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Based on review of documentation and interview, it was determined that the facility failed to complete its medical records within state and federal timelines.

Findings were:

Cross refer to:

A0469
A0457
A0468

In an interview with the Chief Executive Officer on 2/26/13, the numerous delinquent medical records were confirmed.

Based on observation, interview and record review, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patients.

Findings were:

Cross refer to:

A0748
A0749

In an interview with the Infection Control Nurse, the Chief Executive Officer and the Environmental Services Director on 2/27/2013, the above deficiencies were confirmed.

Based on review of documentation, of medical records and interview, it was determined that the facility failed to authenticate all of its medical doctor ' s telephone orders within 72 hours.

Findings were:

Facility policy entitled " Record of Care, Treatments and Services " stated in part " All verbal orders shall be co-signed and dated by the ordering physician or another member of the medical staff within 48 hours or as outlined in the State Administrative Code. "

Facility document entitled " Chart Deficiency Delinquency Report " reviewed 2/26/2013 revealed that between the dates of January 1st 2012 and January 31st 2013, there were 151 unsigned verbal orders. According to the Health Information Manager, these verbal orders were still unauthenticated on 2/26/2013.

In an interview with the Chief Executive Officer, the Health Information Manager and the Quality Manager on 2/26/2013, the above unauthenticated verbal orders were acknowledged.

Based on review of documentation, of medical records and interview, it was determined that the facility failed to complete all discharge summaries within 30 days of a patient ' s discharge.

Facility policy entitled " Record of Care, Treatments & Services-Closed Medical Records " stated in part, " A discharge diagnosis form must be completed or a discharge summary must be dictated by the attending physician within 14 days of the discharge date for all inpatients ...Discharge Summary: A dictated discharge summary is a required element of the medical record and must be completed within 30 days of the discharge date, regardless of whether a discharge diagnosis form is used or suspension shall occur. "

Facility document entitled " Chart Deficiency Delinquency Report " reviewed 2/26/2013 revealed that between the dates of January 1st 2012 and January 31st 2013, of 274 patient discharges, 32 incomplete discharge summaries were found. According to the Health Information Manager, these discharge summaries were still incomplete as of 2/26/2013.

In an interview with the Chief Executive Officer, the Health Information Manager and the Quality Manager on 2/26/2013, the delinquent discharge summaries were acknowledged.

Based on review of documentation, of medical records and interview, it was determined that the facility failed to complete all of its medical records within 30 days of discharge.

Findings were:

" Medical Staff Bylaws " stated in part, " Each staff member will ...(be responsible for) " accurate, timely and legible completion of medical records. " Under Section 8 of the same Medical Staff Bylaws it stated, " A temporary suspension in the form of withdrawal of a Practitioner ' s admitting privileges effective until medical records are completed, may be imposed automatically after warning of delinquency for failure to complete medical records in accordance with the Rules and Regulations. Such notice shall be forwarded via certified mail and shall provide at least seven days for the completion of outstanding medical records prior to the suspension of the practitioner. "

Facility policy entitled " Record of Care, Treatments and Services " stated in part, " All medical records shall be complete within 30 days of the discharge date. This shall include all dictated reports, written forms and required signatures. "

Review of facility documents and interview revealed 274 discharged patients between January 1st 2012 and January 31st 2013. Of the 274 medical records audited, 115 were found to be delinquent.

In an interview with the Chief Executive Officer, the Health Information Manager and the Quality Manager on 2/26/2013, the delinquent records were acknowledged.

Based on review of documentation and interview, it was determined that the facility failed to perform annual maintenance on all of its equipment.

Findings were:

Facility document entitled "Annual Preventative Maintenance for Gulf Coast Multiplace Hyperbaric Chamber at Mesa Hills Specialty Hospital, El Paso, Texas " described the annual preventative maintenance of the hyperbaric chamber.

Facility document entitled " Annual System Certification Clinical Hyperbaric Treatment Chamber Systems " stated the last machine maintenance on the hyperbaric chamber was done on 9/14/2011.

In an interview with the Environmental Services Director on 2/27/2013, it was acknowledged that the required preventative maintenance on the hyperbaric chamber was overdue by 5 months.

Based on review of documentation and interview, it was determined that the facility failed to provide infection control education to the Infection Control Nurse as promised on the Plan of Correction dated 10/08/2012.

Findings were:

Plan of Correction dated 10/08/2012 stated, " An LVN presently working at Mesa Hills Specialty Hospital was designated the Infection Control Officer on July 27, 2012. Mesa Hills Specialty Hospital will send a nurse (LVN) to training within the next six months. " Completion date designated by the facility was stated as " August 20, 2012 (1 month previous to the State survey. Joint Commission survey that prompted the State survey took place September 5, 2012.)

No Infection Control training has been scheduled for the Infection Control Nurse as of 2/27/2013. The Chief Executive Officer and the Infection Control Nurse both stated on 2/27/2013 that she would likely go to training " sometime in May. "

Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patients.

Findings were:

" OSHA/Blood Borne Pathogen Regulations Policy #138-030-060 " stated in part " The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. "

Facility policy entitled " Terminal Cleaning of Patient Room " stated the procedure for terminally cleaning an empty patient room:

· Remove all linen from the bed and room and place in linen hamper. Take to soiled utility room.
· Pick up all disposables and trash and place in waste container. Empty all waste containers, damp wipe interior/exterior and replace with new can liners. Tie full trash liners securely before depositing into soiled utility room.
· Remove any red-bag trash from the medical waste container and place in the soiled utility room. Damp wipe the interior and exterior of the medical waste container.
· Dust the ceiling vents, lights, ceiling corners, door tops, TV, window casings etc. using a high dusting tool.
· Damp wipe bedside cabinet and over bed table including top, sides, legs, mirror, inside all drawers and shelves.
· Damp wipe the telephone, including handset base and cords
· Damp wipe all other standard furniture and horizontal surfaces including chairs, countertops, heating units, shelves, hangers, door and door handle ...
· Dust mop and wet mop the floors and baseboards in room and bathroom "

Tour of the patient floor on 2/26/2013 revealed the following:

· Gouged and cracked floor tiles throughout the patient area, making thorough cleaning of the floor impossible.
· The Dirty Utility room had dirty linen (smeared with fecal material) in a plastic bag that was thrown on the floor of the room rather than placed in the dirty linen cart
· The Dirty Utility Room also had a used 5cc syringe lying on the floor
· 3 stained ceiling tiles were observed in the patient hallway, indicating water damage

All patient rooms were occupied except for room 512. The survey team was directed to this room for inspection. In this room:

· The restroom had an emergency pull cord wrapped around the safety railing which rendered it inoperable. If a patient fell in this restroom, it would be impossible to pull the cord and call for assistance.
· Also in the restroom, the toilet bowl was cracked and there was a hole that measured approximately 2x2 in the sheet rock that opened to a drain pipe. This hole in the sheet rock could allow entry of vectors into the facility.
· The exposed under sink piping cover in the restroom was visibly dirty with patches of black dirt. This indicated improper cleaning of the area.
· 1 foot of paper tape was noted to be dangling from the light fixture pull cord. This dirty tape could be a source of cross contamination.
· The laminate covering on the bedside cabinet was chipped and peeling, making thorough cleaning impossible.
· 4 ceiling tiles were stained and brown, indicating water damage
· Molding was observed to be pulling away from the walls, making thorough cleaning of the area impossible.
· The fitted cotton sheet on the bed had several small holes
· All high horizontal areas to include light fixtures, window frames and picture frames were dusty, indicating improper cleaning of the area.

In an interview with the Chief Executive Officer and the Environmental Services Director, the above infection control deficits were acknowledged. In regard to Room 512, the Environmental Services Director stated that the room had been " terminally cleaned " before the survey team inspected the room.