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.
| BAYLOR SCOTT & WHITE PAVILION - TEMPLE | 2401 S 31ST ST TEMPLE, TX 76508 | Sept. 22, 2011 |
| VIOLATION: PHYSICAL ENVIRONMENT | Tag No: A0700 | |
| Based on observation during a tour of the hospital and interview with staff, the physical environment in the kitchen, loading dock, inpatient units, surgical suite, and psychiatric unit, were not maintained to ensure the safety and well-being of the patients. Findings were: Based on observation and staff interviews during a tour of the facility conducted on 9/19/11 and 9/20/11, the condition of the physical plant included holes in walls, broken floor tiles, water damaged ceilings, torn coverings on examination and operating room tables, rust in the operating rooms, disintegrated freezer door seals, rancid-smelling standing water, non-intact walls, and other safety issues, which prevented proper cleaning and made possible the entry of dirt particles, rodents, and insects. Cross Refer A0701 Maintenance of Physical Plant, CFR 482.41(a) |
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| VIOLATION: MAINTENANCE OF PHYSICAL PLANT | Tag No: A0701 | |
| Based on observation throughout the hospital with multiple staff members, the facility physical plant had not been maintained in all areas for the safety of patients. FIndings were: Observation in the kitchen during a tour the morning of 9-19-11, accompanied by Staff #39 and #60, the entry hall, paint was peeled back leaving exposed wall for an 18 inch strip, which allowed moisture in the sheetrock and prevented proper cleaning. In the main kitchen there was a two inch crack and hole in the ceiling. Approximately a 6x3 foot area of the main kitchen ceiling had multiple reddish-orange splashed areas, which included approximately 6-8 splashes per square foot. In the dishwashing area, wall tiles were missing and/or broken, revealing sheetrock underneath which could not be properly cleaned or kept dry. An 8 inch hole in the wall was observed in the flat tray line area revealing sheetrock underneath. Cracks and holes were observed in the baseboard tile near the fryers revealing sheetrock underneath which could not be properly cleaned or kept dry. Raised white, grey and black dust was observed on 6 metal air vents in the kitchen area ceiling; a black raised substance, mold-like in appearance, was observed on one metal air vent in the dry food storage. A layer of white dust was observed on the vent of 1 of 2 ice machines. Dirt particles and debris and four dead bugs were observed in the light fixtures over the salad bar preparation area. In the dry food storage area, raised dirt, pieces of crumbled paper, and other debris were observed on the floor; dirt and food debris were observed on the blue hard plastic potato cart, and dirt and debris were observed in the drain under the soda fountain mixers. On the corner of the wall, the corner edge molding was missing and the wall laminate was peeling back on the bottom left edge, which preventing effective cleaning. The direct openings made possible the entry of dirt particles, rodents, and insects. The door seals for freezers/refrigerators 155B, 158, 158A, and159 were not intact and disintegrated, which could allow the possible entry of dirt particles, rodents, or insects, and would not ensure that the correct temperature range was maintained for food storage. An area of formed ice, approximately 4x2 feet, was observed and dripping from the ceiling in freezer 153A. A 12x18 inch area of dark grey raised dust was observed in front of the fan on the ceiling in production walk-in refrigerator 155B. Two seams in the ceiling were dirty with a black substance and caulk was missing in one seam in the ceiling of refrigerator 159, which provided an entry for dirt particles, rodents, or insects, and would not ensure that the correct temperature range was maintained for food storage. The above was confirmed by observation and in interview with Staff #58 and Staff #60 on 9-19-11. A 6x10 foot area of milky colored water was observed pooled next to the drain at the base of the trash compactor on the left side of the kitchen loading dock. This area was unable to drain as the entry to the drain was higher than the water. There was a rancid aroma arising from the area of standing water. The above was observed and confirmed in interview with Staff #58 and Staff #60 on 9-19-11. During a tour of the entryway to the trash disposal and dirty linen room on the second floor, a 12 x 6 inch hole was observed in the sheetrock, which could allow moisture to be absorbed in to the wall or permit the entry of dirt or dust particles, rodents, or insects. This was observed and confirmed in interview on 9-19-11 with Staff # 36 and Staff #39. During a tour of the second floor of the hospital on 9-19-11, observation of a portion of the wall between the orthopedic equipment storage room and the cardiac equipment storage room revealed a large portion of the wall was missing and not intact between the two rooms. A white board, approximately 6x10 feet, was taped to the wall to cover the opening. In the room on one side of the wall, the orthopedic equipment storage room contained used and unusable medical and patient use equipment, not all of which had been cleaned. In the room on the other side of the wall, the cardiac equipment storage room contained an allograft freezer, containing frozen human tissue and specimens. The taped board extended to the ceiling and up to an opened ceiling air conditioning vent, which allowed an exchange of air between the two rooms and did not provide a barrier or separation between the clean and dirty areas. The above was observed and confirmed in interview with Staff #36 and #39. Observation in the surgical instrument sterilization area of the second floor during a tour of the hospital on 9-20-11 revealed a hole in the wall behind the endoscope cleaning tanks and adjacent to sink used for the cleaning of surgical instruments. The hole was approximately 3 x 4 foot square, leaving exposed lumber and sheetrock, which could become contaminated with moisture and airborne bacterial particles from the endoscope and instrument cleaning process, and which also provided an opening for dust particles, rodents and insects. There were 10 holes in the sheetrock above the instrument cleaning sink, 8 of the holes were ? inch in diameter; one hole was 1.5x2 inches, and one hole was 1x 1 inches. Under another sink in the room there was a 1x2 foot hole in the sheetrock, leaving exposed sheetrock and pipes. These holes could become contaminated with moisture and airborne bacterial particles from the instrument cleaning process and provided an opening for dirt particles, rodents and insects. The above was observed and confirmed in interview with Staff #36, #39, and #62. A tour of the labor, delivery and antepartum suite was conducted the morning of 9/20/11 in the company of Staff #39, Staff #36, and Staff #66. In postpartum room NT 322, available for patient use, there were two brown areas in the ceiling tile, which appeared to be water damage. One area was 8x14 inches in diameter, the other area was 4x5 inches in diameter. This was confirmed by observation and in interview with Staff #36, Staff #39, and Staff #66. A tour of the psychiatric unit was conducted the afternoon of 9/20/11 in the company of Staff #36, Staff #39, and Staff #59. In patient room S-180, available for patient use, wall and floor tiles in the shower were cracked and missing and the baseboard was separated from the wall, rendering the shower unable to be properly cleaned or disinfected. In patient room S-188, available for patient use, wall and floor tiles in the shower were cracked and missing; the caulk had disintegrated; and the baseboard was separated from the wall, which rendered the shower unable to be properly cleaned or disinfected. In patient room S-180, available for patient use, wall and floor tiles in the shower were cracked and missing; the caulk had disintegrated; and the baseboard was separated from the wall; which rendered the shower unable to be properly cleaned or disinfected. Under the toilet, the baseboard had separated from the wall, creating an area which was not able to be properly cleaned or disinfected. In patient room S-172, available for patient use, there was a hole in the baseboard in the corner of the room, which contained brown and grey dust and provided an opening for dirt particles, rodents and insects. There were black and brown smeared marks in the shower; a dried cheerio and other debris in the floor of the shower; wall and floor tiles in the shower were cracked and missing; the caulk had disintegrated; and the baseboard was separated from the wall; which rendered the shower unable to be properly cleaned or disinfected. There was raised brown and black dirt and raised grey dust on the floor of the entry to the room behind the door. In the seclusion room, the baseboard had separated from the wall in sections which prevented proper cleaning of the floor. The above was confirmed by observation and in interview with Staff #36, Staff #39, and Staff #66 on 9/20/11. |
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| VIOLATION: INFECTION CONTROL | Tag No: A0747 | |
| Based on review of documentation, observation, and interviews with staff, the facility failed to ensure a sanitary environment to avoid sources and transmission of infections and communicable diseases, as 7 patient care areas of the hospital and 1 off-site clinic were not clean and sanitary; 8 of the 8 unsanitary patient care units were not identified by the infection control officer as areas needing infection control intervention. Findings were: Tours of the surgery suite, labor and delivery suite, pediatric units, radiology department, psychiatric unit, physical therapy, STC-4 (nursing unit), and off-site rehabilitation clinic were conducted during the survey, 9/19/11 - 9/22/2011 in the company of facility administrative and clinical staff. In the labor and delivery suite and in the pediatric unit, areas of blood and blood spatter were found on equipment and beds available for patient use. Tears in outer coverings of mattresses and patient positioning devices were also observed in labor and delivery, surgery, radiology, physical therapy, and in an off-site clinic; old peeling tape was also found on some of these items which were available for patient use. These items could absorb body fluids due to the tears in the outer coverings and could not be cleaned between patients. Dirt, dust and other debris were found in all 8 areas. Hinged surgical instruments found in 2 areas were not adequately sterilized and were available for patient use. CROSS REFER to Tag A0749 - CFR ? 482.42, Infection Control Officer Responsibilities |
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| VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY | Tag No: A0143 | |
| Based on observation and interview, it was determined that the facility failed to provide privacy to its patients by monitoring patients in their bedrooms and part of their bathrooms without fully disclosed consent, displaying electronic monitoring of patient personal areas on monitors, and displaying patient resuscitation status outside patient rooms. Findings were: A tour of the psychiatric unit (STC-1) was conducted the afternoon of 9/20/11 in the company of Staff #39, and Staff #59. 12 of 18 patient bedrooms on STC-1 had electronic monitoring surveillance equipment/cameras mounted in their ceilings. The monitors, were located above the nurses station but were visible to people, including hospital staff or other patients who might be standing or walking near the station. The monitors clearly showed real time monitoring of each patient room (bed, sitting area and partial restroom). Facility policy entitled " Photography, Filming and Recording " stated in part " This policy is designed to provide patient confidentiality in the use of photography, filming or recording for purposes other than treatment, diagnosis and identification. These activities are separate from diagnostic images obtained in the course of patient care ... Because these activities may compromise patient ' s privacy and confidentiality, Scott and White requires that appropriate consent be obtained from the patient with the below exceptions: ? Photography, Filming and/or Recording for Treatment, Identification or Diagnosis: a) Photography, filming and/or recording is permitted for the identification, diagnosis and treatment of the patient and may be performed as part of the course of treatment without separate consent. b) The use of photography, filming and/or recording as part of the patient ' s treatment process should be documented in the patient ' s health record. " The same policy continued, " Consent is obtained as follows: ? Psychiatric: Patient completes Patient Consent for Photography, Recording and Filming (MR Form-H8002-100) is completed. " Facility document entitled " Patient Consent for Photography, Recording and Filming " (MR Form-H8002-100) stated in part " I (print patient ' s full name) consent to the filming, photographing and/or other recording of myself and/or the portion (s) of my body involved in my medical condition, diagnosis, treatment, operation (s) and/or procedure (s) for medical education, internal quality control, performance improvement and/or other purposes. " Facility document entitled " General Consent for Treatment/Financial Responsibility/Advance Directive Information " stated in part " I consent to the possible videotaping, photographing, or other recording of myself or parts of my body involved in diagnosis or treatment. This may be for medical education or quality improvement. If I do not want my recordings used for these purposes, I must tell Scott and White Healthcare in a reasonable time before they are used. " Facility document (promulgated by the Department of Mental Health and Mental Retardation) entitled " Patient ' s Bill of Rights " stated in part " You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity ...You have the right to be informed of the current and future use of products of special observation and audiovisual techniques, such as one way vision mirrors, tape recorders, television, movies or photographs. " Facility document entitled " Patients ' Rights and Responsibilities " stated in part " Patients have a right to: " Expect personal privacy and confidentiality of medical information as required by law ....Provide informed consent or decline participation in experimental research, in the recording/filming for reasons other than treatment, diagnosis, or identification and in the training of students and residents ....Have reasonable access to care, receiving treatment and medical services in a safe environment and without discrimination based on race, age, religion, national origin, sex, sexual preferences or disability. " In an interview with Staff #59, she stated that the general hospital consent was signed by patients, and that the Consent form for Photography, Recording and Filming is only signed if the facility is actually recording, which is rarely done. Staff #59 stated that the electronic monitoring is not recorded; it is real time observation of patients. A consent form for real time observation of patients in their bedrooms and part of their bathrooms was not provided. This was confirmed in interview on 9/20/11 with Staff #59 and Staff #39. A tour of the patient floor, 4 North was conducted the afternoon of 9/21/11 in the company of Staff #39 and Staff #59. Two of two patient rooms had " DNR " (Do Not Resuscitate) placards mounted on the wall beside each patient room door. The above findings were observed and confirmed in an interview on 9/21/2011at 4:00pm with Staff #39 and Staff #59. Facility document entitled " Patients ' Rights and Responsibilities " stated in part " Patients have a right to: " Expect personal privacy and confidentiality of medical information as required by law Facility document entitled " It ' s Your Choice, Information on your rights under the Patient Self-determination Act and Texas Natural Death Act " stated in part " An Advance Directive is a legal document that allows you to tell your physician and family your preferences for medical treatment before you actually need care ....Directive to Physicians and Family or Surrogates (Living Will) that instructs your health care providers to administer, withhold, or withdraw life-sustaining treatment when you have a terminal or irreversible condition, and you cannot speak for yourself ....If you provide Scott and White with a completed directive, the existence of a Directive is documented in your medical record. Formal policies have been adopted to assure that your rights to make medical treatment decisions will be honored. " Definition of " DNR " (Do Not Resuscitate) from Lawers.com stated, " For some medical conditions such as terminal cancer, end-stage renal disease, or severe pneumonia, life saving intervention is not warranted when patients stop breathing or when their hearts stop beating. A valid do not resuscitate order (DNR) tells medical professionals not to perform cardiopulmonary resuscitation (CPR) on a patient. DNR orders prove to be beneficial in preventing unnecessary or unwanted treatment at the end of an individual's life. " |
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| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on observation, review of documentation and interview, it was determined that the facility did not protect the rights of its patients, including the right to personal privacy and providing care in a safe setting. Patients were monitored via camera in their personal area without proper consent and patient health information was being displayed; emergency call systems were not available or inaccessible, and restraint devices were unsecured. Findings were: During a tour of the psychiatric unit on 9/20/11, 12 of 18 patient bedrooms and partial bathrooms were being monitored with real time electronic surveillance monitoring cameras, the display was visible to those outside the nursing station, and the general consent form did not fully disclose this monitoring. During a tour of the 4 North inpatient unit on 9/21/11, patient health information was displayed outside of 2 of 2 patient rooms. Cross refer: A 0143 Patient Rights, Personal Privacy, CFR 482.13(c)(1) During a tour of the emergency department on 9/20/11, as restraint devices were available for patients in the " Safe Room " and during a tour of the emergency department and labor and delivery area on 9/20/11 emergency call systems were not available or were inaccessible. Cross refer: A0144 Patient Rights, Care in a Safe Setting, CFR 482.13(c)(2) |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| Based on observation and interview, it was determined that the facility failed to provide a safe environment for its patients, as restraint devices were available for patients in the " Safe Room " and emergency call systems were not available or were inaccessible. Findings were: Facility document entitled " Patients ' Rights and Responsibilities " stated in part " Patients have a right to: " Have reasonable access to care, receiving treatment and medical services in a safe environment and without discrimination based on race, age, religion, national origin, sex, sexual preferences or disability. " Observation of the labor and delivery area during a tour of the facility on 9-20-11 revealed that in 3 of 3 patient rooms, 340, 341, and 322, the call light cords in the bathrooms were looped around the ADA (Americans with Disabilities Act) grab bar, rendering it inaccessible and non-functional to a patient suffering a fall. The above was confirmed in interview with Staff #36 and #39 on 9-20-11. Observation in Nursing Unit STC4 on 9/21/2011 at 3:25pm revealed that in the patient waiting room restroom (Room S402), there was no emergency cord or any call out system in case of an emergency. This was confirmed in an interview on 9/21/2011 at 3:25pm by Staff #44 and #65. Observation in the Emergency Department on 9/20/2011 at 8:45am, in room STG15, referred to by staff as " the safe room " revealed a cabinet with an unlocked combination lock on it. The surveyor opened the unlocked cabinet where two large black duffel bags full of leather restraints were found accessible to patients. This was a potential for self harm. This was confirmed in an interview on 9/20/2011 at 8:55 am with staff members #42, #43, #46, #47, #48, and #49. Hospital Policy entitled, " Environmental Suicide Precautions " , stated " D. Measures to Create a Safe Environment, In order to create a safe environment, the nurse should undertake the following measures: 3. Assess the patient ' s environment and take steps to reduce environmental risk factors that could be used to cause self harm and that are not necessary to patient care. " |
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| VIOLATION: GOVERNING BODY | Tag No: A0043 | |
| Based on review of available documentation, observation and staff interviews, the governing body failed to be responsible for all areas of hospital operation; for example- the infection control program, physical plant, and patient rights within the hospital. Findings were: 1. On 2-24-11, review of the meeting minutes from the Governing Body revealed that the Infection Control plan and evaluation including changes was presented and approved. There was no documentation of any areas of the hospital being inspected/viewed by Infection Control staff for Infection Control problems as there was no data available. Observation in the surgical suite, including operating rooms, pre- and post-operative areas, labor and delivery, nursery, radiology, and pediatric areas revealed there were multiple areas in need of monitoring for infection control practices. Cross Refer: A747 2. The right of patients to personal privacy and to care in a safe setting was not met as patients were monitored via camera in their personal area and patient health information was being displayed; emergency call systems were not available or inaccessible, and restraint devices were unsecured. During a tour of the psychiatric unit on 9/20/11, 12 of 18 patient bedrooms and partial bathrooms were being monitored with real time electronic surveillance monitoring cameras and the display was visible to those outside the nursing station, and during a tour of the 4 North inpatient unit on 9/21/11, patient health information was displayed outside of 2 of 2 patient rooms. During a tour of the emergency department on 9/20/11, as restraint devices were not secured and were available for patients in the " Safe Room ". Additionally, during a tour of the emergency department and labor and delivery area on 9/20/11 emergency call systems were not available or were inaccessible. Cross Refer: A0115 3. Observation during a tour of the hospital and interviews with staff revealed the physical environment, including the kitchen, loading dock, inpatient units, surgical suite, and psychiatric unit, were not maintained to ensure the safety and well-being of the patients as there were holes in walls, broken floor tiles, water damaged ceilings, torn coverings on examination and operating room tables, rust in the operating rooms, disintegrated freezer door seals, rancid-smelling standing water, non-intact walls, and other safety issues, which prevented proper cleaning and made possible the entry of dirt particles, rodents, and insects. Cross Refer: A0701 |
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| VIOLATION: CONTRACTED SERVICES | Tag No: A0083 | |
| Based on review of available documentation, observation and staff interviews, the governing body failed to be responsible for services furnished within the hospital operation; for example- the infection control program, physical plant, and patient rights within the hospital. Findings were: 1. On 2-24-11, review of the meeting minutes from the Governing Body revealed that the Infection Control plan and evaluation including changes was presented and approved. There was no documentation of any areas of the hospital being inspected/viewed by Infection Control staff for Infection Control problems as there was no data available. Observation in the surgical suite, including operating rooms, pre- and post-operative areas, labor and delivery, nursery, radiology, and pediatric areas revealed there were multiple areas in need of monitoring for infection control practices. Cross Refer: A747 2. The right of patients to personal privacy and to care in a safe setting was not met as patients were monitored via camera in their personal area and patient health information was being displayed; emergency call systems were not available or inaccessible, and restraint devices were unsecured. During a tour of the psychiatric unit on 9/20/11, 12 of 18 patient bedrooms and partial bathrooms were being monitored with real time electronic surveillance monitoring cameras and the display was visible to those outside the nursing station, and during a tour of the 4 North inpatient unit on 9/21/11, patient health information was displayed outside of 2 of 2 patient rooms. During a tour of the emergency department on 9/20/11, as restraint devices were not secured and were available for patients in the " Safe Room ". Additionally, during a tour of the emergency department and labor and delivery area on 9/20/11 emergency call systems were not available or were inaccessible. Cross Refer: A0115 3. Observation during a tour of the hospital and interviews with staff revealed the physical environment, including the kitchen, loading dock, inpatient units, surgical suite, and psychiatric unit, were not maintained to ensure the safety and well-being of the patients as there were holes in walls, broken floor tiles, water damaged ceilings, torn coverings on examination and operating room tables, rust in the operating rooms, disintegrated freezer door seals, rancid-smelling standing water, non-intact walls, and other safety issues, which prevented proper cleaning and made possible the entry of dirt particles, rodents, and insects. Cross Refer: A0701 |
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