HospitalInspections.org

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

A. establish and enforce data collecting and reporting from the Emergency Department, Surgical Department, and Nursing Department.

B. collect data from the Emergency Department, Surgical Department, and Nursing Department and report to the the facility's Quality/ Safety/ Survey/Readiness (QSSR).

C. maintain a hospital wide reporting and tracking system of all its departments.

A. Review of the "Quality/ Safety/ Survey/Readiness Committee Meeting Minutes Second & Third Quarter" of 2010, dated December 9, 2010, there was no reporting from Emergency Department, Surgical Department, or Nursing Department.

Review of the"Quality/ Safety/ Survey/Readiness Committee Meeting Minutes Fourth Quarter" of 2010, dated March 23, 2011, there was no reporting from Emergency Department, Surgical Department, or Nursing Department.

Interview with Administer and Quality Improvement Director on April 13, 2011 at 4:00 PM confirmed that the Emergency Department, Surgical Department, and Nursing Department had not reported any QAPI data in the last year.

B. Review of the "Quality/ Safety/ Survey/Readiness Committee Meeting Minutes Second & Third Quarter" of 2010, dated December 9, 2010, there was no reporting from Emergency Department, Surgical Department, or Nursing Department.

Review of the "Quality/ Safety/ Survey/Readiness Committee Meeting Minutes Fourth Quarter" of 2010, dated March 23, 2011, there was no reporting from Emergency Department, Surgical Department, or Nursing Department.

Interviewed Quality Improvement Director on April 13, 2011 at 4:00 PM, confirmed that the Emergency Department, Surgical Department, and Nursing Department had not collected any data and reported to the Quality/ Safety/ Survey/Readiness (QSSR) Committee. Further interview established that the (QSSR) is the Quality Assurance Performance Improvement (QAPI).

C. Review of the Fire Extinguishers Logs for the years 2011 revealed that the portable fire extinguishers checks were not conducted for the months of February or March of 2011.

Review of the Fire Drill Logs for the years 2009 revealed that only 9 of 12 required fire drills were done.

Review of the Fire Drill Logs for the years 2010 revealed that only 1 of 12 required fire drills were done.

Review of the Fire Drill Logs for the years 2011 revealed that none of 12 required fire drills were done.

Review of the Look Back Records (records of recipients who have received blood from donors that test positive for exposure to communicable diseases) on 04/13/2011 at 12:30 in the Lab Directors office revealed a recipient had received possible contaminated blood on 1/29/01. The Lab Director received a Look Back request from the blood center on 03/25/10. The Lab Director reviewed the medical record that revealed the recipient had died. The lab director recorded " Patient expired " on the Look Back Record. No other follow up was done.

Review of the Authority Statement Policy # EOC-103, revealed " The Governing Body of ETMC-Mt. Vernon delegates responsibility of the Environment of Care program to the Safety/ Risk Management, Infection Control Committee in conjunction with the Safety Officer and the hospital Administrator. "

Review of the Environmental Survey Rounds Policy # EOC-106, revealed " Quarterly environmental rounds will be conducted by the Safety/Risk Management/Infection
Control Committee to assess and inspect the facility for compliance and deficiencies in the areas of facility condition, life safety, security, emergency preparedness, electrical safety, utility systems and infection control. "

Review of the Environment of Care Management Plan Policy # EOC-105, revealed " Responsibility: The Safety/Risk Management/Infection Control Committee is responsible for designing, implementing, education and evaluating the Plan. "

Interview with the interim Safety Officer/Administrator on 4/13/2011 at 0930 in the Conference room confirmed that the required 12 fire drills for the years of 2009 and 2010 had not been conducted and no drills for the first quarter of 2011 had been conducted. Inspection of the portable fire extinguisher for February or March of 2011 had not been conducted nor had the annual disaster drill for 2010 been conducted. Further interview with the Safety Officer/Administrator confirmed that the Safety/Risk Management/Infection Control Committee was the same as the Quality Safety Survey Readiness Committee (QSSR).

Interview with the Quality Improvement (QI) Director in the QI office on 4/12/2011 at 1:45PM confirmed that the required 12 fire drills for the years of 2009 and 2010 had not been conducted and no drills for the first quarter of 2011 had been conducted. Inspection of the portable fire extinguisher for February or March of 2011 had not been conducted nor had the annual disaster drill for 2010 been conducted. Further interview with the Quality Improvement (QI) Director confirmed that the Safety/Risk Management/Infection Control Committee was the same as the Quality Safety Survey Readiness Committee (QSSR).

Based on record review and interview the facility failed to ensure that documentation of Advance Directives were provided to patient, with acknowledgment of type of Advance Directive, and date that patient and/or witness signed document. Citing 10 of 23 medical records reviewed.

Findings: East Texas Medical Center(ETMC) Mt. Vernon policy:
Subject: Advanced Directives
Department: Health Information management
Policy #: 980.4.1 Reviewed: 7/2009
"Advance Directives provided by patients and patient families will be kept on file in the Health Information(HIM) Department and made available on the record each time the patient is admitted to the hospital.
Procedure: 1. An alphabetical Advanced Directive file will be maintained in the HIM department containing copies of all Advanced Directives, Durable Power of Attorney and/or Directives to Physician that have been provided to the hospital by patients and/or their families.
2. When a patient is admitted and nursing services or physician requests a copy be placed on the patient's current chart, the file will be checked and if found, a copy wilt be sent to the patient current chart at the nursing station.
3. If none is found in the file, the patient medical record in permanent file wilt be checked for any directive. If located, it will be copied for the Advanced Directive file in the HIM department and also for the current chart at the nursing station.
4. The copies in the Advanced Directives file in the HIM department will never leave the file except to be copied for placement on a current chart at the nursing station."

Review of patient medical records on 4/12/2011 and 4/13/2011 in the conference room revealed:
1. Review of medical record for patient #7 on 4/12/2011 revealed no documentation that Advance Directives were given to the patient and no date documented when document and/or information were witnessed.
2. Review of medical record for patient #8 on 4/12/2011 revealed no documentation that Advance Directives were given to the patient and no date documented when document and/or information was reviewed and signed by the patient.
3. Review of medical record for patient #9 on 4/12/2011 revealed no documentation of the types of Advance Directives chosen by patient and no documentation of the date that document and/or information were witnessed.
4. Review of medical record for patient #13 on 4/13/2011 revealed no documentation that Advance Directives were given to patient and/or the types of Advance Directives chosen by patient. Also no documentation of the date that document and/or information were signed by patient and witness.
5. Review of medical record for patient #14 on 4/13/2011 revealed no documentation of the types of Advance Directives chosen by patient and no documentation of the date that document and/or information were signed by patient and/or witness.
6. Review of medical record for patient #15 on 4/13/2011 revealed no documentation that written information on Advanced Directives and/or the types of Advance Directives was given to the patient.
7. Review of medical record for patient #16 on 4/13/2011 revealed no documentation that written information on Advanced Directives and/or types of Advance Directives was given to patient.
8. Review of medical record for patient #18 on 4/12/2011 revealed no documentation of the types of Advance Directives chosen by patient and no documentation of the date that document was signed by patient and/or witness.
9. Review of medical record for patient #19 on 4/13/2011 revealed no documentation of the types of Advance Directives chosen by patient and no documentation of the date that document and/or information was signed by patient and/or witness.
10. Review of medical record for patient #22 on 4/13/2011 revealed no documentation that written information on Advanced Directive was made available to patient and/or responsible party and no documentation of type of Advance Directive chosen by patient and/or responsible party.

Interview with Medical Records Director on 4/13/2011 confirmed that documentation of Advanced Directives was not complete per hospital policy.

A. Based on record review and interview with the Lab Director the facility failed to follow up on a critical blood transfusion.

B. the facility failed to conduct the required monthly portable fire extinguishers checks.

C. the facility failed to conduct the required annual disaster drill for 2010.

A. Review of the Look Back Records (records of recipients who have received blood from donors that test positive for exposure to communicable diseases) on 04/13/2011 at 12:30 in the Directors office revealed a recipient that received possible contaminated blood 1/29/01. The Lab Director received a Look Back request from the blood center on 03/25/10. The Lab Director reviewed the medical record that revealed the recipient had died. The lab director recorded " Patient expired " on the Look Back Record. No other follow up was done.

Review of the Blood Bank Look Back Policy revealed " When notified by Carter BloodCare of a look back recipient the lab supervisor will immediately review blood bank records to determine what patient received the component. The patient ' s attending physician will be notified of the possible exposure and has the responsibility to follow up with the patient. If the patient ' s attending physician is unable to contact the patient, the lab manager will attempt to notify the patient or responsible individual at least three times to contact a physician for follow up testing. The lab manger will document in the patient records all attempts to contact the patient as well as any conversations with the patient and any follow up testing. If the patient is deceased the legal representative of the patient will be notified. All records will be reviewed by the medical director of the laboratory and Carter BloodCare will be notified of the results of the procedure. "

Interview with the Lab Director on 04/13/2011 at 12:30 in the Directors office confirmed the only follow up on the Look Back Record was the review of the medical record, confirming the death of the patient and recording the " patient expired " .


B. Review of the Fire Extinguishers Logs for the years 2011 revealed that the portable fire extinguishers checks were not conducted for the months of February or March.

Review of the Life Safety Management Plan, Policy # EOC-701, Procedure " Managing portable fire extinguisher, including monthly inspection and an annual inspection by an out side agency. "

Observation of 5 of 5 portable fire extinguishers revealed that January was the last month extinguishers were checked.

Interview with the interim Plant Operation Supervisor on 4/12/2011 at 1:00PM in the Conference room confirmed that the required monthly portable fire extinguishers checks were not conducted for the months of February or March of 2011.

Interview with the interim Safety Officer/Administrator on 4/13/2011 at 0930 in the Conference room confirmed that the required monthly portable fire extinguishers checks were not conducted for the months of February or March of 2010.

Interview with the Quality Improvement (QI) Director in the QI office on 4/12/2011 at 1:45PM confirmed no monthly portable fire extinguishers checks were conducted or reported to the Quality Safety Survey Readiness Committee (QSSR) for the months of February or March of 2011.

C. Review of the Emergency Management Plan, Policy # EOC-403 reveled " The Emergency Management Plan is tested and inspected through drills, surveys, and real life and/or simulated disasters. The Safety/Risk Management/Infection Control Committee will evaluate the objectives, scope, performance and effectiveness of the Emergency Management Plan annually.

Interview with the interim Plant Operation Supervisor on 4/12/2011 at 1:00PM in the Conference room confirmed that the required annual disaster drill was not done for 2010.

Interview with the interim Safety Officer/Administrator on 4/13/2011 at 0930 in the Conference room confirmed that the required annual disaster drill was not done for 2010.

Interview with the Quality Improvement (QI) Director in the QI office on 4/12/2011 at 1:45PM confirmed that the required annual disaster drill was not done 2010

Based on record review and interview the facility failed to update Nursing Services Policies and Procedures.

Review of East Texas Medical Center MT. Vernon Nursing Services Policies and Procedures Manual revealed no update since March 2009.

Review of record titled Hospital Plan for Provision of Nursing Care (Reference 610-200)
ANNUAL REVIEW:
The hospital's plans for providing nursing and staffing plans are reviewed / or revised at least annually as part of the established budget process taking into consideration the following elements:
1. Patient requirement for nursing care and the effectiveness of the hospital ' s plan for nurse staffing.
2. Existing and proposed patient care programs offered by the hospital and / or patient populations that were added or eliminated and resultant changes in case mix.
3. Analysis of actual staffing patterns and variance reports in meeting patient requirements for nursing care, with special attention to patterns or trends.
4. Findings from quality assurance, risk management, utilization review, productivity studies and other hospital-wide activities that relate to the nursing staffing plan.

Review of records for nurse staff meetings revealed that the last meeting held was February 10, 2010. There has been no other patient care communication between the Director of Nursing and the facility nursing staff in the last year.

Interview with the Director of Nursing 4/13/2011, confirmed the East Texas Medical Center MT. Vernon Nursing Services Policies and Procedures Manual had not been updated since March 2009 and nursing staff meetings have not been held.

Based on record review and interview the facility failed to ensure the Registered Nurse(RN) evaluated the nursing care for each patient admitted into the facility. Citing 5 of 23 patient medical records reviewed.

Findings: East Texas Medical Center(ETMC) Mt. Vernon Policy
Subject: Patient Care: Patient Assessment and Reassessment
Department: Nursing Services
Policy #: 610-100 Revised: 09/09
"Each patient's need for nursing care related to his/her admission is assessed by a registered nurse. He/she will determine any immediate needs and appropriate assignment of the care and data collection. Delegation of specific aspects of data collection is based upon patient's condition and the defined competencies of other patient care personnel and scope of practice.
Purpose: The musing process begins with assessment. Steps should be taken to plan care and intervene according to information gathered. The assessment, planning, intervention, and evaluation is documented for each hospitalized patient admission to discharge. As appropriate, data from the patient's significant other(s) are included in the assessment."

Review of patient medical records were done on 4/12/2011 and 4/13/2011 in the conference room.

1. Review of medical record for patient #9 revealed the Assessment History Report(Admission RN Assessment) was completed on 11/8/2010 by Licensed Vocational Nurse(LVN) at 1140(11:40 am)
2. Review of medical record for patient #11 revealed the Assessment History Report(Admission RN Assessment) was completed on 3/9/2011 by Licensed Vocational Nurse(LVN) at 1541(3:41 pm).
3. Review of medical record for patient #14 revealed the Assessment History Report( Admission RN Assessment) was completed on 1/11/2011 by Licensed Vocational Nurse(LVN) at 1146(11:46 am).
4. Review of medical record for patient #15 revealed the Assessment History Report( Admission RN Assessment) was completed on 11/21/2010 by Licensed Vocational Nurse(LVN) at 1405(2:05 pm).
5. Review of medical record for patient #18 revealed the Assessment History Report( Admission RN Assessment) was completed on 2/14/2011 by Licensed Vocational Nurse(LVN) at 1609(4:09 pm).

Interview with Director of Nurses on 4/13/2011 confirmed the Admission RN Assessments were completed by an LVN and should've been completed by RN.

Based on record review and interview the facility failed to ensure medication orders for the safety of surgical patients were completed by the prescribing physician on four of five surgical records.

Surgical record #25 had no prescribing physician's orders for the admission to Day surgery, procedure, medication, or discharge order to Post Operative area.

Surgical record #24 had no prescribing physician's orders for the medication being given for conscious sedation during the surgical procedure.

Surgical record #26 had no prescribing physician's orders for the medication being given for conscious sedation during the surgical procedure. The physician's orders were not signed by a licensed nurse that the orders had been completed.

Surgical record #27 had no prescribing physician's orders for the medication being given for conscious sedation during the surgical procedure. The physician's orders were not signed by a licensed nurse that the orders had been completed.

Interviewed Director of Surgery on 4/11/2011, it was confirmed the prescribing physician's orders had not been completed.

Based on record review and interview the facility failed to ensure all medical records were complete, dated, timed, and authenticated. Citing 6 of 23 patient medical records reviewed.

Findings: Review of Medical Records was completed on 4/12/2011 and 4/13/2011 in the conference room of the facility.
1. Review of medical record for patient #8 on 4/12/2011 revealed that Acknowledgement of Privacy Practices were not dated and timed to document when patient received notice.
2. Review of medical record for patient #11 on 4/12/2011 revealed that Acknowledgement of Privacy Practices were not dated and timed to document when patient received notice. Also Pulmonary Function test result had no documentation of the date the procedure was done and no date or time the facility provider authenticated the document.
3. Review of medical record for patient #13 on 4/13/2011 revealed that Acknowledgement of Privacy Practices were not dated and timed to document when patient received notice.
4. Review of medical record for patient #14 revealed a Preliminary Echocardiography Report with no documentation of the date the procedure was done and no date and time the report was authenticated by facility staff.
5. Review of medical record for patient #18 on 4/13/2011 revealed that Acknowledgement of Privacy Practices were not dated and timed to document when patient received notice.
6. Review of medical record for patient #19 on 4/13/2011 revealed that Acknowledgement of Privacy Practices were not dated and timed to document when patient received notice.

Interview with Medical Records Director on 4/13/2011 at 2:00 pm confirmed there was no documentation of the date and time the Notice of Privacy Practice was given to the patient for signature. Acknowledgement of Privacy practices document.

Based on record review and interview the facility failed to ensure that verbal orders written by facility physicians provided documentation of the date and time the orders were authenticated. Citing 9 of 23 medical records reviewed.

Findings: Medical records were reviewed on 4/12/2011 and 4/13/2011 in the conference room.
1. Medical records for patient #7 revealed on 10/20/2010 verbal order was dated and timed by nurse on 10/20/2010 at 1430(4:30 pm). The physician signed the order but did not date and time his signing.
2. Medical records for patient #8 revealed on 1/26/2011 at 2010(8:10 pm) verbal order dated and timed by nurse. The physician signed the order but did not date and time his signing.
3. Medical record for patient #10 revealed on 11/11/2010 at 0730(7:30 am) verbal order was dated and timed by nurse. The physician signed the order but did not date and time his signing.
4. Medical record for patient #11 revealed on 3/11/2011 at 0820(8:20 am) and on 3/16/2011 at 1015(10:15 am) verbal orders were dated and timed by nurse. The physician signed the order but did not date and time his signing.
5. Medical record for patient #14 revealed on 1/11/2011 at 1300(1:00 pm) and 1/11/2011 at 2010(8:10 pm) verbal orders were dated and timed by nurse. The physician signed the order but did not date and time his signing.
6. Medical record for patient #12 on 2/13/2011 at 1415(2:15 pm), 2/13/2011 at 1710(5:10 pm), and on 2/13/2011 at 1845(6:45 pm) orders were dated and timed by nurse. The physician signed the order but did not date and time his signing.
7. Medical record for patient #19 revealed on 12/18/2010 at 2150(9:50 pm) verbal order dated and timed by nurse. The physician signed the order but did not date and time his signing.
8. Medical record for patient #20 revealed on 3/16/2011 at 2300(11:00 pm), 3/16/2011 at 1949(7:49 pm), 3/17/2011 at 0317(3:17 am), 3/17/2011 at 0430(4:30 am), and 3/21/2011 at 1100(11:00 am) verbal orders were dated and timed by nurse. The physician signed the order but did not date and time his signing.
9. Medical record for patient #23 revealed on 3/5/2011 2110(9:21 pm) and on 3/7/2011 at 0800(8:00 am) verbal orders were dated and timed by nurse. The physician signed the order but did not date and time his signing.

Interview with Director of Medical Records on 4/13/2011 confirmed the verbal orders didn't document date and time they were authenticated by physician.

Based on record review and interview with the Lab Director the facility failed to follow up on a critical blood transfusion.

Review of the Look Back Records (records of recipients who have received blood from donors that test positive for exposure to communicable diseases) on 04/13/2011 at 12:30 in the Directors office revealed a recipient that received possible contaminated blood 1/29/01. The Lab Director received a Look Back request from the blood center on 03/25/10. The Lab Director reviewed the medical record that revealed the recipient had died. The lab director recorded " Patient expired " on the Look Back Record. No other follow up was done.

Review of the Blood Bank Look Back Policy revealed " When notified by Carter BloodCare of a look back recipient the lab supervisor will immediately review blood bank records to determine what patient received the component. The patient ' s attending physician will be notified of the possible exposure and has the responsibility to follow up with the patient. If the patient ' s attending physician is unable to contact the patient, the lab manager will attempt to notify the patient or responsible individual at least three times to contact a physician for follow up testing. The lab manger will document in the patient records all attempts to contact the patient as well as any conversations with the patient and any follow up testing. If the patient is deceased the legal representative of the patient will be notified. All records will be reviewed by the medical director of the laboratory and Carter BloodCare will be notified of the results of the procedure. "

Interview with the Lab Director on 04/13/2011 at 12:30 in the Directors office confirmed the only follow up on the Look Back Record was the review of the medical record, confirming the death of the patient and recording the " patient expired " .

While on site the Lab Director took action on the Look Back Record by writing a letter to the patient ' s physician. The Director assured the surveyor that the Blood Bank Look Back Policy would be enforced and followed.

Based on record review and interviews with the interim Plant Operation Supervisor, Quality Improvement (QI) Director and the interim Safety Officer/Administrator, the facility failed to conduct the required 12 fire drills.

Review of the Fire Drill Logs for the years 2009 revealed that only 9 of 12 required fire drills were done.

Review of the Fire Drill Logs for the years 2010 revealed that only 1 of 12 required fire drills were done.

Review of the Fire Drill Logs for the years 2011 revealed that none of 12 required fire drills were done for the first quarter.

Review of the State Of Texas licensing rule, X1193 requires that at least 12 fire drills will be conducted each year.

Review of the Fire Drill Procedure, Policy #EOC-702.1 revealed " Fire drills, totaling at least one per shift per quarter, are conducted to include all Hospital departments, according to an established schedule.

Review of the Life Safety Management Plan, Policy # EOC-701 revealed " Fire Drills, Evacuation Drills frequency are quarterly " .

Interview with the interim Plant Operation Supervisor on 4/12/2011 at 1:00PM in the Conference room confirmed that the 12 required fire drills had not been conducted for the years 2009, 2010. No fire drills had been conducted for the first quarter of 2011.

Interview with the interim Safety Officer/Administrator on 4/13/2011 at 0930 in the Conference room confirmed that the 12 required fire drills had not been conducted for the years 2009, 2010. No fire drills had been conducted for the first quarter of 2011.

Interview with the Quality Improvement (QI) Director in the QI office on 4/12/2011 at 1:45PM confirmed the 12 required fire drills had not been conducted for the years 2009, 2010. No fire drills had been conducted for the first quarter of 2011.

Based on record review and interviews with the interim Plant Operation Supervisor, Quality Improvement (QI) Director and the interim Safety Officer/Administrator, the facility failed to conduct the required 12 fire drills.

Review of the Fire Drill Logs for the years 2009 revealed that only 9 of 12 required fire drills were done.

Review of the Fire Drill Logs for the years 2010 revealed that only 1 of 12 required fire drills were done.

Review of the Fire Drill Logs for the years 2011 revealed that none of 12 required fire drills were done for the first quarter.

Review of the State Of Texas licensing rule, X1193 requires that at least 12 fire drills will be conducted each year.

Review of the Fire Drill Procedure, Policy #EOC-702.1 revealed " Fire drills, totaling at least one per shift per quarter, are conducted to include all Hospital departments, according to an established schedule.

Review of the Life Safety Management Plan, Policy # EOC-701 revealed " Fire Drills, Evacuation Drills frequency are quarterly " .

Interview with the interim Plant Operation Supervisor on 4/12/2011 at 1:00PM in the Conference room confirmed that the 12 required fire drills had not been conducted for the years 2009, 2010. No fire drills had been conducted for the first quarter of 2011.

Interview with the interim Safety Officer/Administrator on 4/13/2011 at 0930 in the Conference room confirmed that the 12 required fire drills had not been conducted for the years 2009, 2010. No fire drills had been conducted for the first quarter of 2011.

Interview with the Quality Improvement (QI) Director in the QI office on 4/12/2011 at 1:45PM confirmed the 12 required fire drills had not been conducted for the years 2009, 2010. No fire drills had been conducted for the first quarter of 2011.

Based on record review, observation, and interview, the facility failed to ensure expired items were removed from patient care areas. Twenty-three (23) expired items were found in the ED (Emergency Department) treatment rooms. Forty-five (45) expired items were found in the Surgical Department.

Findings include:

During inspection of the ED treatment rooms on 4/13/2011, the following expired items were found:
-14 gauge Jelco catheters (exp. 02/2011) x 4
-14 gauge Jelco catheters (exp. 12/2010) x 4
- Arrow Triple Lumen Kit (exp. 07/2010)
-Tracheotomy Tube 6 FEN (exp. 06/2010)
- Tracheotomy Tube 8 FEN(exp. 04/2010)
- O-Vicryl J 610H (exp. 01/2011) Box
-4-O-Vicryl 1629 (exp. 01/2011) Box
- Save -a -Tooth (exp. 06/2009)
- Blood Tubes- Blue (exp. 11/2010) x 2 (Crash Cart)
- Blood Tubes-Green (exp. 11/2010) x 2 (Crash Cart)
- Blood Tubes-Pink (exp. 01/2011) x 2 (Crash Cart)
- Blood Tubes-Red (exp. 11/2010) x 3 (Crash Cart)
-Lidocaine 500cc Bag (exp. 01/2011) (Crash Cart)

During inspection of the Surgical Department on 4/11/2011, the following expired items were found:
-Arrow Arterial Catheter (exp. 05/2010)
-18 gauge Jelco catheter (exp. 05/2010)
-IV Start Kits (exp. 03/2011) x 8
-Scrub Tray (exp. 09/2010)
-Poole Suction Catheters (exp. 09/2010) x 5
-Endopath Trocars (exp. 07/2010) (Box of 6) x 4 boxes
-Specimen Trap (exp. 09/2009) Box
-Clips Resolution (exp. 03/2011) Box
-Lidocaine 2% open vial (exp. 03/2011)












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Based on record review, observation and interviews with the interim Plant Operation Supervisor, Quality Improvement (QI) Director and the interim Safety Officer/Administrator, the facility failed to conduct the required monthly portable fire extinguishers checks.

Review of the Fire Extinguishers Logs for the years 2011 revealed that the portable fire extinguishers checks were not conducted for the months of February or March.

Review of the Life Safety Management Plan, Policy # EOC-701, Procedure " Managing portable fire extinguisher, including monthly inspection and an annual inspection by an out side agency. "

Observation of 5of 5 portable fire extinguishers revealed that January was the last month extinguishers were checked.

Interview with the interim Plant Operation Supervisor on 4/12/2011 at 1:00PM in the Conference room confirmed that the required monthly portable fire extinguishers checks were not conducted for the months of February or March of 2011.

Interview with the interim Safety Officer/Administrator on 4/13/2011 at 0930 in the Conference room confirmed that the required monthly portable fire extinguishers checks were not conducted for the months of February or March of 2010.

Interview with the Quality Improvement (QI) Director in the QI office on 4/12/2011 at 1:45PM confirmed no monthly portable fire extinguishers checks were conducted or reported to the Quality Safety Survey Readiness Committee (QSSR) for the months of February or March of 2011.

Based on record review and interview the facility failed to ensure the surgical refrigerator temperature record was being maintained for proper storage of biologicals.

On observation tour of the Surgical Department on 4/11/2011 at 4:00 PM, it was observed that the refrigerator temperature record had not been recorded since November 16, 2010. In the month of November 2010 the recorded dates were November 2, 10, and 16. This was the last month that the temperature record was recorded in the Surgical Department.

Interview with the Director of Surgery on 4/11/2011 at 4:00 PM, confirmed the surgical refrigerator temperature record was not being maintained for proper storage of biologicals.

Based on record review and interview the facility failed to update Surgical Policies.

Review of East Texas Medical Center MT. Vernon G.I. Policy and Procedure Manual revealed no update since March 2009.

Review of record titled Hospital Plan for Provision of Nursing Care (Reference 610-200)
ANNUAL REVIEW:
The hospital's plans for providing nursing and staffing plans are reviewed / or revised at least annually as part of the established budget process taking into consideration the following elements:
1. Patient requirement for nursing care and the effectiveness of the hospital ' s plan for nurse staffing.
2. Existing and proposed patient care programs offered by the hospital and / or patient populations that were added or eliminated and resultant changes in case mix.
3. Analysis of actual staffing patterns and variance reports in meeting patient requirements for nursing care, with special attention to patterns or trends.
4. Findings from quality assurance, risk management, utilization review, productivity studies and other hospital-wide activities that relate to the nursing staffing plan.

Interview with the Director of Surgery 4/11/2011 at 4:00 PM, confirmed the East Texas Medical Center MT. Vernon G.I. Policy and Procedure Manual had not been updated since March 2009.

Based on record review and interview the facility failed to update Emergency Services Policies and Procedures.

Review of East Texas Medical Center MT. Vernon Emergency Services Department Policies and Procedures Manual revealed no update since March 2009.

Review of record titled Hospital Plan for Provision of Nursing Care (Reference 610-200)
ANNUAL REVIEW:
The hospital's plans for providing nursing and staffing plans are reviewed / or revised at least annually as part of the established budget process taking into consideration the following elements:
1. Patient requirement for nursing care and the effectiveness of the hospital ' s plan for nurse staffing.
2. Existing and proposed patient care programs offered by the hospital and / or patient populations that were added or eliminated and resultant changes in case mix.
3. Analysis of actual staffing patterns and variance reports in meeting patient requirements for nursing care, with special attention to patterns or trends.
4. Findings from quality assurance, risk management, utilization review, productivity studies and other hospital-wide activities that relate to the nursing staffing plan.

Interview with the Director of Nursing 4/13/2011, confirmed the East Texas Medical Center MT. Vernon Emergency Services Department Policies and Procedures Manual had not been updated since March 2009.

Based on records review and interviews the facility failed to monitor and assess operations of the facility by not doing monthly inspections of portable fire extinguishers for February or March of 2011. The facility failed to conduct the required 12 fire drills per year for the years 2009 or 2010 and had not conducted fire drills for the first quarter of 2011. The facility failed to follow up on a critical blood transfusion and failed to perform the annual disaster drill for 2010.

Review of the Fire Extinguishers Logs for the years 2011 revealed that the portable fire extinguishers checks were not conducted for the months of February or March of 2011.

Review of the Fire Drill Logs for the years 2009 revealed that only 9 of 12 required fire drills were done.

Review of the Fire Drill Logs for the years 2010 revealed that only 1 of 12 required fire drills were done.

Review of the Fire Drill Logs for the years 2011 revealed that none of 12 required fire drills were done.

Review of the Look Back Records (records of recipients who have received blood from donors that test positive for exposure to communicable diseases) on 04/13/2011 at 12:30 in the Lab Directors office revealed a recipient had received possible contaminated blood on 1/29/01. The Lab Director received a Look Back request from the blood center on 03/25/10. The Lab Director reviewed the medical record that revealed the recipient had died. The lab director recorded " Patient expired " on the Look Back Record. No other follow up was done.

Review of the Authority Statement Policy # EOC-103, revealed " The Governing Body of ETMC-Mt. Vernon delegates responsibility of the Environment of Care program to the Safety/ Risk Management, Infection Control Committee in conjunction with the Safety Officer and the hospital Administrator. "

Review of the Environmental Survey Rounds Policy # EOC-106, revealed " Quarterly environmental rounds will be conducted by the Safety/Risk Management/Infection
Control Committee to assess and inspect the facility for compliance and deficiencies in the areas of facility condition, life safety, security, emergency preparedness, electrical safety, utility systems and infection control. "

Review of the Environment of Care Management Plan Policy # EOC-105, revealed " Responsibility: The Safety/Risk Management/Infection Control Committee is responsible for designing, implementing, education and evaluating the Plan. "

Interview with the interim Safety Officer/Administrator on 4/13/2011 at 0930 in the Conference room confirmed that the required 12 fire drills for the years of 2009 and 2010 had not been conducted and no drills for the first quarter of 2011 had been conducted. Inspection of the portable fire extinguisher for February or March of 2011 had not been conducted nor had the annual disaster drill for 2010 been conducted. Further interview with the Safety Officer/Administrator confirmed that the Safety/Risk Management/Infection Control Committee was the same as the Quality Safety Survey Readiness Committee (QSSR).

Interview with the Quality Improvement (QI) Director in the QI office on 4/12/2011 at 1:45PM confirmed that the required 12 fire drills for the years of 2009 and 2010 had not been conducted and no drills for the first quarter of 2011 had been conducted. Inspection of the portable fire extinguisher for February or March of 2011 had not been conducted nor had the annual disaster drill for 2010 been conducted. Further interview with the Quality Improvement (QI) Director confirmed that the Safety/Risk Management/Infection Control Committee was the same as the Quality Safety Survey Readiness Committee (QSSR).

Based on record review and interview the facility failed to collect any data for the Emergency Department, Surgical Department, and Nursing Department to the Quality Assurance Performance Improvement (QAPI) committee.

Review of record titled; Quality/ Safety/ Survey/Readiness Committee Meeting Minutes Second & Third Quarter of 2010, dated December 9, 2010, there was no reporting from Emergency Department, Surgical Department, or Nursing Department.

Review of record titled; Quality/ Safety/ Survey/Readiness Committee Meeting Minutes Fourth Quarter of 2010, dated March 23, 2011, there was no reporting from Emergency Department, Surgical Department, or Nursing Department.

Interviewed Quality Improvement Director on April 13, 2011 at 4:00 PM, confirmed that the Emergency Department, Surgical Department, or Nursing Department had not collected any data for the Quality/ Safety/ Survey/Readiness (QSSR) Committee. Further interview established that the (QSSR) is the Quality Assurance Performance Improvement (QAPI).

Based on record review and interview the facility failed to establish and enforce Quality Assurance Performance Improvement (QAPI) data reporting for the Emergency Department, Surgical Department, and Nursing Department.

Meeting titled; Quality/ Safety/ Survey/Readiness Committee Meeting Minutes Second & Third Quarter of 2010, dated December 9, 2010, there was no reporting from Emergency Department, Surgical Department, or Nursing Department.

Meeting titled; Quality/ Safety/ Survey/Readiness Committee Meeting Minutes Fourth Quarter of 2010, dated March 23, 2011, there was no reporting from Emergency Department, Surgical Department, or Nursing Department.

Quality Assurance Performance Improvement (QAPI) data from the Emergency Department, Surgical Department, and Nursing Department was last reported in the Quality/ Safety/ Survey/Readiness Committee Meeting Minutes First Quarter of 2010, dated June 23, 2010.

Interview with Administer and Quality Improvement Director on April 13, 2011 at 4:00 PM confirmed that the Emergency Department, Surgical Department, and Nursing Department had not reported any QAPI data in the last year.

Based on record review and interview the facility failed to collect any data from high risk and high volume areas of the facility (Emergency Department), and (Surgical Department) to the Quality Assurance Performance Improvement (QAPI) committee.

REFER TO TAG #276