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.

CLEVELAND EMERGENCY HOSPITAL 1017 S TRAVIS AVE CLEVELAND, TX 77327 May 9, 2019
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observation, interview and document review the facility failed to properly staff 4 (CEH, HOPD Porter, Spring and Humble) of 5 (CEH, TEH, HOPD Porter, Spring and Humble) emergency departments with adequate nursing staff. The facility utilized Emergency Medical technicians and Licensed Vocational Nurses in place of Registered Nurses for three months, March, April and May of 2019

This deficient practice had the likelihood to effect all patients of the hospitals emergency department.

Findings included:


On the morning of 5/8/2019 in the conference room, the staffing plan and staffing grid for all of the hospitals Emergency Departments (ED) were reviewed. An interview with the Chief Nursing Officer (CNO) confirmed only campus B had a a full compliment of Registered Nurses (RN's) who worked the ED. The CNO confirmed that only on campus "B" were RN's exclusively placed on the schedule.


The staffing planning and grid reflected the following approved staffing pattern. All facility locations followed a 12 hour first shift (7:00 AM to 7:00 PM), and a 12 hour second shift (7:00 PM to 7:00 AM), to staff for a 24 hours period. Facility CEH and TEH also included a mid shift (1:00 PM to 10 PM)

CEH
First shift, 2 RN's, 1 Mid shift RN for 5 hours
Second shift, 1 RN, mid shift (RN 3 hours), 1 Licensed vocational nurse (LVN) or Emergency Medical Technician (EMT).

On 5/8/2019 in the late afternoon an interview with staff #25, the Director of Nursing, confirmed she was available to come in and cover when they were short. Staff #25 was asked if she had been coming in routinely at 10:00 PM every evening to provide the RN coverage until 7:00 AM and then attending to her clinic duties? She did not confirm this.

From 10:01 PM until 7:00 am the ED has 1 RN and 1 LVN or EMT.

THE
First shift, 2 RN's, 1 Mid shift RN for 5 hours, and an LVN/EMT
Second shift, 1 RN, mid shift (RN 3 hours), LVN EMT.


HOPD (Porter, Spring and Humble) do not utilize a mid shift RN
First shift, 2 RN's, 1 LVN/EMT
Second shift, 1 RN, 1 Licensed vocational nurse (LVN) or Emergency Medical Technician


On 5/8/2019 in the afternoon an interview with the CNO confirmed facility THE was staffed on paper utilizing both RN's and LVN/EMT's, however, the reality was facility TEH utilized only RN's for all positions. All other facility depended on both LVN or EMT services within the ED shift.

State Administrative Code, chapter 773

"(b) Notwithstanding other law, a person who is certified under this chapter as an emergency medical technician-paramedic or a licensed paramedic, is acting under the delegation and direct supervision of a licensed physician, and is authorized to provide advanced life support by a health care facility may in accordance with department rules provide advanced life support in the facility's emergency or urgent care clinical setting, including a hospital emergency room and a freestanding emergency medical care facility."

An EMT is permitted by law to participate in life saving action, such as a code, inside the Hospitals Emergency Department, and that only by permission of the medial staff and approved by the Governing Body.

On 5/8/2019 during an interview with the Chief Executive Officer (CEO), the CEO was overhear to say, "He was not aware an EMT could not be hired to work in a hospital along side a RN in the ED".

A review of the hospitals Medical Staff guidelines and Governing Body rules and regulations failed to identify any clear path of approved skills an EMT was allowed to perform while in the hospital.


Review of the State Board of Nursing Scope of Practice Licensed vocational Nurse (LVN).

"The LVN scope of practice is a directed scope of practice and requires appropriate supervision of a registered nurse, advanced practice registered nurse, physician assistant, physician, dentist, or podiatrist. The LVN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws, rules, regulations, and policies, procedures, and guidelines of the employing health care institution or practice setting. The LVN is responsible for providing safe, compassionate, and focused nursing care to assigned patients with predictable health care needs".

"Though the BON does not regulate employers, and the NPA (Nurse Practice Act) and Board rules are not prescriptive to specific practice settings, the Board believes triage, telephonic nursing, and/or being on-call to handle urgent/emergent issues are all beyond the scope of practice for LVN's. Of concern to the Board are situations where the LVN would be required to independently engage in assessment (either telephonically or face-to-face) for purposes of triaging a patient.

The Board's concerns are based on the fact that LVN's are not educationally prepared to perform triage assessments, either telephonically or in the role of the health care professional initially assessing a patient face-to-face to determine treatment priorities in any setting".


On 5/8/2019 an interview with the CNO confirmed both LVN and EMT were utilized in the ED. The CNO also confirmed that should a code be called the LVN could function as a scribe during the code or she could be the soul nurse available in the ED for patient care until the Code was completed. There was no second RN staffed, on the second shift, to attend other patients that might be in the ED at the time of the code.


On the morning of 5/9/2019 an interview with Staff RN #54 the ED charge Nurse confirmed there was only an LVN, tech or EMT on the medical surgical unit at night. The mid shift RN worked only 3 hours of the night shift (second shift). This left the LVN unsupervised from 10:00 PM until the shift change at 7:00 AM, 9 hours. Staff #54 confirmed if the LVN required assistance one of the two RN's from the ED would assist the LVN on the medical surgical unit. When the LVN required a bathroom break or meal break one of the two RN's from the ED would cover the medical surgical unit. This left one RN in the ED and One RN in the Medical surgical unit for up to 30 minutes (lunch) and two 15 minute breaks.

This was confirmed by staff #25 the Director of Nursing.




A tour was conducted on 5/7/19 at 9:00AM at the Hospital Out Patient Department (HOPD) in Humble, Texas. The Emergency Department (ED) has six exam rooms. There was 1 RN full time, 1 RN in orientation, and a EMT present. Staff #56 stated that Staff #59 was in orientation. Staff #56 stated there is usually just one RN and one LVN/EMT/Paramedic per shift. Staff #56 was asked if she takes a lunch break. Staff #56 stated, "yes". Staff #56 confirmed she was docked for that lunch time period of 30 minutes. When the RN takes a break the LVN or EMT/Paramedic is left unsupervised by an RN.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on record review and interview the facility failed to provide a process for physician oversight for mid level practitioners. The facility had no evidence of physician oversight for 2 of 2 mid level practitioners, Registered Nurse Practitioner # 39 and #40, from January through May 8, 2019.

This deficient practice had the likelihood to effect all patients of the facility.

Findings included

On the afternoon of 5/8/2019, interview with medical records (MR) staff #36, confirmed to her knowledge the MR department had no policy or process to review or track MR for physician oversight of the Registered Nurse Practitioners (RNP), who worked under them. Staff #36 called her supervisor, Staff #37 by phone, who confirmed the MR department did not track physician oversight of their RNP's.

A review of MR revealed RNP #39 and #40 each worked under physician #38. Physician #38 had no method of tracking or reviewing the work provided by the RNP whom he supervised and had submitted no data to the Medical Staff for review.


On 5/8/2019 in the afternoon, an interview with the COO, staff #1, confirmed the Medical Staff had no process established for consistent review of oversight for the RNP's. She produced a plan that was yet to be presented to the Medical Staff and Governing Body, that established the chain of oversight and required review of 10% of the RNP's MR documentation which the state Board of Nursing requires to be in compliance with requirements to function as a RNP
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on review of records and interview, the Governing Body failed to ensure that all contracted services were evaluated for safety and effectiveness through the Quality Assurance / Process Improvement (QAPI) program for 5 out of 5 campus locations (CEH, TEH, HOPDs in Porter, Humble, and Spring).

Findings included:

A request was made on 5-6-2019 for all QAPI reporting data and meeting minutes. A review of the QAPI binder provided by Staff #4 was made on 5-7-2019. The binder contained an agenda and sign-in sheet for a Quality Council meeting held on February 7, 2019. No minutes for this meeting were found. The agenda included the approval of the previous meeting minutes. Minutes of a meeting conducted on October 18, 2018 were included.

An agenda was found for a Quality Council meeting held on April 12, 2019. No sign in sheet or minutes from this meeting were found. The agenda did not include approval of the previous meeting minutes and none were included.

Review of both agendas for 2019 and meeting minutes for the meeting in October 2018 did not contain any information about the evaluation of contracted services for quality and effectiveness.

An interview was conducted with Staff #4 on the afternoon of 5-7-2019. Staff #4 confirmed that the binder was complete. Staff #4 was asked to provide any additional information, evaluations, analysis, or reports that may have been reported through the QAPI program. No other information was provided.

Contracted services includes such areas as Emergency Department Physicians, Respiratory Therapists, Dietary Food Services, and Registered Dietician.




The facility's Governing Body had not reviewed and reconciled the contracts of the Dietary Management Services (FMG), which provided structure, policies, education and hired the dietary manager, and the independently contracted Registered Dietician/Licensed Dietician who provided patient assessment of nutritional needs, recommendation to physician regarding appropriate dietary and patient education. The contracted RD/LD also provided guidance for the dietary manager, education to dietary staff and provided on sight observation of food storage, and safe handling of food.


On the late morning of 5/7/2019 an interview with the facility's contracted Registered Licensed Dietician (RD/LD) staff #27, confirmed she was the dietary services oversight for facilities CEH, and TEH. She confirmed she was an independently contracted RD/LD, not associated with the management contract for the dietary department.


On 5/7/2019 in the afternoon an interview with staff #27, confirmed she had many years experience as a RD/LD. She provided documentation of her visits. The data offered as evidence of the report she submitted to the facility management included the following:

Temperature
Food Quality
Patient Refrigerator
Dining Room Inspection
Correct diet served
Consult Received for dietary triggers/orders
Nutritional consults

Adjacent to each word was a checkmark in a column identified by the word "Yes".

There were no comments or any other measurable data recorded for submission. The documents spanned February, March, April and through May 7, 2019. The RD was asked why there was no narrative or other data recorded on the form? She replied, "They really only want a check list. They don't want to read all that other stuff".


During the interview, staff #27 confirmed she attended the QAPI meetings. She could not provide any measurable data that she submitted to the QAPI committee as evidence of what the dietary department was collecting, tracking and analyzing for the purpose of improving quality in the dietary services department. The RD/LD confirmed the Management services for the dietary department handled that.

On 5/6/2019 in the afternoon an interview with the CEO staff #5, confirmed the facility used a contracted service to provide the nutritional needs of the patients and to provide policy, education and guidance to the dietary department staff.

A review of the job descriptions for the RD/LD identified two (2) in use. One was found in the body of the contract for the RD/LD. The other was found in the policy manual of the contracted dietary services manual.

A review of the job description provided by the Dietary Management Service revealed the RD/LD was responsible to establish the Quality Improvement, including the improvement projects, data collection, tracking and analyzing for the QAPI program. No one the management side or the RD/LD had put into use a mechanism to assess, collect data, track and analyze that data for the Dietary portion of the QAPI program.

A review of the menus in use by the facility's dietary department revealed they had not been approved by the facility's RD/LD for use. The menus in use were not signed by a RD, and the most recently approved menus had been signed by a RD/LD no longer employed by the facility.

Neither the Dietary Management Services nor the RD/LD had provided Quality Improvement Guidance that included Quality assessment, improvement projects, collection of data, tracking and analyzing of the data to the dietary manager.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on review of records and interview, the hospital failed to ensure that the QAPI plan was evaluated each year with a determination made on the number of distinct PI projects for the upcoming year for 5 (CEH, TEH, and HOPD locations at Porter, Spring, and Humble) out of 5 campuses.

Findings included:

A review of the QAPI program was made on 5-7-2019. A binder was provided by Staff #4 that contained all of the QAPI meeting minutes, PI projects, and data that was being tracked.

An interview was conducted with Staff #4 on the afternoon of 5-7-2019. Staff #4 confirmed that the binder was complete. Staff #4 was asked to provide any additional information, evaluations, analysis, or reports that may have been reported through the QAPI program. No other information was provided.

Staff #4 was asked to provide a comprehensive list of departments that were participating in QAPI, PI projects in process, and data that was being tracked and analyzed. Staff #4 was not able to provide a comprehensive list.

The binder contained an agenda and sign-in sheet for a Quality Council meeting held on February 7, 2019. No minutes for this meeting were found. The agenda included a line item for the approval of the previous meeting minutes. Minutes of a meeting conducted on October 18, 2018 were included.

An agenda was found for a Quality Council meeting held on April 12, 2019. No sign in sheet or minutes from this meeting were found. The agenda did not include a line item for the approval of the previous meeting minutes and none were included.

Policy Subject: Emergency Hospital Systems 2018-2019 Performance Improvement & Patient Safety Plan; Effective: 09/21/2018; MEC Committee Approval Date: (blank); Board Approval Date: (blank), was provided and reviewed.

Documents from the QAPI binder and the policy provided did not identify the distinct number of PI projects to be completed annually.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, record review, and interview, the facility failed to maintain a clean and sanitary environment to ensure patient's health, safety and mitigate risks of possible hospital acquired infections in 16 (Supply Room, Patient Room #219, Patient Room #220, Patient Isolation room, Medication room, Sterile Supply Room, Cardiac Catheterization Lab (CCL), Sterile Processing Room, Decontamination Room, the Pre-op Patient Restroom, Operating Room (OR) #1, Operating Room #2, Procedure Room #2, Dietary Department at TEH, Emergency Department at TEH, and Emergency Department in Humble, Texas) of 16 areas observed.



Findings include:

An observation tour was conducted with Staff #49 on 5/8/2019 after 9:30 AM at Texas Emergency Hospital. The following observations were made:


SUPPLY ROOM

Inside the supply room was a clean linen cart that was used to store clean linen for patients. The linen cart was noted to have no protective barrier on the bottom shelf between the floor and the clean linen. The cover over the linen cart was open on the side and the vinyl was noted to be torn exposing the clean linen to possible contaminants.

PATIENT ROOM #219

Patient Room #219 was clean and prepared for a new patient admit. In the bathroom, the hand rail in the shower was covered with rust and hard water stains. The floor around the toilet was soiled with dirt, dust, and debris.

PATIENT ROOM #220

Patient Room #220 was clean and prepared for a new patient admit. In the bathroom, the handrails in the shower were covered with rust, debris and hard water stains. On the toilet, hair, dirt, and dust were noted.

PATIENT ISOLATION ROOM

Inside the Patient Isolation Room, under the sink was heavily soiled with dirt, dust, and debris. The plumbing fixtures were intact but there were open holes where the plumbing connected to the wall leaving an entry for rodents or insects. On the base of the window seal paint was missing and exposing the porous material underneath. The porous material cannot be sanitized to prevent the spread of infectious diseases.


MEDICATION ROOM

In the medication room where patient's medications are prepared the following was observed; Under the sink was visibly covered with heavy dirt, dust, and debris. Inside the patient medication refrigerator dust and debris was observed. On the top shelf inside of the refrigerator was noted to have water pooled. The freezer was soiled with a brown colored stain.

STERILE SUPPLY ROOM

In the sterile supply room were multiple wire racks on wheels used to store patient supplies. Four wire racks were observed to have no barrier between the patient supplies and the floor. This is a risk of cross contamination of dirt, dust, and debris onto patient items.

Staff #49 confirmed the findings.


CCL

Review of the CCL Temperature Logs for the months of March, April, and May 1-5, 2019 was as follows:
Review of the Temperature Log for March 2019 revealed the following:

CCL - The temperature was documented out of range 20 of 21 days.
There was no temperature documented for March 25,2019.


Review of the Temperature Log for April 2019 revealed the following:

CCL - The temperature was documented out of range 20 of 21 days.
There was no temperature documented for April 8, 2019.


Review of the Temperature Log for May 1-6, 2019 revealed the following:

CCL - The temperature was documented out of range 4 of 4 days.



An interview was conducted on 5/7/2019 with Staff #9. Staff #9 was asked what recommendations and guidelines were followed for patient safety. Staff #9 said, "We follow Association of Operating Room Nurses (AORN) guidelines."

Staff #9 confirmed the findings.



Review of the Policy titled, "INFECTION PREVENTION AND CONTROL MEASURES FOR THE CARDIAC CATH LAB, Reference #4001 revealed the following:

" ...Temperature of the procedure rooms shall be maintained at 68 to 75 degrees F. (AORN,2018) ..."



Review of the AORN Perioperative Standards and Recommended Practices,

"...Temperature should be maintained between 68 degrees F to 75 degrees Fahrenheit (20 degrees to 23 C) within the operating room suite. General work areas in sterile processing should be maintained between 68 degrees to 73 degrees F.

Relative humidity should be maintained between 20% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, instrument processing areas, and sterilizing areas and should be maintained below 60% in sterile storage areas..."




An observation tour was conducted on 5/9/2019 with Staff #48 after 9:00 AM at Cleveland Emergency Hospital. The following was observed:


STERILE PROCESSING ROOM

In the sterile processing room the autoclave (equipment used to sterilize surgical instruments) was visibly soiled with several large white stains and dust. The rubber seal around the door was split in several places. This could cause the autoclave to fail during processing of sterile instruments by not allowing it to create a seal to maintain temperature to ensure sterility of all instruments processed for patient use.

DECONTAMINATION ROOM

In the decontamination room, under the sink, the cabinet was heavily soiled with dirt, dust, and debris.


PRE-OPERATIVE PATIENT RESTROOM

The air conditioning return vent in the pre-op patient restroom was heavily soiled with dirt and dust.

Staff #48 confirmed the findings.


OR TEMPERATURE/HUMIDITY LOGS

The temperature was out of range for 49 of 49 days reviewed.


Review of the Surgical Services Temperature Log for the months of March, April, and May 1-9, 2019 was as follows:

Review of the Temperature Log for March 2019 revealed the following:

OR#1 - The temperature was documented out of range 15 of 21 days.
OR#2 - The temperature was documented out of range 16 of 21 days.
Procedure Room #2 - The temperature was documented out of range 6 of 21 days.


Review of the Temperature Log for April 2019 revealed the following:

OR #1 - The temperature was documented out of range 15 of 21 days.
OR #2 - The temperature was documented out of range 19 of 21 days.
Procedure Room #2 - The temperature was documented out of range 15 of 21 days.


Review of the Temperature Log for May 1-9, 2019 revealed the following:

OR #1 - The temperature was documented out of range 6 of 7 days.
OR #2 - The temperature was documented out of range 7 of 7 days.
Procedure Room #2 - The temperature was documented out of range 6 of 7 days.

Staff #6 confirmed the findings.


An interview was conducted with Staff #6 on 5/9/2019 after 9:30 AM. Staff #6 was asked what guidelines the operating room followed. Staff #6 said, "We follow AORN guidelines and recommendations." Staff #6 was asked to provide a current policy on temperature and humidity ranges for the surgical services are. Staff #6 said, "We do not have a specific policy in our department for the temperature and humidity ranges."

Review of the AORN Perioperative Standards and Recommended Practices,

"...Temperature should be maintained between 68 degrees F to 75 degrees Fahrenheit (20 degrees to 23 C) within the operating room suite. General work areas in sterile processing should be maintained between 68 degrees to 73 degrees F.

Relative humidity should be maintained between 20% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, instrument processing areas, and sterilizing areas and should be maintained below 60% in sterile storage areas.

Low humidity increases the risk of electro static charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed.

Humidity should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system.

Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system."




Humble Emergency Department

A tour was conducted on 5/7/19 at 9:00AM at the Hospital Out Patient Department (HOPD) in Humble, Texas. The following items were found:

The mattress in the triage room was soiled with a heavy sticky substance.

Clean biohazard supplies were stored with dirty biohazard materials.

Frozen dinners found in the freezer was found to have no expiration dates.

In the Lab and Sonogram room employee items (back packs, purses ect.) were found stored in the same cabinet as medical supplies.

Biohazard trash was found in clean patient rooms.

In exam room 5 the metal trash can was broken and rusted. The bed spread had a rough surface and long black hairs were stuck to the spread. The bed was soiled underneath the mattress with dust and hair.

A Broselow Pediatric Resuscitation Bag had 2 McGill forceps. The forceps were laying open in the bag and had not been sterilized.





TEH failed to maintain a sanitary environment in 5 of 5 areas, Dietary department, Emergency Department negative pressure room, Emergency department crash cart, Medication room in the Emergency Department. and a laboratory draw station for outpatient use, in the Emergency Department.

Dietary Department:

On the afternoon of 5/6/2019 a tour of the dietary department identified the following:

A newly hired staff member was observed working at the three compartment sink. The sanitation rinse sink was observed with water 3/4 of the way full. Staff #26 was asked where the litmus strips were to test the sanitation solution strength. The strips were produced and a small piece was removed and dipped into the water. Staff #26 was asked how long he left the strip in the rinse before lifting and comparing the color of the strip tape to the color chart provided by the manufacturer. She stated 10 seconds. Observation of the work area did not locate a timer. Staff #26, the Dietary Director confirmed the staff counted off 10 seconds.

A new test strip was dipped for 10 seconds (counted out) and compared to the color chart provided by the manufacturer. The color indicated 150 parts per minim (ppm), rather than the 200 ppm recommended by the manufacture of the sanitizing solution. The color was confirmed by the Dietary Director.

After review of the educational material provided by the management company representative, staff #31 confirmed the desired sanitation strength should read 200-400 ppm. The sanitation rinse was not of sufficient strength to provide effective rinse of kitchen cooking utensils against residual bacteria.

Review of the dietary policy did not identify a policy or procedure established by the facility for manual washing, rinsing and sanitizing pots and pans used in preparing patient nutritional needs. An educational plan with teaching, and testing was provided by staff #31. The management company provided printed educational material which indicated the desired strength of the sanitizing solution should be 200 ppm. If the water was cool the rinse should last 1 full minute. If hot water was used the rinse could be reduced to 30 seconds. No sanitation log was provided for review and no timer was available for use.

This was confirmed by staff #26.


Emergency Department (ED):

On 5/7/2019 during a tour of the ED, staff #33 identified room #9 as the negative pressure room. This room would be used to house a patient with a contagious air born disease such as Tuberculosis. The room had 1 door into an ante room, preceding entry into the actual patient care room. The ante room demonstrated negative pressure when tested with a piece of tissue laid on the floor. The room's negative pressure pulled the tissue into the ante room. However, the patient room had a second doorway which exited directly into the common hallway immediately across from the nurses station. A piece of tissue which was rested on the floor outside this second exit did not demonstrate negative pressure. The tissue was forced back and away from the door into the common hallway.

This was confirmed by staff #33.


Medication room:

The medication storage and preparation room used by the ED nurses was identified to have 2 pieces of equipment available for crushing medications for ease of swallowing and 1 piece of equipment used for cutting patient medication into a fractionalized dose. All three pieces were observed with powdered residue of white and brown coloring. One of the 2 pill crusher was affixed to the counter top and was visibly soiled. This was witnessed and confirmed by staff #33.


Crash Cart ED:

The crash cart identified in the ED was observed to contain
1. A 10 cc syringe of normal saline was identified in drawer #1, the expiration date was 11/2018.
2. A long dark human hair was identified in drawer #4
3. 1 green top blood collection tube expiration date of 4/30/2019
4. One purple top blood collection tube expiration date of 3/31/2019

Lab:

Draw station outside of the ED
1. 14 micro tubes used for blood collection expired 4/30/2019