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.

UT HEALTH EAST TEXAS TYLER REGIONAL HOSPITAL 1000 SOUTH BECKHAM AVE TYLER, TX 75701 Oct. 26, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, interview, and record review, the Governing Body failed to:

A. Protect patient rights, and ensure laundry and linen was processed and stored in a safe setting.

The facility failed to ensure linen was processed and stored in a manner to prevent cross contamination.

Clean linen was stored in a room which had ceiling leaks and in close proximity to a construction area. The area was not properly sealed off in a manner to prevent contamination of the clean linen. The clean linen was stored in open bins and on uncovered shelves. The floor in the room was soiled with trash, lint, linen, lumber and trash.

The soled linen room did not have proper ventilation. The room was found with a strong pungent urine odor and without ventilation. The rooms was filled to capacity with bags of soiled linen which extended over approximately 20 feet. The facility failed to ensure soiled linen was process timely.

It was determined that the deficient practices at the following Conditions of Participation for Patient's Rights posed an Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, impairment and/or subsequent death.

Refer to tag A0144 for additional information.



B. ensure informed consents were obtained from patients before received surgical procedures on 4 of 12 sampled patients (Patient #'s 1, 2, 3, and 5)

Patient #5 had signed consents for a gallbladder and gastric bypass surgery on his chart. Patient #5 also received a hiatal hernia repair during surgery and did not have a consent on his clinical record for it.

Patient #2 had a signed consent for a "Sleeve Gastrectomy Laparoscopic" surgery on his chart. Patient #2 also received a hiatal hernia repair during surgery and did not have a consent on his clinical record for it.

The facility failed to ensure surgical consents were completed with dates and times they were signed by staff.


Refer to tag A0131 for additional information.


C. ensure there was an organized nursing services. The facility failed to ensure adequate numbers and of licensed nurses and patient care assistants on 1 of 2 units (3 North Orthopedic/Bariatric).

The facility failed to have adequate numbers of licensed nurses scheduled as listed on their staffing matrix. The facility substituted licensed vocational nurses for registered nurses and their staffing matrix did not document that could be done.

The facility failed to have adequate numbers of patient care assistants (PCA) scheduled as recommended by their staffing matrix. At times the facility scheduled 1 or 1 patient care assistants for a 36 bed unit

Refer to tag A0392 for additional information.


D. ensure nursing supervise and evaluated care in 2 of 12 sampled patients (Patient #'s 2 and 11).

The facility failed to ensure complete and accurate assessments on skin breakdown. The nursing staff failed to document a continued assessment describing size and color of skin breakdown on Patient #11. The failed to ensure staff provided turning as needed to prevent further breakdown. There was a timeframe of 4 days where staff failed to document turning on Patient #11.

The facility failed to ensure nursing staff assessed and intervened when there were declines in vital signs.

Patient #2 blood pressure dropped to a low abnormal level and staff failed to reassess the patient timely.


Refer to tag A0395 for additional information.


E. ensure medications were administered timely and as physician ordered in 1 of 12 sampled patients (Patient #5).

The pain/fever reliever Acetaminophen 1000 milligrams intravenously was not administered as physician, putting the patient at risk for toxic levels.

The intravenous vitamin supplement Thiamine was administered over 1.5 hours after the scheduled time.


Refer to tag A0405 for additional information.


F. develop a system for identifying and controlling hazardous infection control practices. The facility failed to ensure linen was processed and stored in a manner to prevent cross contamination.

Clean linen was stored in a room which had ceiling leaks and in close proximity to a construction area. The area was not properly sealed off in a manner to prevent contamination of the clean linen. The clean linen was stored in open bins and on uncovered shelves. The floor in the room was soiled with trash, lint, linen, lumber and trash.

The soled linen room did not have proper ventilation. The room was found with a strong pungent urine odor and without ventilation. The rooms was filled to capacity with bags of soiled linen which extended over approximately 20 feet. The facility failed to ensure soiled linen was process timely.


The facility failed to ensure infection control practices were followed on 2 of 2 units (3 North and 6 North).

The facility failed to ensure patients rooms, bathrooms, and equipment were kept clean, rusted equipment was discarded, and walls, floors, coffee brewers, and patient refreshment refrigerators were kept clean and sanitary.

The facility failed to ensure equipment that was ready for patient usage was sanitized and bagged.

The facility failed to ensure biohazardous waste was properly discarded. A patient's hemovac (used for drainage of blood from a surgical site) was discarded in the regular tray. Patient use trash, equipment that was being reprocessed, the tray cart, and a open box of biohazard were all stored in the same room.

The facility failed to ensure staff washed their hands after medication administration.

The facility failed to ensure ultrasound gel was dated when opened.


Refer to tag A0749 for additional information.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview and record review, the facility failed to protect patient rights. The facility failed to:


a. ensure laundry and linen was processed and stored in a safe setting.

The facility failed to ensure linen was processed and stored in a manner to prevent cross contamination.

Clean linen was stored in a room which had ceiling leaks and in close proximity to a construction area. The area was not properly sealed off in a manner to prevent contamination of the clean linen. The clean linen was stored in open bins and on uncovered shelves. The floor in the room was soiled with trash, lint, linen, lumber and trash.

The soled linen room did not have proper ventilation. The room was found with a strong pungent urine odor and without ventilation. The rooms was filled to capacity with bags of soiled linen which extended over approximately 20 feet. The facility failed to ensure soiled linen was process timely.

It was determined that the deficient practices at the following Conditions of Participation for Patient's Rights posed an Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, impairment and/or subsequent death.

Refer to tag A0144 for additional information.



B. ensure informed consents were obtained from patients prior to surgical procedures on 4 of 12 sampled patients (Patient #'s 1, 2, 3 and 5).

Patient #5 had signed consents for a gallbladder and gastric bypass surgery on his chart. Patient #5 also received a hiatal hernia repair during surgery and did not have a consent on his clinical record for it.

Patient #2 had a signed consent for a "Sleeve Gastrectomy Laparoscopic" surgery on his chart. Patient #2 also received a hiatal hernia repair during surgery and did not have a consent on his clinical record for it.

The facility failed to ensure surgical consents were completed with dates and times they were signed by staff.


Refer to tag A0131 for additional information.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure patients rights were not violated in 4 of 12 sampled patients (Patient #'s 1, 2, 3 and 5). The facility failed to:

A. ensure informed consents were obtained from patients prior to surgical procedures.

Patient #5 had signed consents for a gallbladder and gastric bypass surgery on his chart. Patient #5 also received a hiatal hernia repair during surgery and did not have a consent on his clinical record for it.

Patient #2 had a signed consent for a "Sleeve Gastrectomy Laparoscopic" surgery on his chart. Patient #2 also received a hiatal hernia repair during surgery and did not have a consent on his clinical record for it.

B. ensure surgical consents were completed with dates and times they were signed by staff.

This deficiency had the likelihood to cause harm to all patients receiving surgery.



Findings include:

Review of the clinical record on Patient #5 revealed he was a [AGE] year old male who (MDS) dated [DATE].

Review of consents on Patient #5 revealed the following:

Anesthesia consent was signed on 10/22/2018 at 8:15 a.m. by Patient #5. There was documentation that nursing witnessed the consent, but failed to document a date and time of when they witnessed it.

"DISCLOSURE AND CONSENT MEDICAL AND SURGICAL PROCEDURES LAPAROSCOPIC CHOLECYSTECTOMY" dated 10/22/2018 revealed the following was documented as the procedures that would be performed " Laparoscopic Cholecystectomny, Laparoscopic Gastric Bypass" The consent was signed by Patient #5 and the surgeon on 10/22/2018.

Review of an operative report dated [DATE] revealed the physician also performed a hiatal hernia repair.

There was no other consent on the hospital record showing Patient #5 gave consent for a hiatal hernia to be performed.

During an observation on 10/23/2018 after 9:45 a.m., Staff #4 was observed to look at Patient #5's abdominal incisions. Staff #4 reported that Patient #5 had 6 incisions and that normally she sees 5 incisions. Staff #4 informed Patient #5 that he also had a hiatal hernia repair during surgery. Patient #5 replied "I did not know that".
Staff #1 confirmed there was no consent for the hiatal hernia repair on the record.

During an interview on 10/24/2018 after 8:30 a.m., Staff #1 and #2 provided a consent that was sent over from the surgeon's office.

Review of the consent revealed a "CONSENT FOR LAPAROSCOPIC GASTRIC BYPASS" where there was mention of a hiatal hernia repair may be performed during the surgery if needed. This consent was signed on 10/09/2018 (13 days prior to surgery).

The consent was not in the hospital record. The information for consent for a hiatal hernia repair was not updated on the new consent.





Review of the clinical record of Patient #2 revealed he was a [AGE] year old male who (MDS) dated [DATE] for a surgical procedure.

Review of consents on Patient #2 revealed the following:

Anesthesia consent was signed on 09/17/2018 at 8:30 a.m. by Patient #2. There was documentation that nursing witnessed the consent, but failed to document a date and time of when they witnessed it.

"DISCLOSURE AND CONSENT MEDICAL AND SURGICAL PROCEDURES" dated 09/17/2018 revealed the following was documented as the procedures that would be performed " Sleeve Gastrectomy Laparoscopic" The consent was signed by Patient #2 and the surgeon on 09/17/2018.

Review of an operative report dated [DATE] revealed the physician also performed a hiatal hernia repair.

There was no other consent on the hospital record showing Patient #2 gave consent for a hiatal hernia to be performed.

During an interview on 10/24/2018 after 5:00 p.m., Staff #13 reported that Patient #2 and his spouse found out about the hiatal hernia repair when the nurses were giving shift report at bedside. The surgeon did not like to talk to patients the day of surgery. He normally waits until the next day to explain all about the procedure.



Review of the record of Patient #3 revealed he was a [AGE] year old male who (MDS) dated [DATE].

Review of operative report dated [DATE] revealed Patient #3 had surgery on his right shoulder.

Review of consents revealed the following:

Anesthesia consent was signed 10/22/2018 at 6:30 a.m. Patient #3 . There was documentation that nursing witnessed the consent, but failed to document a date and time of when they witnessed it.

The surgery consent was signed by the surgeon,but he failed to date and time to indicate it was signed prior to the surgery.




Review of the clinical record for Patient #1 revealed he was an [AGE] year old male who was admitted to the facility on [DATE]. Patient #1 had complaints of Lumbar Radiculopathy Ataxia (spine pain).
Review of consents revealed the following:

Anesthesia consent signed off by Patient #1 on 07/07/2018 and witnessed by nursing (no time). There was no physician signature on the form.

A "DISCLOSURE AND CONSENT MEDICAL AND SURGICAL PROCEDURE" consent for a computed tomography of the right shoulder dated 07/03/2018. The physician signed the form, but there was no date or time behind his signature.

A "DISCLOSURE AND CONSENT MEDICAL AND SURGICAL PROCEDURE" consent for a computed tomography of the left hip and a conscious sedation consent dated 06/29/2018. The physician did not sign the forms.


During an interview on 10/24/2018 after 3:00 p.m., Staff #1 confirmed the documentation.




Review of the facility's policy named"Informed Consent" revised June 27, 2016 revealed the following:

"..Consent will be obtained in writing prior to performing surgical procedures, non-surgical invasive, diagnostic and /or therapeutic procedures, and all procedures in which anesthesia or sedation is used.

Definition:
Informed consent; is the permission given by a patient to perform a medical treatment or surgical procedure after the patient has been advised of the risks or hazards that could influence a reasonable person in deciding whether or not to consent. In order for the patient to make an informed decision about whether to consent, the patient needs information about the treatment or procedure and the risks associated with it. Informed consent deals with the information provided to the patient and how it is provided when obtaining the patient's permission to perform the treatment or procedure ...

The physician may have the informed consent form completed in his/her office prior to surgery and signed and witnessed. On admission, the patient should bring the original for inclusion in his/her chart and present it to the nursing staff or the physician should forward the consent to the Admitting Office ..."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview, and record review, the facility failed to ensure laundry and linen was processed and stored in a safe setting.

The facility failed to ensure linen was processed and stored in a manner to prevent cross contamination.

Clean linen was stored in a room which had ceiling leaks and in close proximity to a construction area. The area was not properly sealed off in a manner to prevent contamination of the clean linen. The clean linen was stored in open bins and on uncovered shelves. The floor in the room was soiled with trash, lint, linen, lumber and trash.

The soled linen room did not have proper ventilation. The room was found with a strong pungent urine odor and without ventilation. The rooms was filled to capacity with bags of soiled linen which extended over approximately 20 feet. The facility failed to ensure soiled linen was process timely.

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


Findings include:

Review of a complaint and grievance dated 10/09/2018 revealed the following complaint:

"I asked for a hospital gown and clean linens for 11 hours. 11 hours later I was finally brought linens and a gown, which was too small. I was advised there were issues with the laundry service and bariatric gowns were not available at the time. I then changed all of his linens, helped him bathe and put on one of his shirts from myself. Halfway through the next shift we were finally brought a bariatric gown. (Patient stay was 09/17/2018)"

During an observation on 10/23/2018 after 8:58 a.m., the linen cart was checked on 3 North and revealed the linen to be dingy in color. The cart covering was ripped and tethered. The inside of the linen cart was covered with spills and debris.


During an observation on 10/24/2018 after 9:50 a.m., another linen cart on 3 North was found to be with the plastic covering with rips.

Staff #1 confirmed the observations. Staff #1 reported that about 2 months ago the CEO had gotten complaints about the laundry. Some of the administrative staff went down to the laundry department and helped wash linen. They helped because the linen was backed up. Staff #1 reported they were not doing linen there anymore. It had been contracted out to another company as of last week.

During an observation on 10/24/2018 after 10:02 a.m., the clean linen storage area was noted to be in a construction area. There were shelves and large storage bins of clean linen which were uncovered. Some of the linen were stacked all the way up to just beneath the ceiling. The ceiling and water sprinklers were soiled with lint. The ceiling tile in some areas were found with water stains from a leak. A vent in the ceiling was covered with a buildup of lint and dust and clean linen was stored underneath vent. The floor in the room was littered with dust, trash, lumber and linen. There were old rusted lockers in the room and a cart of clean linen were close to them. One wall had missing dry wall and was in need of painting. One part of the room had a wall made of plastic which was not sealed to prevent dust from the construction area that was behind it.

When the door of the soiled linen room was opened there was a strong pungent urine odor noted. There was no ventilation in the room. There were large containers filled with bags of soiled linen which filled the entire room. Some of the stacks almost touched the ceiling. The walls in the room could not be seen. The room was so packed with soiled linen there was no path to walk through the room. Above the bags of linen, the construction workers could be seen in the areas where the washers were working. The soiled linen extended over 20 feet back from the entry of the front door to the construction area.


During an interview, Staff #18 reported he was the supervisor of linen and that he was employed by the contracted company. Staff #18 reported the construction crew were taking the washers and dryers out and they had just started today. Staff #18 reported that they had been working for the facility since last Monday (10/15/2018). Staff #18 was questioned about the stacks of linen in the soiled linen area. Staff #18 reported that a truck comes every night (from the contracted company). Staff #18 reported they were not picking up enough of the soiled linen.

During an interview on 10/24/2018 after 11:00 a.m., Staff #21 reported the last infection control meeting was in September 2018. There were no problems with laundry and no rounding for laundry. Staff #21 reported she questioned the contracted service about the storage of the clean linen and they said it was okay. Staff #21 was questioned about the linen process for patients in isolation for infections. Staff #21 reported it was stored in the same place as the other linen.

During an interview on 10/24/2018 after 11:00 a.m., Staff #2 (Administrative staff) reported this was his first time seeing the area. They moved too fast without having a plan.

During an interview on 10/24/2018 after 11:00 a.m., Staff #9 (Administrative staff) reported being in the last Governing body meeting on September 25,2018. The contract was signed with the contracted service, but there was no discussion about the services.

Review of a facility's policies dated November 2011 revealed the following:

"Handling of Clean Linens"

"POLICY : Exposure to contaminated or other potentially infectious materials could represent a potential hazard to employees, patients and visitors.
It is the policy of the East Texas Medical Center to ensure that laundry staff take all reasonable steps to ensure clean linen does not come into contact with potentially infectious objects.

PROCEDURE:
ETMC Laundry Services will follow procedures outlined below when handling and processing clean laundry.
...Clean linen carts should be kept covered during storage and transport.
Clean linen carts used to store linen should be cleaned and disinfected periodically ...."


" Cleaning of Laundry Area and Equipment"

"POLICY: It is the policy of the East Texas Medical Center to ensure sanitary workspaces and equipment to properly clean linens for hospital use.

PROCEDURE:

ETMC Laundry services will ensure a high-standard of cleanliness and quality oversight is in place to prevent cross-contamination of linen. Each laundry employee is responsible for maintaining a clean workspace including sweeping floors, disinfecting surfaces, vacuuming lint, trash disposal, and other identified tasks.
Laundry management will oversee laundry cleaning process. A checklist tool will direct cleaning efforts.
The following are some of the items identified as part of the normal cleaning process, but do not represent every step of the cleaning process. A cleaning log/checklist reflects regular cleaning duties.
Soiled linen collection room will be swept and mopped with disinfectant at the end of the day shift ..."

"Contaminated Laundry"

"POLICY: Exposure to blood or other potentially infectious materials through contaminated laundry that was improperly labeled or handled could represent a potential hazard to employees, patients, and visitors ..."


It was determined that the deficient practices at the following Conditions of Participation for Patient's Rights posed an Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, impairment and/or subsequent death.
VIOLATION: MEDICAL STAFF CREDENTIALING Tag No: A0341
Based on interview and record review, the facility failed to examine the credentials of 1 of 2 physicians who's credentialing files that were reviewed (Staff #24).

Staff #24 (Physician) was performing bariatric surgeries and other general surgery in the facility and did not have a current delineation of privileges form in his credentialing file. The last form completed by Staff #24 (Physician )was 17 years ago.

This deficient practice had the likelihood to affect all patients who received surgery from Staff #24 (Physician).



Findings include:

Review of the credentialing file on Staff #24 (Physician) revealed he completed an application on 10/28/2016.

Review of the "DELINEATION OF PRIVILEGES" form that was included with the 2016 application revealed the following:

It was signed off by Staff #24 on 04/10/2001 and stamped as being received on 04/17/2001. The privileges were approved 07/12/2001 (17 years ago).

There was a hand written note on the same sheet which read "Laparoscopic Bariatric Surgery (added 05/16/2005)". There was also a check mark beside the privilege. There was no documentation as to who added the notation to the form or when the additional privilege was approved.

The privileges were approved on 02/20/2017 without a current privilege form being obtained.

Review of a letter dated 10/01/2018 revealed there was a request from Staff #24 (Physician) to complete a credentialing application and privilege forms which included a detailed form for Bariatric privileges. There were instructions on the letter that the information was due on Monday 10/22/2018.

During an interview on 10/24/2018 after 9:21 a.m., Staff #22 reported that Staff #24 (Physician) was sent the same credentialing form each time he came up for reappraisal by the last person who was over credentialing. Staff #22 reported that she sent Staff #24 (Physician) new information to be completed, but he had not sent it back yet. Staff #22 reported that Staff #24 (Physician) was not due to go to committee until February 2019.

Review of the facility's "Medical Staff Bylaws, Rules & Regulations & Policies & Procedures" dated July 2018 revealed the following:

"..Approximately six (6) months before the current appointment expiration date of each Staff member or individual with clinical privileges, a reappointment packet will be sent to each individual to be executed. Reappointment packets will be required to be returned ninety (90) days prior to such appointment expiration date. The request shall further include information concerning:

..Request for clinical privileges.."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, and record review, the facility failed to ensure there was an organized nursing services. The facility failed to:

A. ensure adequate numbers of licensed nurses and patient care assistants on 1 of 2 units (3 North Orthopedic/Bariatric).

The facility failed to have adequate numbers of licensed nurses scheduled as listed on their staffing matrix. The facility substituted licensed vocational nurses for registered nurses and their staffing matrix did not document that could be done.

The facility failed to have adequate numbers of patient care assistants (PCA) scheduled as recommended by their staffing matrix. At times the facility scheduled 1 or 1 patient care assistants for a 36 bed unit

Refer to tag A0392 for additional information.


B. ensure nursing supervised and evaluated care in 2 of 12 sampled patients (Patient #'s 2 and 11).

The facility failed to ensure complete and accurate assessments on skin breakdown. The nursing staff failed to document a continued assessment describing size and color of skin breakdown on Patient #11. The facility failed to ensure staff provided turning as needed to prevent further breakdown. There was a timeframe of 4 days where staff failed to document turning on Patient #11.

The facility failed to ensure nursing staff assessed and intervened when there were declines in vital signs.
Patient #2 blood pressure dropped to a low abnormal level and staff failed to reassess the patient timely.


Refer to tag A0395 for additional information.


C. ensure medications were administered timely and as physician ordered in 1 of 12 sampled patients (Patient #5).

The pain/fever reliever Acetaminophen 1000 milligrams intravenously was not administered as physician ordered, putting the patient at risk for toxic levels.

The intravenous vitamin supplement Thiamine was administered over 1.5 hours after the scheduled time.


Refer to tag A0405 for additional information.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on interview and record review, the facility failed to ensure adequate numbers of licensed nurses and patient care assistants on 1 of 2 units (3 North Orthopedic/Bariatric).

The facility failed to have adequate numbers of licensed nurses scheduled as listed on their staffing matrix. The facility substituted licensed vocational nurses for registered nurses and their staffing matrix did not document that could be done.

The facility failed to have adequate numbers of patient care assistants (PCA) scheduled as recommended by their staffing matrix. At times the facility scheduled 1 or 1 patient care assistants for a 36 bed unit


This deficient practice had the likelihood to cause harm to all patients on the unit.

Findings include:


During confidential interviews the following was stated about staffing:

"Normally we have 2 techs or none. When it's like that we are supposed to keep a nurse."


This is a" 36 bed floor and today we have 4 techs, yesterday we had 2. They try to make it work."


"On night shifts there are 2 PCA's a lot of times, sometimes 3."


"Sometimes there are 1-4 (PCA's) here . When there are 2, one takes one side of the unit and the other takes the other side. We take 18 patients each. When there is one scheduled we get the nurses to help out as much as possible."


" We had a big turnover when the hospital changed hands." There is a need for "6 registered nurses and 1 PCA."


Review of staffing matrix and time sheets from 10/13-22/2018 revealed the following:

Two out of ten days the facility was short a licensed vocational nurse.

One day the staffing matrix called for 8 registered nurses and 1 licensed vocational nurse. Instead the facility staffed the unit with 7 registered nurses and 3 licensed vocational nurses.

Another day the staffing matrix called for 7 registered nurses and 1 licensed vocational nurse. Instead the facility staffed the unit with 6 registered nurses and 2 licensed vocational nurses.

The facility used registered nurses and licensed vocational nurses interchangeably and the staffing matrix did not allow for it.


Review of staffing matrix and time sheets from 10/13-22/2018 revealed the following:

Five out of ten days the facility was short staff of PCA's.


Staff #'s 10 and 13 confirmed the numbers.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview and record review, the facility failed to ensure nursing supervised and evaluated care in 2 of 12 sampled patients (Patient #'s 2 and 11). The facility failed to:

A. ensure complete and accurate assessments on skin breakdown. The nursing staff failed to document a continued assessment describing size and color of skin breakdown on Patient #11. They failed to ensure staff provided turning as needed to prevent further breakdown. There was a timeframe of 4 days where staff failed to document turning on Patient #11.

B. ensure nursing staff assessed and intervened when there were declines in vital signs.
Patient #2 blood pressure dropped to a low abnormal level and staff failed to reassess the patient timely.


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


Findings include:


Review of the clinical record of Patient #11 revealed he was a [AGE] year old male who (MDS) dated [DATE] with diagnoses which included [DIAGNOSES REDACTED] and hyperglycemia.

Review of nursing assessments revealed the following:


On 10/10/2018 at 2:00 p.m., Patient #11 had no bruises, lesions, rashes, breakdown or redness. Patient #11 had a Braden (tool used to determine risk for skin breakdown) score of 20 which meant he was at a mild risk.

On 10/12/2018 at 11:10 p.m., Patient #11 had a Braden score of 16 (mild risk) and required assist from staff with bed mobility.

On 10/14/2018 at 8:58 p.m., Patient #11 had a Braden score of 13 which meant a moderate risk. This was a decline in status for Patient #11.

On 10/15/2018 at 11:27 p.m., there was documentation that Patient #11 had a pressure wound to the buttock (sacrum), well approximate, pink to buttock. There was an intervention documented to turn the patient every 2 hours. The Braden score was 14 which meant Patient #11 was at a moderate risk for skin breakdown.

On 10/16/2018 at 7:00 a.m., staff documented that Patient #11 was dependent in bed mobility.


As of 10/24/2018 there was no documentation of an assessment of what size the skin breakdown was and if it was blanachable or not.


Review of turning schedules revealed the following:

10/14/2018 at 11:00 p.m. the patient was on the right lateral side.

10/15/2018 at 7:15 p.m. (over 20 hours later) was the next documented time staff documented turning on Patient #11. There was documentation Patient #11 was turned supine (on his back).

10/15/2018 at 9:05 p.m., Patient #11 was on the left lateral side and 6 hours later there was documentation at 3:25 a.m. that Patient #11 was on the same side.

10/16/2018 at 11:05 p.m., Patient #11 was on the right side and the next documentation was on 10/17 at 3:31 p.m., the patient was up in the chair.

The turning schedule for 10/18 through 10/21/2018 was not documented.

Staff #1 confirmed the assessment and turning schedules.


During an observation on 10/24/2018 at 4:30 p.m., Patent #11's entire sacral-coccygeal (tail bone area) was beet red and excoriated. The sore was approximately 10 centimeters in circumference.


Review of the facility's policy named "Pressure Ulcer Prevention" dated 11/24/2015 revealed the following:

"..3. Conduct a comprehensive skin assessment to include pertinent alterations to intact skin.
4..Document risk assessment findings on the electronic medical record and any pertinent skin alterations/wounds on the "skin man"."

6.. At moderate and high risk -in addition to mild risk interventions add the following:
1.Initiate q 2 hour turning schedule. ..
On the first sign of skin breakdown, or non-blanching [DIAGNOSES REDACTED], consult WOC nurse for evaluation and treatment of wounds."







Review of the clinical record of Patient #2 revealed he was a [AGE] year old male who (MDS) dated [DATE] for laparoscopic gastric sleeve.

Review of nurses notes and vital sign sheets revealed the following:

Preoperative

On 09/17/2018 at 9:18 a.m., the initial vital signs were temperature 97.8 degrees Fahrenheit, pulse 110,respirations 18 and blood pressure of 134/64.

Postoperative

On 09/18/2018 at 1219 midnight the vital signs were temperature 97.6 degrees Fahrenheit, pulse 81,respirations (none documented) and blood pressure of 108/57.

On 09/19/2018 at 1255 midnight vital signs, no temperature was documented, pulse 91, respirations 16 and blood pressure of 100/38.

Nursing did not document taking another blood pressure on Patient #2 until 3.5 hours later at 4:03 a.m.

During an interview on 10/24/2018 after 3:00 p.m., Staff #1 confirmed the vital signs.

During an interview on 10/24/2018 after 5:00 p.m., Staff #13 reported they were only concerned with the systolic pressure. They called the physician when there were problems with the systolic pressure.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure medications were administered timely and as physician ordered in 1 of 12 sampled patients (Patient #5).

The pain/fever reliever Acetaminophen 1000 milligrams intravenously was not administered as physician ordered, putting the patient at risk for toxic levels.

The intravenous vitamin supplement Thiamine was administered over 1.5 hours after the scheduled time.

This deficient practice had the likelihood to cause harm to all patients on the unit (3 North Orthopedic/Bariatric).



Findings include:

Review of the clinical record on Patient #5 revealed he was a [AGE] year old male who (MDS) dated [DATE] for gallbladder and gastric bypass surgery.

Review of physician orders dated 10/22/2018 revealed Patient #5 was to receive Acetaminophen 1000 milligrams every 6 hours for 4 doses. The maximum dose that could be given in a 24 hour time frame was 4 grams according to the physician.

Review the medication administration records for 10/22/2018 revealed the following:
A dose was scheduled for 4:00 p.m. and it was administered at 6:35 p.m. (2.5 hours after it was due).

The next dose was scheduled for 10:00 p.m., but it was administered at 9:15 p.m. (2 hours and 35 minutes after the last dose.)

The medication was not administered within the timeframe ordered by the physician.

Staff #1 confirmed the medication was not administered as ordered.

During an observation on 10/23/2018 after 9:36 a.m., Staff #4 was observed to start medication administration for Patient #5.

Staff #4 reported Patient #5's Thiamine (vitamin supplement) was scheduled for 9:00 a.m. also, but it was not in the medication room.

Staff #4 hung the Acetaminophen at 9:45 a.m.

According to the medication administration record, Patient #5 was also on Acetaminophen (IV) 1000 milligrams every 6 hours. The last time it was administered was at 4:29 a.m. on 10/23/2018 (5 hours ago).

The medication was hung too close in time to the last dose.


During an interview on 10/23/2018 after 11:30 a.m., Staff #4 reported that the Thiamine was hung at 10:45 a.m. (over an 1.5 after it was scheduled to be given).

Review of the facility's policy named "Medication Administration" dated 08/21/2013 revealed the following:

"..1. Standard administration times shall be adhered to whenever possible.
2. Medications that are designated as time-critical scheduled medications must be administered within 30 minutes prior to or 30 minutes after the scheduled administration time.."
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and review, the facility failed to ensure nursing staff monitored and accounted for narcotic use in 3 of 12 sampled patients (Patient #'s 2, 3, and 8).


Patients were on narcotics which were administered via PCA pumps. Nursing staff failed to monitor and keep account of the medication the patients were taking per shift.

This deficient practice had the likelihood to cause harm to all patients receiving narcotics via PCA pump.

Findings include:



Review of the record of Patient #3 revealed he was a [AGE] year old male who (MDS) dated [DATE]. Review of operative report dated [DATE] revealed Patient #3 had surgery on his right shoulder.

Review of the medical record revealed a physician order for Patient #3 to be placed on the narcotic Morphine via PCA pump on 10/22/2018 at 12:41 p.m.

Review of the pain category and nurses notes revealed no documentation of staff logging what was being taken in and what was left of the narcotic per shift.


During an interview on 10/23/2018 after 3:00 p.m., Staff #1 confirmed the documentation. Staff #1 reported a new category had been added in the notes under the pain category for nurses to keep up with the amount of the narcotic every shift. The section was added over 6 months ago.




Review of the clinical record of Patient #8 revealed she was a [AGE] year old female who was admitted to the facility on [DATE].

Review of the chart revealed the narcotic Hydromorphone via PCA was initiated on 10/21/2018 at 6:58 p.m. Patient #8 administered 4.9 milligrams at that time.

Review of the chart revealed documentation on 10/22/2018 at 6:13 p.m. revealing that 5.4 milligrams was administered and at 8:24 p.m. it showed Patient #8 used 3.6 milligrams of the medication.



During an observation on 10/23/2018 after 11:42 a.m., Staff #8 wasted the narcotic pain medication Hydromophone with Staff #4 witnessing. They wasted 3 cc's (3 milligrams). The syringe was a 30 cc/30 mg syringe.

Review of the chart and Pyxis (medication storage unit) revealed there was no documentation of what the balance was after the last shift.



Staff #8 reported the medication belonged to Patient #8 and had been taken from the PCA pump. Staff #8 reported she did not log how much was in there when she started her shift 7:00 a.m. this morning.
Staff #8 checked the chart and Pyxis revealed there was no documentation of what the balance was after the last shift.





Review of the clinical record of Patient #2 revealed he was a [AGE] year old male who (MDS) dated [DATE] for a surgical procedure.

Review of physician orders dated 09/17/2018 at 12:54 p.m., revealed an order for PCA Morphine 1 milligram/ milliliter every 10 minutes with a limit of 25 milligrams /4 hours.

Review of nursing documentation revealed the following:

On 09/17/2018 at 7:33 p.m., 6 milligrams was administered.
On 09/18/2018 at 7:29 a.m. and 10:32 a.m., entries were made in the pain category, but staff failed to document the amount of Morphine the patient took.
On 09/19/2018 at 5:37 a.m., 1 milligrams was administered.



During and interview 10/24/2018 after 2:00 p.m., Staff #1 confirmed the documentation.



Review of a facility's policy named "Medication Administration" dated 08/21/13 revealed:

"A record of the narcotic count will be maintained on each unit of all narcotics not stored in the Pyxis that have been released by Pharmacy"

According to the Institute for Safe Medication Practices article " Safety issues with PCA Part II- How to Prevent Errors dated 07/24/03 revealed:


"'Verify PCA settings every shift, immediately after receiving report."
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation, interview and record review, the facility failed to ensure patient care equipment was maintained and preventive maintenance were performed timely in 3 of 4 departments (3 North Orthopedic, Physical therapy, and 6 North Medical-Surgical/Oncology).

The facility failed to ensure intravenous pumps, patient beds, warmers and orthopedic equipment were maintained in safe operating condition.

The facility failed to have a system in place to ensure medication scanners were functional.

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

Findings include


3 NORTH ORTHOPEDIC UNIT


During an observation on 10/23/2018 after 8:55 a.m., a CPM machine on the orthopedic floor (3 North), did not have a preventative maintenance sticker on it.

Staff #1 and #25 confirmed the equipment did not have a safety check. Staff #1 reported the equipment was not on the preventative maintenance log. It was new equipment and not due for a safety check.




During an observation on 10/23/2018 after 10:06 a.m, an IV pump was found at the nurse's station with the following sign on it "Shows need to charge even when plugged in."

Staff #6 confirmed the observation and said that the pump was placed there on yesterday. It had been placed there during her 3 days off. Staff #6 reported that the nurse did not write up a work order on it. When staff have non-functioning equipment they are supposed to call right away to have it repaired.


During an observation on 10/23/2018 after 11:51 a.m., Staff #8 tried to scan medication to administer to Patient #9. The scanner would not work. Staff #8 had to use the back up scanner to scan the medication.
Staff #8 reported that on this morning the backup scanner would not work and the one in the room would. Staff #8 reported that sometimes they have problems with the scanners not working.

During an interview on 10/23/2018 after 1:21 p.m., Staff #1 reported that there was no system in place to check if the batteries were being changed in the scanners.



During an observation on 10/23/2018 after 10:55 a.m., Patient #7 was observed laying on his back, had scooted down with his legs hanging off the foot board of the bed. Staff #'s 6 and 12 were at the bedside trying to get the head of the bed to lower, but it would not function. After manipulating the settings, the bed finally started working and staff were able to position Patient #7 up in the bed.

Patient #7's spouse reported that a staff member had to "work with the bed yesterday. It wouldn't work.'

Review of maintenance logs revealed no documentation of there being a request for maintenance on the bed.

PHYSICAL THERAPY

During an observation on 10/23/2018 after 1:46 p.m., a patient Hoyer lift was found with a preventative maintenance sticker due date of 09/18/2018 last month.

Staff #'s 1 and 25 confirmed the observation.


CLEAN SUPPLY ROOM ON 3 NORTH (ORTHOPEDIC)

A warmer used for Chlorahexidine cloths had not been checked for safety.
Staff #1 confirmed the observation and reported the equipment was new.


6 NORTH MEDICAL SURGICAL/ONCOLOGY UNIT

During an observation on 10/24/2018 after 11:05 a.m., a warmer used for Chlorahexidine cloths had not been checked for safety.

Staff #10 confirmed the observation.


Review of the facility's policy named "Preventative Maintenance Inspection" dated 03/01/2018 revealed the following:

"POLICY:

A preventative maintenance inspection of equipment shall be performed by the Biomedical Services Department or the original equipment manufacturer or contracted vendor.

PROCEDURE:
Inspection
Performance tests
Lubrication
Other operations specified for equipment by manufacturers instructions and preventative maintenance guidelines ....

Upon completion of the inspection, the respective unit will be tagged and returned to service if all aspects of the unit are found to be satisfactory ...

If a defect is found which is dangerous to the patient, operator or equipment, the item will be tagged and withdrawn until repaired."
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, interview and record review, the facility failed to develop a system for identifying and controlling hazardous infection control practices. The facility failed to:


A. ensure linen was processed and stored in a manner to prevent cross contamination.

Clean linen was stored in a room which had ceiling leaks and in close proximity to a construction area. The area was not properly sealed off in a manner to prevent contamination of the clean linen. The clean linen was stored in open bins and on uncovered shelves. The floor in the room was soiled with trash, lint, linen, lumber and trash.

The soled linen room did not have proper ventilation. The room was found with a strong pungent urine odor and without ventilation. The rooms was filled to capacity with bags of soiled linen which extended over approximately 20 feet. The facility failed to ensure soiled linen was processed timely.

It was determined that the deficient practices at the following Conditions of Participation for Infection control posed an Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, impairment and/or subsequent death.


B. ensure infection control practices were followed on 2 of 2 units (3 North and 6 North).

The facility failed to ensure patients rooms, bathrooms and equipment were kept clean, rusted equipment was discarded, and walls, floors, coffee brewers, patient refreshment refrigerators were kept clean and sanitary.

The facility failed to ensure equipment that was ready for patient usage was sanitized and bagged.

The facility failed to ensure biohazard waste was properly discarded. A patient's hemovac( used for drainage of blood from a surgical site) was discarded in the regular tray. Patient use trash, equipment that was being reprocessed, the tray cart, and a open box of biohazard were all stored in the same room.

The facility failed to ensure staff washed their hands after medication administration.

The facility failed to ensure ultrasound gel was dated when opened.


Refer to tag A0749 for additional information.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview and record review, the facility failed to develop a system for identifying and controlling hazardous infection control practices. The facility failed to:.

A. ensure linen was processed and stored in a manner to prevent cross contamination.

Clean linen was stored in a room which had ceiling leaks and in close proximity to a construction area. The area was not properly sealed off in a manner to prevent contamination of the clean linen. The clean linen was stored in open bins and on uncovered shelves. The floor in the room was soiled with trash, lint, linen, lumber and trash.

The soled linen room did not have proper ventilation. The room was found with a strong pungent urine odor and without ventilation. The room was filled to capacity with bags of soiled linen which extended over approximately 20 feet. The facility failed to ensure soiled linen was process timely.

It was determined that the deficient practices at the following Conditions of Participation for Infection control posed an Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, impairment and/or subsequent death.

B. ensure infection control practices were followed on 2 of 2 units (3 North and 6 North).

The facility failed to ensure patients rooms, bathrooms and equipment were kept clean, rusted equipment was discarded, walls, floors, coffee brewers, patient refreshment refrigerators were kept clean and sanitary.

The facility failed to ensure equipment that was ready for patient usage was sanitized and bagged.

The facility failed to ensure biohazardous waste was properly discarded. A patient's hemovac( used for drainage of blood from a surgical site) was discarded in the regular tray. Patient use trash, equipment that was being reprocessed, the tray cart, and a open box of biohazard were all stored in the same room.

The facility failed to ensure staff washed their hands after medication administration.

The facility failed to ensure ultrasound gel was dated when opened.


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


Findings include:



A. LAUNDRY DEPARTMENT


Review of a complaint and grievance dated 10/09/2018 revealed the following complaint:

"I asked for a hospital gown and clean linens for 11 hours. 11 hours later I was finally brought linens and a gown, which was too small. I was advised there were issues with the laundry service and bariatric gowns were not available at the time. I then changed all of his linens, helped him bathe and put on one of his shirts from myself. Halfway through the next shift we were finally brought a bariatric gown. (Patient stay was 09/17/2018)"

During an observation on 10/23/2018 after 8:58 a.m., the linen cart was checked on 3 North and revealed the linen to be dingy in color. The cart covering was ripped and tattered. The inside of the linen cart was covered with spills and debris.


During an observation on 10/24/2018 after 9:50 a.m., another linen cart on 3 North was found to have a plastic covering with rips.

Staff #1 confirmed the observations. Staff #1 reported that about 2 months ago the CEO had gotten complaints about the laundry. Some of the administrative staff went down to the laundry department and helped wash linen. They helped because the linen was backed up. Staff #1 reported they were not doing linen there anymore. It had been contracted out to another company as of last week.

During an observation on 10/24/2018 after 10:02 a.m., the clean linen storage area was noted to be in a construction area. There were shelves and large storage bins of clean linen which were uncovered. Some of the linen were stacked all the way up to just beneath the ceiling. The ceiling and water sprinklers were soiled with lint. The ceiling tile in some areas were found with water stains from a leak. A vent in the ceiling was covered with a buildup of lint and dust and clean linen was stored underneath vent. The floor in the room was littered with dust, trash, lumber and linen. There were old rusted lockers in the room and a cart of clean linen were close to them. One wall had missing dry wall and was in need of painting. One part of the room had a wall made of plastic which was not sealed to prevent dust from the construction area that was behind it.

When the door of the soiled linen room was opened there was a strong pungent urine odor noted. There was no ventilation in the room. There were large containers filled with bags of soiled linen which filled the entire room. Some of the stacks almost touched the ceiling. The walls in the room could not be seen. The room was so packed with soiled linen there was no path to walk through the room. Above the bags of linen, the construction workers could be seen in the areas where the washers were working. The soiled linen extended over 20 feet back from the entry of the front door to the construction area.


During an interview Staff #18 reported he was the supervisor of linen and that he was employed by the contracted company. Staff #18 reported the construction crew were taking the washers and dryers out and they had just started today. Staff #18 reported that they had been working for the facility since last Monday (10/15/2018). Staff #18 was questioned about the stacks of linen in the soiled linen area. Staff #18 reported that a truck comes every night (from the contracted company). Staff #18 reported they were not picking up enough of the soiled linen.

During an interview on 10/24/2018 after 11:00 a.m., Staff #21 reported the last infection control meeting was in September 2018. There were no problems with laundry and no rounding for laundry. Staff #21 reported she questioned the contracted service about the storage of the clean linen and they said it was okay. Staff #21 was questioned about the linen process for patients in isolation for infections. Staff #21 reported it was stored in the same place as the other linen.

During an interview on 10/24/2018 after 11:00 a.m., Staff #2 (Administrative staff) reported this was his first time seeing the area. They moved too fast without having a plan.

During an interview on 10/24/2018 after 11:00 a.m., Staff #9 (Administrative staff) reported being in the last Governing body meeting on September 25,2018. The contract was signed with the contracted service, but there was no discussion about the services.

Review of a facility's policies dated November 2011 revealed the following:

"Handling of Clean Linens"

"POLICY : Exposure to contaminated or other potentially infectious materials could represent a potential hazard to employees, patients and visitors.
It is the policy of the East Texas Medical Center to ensure that laundry staff take all reasonable steps to ensure clean linen does not come into contact with potentially infectious objects.
PROCEDURE:
ETMC Laundry Services will follow procedures outlined below when handling and processing clean laundry.
...Clean linen carts should be kept covered during storage and transport.
Clean linen carts used to store linen should be cleaned and disinfected periodically ...."


" Cleaning of Laundry Area and Equipment"

"POLICY: It is the policy of the East Texas Medical Center to ensure sanitary workspaces and equipment to properly clean linens for hospital use.

PROCEDURE:

ETMC Laundry services will ensure a high-standard of cleanliness and quality oversight is in place to prevent cross-contamination of linen. Each laundry employee is responsible for maintaining a clean workspace including sweeping floors, disinfecting surfaces, vacuuming lint, trash disposal, and other identified tasks.
Laundry management will oversee laundry cleaning process. A checklist tool will direct cleaning efforts.
The following are some of the items identified as part of the normal cleaning process, but do not represent every step of the cleaning process. A cleaning log/checklist reflects regular cleaning duties.
Soiled linen collection room will be swept and mopped with disinfectant at the end of the day shift ..."

"Contaminated Laundry"

"POLICY: Exposure to blood or other potentially infectious materials through contaminated laundry that was improperly labeled or handled could represent a potential hazard to employees, patients, and visitors ..."



B. 3 NORTH ORTHOPEDIC UNIT

During an observation on 10/23/2018 after 9:00 a.m. the following was found:


Room #3510

There was dried spills on the floor. The floor was littered with papers and debris.
A urinal filled with urine was sitting on the bedside table with dressing supplies and next to a bottle of Hy[DATE] (solution used to prevent and treat skin and tissue infections).
The base of the bathroom, toilet had a dried red substance which had the appearance of blood.
The bedside toilet chair was rusted.

Patient #4 reported they change the trash, but do not mop the floor.


Room 3508

The bedside toilet chair was rusted.


Biohazard room

There was an open cart for trash, a bag for collecting compression sleeves or pneumatic tourniquets for reprocessing, an open box with biohazard equipment in it and the patient tray cart were all stored in the room together.

The tile floor just outside of the room had dried brown spills. The baseboard had a buildup of debris. One of the walls outside the room, near the baseboard area had an approximate 6 inch hole in the wall.


Patient refreshment area

The coffee brewer was soiled with dried coffee spills.

Patient supplement refrigerator had a buildup of dried substance in the rubber door sealing. The floor in front of the refrigerator was soiled with dried spills.


Medication administration

During an observation on 10/23/2018 after 9:45 a.m., Staff #4 was observed to complete medication administration to Patient #5. The observation included administration of injectables and IV medications. Staff #4 was observed to go to her computer in the room and touch the keyboard without removing her gloves first.


Equipment room 3 North

An open bottle of ultrasound gel was observed with the bladder scanner. The bottle did not have an open date logged on it.

According to the manufacturer guideline (AquasonicGel.com) revealed the following instructions:

"Shelf Life and Storage of Aquasonic Ultrasound Transmission Gel"

"..Since there is no effective way to determine whether an opened bottle of gel has been contaminate general guidelines are that gel should be marked to expire 28 days after open. Using a warmer does not impact the expiration time.."

A pulse oximeter attached to clean equipment was found covered in remnants of old tape.

Two patient portable oxygen tanks were sitting directly on the floor.


Nurses station on 3 North

Three dopplers were stored at the nurses station area. One was not bagged to indicate it was clean.
Staff #6 confirmed the observation and reported that they were bagged when cleaned.

Room #3501

During an observation on 10/23/2018 after 10:55 a.m., a hemovac with blood in it was in the regular trash at the bed side.

The floor in the room was littered with trash.

The bedside toilet seat in the room had a paper strip on it indicating it was clean. The legs on the toilet seat were rusted and there was a dried brown substance underneath the seat which had the appearance of feces.

Staff #6 confirmed the observations and reported that the hemovac was not supposed to be in the trash. It was supposed to be in the biohazard container.


C. 6 NORTH MEDICAL -SURGICAL ONCOLOGY UNIT

During an observation on 10/24/2018 after 11:05 a.m. , two patient walkers were stored in the clean equipment room. They had strips of paper on them that indicated they were clean. The walkers had old tape wrapped around the bars on the walker. With the tape on them there was no way the walkers could be sanitized. One of the walkers had tennis balls on the bottom of them that were soiled and had lint buildup.

Staff #10 confirmed the observations.
VIOLATION: ORGANIZATION OF RESPIRATORY CARE SERVICES Tag No: A1152
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure respiratory services was organized in a manner to provide appropriate care in 2 of 12 patients (Patient #'s 2 and 6). The facility failed to:

A. ensure physician's complete orders for usage of CPAP's (Continuous positive airway pressure- A form of positive airway pressure ventilator).

B. ensure respiratory staff documented complete assessments on patients using CPAPs.

C. ensure staff implement their policy when patients brought in their home units.


This deficient practice had the likelihood to cause harm to all patients on CPAPS.

Findings include:



Review of the clinical record of Patient #6 revealed she was a [AGE] year old patient admitted on [DATE].

Review of an admission assessment dated [DATE], revealed Patient #8 had diagnoses which included sleep apnea and had a history of using a CPAP.

Review of physician orders revealed no documentation of an order for the CPAP with the settings.

Review of respiratory assessment dated [DATE] at 9:45 a.m., revealed Patient #6 had the CPAP for sleep apnea. There was not any other documentation in respiratory notes about the CPAP.

Review of nurses notes from 10/20/2018 -10/23/ revealed no documentation about the CPAP.

During an observation on 10/23/2018 after 10:25 a.m., a CPAP was found on the bedside table with the mask attached in Patient #6's room.

Staff #6 confirmed it belonged to Patient #6. Staff #6 confirmed the missing nursing assessments, respiratory assessment and physician orders for the CPAP. Staff#6 reported not knowing how long Patient #6 had been using the CPAP.






Review of the clinical record of Patient #2 revealed he was a [AGE] year old male who (MDS) dated [DATE] for a surgical procedure.

Review of physician orders dated 09/17/2018 revealed the following orders:

At 12:40 p.m., "CPAP at hours of sleep-Use pts usual settings."
At 9:00 p.m., "CPAP Home Unit RTQHS and prn."

There was no documentation of what the settings were in the orders.

Respiratory notes on 09/17/2018 at 8:26 p.m. and 09/18/2018 at 9:45 p.m. revealed Patient #2 was using CPAP from home. There was no documentation of what the settings were.

During an interview on 10/24/2018 after 2:50 p.m., Staff #14 (Respiratory staff) reported sometimes the doctors order settings and sometimes they wont. They have to titrate the rate when we don't have an order. When patients bring their home units they are asked to use the hospital's units instead.


During an interview on 10/14/2018 after 5:00 p.m., Staff #9 and 13 reported they don't routinely use the patient's home units.

Review of the facility 's policy named" Non-Invasive Ventilation" dated 02/07/2017 revealed the following:

"1.PURPOSE

To establish guidelines that will be followed when treating a patient with non invasive ventilation for respiratory distress as ordered by the physician. The goals to support ventilation and oxygenation, decrease work of breathing, and avoid endotracheal intubation.

11. POLICY

Upon order for non invasive ventilation, therapist will place patient on machine (S/T or AVAPS mode) and adjust accordingly to meet specific tidal volume, oxygenation, and work of breathing goals while insuring optimal patient comfort and compliance...

10. PATIENTS WITH HOME CPAP/BIPAP

Patients are encouraged to bring in any CPAP or BIPAP device they use at home with them for use in the hospital since their prescribed settings area contained within that unit. Upon visual inspection, if any part of the home unit looks of any kind damaged or may present a hazard(electric, etc.) that unit will not be used until an inspection is performed by our biomedical department. In this case or if patients cannot bring in their unit, they will be supplied with one of our Respironic auto titrator units."