adenocarcinoma of the lung, coronary artery disease, diabetes and hypertension.

Patient #11's abdominal/pelvis CT scan dated 1/10/14 indicated she had a pathologic fracture of the left hip. On 1/13/14 Patient #11 underwent an Open Reduction Internal Fixation (ORIF) of the left hip. The nursing care plan was not updated to reflect the patient's change of condition.

In an interview on 2/06/14, Personnel #1 was informed of the above findings. Personnel #1 confirmed Patient #11 did not have a care plan addressing the patients change in condition following her surgery.

2) Patient #31's history and physical dated 01/27/14 timed at 11:37 AM, reflected, "25 year old who presented to the ED (emergency department with RUQ (right upper quadrant) pain...n/v (nausea, vomiting)... radiology...ultrasound of the abdomen...multiple gallstones...follow-up in surgery clinic..."

The Operative Report dated 01/29/14 timed at 03:31 AM, reflected, "Symptomatic cholelithiasis...minimal blood loss...taken to operating room for cholecystectomy...sent to unit...stable..."
The nursing flowsheet dated 01/28/14 timed at 20:20 PM, reflected, "Incision laparoscopic punctures...four covered with dermabond..."

On 02/06/14 Personnel #1 reviewed Patient #31's medical record and care plan with the surveyor. Personnel #1 verified no care plan was initiated which addressed Patient #31's surgery and/or incision site.

The policy and procedure entitled, "Provision of Care" with an effective date of 07/18/13 reflected, "Interdisciplinary plan of care...addresses the execution of care, treatment, and services...plan of care is based upon the identified needs of the patient...current..."

Based on observations, interviews and record reviews the hospital failed to ensure the Director of Dietary Services supervised and maintained the dietary department for 2 of 2 dietary areas (the main hospital dietary department and the psychiatric hospital dietary department) in a responsible manner in that the following was observed during the survey:

A) The Main hospital dietary department:
1) Two bottles of cleaning solution were observed in 1 of 1 china cabinet.
2) Two boxes of single use foam cups were stored directly on the floor of 1 of 1 catering supply room.

B) The Psychiatric hospital dietary department:
1) Cleanliness issues were observed in the serving line, kitchen, and patient dining areas.
2) 1 of 3 hot food items did not meet an adequate serving temperature.

Findings Included:

A) The main hospital dietary department:

1) On the morning of 2/04/14 during a tour of the hospital's kitchen catering area, a bottle of professional strength glass cleaner and a bottle of cleaner degreaser were observed in a china cabinet containing dishes. Personnel #21 stated they should not be stored in the cabinet and instructed Personnel #27 to take and store the bottles with other cleaning products located in a separate storage area.

Review of the Material Safety Data Sheet for the Power Force Premium Cleaner Degreaser indicated that caution should be used. Potential acute health effects could include moderate irritation to eyes and slightly irritating effects to the skin. The Material Safety Data Sheet for the OASIS PRO 42 Glass Force Professional Strength Glass Cleaner indicated caution should be used. The product's potential acute health effects included moderate irritation to eyes and skin. If inhaled the product could cause moderate irritation to the respiratory system and could be harmful if swallowed.

2) During a tour of the hospital kitchen's catering supply room during the morning of 2/04/14, there were 2 boxes containing single-use foam cups stored directly on the floor. Personnel #24 confirmed the boxes were on the floor and not on a pallet.

B) The hospital psychiatric dietary department:

1) On 02/04/14 from 11:00 AM to 11:55 AM observation rounds were conducted with Personnel #1, Personnel #21 and Personnel #24. The following observations were made in the serving line, kitchen and dining areas:

The Serving Line:

The lowerator which houses the dietary trays at the entrance to the patient serving line had greater than 25 trays stacked on top of each other wet. Seven patients were in the serving line with wet trays. Personnel #21 verified the trays should not be wet.

A soiled sink behind the serving line was observed with two full pitchers of tea sitting in the sink. Personnel #40 verified the pitchers of tea should not be sitting in the sink and the tea was for the lunch meal.

The ice machine behind the serving line was observed. The lid to the ice machine was raised. The underside of the lid was soiled with a brown substance. Personnel #21 was asked to wipe the lid. The wet cloth Personnel #21 used to wipe the lid had a collection of brown debris. The exterior ice machine filters were dusty and soiled. Personnel #21 verified the above findings and acknowledged the items needed to be cleaned.

A three shelf cart was observed behind the serving line. The shelves of the cart were soiled with grime and debris. The bottom shelf of the cart had two open bags of plastic lids. The open plastic bags were lying on the floor which was soiled and dirty. Personnel #21 removed the open bags of plastic lids and placed the open bags on top of a metal shelf in the middle of the kitchen. Personnel #21 verified the above findings.

The Kitchen:

The kitchen microwave's exterior surface was soiled with a collection of debris. Personnel #21 was asked to wipe the exterior surface of the microwave with a wet cloth. The wet cloth had a collection of brown debris. Personnel #21 verified the above findings.

A large bin with multiple 4 ounce cups of pear juice were observed. The interior surface of the bin was soiled and sticky. Personnel #24 verified the findings.

A second large bin which housed "pie wedges" plastic covers for pies was observed. The interior of the bin was soiled with debris and crumbs. A third bin's interior had a red spill with crumbs and debris. Personnel #24 verified the above findings.

The interior/exterior surface of the refrigerator was soiled with a collection of dirt and debris. Personnel #21 verified the above.

The warmer oven had a collection of dried brown rice on the bottom and needed cleaning. Personnel #24 verified the kitchen observations.

The dry goods storage area was observed. One of the walls had peeling paint and a hole was observed in the wall. Personnel #24 verified the findings.

The wall behind the dish machine was soiled with a collection of a brown/black substance. The exterior surface of the paper towel dispenser on the wall next to the dish machine was soiled with a brown substance. Chemicals were observed sitting on a wire rack next to the dish machine. The metal rack was rusted and could not be sanitized.

The Dining area:

The microwave housed in the dining area was observed. A piece of ham and a collection of debris was inside the microwave. Personnel #21 verified the above findings.

A two shelf cart was observed along the wall of the dining room. The shelves were soiled and dirty with food debris. A box of cereal was stuck to the floor of the top shelf, a piece of paper, a styrofoam cup and peanut butter cups were sitting on the rusted shelf. The corners and edges of the shelf had a collection of a brown gelatin like substance. Personnel #21 verified the above observations.

Two of three tray carts were soiled with spills and debris both on the interior and exterior surface. The carts were identified as ready for patient trays. Personnel #21 verified the findings.

2) The steam table housed lunch meal items which included flank steak. Personnel #40 was observed standing behind the counter asking patients what hot items they wanted. Personnel #40 was asked if she recorded the food temperature for the flank steak prior to serving patients. Personnel #40 stated "No, she was going to do it later so she did not keep the patients waiting." Personnel #40 was asked to measure the temperature for the flank steak. The flank steak measured 110 degrees Farenheit. Personnel #40 verified the meat was not at the right temperature and could not be used.

The Director of Nutritional Services Job Description signed and dated 02/05/14 reflected, "The Director...nutritional services is responsible for managing...operational and clinical nutrition...plans, directs, organizes and coordinates all departmental services..."

The policy and procedure entitled,"Sanitation Procedures" with a revision date of 10/01/13 reflected, "Work procedures...keep work surfaces, cabinets, drawers, floor and food carts free of dirt, food and clutter...should be clean and sanitized...keep all refrigerators and shelves clean...wash and dry trays carefully after each meal and clean tray lowerators before pulling clean trays on them...anything that comes into contact with food should be clean and free from contamination..."

The policy and procedure entitled, "Infection Prevention and Control" nutritional services with a revision date of 10/01/13 reflected, "Food is prepared following the Texas State Department of Health Food Establishment Rules and the City of Fort Worth regulations...this includes appropriate sanitation of food production equipment and work surfaces, practice of employee safe food handling techniques, proper cooking of food items to reach safe internal temperatures...and following safe timelines for production and services of cooked food...temperatures of foods are tested during each meal..."

The policy and procedure entitled, "Food Temperatures" with a revision date of 10/13/13 reflected, "The cook is responsible for recording the temperature of hot foods before the tray line starts...dietary aides record the temperature of the food items they deliver to...kitchen...minimum safe food temperatures include...145 degrees for other meats (beef, pork)...hot food are served at a holding temperature of above 135 degrees...if the foods do not meet appropriate temperature levels...the production staff removes the items and replaces them with those that meet proper temperature..."

Based on observation and interview, the hospital failed to ensure that the condition of the hospital environment was maintained to protect the safety and well being of patients, visitors, and/or staff, citing 1 of 1 unit (dialysis unit), 2 of 10 patient rooms (room 224 and 225) and 1 of 1 soiled laundry room.

Findings included:

1) During a tour of the hospital's dialysis unit on 2/3/14 at 12:45 PM, the surveyor observed that there was an approximately softball sized hole approximately one to one and a half inches in depth and included cracked tiles surrounding the hole in front of the door inside the treatment area.

This finding was confirmed in an interview on 2/3/14 at 12:50 PM with Personnel #10.

2) On 02/04/14 at 02:55 PM observation rounds were conducted in the psychiatric hospital on the two north west unit with Personnel #1 and Personnel #45. Random room inspections were conducted. The surveyor entered room 224. Standing water was observed on the floor of the bathroom and a puddle of water was observed in the entrance of the room. Room 225 had standing water on the floor of the bathroom. Personnel #1 verified the above observations.

3) On 02/04/14 at approximately 16:45 PM, observation rounds were conducted in the soiled laundry room with Personnel #1 and Personnel #97. The ceiling vents (7 total) were dirty/dusty and needed cleaning. Personnel #97 verified the above observation and acknowledge the vents needed cleaning.

Based on observation, interview, and record review, the facility's infection control officer did not implement the policy governing control of infection in that:

A) 3 of 6 personnel (Personnel #79, #80 and #82) in the Microbiology Laboratory (Micro Lab) did not demonstrate appropriate hand hygiene after removing their gloves on 02/06/14,
B) 1 of 1 dialysis unit's floor was covered with corrosion and dirty linens on 02/03/14,
C) 1 of 1 Gross Specimen Pathology processing area and 1 of 1 Blood Bank had soiled equipment and various items needed cleaning,
D) Housekeeping carts used throughout patient care areas and other cleaning equipment used in patient care areas were observed in need of cleaning.
E) 1 of 1 Registered Nurse (Personnel #98) in the dialysis unit did not cleanse the dialysis catheter venous and arterial ports with an antiseptic solution prior to the administration of saline and Heparin on 2/5/14.

Findings included:

A) On 02/06/14 at 11:43 AM, a tour of the Micro Lab was conducted with Personnel #77. Personnel #80 and #82 were observed wearing gloves working at the back area of the laboratory. The surveyor asked Personnel #80 to explain the process of taking off and placing on clean gloves. Personnel #80 replied he would demonstrate the process. Personnel #80 removed his soiled gloves and obtained a pair of clean gloves. Personnel #80 did not perform handwashing and/or apply hand sanitizer prior to placing a clean pair of gloves on. The surveyor asked if he (Personnel #80) applies hand sanitizer before putting on a pair of clean gloves. Personnel #80 replied "no." The surveyor asked Personnel #82 if his process was the same as Personnel #80's. Personnel #82 replied "yes." Personnel #82 stated he did not do hand hygiene because the specimen he was handling was sensitive to time. Personnel #77 stated Personnel #80 and #82 should have performed hand hygiene and confirmed the above findings.

At 11:55 AM, the surveyor continued the tour of the Micro Lab and observed Personnel #79 remove her right hand glove. Personnel #79 put a clean glove on the right hand with the aid of the left hand used glove. Personnel #79 proceeded to handle specimen samples.

In an interview on 02/06/14 at approximately 11:57 AM, Personnel #78 was informed of the above findings and she confirmed the findings.

B) During a tour of the facility's dialysis unit on 02/03/14 at 9:30 AM, the surveyor observed the room behind the dialysis treatment beds included a floor covered with reddish orange colored corrosion, two piles of approximately 4 to 6 dirty dried grayish white linens and towels were on the floor, and 3 pieces of nickel sized black materials were scattered under the pipes. When Personnel #29 was asked what the room was used for, he replied, "That's where we fix our electricity when it trips or when we have water leaks."

The above findings were confirmed in an interview with Personnel #10 on 02/03/14 at 9:40 AM.

C) On 02/06/14 at 12:00 PM, a tour of the Blood Bank was conducted with Personnel #83. The sink which contained the eye wash setup was observed. The interior surface was soiled with white/black colored, 1/2 by 1 inch matter. On the ledge of the sink, a pair of unlabeled scissors was observed.

The above findings were confirmed in an interview with Personnel #83 on 02/06/14 at 12:00 PM. Personnel #83 was asked what the white/black matter was. Personnel #83 said she did not know. Personnel #83 was asked if the scissors were clean, Personnel #83 picked them up, stated she did not know. Personnel #83 put the scissors down on the counter and put her hand in her pocket.

On 02/06/14 at 12:20 PM, a tour of the Gross Specimen Pathology processing area was conducted with Personnel #94. Two black phones were observed sitting on the counter. The surface of the phones had white spots of debris. The surveyor observed one fire extinguisher with white spots of debris scattered on the fire extinguisher. Two exhaust vents located in the wall were dusty and/or dirty. A one inch "separator" had rust covering the top plate.

The above findings were confirmed in an interview with Personnel #94 on 02/06/14 at 12:20 PM.

The undated policy and procedure entitled, "LAB 1047- Infection Control Procedures" reflected, "IV...B...5...f...work surfaces are decontaminated and disinfected with an approved disinfecting agent...at completion of work...IV...B...6...c. All instrument components are decontaminated before reuse...IV...B...7...contaminated work surfaces are cleaned appropriately...after completion of each procedure...at the end of each work shift ...IV...C...barrier protection 1.a...ix...wash hands immediately after removing gloves...IV...H...5...all equipment stored or in use, is considered contaminated and handled appropriately... "

D) Observational rounds in the psychiatric hospital were conducted with Personnel #1 and Personnel #4 on 02/04/14 between 12:30 PM and 4:30 PM. The following observations were made:

The exam room on the hospital's 2 Northwest (NW) Unit had a dusty nightstand. Personnel #6 was asked to wipe the stand. The wipe was stained with a dark black color. The 2 NW unit's nourishment room had a puddle of water on the floor.

Two stained laundry bins with grimey and soiled lids were observed on the Longterm Commitment Alternative (LCA) Unit. A housekeeping cart with a toilet cleaning brush in a clear liquid and an open stryrofoam cup filled half with clear liquid were observed unlocked in the hallway.

The dryer on the adolescent patient unit was full of lint. The washer had a grimey substance on the interior of the machine. Personnel #4 stated the washer had been cleaned four days ago.

Personnel #96 was observed next to her housekeeping cart outside the adolescent unit. Personnel #96 stated she used the bathroom cleaning liquid "all day" and then would "dump it." Personnel #96 stated the last time she got a new toilet bowl cleaning brush was "three months ago."

Personnel #46 was observed outside the Southwest (SW) unit next to a housekeeping cart which was observed stained and grimey on the outside. White spots covered one side of the cart. A bucket with a dark-colored liquid had an immersed mophead. Personnel #46 stated the carts did not get cleaned. Personnel #1 and Personnel #4 verified the above findings.

Observational rounds in the main hospital were conducted with Personnel #1 on 02/05/14 between 2:45 PM and 4:10 PM. The following observations were made:

A large open plastic bag with rolls of toilet paper were left unattended in the main hospital's endoscopy waiting area.

A stained and grimey housekeeping cart was observed pushed by Personnel #65 in the hallway leading to the endoscopy waiting area. Personnel #65 denied there was a cleaning schedule for the cart and stated she had not replaced the toilet bowl cleaning brush.

The hospital's Emergency department (ED) case management area was used for storage. A stretcher was covered with dust. Two blood pressure Dynamap machines marked as clean and sanitized had dusty and grimey stands. Sixteen dusty chairs were stacked together.

A room identified by Personnel #66 as a "clean utility room" contained a grimey yellow housekeeping cart with brownish stained cotton rags. A stained barrel identified by Personnel #67 as containing clean rags was filled with grayish rags. A rolled up glove was observed on the interior of the barrel. A metal cabinet located in the room had one broken shelf, and two shelves were covered with a brownish substance. A black wool coat was sitting on one of the shelves.

The hospital's intensive care unit room P302 contained an open, unattended blue plastic bag with dirty linens. Personnel #69 entered the room and picked up the blue plastic bag and slung it over her shoulder. Personnel #69 then walked out of the room and down the hallway.

A housekeeping cart with three mopheads immersed in a bucket with liquid was observed in the hallway leading to the Pharmacy. Personnel #70 was asked how old the toilet bowl cleaning brush was that she had on her housekeeping cart. Personnel #70 stated she did not know.

A housekeeping cart was left unattended in front of the hospital's Pharmacy. An open trashbag and four mop heads in a bucket with liquid were observed.

Personnel #1 verified the above findings.

On 02/05/14 at 01:15 PM, Personnel #60 was interviewed. Personnel #60 stated infection control rounds are conducted throughout the hospital. Personnel #60 offered no explanation regarding the above observations made by the surveyors.

E) During a tour of the dialysis unit on 2/5/14 at 11:00 AM, Personnel #98 flushed the central venous catheter of Patient #20 with 10cc syringes filled with Normal Saline without cleansing the venous and arterial catheter ports with an antiseptic. Personnel #98 attached 3 cc syringes filled with Heparin to the venous and arterial catheter ports without cleansing the ports with an antiseptic.

This finding was confirmed in an interview with personnel #10 on 2/5/14 at 11:10 AM.

The policy and procedure entitled, "Infection Prevention and Control with an effective date of 01/01/12 reflected, "Staff members are to be familiar with...practices of the control of infections...good hand hygiene...familiar with policies and procedures related to infection control..."