HospitalInspections.org

Based on observation, Interview, and record review, the facility's governing body failed in its oversight responsibilities for quality of care as stated in its Bylaws. The governing body failed to:

A. Ensure the hospital CEO fulfilled his responsibility in the overall management of the hospital [ lack of ICU nursing job descriptions with requirements for specific licensure, certifications, education, training /competencies ; and lack of a nursing orientation policy].

B. Make certain a Nursing Staffing Advisory Committee was established per Texas Health & Safety Code 161.031- 161.033.

Findings included :

Review of facility "Governing Board Bylaws, dated December 2021, showed:

-The Board is charged with the overall responsibility for the quality of care in the hospital;
-The Governing Body selects and appoints a qualified and competent chief executive officer who will be responsible for the day-to-day management of the hospital;
-[Board] Objectives include: employment of personnel with qualifications commensurate with their responsibilities.
-"The hospital will work to maintain accreditation by the Department of Health and Hospitals for the state of Texas (sic) and the CIHQ on Accreditation of Healthcare Organizations (sic)..."

A. CEO responsibilities: hospital management:

Review of Staff A, CEO's, job description, signed 7/26/2016, showed his responsibilities included:

- accountability for operational oversight of the Hospital in a manner that optimizes provision of care and outcomes for long-term acute care patients who range in age from adolescents to geriatric adults experiencing medical complex conditions and wound care needs. The CEO's direct reports included the Director of Human Resources and the Chief Nursing Officer.

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1. Nursing Job Descriptions:

During an interview on 8/3/2022 at 1:30 PM with Staff C, CNO, she stated there were six ( 6) ICU nurses : Staff T, R, S, G, E, H- all staff RNs

Record review of personnel and training records of staff T, S, G, E, H showed a job description titled "Registered Nurse." Review showed it to be a 'generic' nursing job description. It is not geared in any way to the care of ICU patients. Further review showed:

-"EDUCATION:" only requirement listed is :"unrestricted Texas license to practice" (**does not specify what type of license).

- EXPERIENCE REQUIREMENTS: only item listed is : three (3) years long- term care nursing experience in an inpatient setting preferred [long- term care is nursing homes/facilities].

There is no mention of the following:

1. a basic CPR requirement (standard for all nursing patient care positions) ;
2. an ACLS requirement, which is a professional standard for ICU nursing;
3. ICU or critical care experience or any experience in a medical /surgical hospital ;
4. ICU skill set, competencies
4. Adherence to professional standards of nursing practice

Interview with the CNO at the time of the personnel file review, she stated all of the RNs had this same job description. She had thought there was an ICU Nurse job description. The CNO said the six (6) ICU nurses should have a job description specific to ICU.

Review of Staff T's [ICU -RN) personnel file showed documentation of ICU /CCU competencies and skills that included (*not all inclusive):

1. Basic & advanced EKG interpretation;
2. Knowledge of dosage calculations; drug titration; mechanism of action; side effects; and safe administration of high- risk critical care IV drugs such as Levophed, Nipride, Amiodarone, Dopamine, and others.
3. Assessment and care of ICU patients on ventilators and those with: central IV lines; tracheostomies; chest tubes, PEG tubes, N/G tubes & receiving TPN.
4. Knowledge of waived testing procedures ; critical lab values; blood administration; ABG interpretation; cardiogencic shock; pulmonary embolism; diabetic ketoacidosis; DVT; and many others.

Staff T's "RN Job Description" did not include or address any of the ICU/CCU competencies, knowledge, or skills listed above.
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2. Nursing orientation policy:

Record review on 08/04/2022 of facility policy titled " Orientation of Personnel ," dated 12/05/2021, showed :

"Nursing Orientation will consist of two days or longer. Items to be covered are:

Hospital's mission & vision
Patient Rights & ethics
Quality Service- QA
Blood borne pathogens
Infection Control
Fire electrical safety
Body Mechanics
PI/ Risk Management
Benefits
Time Clocks
Incident reports
Dress Code

"The following items will be examined with a written test: Identification of victims of abuse; infection control; safety; body mechanics; Violence in the hospital; fire safety; patient rights;and nursing assistant test."

This "nursing orientation" portion of the policy failed to include any details or reference to specific ICU /CCU or medical /surgical nursing unit-based orientation.

Record review on 08/04/2022 of the index of all hospital policies failed to show other policies related to orientation/ training.


B. Nursing staffing Advisory Committee per HSC :

Review of Texas HSC 161.031-161.033 showed the responsibilities of this nursing advisory committee include: the development, ongoing monitoring, and evaluation of the staffing plan.

On 08/2/2022 survey team requested the Staffing Advisory Committee policy and the meeting minutes for the last 12 months.

On 08/02/2022 at 1:30 PM, Staff A, CEO, said "we don't have a nursing advisory committee."

During an interview on 08/3/2022 at 1: 40 PM with Staff- C, CNO , she stated they had a brief meeting to organize the nursing advisory committee in early April 2022- but it was not a functional committee, as yet.

Based on interview and record review, the facility did not ensure adequate numbers of nurses to safely meet patient's needs. The facility :

a. failed to adhere to hospital-approved staffing guidelines: three (3) night shifts had only one (1) nurse on the unit; the staffing policy requires a minimum of 2 nurses. During these shifts , there were several ICU patients on the unit, some on ventilators.
b. failed to assign nursing staff according to hospital staffing criteria for 1:1 patient care [on 1/06/2022; 1/10/2022)

Cross refer : A-0392
__________

Based on interview and record review, the facility Chief Nursing Officer (CNO) failed to ensure compliance with a Texas Board of Nursing (BON) order pertaining to the licensure of a registered nurse employed by the facility ( RN / ID -H ).

Cross refer: A-0394
__________

Based on observation, interview, and record review, nursing staff failed to provide nursing care according to accepted standards of practice and facility policy. Nursing staff :

a. failed to provide wound care per accepted standards of practice and facility policy on two (2) current patients: Patient IDs # 5, #8 .
b. failed to ensure (4) of 4 current patients with indwelling urinary catheters had the catheter tubing secured per facility policy [Patient ID # 8, 9, 2, 5 ]
c. failed to measure and document the depth of Stage IV pressure ulcers per facility protocol for 9 of 11 patients (current & discharged) with Stage IV pressure ulcers [Patient IDs # 8, 29, 31, 37, 38, 39, 40, 41, 42].
d. failed to perform and document a nursing assessment for 3 shifts for Patient ID # 17.

Cross refer: A-0395
______________

Based on observation, interview, and record review, the facility failed to ensure patient care was assigned to nurses with appropriate education, experience, and competence; based on the complexity of patient needs.

a. the Chief Nursing Officer (CNO) was not involved in the nursing staffing and assignment processes.
b. three (3) of six (6) nurses listed by facility CNO as "ICU nurses" lacked facility ICU competencies; and completion of facility CCU test and advanced EKG course.
c. three (3) RNs without ICU competencies and training provided care to critical patients who were either on ventilators or receiving critical IV medications that required frequent titration ( RN staff ID: E, G, S].

Cross refer: A-0397

Based on interview and record review, the facility did not ensure adequate numbers of nurses to safely meet patient's needs. The facility :

a. failed to adhere to hospital-approved staffing guidelines: three (3) night shifts had only one (1) nurse on the unit; the staffing policy requires a minimum of 2 nurses. During these shifts , there were several ICU patients on the unit, some on ventilators.

b. failed to assign nursing staff according to hospital staffing criteria for 1:1 patient care [on 1/06/2022; 1/10/2022)

Findings included:

TX00384558; TX00370713; TX00331833; TX00363450

a.

Review of facility policy titled "Staffing Guidelines Medical/Surgical & ICU Units," dated 12/05/2021, showed: minimum number of nurses each shift is two (2) nurses: 1 RN, 1 LVN.

Record review on 08/05/2022 of nursing schedules, payroll time records, patient census forms, & respiratory therapy documents for December 2021 and January 2022 showed :

12/18/2021: night shift ( 7 PM- 7 AM) : only one nurse on unit: 12 patients. ( 1 patient was on a ventilator)

12/29/2021: night shift ( 7 PM-7 AM) : only one nurse on unit: 11 patients. *Three (3) of 11 patients were classified as ICU patients ( 2 patients were on ventilators).

01/12/2022: night shift (7 PM-7 AM) : only one nurse on unit: 14 patients. *Four (4) of 14 patients were classified as ICU patients ( 3 patients were on ventilators).

On 08/05/2022 at 3:30 PM , the above staffing findings were discussed, reviewed, and verified with Staff A-CEO and Staff C-CNO.

b.

Review of facility policy titled "STAFFING : CRITERIA FOR 1 TO 1 PATIENT CARE," dated 12/05/2021, showed the following general criteria will be utilized for classifying patients requiring 1:1 nursing care: "hemodynamically unstable requiring continuous dosing /frequency of vasopressors for hemodynamic support."

Record review of the clinical records of Patients # 12 and # 17 showed:

-1/06/2022 : Patient # 12: Staff E,RN, administered Levophed 3 mcg continuous IV drip ordered to titrate " to maintain systolic blood pressure above 95 (mm Hg)"-[7A-7P]

-1/10/2022: Patient # 17 : Staff E, RN, administered Levophed 3 mcg continuous IV drip ordered to titrate "to maintain systolic blood pressure above 95 (mm Hg)"-[7A-7P]

[* Levophed is a vasopressor , similar to adrenaline, used to treat life-threatening low blood pressure (hypotension) that can occur with certain medical conditions or surgical procedures. Levophed is often used during or after CPR .]

Review of January 2022 Nursing Schedules showed: on 1/6/2022 and on 1/10/2022 : Staff-E had seven (7) patients assigned to her care.

Based on interview and record review, the facility Chief Nursing Officer (CNO) failed to ensure compliance with a Texas Board of Nursing (BON) order pertaining to the licensure of a registered nurse employed by the facility ( RN / ID -H ).

Findings included:

TX00384558

Record review on 08/03/2022 of the personnel file of RN-H showed he was currently under a Texas Board of Nursing "Order of the Board": "Reprimand with Stipulations", signed by RN-H on 01/10/2022; final order by BON dated 3/08/2022.

This final board order stipulated "Employment Requirements" included:

["Respondent shall cause employer to"]:

1. Submit a "Notification of Employment" form within 10 days of receipt of Board Order to the BON.

2. Provide indirect supervision of RN-H by an RN who is on the premises. Supervising nurse shall have a minimum of two (2) years experience in the practice setting to which RN-H is working.

3. Employer shall submit "Nursing Performance Evaluations" related to RN-H's capability to practice nursing. These reports shall be completed by the individual who supervises the RN--and submitted by the end of each three (3) month quarterly period for eight (8) quarters (2 years) of employment as a nurse.
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Continued review of the personnel file of RN-H showed his date of hire was 12/28/2021. There were no copies of any completed "Notification of Employment" or "Nursing Performance Evaluations" submitted to the BON located in RH-H's personnel file .

During an interview on 08/ 04/2022 at with Staff-C, CNO, she stated she was aware of the Board Order for RN-H. She sent the BON a letter a few weeks ago. She gave it to someone in administration to mail for her. It was not sent registered mail and she did not keep a copy. The CNO contacted the BON and they said they did not receive any correspondence from her.The CNO said she will resubmit to the BON.

Based on observation, interview, and record review, nursing staff failed to provide nursing care according to accepted standards of practice and facility policy. Nursing staff :

a. failed to provide wound care per accepted standards of practice and facility policy on two (2) current patients: Patient IDs # 5, #8 .

b. failed to ensure (4) of 4 current patients with indwelling urinary catheters had the catheter tubing secured per facility policy [Patient ID # 8, 9, 2, 5 ]

c. failed to measure and document the depth of Stage IV pressure ulcers per facility protocol for 9 of 11 patients (current & discharged) with Stage IV pressure ulcers [Patient IDs # 8, 29, 31, 37, 38, 39, 40, 41, 42].

d. failed to perform and document a nursing assessment for 3 shifts for Patient ID # 17.

Findings included:

TX00370713; TX00369403;TX00384558:

a. Wound care :

Review of facility policy titled "Wound Care Guidelines/ Protocol,"dated 12/05/2021, showed treatment modalities for Stage 1-IV and unstagebale ulcers.

Record review of facility "Daily Wound Report" dated 8/03/2022 : showed two current (2) patients with Stage IV sacral pressure ulcers [Patient ID # 5, # 8].

Patient # 8:

Observation on 8/3/2022 at 10:10 AM showed Staff -H, RN provided wound care to Patient # 8. Staff H was assisted by another RN, Staff-N.

Patient # 8 had multiple wounds: one (1) Stage IV-sacrum; one(1) Stage lll- left gluteal; 3 other wounds- not described except for location: left foot, right foot, left heel)

During wound care observation performed by Staff- H, RN- the following was observed:

1. multiple, serious deficient practices related to infection control were observed [*see Tag-0749].

2. Patient # 8 had an indwelling urinary catheter. When Staff-H turned the patient to her right side, he failed to relocate the urinary drainage bag to the other side of the bed. This resulted in tension and pulling of the drainage tubing; potential for catheter dislodging and irritation to the patient's urinary meatus.

3. Staff -H failed to gather all the supplies needed prior to beginning wound care.

4. When Staff-H went to the door to request additional supplies; he failed to close the door to maintain privacy for the patient. The door remained opened for several minutes while Staff H continued wound treatment to Patent # 8's sacrum. An unidentified staff person from the hallway closed the door.

5. After removing the old dressing from Patient # 8's sacrum, Staff-H disposed of the dressing without observing for drainage or odor.

These findings were discussed with Staff-H following the wound care observation.

Patient ID # 5

Patient # 5 had multiple wounds: one (1) left hip-surgical incision; Stage IV-right lower back; Stage lll-sacrum.

Observation on 8/3/2022 at 10:30 AM showed Staff -N , RN provided wound care to Patient # 5. Staff L was assisted by a nursing assistant.

During wound care observation with Staff- N, RN- the following was observed:

1. serious deficient practices related to infection control were observed [*see Tag-0749].

2. Patient # 5 had an indwelling urinary catheter. When Staff-N turned the patient to her right side, he failed to relocate the urinary drainage bag to the other side of the bed. This resulted in tension and pulling of the drainage tubing; potential for catheter dislodging and irritation to the patient's urinary meatus.

These findings were discussed with Staff-N following the wound care observation.

Immediately following the wound care observations of Staff-H and Staff-N, the findings were discussed with Staff-C, CNO. The CNO acknowledged the findings and said they did not meet nursing standards of practice or her expectations.

b.) Unsecured indwelling urinary catheters:

Review of facility policy titled "Urinary Catheter Use & Management Guidelines," dated 4/01/2022, showed following insertion of a "Foley" catheter to : "secure catheter properly to prevent irritation."

Observation on 8/02/2021 during initial tour of the facility showed Patients ID # 8 & 9 with indwelling urinary catheters . Staff E, RN, who accompanied surveyor was asked to show surveyor how the catheter tubing was secured to patients' leg. Neither patient had the tubing secured their leg.

During an interview with Staff C-CNO on 8/03/2022 at 1:15 PM , she stated all "Foley catheters" should be secured to the patient's leg.


38015

b.) Unsecured indwelling urinary catheters:

Observation on 8/2/22 at 9:25 am showed that Patients # 2 & 5 had urinary catheters which were not secured by any type of anchor mechanisms, which are used to prevent inadvertent dislodgment.

In an interview on 8/2/22 at 9:30 am, Staff #F, LVN she stated the Foley catheter anchors were not in use because the facility had run-out of these supplies.

Record review of facility incident reports for year 2022 showed Patient ID # 24 removed his indwelling urinary catheter on 6/11/2022 .

c. ) Wound measurements ( depth) :

Record review of facility titled "Wound Assessment," dated 12/05/2022, showed:
-wound assessments will, be done initially and every week thereafter;
-wound assessment includes the following: location of wounds; wound stage, wound measurements in cm ( length, width, and depth),

Review of facility "Daily Wound Report" from February 1,2022 through August 5, 2022 showed 11 patients with Stage IV pressure ulcers. Nine (9) of the eleven (11) patients did not have the depth of their Stage IV pressure ulcer documented [ Patient IDs # 8, 29, 31, 37, 38, 39, 40, 41, 42].

During an interview with Staff- E, RN on 8/4/2022 at 10:30 AM , she said pictures were taken weekly and measurements were determined. She was asked about measuring the depth of the wounds. Staff-E said the nurses do it and tell Staff-B, COO the measurement.

During an interview on 08/ 04/2022 at 11:15 AM with Staff C, CNO, she said all Stage IV wounds should have the depth measured weekly. The COO maintained and updated the "Daily Wound Report."

d.) Nursing assessments not performed & documented :

Review of facility policy titled "Assessment: Medical Nursing Flowsheet", dated 12/5/21, showed that Nursing Flowsheets , are to be completed every nursing shift, which is every 12 hours.

Record review on 8/5/22 of Patient #17's clinical record failed to show completed nursing assessments for three shifts: 1/10/22 for shift 7pm-7am, 1/12/22 for shift 7am-7pm, and 1/12/22 for shift 7pm-7am. Patient # 17 expired on 01/13/2022.

In an interview on 8/5/22 at 1:40 pm with Staff C, CNO, she stated that all patients must have a nursing assessment completed for every shift. The CNO was unable to locate the three nursing assessments for Patient # 17 for 1/10/2022 and 1/12/2022. She said the assessments should have been in the patient's chart.

Based on observation, interview, and record review, the facility failed to ensure patient care was assigned to nurses with appropriate education, experience, and competence; based on the complexity of patient needs.

a. the Chief Nursing Officer (CNO) was not involved in the nursing staffing and assignment processes.

b. three (3) of six (6) nurses listed by facility CNO as "ICU nurses" lacked facility ICU competencies competencies; and completion of facility CCU test and advanced EKG course.

c. three (3) RNs without ICU competencies and training provided care to critical patients who were either on ventilators or receiving critical IV medications that required frequent titration ( RN staff ID: E, G, S].

Findings included:

TX00384558; TX00370713; TX00331833; TX00363450

a.) Nursing staffing and assignment processes:

Review of facility policy titled "Staffing: Nursing," dated 12/05/2021, showed :

-Scheduling of staff is the ultimate responsibility of the Chief Nursing Officer.
-The CNO will assure that patient care assignments are made commensurate with the qualifications of nursing personnel involved and patient acuity;

Review of the job description for Staff -C, Chief Nursing Officer (CNO) , signed 01/16/2017, showed: CCO ( Chief Clinical Officer ) is responsible for making staffing decisions and completing staff assignments based on patient acuity and / or staffing grid.

During an interview on 08/04/2022 at 10:30 AM with Staff -C , CNO, she was asked to describe the nursing staffing and scheduling process. Staff-C, CNO, said that she has not made a nursing schedule for at least one (1) and a half years. She said that the schedule was done by Staff L, Respiratory Therapist /Safety Officer and then approved by Staff M, facility Medical Director. The CNO said that she has tried to explain clinical experience and patient acuity to Staff L. The CNO said that at one time she did sign off on the schedules but no longer does that.

b.) ICU Nursing staff -ICU training / ICU competencies :

Record review on 08/04/2022 of facility policy titled " Orientation of Personnel ," dated 12/05/2021, showed : "Nursing Orientation will consist of two days or longer.... " This policy failed to address nursing competencies ( ICU, medical/surgical, geriatric); nursing-specific training, or testing requirements ( i.e. EKG, IV medications, etc..). [cross reference to Tag A-0057]

During an interview on 08/04/2022 at 3:30 PM with Staff -C , CNO, she said all RNs scheduled for and providing care for ICU patients should have ICU orientation competencies; CCU/ICU test; and the Advanced EKG test. She went on to say that she would expect ICU nurses to have 2 to 3 years experience in ICU and have proficient understanding of titration of critical IV drips such as epinephrine, levophed and others.

The CNO provided a list of the six(6) ICU nurses employed by the facility :Staff T, R, S, G, E, H- all staff RNs. The surveyor and the CNO reviewed these files together

Review of Staff T, H, Rs personnel and training records showed documentation of ICU /CCU competencies; CCU/ICU test; and Advanced EKG test. They included the components (*not all inclusive):

1. Basic & advanced EKG interpretation;
2. Knowledge of dosage calculations; drug titration; mechanism of action; side effects; and safe administration of high- risk critical care IV drugs such as Levophed, Nipride, Amiodarone, Dopamine, and others.
3. Assessment and care of ICU patients on ventilators and those with: central IV lines; tracheostomies; chest tubes, PEG tubes, N/G tubes & receiving TPN.
4. Knowledge of waived testing procedures ; critical lab values; blood administration; ABG interpretation; cardiogencic shock; pulmonary embolism; diabetic ketoacidosis; DVT; and many others.

Review of the personnel files of "ICU RNs" -Staff E, G, & S failed to show these nurses had completed facility ICU /CCU competencies; CCU/ICU test; and the Advanced EKG test. The CNO said at the time of review all nurses providing care for ICU patients should have these ICU/CCU competencies and tests completed.


38015


c.) RNs with no facility ICU training/ competencies : assigned to ICU Patients-[multiple days] :

Observation on 08/02/2022 at 9:15 AM during initial tour showed Staff-E , RN assigned to Patient # 8, who was on a ventilator. It was later determined Staff-E had no facility ICU training or ICU competencies.

Patients on Ventilators:

Record review of facility forms titled "Respiratory Therapy Charge Master" showed the following four patients [ #12, 17,18, & 26] were on ventilators on the dates listed below.

On 08/04/2022 , surveyor and facility CNO reviewed the medical records of Patients #12, 17, 18, & 26. This record review of the nursing flowsheets showed :

-these patients were on ventilators on the days listed below;

-RNs without facility ICU training were assigned to care for these patients on multiple days ( RNs # G, S, E)

The results of the record review is as follows:

Patient #26:

RN-Staff #G on 11/1/21, 11/3/21;
RN-Staff #E on 11/1/21, 11/2/21, 11/3/21,11/4/21,11/6/21
RN-Staff #S on 11/2/21, 11/4/21, 11/5/21, 11/6/21, 11/7/21, 12/15/21

Patient #12:

RN-Staff #E on 1/3/22, 1/5/22, 1/6/22
RN-Staff #S on 12/30/21, 12/31/21, 1/1/22, 1/2/22, 1/6/22, 1/7/22, 1/8/22, 1/9/22

Patient #18 :

RN-Staff #E on 12/29/21, 12/30/21, 1/3/22
RN-Staff #S on 12/25/21, 12/26/21, 12/28/21, 12/30/21, 12/31/21, 12/31/21, 1/1/22, 1/2/22

Patient #17 :

RN-Staff #E on 1/6/22, 1/10/22, 1/13/22
RN-Staff # S on 1/6/22, 1/7/22, 1/8/22, 1/9/22

During an interview on 8/4/22 at 2:30 pm with Staff -C, CNO, she verified that RN-Staff RNs #'s E, G, & S did not have facility ICU training or competencies .

Administration of critical IV medication:

Further review of the clinical records of Patients # 12 and # 17 showed:

-1/06/2022 : Patient # 12: Staff E, RN, administered Levophed 3 mcg continuous IV drip ordered to titrate " to maintain systolic blood pressure above 95 (mm Hg)"-[7A-7P]

-1/10/2022: Patient # 17 : Staff E, RN, administered Levophed 3 mcg continuous IV drip ordered to titrate "to maintain systolic blood pressure above 95 (mm Hg)"-[7A-7P]

[* Levophed is a vasopressor , similar to adrenaline, used to treat life-threatening low blood pressure (hypotension) that can occur with certain medical conditions or surgical procedures. Levophed is often used during or after CPR .]

LEVOPHED - Black Box Warning [drug label /manufacturer insert]: Common adverse reactions include bradyarrhythmia, hypertension, extravasation injury, necrosis, nausea, vomiting, confusion, headache, tremor, anxiety, restlessness, and urinary retention.

On 08/04/2022 , facility CNO reviewed the medical records of Patients #12, 17 and verified Staff E , RN had administered Levophed and did not have the required ICU training/competencies completed .

Based on observation and interview, the facility medication room was left unsecured with the door propped opened on 8/03/2022.

- the medication room door was secured following surveyor intervention.

Findings included:

TX00384558

Review of facility policy titled: "Security of Pharmacy and Medications," dated 12/6/2021, showed:

-DRUG STORAGE AND DRUG PREPARATION AREAS: Security of drug storage shall be maintained in accordance with federal, state and local laws;
-Access to drug storage areas is limited to pharmacy personnel and persons authorized to handle and administer these drugs

Findings included:

Observation on 08/03/2022 at 10:25 AM showed Staff-N, RN preparing to perform wound care. He obtained wound care supplies from the medication room. He propped the medication room door open with a chair.

When Staff-N exited the medication room, he left the door propped open and failed to secure the room. Staff-N then entered Patient # 5's room.

Surveyor located Staff-C, CNO, and informed her the medication room door was wide-open and room unattended. The CNO proceeded to secure the medication room and informed the surveyor it was done.

Based on observation, interview, and record review, the facility failed to employ effective methods to prevent and control infections within the hospital and other settings. The facility :

a. failed to ensure nursing staff implemented: appropriate use of gloves; hand hygiene; and methods to prevent contamination of medication/solutions; open sacral wound; bed rails; door handles; and clean linen;

b. failed to ensure Infection Control policies were updated according to professional guidelines (CDC) ; there were no policies related to COVID-19;

c. failed to ensure healthcare staff followed CDC requirement for mask-wearing based on current community COVID transmission level;

d. failed to maintain the wound care supply cart in a clean and sanitary manner.

Findings included:

TX00370713; TX00369403;TX00384558:

Review of facility policy titled "Hand Hygiene," dated 12/5/2021, showed:

-"Hand hygiene is the single most effective method for preventing the transmission of infection."

- Indications for hand hygiene include : between contacts with different care sites on same patient ( moving from a contaminated body site to a clean body site); after removing gloves.

Review of facility policy titled "Isolation Precautions,"dated 12/5/2021, showed: -change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms

a. Nursing staff: glove usage, hand hygiene, contamination issues:

Staff-H, RN & Staff-N : wound care observation:

Observation on 8/3/2022 at 10:10 AM showed Staff -H, RN provided wound care to Patient # 8. Staff H was assisted by another RN, Staff-N.

Patient # 8 had multiple wounds: one (1) Stage IV-sacrum; one(1) Stage lll- left gluteal; 3 other wounds- not described except for location: left foot, right foot, left heel)

During wound care observation performed by Staff- H, RN- & Staff-N, RN the following infection control deficient practices were observed:

Staff-H, RN :

1. Staff-H, RN entered the medication room and obtained the needed medication & solutions ordered for the wound care treatment. Staff-H, took 3 small medication cups and placed: betadine in 1 cup; triple antibiotic ointment in 1 cup ; and ExSept-Plus wound cleaning solution in the 3rd cup.

-Staff-H then stuck 3 fingers of his right ( ungloved ) hand, one finger each, into the 3 cups. His bare fingers were noted to be touching the antiseptic, wound cleanser, & antibiotic. He transported the 3 cups into Patient # 8's room with his fingers stuck into the cups.

-When Staff-H passed by the nurses's station carrying the cups in this manner, Staff-M, facility medical director, was heard pointing-out this issue to Staff-H. Despite being given this information, Staff-H utilized the contaminated contents to perform wound care on Patient # 8.

2. During the wound care treatment, it was necessary for Staff-H to clean a large amount of loose feces from Patient # 8's buttocks.

- While wearing feces-contaminated gloves, Staff-H removed the old dressing from the patient's Stage IV sacral wound. Staff-H slid his fingers under the tape to loosen the dressing. It appeared that his contaminated fingers were positioned close to the wound.

3. Staff-H, RN failed to sanitize his hands between glove changes at least five (5) times during the wound care treatment.

4. Staff-H applied petroleum jelly to the area surrounding the patient's sacral wound. He applied the jelly using a gloved finger. Using the same gloved singer, he applied triple antibiotic to the sacral wound, potentially introducing petroleum jelly into the wound.

5. When Staff H completed the wound care treatment, he removed his gloves and failed to sanitize his hands before leaving the patient's room.

Staff-N, RN :

1. Staff-N assisted in cleaning feces from the patient's buttock's. He did not change his gloves after finishing.

2. While wearing feces-contaminated gloves , Staff-N grasped the patient's room door handle and exited the room. He contaminated the door handle. He walked to the linen cart and reached into it wearing the same gloves. He contaminated the clean linen he touched in the cart.

3. Wearing the same contaminated gloves, Staff-N returned to Patient # 8's room. He assisted in repositioning the patient. This included touching her pillow and the side rails of the bed, contaminating both of them.
~~~

4. On 08/03/2022 at 10:30 AM , Staff N was observed providing wound care to Patient # 5. He changed his gloves several times without sanitizing his hands in between.

5. When Staff N completed the wound care treatment, he removed his gloves and failed to sanitize his hands prior to leaving the patient's room.

Immediately following the wound care observations of Staff-H and Staff-N, the findings were discussed with Staff-C, CNO. The CNO acknowledged the findings and said they did not meet facility policy or nursing standards of practice.


b. Infection control policies outdated; no policies related to COVID-19:

Review off all infection control policies provided by Staff B-COO, IC person, showed:

1. "Isolation Precautions,"policy dated 12/5/2021, showed:

a. no mention of COVID 19
b. ISOLATION PRECAUTIONS QUICK REFERENCE GUIDE ( facility capitalization) Updated 2/2010 ; 10 pages of diseases and conditions. It did not include precautions or any references to COVID 19.

Surveyor requested facility policy on PPE. The policy below was provided :

2. "Admission Screening Protocol," dated 12/5/2021, showed:

Section b. "Initiation of Isolation" referred only to MRSA and MDRO positive cultures

V. Standard precautions: :"PPE includes items such as gloves, gowns, mask, respirators, and eyewear to create barriers... PPE is used as a last resort when work practices and engineering controls alone cannot eliminate worker exposure. The items selected will depend on the type of interaction a public health worker will and have withe the patient nd the likely mode of transmission..." wear a surgical masks and goggles or face shield if there is a reasonable chance that a splash or spray of blood or body fluid may occur to the eyes, mouth, or nose...,"

Surveyor reviewed the index of all facility infection control policies : there were no policies listed related to COVID-19.
b. Face mask usage per CDC guidelines:

Observation on 8/2/2022 showed Staff-F, LVN and the Unit secretary wearing masks below their noses.

Observation on 08/3/2022 showed Staff-F, LVN not wearing a mask while sitting at the nurses station. Staff -F told surveyor she did not need to wear a mask because she was not in a patient room and she was 7 feet away from the patients. Surveyor informed Staff F of the CDC guidelines related to mask wearing.

Observation on 8/2/2022 showed Staff M, facility medical director, wearing a mask below his nose in the hallway of the ICU unit.

Observation on 0/3/2022 at 10:15 AM showed Staff M, facility medical director, not wearing a mask while sitting st the nurse's station. He was asked to put on a mask.

Observation on 08/4/2022 at 11 AM, an unknown man in scrubs standing next to nurses' station - no mask.

Record review of CDC "Facemasks Dos & Don'ts for HCP," dated 6-2-2020 showed: "...Put your face mask on so it fully covers your mouth and nose. Don't wear your face mask under your nose...under your chin..."

Record review of CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," last updated 02/02/2022, showed :

"Implement Source Control Measures":

Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing

Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have:

- Are not up to date with all recommended COVID-19 vaccine doses; or
- Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or

-Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection for 10 days after their exposure, including those residing or working in areas of a healthcare facility experiencing SARS-CoV-2 transmission (i.e., outbreak); or

-Have moderate to severe immunocompromise; or

-Have otherwise had source control and physical distancing recommended by public health authorities.

While it is generally safest to implement universal use of source control for everyone in a healthcare setting, the following allowances could be considered for individuals who are up to date with all recommended COVID-19 vaccine doses (who do not otherwise meet the criteria described above) in healthcare facilities located in counties with low to moderate community transmission."

Review of "CDC Covid Community Level tracking " for Fort Bend County for August 2-5, 2022 showed the COVID community level to be "HIGH." CDC recommended actions based on current level is to wear a mask indoors (all settings).


c. Wound care cart : unsanitary

Observation on 08/2/2022 at 9:10 AM during initial tour of the facility showed a wound care supply cart in the hallway of the ICU unit..

This wound cart contained a contaminated glove; dust; dirt / debris; and stains.

Multiple areas in the drawers were not able to be cleaned due to the build-up of adhesive residue from old tape.

Later in the day on 8/2/2022, the wound care supply cart was shown to the CNO, who said this was not an acceptable practice.