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Based on interview and record review, the hospital failed to inform each patient of their rights in advance of discharge, in that 3 of 3 (Patients #24, #27, and #29) patient's did not receive a copy of the Important Message from Medicare (IMM) within in 48 hours of discharge.

Findings included

Patient #24 was discharged on 09/25/18. The IMM is signed but undated.
Patient #27 was discharged 01/21/19. The IMM is dated 01/14/19.
Patient #29 was discharged on 03/01/19. The IMM is dated 02/11/19.

During an interview on 03/19/19 at 1052 Personnel #37 was asked to verify the above findings. Personnel #39 agreed that the IMM's had been not been signed within 48 hours of discharge.

The Case Management Policy titled Important Message From Medicare reviewed 11/18 reflected..." Hospital must also deliver a copy of the signed notice of each beneficiary not more than two (2) days before the day of discharge..."

Based on record review and interview, the hospital failed to complete a discharge summary within 30 days of the patient's discharge, citing 4 of 6 (Patient #24, #25, #26, and #27) patients' discharge summaries that were reviewed on 03/19/19.

Findings included:

Patient #24's medical record reflected the discharge date of 09/25/18. The discharge summary reflected a dictated date of 11/09/18.

Patient #25's medical record reflected the discharge date of 09/22/18. The discharge summary reflected a dictated date of 10/31/18.

Patient #26's medical record reflected the discharge date of 11/03/18. The discharge summary reflected a date of 12/19/18.

Patient #27's medical record reflected the discharge date of 01/21/19. The discharge summary reflected a date of 03/08/19.

During an interview on 03/19/19 at 10:52 AM, Personnel #37 was asked to verify the above findings. Personnel #39 agreed, the discharge summaries were completed more than 30 days after the patient's discharged from the hospital.

The facilities' Rules and Responsibility for Medical Staff approved 10/31/18 reflected ..." 17. a. The Patient's Medical Record should be completed at the time of discharge, including Progress Notes, final diagnosis...b. The record will be considered delinquent if it has not been completed within thirty (30) days following the patient's discharge..."

Based on observation, interview, and record review, the registered nurse (Personnel #40) failed to provide patient safety in delivery of biologicals, in that intravenous (IV) fluid: Lactated Ringers (LR) 1000 cc bag was administered without confirming physician's order, citing 1 of 2 tracer patients (Patient #30) in the preoperative unit on 03/19/19.

Findings included:

On 03/19/19 at 9:29 AM, Patient #30 was in the preoperative unit for a scheduled "anterior cruciate ligament reconstruction-left knee." Personnel #40 administered Lactated Ringers 1000 cc. Reviewing the physician's preoperative written standing orders, "box #7" was not marked and reflected "IV...Infuse 1000 mL Lactated Ringers at 50 mL per hour...Exception: For patients without history of renal disease, infuse 500 mL normal saline at 25 mL per hour..." Personnel #40 was asked how she knew that LR was the choice of IV fluid to be given to Patient #30. Personnel #40 stated the computerized physician order indicated LR was to be administered. Reviewing the orders in the computer, the physician did not mark box 7 which was IV fluid to use for Patient #30. Personnel #40 was surprised that the IV fluid standing order was not marked in the computer.

On 03/19/19 at 11:00 AM, Personnel #53 confirmed the hospital adheres to AORN (Association of periOperative Registered Nurses) PeriOperative Standards and Recommended Practices.

On 03/19/19 at 2:05 PM, Personnel #3 was informed of the above findings. Personnel #3 was asked how the RNs know which IV fluid to give to preoperative patients, whether LR or normal saline if there was no order. No explanation was given to the surveyor.

The AORN PeriOperative Standards and Recommended Practices in Inpatient and Ambulatory Settings, 2014 Edition, page 289 reflects "VII.a.1. The perioperative RN should contact the prescriber when clarification is needed for medication orders...as standing or preprinted orders."

Based on observation, interviews, and record review, the hospital Director of dietary services failed to ensure safety practices for food handling in the hospital's only kitchen and was not in compliance with the Texas Food Establishment (October 2015) rules/regulations.

The facility failed to:

1.Keep the Flat Top grill clean and free of spills and grease.
2.Empty and discard old cooking oil in deep fryer.
3.Clean the surrounding surface of deep fryer and stove of splashed grease.
4.Clean the Mixer removable parts.
5.Sweep and mop the underneath and behind the flat top grill and the deep fryer floor.
6.Ensure the dietary manager was wearing beard net while preparing patient's food.
7. Ensure the sanitizer test strips for the 3 compartment sink was available and in use.

These failures could affect patients who received their meals from the hospital's only kitchen by placing them at risk for food-borne illness.

Findings included:

Observations of the kitchen on 03/18/19 at 09:30 AM revealed the following:

1.The flat top grill was observed to have spilled grease, grime and food residue and crumbs on top.
2.The deep fryer had dark brown cooking oil with surrounding surface covered with crumbs and food debris.
3.The surrounding surface of deep fryer and stove had grease, grime and food residues on the sides.
4.The Mixer removable parts were dirty and dusty.
5. The underneath and behind flat top grill and the deep fryer floor had dark-brown stain, dirt and food crumps.
6.The dietary manager was observed preparing patient's food and was not wearing beard net despite having noticeable long beards.
7.The hospital was sanitizing its hospital kitchen dishes in the 3 compartment sink without using the sanitizer test strips to monitor the concentration of the sanitizer.

Interview with Personnel #48 on 03/18/19 at 10:45 AM revealed he had no cleaning schedule that was in place. He said the hospital has contracted a cleaning company that comes every four months. He agreed the flat top grill, the deep fryer surface, exterior and interior surface of the stove needed cleaning. He said the mixer removable parts needed cleaning as well as the underneath, and behind flat top grill and the deep fryer floor. He stated he would put in place a cleaning schedule. He said he had no had sanitizer test strips for the 3 compartment sink for a week since the last one expired. He reported he had been sanitizing dishes in the 3 compartment sink without using the sanitizer test strips to monitor the concentration of the sanitizer. He said he had ordered it and would follow it up. He said he did not know he was supposed to wear beard net.

An interview with Personnel #49 on 03/18/19 at 11:35 AM confirmed the deep fryer grease needed to be changed and exterior and interior surfaces of the stove and deep fryer needed cleaning. He said there was no cleaning schedule but staff member's responsibility to make the kitchen clean.

Interview with Personnel #50 on 03/18/19 at 11:46 AM confirmed the deep fryer grease needed to be changed and exterior and interior surfaces of the stove and deep fryer needed cleaning. She said she had not monitored the concentration of the sanitizer for a week since the test strips were not available.

Review of the hospital's policy titled "Cleaning and sanitation of the kitchen" last revised November 2018, revealed " All areas of the kitchen will be cleaned and maintained by following scheduled routine procedures to achieve maximum sanitation and reduce any risk of cross contamination or infection."

The Food and Drug Administration Code 2017, 4-602.13 Nonfood-Contact Surfaces reflected "The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests."

The TFER 228.114 (b) ruled indicated "...The food-contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours..."

Based on observation, interview, and record review the designated infection control officer did not ensure infection control policies were adhered to, in that on 03/19/19 appropriate hand hygiene was not followed, and proper utilization and discarding of PPEs were not performed, citing 5 of 8 healthcare providers (Personnel #41, #45, #51, Physician #42, and Physician #44).

Findings included:

The following observations were made while following tracer patients on 03/19/18:

At 9:29 AM, Patient #30 (tracer #1) was in the preoperative area. He was scheduled for "anterior cruciate ligament reconstruction-left knee." At 10:10 AM Personnel #41 was instructed to shave Patient #30's left lower extremity. Personnel #41 did not wear gloves when shaving Patient #30. This was confirmed by the preoperative registered nurse (RN) in charge of Patient #30's care.

At 10:50 AM, a physician with a mask on was entering the preoperative area from the restricted area. Personnel #52 was asked who the physician name was. He replied it was Physician #44. Personnel #52 confirmed Physician #44 was wearing a mask outside the restricted area. The mask should have been discarded after the procedure was completed.

At 11:10 AM, Patient #5 (tracer #2) was in operating room (OR) #4. There were 2 healthcare providers (Physician #42 and Personnel #51) that did not appropriately tie their masks. The masks were loosely tied that allowed venting. At 11:19, AM Personnel #45 took off her used gloves and without proper hand hygiene donned on a pair of clean gloves. At 11:28 AM, Physician #42 took off the used gloves and without appropriate hand hygiene continued to provide direct patient care. These observations were confirmed by Personnel #53.

On 03/19/19 at 11:00 AM, Personnel #53 confirmed the hospital adheres to AORN (Association of periOperative Registered Nurses) PeriOperative Standards and Recommended Practices.

Hospital policy #11 "Infection Control-Hand Hygiene" reviewed 01/2019 required "Hand hygiene...A. Indications for Use 1. Before and after patient contact...4. Before and after using gloves..."

Hospital policy #35 "Provisions of Care-OR policies..." reviewed 01/2019 required "6...Masks are to be removed before leaving the OR suite..." The policy did not address masks were to be tied securely to prevent venting per AORN (Association of periOperative Registered Nurses) PeriOperative Standards and Recommended Practices in Inpatient and Ambulatory Settings, 2014 Edition, page 56.