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.
| THE MEDICAL CENTER OF SOUTHEAST TEXAS | 2555 JIMMY JOHNSON BLVD PORT ARTHUR, TX 77640 | Aug. 8, 2017 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on observation, document review, and interview, the facility failed to provide a safe setting for the patient in 1 of 1 areas of the hospital. The facility failed to provide a sanitary and clean environment for patients on the 24 bed Cardiovascular Intensive Care Unit (CVICU) by not providing hot water for basic bathing needs. Also, there was no hot water in the 3 bathrooms that were being used by the staff in the CVICU. The facility staff working in the CVICU were using the coffee machine and the microwave to heat water to provide warm water for bathing the patients. There was no hot water in the staff bathrooms for the staff to wash their hands. In addition, the floors in the patients' rooms were observed to have an unclean and dirty appearance in 6 of 6 areas of the CVICU. The main hallway, staff bathrooms, medication room, coffee breakroom, supply room, and nursing station of the CVICU area were all found with discolored floors and pieces of paper trash were found on the floor. Dust, lint, and hair were also found in the corners of the areas as listed. Cross Refer: A 0144 |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| Based on observation, document review, and interview, the facility failed to provide a safe setting for the patient in 1 of 1 areas of the hospital. The facility failed to provide a sanitary and clean environment for patients on the 24 bed Cardiovascular Intensive Care Unit (CVICU) by not providing hot water for basic bathing needs. Also, there was no hot water in the 3 bathrooms that were being used by the staff in the CVICU. The facility staff working in the CVICU were using the coffee machine and the microwave to heat water to provide warm water for bathing the patients. There was no hot water in the staff bathrooms for the staff to wash their hands. In addition, the floors in the patients' rooms were observed to have an unclean and dirty appearance in 6 of 6 areas of the CVICU. The main hallway, staff bathrooms, medication room, coffee breakroom, supply room, and nursing station of the CVICU area were all found with discolored floors and pieces of paper trash were found on the floor. Dust, lint, and hair were also found in the corners of the areas as listed. These deficient practices of infection control issues in the CVICU of the hospital had the likelihood to cause infection, harm or injury to the patients receiving care in the facility. Prior to the tour, an interview was held with the Staff #7 (Director of CVICU) on 08/08/2017 at 9:30 AM. Staff #7 was asked do you recall any water issues that your staff has complained about. Staff #7 stated, "I did have one of my charge night nurses mention that there was no hot water for bathing patients." Staff #7 was asked when did it occur and was the problem reported. Staff #7 stated, "I think it was about a month ago and no I did not report the issue." An interview with the Chief Nursing officer on 08/08/2017 at 9:15 revealed that she had no staff complaints about water issues in the CVICU area. During a tour of the 24 bed CVICU on 08/08/2017 at 10:00 AM the following unclean sanitary conditions and infection control issues were observed: 1. In CV Room #2 ran the hot water for over 3 minutes and there was no hot water. Also, observed brown stained ceiling tile in this room. 2. In CV Room #9 ran the hot water for over 3 minutes and there was no hot water. 3. In CV Room #12 ran the hot water for over 3 minutes and there was no hot water. The above observations were confirmed by Director of CVICU, Director of Quality, and the Chief Nursing Officer on 08/08/2017 at 10:15 AM. Also, during the tour of the CVICU on 08/08/2017 went into all 3 staff bathrooms and ran the hot water. There was no hot water for the staff to wash their hands. When trying to wash your hands in the patient's room or the staff bathrooms the paper dispenser or the paper towels did not fit the dispenser correctly and the paper towels would not come out or the paper towels would tear into small pieces. The above observations were confirmed by Director of CVICU on 08/08/2017 at 10:45 AM. An interview with Staff #9 (Day Charge Nurse) was conducted on 08/08/2017 at 10:30 AM in the patient consultation room. Staff #9 was asked how long the unit has been without hot water in the patients' rooms. Staff #9 stated, "Several months." Also, Staff #9 was asked if they had heard of the nurses using the coffee machine to get hot water for bathing the patients. Staff #9 stated, "Yes, and they use the microwave to heat water too." Staff #9 was asked if anyone had reported the hot water issue. Staff #9 stated, "Yes, several work orders have been placed and phone calls made to the maintenance department, just ask Staff #8." An interview with Staff #8 was conducted on 08/08/2017 at 10:35 AM in the charge nurse office. Staff #8 was ask how long the unit had been without hot water in the patients' rooms. Staff #8 stated, "A long time and I can show you a copy of a work order that was put in couple of months ago." Staff #8 was asked if they had placed any work orders. Staff #8 stated, "No, but I have called maintenance several times and I know other staff members have put in work orders." A phone interview was conducted with Staff #10 (Night Charge Nurse) on 08/08/2017 at 11:00 AM. Staff #10 was asked how long had the CVICU been without hot water. Staff #10 stated, "Since October 2016." Staff #10 was asked if they had heard of the nurses using the coffee machine and microwave to get hot water to bathe the patients. Staff #10 stated, "Yes, the nurses use the microwave and the coffee machine to get hot water for bathing the patients. A phone interview was conducted with Staff #11 (Night Charge Nurse) on 08/08/2017 at 9:00 PM. Staff #11 was asked how long had the CVICU been without hot water. Staff #11 stated, " I have been here a year and I can't remember having hot water. Staff #10 was asked if they had nurses using the coffee machine and microwave to get hot water to bathe the patients. Staff #10 stated, "Yes." Further observation during the tour of the CVICU observed the following areas of the main hallway, staff bathrooms, medication room, coffee breakroom, supply room, and nursing station were all found with discolored floors and pieces of paper trash were found on the floor. The surveyor took a piece of white paper towel and wiped it across the floor. The paper towel was covered with dirt, dust, lint, and hair. The patient rooms had greasy black dirt build-up around the commodes. Dust, lint, and hair were also found in the corners of the rooms. There was plaster missing from wall, entrance way to the rooms and storage areas had paint missing, and there was dust noted on the "Pyxis" medication storage and equipment. The above observations were confirmed by Director of CVICU, Director of Quality, and the Chief Nursing Officer on 08/08/2017 at 10:45 AM. A review of a copy of the work order # 8 was found hanging on the wall in the charge nurse office. The work order was placed on 06/10/2017 at 5:06 AM and the work order read "There is NO hot water in ICU for exactly 1 year, that I am aware of. Location: every patient room in ICU." A review of another work order # 0 was also placed on 06/10/2017 at 6:44 AM. The work order read, "The unit's cv/med/icu in every room, there is no hot water available. The patients are to be bathed every night, and there is no hot water. Comments; -we cannot go on bathing patients with cold water." A review of the work order summary report from 03/20/2017 to 08/08/2017 revealed the following: Work order # 8 for 06/10/2017 was not found in the summary. The system work order showed # 8 was a repair for ER ceiling, but the date was 08/03/2016. A review of the work order summary report from 03/20/2017 to 08/08/2017 revealed that all 19 plumbing repair work orders were completed, but during the tour there was still no hot water in the CVICU area. An interview with the Staff #12 (plant operations) on 08/08/2017 at 11:30 AM stated, "I have no explanation to why work order # 8 was showing in the system dated 08/03/2016 and that there was a work for the same number for 06/10/2017. Staff #12 was asked about no hot water in CVICU and he stated, "I get a lot of phone calls, seems like I do remember a problem with the hot water in the month of April. We had a pump regulator that had to be repaired." A review of the form titled, "Hazard surveillance Rounds data Collection Form" revealed the following: 1. The Hazard Surveillance Rounds Data Collection Form was scheduled to be completed in January and July 2017 for CVICU. 2. A review of the Hazard Surveillance Rounds Data Collection Form dated February 2017 revealed issues with dust and plaster missing from the walls. There was nothing addressed in the report about hot water issues. 3. A review of the Hazard Surveillance Rounds Data Collection Form dated July 2017 revealed issues with the patient rooms not being clean and dust. There was nothing addressed in the report about hot water issues. An interview with the Staff #4 (Director of Quality) on 08/08/2017 at 2:00 PM confirmed that the hot water issue in the CVICU area had not been addressed and that there was lack of communication and reporting among the staff to administration. Also, the Environment of care (EOC) meetings are held quarterly and there has been no mention of hot water issues. Staff #4 also stated that the facility does a huddle with the key staff members and there has been no mention of the hot water issues. The above findings were confirmed by the Director of CVICU, Director of Quality, Chief Nursing Officer, Plant Operations Director, and the Chief operating officer on 08/08/2017 at 2:00 PM. It was determined that this deficient practice created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failed practices had the likelihood to affect all patients being cared for in the facility. |
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| VIOLATION: INFECTION CONTROL | Tag No: A0747 | |
| Based on observation, document review, and interview, the infection control program failed to provide a sanitary environment to avoid sources and transmission of infectious and communicable diseases in 1 of 1 areas of the hospital. The facility failed to ensure a sanitary and clean environment for patients on the 24 bed Cardiovascular Intensive Care Unit (CVICU) by not providing hot water for basic bathing needs. Also, there was no hot water in the 3 bathrooms that were being used by the staff in the CVICU. The facility staff working in the CVICU were using the coffee machine and the microwave to heat water to provide warm water for bathing the patients. There was no hot water in the staff bathrooms for the staff to wash their hands. In addition, the floors in the patients' rooms were observed to have an unclean and dirty appearance in 6 of 6 areas of the CVICU. The main hallway, staff bathrooms, medication room, coffee breakroom, supply room, and nursing station of the CVICU area were all found with discolored floors and pieces of paper trash were found on the floor. Dust, lint, and hair were also found in the corners of the areas as listed. Cross Refer: A 0749 |
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| VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES | Tag No: A0749 | |
| Based on observation, document review, and interview, the infection control program failed to provide a sanitary environment to avoid sources and transmission of infectious and communicable diseases in 1 of 1 areas of the hospital. The facility failed to ensure a sanitary and clean environment for patients on the 24 bed Cardiovascular Intensive Care Unit (CVICU) by not providing hot water for basic bathing needs. Also, there was no hot water in the 3 bathrooms that were being used by the staff in the CVICU. The facility staff working in the CVICU were using the coffee machine and the microwave to heat water to provide warm water for bathing the patients. There was no hot water in the staff bathrooms for the staff to wash their hands. In addition, the floors in the patients' rooms were observed to have an unclean and dirty appearance in 6 of 6 areas of the CVICU. The main hallway, staff bathrooms, medication room, coffee breakroom, supply room, and nursing station of the CVICU area were all found with discolored floors and pieces of paper trash were found on the floor. Dust, lint, and hair were also found in the corners of the areas as listed. These deficient practices of infection control issues in the CVICU of the hospital had the likelihood to cause infection, harm or injury to the patients receiving care in the facility. Prior to the tour, an interview was held with the Staff #7 (Director of CVICU) on 08/08/2017 at 9:30 AM. Staff #7 was asked do you recall any water issues that your staff has complained about. Staff #7 stated, "I did have one of my charge night nurses mention that there was no hot water for bathing patients." Staff #7 was asked when did it occur and was the problem reported. Staff #7 stated, "I think it was about a month ago and no I did not report the issue." An interview with the Chief Nursing officer on 08/08/2017 at 9:15 revealed that she had no staff complaints about water issues in the CVICU area. During a tour of the 24 bed CVICU on 08/08/2017 at 10:00 AM the following unclean sanitary conditions and infection control issues were observed: 1. In CV Room #2 ran the hot water for over 3 minutes and there was no hot water. Also, observed brown stained ceiling tile in this room. 2. In CV Room #9 ran the hot water for over 3 minutes and there was no hot water. 3. In CV Room #12 ran the hot water for over 3 minutes and there was no hot water. The above observations were confirmed by Director of CVICU, Director of Quality, and the Chief Nursing Officer on 08/08/2017 at 10:15 AM. Also, during the tour of the CVICU on 08/08/2017 went into all 3 staff bathrooms and ran the hot water. There was no hot water for the staff to wash their hands. When trying to wash your hands in the patient's room or the staff bathrooms the paper dispenser or the paper towels did not fit the dispenser correctly and the paper towels would not come out or the paper towels would tear into small pieces. The above observations were confirmed by Director of CVICU on 08/08/2017 at 10:45 AM. An interview with Staff #9 (Day Charge Nurse) was conducted on 08/08/2017 at 10:30 AM in the patient consultation room. Staff #9 was ask how long the unit has been without hot water in the patients' rooms. Staff #9 stated, "Several months." Also, Staff #9 was asked if they had heard of the nurses using the coffee machine to get hot water for bathing the patients. Staff #9 stated, "Yes, and they use the microwave to heat water too." Staff #9 was asked if anyone had reported the hot water issue. Staff #9 stated, "Yes, several work orders have been placed and phone calls made to the maintenance department, just ask Staff #8." An interview with Staff #8 was conducted on 08/08/2017 at 10:35 AM in the charge nurse office. Staff #8 was ask how long the unit had been without hot water in the patients' rooms. Staff #8 stated, "A long time and I can show you a copy of a work order that was put in couple of months ago." Staff #8 was asked if they had placed any work orders. Staff #8 stated, "No, but I have called maintenance several times and I know other staff members have put in work orders." A phone interview was conducted with Staff #10 (Night Charge Nurse) on 08/08/2017 at 11:00 AM. Staff #10 was asked how long had the CVICU been without hot water. Staff #10 stated, "Since October 2016." Staff #10 was asked if they had heard of the nurses using the coffee machine and microwave to get hot water to bathe the patients. Staff #10 stated, "Yes, the nurses use the microwave and the coffee machine to get hot water for bathing the patients. A phone interview was conducted with Staff #11 (Night Charge Nurse) on 08/08/2017 at 9:00 PM. Staff #11 was asked how long had the CVICU been without hot water. Staff #11 stated, " I have been here a year and I can't remember having hot water. Staff #10 was asked if they had nurses using the coffee machine and microwave to get hot water to bathe the patients. Staff #10 stated, "Yes." Further observation during the tour of the CVICU observed the following areas of the main hallway, staff bathrooms, medication room, coffee breakroom, supply room, and nursing station were all found with discolored floors and pieces of paper trash were found on the floor. The surveyor took a piece of white paper towel and wiped it across the floor. The paper towel was covered with dirt, dust, lint, and hair. The patient rooms had greasy black dirt build-up around the commodes. Dust, lint, and hair were also found in the corners of the rooms. There was plaster missing from wall, entrance way to the rooms and storage areas had paint missing, and there was dust noted on the "Pyxis" medication storage and equipment. The above observations were confirmed by Director of CVICU, Director of Quality, and the Chief Nursing Officer on 08/08/2017 at 10:45 AM. A review of a copy of the work order # 8 was found hanging on the wall in the charge nurse office. The work order was placed on 06/10/2017 at 5:06 AM and the work order read "There is NO hot water in ICU for exactly 1 year, that I am aware of. Location: every patient room in ICU." A review of another work order # 0 was also placed on 06/10/2017 at 6:44 AM. The work order read, "The unit's cv/med/icu in every room, there is no hot water available. The patients are to be bathed every night, and there is no hot water. Comments; -we cannot go on bathing patients with cold water." A review of the work order summary report from 03/20/2017 to 08/08/2017 revealed the following: Work order # 8 for 06/10/2017 was not found in the summary. The system work order showed # 8 was a repair for ER ceiling, but the date was 08/03/2016. A review of the work order summary report from 03/20/2017 to 08/08/2017 revealed that all 19 plumbing repair work orders were completed, but during the tour there was still no hot water in the CVICU area. An interview with the Staff #12 (plant operations) on 08/08/2017 at 11:30 AM stated, "I have no explanation to why work order # 8 was showing in the system dated 08/03/2016 and that there was a work for the same number for 06/10/2017. Staff #12 was asked about no hot water in CVICU and he stated, "I get a lot of phone calls, seems like I do remember a problem with the hot water in the month of April. We had a pump regulator that had to be repaired." A review of the form titled, "Hazard surveillance Rounds data Collection Form" revealed the following: 1. The Hazard Surveillance Rounds Data Collection Form was scheduled to be completed in January and July 2017 for CVICU. 2. A review of the Hazard Surveillance Rounds Data Collection Form dated February 2017 revealed issues with dust and plaster missing from the walls. There was nothing addressed in the report about hot water issues. 3. A review of the Hazard Surveillance Rounds Data Collection Form dated July 2017 revealed issues with the patient rooms not being clean and dust. There was nothing addressed in the report about hot water issues. An interview with the Staff #4 (Director of Quality) on 08/08/2017 at 2:00 PM confirmed that the hot water issue in the CVICU area had not been addressed and that there was lack of communication and reporting among the staff to administration. Also, the Environment of care (EOC) meetings are held quarterly and there has been no mention of hot water issues. Staff #4 also stated that the facility does a huddle with the key staff members and there has been no mention of the hot water issues. The above findings were confirmed by the Director of CVICU, Director of Quality, Chief Nursing Officer, Plant Operations Director, and the Chief operating officer on 08/08/2017 at 2:00 PM. It was determined that this deficient practice created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failed practices had the likelihood to affect all patients being cared for in the facility. |
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