The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

CHRISTUS GOOD SHEPHERD MEDICAL CENTER MARSHALL 811 S WASHINGTON MARSHALL, TX 75670 Aug. 23, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview, the facility failed to notify the patient or patient's representative of the patient's rights contained in the Important Message from Medicare about Your Rights form prior to admission and prior to discharge in 2 (Patient #1 and Patient #3) of 10 patients (Patient #'s 1, 2, 3, 4, 5, 6, 7, 18, 19, and 20). Findings are as follows:

Review of Patient #1's chart showed that he was a [AGE]-year-old male admitted to the hospital through the emergency room . Upon the emergency room physician's examination, the patient was found to be alert and oriented. He had a right lower extremity wound and pneumonia. He was admitted for intravenous antibiotics (antibiotics administered directly into the blood vein). The patient had signed his admission paperwork on 2-14-2016 at 12:10 P.M. The Important Message from Medicare about Your Rights form was noted "Pt unable to sign - no family" with an admission staff member signature next to the notation. It was dated 2-14-2016 at 4:00 P.M. Per emergency room nurse charting, the patient left the emergency room to go to his inpatient hospital room on 2-14-2016 at 4:15 P.M. There was nothing found in the notes to indicate the patient status had changed from 4 hours prior when the patient signed all of his admission paperwork. A second attempt to deliver the form was documented on 2-18-2016 at 11:16 A.M. It was documented "pt unable to sign". No staff signature was on this entry. The patient discharged on [DATE]. No documentation in the chart was found to indicate why the patient was unable to sign or that any attempts had been made to establish and contact a patient representative since the patient was unable to sign.

Review of Patient #3's chart showed that he was a [AGE]-year-old male admitted to the hospital through the emergency room . The patient had advanced dementia. His son was his caretaker and was present in the emergency room upon admission. Admission paperwork was signed by his son on 2-19-2016 at 11:10 A.M. The patient left the emergency room for his inpatient room at 10:47 P.M. The Important Message from Medicare about Your Rights form was noted, "Pt unable to sign (AMS)" and had an admission staff member signature. It was dated 2-19-2016 at 2:52 P.M. At the bottom of the form was a written entry "No family #2 unable to sign" this was dated 2-25-2016 at 11:23 A.M and did not have a staff signature. The patient was discharged on [DATE]. No documentation was found in the chart to indicate that the son, who was the caretaker, had ever been contacted and advised, upon admission or prior to discharge, of the patient rights contained in the Important Message from Medicare about Your Rights.

Staff #1 and Staff #2 were interviewed on the afternoon of 8-23-2016 in the conference room. Staff #2 explained that admissions staff are responsible for the first delivery of the Important Message from Medicare about Your Rights form, as well as the second delivery prior to discharge. Staff #2 confirmed that an authorized representative should have been contacted when the patient was unable to sign. Staff #1 stated, "We need a process for closing the loop" when patients are not able to sign their own paperwork.

Review of 42 CFR 489.27(a) revealed each Medicare beneficiary who is an inpatient or his/her representative must be provided the standardized notice, "An Important Message from Medicare" within 2 days of admission and not more than 2 calendar days in advance of patient discharge.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of records and interview, the facility failed to ensure 1 (Patient #2) out of 10 patients (Patients #'s 1, 2, 3, 4, 5, 6, 7, 18, 19, and 20) had their Advance Directive on the chart and available for physicians and staff.

Review of Patient #2's chart showed that he was an [AGE]-year-old male admitted to the hospital with bacterial pneumonia. Upon admission, the patient was asked if he had formed an advance directive. The patient indicated that he had formed an advance directive. Nursing notes indicated that the wife was going to bring the advance directive to the hospital. Review of the chart revealed that there was not an advance directive on the chart or further mention of the wife obtaining the advance directive.

Review of policy number VI-2 titled "Delay in Obtaining an Advance Directive", section III "Responsibility", stated: "If a patient chooses to form an Advance Directive, or modify their existing Advanced Directive at this time, the nurse or case manager will ensure that a copy of the document is placed in the patient's medical record."

An interview with Staff #2 and Staff #6 was conducted on the afternoon of 8-23-2016. Staff #6 stated that the nurse would normally follow up on this, but had probably found his advanced directive attached to one of his previous visits, so wouldn't attach it to this visit also. Staff #2 stated he would go check with medical records to see if the advance directive had been attached to a previous record. Upon return, Staff #2 stated that an advanced directive could not be located in Patient #2's chart for any of his admissions to the hospital.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation and interview, the hospital failed to

A) ensure supplies stored in the Emergency Crash Carts (a cart that contains emergency supplies to rapidly treat a patient experiencing an unexpected emergency medical event) were not expired and were safe to be used on the patient in an emergency situation. Three out of four drawers inspected on the Emergency Crash Cart contained expired supplies. This practice placed all patients at risk of harm.

B) ensure patient equipment was inspected and serviceable in 1 out of 6 pieces of equipment identified as ready for patient use.

Findings are as follows:

A tour of the 5th Floor Intermediate Care (IMC) Unit was conducted on 8-22-2016 with Staff #2 and Staff #6. Per Staff #6, the IMC floor receives patients who have cardiac (heart) problems or stroke patients. They also receive patients who are improving after being in the Intensive Care Unit (ICU).

A) A storage room across from the nurse's station was used to store the Emergency Crash Cart. The first drawer of the crash cart contained supplies to start intravenous (IV) access (access to a vein for delivery of medication directly into the blood system of a patient). This is done by placing a catheter into the vein. Five out of five 18 gauge (IV catheter sizes are measured in gauges) IV catheters had expired as of June 2016. Five out of six 22 gauge IV catheters had expired as of October 2015. The second drawer of the crash cart contained various supplies to include a Multi-lumen Central Venous Catheter kit. This is placed by a physician into a deep vein and has multiple ports (lumens) to inject different medications simultaneously into the patient's blood system. This kit was found to be expired as of March 2016. The third drawer had equipment to manage the breathing airway of a patient experiencing an emergency medical condition. A Stylet Stick used to guide an emergency airway breathing tube into correct position was found to be expired as of May 2015.

Findings were confirmed by Staff #2 and Staff #6.

B) A room was designated as a clean supply room and contained 6 pieces of equipment that were clean and ready for patient use. One item was a machine for monitoring patient vital signs to include blood pressure, pulse, and temperature. It had a plastic bag over it to prevent dust contamination. Upon removing the bag, it was found to have a periodic maintenance sticker that showed it was last inspected in April of 2015 and was due inspection every 12 months. Staff #2 confirmed the equipment was overdue inspection and should be removed from service until inspected.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, review of records, and interview, the facility failed to maintain a sanitary environment in 1 area (Kitchen) out of 3 areas toured (4th floor, 5th floor, and Kitchen). This deficient practice placed all patients at risk of harm.

Findings are as follows:

On 8-22-2016 at 11:20 A.M. a tour of the kitchen was conducted with Staff #2, Staff #6, and Staff #7 present.

In the food supply storage area, on the food supply shelf for use, was a container of Worcestershire Sauce that was marked as received on 7-12-2016. It had been opened and was partially empty. Staff #7 was asked how long it had been opened. Staff #7 stated he did not know. When asked how long it could remain on the shelf after opening, Staff #7 stated he thought it was 3 months, but would have to check in the computer. When asked if it should be marked as to the date it was opened, Staff #7 confirmed there was a process for labeling food items for the date it was received, the date it was opened and the date it expired after opening. Staff #7 stated the kitchen employees were not following the proper process.

The following items were found on the food supply shelf and did not have a received date:
Creamy Caesar Dressing 1 bottle
Hellman's Mayonnaise 3 bottles
Sweet Baby Ray's Barbeque Sause 1 bottle
Arrozzio Vegetable Oil 2 bottles
Real Lemon lemon juice 3 bottles
Salsa 1 bottle
Toasted Sesame Oil 2 bottles
Real Lime lime juice 1 bottle

Staff #7 stated he had been out the previous week and staff did not follow procedures for marking supplies when the supply truck delivered food products.

Red storage bins for bulk food items had dirt, dust, and trash in them. Food containers had dirt and dust on them. Staff #7 was asked for the cleaning schedule for the food supply area. Staff #7 stated he cleaned out the bins once a week when the food trucks delivered food, but there was not a cleaning schedule. He stated the bins had been cleaned out the previous week, but then said he was out the previous week. It could not be determined when the last time the food storage area had been cleaned.

Cardboard shipping boxes were on the shelves in the food storage area. Cardboard shipping boxes could be a potential source of contamination for food items. Staff #7 stated he knew he wasn't supposed to store items in their shipping containers but stated he didn't have enough of the red storage bins. When asked by Staff #2 if he had requested more red storage bins, Staff #7 answered, "No."

Metal carts for transporting food trays and supplies were found inside of the kitchen. The insides of the carts, outsides, wheels and castors were visibly soiled. When asked where the carts travel, Staff #7 stated they were used to transport meal trays and supplies to the various hospital departments to include the emergency room , Intensive Care Unit, Intermediate Care Unit, and Medical/Surgical Unit. When asked if the carts and wheels were cleaned before coming back into the kitchen, Staff #7 said no. Staff #7 was not able to provide a cleaning schedule for the carts. Staff #7 stated there is not a staging area that dirty carts were not allowed to go beyond. The only dirty area identified was for receiving dirty food trays. The carts were used to transport dirty trays to the designated dirty area and were then brought into the kitchen without cleaning.

When asked about the process for drying dishes, Staff #7 stated the dishes were allowed to air dry before stacking. A rack of clean pans was examined. Twenty-two out of twenty-two baking pans were wet and had thick, blackened food build up around the edges of the pan. One pan had large chunks food particles stuck to it.

A warming oven in the kitchen was unserviceable. Per Staff #7, it was being worked on while still in the kitchen. It was located in the kitchen and was visibly soiled with dirt, grease, and food particles. The food warmer next to it contained uncovered food on trays. The inside was visibly soiled with dried spills and food particles.

A refrigerator unit with four doors was located in the corner of the kitchen. It contained 9 containers of prepared food that were not labeled as to when the food was prepared or expired. One container of food had a plastic-wrap cover that was sunken in with the weight of spilled liquid on it. Juice containers (9 each) were sitting in liquid on a tray. Milk cartons (12 each) were sitting on a tray with spilled milk on it. A container of heavy whipping cream was past its expiration date of 8-20-2016. What appeared to be shredded cheese was wrapped up in plastic wrap with no labels as to content or age. Salsa, cocktail sauce, and minced garlic in manufacturer containers in the refrigerator did not contain the delivered or opened date. The refrigerator exterior and interior were visibly soiled with food particles and dried spillage. The floor under the refrigerator door had liquid spillage that had not been wiped up.

Three commercial ovens were in use. Each had double glass doors. Residue buildup on all doors was so heavy that the inside of the oven could not be seen. Piles of burnt matter were on the floor of the oven. One oven had bits of aluminum foil on the floor of it. The outside door handles and knobs had a buildup of sticky residue.

The steamer box drain had pieces of food sitting in warm liquid in it and a build-up of food matter around the drain hole.

The meat slicer was observed to be stored. Staff #7 confirmed it was clean and ready for used. The meat slicer was visibly soiled with small particles of meat on the slicing tray. It had rusting areas on its finish that could not be adequately cleaned.

The commercial food mixer observed to be stored. Staff #7 confirmed it was clean and ready for used. It was visibly soiled with drops of dried food matter. The finish was chipped and rusted and could not be adequately cleaned.

The sink area where the backsplash met the wall was visibly soiled and had cracked and peeling caulk.

Staff #2 provided copies of the labeling system for marking opened food items along with a list of expirations dates. Staff #2 stated that he could not provide me with the environmental rounds reports that showed the kitchen had been inspected for cleanliness by infection control and the environmental rounds team.