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.

Based on observation, record review, and interview, the facility failed to:

A. ensure Licensed Vocational Nurses and Patient Care Technicians were practicing within their scope of practice as required by the Texas Board of Nursing Nurse Practice Act.

B. ensure the pickup wands in the jugs of dialysate and bicarbonate were secured in the jugs while the patient was receiving dialysis treatment.

Findings include:

A. A review of the facility policy titled "LVN and PCT Role in the Inpatient Dialysis Setting," revealed under "Process or Procedures: D 2 - LVN.LPN Role in Dialysis; k - Access vascular hemodialysis devices (no performance of CVC access or care.) and D 3 - PCT/CCHT Role in Dialysis; b - The CCHT may access a vascular device if competency has been validated (no CVC access or care). The PCT may not access a vascular device."

A review of the Texas Nurse Practice Act revealed no provision to allow LVN (Licensed Vocational Nurses) and PCT/CCHT (Patient Care Technicians/ Certified Clinical Hemodialysis Technician) to be delegated the task of accessing dialysis vascular devices, such as, arteriovenous fistula (AV Fistula), arteriovenous grafts (AV Graft), and central venous catheters (CVC), in an acute care setting such as inpatient hemodialysis in hospitals. Only a Registered Nurse may access a vascular device used for hemodialysis in an acute inpatient hospital dialysis setting.

An interview with Staff #2 and Staff # 13 on 12/14/2021 at 10:00 AM confirmed the above findings.

B. During a tour of the acute dialysis unit on 12/13/2021 at 11:00 AM, acid and bicarbonate pick-up wands were observed unsecured in the jugs, leaving the jugs open. This practice of not securing the pickup wands in the bicarbonate and acid used for patient dialysis, allows for the possible contamination of the acid with blood, dust, and/or dirt.

This deficient practice allowed for cross contamination and acid spills from the acid jug. While, acid concentrate is not susceptible to bacteria contamination, every effort should be made to keep the system closed to prevent nonbacterial contamination and evaporation per the ANSI/AAMI [American National Standards Institute/Association of the Advancement of Medical Instrumentation Standards of 2017] standards.

An interview with Staff # 13 on 12/13/2021 at 11:15 AM confirmed the above findings.

Based on document review and interview the facility failed to follow their own policy and ensure that 2 (Patient #12 and #14) of 4 patients were assessed/evaluated by a Registered Nurse after a fall in the facility.

This deficient practice had the likelihood to cause harm in all patients that had a fall in the facility.

Findings include:

Patient #12

A chart review was conducted with Staff #24 on 12/13/2021 at 1:05 PM. The following was confirmed:

Patient #12 was an [AGE]-year-old female admitted to the facility on [DATE] with intractable lower back pain.

A review of the documentation by Staff #25 revealed the Occupational Therapy was completed at 12:37 PM on 7/1/2021. Further review revealed Patient #12 was left sitting in the bedside chair, the call light was within reach, and the chair alarm was on.

There was no documentation within the medical record of the fall until an order was placed by Staff #27 at 2:25 PM for a stat (emergent) Cat Scan of the Head/Brain. Staff #24 stated, "I think the time of the ground level fall was between 2:00 and 3:00 PM.

A review of the Nurses Note dated 7/1/2021 at 6:00 PM by Staff #26 was as follows:

" ...Patient had a fall this afternoon, which I was notified and arrived to the room. Unit Tech and Staff #24 were in the room helping patient get settled in bed with gauze and ice packs to patients left forehead. Stat CT of the brain was ordered per MD. I then proceeded to transport patient to CT and back up to her room after it was done ..." This was 3 hours after the Cat Scan was completed.

A review of the Cat Scan Results at 3:03 PM revealed the patient had a left frontal scalp contusion with a small subarachnoid hemorrhage (brain bleed) A shift assessment, including a neuro assessment by the oncoming nurse was completed at 7:54 PM. This was the first nursing assessment after the patients fall. The patient was transferred to the Neuro ICU (Intensive Care Unit) for monitoring at 10:08 PM.

A review of the nursing head-to-toe assessments flow sheet dated 7/1/2021 did not reveal a post fall assessment was completed. Staff #24 confirmed there was no head-toe-assessment by a Registered Nurse in the medical record after the fall.

Staff #24, #28, and #29 confirmed the findings.

Patient #14

On 12/14/2021 at 9:25 AM Patient #14's medical record was reviewed with Staff #23. The following was revealed:

Patient #14 was a [AGE] year old man admitted to the facility on [DATE] for a Right Rotator Cuff Arthropathy (Shoulder surgery).

A review of the event record dated 12/7/2021 was as follows:

" ...Date of Event: 12/6/2021. Event Time: 23:35 (11:35 PM)
Described Event/Concern: Pt. fell in his room. He was found on the floor by the unit tech. He was not injured just confused. Call light was within reach and bed on low setting ..."

Staff #23 confirmed there was no documentation in the medical record of a fall. Staff #23 also confirmed there was no Registered Nurse head-toe-assessment after the fall.

Staff #23 and Staff #24 confirmed the findings.

A review of the facility policy titled, "Fall Prevention Protocol", Reference Number 8705-0001a with an effective date of 8/03/2020 was as follows:

" ...VI. Interventions:
D. Post Fall Management
1. Immediately following a fall, initiate the post fall response and documentation.
CTMF: After a fall the Registered Nurse should complete a head-to-toe assessment. Details of the event should be documented in the medical record ..."