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Based upon record review and interview, the facility failed to have a formalized written institutional plan that included expenditures and sources of financing for the expansion of the facility.

Review of budget documents that included an income and expense statement revealed the statements for fiscal year 2008, 2009, and 2010. The capital expenditures documents were provided for fiscal year 2009, 2010, and 2011. The capital expenditures for 2009 contained the same line items for 2010 indicating the same purchases in two consecutive years. The capital expenditures for fiscal year 2011 contained only expenditures to furnish the facility following a major construction project and purchase equipment for nursing and emergency departments only. There were no expenditures on the 2011 capital expenditures for any other departments.

An interview was conducted with the Administrator on 6/26/2010 at 1:00 pm. in the Administrator's office.
The administrator reported there was no institutional plan developed by the governing body and medical staff. The administrator also reported there was no process in place for preparing an institutional plan or for reviewing or revising an institutional plan annually.

Based upon record review and interview, the facility failed to develop an institutional plan and review and update annually.

See Tag A0076

Based upon record review and interview, the facility failed to develop an institutional plan that was prepared by representatives of the governing body, administrative staff and medical staff.

See Tag A073

Based upon record review and interview, the facility failed to ensure 28 of 28 patients records reviewed contained documentation that patients were provided information of the patient rights.

Review of a policy from the Administrative Manual titled "Statement of Patient's Bill of Rights and Responsibility" revealed a listing of patient rights whild a patient at that facility. The policy did not contain information as to how or when those rights and responsibility would be provided to the patient.

Review of 28 of 28 patient records revealed no documentation that patient rights had been provided to the patient on admission. There was not a copy of the patient rights or any acknowledgement signed by the patient that they had received information about patient rights.

An interview was conducted on 6/22/10 at 3:00 pm with staff #33 (admission clerk). Staff #33 waw asked to provide surveyors with a copy of the forms completed or provided to a patient upon admission. Staff #33 provided the following forms: 1.)Patient Face Sheet, 2.)Consent Form containing sections titled "My Care", "My Valuables", "Financial Responsibility/Insurance Assignment", "Release of Information", "Recurring Outpatient Treatment", "Photography", "Inpatient and Day Surgery Patients Only", 3.) Acknowledgement of Notice of Privacy Practices, 4.) Medicaid Release/Patient Responsibility Acknowledgement, 5.) Medicare Release/Patient Responsibility Acknowledgement, and 6.) Important Message from Medicare. Staff #33 reported that she does not provide the patient with patient rights on admission.

Based upon observation, record review, and interview, the facility failed to ensure privacy was maintained for all patients as evidenced by the patient's name being displayed on the patient room entrance.

During observation tour on 6/22/10 at 2:30 pm, patient names were observed displayed on the patient room entrance.

Review of the facility's form "Patient Information on Patient Rights" revealed the following statement: "You have the right, within the law, to personal and informational privacy and confidentiality of your medical record."

An interview was conducted with the Director of Nurses while conducting the observation tour on 6/22/2010 at 2:30 pm. The Director of Nurses confirmed patient names on the door and reported they had always put patient names on the door.

Based on record review and interview the facility failed to follow their own policy to ensure that vital signs on patients in emergency department were taken and documented on patient record every 15 minutes until stable then every hour hour once the patient was stabilized per written Policy and Procedure. This was noted on 6 of 12 emergency room records reviewed.

Findings: Review of medical records on 6/22/2010 at 10:00 am in conference room revealed that 6 of 12 emergency room records failed to document vital signs as specified on Policy # T-3 Trauma Team Roles and Responsibilities. Nurse Responsibilities: performs the following nursing interventions. Assesses Patients vital signs at least every 15 minutes until stable, and then every 1 hour.

1. Patient #10 was admitted on 3/22/2010 at 5:05 am to Room 1 in emergency room with admit vital signs taken and recorded. Patient was discharged to University Texas Medical Branch Galveston (UTMB) via ambulance at 11:25 am. No vital signs documented from 6:00 am till discharge vital signs when patient left for UTMB.
2. Patient #5 was admitted on 2/25/2010 at 5:54 pm to Room 3 via stretcher with admit vital signs taken and recorded. Patient was discharged home at 7:57 pm with only discharge vital signs documented on patient record.
3. Patient #4 was admitted on 2/24/2010 at 4:40 pm to room 1. Admit vital signs taken and documented on patient record. Patient was admitted to floor at 8:50 pm with only discharge vital signs documented on patient record from 4:40 pm till 8:00 pm.
4. Patient #3 was admitted on 1/2/2010 at 11:05 pm to trauma room 1 with admit vital signs taken and documented on patient record. Patient was transferred Herman Hospital Houston on 1/3/2010 at 3:45 am with no other documentation of vital signs noted until 3:45 am on patient record when patient was discharged.
5. Patient #2 was admitted on 1/2/2010 at 1:38 pm to trauma room 1 with admit vital signs documented on patient record. Patient was transferred to East Texas Medical Center Crockett via ambulance at 6:20 pm with only discharge vital signs documented on patient record.
6. Patient #1 was admitted on 1/1/2010 at 10:00 am to emergency room. Admit vital signs were taken and documented on patient record. Patient was transferred to UTMB Galveston at 6:40 pm per ambulance with only discharge vital signs documented on patient record.

Interview with Director of Nurses confirmed that documentation of vital signs was missing on patient record. Director of Nurses reported that patient vital signs were monitored on hourly with monitor, and record of vital signs was attached to chart. No documentation of hourly monitoring was documented where vital signs should have been recorded and no hourly strips found on emergency room record.





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Based on observation and 9 of 9 patient records reviewed the facility failed to insure an RN on the medical-surgical unit evaluate, identify and intervene in the needs of the patient on an on-going basis.

Observation of patients #13, who was dependent on staff for nutritional and mobility needs being met, was in a supine position from 8:30 until 12:00 on 6/24/2010.
Patients #13 & #14 were observed to eat less than 25% of the noon meal on 6/22, 6/23, 6/24.
On 6/24/2010 a staff member noticed patient #13 had no dentures in place and was receiving a regular texture meal. The texture was changed for patient #13 on that day to blended.
There was no evidence of a documented nutritional referral to the dietician. There was no evidence of documentation to dietary services for evaluation of texture changes or any other intervention to promote or improve either patient's dietary intake prior to 6/24/2010.

Records for patient #16 revealed no documentation on the form titled "Patient Discharge/Referral".

Records for patient #17 revealed the Nutritional Screening section of the Patient Admission Assessment indicating "High Risk". The nurses note records Dietary consult for patient: 1/8/10 Computer. There was no evidence documented that the dietician or dietary supervisor received the referral.

Records for patient #18 revealed the 2 page document titled "Patient Discharge/Referral" had nothing filled in at all. The patient was treated with oxygen and nebulizer treatments but there was no nursing intervention to provide for after discharge care.

Records for patient #19 had no Nutritional Screening in the Patient Admission Assessment. The facility policy titled "Initial Screening/Nutritional Assessments of Patients" requires that nursing complete the nutritional screening in 24 hours of admission and be kept on the chart. The patient was admitted with a diagnosis of Coronary Artery Disease, Previous Miocardial Infarction, Peripheral Vascular Disease, Congestive Heart Failure, Mitral Regurgitation, Hypertension, Degenerative Arthritis and Atrial Fibrillation. This patient was discharged with all of the preceding diagnosis plus Deep Venous Thrombophlebitis of the lower legs. The nursing staff only identified "foot wound - Potential for infection" in the nursing care plan.

Records for patient #20 revealed the Nutritional Screening section of the Patient Admission Assessment as "Moderate Risk" there was no referral to dietary services or the dietician documented. The patient nutritional intake flow sheet records less than 25% of all meals except one and no nutritional intake recorded for 4 meals. The patients records reflect both stage III and stage IV wounds evident on admission. There was no further assessment for nutritional needs or wound care. The discharge care planning form titled "Patient Discharge/Referral" had no documentation other than discharge to psychiatric facility although the doctors progress notes reads discharge to "Long Term Acute Care facility".

Records for patient #21 revealed nursing assessment for Chronic Obstructive Pulmonary Disease (COPD) although the patient was admitted for Gastroenteritis and dehydration.
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Records for patient #22 reveals the Nutritional Screening section of the Patient Admission Assessment was incomplete. The "Skin Integrity" section of the Patient Admission Assessment reveals a patient score of "6" with instructions for nursing intervention. There are none documented. The "Potential Fall Criteria" section of the Patient Admission Assessment indicated a patient score of #16 with instructions for nursing interventions if the patient's score was greater than "5". There was no intervention documented in the nurses narrative.

Based on Observation, policy & patient record review the facility failed to ensure an RN developed and kept current a nursing care plan for 8 of 9 patient reviewed (#13, #16, #17, #18, #19, #20, #21, #22)

Observation of patient #13, who was dependent on staff for nutritional & mobility needs being met, revealed the patient was in a supine position from 8:30 until 12:00. There was no care planning for a dependent patient who would require repositioning . The nursing care plan included Fear/Anxiety R/T hospitalization, Actual fluid volume excess R/T CHF and Risk for infection R/T Pyelonephritis. The physician recorded in the patients admitting History and Physical records "poor intake and weight loss" "For the past few days, she has had decreasing oral intake, generalized weakness and decline in strength and weight." The patients was observed to eat less than 25% of the noon meal on 6/23, 6/24. On 6/24/2010 a staff member noticed patient #13 had no dentures in place and was receiving a regular texture meal. There was no nursing care plan to address any nutritional needs for this patient.

A review of East Texas Medical Center Trinity Policy titled Initial screening/Nutritional Assessments of Patients.
1.)The nursing service will complete the nutritional screening within 24 hours of admission on each patient. The screening is placed in the patient's chart.
2.)The CDM or Consultant Dietician will be notified by the nursing staff by phone or computer print out regarding the need for nutritional assessment.
3.)The patients which are classified as moderate or high risk will be evaluated by the CDM within 72 hours of admission.
4.)All pertinent information is charted in the medical record.
5.) Re-assessment may occur depending on the patient condition, diagnosis, and/or response to care.

Patient record #16 had no discharge care planning.

Patient record #17 revealed the nutritional screening section of the initial nursing assessment indicated the patient was at "High Risk". In the nurses notes it was recorded "Dietary consult for patient: 1/8/10 Computer". A review of the Nutritional Needs Screening section of the initial nursing assessment instructs the nurse to request a dietary consult within 24 hours. There was no evidence documented that the dietician or dietary supervisor received the referral and no care planning.

Patient record #18 had no documented discharge care plan. The 2 page document titled Patient Discharge/Referral had nothing filled in, at all. The patient was treated with oxygen and nebulizer treatments but there was no nursing care plan for respiratory problems.

Patient record #19 had no nutritional screening as part of the initial nursing assessment. The patient was admitted with diagnosis of Coronary Artery Disease, Previous Miocardial Infarction, Peripheral Vascular Disease, Congestive Heart Failure, Mitral Regurgitation, Hypertension, Degenerative Arthritis and Atrial Fibrillation. This patient was diagnosed with all of the preceding diagnosis plus Deep Venous Thrombophlebitis of the lower legs. The nursing care plan was for one problem "foot wound - Potential for infection".

Patient record #20 revealed the nutritional screening section of the initial nursing assessment that indicated "Moderate Risk". No referral to dietary services or the dietician was documented. The patient nutritional intake flow sheet records less than 25% of all meals except one and no nutritional intake recorded for 4 meals. The patients record reflect both stage III and stage IV wounds evident on admission. There was no care planning for nutritional needs. There was no care planning for the patients stage III & stage IV wounds. The discharge care planning form had no documentation other than discharge to psychiatric facility although the doctors progress notes says discharge to "Long Term Acute Care facility".

Patient record #21 revealed a nursing care plan for Chronic Obstructive Pulmonary Disease (COPD) although the patient was admitted for Gastroenteritis and dehydration.

A review of patient record #22 revealed the Nutritional Screening section of the initial nursing assessment was incomplete. A skin risk assessment score of #6 and a Fall Risk Assessment score of #16 indicating nursing intervention. There was no care planning.

Based upon record review and interview, the facility failed to follow their own policy to ensure that two out two (#1,#2) non-employee licensed nurses were provided orientation, adequate supervision, and evaluation.

Findings:

Review of policy # 600-00-014 Outside Agency Nurse /Temporary Nursing Personnel revealed "before any temporary nurse performs nursing functions within a patient care area, they are provided an orientation to that area by the Charge Nurse, Unit Director, and/or by his/her designee. Agency nursing personnel shall be evaluated by the Unit Manager at the end of their first assignment. If the agency nurse consistently works here, the agency nurse should be evaluated annually using the evaluation form used to evaluate our nursing personnel. If an agency nurse is not performing to our standards, the Unit Director or Director of Nursing will contract the agency immediately. The scope of activities of a temporary /agency nurse will be same as those for nurses of the same degree in our hospital employment. The Nursing Department /Service is responsible for nursing care, no matter who performs nursing duties. The Unit Director is responsible for nursing care performed on his/her shift. Further review of the policy revealed no provisions for orientation of hospital policy and procedures, nursing policy and procedures, emergency procedures, or safety policy and procedures prior to providing care.

Review of the instructions for agency nurse orientation packet, it is written that the agency nurse will complete the "Temporary/Agency Nurse Orientation Record" form. Following the first shift this nurse works, the" Temporary /Agency Nurse Evaluation Record" is to be completed by the Charge Nurse.

A review of agency staff #1 personal file revealed that the "Temporary/Agency Nurse Orientation Record" form was not completed by a signature of the charge nurse on the shift that she had worked. The Temporary /Agency Nurse Evaluation record was not completed by the Charge Nurse/ Unit Manager at the end of the first shift.

A review of agency staff # 2 personal file revealed that the "Temporary/Agency Nurse Orientation Record" form was not completed or signed by the charge nurse on the shift that she had worked. The "Temporary /Agency Nurse Evaluation Record" was not completed by the Charge Nurse at the end of the first shift.

An interview was conducted on 06/24/10 at 1:30 PM with the Human Resources (HR) Coordinator who confirmed that the personnel files were incomplete. The Coordinator stated "non-employee licensed nurses are not provided an orientation time before they begin their first shift at the facility."

Based on observation and interview the facility failed to maintain the physical plant of the hospital in safe and sanitary conditions.


During a tour of the dietary department on 6/23/2010 at 1100 AM this surveyor observed two (2) air vents and ceiling tiles over a food preparation were black. The floor of the dietary department had numerous large chunks of concrete missing and the tile was broken and stained. There was a 10 inch area beneath a drain on the dirty dish counter where brown liquid had accumulated on a plastic mat. The dish washer was not in use because the drain was not emptuying properly and there was water scale on the stainles steel surfaces. The floors at the based boards were brown and stained.

When asked about these items the dietary superviosr stated "when we get our new kithcen all this will begone"