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 MEDICAL CENTER - TEMPLE 2401 S 31ST ST TEMPLE, TX 76508 Dec. 6, 2016
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation, interview and record review the facility failed to ensure patient's privacy when a patient was exposed during perineal care, while being transported and patient information was left open on a computer in the hallway.

Findings include:

Review of the facility provided document Patient Rights and Responsibilities, (Last Revision Date: 4/2015) reflected " ...We will treat all with dignity. ..."

An observation made on the morning of 12/5/16 on the facility's 5th floor inpatient unit revealed two transport personnel standing in the hallway with an elderly patient on a bed. One of the transport personnel lifted the sheet up over the patient's head to rearrange the sheet. When the sheet was lifted the patient was observed to be wearing an incontinence brief; he was not wearing a gown. The patient quickly grabbed the sheet to cover himself.

During an interview on the morning of 12/6/16, on the facility's 5th floor inpatient unit Staff #9, Nursing Director stated, "...The patient should not be exposed....We'll will talk to them..."

During a tour of the Intensive Care Unit an unattended computer monitor, in the hallway, was left open with patient health information on the screen and was easily viewable to visitors and staff not caring for the patient.

An observation on the morning of 12/6/16, on the North Tower 7th floor medical inpatient unit revealed Patient #3 being provided perineal care for an incontinent episode. Patient #3 was completely uncovered and exposed during the perineal care.

Review of the facility provided document Skills; Perineal Care (undated) reflected "...3. Drape the patient with the bath blanket ....4. Fold the lower half of the bath blanket up to expose the upper thighs. Wash the thighs with soap and water and then dry and cover them with bath towels....5. Fold back the bath blanket to expose the genitalia...."

During an interview on the morning of 12/6/16, Staff #1, Clinical Competency Administrator when asked for a policy on incontinence care stated, "We do not have a policy, we follow Mosby....Perineal care is not covered in the nursing training...."
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on interview and record review the facility's governing body failed to ensure the effective operation of the grievance process when a complaint involving patient care was not handled as a grievance as the facility policy required.

Findings include:

Review of the facility provided document "Patient Complaints and Grievances, Grievance (Last Revision Dated: 8/23/2016) Definition: A formal or informal written or verbal Complaint that Is: ...Regarding the patient's care (when the Complaint Is not resolved at the time of the Complaint by staff present),abuse or neglect, or issues related to the facility's compliance with the Centers for Medicare and Medicaid Services ("CMS") Conditions of Participation ("CoPs") ....When a Grievance Is resolved, the Patient Is notified. In writing, of the resolution of the Grievance, or If multiple Grievances are received the resolution of each, and the following Information is Included:
Contact person's name,
Date Grievance received,
Steps taken to resolve the Grievance,
Results of the Grievance process; and,
Date of completion ...Quality improvement Concerns/Complaints, and Grievances are reviewed as part of quality improvement and/or Risk Management with appropriate leaders and committees ...."

Review of the facility provided document "Patient Rights and Responsibilities, (Last Revision Date: 4/2015) ...We will treat all with dignity ...To speak up and ask questions if the patient or surrogate decision-maker does not understand or feels dissatisfied with the treatment and care we are providing or if the patient or surrogate decision-maker feels the patient is unsafe while under our care ...."

Review of the following facility provided Event Occurrence Executive Summary reports reflected:
On 1/8/16, the complainant, during a 4 hour interview, had voiced concerns regarding the physician's communication, medication administration and infection control issues. The complaint form did not include actions to be taken to address the concerns or to inform the complainant of a resolution. The report ended with "felt at ease that I was going to see this through ..."

The report did not list Steps taken to resolve the Grievance, Results of the Grievance process; and Date of completion, and was not reviewed as part of quality improvement and/or Risk Management with appropriate leaders and committees.

And on 1/13/16 the complainant brought concerns to the management, "...Pointed out all infractions and was threatening to call the state...."

The report did not list the infractions and did not include actions to be taken to address the concerns or to inform the complainant of a resolution.

During an interview on the morning of 12/5/16, in the board room, Staff #7, Vice President Patient Relations stated, "Public relations met with the complainant on the 8th. The complaint was not a grievance; it was handled by the nurse manager...The patient was moved to another unit..." When asked if the complainants concerns were incorporated into the quality program Staff #7 stated, "No." When asked why the complaint had not been handled as a Grievance, since there were multiple patient care concerns and the complainant had voiced concerns on two occasions, Staff #7 stated, "We thought it had been resolved."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview and record review the facility failed to provide care in a safe setting when medications delivered by Nasogastric (NG) tube were not mixed with sterile water as the policy dictated, were mixed in the patient bathroom and the medications were administered by being pushed into the Nasogastric tube instead of by gravity, possibly causing abdominal distention and pain.

Findings include:

An observation made on the morning of 12/6/16 on the North Tower 7th floor medical inpatient unit revealed Staff #10, RN administering medications to Patient #3. Staff #10 was observed taking the medications into the patient bathroom. Staff #10 crushed the medications in the patient bathroom, where the pill crusher was being stored. Staff #10 used tap water to dilute the medication and drew up the medication into a 30 ml (milliliter) feeding syringe; the syringe had been sitting on a shelf directly above the uncovered commode where a graduated plastic container with visible yellow liquid was sitting in the container. Staff #10 attached the feeding syringe to the NG port and pushed the end of the syringe to administer the medications, she then flushed, by pushing, the NG port with a new syringe, with water she had obtained from the bathroom hand sink. Staff #10 went back and forth to the bathroom preparing multiple medications.

During an interview on the morning of 12/6/16, Staff 1, Clinical Competency Administrator stated, "We do not have a policy for the administration of medications." When asked what the nurses are taught, Staff #1 stated, "We use Mosby's for the Nursing standards of practice ....I wasn't aware we needed to use Sterile water to mix the medications ..." When asked if the medications are supposed to be delivered by gravity or pushed Staff #1 stated, "I'm not sure."

During an interview in the afternoon on 12/6/16, in the board room, Staff #11, Infection Prevention Manager, when asked if it was acceptable to be using the bathroom to prepare medications Staff #11 stated, "They shouldn't be using the bathroom...."

Review of the facility provided document Skills: Feeding Tube: Medication Administration (undated)
"Feeding Tube: Medication Administration
13. Fill a graduated container with sterile water.... Draw 30 ml of water into a 30-ml or larger syringe, insert the tip of the syringe into the feeding tube, and flush the tube....
22. Administer liquid or dissolved medication by pouring it into the syringe (Figure 2) and flush.... i. If water or medication does not flow freely, raise the height of the syringe to increase the rate of flow or have the patient change position slightly because the end of the feeding tube may be against the gastric mucosa.
l. If these measures do not improve the flow, a gentle push with the bulb or plunger of the oral syringe may facilitate the flow...."
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on observation, interview and record review the facility failed to identify opportunities for improvement when a verbal complaint regarding the patient's care was not handled as a grievance.

Findings include:

Review of the facility provided document Patient Complaints and Grievances, Grievance (Last Revision Dated: 8/23/2016) reflected,
"Definition: A formal or informal written or verbal Complaint that Is: ...Regarding the patient's care (when the Complaint Is not resolved at the time of the Complaint by staff present),abuse or neglect, or issues related to the facility's compliance with the Centers for Medicare and Medicaid Services ("CMS") Conditions of Participation ("CoPs")....When a Grievance Is resolved, the Patient Is notified. In writing, of the resolution of the Grievance, or If multiple
Grievances are received the resolution of each, and the following Information is Included:
Contact person's name,
Date Grievance received,
Steps taken to resolve the Grievance,
Results of the Grievance process; and,
Date of completion ...Quality improvement Concerns/Complaints, and Grievances are reviewed as part of quality improvement and/or Risk Management with appropriate leaders and committees...."

Review of the following facility provided Event Occurrence Executive Summary reports reflected:
On 1/8/16, the complainant, during a 4 hour interview, had voiced concerns regarding the physician's communication, medication administration and infection control issues. The complaint form did not include actions to be taken to address the concerns or to inform the complainant of a resolution. The report ended with "felt at ease that I was going to see this through..."

On 1/13/16, the same complainant" ...Pointed out all infractions and was threatening to call the state ...."

The report did not list the infractions and did not include actions to be taken to address the concerns or to inform the complainant of a resolution.

During an interview on the morning of 12/5/16, in the board room, Staff #7, Vice President Patient Relations stated, "Public relations met with the complainant on the 8th. The complaint was not a grievance; it was handled by the nurse manager...The patient was moved to another unit..." When asked if the complainants concerns were incorporated into the quality program Staff #7 stated, "No." When asked why the complaint had not been handled as a Grievance and as the facility's policy required, Staff #7 stated, "We thought it had been resolved."

Review of the facility provided document "Patient Rights and Responsibilities, (Last Revision Date: 4/2015)... To speak up and ask questions if the patient or surrogate decision-maker does not understand or feels dissatisfied with the treatment and care we are providing or if the patient or surrogate decision-maker feels the patient is unsafe while under our care...."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview and record review the facility failed to provide nursing services in an ornagized manner.

Cross Reference:
A0385- Organization of Nursing Services
A0144- Patient Rights: Care in a Safe Setting
A0143- Patient Rights Personal Privacy
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on observation, interview and record review the facility failed to provide nursing services in an ornagized manner when:

A.) Nursing staff did not provide perineal care using aseptic technique (cleaned specifically in a way that prevents infection).

B.) Supplies to administer medications by Nasogastric tube were being stored in the patient bathroom along with a used urinal, the medications were being prepared in the bathroom, and the tap water from the bathroom hand sink was being used to prepare the medications.

Findings include:

A.) An observation on the morning of 12/6/16, on the North Tower 7th floor medical inpatient unit revealed Patient #1 being provided perineal care for an incontinent episode.

Staff13, RN Infection Preventionist donned clean gloves and sprayed perineal care wash onto a clean cloth. Staff #13 wiped loose stool onto the cloth, she performed this step several times. Staff #13 changed gloves and continued to wipe the loose stool from the bed. Staff #13 then removed a blue foam wedge from behind the patient's back, with the contaminated gloves, and placed the foam wedge onto the patient's bedside couch. Staff #13 handled the clean linens and the patient with the soiled gloves.

An unidentified Certified Nursing Assistant (CNA) proceeded to assist in wiping Patient #1's scrotum and remove the soiled linens. The CNA did not change her soiled gloves before assisting the nurses to place the clean linens and reposition Patient #1.

Staff #10, RN wiped Patient #1's scrotum. Staff #10 then touched Patient #1's upper torso, removed the soiled linens and touched the clean linens with contaminated gloves.


During an interview on the morning of 12/6/16, on the North Tower 7th floor medical inpatient unit Staff #6, Quality Specialist stated, "I saw she didn't change her gloves after wiping the BM from the bed...."

During an interview on the morning of 12/6/16, Staff #1, Clinical Competency Administrator when asked for a policy on incontinence care stated, "We do not have a policy, we follow Mosby....Perineal care is not covered in the nursing training...."

Review of the facility provided document Skills; Perineal Care
Perineal Care ...
1. Perform hand hygiene before patient contact.
13. Prepare equipment and supplies.
3. Drape the patient with the bath blanket.
4. Fold the lower half of the bath blanket up to expose the upper thighs. Wash the thighs with soap and water and then dry and cover them with bath towels.
5. Fold back the bath blanket to expose the genitalia....
10. Have the patient abduct his legs. Gently cleanse the shaft of the penis and the scrotum.
a. Carefully clean the underlying surface of the penis.
b. Lift the scrotum carefully and wash underlying skinfolds.
c. Rinse and dry thoroughly....
15. Discard supplies, remove gloves, and perform hand hygiene.

The Perineal Care procedure does not include removing and washing hands when gloves have become contaminated.
B.) An observation made on the morning of 12/6/16 on the North Tower 7th floor medical inpatient unit revealed Staff #10, RN administering medications to Patient #3. Staff #10 was observed taking the medications into the patient bathroom. Staff #10 crushed the medications in the patient bathroom, where the pill crusher was being stored. Staff #10 used the bathroom tap water to dilute the medication and drew up the medication into a 30 ml (milliliter) feeding syringe; the syringe had been sitting on a shelf directly above the uncovered commode where a graduated plastic container with visible yellow liquid was sitting in the container. Staff #10 attached the feeding syringe to the NG port and pushed the end of the syringe to administer the medications, she then flushed, by pushing, with a new syringe filled with water she had obtained from the bathroom hand sink. Staff #10 went back and forth to the bathroom preparing multiple medications.

During an interview in the afternoon on 12/6/16, in the board room, Staff #11, Infection Prevention Manager, when asked if it was acceptable to be using the bathroom to prepare medications Staff #11 stated, "They shouldn't be using the bathroom...."

Review of the facility provided document Skills: Feeding Tube: Medication Administration (undated)
"Feeding Tube: Medication Administration
13. Fill a graduated container with sterile water.... Draw 30 ml of water into a 30-ml or larger syringe, insert the tip of the syringe into the feeding tube, and flush the tube ....
22. Administer liquid or dissolved medication by pouring it into the syringe (Figure 2) and flush.... i. If water or medication does not flow freely, raise the height of the syringe to increase the rate of flow or have the patient change position slightly because the end of the feeding tube may be against the gastric mucosa.
l. If these measures do not improve the flow, a gentle push with the bulb or plunger of the oral syringe may facilitate the flow...."

During an interview on the morning of 12/6/16, Staff 1, Clinical Competency Administrator stated, "We do not have a policy for the administration of medications." When asked what the nurses are taught, Staff #1 stated, "We use Mosby's for the Nursing standards of practice....I wasn't aware we needed to use Sterile water to mix the medications..." When asked if the medications are supposed to be delivered by gravity or pushed Staff #1 stated, "I'm not sure."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, interview and record review the facility failed to administer medication according to the facility procedures when medications delivered by Nasogastric tube were not mixed with sterile water as the policy dictated, were mixed in the patient bathroom and the medications were administered by being pushed instead of by gravity, which would prevent possible distention and abdominal pain.

Findings include:

An observation made on the morning of 12/6/16 on the North Tower 7th floor medical inpatient unit revealed Staff #10, RN administering medications to Patient #3. Staff #10 was observed taking the medications into the patient bathroom. Staff #10 crushed the medications in the patient bathroom, where the pill crusher was being stored. Staff #10 used the bathroom tap water to dilute the medication and drew up the medication into a 30 ml (milliliter) feeding syringe; the syringe had been sitting on a shelf directly above the uncovered commode where a graduated plastic container with visible yellow liquid was sitting in the container. Staff #10 attached the feeding syringe to the NG port and pushed the end of the syringe to administer the medications, she then flushed, by pushing, with a new syringe filled with water she had obtained from the bathroom hand sink. Staff #10 went back and forth to the bathroom preparing multiple medications.

During an interview in the afternoon on 12/6/16, in the board room, Staff #11, Infection Prevention Manager, when asked if it was acceptable to be using the bathroom to prepare medications Staff #11 stated, "They shouldn't be using the bathroom...."

Review of the facility provided document Skills: Feeding Tube: Medication Administration (undated)
"Feeding Tube: Medication Administration
13. Fill a graduated container with sterile water.... Draw 30 ml of water into a 30-ml or larger syringe, insert the tip of the syringe into the feeding tube, and flush the tube....
22. Administer liquid or dissolved medication by pouring it into the syringe (Figure 2) and flush .... i. If water or medication does not flow freely, raise the height of the syringe to increase the rate of flow or have the patient change position slightly because the end of the feeding tube may be against the gastric mucosa.
l. If these measures do not improve the flow, a gentle push with the bulb or plunger of the oral syringe may facilitate the flow...."

During an interview on the morning of 12/6/16, Staff 1, Clinical Competency Administrator stated, "We do not have a policy for the administration of medications." When asked what the nurses are taught, Staff #1 stated, "We use Mosby's for the Nursing standards of practice....I wasn't aware we needed to use Sterile water to mix the medications..." When asked if the medications are supposed to be delivered by gravity or pushed Staff #1 stated, "I'm not sure."
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, interview and record review the facility failed to provide an active surveillance program to identify infectious risks and communicable diseases.

Findings include:

Cross reference:
A0748-Infection Control Officer Responsibilities
A0144 Patients Rights: Care in a Safe Setting
A0405- Administration of Drugs
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on observation, interview and record review the facility failed to develop and implement policies to prevent the control of infections when:

A.) Nursing staff did not provide perineal care using aseptic technique (cleaned specifically in a way that prevents infection).

B.) Supplies to administer medications by Nasogastric tube were being stored in the patient bathroom along with a used urinal, the medications were being prepared in the bathroom, and the tap water from the bathroom hand sink was being used to prepare the medications.

C.) IV (Secondary Intravenous tubing), a peripheral catheter , and a central line dressing were not labeled.

Findings include:

A.) An observation on the morning of 12/6/16, on the North Tower 7th floor medical inpatient unit revealed Patient #1 being provided perineal care for an incontinent episode.

Staff# 13, RN Infection Preventionist donned clean gloves and sprayed perineal care wash onto a clean cloth. Staff #13 wiped loose stool onto the cloth, she performed this step several times. Staff #13 changed gloves and continued to wipe the loose stool from the bed. Staff #13 then removed a blue foam wedge from behind the patient's back, with the contaminated gloves, and placed the foam wedge onto the patient's bedside couch. Staff #13 handled the clean linens and the patient with the soiled gloves.

An unidentified Certified Nursing Assistant (CNA) proceeded to assist in wiping Patient #1's scrotum and remove the soiled linens. The CNA did not change her soiled gloves before assisting the nurses to place the clean linens and reposition Patient #1.

Staff #10, RN wiped Patient #1's scrotum. Staff #10 then touched Patient #1's upper torso, removed the soiled linens and touched the clean linens with contaminated gloves.


During an interview on the morning of 12/6/16, on the North Tower 7th floor medical inpatient unit Staff #6, Quality Specialist stated, "I saw she didn't change her gloves after wiping the BM from the bed...."

During an interview on the morning of 12/6/16, Staff #1, Clinical Competency Administrator when asked for a policy on incontinence care stated, "We do not have a policy, we follow Mosby....Perineal care is not covered in the nursing training...."

Review of the facility provided document Skills; Perineal Care
Perineal Care ...
1. Perform hand hygiene before patient contact.
13. Prepare equipment and supplies.
3. Drape the patient with the bath blanket.
4. Fold the lower half of the bath blanket up to expose the upper thighs. Wash the thighs with soap and water and then dry and cover them with bath towels.
5. Fold back the bath blanket to expose the genitalia....
10. Have the patient abduct his legs. Gently cleanse the shaft of the penis and the scrotum.
a. Carefully clean the underlying surface of the penis.
b. Lift the scrotum carefully and wash underlying skinfolds.
c. Rinse and dry thoroughly....
15. Discard supplies, remove gloves, and perform hand hygiene.

The Perineal Care procedure does not include removing and washing hands when gloves have become contaminated.


B.) An observation made on the morning of 12/6/16 on the North Tower 7th floor medical inpatient unit revealed Staff #10, RN administering medications to Patient #3. Staff #10 was observed taking the medications into the patient bathroom. Staff #10 crushed the medications in the patient bathroom, where the pill crusher was being stored. Staff #10 used tap water to dilute the medication and drew up the medication into a 30 ml (milliliter) feeding syringe; the syringe had been sitting on a shelf directly above the uncovered commode where a graduated plastic container with visible yellow liquid was sitting in the container. Staff #10 attached the feeding syringe to the NG port and pushed the end of the syringe to administer the medications, she then flushed, by pushing, the NG port with a new syringe, with water she had obtained from the bathroom hand sink. Staff #10 went back and forth to the bathroom preparing multiple medications.

During an interview in the afternoon on 12/6/16, in the board room, Staff #11, Infection Prevention Manager, when asked if it was acceptable to be using the bathroom to prepare medications Staff #11 stated, "They shouldn't be using the bathroom...."

Review of the facility provided document Skills: Feeding Tube: Medication Administration (undated)
"Feeding Tube: Medication Administration
13. Fill a graduated container with sterile water.... Draw 30 ml of water into a 30-ml or larger syringe, insert the tip of the syringe into the feeding tube, and flush the tube ....

During an interview on the morning of 12/6/16, Staff 1, Clinical Competency Administrator stated, "We do not have a policy for the administration of medications." When asked what the nurses are taught, Staff #1 stated, "We use Mosby's for the Nursing standards of practice....I wasn't aware we needed to use Sterile water to mix the medications..."

C.) Observations made on 12/5/16 on the facility's 5 STC (Special Treatment Center) unit revealed Patient #3 had an IV (intravenous catheter) in his left arm; the insertion dated, the time and the name of the individual inserting the IV were missing. Additionally, the IV tubing for an antibiotic was not labeled.

An observation on the morning of 12/6/16, on the facility's 700 North Tower revealed Patient #4's Central Catheter line dressing was not labeled.

Review of the facility provided documents reflected:
"Clinical / IV Therapy Practice / Medication Administration (Revised 02/2012) ... C. IV Site Placement: ...
2. Apply Transparent Dressing
3. Secure Tubing
4. Label Dressing:
a. Date and time inserted
b. Size of device
c. Initials of nurse....
E. Tubing:
1. Tubing Changes-Change tubing....every 96 hours. Consider short extension tubing connected to the catheter to be a portion of the device....
3. Tubing labels.
Label each:
a. Start date and time
b. Stop date and time
c. Initials of nurse ...
b. Secondary tubing administration sets with primary administration sets expires at 96 hours ...."

Review of the facility provided documents "Infection Prevention Rounds" did not reflect observations of the delivery of direct patient care.

During an interview in the afternoon on 12/6/16, in the board room, Staff #11 Infection Prevention Manager stated, "All employees receive infection control training in the new hire orientation. They are assigned training and tests through HCL (Healthcare Learning Center) ...everything is unit specific ...we do additional training with the nursing staff ...we don't teach the lab techs....We do full tracers monthly....We don't go into patient's rooms when there is a patient, only to see if the room is ready and set up for the next patient...."