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.

1. Based on reviews of medical records, observations, and staff interviews University Health System failed to ensure properly executed informed consents were obtained prior to performing surgical procedures specified by List A of the Texas Medical Disclosure Panel.
a. A review of surgical consent forms conducted in the Hospital's main surgical suite at 2:00 p.m. on 1/15/13 and again in the Outpatient Pre-operative suite at 10:30 a.m. on 1/16/13 with staff members P17, P18, and P19 revealed the nursing staff and medical staff failed to utilize surgical consent forms developed and approved for use by the Governing Body to ensure patients and or their guardians were fully informed of specific hazards and risk associated with their scheduled procedure.
b. On 1/15/13 at 1:30 p.m. in the holding area of the main operating suite along with staff members P17, P18, and P19 and again on 1/16/13 at approximately 11:00 a.m. in the outpatient surgical pre-operative area we observed preoperative nursing staff members and physician(s) failed to use consent forms with addendums for procedures requiring full disclosure from List A of the Texas Medical Disclosure Panel. To meet standards the patient would need to provide their initials next to the procedures they were undergoing. Physicians provided their own list of hazards and risks that did not meet or exceed those required by state and federal regulations. The nursing staff failed to ensure the completeness of the forms prior to witnessing and or obtaining the patient ' s signature.
c. During interviews with staff members P17, P18, and P19 conducted on 1/16/13 at 3:45 p.m. in the conference room following their own reviews of the findings they all acknowledged they could not provide evidence of compliance with the requirement of obtaining consent for surgical procedures listed in Texas Medical Disclosure Panel - List A and Policy No 9.02 utilizing Appendix I and Addenda I through VIII on forms approved for use by University Health System.
Based on staff file review and staff interview the facility failed to ensure that patient care was performed by staff whose competencies had been verified in the specific area of care to their patient population.

The findings included:

a. During review of staff files for competency verification on 1/15/13 and 1/16/13 in a conference room of the facility it was noted 6 of 12 staff files reviewed did not have documentation of the verification the staff member was competent to perform the skills necessary to care for the patient population in their department. The discrepancies were noted in staff file (S1, S2, S3, S4, S5, & S6). 6 of 6 staff members did not have documented competency by examination or skills check off for water testing for the reverse osmosis water system being operated and used by the staff in the in patient dialysis unit.

b. During staff interview with (S12, S13, & S4) on 1/15/13 and 1/16/13 in a conference room of the facility each verified I would not find the competency test or skills checklist appropriate to the testing of the water system for the appropriate care of the patients in the in patient dialysis unit. No documentation was provided where discrepancies were found.
Based on review of facility policy and patient records, the facility failed to ensure that informed consent was obtained or informed consent paperwork was completed prior to initiation of hemodialysis, prior to the administration of blood products, and or prior to placement of a hemodialysis catheter.

The Findings Included:

a.Review of (P2) medical records on 1/15/12 at 1:00p.m. in the dialysis treatment room revealed that the patient was completing hemodialysis. Observation and review of treatment flow sheets revealed that the patient received 2 units of PRBC ' s during treatment. Review of the patient ' s medical records revealed that consent for hemodialysis and consent for blood products were not obtained prior to initiation.

Review of (P4)medical records on 1/16/12 at the nurses ' station revealed that at 12:36p.m. on 1/16/12 revealed that the placement of a temporary dialysis catheter was placed at the bedside. Review of the Disclosure and Consent Medical and Surgical procedures revealed that the patient ' s husband signed for consent for a temporary hemodialysis catheter on 1/13/12. Witness and physician signatures on the consent from were blank.

b. Review of policy titled: Blood/Blood Components Management Guideline stated every effort should be made to obtain informed consent exclusive for blood/blood products. Inform the patient of the risks and benefits as well as the possible alternatives to transfusion of blood/blood components.

c. Interview conducted with (S3) on 1/15/12 at 1:25p.m. confirmed that consent was not obtained for (P2) prior to initiation of treatment and or prior to the blood being administered. (S3) stated the nephrologist obtains consent for procedures not the nursing staff.

Interview conducted with (S12) on 1/16/12 at 2:05p.m. at the nurses ' station after her own review of the findings confirmed that the physician did not sign to confirm that he had explained to the patient or legal representative the disclosure and consent required for the placement of the temporary dialysis catheter.
Based on review of equipment disinfection logs, policy review, review of manufacturer recommendations, and staff interview failed to ensure dialysis equipment was disinfected and maintained per manufacturer recommendation.

The findings included:

a. Review of machine disinfection logs on 1/15/13 in the in patient dialysis treatment room revealed 17 of 17 machine disinfection logs had discrepancies noted in disinfection of the machine per manufacturer recommendations and facility policy.
16 of 17 hemodialysis machines did not have bi-weekly diasafe integrity testing documented as per policy titled "Instruction for Completing Machine Disinfection, Diasafe Integrity Test Log". Policy stated " All Fresenius dialysis machine equipped with Diasafe pyrogen filter will be tested on a bi-weekly schedule. Test result must be documented as Passed/Failed."
17 of 17 hemodialysis machine disinfection logs do not indicate whether machine was used for tretment on the specific day or not in use or out of service. Staff has no way to readily verify last time machine was used and if it was disinfected after previous use.
14 of 17 hemodiaysis machine documentation logs did not reveal documentation the machine had been heat disinfected on a daily basis except on the day of disinfection by bleach as per manufacturer recommendation.

b. Interview with (S4) and (S5) on 1/15/13 in the in patient treatment room of the dialysis room revealed if there was no documentation on the log there was no way to know if the procedure was performed and there is no indication on the log to indicate if the machine was not used or out of service on any specific date.