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.

SHELBY REGIONAL MEDICAL CENTER 602 HURST STREET CENTER, TX Oct. 5, 2012
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on records review, observations and interviews, the facility failed to maintain a clean and safe environment for the patients it served. Patient care equipment in current use had not had recent safety inspections to ensure they were in safe working condition. The facility failed to ensure proper air exchange and ventilation in patient rooms due to dirty, clogged air conditioner filters. The facility failed to ensure ceiling plaster was in good repair in the dietary department to prevent plaster from falling into the patient food service line and contaminating the food.

Refer to A701

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 potential to affect all patients admitted to the facility.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based record review, observation, and interview, the facility failed to maintain a clean and safe environment for the patients it served. Patient care equipment in current use had not had recent safety inspections to ensure they were in safe working condition. The facility failed to ensure proper air exchange and ventilation in patient rooms due to dirty, clogged air conditioner filters. The facility failed to ensure ceiling plaster was in good repair in the dietary department to prevent plaster from falling into the patient food service line and contaminating the food.

The following was a list of patient care equipment observed while touring the facility on 10/4-5/2012, which was being presently used by patients or was available for patient care use. The safety/preventive maintenance checks were due to be done by August 2012.

Treadmill/Electrocardiogram machine that was for performing patient exercise stress test
Ultrasound echocardiogram machine (ECHO) 8/2012
Electroencephalogram (EEG) machine 8/2012
Electrocardiogram machine that was used on the floor and in the emergency room for a 12 lead EKG 8/2012
Pulmonary Function Test screening machine x 2 (no preventive maintenance sticker indicating when the safety had been checked)

A review of the schedule for patient testing using the equipment in the cardio/pulmonary department revealed, the EKG machine had been used 27 times, ECHO machine was used 10 times, EEG, and the exercise stress test had been used once. This equipment was due to be checked by August 2012.

An interview with staff #1, #20, and (#21 by phone interview) on 10/4/2012 at 10:00 AM while in the cardiopulmonary department confirmed the equipment had be used on patients with the preventive maintenance safety checks not being done.

Intravenous pump # 182 (no preventive maintenance sticker indicating when the safety had been checked); this piece of equipment was presently being used on a patient
Intravenous pump # 999 (no preventive maintenance sticker indicating when the safety had been checked); this piece of equipment was presently being used on a patient
Intravenous pump # 321 (safety sticker dated 5/2012) (located in the equipment room)
Intravenous pump # 0 (no preventive maintenance sticker indicating when the safety had been checked) (located in the emergency room )
Intravenous pump # 324 (safety sticker dated 4/2010) (located in the emergency room )
Intravenous pump # 8 (safety sticker dated 8/2012) (located in the emergency room )

Medtronic Lifepak # 780 (cardiac monitoring machine) (no preventive maintenance sticker indicating when the safety had been checked) (located in the emergency room )
Medtronic Lifepak # 1 (no preventive maintenance sticker indicating when the safety had been checked) (located in the emergency room ) this piece of equipment was currently being used on a patient in the emergency room

Phillips Neonatal monitor U24CT # 9 (no preventive maintenance sticker indicating when the safety had been checked) (located in the emergency room )

Hydrotherapy machine (portable) (safety sticker dated 8/2012)
Whirlpool machine (portable) (safety sticker dated 8/2012)

Ventilator #567= (safety sticker dated 8/2012)
Ventilator (portable) (on the equipment shelf) (safety sticker dated 8/2012)

Gomco #1346 (patient suction machine for constant and intermittent use to eliminate gastric secretions) (no preventive maintenance sticker indicating when the safety had been checked)
Gomco #3001 (no preventive maintenance sticker indicating when the safety had been checked)
Gomco (on a stand) labeled not working dated 11/21/2011 (this piece of equipment was in the room with all the other patient care equipment cleaned bag and ready for patient use)
Gomco #SC0424 (no facility tag or preventive maintenance safety sticker) (located in the emergency room ) the tag on the equipment indicated it belonged to another hospital.

Enteral Feeding pump (safety sticker dated 8/2012)
Enteral Feeding pump # 547 (no preventive maintenance sticker indicating when the safety had been checked)

Compression machine (used to promote circulation in the lower extremities) preventive maintenance safety sticker indicated last check was 5/12/2012
Compression machine # 3 no preventive maintenance safety sticker
Compression machine # 6 no preventive maintenance safety sticker

Hypo/Hyperthermia Unit (K-thermia pad) (safety sticker dated 8/2012)
Regular Home Heating Pad with no type of covering for the pad (no facility tag or preventive maintenance safety sticker)

Box fans x 2 being used in patient rooms with no facility tag or preventive maintenance safety sticker

Hoyer Lift (no preventive maintenance safety sticker)

Patient beds x 2 with signs on them written broken

Autoclave (used for sterilization of instruments) in the hospital has been broken for over a month. Staff # 3 reported unable to get approval for the repair work. The issue was reported to staff #1 in which she had requested advice from the administrator on how to proceed with getting the autoclave repaired.

An interview with staff #1 on 10/4/2012 at 12:00 PM while touring the facility patient care areas confirmed, the equipment had been used on patients with the preventive maintenance safety checks not being done. Broken equipment was tagged broken, but still available in patient care areas. Staff #1 reported the preventive maintenance safety checks had not been performed, and broken equipment has not being repaired, due to the biomedical contract person not being paid and he will not come until he receives a check for $2,500.

During a tour of the dietary department on 10/4/2012 at approximately 2:00 PM with staff #1 and #12 observed in the kitchen ceiling a hole where the plaster was missing and there were several large cracks in the plaster. The plaster had turned loose from the ceiling, appears to have been a water leak in the ceiling. The plaster had fallen in to the patient food buffet line. This buffet line is where the food is kept while dietary staff prepares food trays to be served to the patients. Also observed in the same area was an air conditioner vent covered with brown dust and on the ceiling surrounding the vent. The air conditioner vent was directly over the food buffet line where patient food trays were prepared.

An interview with staff #12 on 10/4/2012 at 2:00 PM while in the dietary department confirmed the air conditioner vent with dust and the falling ceiling tile had been reported to maintenance a month ago. Staff #12 voiced concern that the plaster in the ceiling has been falling on to the food buffet line table and the ceiling has become worse since she reported the problem a month ago. During the interview staff #12 reported the vendor (supplier #5) had informed the facility that unless the invoices from 5/28/2012, 6/25/2012, 7/23/2012, 8/20/2012, and 9/17/2012 were paid, the dishwasher, (which required monthly service or would not function) and the solution for washing dishes and utensils would not be delivered to the facility.

A telephone interview with the representative of (supplier # 5) on 10/5/2012 at approximately 10:00 AM confirmed, the facility (dietary equipment) would not be serviced until the bill was paid in full with the total amount $1,257.97.

The one and only portable x-ray machine in the facility had been broken since September 2, thru October 3, 2012. On 9/27/2012 staff #9 used her personal credit card to order a battery for the portable x-ray machine. Staff #9, #10, and #11 placed a battery in the portable x-ray machine. The portable x-ray machine had not been serviced by a qualified radiology equipment service. This piece of equipment was used in the emergency room and on the nursing unit for critically ill patients that could not go to the radiology department.

Staff #9 reported that a patient had come to the emergency room in a full cardio/pulmonary arrest and needed to be intubated (a breathing tube to assist the patient with breathing.) A chest x-ray for breathing tube placement was ordered by the physician. The patient was moved from the emergency room to radiology department (which is down the hall) to get a chest x-ray for breathing tube placement. This movement of the patient could cause dislocation of the breathing tube and injury or death due to the extraneous movement of the patient.

An interview with staff #9 on 10/4/2012 at 3:00 PM in the radiology department confirmed, she had reported the portable x-ray machine was non-functional to the Assistant administrator for a month. The Assistant Administrator had reported to Administrator, Chief Financial Officer, and the Owner of the Hospital the portable x-ray machine was non-functional. A review of a daily report sheet completed by the Assistant Administrator and sent to the Administrator, Chief Financial Officer, and the Owner of the Hospital verified the report had been sent daily from September 2, thru October 2, 2012 and it was written on the report the portable x-ray machine was down. Staff #9 confirmed she had used her personal credit card to buy the battery and that her and two other staff members had installed the battery themselves in the x-ray machine.

An interview with staff #1 on 10/4/2012 at 4:00 PM confirmed staff #9 had purchased the battery with her personal credit card and staff #9, #10, and #11 placed the battery in the portable x-ray machine. The x-ray machine had not been checked by a qualified radiology equipment service. Staff #1 reported when she asked the administrator and chief financial officer for funds to repair the equipment they reported there was no money.

A tour of the nursing unit was conducted on 10/4/2012 at 11:00 AM with staff #1. The tour consisted of going to each patient room. The facility was licensed for 54 beds. The facility had 20 patient rooms (with the capacity of 2 patients to a room). During the tour only 3 (#101, #121, and #126) of 20 patient rooms were fully functional for the use of patient care.

Room #102 had only 1 call light for 2 patients, the air conditioner and heating unit was not working, the vent cover on the unit was completely gone, and a button on the control panel was missing and metal was showing.

Room #103 had only 1 call light for 2 patients.

Room #107 had only 1 call light for 2 patients.

Room #108 had no call lights, the cover for the ceiling air conditioner was gone and all the inside of the unit was rusty metal and the unit was not working. Staff #1 reported it was used for temporary storage.
Room #109 (patient room), Staff #1 reported this was storage for RAC (Real Application Clusters) supplies.

Room #110 (patient room), Staff #1 reported this was storage for Intravenous Fluids and Intravenous Pumps.

Room #111 (patient room), Staff #1 reported this was going to be the sleep room for the emergency room physicians. The heat did not work in the room and there was a hole beside the heating unit where you could see the outside ground.

Room #112 had 1 bed and 1 call light. The room was currently being used by a patient and she complained of not having any air conditioning for 7 days. The patient was using a box fan sitting on a bedside table. The fan had no labeled with a facility tag or a preventive maintenance sticker. The intravenous pump in use on the patient had no preventive maintenance sticker. The curtains in the room were torn and touching the floor.

Room #113 had 1 bed and 1 call light.

Room #114 had 1 bed and 1 call light.

Room #115 had 2 beds and 1 call light, the air conditioner was not working and the vent cover to the unit was gone. The door to the patient room would not stay open and it was tied open with a plastic bag to a towel rack.

Room #118 had 1 call light and the air conditioner/heating unit was not working. This room was being currently being used by a patient.

Room #119 had 1 call light.

Room #120 had 1 call light.

Room #122 (patient room), Staff #1 reported this room was used for storage and it contained 2 broken beds.

Room #123 had only 1 call light for 2 patients.

Room #124 (patient room), Staff #1 reported this room was used for storage and it contained baby cribs and the Hoyer lift.

Room #125 had 1 call light and the air conditioner unit was not working. This room was currently being occupied by a patient. The room had a portable air conditioner unit sitting on the bedside table and the unit was vented through an open tile in the ceiling.

An interview with staff #1 on 10/4/2012 at 4:00 PM after the tour was completed confirmed she only had 3 patient rooms fully functional. Staff #1 reported the room issues to the owner of the facility last month and he still had not advised her on how to fix the patient care rooms.

A review of the air conditioner filter log for the main units of the facility revealed the filters had not been changed since June 2012. Questioned staff #3 on how often filters were to be changed and he answered "every 30 days".

An interview with staff #3 on 10/5/2012 at 10:00 AM confirmed that supplier # 6 was the only company they could get the filters from that fit the old air conditioner units for the facility and they had to pre- pay because of bad credit.

An interview with staff #1 on 10/5/2012 at 10:00 AM confirmed that supplier # 6 needed to be paid in order to obtain the air conditioner filters for the facility. She reported that the Administrator had been notified of the problem with insufficient funds.

An interview with staff #2 on 10/5/2012 at 1:00 PM reported to one of the surveyors, the facility had insufficient funds and did not know where he would get the money to pay the vendors.
VIOLATION: INFECTION CONTROL Tag No: A0747
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records review, interviews and observations conducted 10/4/2012 thru 10/5/2012, the facility failed to provide a safe and sanitary environment to prevent infections in the hospital setting. The facility failed to properly sanitize invasive instruments used in radiology,
ensure proper air exchange and ventilation in patient rooms due to dirty, clogged air conditioner filters, and failed to ensure ceiling plaster was in good repair in the dietary department to prevent plaster from falling into the patient food service line and contaminating the food.

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 potential to affect all patients admitted to the facility.


On tour of the facility in the Soiled Utility Room near the nurses' station, the surveyor saw a container of Cidex. The container was used for floor use instruments and the ultrasound intravaginal probe from radiology. During the tour, staff #6 was questioned on how often the Cidex solution was being changed and tested and the answer was "I change it every 14 days and test the solution before every use."

Review of Cidex OPA product insert revealed:

"CIDEX OPA Solution may be reused for up to a Maximum of 14 days provided the required conditions of ortho-phthalaldehyde concentration and temperature exist based upon monitoring described in the Direction for use. Do not rely solely on day in use. Concentration of this product during its reuse life must be verified by the CIDEX OPA Solution Test Strips prior to each use to determine that the concentration of ortho-phthalaidehyde is above the MEC of 3%. The Product must be discarded after 14 days." On the bottle of Cidex -OPA test strips the label reads "Caution: Do not use after 90 days of opening the bottle."

Review of the log for checking the concentration of the Cidex revealed that it had been checked by Staff #10 for the cleaning of the intravaginal probe. On day one of the tour (10/4/2012), the Cidex test strips were checked and pulled from the room. The Cidex test strips had expired on ,d+[DATE] and the container was not labeled with when the Cidex test strips were initially opened. The test strip bottle stated that the strips were only good for 90 days once the bottle was opened. Subsequent review of the log (on 10/4/2012) revealed that the solution was tested on [DATE]. There was no documentation to show when the bottle of Cidex-OPA test strips was opened and if the use life of the test strips were still effective. Further review of the log indicated that the intravaginal probe had been placed in the Cidex solution on 9/27/2012 and was still present on the tour, 10/04/2012.

An interview with staff # 6 and # 10 on 10/4/2012 confirmed that the Cidex-OPA test strips were expired and the bottle was never labeled to know how long test strips had been opened and if the test strips were still effective for checking the Cidex solution for the disinfection of instruments..

A review of the air conditioner filter log for the main units of the facility revealed the filters had not been changed since June 2012. Staff #3 was questioned on how often filters were to be changed and he answered "every 30 days." Staff #3 voiced concerns that if you checked the air filters the filters would be black.

An interview with staff #3 on 10/5/2012 at 10:00 AM, reported that Supplier #6 was the only company they could get the filters from that fit the old air conditioner units for the facility and they had to pre- pay because of bad credit.

An interview with staff #1 on 10/5/2012 at 10:00 AM confirmed that Supplier #6 needed to be paid in order to obtain the air conditioner filters for the facility. Staff #1 reported the issues to the Administrator.

An interview with staff #2 on 10/5/2012 at 1:00 PM confirmed with one of the surveyors, the facility has insufficient funds and did not know where he would get the money.

During a tour of the dietary department on 10/4/2012 at approximately 2:00 PM with staff #1 and #12, the surveyor observed a hole in the kitchen ceiling where the plaster was missing and there were several large cracks in the plaster. The plaster had turned loose from the ceiling, appeared to have been caused by a water leak in the ceiling. The plaster was falling into the patient food buffet line. This buffet line is where the food is kept while dietary staff prepares food trays to be served to the patient. Also observed in the same area was an air conditioner vent covered with brown dust and on the ceiling surrounding the vent. The air conditioner vent was directly over the food buffet line where patient food trays were prepared and had the potential to contaminate the food served to patients.

An interview with staff #12 on 10/4/2012 at 2:00 PM, while in the dietary department, confirmed that the air conditioner vent with dust and the falling ceiling tile had been reported to maintenance a month ago. During the interview staff #12 reported that supplier #5 had informed the facility that unless the invoices from 5/28/2012, 6/25/2012, 7/23/2012, 8/20/2012, and 9/17/2012 were paid, the dishwasher (which required monthly service or would not function) and the solution for washing dishes and utensils would not be delivered to the facility.

A telephone interview with supplier #5's representative on 10/5/2012 at approximately 10:00 AM who confirmed that the facility (dietary equipment) would not be serviced until the bill was paid in full with the total amount of $1,257.97.

During an interview with staff #1 on 10/4/2012 at 2:00 PM, while in the Dietary Department, staff #1 reported that she had requested supplier #5's check be issued and the kitchen ceiling to be repaired but she had not received any direction from the Administrator and the owner of the hospital.

A tour of the nursing unit was conducted on 10/4/2012 at 11:00 AM with staff #1. The tour consisted of going to each patient room. During the tour it was observed in patient rooms'
#112, #115, #118, and #125 that the curtains were stained. In room #112 the curtains were torn, stained, and dragging on the floor.

Review of policy titled " Monthly Cleaning Schedule" revealed that curtains would be changed monthly. Review of the schedule for changing the curtains revealed the curtains were last changed on the 1st week of August.

An interview with staff #4 on 10/4/2012 at 3:00 PM revealed that there were no extra curtains in the facility and the surveyor was informed that all the curtains were at the cleaners (supplier #7). Staff #4 reported that the invoice for the cleaners was 90 days past due and the total bill was $2028.61. The cleaners would not release the curtains until the bill was paid in full. Review of the invoice showed the total bill was $2,028.61.

An interview with staff #1 on 10/4/2012 at 3:30 PM confirmed that she had requested the bill to be paid so the curtains could be picked up from the cleaners. The Administrator had not given any advice on how the invoice would be paid or if it would be paid.

During the tour of patient's rooms conducted on 10/4/2012, room #125 had an air conditioner unit not working and a patient was in the room. The room had a portable air conditioner unit sitting on the bedside table and the unit was vented through an open tile in the ceiling. The ceiling tile was pushed back and the air conditioner hose was placed in the tile opening.

During the tour of the emergency room conducted on 10/5/2012, the same type of portable air conditioner was being used due to the air conditioner not working in the emergency department. The tile was pushed back and the air conditioner hose was placed in the tile opening of the ceiling.

An interview with staff #1 on 10/5/2012 at 10:00 AM confirmed the use of the portable air conditioners in patient rooms and the emergency room with the hose being placed in open area where ceiling tile should be placed. Staff #1 reported that she has been reporting this problem to the owner of the hospital and was still waiting for response on how to handle the problem. A record review revealed an e-mail dated October 1, 2012 at 19:02 (7:02 PM) sent by staff #1 to the administrator and the owner of the hospital discussing dietary issues, air conditioner/heating units not working, broken beds, and vendors not being paid which had caused a serious repercussion of patient safety issues not being addressed in the facility.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record review and interview, the facility failed to follow their Governing Board Bylaws related to the Governing Board being legally responsible for the conduct of the
hospital. The Governing Board also failed to ensure financial responsibility for the daily operation of the hospital to ensure care in a safe setting.

A review of the document titled "Shelby Regional Medical Center, Rules and Regulations of the Governing Body," revealed:

The purpose of the Governing Board is to recommend and implement hospital policy, promote patient safety and performance improvement, provide quality patient care, and provide for organizational management and planning of the Hospital.

The functions and duties of the Governing Board (hereinafter referred to collectively as the "Governing Board " or individual members as "member") shall be as directed by the Board of Directors of the Corporation.

The Governing Board shall be appointed by the Board of Directors and shall be composed of no more than six (6) members, including the Hospital Administrator as a voting and other hospital representatives as non-voting members.

A telephone interview was conducted with Staff #2 on 10/16/12 at 8:30 AM. Staff #2 reported that he was the Hospital Administrator. He was 1 of 4 members of the Governing Board and the only voting member. He was 1 of 2 members of the Board of Directors with the other member being the owner. Staff #2 reported that the Governing Board made suggestions to the owner for the operation of the facility and did not make the final decisions for facility operations and/or financial issues. Staff #2 further reported that the owner was the ultimate decision maker of the conduct, operations, and financial issues of the facility. Staff #2 also reported that it would be an accurate assessment that the Governing Board functioned as an advisory committee making suggestions to the owner which was contrary to the regulatory requirement that the hospital must have an effective governing body legally responsible for the conduct of the hospital as an institution.

A review of the bill for services rendered, by Supplier #1 revealed the facility had not paid for service for three months. The document showed a total amount due of $36,361.01 due for the billing date of 09/29/2012. Supplier #1 was the lab service used by the hospital for services that could not be performed at the hospital lab.

On 10/05/2012 at 1:00 PM and of 10/08/2012 at 08:00 AM, an interview with the billing representative of supplier #1 confirmed that the facility owed for services rendered in the amount of $36,361.01. The lab supplier had started the ten day process for discontinuing services.

A review of the billing statement for services rendered by Supplier #2 revealed that the facility had not paid the bill for services rendered. The billing date for the statement reviewed was 10/01/2012 in the amount of $2,000.00. Supplier #2 provided the storage area for closed patients' medical records.

On 10/05/2012 at 11:00 AM and of 10/08/2012, an interview with the billing representative of supplier #2 confirmed the facility owed five months of services rendered in the amount of $2,000.00. The billing representative of supplier #2 confirmed actions would be taken as of 12/2012 if payment was not received.

A review of the bill for services rendered by Supplier #3 revealed the facility had not been paid for service in four years. The document showed an amount due for year 1/01/2008 -12/31/2008 of $1,200.00, for year 01/01/2009-12/31/2009 of $1,200.00, for year 01/01/2011-12/31/2011 and for year 01/01/2012-12/31/12 of $1,200.00, a total of $4,800.00. The bill was dated 09/20/2012. Supplier #3 provided the communication tower the facility used to communicate with ambulances and helicopters.

On 10/05/2012 at 11:00 AM, an interview with the billing representative of supplier #3 confirmed that the facility owed for services rendered in the amount of $4,800.00.

A review of the billing statement for services rendered by Supplier #4 revealed that the facility had not paid the bill for services rendered. The billing date for the statement reviewed was 9/30/2012 in the amount of $4,223.97. Supplier #4 provided the transcription services for the physicians caring for the patients at the facility.

An interview with the representative of Supplier #4 on 10/4/2012 11:30 AM confirmed that the facility owed a total of $4,223.97 to the transcription services. A record review of the transcription services invoice showed a balance of $4,223.97.

Phone interviews were conducted with vendors on 10/05/2012 at 2:00 PM in the assistant administrator's office, staff #1 was present during the phone interviews with supplier #1, supplier #2, supplier #3 and supplier # 4. Staff #1 confirmed the interviews.

In an interview with Governing Board member #13 on 10/05/2012 at 1:30 PM in the assistant administrator's office, the member was asked if she was aware of the unpaid bills. GB member #13 stated "No " .

On 10/05/2012 at 10:00 AM by phone interview, the bills owed to supplier #1, #2, #3, and
#4 were reviewed with staff #2. Staff #2 stated he was not sure if the bills had been paid or not. He was aware of a money flow problem and was not sure when the bills could be paid. Staff #2 stated that the corporation had been busy for the past five weeks meeting meaningful use (use of health information technology is an umbrella term for rules and regulations that hospitals and physicians must meet to qualify for federal incentive funding) and will be filing the attestations (the act of attending the execution of a document and bearing witness to its authenticity) and hopefully this would help.

On 10/04/2012 at 11:00 AM, an interview with staff #29 for evidence of an institutional budget plan that included annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing. Staff #29 stated that he had no knowledge of such a plan. The billing statements for suppliers #1, #2, #3, and #4 were reviewed and staff #29 had no knowledge of the bills. Staff #29 stated that he only signed the checks; it was staff #1 and staff #2 responsibilities to submit the bills.
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0073
Based on record review and interview, the Board of Directors failed to have an institutional plan that addressed the annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing.
ARTICLE I, GOVERNING BOARD FUNCTIONS AND DUTIES, The functions and duties of the Governing Board (hereinafter referred to collectively as the "Governing Board" or individual members as "member" ) shall be as directed by the Board of Directors of the Corporation (hereinafter "Board of Directors" ), consistent with the applicable laws and regulations.

ARTICLE VIII. GOVERNING BOARD OPERATION, Section 1. General Functions, The Governing Board shall have responsibility for the business and affairs of the Hospital to the extent delegated by the Board of Directors. The Governing Board shall delegate responsibility and authority for the day-to-day management of the Hospital to the Hospital Administrator.

Section 4. Planning Function. The Governing Board shall participate in and support an institutional planning process to periodically evaluate the Hospital's goals, policies and programs. At the Governing Board's discretion, this planning function may be performed by a committee (the "Governing Board Planning Committee" ) which includes representatives of the Governing Board, administration, nursing, other appropriate advisers, and the Medical Staff.

Section 8. Facility Plans and Budgets. The Governing Board, together with the Hospital Administrator, shall develop short-term and long-term financial management plans including, but not limited to, annual capital and operating budgets, and a long-range master plan, to the end that the Hospital may effectively serve its community. Such plans shall be submitted to the Board of Directors or its designee for review and approval.

On 10/05/2012 at 2:00 PM in the assistant administrator's office a request was made of staff #1 for evidence of an institutional budget plan that includes annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing. Staff #1 stated she had no knowledge of such a plan.
On 10/05/2012 at 10:00 AM by phone interview a request was made of staff #2 for evidence of an institutional budget plan that includes annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing. Staff #2 stated they had not developed an annual budget or an institutional plan.
On 10/04/2012 at 11:00 AM interview, a request was made of staff #29 for evidence of an institutional budget plan that included annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing. Staff #29 stated he had no knowledge of such a plan.
In an interview with Governing Board member #13 the question was asked:
1) had the Governing Board been presented with or had the board participated in the developing of an institutional budget plan that included annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing? The Governing Board member #13 stated "No."
2) had staff #2 made available to her or presented in the Governing Board meetings any of the facility's finances as they relate to past due bills resulting in shut off notices or a list of the vendors that were not doing business with the facility due to delinquent payments? The Governing Board member #13 stated "No."
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0076
Based on interviews, the facility failed to develop an institutional plan therefore no annual review or update had been addressed by the governing body.
On 10/05/2012 at 2:00 PM during an interview in the assistant administrator's office, a request was made of staff #1 for evidence of an institutional budget plan that included the annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing. Staff #1 stated she had no knowledge of such a plan.
On 10/05/2012 at 10:00 AM by phone interview, a request was made of staff #2 for evidence of an institutional budget plan that included the annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing. Staff #2 stated they had not developed an annual budget or an institutional plan.
On 10/04/2012 at 11:00 AM during an interview, a request was made of staff #29 for evidence of an institutional budget plan that included annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing. Staff #29 stated he had no knowledge of such a plan.
In an interview with Governing Board member #13 the question was asked:
1) had the Governing Board been presented with or had the board participated in the developing of an institutional budget plan that included annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing? The Governing Board member #13 stated "No."
2) had staff #2 made available to her or presented in the Governing Board meetings any of the facility's finances as they relate to past due bills resulting in shut off notices or a list of the vendors that were not doing business with the facility due to delinquent payments? The Governing Board member #13 stated "No."
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0077
Based on interviews, the facility failed to develop an institutional plan. No evidence was presented by the Board of Directors that the Governing Body, Administrative staff or Medical staff was involved in the institutional plan of the facility.
On 10/05/2012 at 2:00 PM in the assistant administrator's office, a request was made of staff #1 for evidence of an institutional budget plan that included annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing. Staff #1 stated she had no knowledge of such a plan.
On 10/05/2012 at 10:00 AM by phone interview, a request was made of staff #2 for evidence of an institutional budget plan that included annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing. Staff #2 stated they had not developed an annual budget or an institutional plan.
On 10/04/2012 at 11:00 AM during an interview, a request was made of staff #29 for evidence of an institutional budget plan that included annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing. Staff #29 stated he had no knowledge of such a plan.
In an interview with Governing Board member #13 the question was asked:
1) had the Governing Board been presented with or had the board participated in the developing of an institutional budget plan that included annual operating budget, anticipated income and expenses, capital expenditure and the anticipated sources of financing? The Governing Board member #13 stated "No."
2) had staff #2 made available to her or presented in the Governing Board meetings any of the facility's financial as they relate to past due bills resulting in shut off notices or a list of the venders that are not doing business with the facility due to delinquent payments? The Governing Board member #13 stated "No".
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based record reviews, observations and interviews, the facility failed to maintain a clean and safe environment for the patients it served. Patient care equipment in current use had not had recent safety inspections to ensure they were in safe working condition. The facility failed to ensure proper air exchange and ventilation in patient rooms due to dirty, clogged air conditioner filters. The facility failed to ensure ceiling plaster was in good repair in the dietary department to prevent plaster from falling into the patient food service line and contaminating the food.

Refer to A144, A701

It was determined 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 potential to affect all patients admitted to the facility.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on records review, observations and interviews, the facility failed to maintain a clean and safe environment for the patients it served. Patient care equipment in current use had not had recent safety inspections to ensure they were in safe working condition. The facility failed to ensure proper air exchange and ventilation in patient rooms due to dirty, clogged air conditioner filters. The facility failed to ensure ceiling plaster was in good repair in the dietary department to prevent plaster from falling into the patient food service line and contaminating the food.

The following was a list of patient care equipment observed while touring the facility on 10/4-5/2012, which was being presently used by patients or was available for patient care use. The safety/preventive maintenance checks were due to be done by August 2012.

Treadmill/Electrocardiogram machine that was for performing patient exercise stress test

Ultrasound echocardiogram machine (ECHO) 8/2012

Electroencephalogram (EEG) machine 8/2012

Electrocardiogram machine that was used on the floor and in the emergency room for a 12 lead EKG 8/2012

Pulmonary Function Test screening machine x 2 (no preventive maintenance sticker indicating when the safety had been checked)

A review of the schedule for patient testing using the equipment in the cardio/pulmonary department revealed that the EKG machine had been used 27 times, ECHO machine was used 10 times, EEG, and the exercise stress test had been used once. This equipment was due to be checked by August 2012. This evidence indicated that the facility was using the equipment that had not been maintained and tested for patient safety creating a potential risk for harm to patients.

An interview with staff #1, #20, and (#21 by phone interview) on 10/4/2012 at 10:00 AM while in the cardiopulmonary department confirmed the equipment had been used on patients with the preventive maintenance safety checks not being done.

Intravenous pump # 182 (no preventive maintenance sticker indicating when the safety had been checked); this piece of equipment was presently being used on a patient

Intravenous pump # 999 (no preventive maintenance sticker indicating when the safety had been checked); this piece of equipment was presently being used on a patient

Intravenous pump # 321 (safety sticker dated 5/2012) (located in the equipment room)

Intravenous pump # 0 (no preventive maintenance sticker indicating when the safety had been checked, located in the emergency room )

Intravenous pump # 324 (safety sticker dated 4/2010, located in the emergency room )

Intravenous pump # 8 (safety sticker dated 8/2012, located in the emergency room )

Medtronic Lifepak # 780 (cardiac monitoring machine located in the emergency room ; no preventive maintenance sticker indicating when the safety had been checked)

Medtronic Lifepak # 1 (no preventive maintenance sticker indicating when the safety had been checked; located in the emergency room ). This piece of equipment was currently being used on a patient in the emergency room

Phillips Neonatal monitor U24CT # 9 (no preventive maintenance sticker indicating when the safety had been checked; located in the emergency room )

Hydrotherapy machine,portable (safety sticker dated 8/2012)

Whirlpool machine, portable (safety sticker dated 8/2012)

Ventilator #567= (safety sticker dated 8/2012)

Ventilator, portable (located on the equipment shelf; safety sticker dated 8/2012)

Gomco #1346 (patient suction machine for constant and intermittent use to eliminate gastric secretions) (no preventive maintenance sticker indicating when the safety had been checked)

Gomco #3001 (no preventive maintenance sticker indicating when the safety had been checked)

Gomco (on a stand) labeled not working dated 11/21/2011 (this piece of equipment was in the room with all the other patient care equipment cleaned bag and ready for patient use)

Gomco #SC0424 (no facility tag or preventive maintenance safety sticker; located in the emergency room ). The tag on the equipment indicated it belonged to another hospital.

Enteral Feeding pump (safety sticker dated 8/2012)

Enteral Feeding pump # 547 (no preventive maintenance sticker indicating when the safety had been checked)

Compression machine (used to promote circulation in the lower extremities) preventive maintenance safety sticker indicated last check was 5/12/2012

Compression machine # 3 no preventive maintenance safety sticker

Compression machine # 6 no preventive maintenance safety sticker

Hypo/Hyperthermia Unit (K-thermia pad) (safety sticker dated 8/2012)

Regular Home Heating Pad with no type of covering for the pad (no facility tag or preventive maintenance safety sticker)

Box fans x 2 being used in patient rooms with no facility tag or preventive maintenance safety sticker

Hoyer Lift (no preventive maintenance safety sticker)

Patient beds x 2 with signs on them written broken

All of the above patient care equipment had not been inspected for safety and tagged as safe for patient care but were continuing to be used for patients and created a potential risk of harm to patients.

Autoclave (used for sterilization of instruments) in the hospital has been broken for over a month. Staff # 3 reported that she was unable to get approval for the repair work. The issue was reported to staff #1 in which she had requested advice from the administrator on how to proceed with getting the autoclave repaired.

An interview with staff #1 on 10/4/2012 at 12:00 PM while touring the facility patient care areas confirmed that the equipment had been used on patients with the preventive maintenance safety checks not being done. Broken equipment was tagged broken, but still available in patient care areas. Staff #1 reported the preventive maintenance safety checks had not been performed, and broken equipment had not been repaired due to the biomedical contract person not being paid and he will not come until he receives a check for $2,500.

During a tour of the dietary department on 10/4/2012 at approximately 2:00 PM with staff #1 and #12, surveyor observed a ceiling a hole in the kitchen where the plaster was missing and there were several large cracks in the plaster. The plaster had turned loose from the ceiling, appears to have been caused by a water leak in the ceiling. The plaster had fallen into the patient food buffet line. This buffet line is where the food is kept while dietary staff prepares food trays to be served to the patients. Also observed in the same area was an air conditioner vent covered with brown dust and on the ceiling surrounding the vent. The air conditioner vent was directly over the food buffet line where patient food trays were prepared. This created a potential risk for contamination of patient food trays.

An interview with staff #12 on 10/4/2012 at 2:00 PM while in the dietary department confirmed that the air conditioner vent with dust and the falling ceiling tile had been reported to maintenance a month ago. Staff #12 voiced concern that the plaster in the ceiling has been falling on to the food buffet line table and the ceiling has become worse since she reported the problem a month ago. During the interview staff #12 reported that the vendor (supplier #5) had informed the facility that unless the invoices from 5/28/2012, 6/25/2012, 7/23/2012, 8/20/2012, and 9/17/2012 were paid, the dishwasher, (which required monthly service or would not function) and the solution for washing dishes and utensils would not be delivered to the facility.

A telephone interview with the representative of supplier # 5 on 10/5/2012 at approximately 10:00 AM confirmed that the facility (dietary equipment) would not be serviced until the bill was paid in full with the total amount of $1,257.97.

The one and only portable x-ray machine in the facility had been broken since September 2, thru October 3, 2012. On 9/27/2012 staff #9 used her personal credit card to order a battery for the portable x-ray machine. Staff #9, #10, and #11 placed a battery in the portable x-ray machine. The portable x-ray machine had not been serviced by a qualified radiology equipment service. This piece of equipment was used in the emergency room and on the nursing unit for critically ill patients that could not go to the radiology department.

An interview with staff #9 on 10/4/2012 at 3:00 PM in the radiology department confirmed that she had reported the portable x-ray machine was non-functional to the Assistant Administrator for a month. The Assistant Administrator had reported to Administrator, Chief Financial Officer, and the Owner of the Hospital that the portable x-ray machine was non-functional. A review of a daily report sheet completed by the Assistant Administrator and sent to the Administrator, Chief Financial Officer, and the Owner of the Hospital verified that the report had been sent daily from September 2, thru October 3, 2012 and it was written on the report the portable x-ray machine was down.
An interview with staff #1 on 10/4/2012 at 4:00 PM confirmed that staff #9 had purchased a battery with her personal credit card and staff #9, #10, and #11 placed the battery in the portable x-ray machine. However, the x-ray machine had not been checked by a qualified radiology equipment service to determine if the battery was indeed the issue that caused the equipment to be non-functioning. The lack of inspection of this critical equipment caused potential harm to all patients requiring use of the portable x-ray machine.

A tour of the nursing unit was conducted on 10/4/2012 at 11:00 AM with staff #1. The tour consisted of going to each patient room. The facility was licensed for 54 beds. The facility had 20 patient rooms (with the capacity of 2 patients to a room). During the tour, only 3
(#101, #121, and #126) of 20 patient rooms were fully functional for patient care.

Room #102 had only 1 call light for 2 patients, the air conditioner and heating unit was not working, the vent cover on the unit was completely gone, and a button on the control panel was missing and metal was showing.

Room #103 had only 1 call light for 2 patients.

Room #107 had only 1 call light for 2 patients.

Room #108 had no call lights, the cover for the ceiling air conditioner was gone and all the inside of the unit was rusty metal and the unit was not working. Staff #1 reported the room was used for temporary storage.
Room #109 (patient room), Staff #1 reported that this was storage for RAC (Real Application Clusters) supplies.

Room #110 (patient room), Staff #1 reported that this was storage for Intravenous Fluids and Intravenous Pumps.

Room #111 (patient room), Staff #1 reported that this was going to be the sleep room for the emergency room physicians. The heat did not work in the room and there was a hole beside the heating unit where you could see the outside ground.

Room #112 had 1 bed and 1 call light. The room was currently being used by a patient and she complained of not having any air conditioning for 7 days. The patient was using a box fan sitting on a bedside table. The fan had no facility tag or a preventive maintenance sticker. The intravenous pump in use on the patient had no preventive maintenance sticker. The curtains in the room were torn and touching the floor.

Room #113 had 1 bed and 1 call light.

Room #114 had 1 bed and 1 call light.

Room #115 had 2 beds and 1 call light, the air conditioner was not working and the vent cover to the unit was gone. The door to the patient room would not stay open and it was tied open with a plastic bag to a towel rack.

Room #118 had 1 call light and the air conditioner/heating unit was not working. This room was currently being used by a patient.

Room #119 had 1 call light.

Room #120 had 1 call light.

Room #122 (patient room), Staff #1 reported that this room was used for storage and it contained 2 broken beds.

Room #123 had only 1 call light for 2 patients.

Room #124 (patient room), Staff #1 reported that this room was used for storage and it contained baby cribs and the Hoyer lift.

Room #125 had 1 call light and the air conditioner unit was not working. This room was currently being occupied by a patient. The room had a portable air conditioner unit sitting on the bedside table and the unit was vented through an open tile in the ceiling.

An interview with staff #1 on 10/4/2012 at 4:00 PM after the tour was completed confirmed that she only had 3 patient rooms that were fully functional. Staff #1 reported the room issues to the owner of the facility last month and he still had not advised her on how to fix the patient care rooms.

A review of the air conditioner filter log for the main units of the facility revealed the filters had not been changed since June 2012. Questioned staff #3 on how often filters were to be changed and he answered "every 30 days".

An interview with staff #3 on 10/5/2012 at 10:00 AM confirmed that supplier # 6 was the only company they could get the filters from that fit the old air conditioner units for the facility and they had to pre- pay because of bad credit.

An interview with staff #1 on 10/5/2012 at 10:00 AM confirmed that supplier # 6 needed to be paid in order to obtain the air conditioner filters for the facility. She reported that the Administrator had been notified of the problem with insufficient funds.

An interview with staff #2 on 10/5/2012 at 1:00 PM reported to one of the surveyors, the facility had insufficient funds and did not know where he would get the money to pay the vendors.