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.

RENAISSANCE HOSPITAL TERRELL 1551 HWY 34 S TERRELL, TX Jan. 10, 2013
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observations, records review, and interviews, the facility failed to provide a secure place for drugs and biological to be stored.


Observed on tour of the facility on 1/9/2012 with staff #58 at approximately 10:00 AM, the medication cart in the nurses' medication room which contains patient's individual medication was unlocked with the keys left in the lock.


An interview with Staff #58 on 1/9/2012 at approximately 10:00 AM, confirmed the keys were left in the medication cart which is stored in the nurses' medication room.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0709
Based on records review, observations, and interviews, the facility failed to conduct fire drills on evenings and night shift for the facility staff members. Also, the facility failed to have the fire extinguishers inspected.


A review of 11 fire drill records revealed that there were no fire drills held on the evening or night shifts for the staff members of the facility.


A review of records and observation revealed that 2 fire extinguishers had not been inspected since 2010, 12 fire extinguishers had not been inspected since 2011 and 8 fire extinguishers had not been inspected since 2012.


An interview with staff #46 on 1/9/2013 at 1:00 PM confirmed that there were no fire drills held on evening or night shifts for staff members and the fire extinguishers in the facility had not been inspected.
VIOLATION: ORGAN, TISSUE, EYE PROCUREMENT Tag No: A0884
Based on interview and record review, the facility failed to ensure that the facility have a written agreement with an Organ Procurement Organization (OPO) which addressed how donor issues would be handled with patients.

This deficient practice was found in 7 of 30 (#s 35, 36, 53, 56, 57, 58, and 59) charts reviewed.

The facility failed to ensure that there was a trained Organ Procurement Organization representative or requestor.

The facility failed to ensure patient care staff were trained in donation issues.

The facility failed to ensure policies and procedures were in place to ensure coordination between an Organ Procurement Organization (OPO) and the facility to review death records.

Refer to tags A0886, A0889, A0891 and A0892 for additional information.
VIOLATION: LABORATORY SERVICES Tag No: A0576
Based on records review and interviews, the facility:

A. Failed to provide an ongoing process of the Quality Assurance and Performance Improvement (QAPI) program that measures, analyzes, and tracks adverse patient events, infection control and other aspects of performance improvement for the laboratory department.

While reviewing the laboratory departments documentation of QAPI activity on 1/8/2013, there was no evidence of documentation that any staff member had taken responsibility for collecting, measuring, analyzing, or tracking performance improvement in the laboratory department for the facility.

Interview with staff #19 on 1/8/2013 confirmed that at this time the facility has no organized QAPI program program in which the laboratory department can participate and no data had been collected.


B. Failed to adopt, implement, and enforce policies and procedures for receipt and reporting of tissue specimens.

Refer to tag A0585

C. Failed to adopt, implement, and enforce policies and procedures for general blood safety issues concerning look back activities.

Refer to tag A0586
VIOLATION: CONTENT OF RECORD - INFORMED CONSENT Tag No: A0466
Based on records review and interviews, the facility failed to ensure that consent forms were properly executed and complete. Citing 3 of 30 medical records reviewed. (#8, 42, and 47).


Review of patient medical record on 1/9/2013 and 1/10/2013 revealed the following:

1. Chart #42- patient name missing on consent for treatment dated 11/23/2012.

2. Chart #8- no physician signature and/or date and time on consent for blood transfusion patient received on 11/13/2012. No consent found for blood transfusion patient received on 11/14/2012.

3. Chart #47- No patient signature and/or witness signature on consent for treatment dated 11/15/2012.

Interview with staff #42 on 1/10/2013 confirmed the findings for charts #8, 42, and 47.
VIOLATION: LICENSURE OF PERSONNEL Tag No: A0023
Based on record review and interview the facility failed to ensure and provide documentation of current annual competencies, annual skills competencies, Cardiopulmonary Resuscitation (CPR), Advance Cardiac Life Support (ACLS), and/or current certifications required for nurses working in the emergency department and other personnel providing direct patient care. This has the potential to provide an unsafe environment for all patients receiving care at this facility. Citing 22 of 30 personnel files reviewed. ( #'s 3, 4, 5, 11, 14, 17, 24, 25, 30, 31, 32, 34, 36, 37, 38, 41, 42, 44, 45, 46, 50, and 51).

Review of personnel records on 1/8/13 and 1/9/13 revealed the following:

1. Staff #3 - No documentation of current annual training including infection control, annual skills competencies, and no certification to work in the emergency room , Pediatric Advanced Life Support (PALS) and/or Trauma Core Nurse Course (TNCC) found.

2. Staff #4- No documentation of current annual training including infection control, annual skills competencies, and/or current certification to work in the emergency room , PALS and /or TNCC found.

3. Staff #5- No documentation of current PALS/TNCC found.

4. Staff #11- No documentation of current annual competencies, infection control, and/or annual skills competencies found.

5. Staff #14- No documentation of current annual skills competencies found.

6. Staff #17- No documentation of current annual competencies and/or annual skills competencies found.

7. Staff #24- No documentation of current annual training including infection control and/or annual skills competencies found.

8. Staff #25- No documentation of current annual training including infection control, no annual skills competencies, and no certification to work in the emergency room , PALS and/or TNCC found.

9. Staff #30- No documentation of current PALS and/or TNCC. Also Cardiopulmonary Resuscitation (CPR) expired 9/2012.

10. Staff #31- No documentation of annual skills competencies and no documentation of current CPR certification found.

11. Staff #32- No documentation of current annual training including infection control and no annual skills competencies. No documentation of Advances Cardiac Life Support (ACLS) and/or current CPR certification.

12. Staff #34- No documentation of current annual skills competencies found.

13. Staff #36- No documentation of current certifications to work in the emergency room , PALS and/or TNCC. No documentation of current ACLS certification found.

14. Staff #37- No documentation of current annual skills competencies, and no certifications to work in the emergency room , PALS and/or TNCC found.

15. Staff #38- No documentation of current annual skills competencies, and no certification to work in the emergency room , PALS and /or TNCC found.

16. Staff #41- No documentation of annual skills competencies, and no certification to work in the emergency room TNCC found.

17. Staff #42- No documentation of current certifications PALS and/or TNCC found.

18. Staff #44- No documentation of annual skills competencies found.

19. Staff #45- No documentation that employee signed annual training and/or annual skills competencies. No documentation of a current ACLS certification found.

20. Staff #46- No documentation of skill check off and/or training for use of Cidex to sterilize equipment. No signature and/or date and time on annual skills competencies found.

21. Staff #50- No documentation of annual training including infection control and/or annual skills competencies found.

22. Staff #51- No documentation of job description, application, annual training including infection control, annual skills competencies, and no certification to work in the emergency room , PALS and/or TNCC found.

Interview on 1/9/2013 with staff #2 confirmed that the personal files were missing current annual training including infection control, skills competencies, current CPR and ACLS certifications, and current PALS and TNCC required to work in the emergency department.
VIOLATION: GENERAL BLOOD SAFETY ISSUES Tag No: A0593
Based on records review and interviews, the facility failed to adopt, implement, and enforce policies and procedures for general blood safety issues concerning look back activities.

On 1/9/2013 while reviewing the Policy and Procedure Manual for the laboratory department, no Policies and Procedure were found for blood safety issues concerning notification and counseling of recipients that may have received infectious blood and blood products. (Look Back Policy)

Interview with Director of Laboratory on 1/9/2013 confirmed that the department did not have any policies and procedures concerning look back policy. The Director of Laboratory also advised that the laboratory department received paperwork from Carter Blood Bank for the follow-up of a possible exposure and the follow-up was done.
VIOLATION: DESIGNATED REQUESTOR Tag No: A0889
Based on interview and record review, the facility failed to ensure that there was a trained Organ Procurement Organization representative or requestor.


Review of the facility's "ORGAN/TISSUE DONATION PROTOCOL" dated 03/01/10 revealed no information outlining who the trained representive or requestor would be for the facility. There was no documentation about the formal training required for the donor request process.

Review of the protocol revealed no written signed agreement for services between the OPO and the facility which outlined training for the donor requestor.

During an interview on 01/08/13 at 10:38 a.m., Staff #5 reported that she could not find any agreements with an OPO. There was no agreement addressing the designated requestor training program. Staff #5 reported they did not have a trained requestor. As of 12/28/12, her and two other staff members were handling it, but no one had any formal training. Before 12/28/12 Staff #1 the previous (Chief Nursing Officer) took care of the program.

Staff #5 provided an unusual event report dated 01/08/13 indicated they needed to meet with the OPO "concerning their protocol, paperwork and QI." Staff #5 reported they needed to assign someone to be the contact person for the OPO and their facility and they needed the OPO to "come to their facility and have an in-service."
VIOLATION: RADIOLOGIC SERVICES Tag No: A0528
Based on records review and interviews, the facility failed to have an ongoing process of Quality Assessment and Performance Improvement (QAPI) program that measures, analyzes, and tracks adverse patient events, infection control and other aspects of performance improvement for the radiology department.


While reviewing the radiology departments documentation of QAPI activity on 1/8/2013, there was evidence of documentation that staff members had taken responsibility for collecting data for discussion at department director meetings. No documentation found to validate that it was taken forward for review by the QAPI program.


Interview with staff #50 on 1/8/2013 confirmed that at this time the facility has no organized QAPI program in which the radiology department can participate .

.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on records review and interviews, the facility failed to ensure all medical record entries were dated, timed, and appropriately authenticated by the person who is responsible for ordering, providing, or evaluating the service provided. Citing 8 of 30 records reviewed. (#8, 32, 39, 40, 42, 45, 47, and 48)


Review of medical records on 1/9/2013 and 1/10/2013 revealed the following:

1. Patient record #39- no physician signature on history and physical transcribed on 11/26/2012. No physician signature and/or date found on discharge summary transcribed 11/29/2012.

2. Patient record #40- no physician signature and/or date on progress notes date 11/22/2012 and 11/28/2012.

3. Patient record #32- no physician signature and/or date on history and physical transcribed 11/26/2012. No signature and/or date on discharge summary transcribed on 11/28/2012.

4. Patient record #42- no physician signature and/or date on discharge summary transcribed on 11/23/2012.

5. Patient record #45- no physician signature and/or date on history and physical transcribed on 11/25/2012.

6. Patient record #48- no physician signature and/or date on history and physical transcribed on 11/21/2012.

7. Patient record #47- no physician signature and/or date on history and physical transcribed on 11/15/2012.

8. Patient record #8- no physician signature and/or date on history and physical dated 11/13/2012.

Interview with staff #42 on 1/10/2013 confirmed the findings for medical records #8, 32, 39, 40, 42, 45, 47, and 48.
VIOLATION: STAFF EDUCATION Tag No: A0891
Based on interview and record review, the facility failed to ensure that patient care staff were trained in donation issues.

This deficient practice had the potential to cause harm to all patients.

Review of the facility's "ORGAN/TISSUE DONATION PROTOCOL" dated 03/01/10 revealed no information outlining the training staff needed and that was in cooperation with the OPO and tissue bank.

Review of the protocol revealed no written signed agreement for services between the OPO and the facility which outlined staff training.

During an interview on 01/08/13 at 10:38 a.m., Staff #5 reported she could not find any agreements with the OPO. There was no agreement addressing the designated requestor training program or staff training. Staff #5 reported that she could find no documentation of staff being trained.

Staff #5 provided an unusual event report dated 01/08/13 indicated they needed to meet with the OPO "concerning their protocol, paperwork and QI." Staff #5 reported they needed to assign someone to be the contact person for the OPO and their facility and they needed the OPO to "come to their facility and have in-service."
VIOLATION: CONFIDENTIALITY OF MEDICAL RECORDS Tag No: A0441
Based on observations and interviews, the facility failed to ensure the security of patient records in the emergency department.


During the tour of the emergency department on 1/7/2013, a filing cabinet storing patient records was observed unlocked and unattended by facility staff. The cabinet could be accessed by any unauthorized persons.


Interview with staff #42 on 1/7/2013 confirmed that the patient charts located in the hallway of the emergency department were not secure and could be accessed by any unauthorized persons.


Review of Policies and Procedure Manual for medical records revealed the following:


Subject: Policy for Confidential/Security of Patient Health Information
Revised: March 1,2010

I. To assure safety, security, and confidentiality of all medical records maintained by Renaissance Hospital in an organized and readily accessible environment.

II. The health record is the property of Renaissance Hospital and shall be maintained to serve the patient, the health care provider, and the institution in accordance with legal, accrediting and regulatory agency requirements. The information contained in the health record belongs to the patient, and the patient is entitled to the protected right of information. All patient care information shall be regarded as confidential and available only to authorized users.

IV. Storage:

A. All primary heath records shall be housed in physically secure areas.

B. Secondary records, indices or other individually identifiable patient health information maintained by the institution are subject to the stated policies for maintenance of confidentiality of patient health information.

F. When in use within the institution, health records should be kept in secure areas at all times. Health records should not be left unattended in areas accessible to unauthorized individuals.
VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS Tag No: A0726
Based on observations, records review, and interviews, the facility failed to monitor temperature and humidity in the surgical suites and the sterile processing room where supplies are stored.


Review of the facility's Surgery policies revealed that there was no policy on monitoring temperature and humidity in the area where sterile supplies are stored.


Review of the AORN (Association of periOperative Registered Nurses) Standards and Recommended Practices revealed, "Temperature should be maintained between 68 degrees F to 73 degrees F." These recommendations apply to both operating rooms and sterile processing areas. A relative humidity level of 30 to 70 percent is acceptable. "Room temperature, humidity, and ventilation of each work area should be monitored and recorded daily."

Review of record with the temperature and humidity recorded revealed the following:

Operating Room #1

December --no recording of temperature/humidity being recorded

January 2013 -- 8 of 8 days temperature were out of range


Operating Room #2

December --no recording of temperature/humidity being recorded

January 2013 -- 8 of 8 days temperature were out of range


Operating Room #3

December --no recording of temperature/humidity being recorded

January 2013 -- 8 of 8 days temperature were out of range


Sterilization Room

December --no recording of temperature/humidity being recorded

January 2013 -- 7 of 10 days temperature were out of range


During a tour on 1/10/2013 at approximately 11:00 AM with staff #46, it was noted that the temperature was 81 degrees in the Sterilization Processing Room. Sterile instruments and supplies are stored in this area.


An interview with Staff #46 on 1/10/2013 at 10:00 AM reported that the air conditioner unit is not functioning properly and has not functioned properly for 2 years. Staff #46 stated, "The heating wires were pulled from the unit 2 years ago. The unit has to be manually turned on and off by going on top of the roof. The unit will only blow cold air and there is no regulating the temperature. If it is cold outside then the unit just has to be turned off manually by going to the roof top of the building."


Interview with staff #57 confirmed temperatures and humidity were not being recorded daily for Operating Room #1, #2, #3, or the sterilization room and no policy for temperature/humidity if recorded out of range.
VIOLATION: DISPOSAL OF TRASH Tag No: A0713
Based on observations, records review, and interviews, the facility failed to dispose of trash and bio-hazard waste appropriately. The facility also failed to store Hazmat supplies in a clean area.


During a tour of the facility on 1/9/2013 at 11:00 AM with staff #46, there were card board boxes stacked up on the dock where supplies come in to the facility in the purchasing department area. Staff #46 was questioned why the boxes were not placed in the trash dumpster and Staff #46 stated, "The dumpster is full and it will not hold any more trash." Staff #46 was questioned why the dumpster has not been emptied and Staff #46 stated, "The dumpster has not been emptied in 3 months because the vendor has not been paid and the service will not come until paid."


During a tour of the facility on 1/9/2013 at 11:30 AM with staff #46, there were 2 carts full sharps containers (45 full bio-hazard sharp containers) in the hallway of the facility. When Staff #46 was questioned why the bio-hazard had not been picked up, Staff #46 stated, "The vendor has not been paid and will not pick up the containers until paid."


During a tour of the facility on 1/9/2013 at 12:00 PM with staff #46 of a room where the red bags of bio-hazard are stored, there was equipment, trash, sharp containers, intravenous infusion pumps, boxes, computers, numerous wires on the ground, and at the very back of the room was a large amount of Hazmat supplies for a disaster.


A review of policy titled "Hazardous Waste Management Plan"

"AUTHORITY AND RESPONSIBILITY

The Chief Executive Officer(CEO) has final legal and moral authority and responsibility for the assurance at a compressive, flexible and integrated Hazardous Waste Management Program. The CEO is responsible for providing financial support necessary for the specific services, equipment and personnel required to maintain the hazardous waste management program The CEO delegates authority and accountability for the Hazardous Waste Program to the Safety Officer."


A review of records titled "Hazardous Waste Policy and Procedure Manual 2001" revealed the policies had not been updated or reviewed since 2001.


An interview with Director of Nurses on 1/9/2013 at 2:00 PM was unaware that the dumpster had not been emptied for 3 months and sharp containers (45) had not been picked up due to vendors not being paid.
VIOLATION: MEDICAL STAFF - SELECTION CRITERIA Tag No: A0050
During the follow-up survey from 1/7/2013 through 1/10/2013 additional findings were as follows:

Based on documents review and interviews, the facility failed to enforce established bylaws for categories of Medical Staff, appointment and re-appointment, and the term of the appointment.

A review of the document titled, "Medical Staff Bylaws," last amended and approved by the Governing Board 11-28-2007, revealed, Article IV Categories of the Medical Staff, Section 1. The Medical Staff, "The Staff shall be divided into Honorary, Active, Courtesy, Consulting and emergency room categories."

Article VI, Clinical Privileges, Section 2. Temporary Appointment, "Upon the recommendation of the chairman of a department and the Chief Executive Officer of the Hospital or his designee who is acting on behalf of the Governing Body, temporary privileges may be granted during the application process for the care of specific patient(s) or locum tenens, All such privileges shall be time limited and granted only when sufficient evidence exists that granting of temporary privileges is prudent."

Article V, Procedures for Appointment and Re-Appointment, Section 1. Application for Appointment, "(7) The Medical Staff Services is responsible for obtaining information from the Texas State Board of Medical Examiners and the National Practitioner Data Bank. (8) The application, complete with information sufficient to resolve doubts in any matter, shall be submitted to the administration, who upon receipt of all information, including licensure, education, training, experience and past or present Medical Staff membership at other facilities, shall submit the application and all supporting material to the Medical Executive Committee."

Section 3, Appointments- Provisional
"A All initial appointments and initial granting of clinical privileges shall be provisional and shall be for one year."

"D. At the successful completion of the provisional period the Practitioner's status will be reviewed for advancement to the requested category."

Section 4. Re-Appointment Process, "A. The Texas Standardized Application shall be fully completed to assure the availability of data necessary to update the member's medical staff file. The completed re-appointment application should include, but not he limited to the following:

(1) request for privileges;

(2) documentation of current, valid state license, DEA and DPS certificates (DEA and DPS certificates not required for pathologists);

(3) continuing training, education and experience since the previous appointment that qualifies the staff member for the privileges sought on re-appointment, or serves as justification for new or expanded privileges;

(4) sanctions of any kind imposed or pending by any other health care institution, professional health care organization or licensing authority: changes of any kind in Medical Staff membership(s), or privileges at any other health care institution or professional health care organization;

(5) documentation of newly obtained board certification or, as appropriate report on timely progress toward meeting pre-certification requirements;

(6) the results of the ongoing monitoring and evaluation of each practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs, shall be available for review in the re-credentialing process;

(7) involvement in professional liability actions including letters of intent, final judgments and or settlement;

(8) agreement that if the applicant is reappointed, he will continue to abide by the Bylaws, Rules and Regulations of the Medical Staff and Hospital ..... When collection and verification are accomplished, the administration shall transmit the application form and supporting materials to the Medical Executive Committee."

Section 5. Terms of Appointment, "Appointments to the Medical Staff shall be made by the Governing Body of the hospital upon the recommendation of the Medical Executive Committee, Appointments shall be for a period of no more than two years."

A review of Medical Staff #8's credentialing files contained a letter dated 03/29/2012, granting Temporary privileges for a period of two years. Staff #8's license expired 12/13/2012.
The Temporary privileges and time period did not meet the Medical Bylaws definition. Staff #8 is scheduled weekly in the hospital with the Hospitalist.

A review of Medical Staff #9's credentialing files contained a letter dated 01/26/2012, granting Provisional privileges for a period of two years. This file does not contain an updated application, request for privileges, the results of the ongoing monitoring and evaluation of the practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs. The provisional period granted does not meet the Medical Bylaws definition.

A review of Medical Staff #26's credentialing files contained a letter dated 01/26/2012, granting Provisional privileges for a period of two years. This file does not contain an updated application, request for privileges, the results of the ongoing monitoring and evaluation of the practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs. The provisional period granted does not meet the Medical Bylaws definition.

The review of Medical Staff #29's credentialing files revealed that the files did not contain an updated application, request for privileges, the results of the ongoing monitoring and evaluation of the practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs. Staff #29's previous re-appointment of 12/17/2010 to 12/17/2012 had expired.

Medical Staff #86 was presented as an active staff. Staff made the application on 05/07/2012. The file contains no evidence of granting privileges by Medical Staff or by the Governing Board. This Allied Health Professional's file had no evidence of a supervising Physician.

A review of Medical Staff #87's credentialing files contained a letter dated 01/26/2012, granting Provisional privileges for a period of two years. Provisional period granted does not meet the Medical Bylaws definition.

A review of Medical Staff #88's credentialing files contained a letter dated 03/26/2012, granting Provisional privileges for a period of two years. Provisional period granted does not meet the Medical Bylaws definition

A review of Medical Staff #89's credentialing files contained a letter dated 01/26/2012, granting Temporary privileges for a period of one year. The Temporary privileges and time period did not meet the Medical Bylaws definition. Staff is scheduled weekly in the hospital with the Hospitalist.

On 01/10/2013 at 9:30 AM, an interview was conducted with staff #55 in the credentialing office. Staff #55 revealed she did the credentialing and had not had any formal training by the facility. Staff #55 had picked it up by talking with other staff members. Staff #55 had discovered that some of the information provided by staff was wrong. Staff #55 stated, "Still continuing to learn." Staff #55 was not able to tell the surveyor what the categories were in the Medical Bylaws. Staff #55 had not read the bylaws. Staff #55 stated the Medical Staff's credentialing files, containing the application and all supporting material, were not being submitted to the Medical Executive Committee. Staff #55 was submitting a form listing the required elements. Staff #55 would make check marks beside the elements and the Medical Executive Committee would review that form.

During an interview on 01/09/2013 at approximately 1:00 PM in the Doctors' Lounge, Medical Staff #29 revealed that neither the Medical Staff nor the Governing Board had been made aware of the survey findings from 11/15/2012 until 01/03/2013 during a called Governing Board Meeting. It was during this meeting that the board was made aware the owner and CEO had brought in three nurses from another facility in an attempt to correct the previously cited problems. Medical Staff #29 was asked, "are there any problems you have voiced concerns about that have not been addressed by the Board of Directors/Owner?" The response was "yes." Staff #29 reported that there have been questions about the credentialing process. Staff #29 reported that the owner just put his doctors in here without going through the credentialing process.
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on records review and interviews, the facility failed to ensure that all patient medical records contained a discharge summary. Citing 4 of 30 patient charts reviewed. (#8, 40, 41, and 48.)

Review of medical records on 1/9/2013 revealed the following:

1. Patient chart #8- Patient discharged on [DATE]- no discharge summary found.

2. Patient chart #48- Patient discharged on [DATE]- no discharge summary found.

3. Patient chart #41- Patient discharged on [DATE]- no discharge summary found.

4. Patient chart #40- Patient discharged on [DATE]- no discharge summary found.

Interview with staff #42 on 1/9/2013 confirmed the findings for charts #8, 40,41, and 48.
VIOLATION: EMERGENCY POWER AND LIGHTING Tag No: A0702
Based on records review, observatiosn, and interviews, the facility failed to provide adequate fuel in the storage tank that runs the facility generator and the underground storage tank had not been inspected by the Texas Commission on Environmental Quality.


During the tour of the facility generator on 1/9/2013 at 9:00 AM with staff #46, the low fuel alarm was alarming on the panel and the print showed low fuel in the tank that supplies the generator for emergency lighting and power. Also observed on the wall beside the alarm panel was a delivery certificate for petroleum storage tank program which expired the last day of September 2012.


A review of the Delivery Certificate revealed "for the specific time period and the Underground Storage tanks (USTs) indicated, this certificate verifies self-certification by the tank owner or operator of compliance with TCEQ rule requirements listed at TAC Sec. 334.8 (c)(3) (D). [regarding tank registration, payment registration fees, UST financial responsibility (e.g., insurance), and technical standards (release detection, spill/over fill prevention, corrosion protection & variances issued by the agency to any of these standards)]. The Texas Water Code Sec. 26.346 requires the tank owner or operator to accurately complete the parts of the registration and self-certification form pertaining to the self-certification of compliance with UST administrative requirements and technical standards. Expires last day of September 2012."


An interview with staff #46 on 1/9/2013 at 9:00 AM confirmed that the the alarm on the fuel tank is recording low fuel and the "Delivery Certificate" for petroleum storage tank program had expired the last day of September 2012.
VIOLATION: PHARMACEUTICAL SERVICES Tag No: A0490
Based on records review, observations, and interviews, the facility's pharmacy:

A. Failed to provide pharmacy policies that were current and approved by the current medical staff. A review of the pharmacy policies revealed that the policies were dated and approved in 2007 by the previous management/owner of the facility.

Pharmacy services were not integrated into the hospital wide Quality Assessment and Performance Improvement Program.


B. Failed to provide a secure place for drugs and biological to be stored.

Refer to Tag A502


C. Failed to provide designated individual (by name and title of qualification) to remove drugs from pharmacy when pharmacy is closed or otherwise unavailable to facility staff members. Nine of nine signatures on the "Pharmacy Entry Log" were not designated individuals to remove drugs from the pharmacy.

The facility staff members and pharmacist failed to complete the "Pharmacy Entry Log" with the required documentation per the facility policy.

Refer to Tag A506


D. Failed to monitor and report adverse drug reactions to Quality Assessment and Performance Improvement Committee.

Refer to Tag A508
VIOLATION: AFTER-HOURS ACCESS TO DRUGS Tag No: A0506
Based on observations, records review, and interviews, the facility failed to designate individuals (by name and title of qualification) to remove drugs from pharmacy when pharmacy is closed or otherwise unavailable to facility staff members.


Nine of nine signatures on the "Pharmacy Entry Log" were not designated individuals to remove drugs from the pharmacy. The facility staff members and pharmacist failed to complete the "Pharmacy Entry Log" with the required documentation per the facility policy.

A review of policy titled "Subject: DISPENSING: OBTAINING DRUGS OR
BIOLOGICALS WHEN THE PHARMACY IS CLOSED OR OTHERWISE UNAVAILABLE" revealed:


"POLICY:
When drugs are not available from the patient's supply or other stocks, they shall be obtained from the pharmacy. A pharmacist shall be contacted if needed. When the pharmacy is closed or otherwise unavailable, drugs shall be removed in accordance with the following procedure.


REMOVING DRUGS FROM THE PHARMACY

PREPACKAGED DRUGS:
Drugs that have been prepackaged (by the manufacturer or pharmacy) shall be removed when available. If drugs are not prepackaged, the person making the withdrawal shall take the entire bulk container. Doses shall be removed from the container as needed and the container shall remain at the patient care area until retrieved by the pharmacy staff.

AMOUNT OF DRUGS TO REMOVE:
Only amounts of drugs sufficient for immediate therapeutic needs may be removed from the pharmacy. The amount removed may extend beyond a single dose, but should not exceed an amount to last until a pharmacist is available.

RESTRICTIONS ON LABELING AND TRANSFERRING DRUGS:
Non-pharmicists shall not label drugs or transfer drugs from one container to another. This is a dispensing function reserved for pharmacists.

WHO MAY REMOVE DRUGS FROM PHARMACY:
Only designated individuals (by name and title of qualification) shall remove drugs from the pharmacy. These individuals shall be oriented to the removal of drugs from the pharmacy.

REVIEW OR REMOVALS BY A PHARMACIST:
A licensed pharmacist shall review all orders for drugs removed from the pharmacy.

RECORDING THE REMOVAL:
The person who removes a drug from the pharmacy shall record the following:
Time and date of removal
Location and name of the patient
Drug name, strength and dosage form
Dose prescribed
Quantity taken and (amount removed)
Signature of person making the removal
Signature of pharmacist who verified the removal
Date and time of pharmacist verification"

Review of the record titled "Pharmacy Entry Log" revealed 9 different nurse's signatures on the "Pharmacy Entry Log" (sign out record for drugs being removed from the pharmacy by nursing staff after the pharmacy is closed.)

Review of records titled "Pharmacy Entry and Pass code Rules" for the year 2012 revealed 9 of 9 staff members signing out drugs from the pharmacy after the pharmacy was closed, had not signed the "Pharmacy Entry and Pass code Rules" record.

A review of the record titled "Pharmacy Entry Log" from 11/1/2012 thru 1/5/2013 revealed missing information from the log;

Time and Date of removal----15 of 35 were missing

Location and name of the patient----6 of 35 were missing

Drug name, strength and dosage form----15 of 35 were missing

Dose prescribed---- 35 of 35 (sign out form does not have documentation for the dose prescribed)

Quantity taken and (amount removed) ----20 of 35 were missing

Signature of person making the removal----21 of 35 were missing

Signature of pharmacist who verified the removal----35 of 35 were missing

Date and time of pharmacist verification ----35 of 35 were missing


A review of the record titled "Pharmacy Entry and Pass code Rules" revealed no documentation that the pharmacist had checked what the nursing staff was removing from the pharmacy after it was closed per the facility policy.


An interview with Staff #48 on 1/9/2013 at approximately 3:00 PM, confirmed that the staff members signing out drugs after the pharmacy is closed were not designated individuals to have authority to remove drugs from the pharmacy per the facility policy.

Staff #48 and #58 confirmed the "Pharmacy Entry Log" had missing documentation per the facility policy.
VIOLATION: PERIODIC EQUIPMENT MAINTENANCE Tag No: A0537
Based on records review and interviews, the facility failed to ensure preventative maintenance was current on equipment used in radiology.


During the tour of the radiology department on 1/9/2013, surveyor observed no preventative maintenance sticker on the x-ray table in room #2. Model # 46- 258.


Interview with staff #50 confirmed no preventative maintenance had been done in years in the radiology department. Staff #50 reported she had been employed since 2009. Was advised the physicist comes yearly to perform his routine checks. Staff #50 also advised, "I can't remember the last time the x-ray table had it's routine preventative maintenance."
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations, records review, and interviews, the facility failed to provide and maintain a safe and clean environment for patient care.


During observation tour of the facility with staff #42 on 1/8/2013 and staff #46 on 1/9/2013, observed the following:


emergency room

During observation on 01/07/13 at 12:02 p.m., the sink in Treatment Room #2 (emergency room ) was found with two basins stored underneath the pipes. The inside of the basins were stained brown from water leakage. The floor beneath the sink had buckled and the particle board underneath could be seen.

During observation on 01/08/13 at 8:51 a.m., the entrance door to the Emergency Biohazard room was found with 2 approximate one inch holes and 1 two inch hole above the door knob. There was a sign on the outside of the door that read "Warning Biohazard" and the room was unlocked.

Inside the room there were three bags of trash stored on the floor, two portable toilet seats, and a box of open biohazard trash. Inside the biohazard box was a used basin and urinal which were not bagged.

The cabinet underneath the sink had a missing door and front panel. Stored under the sink were two containers of biohazard treatment solution Isolyser.

On the wall, at the entry of the room was an exposed electrical junction box.


Patient Rooms 100 Hallway

Room 116--Observed a 4 inch gap between the wall and the floor, the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. In this room, a large tear (hole) in the vinyl upholstery of the sleep chair was also observed. There were dust particles in air conditioner/heating unit. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission.

Room 115--Observed a 4 inch gap between the wall and the floor, the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. This room was available for patient admission.

Room 114-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. There were dust particles and insects in air conditioner/heating unit. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission.

Room 113-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. This room was available for patient admission.

Room 112-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor, the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found.

Room 111-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. This room was available for patient admission.

Room 110-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed was found.

Room 109-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found.

Room 108-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found.

Room 107-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission.

Room 105-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed. There was a dead mouse on the floor. This room was available for patient admission.

Room 104-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found.

Room 103-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed. The floor had missing tile. This room was available for patient admission.

Patient Rooms 200 Hallway

Isolation Room 213 -- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. There was a patient next door to the isolation room. There was no negative air flow for the isolation room. There were blood tubes that had expired in 5/2012 found in the isolation cart at the entrance of the isolation room. This room was available for patient admission.

Room 214 Dialysis Room-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The hoses for the water treatment and the drain hoses were routed thru the wall and into the bathroom where it drained into the bathtub. The cover for the air conditioner/heating unit was off and the electrical wiring was showing with dust and dirt. This room was available for patient admission.

Room 215--Patient being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Dust particles and trash observed in the air conditioner/heating unit. No preventive maintenance sticker on the patient bed was found.

Room 217-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission.

Room 219-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed was found. The electrical outlet on the wall had plaster missing from around the electrical outlet. This room was available for patient admission.

Room 221-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. There were several chips in the ceiling tile and stains observed in the patient room. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission.

During the tour of the main hallway, the floor was dirty and stained. This hallway with patient rooms was used for pediatric and adult patients.

There was large hole in the wall beside some type of call system with electrical wiring exposed and maintenance cover was missing from the cabinet in the soiled utility room on hallway 200.

There was large hole in the ceiling observed in the equipment room on hallway 200. This was the room where cleaned patient equipment was stored. The floor in the equipment room was dirty and stained.

There was computers, numerous cords, and trash on the floor in the electrical room on hallway 200.

Decontamination Room

During the tour with staff #2 on 1/7/2013 at 10:00 AM, the bottom cabinet 2 shelves were observed to have brown substance (appears to be rust and dirt). This cabinet had surgical instrument trays stored on the shelf.

Oxygen Tank Storage Area

During the tour of the storage area on 1/9/2013 at 9:00 AM 4 (H- cylinders large oxygen tanks) and 11(E-cylinders small oxygen tanks) were observed lying on the ground and/or standing without being secured.

Purchasing Department

During the tour of the purchasing department 1/9/2013 at 1:00 PM with staff #51, there were card board boxes stored on shelves above the sterile supplies. The shelves where sterile supplies were being stored were dusty. The purchasing room opens up to the back dock where supplies are bought in from the outside vendors and this door was open.

During the tour, it was observed in the purchasing department numerous opened card board boxes. Questioned why the boxes were still present? Staff #51 stated "the dumpster is full and has not been emptied in 3 months."

Medical Records Storage

During the tour of the medical record storage area with staff #46 on 1/9/2013, there were medical records piled on the floor approximately 3 feet high without any type of shelving.



Boiler Room


During the tour of the boiler room with staff #46, there was a fan on the floor connected to electrical outlet by a long extension cord. The fan was blowing air on the boiler motor.



Air conditioner Unit


During an interview on 1/10/2013 at 10:00 AM, staff #46 reported that the air conditioner unit was not functioning properly and has not functioned properly for 2 years. Staff #46 stated that "The heating wires were pulled from the unit 2 years ago. The unit has to be manually turned on and off by going on top of the roof. The unit will only blow cold air and there is no regulating the temperature. If it is cold outside then the unit just has to be turned off manually by going to the roof top of the building."


Staff #46 confirmed that this air conditioner unit supplies air flow and regulates the temperature for the emergency room , Kitchen, Gastrointestinal Lab, Day Surgery, Medical/Surgical Floor, Front Office, Medical Records, and Sterilization where sterile supplies and instruments are stored. This Air conditioner unit supplies air flow to half the facility.


An interview with staff #46 on 1/9/2013 at 2:00 PM stated that "the facility has a foundation problem and the gap between the walls and floor can increase due to change in the weather conditions."


Staff #46 confirmed there is bio-hazard waste and trash that needs to emptied, storage areas need to be cleaned and repaired, areas in the facility need repair work along with infection control issues, and the isolation room does not have negative air flow.


Staff #46 confirmed all the findings found during the facility tour on 1/9/2012.



A review of records titled "Safety Committee Meeting" revealed the last safety committee meeting was held December 2, 2010.


An interview with the safety officer on 1/10/2013 at 10:00 AM confirmed the facility last held safety meeting was December 2, 2010.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observations, records review, and interviews, the facility:


A. Failed to provide and maintain a safe and clean environment for patient care.

Refer to Tag A701


B. Failed to provide adequate fuel in the storage tank that runs the facility generator and the underground storage tank had not been inspected by the Texas Commission on Environmental Quality.

Refer to Tag A702


C. Failed to provide fire drills on evenings and night shift for the facility staff members. Also, the facility failed to have the fire extinguishers inspected.

Refer to Tag A709


D. Failed to dispose of trash and bio-hazard waste. The facility also failed to store Hazmat supplies in a clean area.

Refer to Tag A713


E. Failed to ensure preventative maintenance was being done for patient care equipment.
Refer to Tag 724

F. Failed to monitor temperature and humidity in the surgical suites and the sterile processing room where supplies are stored.

Refer to Tag A726
VIOLATION: REPORTING ADVERSE EVENTS Tag No: A0508
Based on observations, records review, and interviews, the facility's pharmacy failed to monitor and report adverse drug reactions to the Quality Assessment and Performance Improvement Committee.


A review of record titled, "Department of Pharmacy Services Quarterly Quality Improvement Third Quarter 2012" revealed adverse drug reaction monitoring was documented on the report as a "-1, (# of Response -1, Threshold % -1, % of Outcome-1, and Remarks Poor documentation by nursing department.)."


An interview with staff #57 on 1/8/2013 at approximately 5:00 PM confirmed that the facility does not have Quality Assessment and Performance Improvement (QAPI) committee or QAPI data to be submitted to a committee.


An interview with staff #58 on 1/9/2013 at 2:00 PM revealed that if the pharmacy finds a medication error with nursing services, a verbal report is given to the Director of Nursing. Staff #58 was questioned if an occurrence report is completed and she stated "No, I just report the medication error to the Director of Nursing and the Pharmacist."


An interview with staff #48 on 1/9/2013 at 3:00 PM stated that "the nursing staff does not report to the pharmacy when a patient has had a drug reaction and we realize this is a problem." Staff #48 reported that he has not attended any type of QAPI meeting and the last Pharmacy meeting was October 2012.
VIOLATION: FOOD AND DIETETIC SERVICES Tag No: A0618
Based on records review and interviews, the facility:

A. Failed to have an ongoing process of Quality Assurance and Performance Improvement (QAPI) program that measures, analyzes, and tracks adverse patient events, infection control, and other aspects of performance improvement for the dietary department. While reviewing the dietary departments documentation of QAPI activity on 1/8/2013, there was no evidence that any staff member had taken responsibility for collecting, measuring, analyzing, or tracking performance improvement in the dietary department for the facility.


B. Failed to ensure adequate provisions for dietary consultation that meets the needs of the patients when the dietician is not available.


Refer to tag A0621


C. Failed to ensure the nutritional needs were being met for patient receiving artificial nutrition.


Refer to tag A0628
VIOLATION: WRITTEN PROTOCOL FOR TISSUE SPECIMENS Tag No: A0585
Based on records review and interviews, the facility failed to adopt, implement, and enforce policies and procedures for receipt and reporting of tissue specimens.

On 1/9/2013 while reviewing the Policy and Procedure Manual for the laboratory department, no Policies and Procedure were found for instructions for the collection, preservation, transportation, receipt, and reporting of tissue specimen results in the laboratory department.

Interview with Director of Laboratory on 1/9/2013 confirmed that the department did not have any policies and procedures concerning tissue specimens. The Director of Laboratory also advised, "The laboratory department received the tissue specimens and they were sent out to another facility for processing."
VIOLATION: ANESTHESIA SERVICES Tag No: A1000
Based on records review and interviews, the facility failed to provide an organized Anesthesia Service.

Administration was requested to provide documentation of a policy and procedure manual for Anesthesia Service. No type of documentation was provided for Anesthesia Service. The facility does not have a staff member to provide information on Anesthesia Services.

A review of record titled "Anesthesiology Service Agreement Coverage Agreement" revealed that neither the facility's Administration staff nor the Anesthesiology Service had signed the agreement.

An interview on 1/7/2013 at approximately 5:00 PM with staff #5 stated, "there is no Anesthesia policy manual or an employee of the Anesthesia Service to provide information"
VIOLATION: OPO AGREEMENT Tag No: A0886
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interview and review record, the facility failed to ensure that the facility have a written agreement with an Organ Procurement Organization (OPO) which addressed how donor issues would be handled with patients. This deficient practice was found in 7 of 30 (#s 35, 36, 53, 56, 57, 58, and 59) charts reviewed.


Review of the facility's "ORGAN/TISSUE DONATION PROTOCOL" dated 03/01/10 revealed the following:


"For all deaths/potential deaths, a mandatory referral" would be made to an Organ Procurement Organization," allowing as much time prior to death as possible." The Organ Procurement Organization would "notify the eye/tissue bank."


"The Emergency Department Physician and Nursing personnel in the Emergency Department will be responsible for the mandatory routine referral when receiving victims of accident or trauma who are dead on arrival or are near death."


"Nursing personnel caring for an inpatient that is near death or expires will notify the" Organ Procurement Organization "for further instructions as to the patient being a potential donor."


There was an OPO and tissue bank listed on the protocol as who to make referrals to.


Review of the protocol revealed no information about a written signed agreement for services between the OPO and the facility.


Review of a facility admit packet revealed an "admit record" which was one of the initial assessment tools used by nursing. There was a section on the tool which asked if the patient was an organ donor.


Review of a facesheet on Patient #35 revealed he was a [AGE] year old male admitted to the facility on [DATE] at 2:45 p.m. with a diagnosis of "flu like symptoms."


Review of emergency room (ED) nursing assessments on Patient #35 revealed no documentation of his organ donation status. Review of a death report dated 12/28/12 revealed that Patient #35 expired on [DATE] at 6:15 p.m.. Review of ED nurses notes dated 12/28/12 at 7:23 p.m. revealed that the OPO was called at this time over an hour after the death.


Review of charts on Resident #s 36, 53, 56, 57, 58, and 59 revealed no documentation of staff obtaining information about organ donation status.


During an interview on 01/08/13 at 10:38 a.m., Staff #5 reported that she could not find any agreements with an OPO. There was no agreement addressing immiment death, timely notification, medical suitability for organ donation, designated requestor training program, maintaining organ viablity, and permitting the OPO access to the hospital death record.


Staff #5 provided an unusual event report dated 01/08/13 indicated they needed to meet with the OPO "concerning their protocol, paperwork and QI."
VIOLATION: OUTPATIENT SERVICES Tag No: A1076
Based on records review and interviews, the facility failed to provide an ongoing process of the QAPI program that measures, analyzes, and tracks adverse patient events, infection control, and other aspects of performance improvement for out patient services.

While reviewing out-patient services for documentation of QAPI activity on 1/8/2013, there was no evidence of documentation that any staff member had taken responsibility for collecting, measuring, analyzing, or tracking performance improvement for out patient services.

Interview with staff #57 on 1/8/2013 confirmed that at this time the facility has no organized QAPI program and no data had been collected.
VIOLATION: DEATH RECORD REVIEWS Tag No: A0892
Based on interview and review record the facility failed to ensure policies and procedures were in place to ensure coordination between an Organ Procurement Organization (OPO) and the facility to review death records.


Review of the facility's "ORGAN/TISSUE DONATION PROTOCOL" dated 03/01/10 revealed no direction on how the facility would coordinate with the OPO on reviewing death records. There was no directive on how they would improve identification of potential donors. There was no directive on how confidentialty would be maintained between the facility and the OPO.

Review of the protocol revealed no written signed agreement for services between the OPO and the facility which outlined how to handle death record reviews.

During an interview on 01/08/13 at 10:38 a.m., Staff #5 reported she could not find any agreements with the OPO. There was no agreement addressing immiment death, timely notification, medical suitability for organ donation, designated requestor training program, maintaining organ viablity, and permitting the OPO access to the hospital death record. Staff #5 reported she could provide no evidence of charts reviewed by the OPO.

Staff #5 provided an unusual event report dated 01/08/13 indicated they needed to meet with the OPO "concerning their protocol, paperwork and QI." They needed to assign someone to be the contact person for the OPO and their facility and they needed the OPO to "come to their facility and have in-service."

Staff #5 reported she could provide no evidence of chart reviewed by the OPO.
VIOLATION: MEDICAL STAFF Tag No: A0338
During the follow-up survey from 1/7/2013 through 1/10/2013 additional findings were as follows:


Based on documents review and interviews, the facility failed to enforce the established bylaws for categories of Medical Staff, appointment and re-appointment, and the term of the appointment.

A review of the document titled "Medical Staff Bylaws" last amended and approved by the Governing Board 11-28-2007, revealed Article IV Categories of the Medical Staff, Section 1. The Medical Staff, "The Staff shall be divided into Honorary, Active, Courtesy, Consulting and emergency room categories."


Article VI, Clinical Privileges, Section 2. Temporary Appointment, "Upon the recommendation of the chairman of a department and the Chief Executive Officer of the Hospital or his designee who is acting on behalf of the Governing Body, temporary privileges may be granted during the application process for the care of specific patient(s) or locum tenens, All such privileges shall be time limited and granted only when sufficient evidence exists that granting of temporary privileges is prudent."


Article V, Procedures for Appointment and Re-Appointment, Section 1. Application for Appointment, "(7) The Medical Staff Services is responsible for obtaining information from the Texas State Board of Medical Examiners and the National Practitioner Data Bank. (8) The application, complete with information sufficient to resolve doubts in any matter, shall be submitted to the administration, who upon receipt of all information, including licensure, education, training, experience and past or present Medical Staff membership at other facilities, shall submit the application and all supporting material to the Medical Executive Committee."


Section 3, Appointments- Provisional

"A All initial appointments and initial granting of clinical privileges shall be provisional and shall be for one year."
"D. At the successful completion of the provisional period the Practitioner's status will be reviewed for advancement to the requested category."


Section 4. Re-Appointment Process,

"A. The Texas Standardized Application shall be fully completed to assure the availability of data necessary to update the member's medical staff file. The completed re-appointment application should include, but not he limited to the following:

(1) request for privileges;

(2) documentation of current, valid state license, DEA and DPS certificates (DEA and DPS certificates not required for pathologists);

(3) continuing training, education and experience since the previous appointment that qualifies the staff member for the privileges sought on re-appointment, or serves as justification for new or expanded privileges;

(4) sanctions of any kind imposed or pending by any other health care institution, professional health care organization or licensing authority: changes of any kind in Medical Staff membership(s), or privileges at any other health care institution or professional health care organization;

(5) documentation of newly obtained board certification or, as appropriate report on timely progress toward meeting pre-certification requirements;

(6) the results of the ongoing monitoring and evaluation of each practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs, shall be available for review in the re-credentialing process;

(7) involvement in professional liability actions including letters of intent, final judgments and or settlement;

(8) agreement that if the applicant is reappointed, he will continue to abide by the Bylaws, Rules and Regulations of the Medical Staff and Hospital ..... When collection and verification are accomplished, the administration shall transmit the application form and supporting materials to the Medical Executive Committee."


Section 5. Terms of Appointment,

"Appointments to the Medical Staff shall be made by the Governing Body of the hospital upon the recommendation of the Medical Executive Committee, Appointments shall be for a period of no more than two years."


A review of Medical Staff #8's credentialing files contained a letter dated 03/29/2012, granting Temporary privileges for a period of two years. Staff #8's license expired 12/13/2012. The Temporary privileges and time period did not meet the Medical Bylaws definition. Staff #8 is scheduled weekly in the hospital with the Hospitalist.


A review of Medical Staff #9's credentialing files contained a letter dated 01/26/2012, granting Provisional privileges for a period of two years. This file did not contain an updated application, request for privileges, the results of the ongoing monitoring and evaluation of the practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs. The provisional period granted does not meet the Medical Bylaws definition.


A review of Medical Staff #26's credentialing files contained a letter dated 01/26/2012, granting Provisional privileges for a period of two years. This file did not contain an updated application, request for privileges, the results of the ongoing monitoring and evaluation of the practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs. The provisional period granted does not meet the Medical Bylaws definition.


The review of Medical Staff #29's credentialing files revealed that the files did not contain an updated application, request for privileges, the results of the ongoing monitoring and evaluation of the practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs. Staff #29's previous re-appointment of 12/17/2010 to 12/17/2012 had expired.


Medical Staff #86 was presented as an active staff. Staff made the application on 05/07/2012. The file contained no evidence of privileges granted by the Medical Staff or by the Governing Board. This Allied Health Professional's file had no evidence of a supervising Physician.


A review of Medical Staff #87's credentialing files contained a letter dated 01/26/2012, granting Provisional privileges for a period of two years. Provisional period granted did not meet the Medical Bylaws definition.


A review of Medical Staff #88's credentialing files contained a letter dated 03/26/2012, granting Provisional privileges for a period of two years. Provisional period granted does not meet the Medical Bylaws definition


A review of Medical Staff #89's credentialing files contained a letter dated 01/26/2012, granting Temporary privileges for a period of one year. The Temporary privileges and time period did not meet the Medical Bylaws definition. Staff is scheduled weekly in the hospital with the Hospitalist.


On 01/10/2013 at 9:30 AM, an interview was conducted with staff #55 in the credentialing office. Staff #55 revealed that she did the credentialing and had not had any formal training by the facility. Staff #55 had picked it up by talking with other staff members. Staff #55 had discovered that some of the information provided by staff was wrong. Staff #55 stated, "Still continuing to learn." Staff #55 was not able to tell the surveyor what the categories were in the Medical Bylaws. Staff #55 had not read the bylaws. Staff #55 stated the Medical Staff's credentialing files, containing the application and all supporting material, were not being submitted to the Medical Executive Committee. Staff #55 was submitting a form listing the required elements. Staff #55 would make check marks beside the elements and the Medical Executive Committee would review that form.

During an interview on 01/09/2013 at approximately 1:00 PM in the Doctors' Lounge, Medical Staff #29 revealed the neither the Medical Staff nor the Governing Board had been made aware of the survey findings from 11/15/2012 until 01/03/2013 during a called Governing Board Meeting. It was during this meeting that the board was made aware that the owner and CEO had brought in three nurses from another facility in an attempt to correct the previously cited problems. Medical Staff #29 was asked, "are there any problems you have voiced concerns about that have not been addressed by the Board of Directors/Owner?" The response was "yes." Staff #29 reported that there have been questions about the credentialing process. Staff #29 reported that the owner just put his doctors in here without going through the credentialing process.
VIOLATION: QUALIFIED DIETITIAN Tag No: A0621
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on records review and interviews, the facility failed to ensure adequate provisions for dietary consultation that meets the needs of the patients when the dietician is not available. Citing 3 of 30 patient medical records reviewed. (#36, 41, and 45).


Review of the dietician schedule on 1/8/2013 revealed availability every Tuesday for 6-8 hours.


Review of patient records on 1/9/13 and 1/10/13 revealed the following:


1. Patient #45 was admitted to facility on 11/25/2012. Registered Nurse (RN) assessment dated [DATE] revealed a referral for a dietary consult. No documentation that a dietary consult was conducted.


2. Patient #36 was admitted to facility on 1/4/2013. RN assessment dated [DATE] revealed a referral for a dietary consult due to patient on Total Parenteral Nutrition (TPN). No documentation that a dietary consult was conducted.


3. Patient #41 was admitted [DATE]. Patient was started on Potassium replacement therapy. No documentation of referral to dietician for consult and education found. No documentation that a dietary consult was done.


Interview with staff #75 on 1/8/2013 confirmed that she only work every Tuesday for 6-8 hours. Staff #75 confirmed that the previous Director of Dietary left sometime in 11/2012. Staff #75 also confirmed that staff #52 had recently been appointed to the position and was currently being oriented and trained. Advised that she reviewed the menu request forms received daily from the nurses station and frequently went out to the nurses station and reviewed patient charts to see if patient's needed dietary consult and education. Staff #75 also stated,"I'm available by phone if staff have any questions."


Interview with staff #42 on 1/10/2012 confirmed the findings for patient medical records, #36, 41, and 45.