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.

METHODIST DALLAS MEDICAL CENTER 1441 NORTH BECKLEY AVENUE DALLAS, TX 75203 Sept. 27, 2011
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, interview, and record review, the facility did not ensure the infection control policies were implemented and enforced. Infection control practices were not adhered to by the physician, registered nurses, and other personnel for 3 of 12 patient care areas throughout the facility (Main OR (operating room), Day Surgery Pavilion OR, & Transplant/ Renal floor).

Findings included:

1. Numerous staff including a physician did not don on surgical masks appropriately;
2. Numerous nursing staff and other personnel did not perform proper hand hygiene practices;
3. Aseptic technique was not adhered to; and
4. Used personal protective equipment (PPE) was worn outside the surgical suite.

Cross refer to Tag A 0749
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview, and record review, the infection control officer did not implement and enforce the hospital's policies and did not collaborate with individuals administratively and clinically responsible for inpatient and outpatient services. Infection control practices were not adhered to by physician, RNs (Registered Nurses), and other personnel, citing:
A. 2 of 2 OR units (operating room) (Main OR & the Day Surgery Pavilion OR); and
B. 2 of 2 RNs (registered nurses) (Personnel #56 and #64) in the transplant/ renal floor.

Findings included:

A. During a tour on 09/20/11 at 10:25 AM in postoperative area (PACU) of the Main OR (operating room), with Personnel #4, #31, #37, #46, and Physician #38, the surveyor observed a female staff (Personnel #39) with gloves on who was disinfecting a piece of equipment called a "cell saver." After cleaning the equipment, she took off her soiled pair of gloves, touched the equipment with her bare hands, and rolled the equipment out of the PACU area. She did not wash her hands or apply alcohol rub after taking off the soiled gloves. At 10:30 AM, the Director of Surgical Services (Personnel #37) and the Nurse Manager of the preoperative and PACU of the Main OR (Personnel #46) were informed of the above findings. Personnel #37 and #46 confirmed the staff should have performed hand hygiene after taking off the gloves.

The tour continued to the preoperative area of the Main OR with Personnel #4, #31, #37, #46, and Physician #38. At 11:10 AM, the surveyor went to room 22 and observed RN (Personnel #40) wrapped the bell portion of her personal stethoscope with a glove & proceeded in performing a lung sound assessment on Patient #34. Personnel #40 then threw the soiled gloves in the trash and continued direct patient care. Personnel #40 did not disinfect her stethoscope and used it with the next patient. At 11:18 AM, Personnel #31 and #37 were informed of the findings and confirmed Personnel #40 should have disinfected her stethoscope prior to delivering care to the next patient.

The tour continued to the restricted area of the Main OR at 1:20 PM on 09/20/11 with Personnel #4, #31, #37, and Physician #38. While inside OR #3, the surveyor observed the CRNA (Certified Registered Nurse Anesthetist) (Personnel #57) did not properly don on the surgical mask. The lower strings of the surgical mask were tied loosely. At approximately 1:25 PM, Personnel #37 was informed of the findings and confirmed masks should be worn in a tight manner to prevent air leak as per their policy. At 1:45 PM, the surveyor was in OR #10 with Personnel #4, #31, #37, and Physician #38. The surveyor observed Physician #38's surgical mask was improperly tied; its lower strings were tied loosely. The surveyor informed Physician #38. At 2:36 PM, the surveyor was in OR #4 with Personnel #4, #31, #37, and Physician #38. The circulator requested carbon dioxide portable tanks. Personnel #37 ran out to obtain the tanks. When Personnel #37 returned to the room, the surveyor observed the surgical mask's upper strings were not tied at all. The surveyor immediately informed Physician #38 who subsequently informed Personnel #37 to tie the surgical mask appropriately.

In an interview on 09/20/11 at approximately 3:20 PM, Personnel #4 was asked to provide the facility's policy with regard to the proper way of donning a surgical mask. Personnel #4 stated the facility had adopted "Mosby's Nursing Skills Book." A print out copy of the Mosby's Nursing Skills on "Donning" surgical mask was provided to the surveyor. The printout indicated that surgical masks with ties should be secured to prevent air leaks.

On 09/22/11 at 9:00 AM on the way to Day Surgery Pavilion OR for a tour with Personnel #31, the surveyor observed a male personnel wearing a disposable bright reddish bouffant (head covering) walking the opposite way. As soon as the male personnel saw the surveyor, he took off his bouffant. At approximately 9:34 AM, Personnel #31 was informed of the findings and stated he also observed the male personnel wearing the bouffant.

At 9:15 AM, the surveyor observed the cleaning of OR #3 after it was used by a patient. Personnel #52 removed his soiled gloves after disinfecting the bed and other OR equipment. Personnel #52 did not wash his hands or apply alcohol rub. He placed another pair of clean gloves on and continued to disinfect the OR tables and other equipment. Personnel #52 took off the soiled gloves and did not perform hand hygiene. The OR RN (Personnel #55) and the OR Technician (Personnel #53) who assisted in cleaning OR #3 did not perform hand hygiene after taking off their gloves at 9:18 AM and 9:19 AM respectively.

At 9:17 AM, the surveyor observed Personnel #53 disinfecting the IV pole (intravenous) with wheels. Using the same disinfectant cloth, she wiped the pole from top to bottom, the wheels, and then again wiped the bottom to the top of the pole. At 9:35 AM, Personnel #31, #37, #48, and Physician #38 were informed of the above findings. All four personnel confirmed the staff did not adhere to the facility's infection control practices and guidelines.

B. During a tour of the transplant/ renal floor on 09/22/11 at 9:50 AM with Personnel #31 and #58, the surveyor observed RN (Personnel #56) checking several medications in the medication room. Personnel #56 was asked what she was doing. Personnel #56 responded she was checking the patients' medications with the computerized MAR (medication administration record). Personnel #56 was asked for the patients' names and replied Patient #43 and #44. Personnel #56 was observed putting Patient #44's medications in her right pocket where she had her personal items. The medications consisted of "Sandostatin 1 ml injectable vial (for diarrhea) & Lisinopril pill (for hypertension)." Personnel #56 was asked if this was a common practice to get multiple patients' medications and put the medications in her pocket. Personnel #58 who was present during the tour, replied this was not the practice and it was against facility policy.

In an interview on 09/22/11 at approximately 2:00 PM and on 10/03/11 at approximately 1:00 PM via phone, the Director of Infection Control (Personnel #21), Personnel #65, and Personnel #66 were asked if they performed hospital surveillance for hand hygiene. Personnel #21 replied she and the other infection control preventionists (Personnel #65 and #66) do not perform the surveillance but depend on the department managers and other administrative staff to conduct the surveillance. Personnel #21 stated they (Personnel #65, #66, and herself) received the results (percentage wise) from the surveillance provided by each department. Personnel #21 was asked if she and the other infection control preventionists (Personnel #65 and #66) monitor compliance for infection control practices in cleaning ORs in between cases. Personnel #21 replied they do not and only the "OR department do the audits." The surveyor informed Personnel #21 that an RN was observed putting patient medications in her pocket along with her personal items. She was asked for her opinion on this matter being the Director of Infection Control. Personnel #21 stated that this was not the "best practice."

On a tour on 09/22/11 at 11:40 AM, the surveyor observed a "Contact Precautions" sign on the door of Patient #45's room. A Patient Care Technician (PCT-Personnel #63) and the surveyor donned personal protective equipment (PPE) and entered the room. Upon entering the room, the surveyor observed the patient's wife who was not wearing PPE and was feeding Patient #45. RN (Personnel #64) was performing wound care to Patient #45's left leg. The surveyor confirmed with the PCT the patient was in "Contact" isolation and the patient's wife was not wearing PPE. The PCT brought to the attention of the patient's wife that "Contact Precautions" was being observed with the patient, and asked her to put on a gown and gloves while in the room. The surveyor observed the RN obtain a box of gloves from the PCT. The RN removed a pair of gloves, and then placed the box of gloves on the mattress, at the foot of the patient's bed. The surveyor observed the RN retrieve a roll of cling gauze and a bottle of Dakin's solution from the window sill of the open window in the patient's room. The RN opened the container of Dakin's solution, and poured it over the gauze while holding it over the trash can in the patent's room. The patient's wife pointed out to the RN that other RN's usually poured the Dakin's solution over the gauze while it was still in the original package. The RN placed the open bottle of Dakin's solution on the window sill. The RN, with the assistance of the PCT, wrapped the patient's leg, from the thigh to the foot with the cling, and then wrapped the patient's leg in a clean chux pad (an absorbent blue under pad).

The surveyor observed as items on the window sill, used for wound care and to change the dressing, began to get wet from the rain and blew off the window sill and onto the floor. The RN removed his contaminated gloves, sanitized his hands, and put on a pair of gloves from the box of gloves at the foot of the patient's bed. The RN retrieved scissors from the window sill and began to cut the dressing from the patient's right leg, and placed the contaminated scissors on the patient's bed. The RN did not remove the contaminated dressing from the bed. The RN sprayed saline solution on the wounds of Patient #45's right leg. The RN used his contaminated gloved hands to retrieve a container of gauze from the drawer of the night stand. The RN removed the contaminated gloves, sanitized his hands, and donned gloves from the box of gloves at the foot of the patient's bed. The RN opened the container of gauze and dried the saline solution on the patient's leg. The RN went to the window sill and retrieved the Santyl ointment and applied it to the patient's leg. The RN removed the contaminated gloves, sanitized his hands, and retrieved gloves from the box of gloves at the foot of the patient's bed. The RN retrieved the open bottle of Dakin's solution from the window sill and poured it over the gauze while still in it's package. With the assistance of the PCT, the RN wrapped the patient's leg, from the thigh to the foot with the gauze, and then wrapped the patient's leg in a clean chux pad. The RN gathered the contaminated dressing and put it in the trash can. The RN used his contaminated gloved hand to place the contaminated scissors in the right pocket of his pants. After removing all PPE's, the surveyor, RN, and PCT went outside of the room and met the Nurse Manager (Personnel #58). The surveyor asked the RN about using the window sill as a work surface. The RN stated the patient's lunch tray was on the bedside table and the patient's wife started feeding the patient before the dressing change. The RN stated he did not have another surface to set up the supplies for the dressing change. The surveyor asked the RN if he had a copy of the physician's order for the dressing change. He stated it was in the patient's room in his bag. The RN opened the door of the patient's room, knelt down and retrieved his fanny pack from the floor, where it lay during the wound care and dressing change.

On 09/22/11 at 3:10 PM, in an interview with the RN and the Nurse Manager (Personnel #64 and #58), the RN stated he does not perform wound care and dressing changes very often. The RN and Nurse Manager confirmed that there were breaks in infection control during the wound care and dressing change.

On 09/21/11 at 11:40 AM, during a tour and observation of the the Transplantation/Renal floor, specifically in the Hemodialysis unit, the surveyor observed RN (Personnel #67) disinfect a scale chair, used for weighing patients. The RN opened the lid of the linen receptacle and disposed of the towel used to disinfect the chair. The RN did not remove the contaminated gloves and sanitize her hands. The RN used her contaminated gloved hands to adjust the patient's blanket and blood pressure cuff.

On 09/21/11 at 11:40 AM, during an interview with the Nurse Manager (Personnel #62) at the time of the observation, she confirmed the above findings.

On 9/22/11 at approximately 02:30 PM, the Infection Control Team stated the facility used Mosby's Nursing Skills Dry and Moist-to-Dry Dressing Quicksheet Comprehensive clinical review: January 2010 as a guide to educating the nurses.

The Quicksheet included:
"6. Place disposable waterproof bag within reach of work area. Fold top of bag to make a cuff. 10. Fold dressing with drainage contained inside, and remove gloves inside out. With small dressings, remove gloves inside out over the dressing. Discard gloves and soiled dressing in a proper trash receptacle. Perform hand hygiene and apply clean gloves.
13. Create a sterile field with a sterile dressing tray or individually wrapped sterile supplies on an overbed table. Pour any prescribed solution into sterile basin. 14. Cleanse wound.
a. Apply clean gloves...b. Clean from least contaminated area to most contaminated...15. Use dry gauze to blot wound dry, blotting from least contaminated area to most contaminated.
17. Apply dressing...b. Moist-to-dry dressing. i. Remove gloves and perform hand hygiene. Apply sterile gloves. ii. Place fine mesh gauze in container of prescribed sterile solution. Wring out excess solution.19. Discard used supplies, remove personal protective equipment, and perform hand hygiene..."

Policy # IC 127: "Hand Hygiene" effective 10/30/10 required "1. All individuals will perform hand hygiene...G. Before...and after removing gloves...Guidelines...4. Compliance Monitoring: A. Monitoring for compliance with hand hygiene practices is done routinely by the Infection Control department...Attachment A...Hand Hygiene Compliance Monitoring Plan...Purpose...the Infection Control Department will monitor hand hygiene practices in all clinical areas on a regular basis...Methodology...2. Data will be collected by MHS ICPs (Infection Control Preventionists) on a regular basis including: A. On weekly...rounds, B. On daily rounds in clinical areas..."

Policy IC 171: "Surgical Attire..." effective 09/06/11 required "...appropriate personal protective equipment (PPE) are worn...within the perioperative environment...Procedure...3. Caps...should be removed when leaving the surgical suite..."

Policy: Hospital Infection Prevention & Control (IP&C) Program Plan" effective 06/30/11 required "III Scope of Practice...2...Surveillance is a critical component of the program...IV 6. Shared Responsibilities for the IP&C Program...C. Healthcare Worker Responsibilities: all healthcare workers... will 1) adhere to hand hygiene...established by the CDC (Centers for Disease Control & Prevention) and organizational policies...V. Risk Assessment...1...D. Risk factors are identified...4) Compliance with infection prevention and control policies and procedures...VI. Priorities and Goals...A. Prevent and/or reduce the Risk of Infections...1) Identifying and preventing the occurrences of healthcare-associated infections by pursuing sound infection control practices such as hand hygiene, aseptic technique...5) Complying with current standards, guidelines, and applicable local, state, and federal regulations..."

The "Plan for the Provision of Patient Care FY 2011," no date, reflected, "Using collaborative approach...the Infection Prevention and Control department analyzes surveillance data and provides guidance for process improvement. Surveillance data is gathered by Infection Preventionists and reported to appropriate...administration, and hospital staff on an ongoing basis."

The "Plan for the Provision of Patient Care FY 2011," no date, reflected "Nursing Administration is staffed with...Wound Care Specialist..."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, and record review, the RN (Registered Nurse) did not supervise and evaluate the nursing care for each patient and assign nursing care to other nursing personnel as needed, in that:
A. Multiple patients were unattended;
B. Multiple patients were being taken cared of by one nurse; and
C. Medications were prepared for more than one patient at a time.

Cross Refer to A 0395
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 RN (Registered Nurse) did not supervise and evaluate the nursing care for each patient and assign nursing care to other nursing personnel as needed, citing:
A. 2 of 3 patients (Patient #36 and #37) in the PACU (postoperative anesthesia care unit) of the Day Surgery Pavilion OR (operating room) were left unattended by the nurses.
B. 3 of 3 patients (Patient #40, #41, and #42) in the GI (gastrointestinal) postoperative unit had one nurse caring for them at the same time;
C. 2 of 2 patients (Patient #43 and #44) in the transplant/renal unit had medications prepared by a nurse at the same time.

Findings included:

A. During a tour on 09/21/11 at 10:49 AM in the PACU of the Day Surgery Pavilion OR with Personnel #31, #37, #48, and Physician #38, the surveyor observed 2 patients in the PACU (Patient #36 and #37). Personnel #47 took care of Patient #36 and Personnel #49 took care of Patient #37.

Patient #36 was a [AGE] year old male patient who underwent "right inguinal hernia repair" under general anesthesia. At approximately 11:07 AM, the surveyor observed that all the PACU bays (a total of 7) did not have a nurse call button for the patient to use if he or she needed nurse assistance. At approximately 11:08 AM, a third patient was brought in the PACU and was situated in the bay next to Patient #36. Personnel #47 then left her patient and proceeded to help the other PACU nurse in the next bay. Patient #36 was left unattended for approximately 10 minutes, without a nurse call button in his possession, and prior to anesthesiologist's evaluation for discharge from the PACU.

In an interview on 09/21/11 at approximately 11:20 AM, Personnel #47 was asked why she left her patient unattended without notifying the other RN. Personnel #47 did not give an explanation and asked the surveyor if it was all right "not to help the other nurse from now on."

Patient #37 was a [AGE] year old male who underwent "closed reduction mandible fracture with intermaxillary fixation" under general anesthesia. The patient received "Labetalol" for a total dose of 20 mg for elevated blood pressures. From 10:00 AM to 10:35 AM, the patient received a total dose of 20 mg (milligrams) via IVP (intravenous push). At 11:00 AM, the patient received "Hydralazine" 10 mg via IVP. (Note: according to Wikipedia encyclopedia on-line obtained on 10/03/11 at 3:44 PM, "Labetalol" is for treating high blood pressure. The common side effects include: drowsiness, fatigue, weakness..."Hydralazine is a direct-acting smooth muscle relaxant used to treat hypertension. The common side-effects include: headache, nausea/ vomiting, compensatory tachycardia...")

On 09/21/11 at approximately 11:23 AM, the surveyor observed the PACU RN left Patient #37 unattended for about 7 minutes without a nurse call button in his possession and prior to anesthesiologist evaluation for discharge from the PACU. In an interview at approximately 11:31 AM, Personnel #49 was asked why she left her patient unattended. Personnel #49 replied she went to "get a report."

In an interview on 09/21/11 at 11:25 AM, Personnel #37 was asked why there were no available nurse call buttons in the PACU bays. Personnel #37 stated it was not necessary to have the nurse call button since the PACU nurse was always with the patient. Note: Two of the PACU nurses (Personnel #47 and #49) left their patients unattended. There was risk for potential patient injury during the nurses' absence.

The policy: "Handoff Communication" effective 04/30/11 required "Guidelines...5. Handoff communication occurs in various settings...C. Temporary absence from patient care assignment (example: staff meal breaks)..."

B. The tour continued to the GI patient care area with Personnel #31 and Physician #38. On 09/21/11 at approximately 11:43 AM, the surveyor observed that there were 2 patients (Patient #40 and #41) in the postoperative area. Patient #40 was a [AGE] year old male who underwent "colonoscopy" under moderate sedation. He arrived in the postoperative area at 11:42 AM. The surveyor observed there was only one postoperative RN (Personnel #50) who was ready to take report on Patient #40. At 11:45 AM, Patient #42, a [AGE] year old male who underwent a "colonoscopy" procedure under moderate sedation was wheeled into the postoperative area. There were a total of three patients in the postoperative unit who were under the care of one RN. At 11:46 AM Personnel #50 was asked how many RNs were assigned to the GI postoperative unit on this date. She replied that there were two, however the other RN was off the floor and was in training. Personnel #50 was asked how long she was alone in the unit. She replied "about 45 minutes now." Personnel #50 was asked if she called her supervisor and asked for assistance. She replied "no, I can handle it."

In an interview on 09/21/11 at 11:55 AM, the Chief Nursing Officer (CNO) (Personnel #6) was informed of the findings. The CNO stated this was an "unacceptable practice."

C. During a tour in the transplant/ renal floor on 09/22/11 at 9:50 AM with Personnel #31 and #58, the surveyor observed RN (Personnel #56) checking several medications in the medication room. She was asked what she was doing. Personnel #56 responded she was checking the patients' medications with the computerized MAR (medication administration record). She was asked for the patients' names and their medications. She replied "Patient #43 and #44." She stated Patient #43 had 8 different types of medications and Patient #44 had 2 types of medications. Personnel #56 was asked if this was a common practice to get multiple patients' medications. Personnel #58, the nurse manager, who had been present during the tour, replied that this was not the practice and that it was against facility policy.

Policy: "Medication Handling and Administration" effective 09/19/11 required "Guidelines: 1. Safe Medication Management...F. Only one individual patient's medications should be retrieved at a time. Medications should be administered immediately and documentation of administration of medications should be completed before obtaining other patients' medications."

The "Plan for the Provision of Patient Care FY 2011," no date, page 8, 9, required "Nursing Services...The MHS Nursing profession upholds...mission, vision, and values by adgering to the Nursing: Mission: We are committed...which nurses provide the best care to every patient, every day...Assignment of authority and Responsibility...Chief Nursing Officer is responsible for...implementation...to provide nursing care, treatment, & services, implementation of...policies & procedures that address...patient...and needs are identified, met, & evaluated...Assuring there is sufficient number of qualified nursing staff to provide nursing care, treatment, & service...Staff Availability...Supervisor reviews the staffing requirement for the nursing departments and assists in meeting the staffing needs..."
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on observation, interview, and record review, the hospital failed to ensure the medical records for 1 of 1 patient (Patient #53) were complete and accurately written.

Findings included:

On 09/21/11 at 12:00 PM, a review of Patient #53's Hemodialysis record reflected the treatment record included contradictory labeling. The 09/21/11 treatment record did not include the actual concentration level results of the total/free chloramine test. The treatment record included in the Machine Assessment section that the result of the total/free chlorine/chloramine test was recorded as "negative."

During an interview on 09/21/11 at 12:15 PM, the Nurse Manager (Personnel #62), confirmed the record was contradictory, and the maximum allowable concentration of total/free chlorine/chloramines is 0.1 mg/L.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation, interview, and record review, the facility did not ensure expired supplies were maintained for safety and quality, in that, 3 of 4 areas surveyed in the Radiology department (Diagnostics, Nuclear Medicine and Interventional Radiology), had one (1) expired spinal needle, twenty-five (25) expired angiocath needles, and forty-six (46) expired insulin syringes available for patient use.

Findings Included:

During a tour of the Radiology department between 9:35 A.M. and 11:00 A.M. on 09/19/11 with the Radiology Nurse Manager (Personnel #59), the surveyor observed the following expired supplies available for patient use in the following patient care areas:

Regular Diagnostics in Main Radiology, Room # 5:
1 - 25 gauge spinal needle, expired 07/11.
1 - 18 gauge angiocath needle, expired 07/11.

Nuclear Medicine, Hot Lab Room:
15 - 18 gauge angiocaths, expired 10/09.
1 - 20 gauge angiocath, expired 07/10.
5 - 18 gauge angiocaths, expired 01/11.
1 - 22 gauge angiocath, expired 07/11.

Interventional Radiology, Nurses' Station:
46 - U-100 insulin syringes, expired 08/11.
1 - 18 gauge angiocath, expired 12/10.
1 - 18 gauge angiocath, expired 07/11.

In interviews during a tour between 9:35 A.M. and 11:00 A.M. on 09/19/11 with Personnel #59, she verified the seventy-two (72) supplies were expired, and were available for patient use in the 3 radiology patient care areas.

The facility "Corporate Storeroom/Receiving Service Level Agreement," dated 03/19/09, "details an agreement between this provider and the facility, and describes their general services which includes "expiration dates for supplies within the ...inventory will be monitored on a monthly basis," and "expired/expiring product will be removed and replaced with fresh stock." The agreement did not include monitoring of patient supplies, once delivered to each departmental unit within the facility. When asked, the facility was not able to provide a policy or procedure for maintaining safe (unexpired) supplies once delivered to individual departments.