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Based on observation, record review, and interview, the facility's Governing Body failed to carry out responsibilities, monitoring, and oversight to ensure facility policies and procedures were followed; and that the Conditions of Participation were met for: A.) Patient Rights, B.) Nursing Services, C.) Medical Record Services, D.) Physical Environment and, E.) Infection Prevention Control.

Findings included:

A.) The facility's Governing Body failed to ensure specific patient rights were protected and promoted, and implement their written policy and procedures that protect and promote each patient's rights for 3 of 3 patients (Patient #6, #8, and #10) reviewed with rights violations. Specifically, the facility failed to ensure:

1.) patient's rights to receive care in a safe setting for Patient #6 reviewed that sustained an injury of unknown origin resulting in a fracture to her right arm.

Refer to A 0144 for evidence of specific findings.


2.) patient's rights to be free from all forms of abuse or harassment by failing to investigate and report an allegation of abuse, neglect, and mistreatment in accordance with their policy for Patient #10 with allegations against facility staff of abuse, neglect or harassment documented.

Refer to A 0145 for evidence of specific findings, and


3.) patient rights free of restraints in accordance with the regulatory requirements and facility's restraint policy and procedures during the implementation of Hand Mitt's that were used as restraints for safety and the management of behavior for Patient #8 observed with Hand Mitt's.

Refer to A 0154 for evidence of specific findings.


B.) The facility's Governing Body failed to ensure nursing services carried out their responsibilities; and followed facility policies and procedures to ensure patient care and safety. Specifically, Nursing Services failed to:

1.) Identify Allergies for Patient #16 and Patient #26.

As a result, Patient #16 was allergic to tape and nursing staff placed tape to Patient #16's abdominal wound during wound care on 6/8/21.


2.) Document on the patient's Medication Administration Record's (MAR's) per the facility's policy and procedures when administering medications for Patient's #13, #16, #18, and #25 MAR's reviewed.

As a result, Patient's #13, #16, #18, and #25 medications administered were not documented per policy which states, the nurse will strike through the time on the MAR and write the exact time the med was administered with initials. If the medication was not administered at the designated time it is circled with a reason. Review of the MARS revealed it could not be determined if medications were provided as scheduled or held. If the medication was held, rationale was not indicated on the MAR per the facility policy. Nurse did not document rationale in MARS or Nurses Notes.


3.) Notify the physician for ordered medication that was not available for administration.

As a result, Patient #16 did not receive Erythromycin as ordered by the physician and nursing staff did not notify the physician that the medication was not available.


4.) Follow Physician orders for Fentanyl Patches and Follow the facility's policy and procedure for the removal and replacement of Fentanyl Patches for Patient's #16 and #25.

As a result, Patient #16's Fentanyl Patch was removed on 6/7/21 before the expiration of 72 hours, in accordance with the PO and was not replaced.


5.) Implement the policy and procedure for first dose monitoring of medication(s) a patient has never received before; documented on the MAR as, ZZ-First Dose Response Monitor. Review of all sampled patient's (Patient #1-#26) MAR's revealed every patient had a standard "ZZ-First Dose Response Monitor" under the Medication Column for nursing staff to complete; when a patient is administered their first dose of a new medication. Further review revealed this ZZ-First Dose Response Monitor was not completed in accordance with the facility's policy. The MAR included the Drug to be written, Nurse name, Education Given: yes/no, and to observe the patient for 24 hours.

As a result, Patient #16 who was allergic to pain medications and tape/adhesive received a First dose for a Fentanyl patch on 5/31/21 and the nursing staff did not complete the ZZ-first dose for the Fentanyl patch on the MAR.


6.) Dialysis Nursing staff failed to ensure Infection Control procedures during Hemodialysis (HD) treatments and ensure the HD machine #159 was bleached with a Chemical/Rinse at least once every seven (7) days.


7.) Nursing staff failed to ensure the Crash Cart contained an Ambu-bag present in accordance with the documentation and facility policy.

Refer to A0392 for evidence of specific findings.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Nursing Services.


C.) The facility's Governing Body failed to ensure there was an effective medical record service that maintained physical and administrative responsibility for medical records. Specifically, the facility failed to:


1). ensure medical records were stored in a secured location; protected from access by unauthorized individuals.

Refer to A0441 for evidence of specific findings.


2). ensure medical records were complete.

Refer to A0449 for evidence of specific findings.


D.) The facility's Governing Body failed to maintain the overall hospital physical plant environment in a manner that ensured the safety and well-being of patients. These deficient practices placed the patients' health and safety at risk.

Refer to A 0701 for specific evidence of findings.


E.) The facility's Governing Body failed to provide a sanitary environment to avoid sources and transmission of infectious and communicable diseases.

Refer to Tag A0749 for evidence of specific findings.


Refer to Conditions of Participation's at: A0115, A0385, A431, A700, A747 for evidence of specific findings.


The cumulative effect of these deficient practices and Conditions of Participation's not met; resulted in the facility's inability to meet the Condition of Participation for Governing Body.

Based on record review and interview, the facility failed to ensure specific patient rights were protected and promoted, and implement their written policy and procedures that protect and promote each patient's rights for 3 of 3 patients (Patient #6, #8, and #10) reviewed with rights violations. Specifically, the facility failed to ensure:

1.) patient's rights to receive care in a safe setting for Patient #6 reviewed that sustained an injury of unknown origin resulting in a fracture to her right arrm.

Refer to A 0144 for evidence of specific findings.


2.) patient's rights to be free from all forms of abuse or harassment by failing to investigate and report an allegation of abuse, neglect, and mistreatment in accordance with their policy for Patient #10 with allegations against facility staff of abuse, neglect or harassment documented.

Refer to A 0145 for evidence of specific findings, and


3.) patient rights to be free of restraints in accordance with the regulatory requirements and facility's restraint policy and procedures during the implementation of Hand Mitt's that were used as restraints for safety and the management of behavior for Patient #8 observed with Hand Mitt's.

Refer to A 0154 for evidence of specific findings.


The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Based on observation, record review, and interview, the facility failed to ensure nursing services carried out their responsibilities; and followed facility policies and procedures to ensure patient care and safety. Specifically, Nursing Services failed to:

1.) Identify Allergies for Patient #16 and Patient #26.

As a result, Patient #16 was allergic to tape and nursing staff placed tape to Patient #16's abdominal wound during wound care on 6/8/21.


2.) Document on the patient's Medication Administration Record's (MAR's) per the facility's policy and procedures when administering medications for Patient's #13, #16, #18, and #25 MAR's reviewed.

As a result, Patient's #13, #16, #18, and #25 medications administered were not documented per policy which states, the nurse will strike through the time on the MAR and write the exact time the med was administered with initials. If the medication was not administered at the designated time it is circled with a reason. Review of the MARS revealed it could not be determined if medications were provided as scheduled or held. If the medication was held, rationale was not indicated on the MAR per the facility policy. Nurse did not document rationale in MARS or Nurses Notes.


3.) Notify the physician for ordered medication that was not available for administration.

As a result, Patient #16 did not receive Erythromycin as ordered by the physician and nursing staff did not notify the physician that the medication was not available.


4.) Follow Physician orders for Fentanyl Patches and Follow the facility's policy and procedure for the removal and replacement of Fentanyl Patches for Patient's #16 and #25.

As a result, Patient #16's Fentanyl Patch was removed on 6/7/21 before the expiration of 72 hours, in accordance with the PO and was not replaced.


5.) Implement the policy and procedure for first dose monitoring of medication(s) a patient has never received before; documented on the MAR as, ZZ-First Dose Response Monitor. Review of all sampled patient's (Patient #1-#26) MAR's revealed every patient had a standard "ZZ-First Dose Response Monitor" under the Medication Column for nursing staff to complete; when a patient is administered their first dose of a new medication. Further review revealed this ZZ-First Dose Response Monitor was not completed in accordance with the facility's policy. The MAR included the Drug to be written, Nurse name, Education Given: yes/no, and to observe the patient for 24 hours.

As a result, Patient #16 who was allergic to pain medications and tape/adhesive received a First dose for a Fentanyl patch on 5/31/21 and the nursing staff did not complete the ZZ-first dose for the Fentanyl patch on the MAR.


6.) Dialysis Nursing staff failed to ensure Infection Control procedures during Hemodialysis (HD) treatments and ensure the HD machine #159 was bleached with a Chemical/Rinse at least once every seven (7) days.


7.) Nursing staff failed to ensure the Crash Cart contained an Ambu-bag present in accordance with the documentation and facility policy.

Refer to A0392 for evidence of specific findings.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Nursing Services.

Based on observation, record review, and interview, the facility failed to ensure there was an effective medical record service that maintained physical and administrative responsibility for medical records. The facility failed to:

1). ensure medical records were stored in a secure location, protected from access by unauthorized individuals.

Refer to A0441 for evidence of specific findings.


2). ensure medical records were complete.

Refer to A0449 for evidence of specific findings.


The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Medical Records.

Based on observation, interview, and record review, the facility failed to maintain the overall hospital physical plant environment in a manner that ensured the safety and well-being of patients.

These deficient practices placed the patients' health and safety at risk.

Refer to A 0701 for specific evidence of findings.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Physical Environment.

Based on observations, interviews, and records review, the facility failed to provide a sanitary environment to avoid sources and transmission of infectious and communicable diseases.

Refer to Tag A0749 for evidence of specific findings.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Infection Control and Prevention.

Based on record review and interview, the facility failed to ensure Patient #6's rights to receive care in a safe setting.
Patient #6 sustained an injury of unknown origin resulting in a fracture to her right arm.

Findings included:

Review of Complaint TX00378778 revealed the complainant reported that she was contacted 2/18/21 regarding her family member (Patient #6); that she had a broken right arm. The facility reported to her that there was swelling noted to the arm so then x-rays were ordered. The x-rays showed a fracture. The hospital did not know how it was broken and stated to the complainant that "they were investigating. The arm was placed in a sling."

Review of the facility's Incident Reports Binder revealed there was not an incident report completed or evidence of an investigation conducted on behalf of Patient #6; who sustained an injury of unknown origin resulting in a fracture to her right arm.


Review of Patient #6's Nursing Additional Narrative Notes revealed the following documentation:

2/17/21 at 19:00 Received Report. Patient (Pt.) withdrawing to pain, crepitus palpated to right humerus. X-ray right arm ordered by Physician-A. PRN (as needed) pain med given to Pt.

"late entry for 2/18/21, 10:27AM [Physician-A] notified of R [right] arm x-ray results."

"late entry for 2/18/21, 13:15 Daughter named [family member] notified of R arm x-ray results.

Review of the Physician Orders (PO) for Patient #6 dated 2/17/21 at 20:00 revealed a telephone order by Physician -A: "Right arm humerous x-ray in am [morning], Right elbow x-ray in am, right shoulder X-ray in am."

Review of Patient #6's Plan of Care from 2/2/21 through 3/12/21 revealed there was not any updates to her Plan of Care following the diagnosis of a right arm fracture.

Review of the Case Management Progress Notes for Patient #6 dated 2/18/21 at 10:45 documented "right humerous/elbow/shoulder x-ray will be done today. "

Further review of Patient #6's CM Progress notes dated 3/11/21 at 10:15 documented "can't turn her to right side because of fracture."

Review of the Physician's Progress Notes for Patient #6 from 2/18/21 through 3/12/21 which included 2/18/21, 2/19/21 and 2/20/21, revealed no documentation from Patient #6's Physician-A regarding the X-ray results of a broken right arm, no documentation from Physician-A regarding an assessment of Patient #6's broken right arm, and no documentation from Physician-A regarding any orders for treatment for Patient #6's broken right arm.

Review of Patient #6's entire medical record with the Chief Nursing Officer (CNO) present revealed the radiology report for the x-ray obtained 2/18/21 was not available for review.

Review of Patient #6's Discharge Summary dated 3/12/21 completed by Physician-A revealed Patient #6 was to be discharged today to a named facility (assisted living facility). The Discharge Summary listed extremities as 1 + (plus) edema. There is no documentation of a right arm fracture. The Assessment listed diagnosis of: Pneumonia, tracheostomy, ventilator dependent, hypertension, Parkinson's disease, malnutrition, and respiratory failure. There was no documentation, assessment or plans listed on the Discharge Summary that included the diagnosis, assessment or care plan for Patient #6's right arm fracture.

Interview on 6/10/21 at 11:25 AM with the facility's CNO stated, she filled out an incident report for Patient #6's discovered injury. The CNO stated, she gave the incident/injury report to the Quality Coordinator (QC) and did not have a copy available. The CNO confirmed the above findings which included the following: Patient #6's Plan of Care was not updated following the right arm fracture. Patient #6's Physician-A did not document any evidence of a diagnosis, an assessment, or any treatment (if any) following the findings of a broken right arm on his Progress notes reviewed 2/18/21, 2/19/21, and 2/20/21. Patient #6's record did not include the radiology report for the x-ray obtained 2/18/21. Patient #6's Discharge Summary did not include the diagnosis, assessment or care plan for Patient #6's right arm when she was discharge to another facility for care.

Interview on 6/10/21 at 11:30 AM with the QC reviewed the facility's Incident Reports Binder and additionally confirmed there was no incident report completed or evidence of an investigation conducted on behalf of Patient #6; who sustained an injury of unknown origin resulting in a fracture to her right arm. The QC was asked if there was an occurrence log to keep track of the incidents that are completed and sent to Quality Management for review and processing and the QC responded there was no log but it had been recommended by their last accreditation survey.

Based on record review and interviews, the facility failed to ensure patient's rights to be free from all forms of abuse or harassment by failing to investigate and report an allegation of abuse, neglect, and mistreatment in accordance with their policy for 1 of 1 patients reviewed (Patient #10) with allegations against facility staff of abuse, neglect or harassment documented.

As a result, these allegations were not thoroughly investigated by the facility for the possible identification of physical abuse or mistreatment and there was no evidence these allegations were reported to Texas Department of State Health & Human Services; in accordance with their policy.

This deficient practice could affect the prevention of possible unidentified abuse, neglect, or mistreatment for all patients in the facility; by compromising their safety.

Findings included:

Review of the facility's Incident Reviews revealed a Complaint/Grievance form dated 4/19/21 at 12:30 PM, completed by the Chief Nursing Officer (CNO) which documented the following:

Patient #10 alleged the following: Patient #10 explained that she could hear staff laughing at her over the weekend and not answering her calls for assistance. She stated that she threw things at the door to try and get someone's attention. She stated that she was wet for a couple of hours and not one checked on her to see if she needed changes. She also stated that a Nurse - Staff #17 was rough when she did change her and "slapped her hand."

The immediate corrective action taken was documented by the CNO that indicated a skin assessment was done by a nursing staff #15 and shifted assignments for Nurse-Staff #17 so that she would no longer care for this patient. CNO further stated she would get Nurse- Staff #17 to get her a statement.

The Investigative Findings (E:) was blank. Investigation conducted by and the date completed was blank.

The Conclusions of Review/Actions Taken indicated the following documented by the Quality Coordinator (QC):
No additional findings noted. Patient is receiving round the clock care by Nursing. Respiratory Therapist in am. I witnessed several people enter her room and it was also noted by PM therapist that the majority of this night was spent in the patient's room assisting her alongside her nursing staff. Day personnel also voiced the same as the night personnel. No one noted any kind report of abuse. Report was relayed to husband and patient was completely stable. A report of self reporting was placed on non- long term care (LTC) Texas Unified Licensure Information Portal (TULIP) site .

Review G: Feedback to Patient and Family: revealed it was blank. There was no information that a written response was sent or delivered to the patient and/or patient's family.

Further review revealed there were not any statements available to review. There was not an assessment documented for Patient #10's following the allegations.

Review of Patient #10's Nursing Narrative Notes for 4/19/21 completed by Nurse Staff #15 revealed there was not any specific documentation of a skin assessment done for Patient #10 following the allegation that she was "slapped" to her hand.

Interview on 6/10/21 at 10:45 AM with the facility's CNO confirmed there was no documented assessment of Patient #10's hand following the allegation that she was "slapped." The CNO stated, she looked at her hand and did not see any injury, however, confirmed she did not document her visual assessment. The CNO also stated that the nurse who was named as the person who "slapped" Patient #10's hand stated she was "tapping for an IV." The CNO confirmed there was no statement where the nurse indicated this is what she did.

Review of the TULIP website on 6/7/21 with the QC present revealed there was not a self-reported incident dated 4/19/21 received by the facility's QC on behalf of Patient #10.

Review of the facility's Abuse, Reporting Suspected Abuse Policy #Cl-2.5 last revised 12/20 revealed the following, in part;
Report immediately any abuse, neglect or illegal, unethical, or unprofessional conduct in accordance with Texas Health and Safety Code 162.132 (e) to the Texas Department of State Health & Human Services Complaint Line at 1-888-973-0022 and/or EMAIL to: cii.hcq@hhsc.state.tx.us

Reporting procedures included if abuse is alleged by a patient against a hospital employee, the patient will immediately be removed from the staff members care. The staff member will be suspended while a full investigation is undertaken. Further steps will be determined based on the investigation results.

Interview on 6/7/21 at 4:10 PM with the Quality Coordinator stated, he had one incident of abuse/neglect that he self-reported on 4/19/21 to the Texas Health and Human Services- TULIP website on behalf of Patient #10. The QC was asked if he received a case number or an email confirmation that he reported this allegation of abuse/neglect and he responded that he did not have a case number or an email confirmation received. He said he had difficulty reporting online because of password issues.

Based on record review and interview, the facility staff failed to ensure patient rights to be free of restraints in accordance with the regulatory requirements and facility's restraint policy and procedures during the implementation of Hand Mitt's that were used as restraints for safety and the management of behavior for 1 of 1 Patient observed (Patient #8) with Hand Mitt's.

Specifically,

Patient #8 had large bulky padded Hand Mitt's on both hands being used as a restraint due to the Velcro straps secured strictly around both wrists preventing the patient to remove independently and preventing the ability of Patient #8 to use her hands.

As a result, the regulatory restraint requirements were not met for physician orders, monitoring, documentation, and assessments for Patient #8.

Findings included:

Observations on 6/9/21 at 11:00 AM conducted at facility (A) of Patient #8 in room #4 revealed the following:

Patient #8 had on large bulky padded white mittens (mitt's) to both hands with Velcro straps secured around both wrists. The left padded mitten's Velcro strap had also attached to Patient #8's bed sheet and she kept trying to lift up her left hand unsuccessfully. Patient #8 was also seen putting her right padded mitten underneath her left armpit area and trying to pull off the left-handed padded mitten unsuccessfully. The mittens were secured around both wrists tight enough that would not allow the patient to remove independently.

Further observations at 3:10 PM of the padded mittens used revealed they were the "Posey Peek-A-Boo Mitt's 2811." Description of the product: A double padded mitt to hinder picking and tube pulling. Mitt's include a hook and loop strap closure for fastening around the wrist.

The instruction information sheet included with the Posey Mitt's provided information about adverse reactions: Severe emotional, psychological, and physical problems may occur if a patient's movement is severely limited. The patient may become restless or agitated if the device is uncomfortable or severely limits movement. Request assistance from a qualified medical authority for an alternative product or intervention.

Warning label: If this device is applied too tightly, circulation will be impaired; If too loose, the patient may be able to slip his/her limb from the device. Check circulation frequently and monitor for skin discoloration.

Review of the facility's Restraint Reduction Plan policy #CL-6.0 revealed the following, in part; The policy required that a physician or other licensed independent practitioner (LIP) responsible for the care of the patient order restraint prior to the application of restraint.

Hand Mitts- If the mitts are applied so tightly that the patient's hand or fingers are immobilized, this would be considered restraint and the requirements would apply. Likewise, if the mitts are so bulky that the patient's ability to use their hands is significantly reduced, this would be considered restraint.

The policy included a Non-Behavioral Restraint Flow Sheet which included monitoring for skin integrity/circulation every 2 hours.

Review of Patient #8's medical record revealed there was not a physician or LIP order for the use and application of Hand Mitts.

Review of Patient #8's medical record revealed there was no documentation of monitoring for Patient #8's skin integrity/circulation after the application of the Hand Mitts. There was no documentation that a physician or LIP ordered the use of the Mitt's.

Interview with Patient #8's Nurse - Staff #13 on 6/9/21 at 11:13 AM stated that Patient #8 was very confused and that the padded mittens were put on her "when agitated" because she was removing her Bi-Pap and oxygen tubing. Nurse - Staff #13 further stated that when Patient #8's family was present; the padded mittens were removed. Nurse -Staff #13 stated the Padded Mittens were not a restraint and that she did not need a physician's order to put on the padded mittens since she was confused and restless and it was a "safety reason" they had to put on the padded mittens. Nurse- Staff #13 further stated there was no monitoring restraint flow sheet (non-behavioral) checklist being used for Patient #8's padded mittens to ensure appropriate circulation and skin integrity.

Interview on 6/9/21 at 1:35 PM with the facility's Chief Nursing Officer (CNO) stated, the padded mitts were not seen as a restraint unless the mitts had ties; then it was considered a restraint. Further interview at 02:00 PM with the CNO stated, the padded mitts were removed from Patient #8; stating "it wasn't working anyhow." The CNO stated Patient #8 was still able to knock off the oxygen tubing with the padded mitt on.

The hospital failed to discharge their responsibilities effectively in providing nursing care and that followed the facility's policies and procedures to ensure patient care and safety. Specifically, Nursing Services failed to:

1.) Identify Allergies for Patient #16 and Patient #26.

As a result, Patient #16 who was allergic to tape, the nursing staff placed tape to Patient #16's abdominal wound during wound care on 6/8/21.


2.) Document on the patient's Medication Administration Record's (MAR's) per the facility's policy and procedures when administering medications for Patient's #13, #16, #18, and #25 MAR's reviewed.

As a result, Patient's #13, #16, #18, and #25 medications administered were not documented per policy which states that the nurse will strike through the time on the MAR and write the exact time the med was administered with initials. If the medication was not administered at the designated time, it is circled with a reason. Review of the MARS revealed, it could not be determined if medications were provided as scheduled or held. If the medication was held, rationale was not indicated on the MAR per the facility policy. Nurse did not document rationale in MARS or Nurses Notes.


3.) Notify the physician for ordered medication that was not available for administration.

As a result, Patient #16 did not receive Erythromycin as ordered by the physician and nursing staff did not notify the physician that the medication was not available.


4.) Follow Physician orders for Fentanyl Patches and follow the facility's policy and procedure for the removal and replacement of Fentanyl Patches for Patient's #16 and #25.

As a result, Patient #16's Fentanyl Patch was removed on 6/7/21 before the expiration of 72 hours in accordance with the physician's order and was not replaced.


5.) Implement the policy and procedure for first dose monitoring of medication(s) a patient has never received before, documented on the MAR as, ZZ-First Dose Response Monitor. Review of all sampled patient's (Patient #1-#26) MAR's revealed that every patient had a standard "ZZ-First Dose Response Monitor" under the Medication Column for nursing staff to complete when a patient is administered their first dose of a new medication. Further review revealed, this ZZ-First Dose Response Monitor was not completed in accordance with the facility's policy. The MAR included the drug to be written, nurse name, education given: yes/no, and to observe the patient for 24 hours.

As a result, Patient #16 who was allergic to pain medications and tape/adhesive received a first dose for a Fentanyl patch on 5/31/21 and the nursing staff did not complete the ZZ-first dose for the Fentanyl patch on the MAR.


6.) Dialysis Nursing staff failed to ensure Infection Control procedures during Hemodialysis (HD) treatments and ensure the HD machine #159 was bleached with a Chemical/Rinse at least once every seven (7) days.


7.) Nursing staff failed to ensure that the Crash Cart contained an Ambu-bag present in accordance with the documentation and facility policy.


Findings included:

1.) Identify Allergies for Patient's #16 and #26

Review of Patient #16's Routine Admission Orders dated 5/31/21 revealed, (DM) Exp Allergies documented as the following: Codeine, Morphine, Zofran, Novocain, Novahistine, Dextromethorphan (DM) Expectorant with Decongestant, Adhesive Bandage.

Review of Patient #16's Daily Nursing Notes dated 6/8/21 documented allergies as; codeine, morphine, and Zofran. There was no documentation to include allergies to Novocain, Novahistine, DM Expectorant with Decongestant, Adhesive Bandage.

Review of Patient #16's MARS revealed allergies documented as: Codeine, Morphine, Zofran, and Novocain. There was no documentation to include allergies to Novahistine, DM Expectorant with Decongestant, Adhesive Bandage.

Observation on 6/8/21 at 12:45 PM of Patient #16 revealed a red wristband for allergies that did not have any allergies listed.

Interview on 6/8/21 at 12:47 PM with the Chief Nursing Officer - Staff #4 confirmed that Patient #16's red wristband used for allergies did not have any allergies listed.

Interview on 6/8/21 at 06:00 PM with Patient # 16's family member/daughter present stated, Patient #16 had allergies "to any type of pain medicine related to anything with Codeine, Morphine, or Novocain" and further stated, Patient #16 had allergies to "every kind of tape." The daughter stated that Patient #16 had Hernia surgery and the tape used for the Hernia surgery made her skin come off. Patient #16's daughter stated today (6/8/21) she saw her mother with tape on her abdominal wound and said, "they have forgotten, and put tape on there. I have told them to take it off." She stated, the nurse today went to change her dressing that was supposed to just be a cloth and binder; and saw that Patient #16 had tape on her.

Review of the Physician Orders dated 6/1/21 documented for Patient #16's mid abdominal wound: Cleanse with NS pat dry, use NS wet to dry packing with dressing cover with abdominal pad. Change TID (three times daily) "No tape."

Review of the Occurrence/Incident Report dated 6/8/21 at 12:15 that was made available on 6/9/21 documented the Wound Care Nurse-Staff #8 noted upon wound care treatment of Patient #16 that patient had "medipore" tape to surgical abdominal-Abd pad. The tape was gently removed, skin assess no irritation noted to peri wound. Daughter at bedside noted patient with no irritation to skin. Current wound care orders for no tape to wound. Secure with abdominal binder. Will continue to monitor.

Interview on 6/9/21 at 10:25 AM with Wound Care RN- Staff #8 regarding Patient #16 stated, Patient #16 was found by her to have adhesive tape across her dressing change from previous wound care treatment on 6/8/21. She stated, "the daughter told me about the tape upon admission. I put no tape on my orders." The Wound Care RN- Staff #8 confirmed, she did not follow up with the nursing supervisor upon finding this incident and further confirmed, she did not complete an Incident Report until the next day after the incident on 6/9/21.


Review of Patient #26's Routine Admission orders dated 1/5/21 revealed, she was admitted for diagnosis to include; sepsis, endocarditis, and respiratory failure. Further review revealed, allergies listed as Penicillin.

Review of the Inpatient Hemodialysis Treatments dated; 1/7/21, 1/9/21, 1/12/21 1/14/21, 1/16/21, and 1/19/21 failed to identify Patient #26's medication allergy to Penicillin. The HD treatment records documented "NKDA" (no known drug allergies) for allergies.


2.) Record review of Medication Administration Record's (MAR's) for Patient's #13, #16, #18, and #25 revealed medications administered were not documented per policy; which states the nurse will strike through the time on the MAR and write the exact time the med was administered with initials. If the medication was not administered at the designated time it is circled with a reason. Review of the MARS revealed, it could not be determined if medications were provided as scheduled or held. If the medication was held, rationale was not indicated on the MAR per the facility policy. Nurse did not document rationale in MARS or Nurses Notes.

Record review of the facility policy, Medication Administration Times, revised 02/2021 states in part ... "The nurse will strike through the time on the MAR and write the exact time the med was administered with initials. If the medication was not administered at the designated time it is circled with a reason, the variance must be documented and the physician notified, if clinically indicated."


a.) Patient #13
Review of Patient #13 MAR's for 2/15/21 and 2/16/21 revealed the following:

-Levemir 100 unit/ml Soln 10 mg daily at 09:00. There was no documentation for the 09:00 dosing.

-Lipitor 40mg every bedtime at 21:00. There was no documentation for the 21:00 dosing.

-NovoLog 100 unit/ml soln 10mg every 6 hours in accordance with a specified sliding scale at 06:00, 12:00, 18:00, and 24:00. There was no documentation for 2/15/21 and 2/16/21 of any dosing given.

-Swabflush saline flush 0.9% Soln 10 ml every 8 hours at 06:00, 14:00, and 22:00. There was no documentation for the saline flushes at 06:00, 14:00, and 22:00.

-Vancomycin HCL 750mg/150ml soln one dose every 36 hours scheduled for 2/15/21 at 24:00. There was no documentation for this dosing of Vancomycin on 2/15/21 at 24:00.

-Meropenem 500mg Solr one dose every 12 hours at 09:00 and 21:00. There was no documentation for the 21:00 dosing on 2/15/21.

-Mycamine 100mg Solr one dose every day at 17:00. There was no documentation for the 17:00 dosing on 2/15/21.


b.) Patient #16
Review of Patient #16 MAR's revealed the following:

6/5/21- Everyday at 18:00, AA Elec W/Cal 5% IN D15W, Multivitamin Inj, Trace Metals, Thiamine 100MG/ML Inj, Folvite 5mg/ml Inj. Drip Rate: 84 ML/HR IV Intravenous. There was no documentation for the 18:00 administration on 6/5/21.

6/6/21-Swabflush Saline Flush 0.9% Soln 10 ML every 8 hours at 06:00, 14:00, and 22:00. There was no documentation for the 14:00 flush.

6/7/21- Glucometer Check before meals and at bedtime Glucometer Check. Times were documented as 07:30, 11:30, 16:30, and 21:00. There was no documentation that Glucometer check was conducted at 21:00.


c.) Patient #18
Review of Patient #18 MAR dated 6/4/21 revealed the following:

-Carvedilol 12.5mg tabs one dose = 25mg = 2 tablets. Twice Daily with meals. Coreg 12.5 mg tab take with food. Times were indicated at 07:30 and 17:00. There was no documentation for the 17:00 dosing.

-Renvela 800 mg Tabs. One dose=1600 mg=2 tablet. Three times a day with meals at 08:00, 12:00, and 17:00. There was not any documentation for the 12:00 and 17:00 dosings.

-Glucometer Check before meals and at bedtime Glucometer check. Times were documented as 07:30, 11:30, 16:30, and 21:00. There was no documentation that Glucometer checks were conducted at 07:30, 11:30, and 16:30. The Glucometer check at 21:00 was completed and documented as 256.


d.) Patient #25
Review of Patient #25 MAR dated 6/7/21 to 6/8/21 and 5/28/21 to 5/29/21 revealed Octreotide Acetate (Sandostatin) 100 mcg/ml Inj every 8 hours at 06:00, 14:00, and 22:00. There was not any documentation for the 06:00 dosing on the MAR for 6/8/21 and 5/29/21.


Interview on 6/8/21 at 4:00 PM with the Chief Nursing Officer stated, the Clinical part of patient's records were monitored every week by completing a random audit of 10 patient records. A copy of the House Supervisor Chart Audit was provided. On the chart audit included the MAR. MAR Reconciled daily, does documentation match MAR (i.e med not given reason. Further interview with the CNO confirmed, the MAR's reviewed for Patient's #13, P#16, P#18, P#25 had medications and/or ordered treatments that were not administered or documented per the medication administrative policy.


3.) Nursing failed to notify the physician for ordered medication that was not available for administration.

Record review of the Medication Administration Record (MARS) for Patient #16 revealed, P#16 was prescribed Erythromycin 250mg IV every 8 hours.

Record review of the MARS revealed the medication was not given on 6/6/21 and 6/7/21 due to the medication not being available as documented by the nurse administering the medication.

Record review of the facility policy, Medication Administration Times, revised 02/2021 states in part ... "the nurse will strike through the time on the MAR and write the exact time the med was administered with initials. If the medication was not administered at the designated time it is circled with a reason, the variance must be documented and the physician notified, if clinically indicated."

Further review of the patient record revealed, the physician was not notified of P#16 not receiving that medication.

Interview on 6/8/21 at 12:40 pm with facility pharmacist- Staff #14 and the Chief Nursing Officer -Staff #4, both confirmed the physician should have been notified by nursing staff so the medication could have been discontinued and another medication would have been prescribed.


4.) Nursing failed to follow Physician orders for Fentanyl Patches and Follow the facility's policy and procedure for the removal and replacement of Fentanyl Patches for Patient's #16 and #25.

Review of Patient #16's MAR's revealed Fentanyl 100 MCG/HR One patch "every 72 hours," and in accordance with the physician's orders. Every 72 hours Duragesic 100 mcg/hr patch. Dispose of patch in smart sink. Nurse and witness sign MAR. Time: Initial: Witness:

Further review of Patient #16's MAR's revealed the following:

5/31/21 at 12:56 a Fentanyl patch was placed on the patient upon admission.

6/3/21 at 1:00 PM the Fentanyl patch was removed and replaced to right shoulder. No witness documented on the MAR.

6/4/21 MAR states, "No dose due."

6/5/21 MAR states, "No dose due."

6/6/21 at 1:00 PM the Fentanyl patch was removed and replaced.

6/7/21 MAR states, "No dose due."

6/7/21 Fentanyl patch was removed (within 24 hours and was not replaced) according to interview with Licensed Vocational Nurse (LVN) Staff-#13.

6/8/21 MAR states, "No dose due."


Observation on 6/8/21 at 6:30 PM revealed, Patient #16 did not have a Fentanyl patch applied to her for pain management in accordance with the physician orders and MAR.


Review of the facility's Policy and Procedure titled, Disposal of Fentanyl Patches, last reviewed/revised 2/2021 documented:

1.Upon removal, the patch will be folded in half so the adhesive sticks to itself, and placed in the Cactus Smart Sink.

2. A nurse or pharmacist will witness the destruction of the patch.

3. The nurse and the witness will document the time of the destruction of the patch on the MAR by making an entry and noting the drug, strength, and time destroyed.


Interview on 6/8/21 at 06:22 PM with LVN-Staff #13 who was caring for Patient #16 stated, she removed Patient #16's Fentanyl patch on 6/7/21 because the MAR on 6/7/21 documented "No dose due." She said, she did not think to question the "every 72 hours." LVN-Staff #13 stated, there was no physician order to remove or discontinue the Fentanyl Patch. LVN-Staff #13 confirmed that Patient #16 did not currently have a Fentanyl patch applied to her for pain management since it had been removed 6/7/21.


Interview on 6/8/21 at 7:00 PM with the facility's Chief Nursing Officer (CNO) stated, the Fentanyl patch should not have been removed on 6/7/21. It was due to be removed and replaced on 6/9/21 at 1:00 PM. CNO further stated, the Fentanyl patch is to be removed and replaced at the same time and there should be another witness when the patch is applied and removed documented on the MAR. CNO stated, they are currently trying to get a new order to replace the Fentanyl patch back onto Patient #16; since the timing was now off.


Interview on 6/9/21 at 9:55 AM with the facility's Pharmacist- Staff #7 stated, the Fentanyl disposal is done using the Smart Sink disposal process and that this process is not monitored by a Pharmacist. She stated, it should be witnessed by another nurse.


Review of Patient #25's MAR revealed Fentanyl 100 MCG/HR One patch "every 72 hours," and in accordance with the physician's orders. Every 72 hours Duragesic 100 mcg/hr patch. Dispose of patch in smart sink. Nurse and witness sign MAR. Time: Initial: Witness:


Review on 6/8/21 of Patient #25's MAR revealed, the Fentanyl patch was scheduled to have Fentanyl Patch dispensed on 6/7/21. The MAR had not been documented the Fentanyl Patch was placed on Patient #25.


Observation on 6/8/21 at 11:25 AM with House Supervisor-Staff #16 present revealed, Patient #25 did have a Fentanyl Patch affixed to his chestwall dated 6/7/21 and initialed on the patch.


Interview on 6/8/21 at 11:25 AM with the HS-Staff #16 confirmed, the MAR for Patient #25 should have been initialed for the Fentanyl patch applied on 6/7/21.


5.) Review of the facility's policy titled First Dose Administration, Monitoring and Review Policy # PH8.3, last revised 04/2020 stated the following, in part, "It is the policy of the hospital to assure patient safety with respect to medications in administering, monitoring the patient's response, and review of orders for all first dose medications that have never been previously administered to a patient.

For all first doses of medication(s) a patient has never received before, nursing shall initiate the "First Dose" monitor procedure. Pharmacy shall review and dispense medication prior to administration.

For all new First Dose Medications ("Yes" has been circled), then the nurse (prior to administration) will educate the patient to the possible side effects and evaluate all pertinent safety information regarding the patient including, but not limited to, the patient's allergies, lab results, and vital signs. As well as monitoring parameters for the specific medication(s)."


Review of all sampled patient's (Patient #1-#26) Medication Administration Records (MAR's) revealed, every patient had a standard "ZZ-First Dose Response Monitor" under the Medication Column for nursing staff to complete when a patient is administered their first dose of a new medication. Further review revealed this ZZ-First Dose Response Monitor was not completed in accordance with the facility's policy. The MAR included the Drug to be written, Nurse name, Education Given: yes/no, and to observe the patient for 24 hours.


Review of Patient #16's Routine Admission Orders dated 5/31/21 revealed, (DM) Exp Allergies documented as the following: Codeine, Morphine, Zofran, Novocain, Novahistine, Dextromethorphan (DM) Expectorant with Decongestant, Adhesive Bandage.


Review of Patient #16's MARS revealed on 5/31/21 at 12:56, a Fentanyl patch was placed on the patient for pain management. Further review of the ZZ-first dose of the MAR revealed the nursing staff did not complete the First Dose Monitor for the Fentanyl patch.


Interview on 6/8/21 at 06:00 PM with Patient # 16's family member/daughter present stated Patient #16 had allergies "to any type of pain medicine related to anything with Codeine, Morphine, or Novocain" and further stated, Patient #16 had allergies to "every kind of tape." Patient #16's daughter stated, she normally takes Oxycodone 30 mg, Methadone 10 mg, and Gabapentin 400 mg at home to manage her pain for Fibromyalgia and Rheumatoid Arthritis. However, they were holding her medications because she can not have anything by mouth, so they applied a Fentanyl Patch upon admission on 5/31/21. The daughter stated, she had never had a Fentanyl Patch used for pain management and was not sure if she would be affected by it due to her allergies to pain medication and tape/adhesive since the Fentanyl patch has adhesive to keep in place.


Interview on 6/8/21 at 2:40 PM with the facility Chief Nursing Office- Staff #4 stated, the ZZ first dose response monitor system is for the first time a medication is given at the facility. The nurse is supposed to write the medication down and educate the patient and monitor the patient for 24 hours.


Interview on 6/8/21 at 2:45 PM with RN - #15 stated, he wasn't sure if the ZZ first response was for new medications or for first medications given at the facility.


Interview on 6/8/21 at 2:48PM with RN - #14 stated, the ZZ first response could be for new medications or only for blood pressure medications. She couldn't remember for which one.


Interview on 6/9/21 at 9:55 AM with the facility's Pharmacist- Staff #7 stated that more education was needed for the nursing staff regarding the "first dose administration" policy and procedures.


6.) Dialysis Nursing staff failed to ensure Infection Control procedures during Hemodialysis (HD) treatments and ensure the HD machine #159 was bleached with a Chemical/Rinse at least once every seven (7) days.

Observations conducted at Facility B on 6/9/21 at 12:08 PM of a non-sampled patient receiving hemodialysis (HD) that is contracted revealed the following: machine lines of machine #159 were draped across the overflowing trashcan with dirty gowns on top of the lines. The Dialysis Registered Nurse (RN) - Staff #9 was seen touching the dirty machine without gloves while donning and doffing gloves. No hand hygiene was performed. Patient was touched with dirty gloves, open pack of gauze sitting open next to patient in the bed for use post treatment.

Review of the Machine Logs for HD machine #159 revealed the machine had not been disinfected (bleach) for the Month of June 2021; 6/1/21 to 6/9/21.

Review of the HD contracted policy titled, Infection Control Policy 736 for Cleaning and Disinfecting - Delivery System revealed that, 4. The Chemical/Rinse program should be used when disinfecting the hydraulic system using corrosive chemicals, such as bleach or peracetic-acid-based disinfectants. The Chemical/Rinse program will be done at least once every seven (7) days.

Interview with Dialysis RN- Staff #9 and Dialysis RN- Staff #10 on 6/9/21 at 12:10 confirmed that machine #159 that the unsampled patient was being dialyzed on during surveyor inspection had not been bleached for more than 7 days according to the documentation of the machine log.


7.) Nursing staff failed to ensure the Crash Cart contained an Ambu-bag present in accordance with the documentation and facility policy.

Observations conducted on 6/7/21 of Facility A at 3:40 p.m. revealed in the hallway, a Crash cart missing an Ambu bag. Resuscitation Box on top of the cart was not locked.

Record review of the crash cart log revealed facility staff documenting that the Ambu bag was present. It was documented that the Ambu bag was present the day the surveyor was observing the crash cart, 6/7/21. There was no Ambu bag present/observed.

Review of the Crash Cart/Defibrillators Policy #CL-1.11BR last revised 2/2021 stated the following, in part, "1. Each crash cart will be inspected and tested at least daily to ensure the integrity of its contents which included: f. Ambu bag is present."

Interview on 6/7/21 at 3:34 PM with the House Supervisor-Staff #2 stated, there was a code last Saturday (6/5/21) where the Ambu bag was used and that the Ambu bag should have been replaced immediately. House supervisor -Staff #2 confirmed, the documentation included the Ambu bag was present when it was not observed on the crash cart on this date. House Supervisor-Staff #2 further confirmed that the resuscitation box should have been locked.

Based on observation and interview, the facility failed to ensure the confidentiality and security of patients medical records.

Specifically, the facility stored patient medical records in an unlocked closet that allowed access of unauthorized individuals.

Findings included:

Observations conducted in facility A on 6/7/21 at 3:45 p.m. revealed, behind the nurses station was a door labeled janitors closet. Surveyor opened the janitors closet door which was unlocked. The room contained medical records that were thinned out from patients charts.

Examples of confidential patient information accessible included from the charts were: patient's medical history and treatment, along with demographic information (name, date of birth, address, phone number, social security number), and emergency contact information.

Interview on 6/7/21 at 3:50 p.m. with the facility House Supervisor confirmed there were medical records stored in the janitors closet. He further confirmed the janitors closet was not locked.

Based on record reviews and interview, the facility failed to ensure medical records were promptly completed for the following Patient's reviewed (P#6, P#10, P#14, P#16, P#18, P#19, P#20, P#23, and P#25). There were no physician signatures, dates nor times for the authentication of physician notes and physician orders for the following entries:

Findings:

P#6: Review of the physician notes from 1/5/21 through 3/12/21 revealed the dates for the following physician orders were not signed, dated, or timed ..... 1/5/21, 1/6/21, 1/7/21, 1/17/21, 1/24/21, 2/2/21, 2/3/21, 2/4/21, 2/5/21, 2/6/21, 2/7/21, 2/8/21, 2/9/21, 2/13/21, 2/14/21, 2/15/21, 2/16/21, 2/17/21, 2/18/21, 2/19/21, 2/20/21, 2/26/21, 2/27/21, 2/28/21, 2/28/21, 3/1/21, 3/2/21, 3/3/21, 3/4/21, 3/6/21, 3/7/21, 3/8/21, 3/9/21, 3/10/21, 3/11/21, 3/12/21.

P#10: Review of Physician orders revealed Telephone Orders dated 5/3/21-5/11/21 that did not have a physician signature, date or time of authentication of the telephone orders.

P#14: Review of the physician notes from 3/30/21 through 4/12/21 revealed none of the physician notes were signed, dated, or timed.

P#16: Review of the physician notes revealed her Routine Admission Notes, dated 5/31/21 was not signed, dated, or timed by the physician. The Do Not Resuscitate (DNR), dated 5/31/21 was signed by the physician, but was not dated or timed.

P#17: Review of physician notes dated 5/24/21 and Admission physician orders were not signed.

P#18: Review of the Hemodialysis consent and HD orders dated 6/4/21 were not signed, dated or timed by the physician.

P#19: Review of the physician notes from 12/8/21 through 12/12/21 revealed none of the physician notes were signed, dated, or timed.

P#20: Review of the DNR dated 5/24/21 was not signed, dated or timed by the physician. Patient's admission orders dated 5/24/21 were not signed by the physician.

P#23: Review of the physician notes from 12/21/20 through 12/25/21 revealed none of the physician notes were signed, dated, or timed.

P#25: Review of the physician notes from 5/21/21 though 6/5/21 revealed none of the physician notes were signed, dated, or timed.


Review of the facility's Medical Staff By Laws, last restated January 2018, indicated Medical Staff were to accurately and legibly prepare and complete, in timely fashion, the medical records for all patients he/she admits or in any way provides care to in the Hospital in accordance with the Rules and Regulations.


Review of the facility's Health Information Management (HIM) Reports for April 2021 revealed the number of incomplete medical records after 30 days of discharge were 100 % delinquent for facility's A and B.


Interview on 6/8/21 at 2:50 PM with the HIM coordinator- Staff #12 stated the facility had been without a HIM coordinator and that she had recently started position. She stated, she was working on a plan of correction to address the delinquent and incomplete medical records following their accrediting organization's survey. The HIM coordinator- Staff #12 stated, she would flag the charts in color coordination with a specific physician and then would contact physicians when there were present to have them complete their records.

Based on observations, interviews with facility staff, and record reviews, the facility failed to maintain the overall hospital physical plant environment in a manner that ensured the safety and well-being of patients.

Findings included:

Observations of the facility revealed the following:

1.) Deficiencies Observed June 7-10, 2021 Brownsville facility:

a. Facility-A (Brownsville, TX) is having issues with their heating, ventilation, and air conditioning (HVAC) system.

During this survey it was observed these issues were in the process of being addressed. The hospital is in the process of correcting the issues throughout the facility. The problem with the HVAC system caused excess humidity and condensation build up in different areas of the facility. Some of these issues were observed and cited on the complaint survey on May 18, 2021.

In Room 1 there is still excess humidity and condensation in the room. The hard ceiling has bubbling around the ceiling vent with much condensation on walls and windows in the room and bathroom and puddle of water on the floor from condensation; room 1 was uncomfortable in temperature.

As of June 9, 2021, tour of the room #1 it was still sealed off and closed for patient use until the conditions can be fully corrected. Rooms # 20 and 40 mentioned in the May 18, 2021 survey, the ceiling tiles were replaced in those rooms.

Throughout several areas in the entire facility, water stained or broken ceiling tiles were observed.


In an interview with the Director of Plant Operation at the Brownsville, TX facility at 2:20pm on June 10, 2021, it was explained that some of the ceiling tiles that had water stains were replaced but within a matter of time the condensation built up again and the water stains reappeared. The contractors working on the HVAC system have been at the facility the week of June 7-10 trying to install and connect computer controllers to the Roof Top Air units this should control the humidity and minimize condensation throughout the facility.


b. On June 7, 2021, during a walkthrough, beds were noticed in the hallway of the facility.

During the tour of the whole facility at Brownsville on June 09, 2021, from 11:40am-2:30pm with the Hospital & Houskeeping Systems (HHS) Director of Integrated Facilities, it was observed that the beds were no longer in the passageways. While randomly choosing patient room to observe physical environment of patient rooms several beds were found pushed into patient room # 33 in the facility. Observed water stained ceiling tiles in several of the inpatient rooms randomly selected to tour.


c. Observation in Kitchen/Dining room in facility at Brownsville: On June 9, 2020, at 11:20 am, of the kitchen area of dietary services with the interim Quality Director present, noticed corrugated boxes containing gallons of water bottles stacked at least 6 ft high in an open area close in proximity to the food preparation area and not in a storage area. Dietary service staff indicated that these boxes of water were for patients if they needed emergency water. These boxes that were stored near the food preparation and cooking areas of the kitchen could be susceptible to moisture, water, vermin, bacteria, and microbial contamination as well as a fire hazard because of its proximity to the cooking area.

- Ceiling tiles in kitchen area that were peeling, cracked, and water stained in certain areas of the kitchen.

- Observed dish washing machine was currently out of order and had not been used for at least two weeks due to leaking water.

The patients as of the week of June 7-10, 2021 were using paper plates and disposable utensils.


Interviewed the HHS Integrated Facility manager at 11:50 am on June 9, 2021, who was aware of the issue and was trying to find a means to pay for contractor services to repair the dishwasher.

Review of the 2021 Capitol Expense plan revealed the dishwasher was not included on this plan. The chief executive officer of the Brownsville facility was aware of the dishwasher being out of order.


2.) Observations of Facility A (Brownsville) on 6/7/21 at 03:38 p.m. during rounds of facility with House Supervisor- Staff #2 present revealed the following:

a. Medication Room revealed - Pill crusher chipped and cracked, handwashing sink at medication room rusted, handwashing sinks back splash at the wall dirty, missing caulk- exposed cracks and gaps between wall and counter tops. Medication refrigerator with a dirty and stained mat, plastic liner on top of refrigerator/under clean supplies was dirty and had a dry residue on it, liquid waste container was dirty with dried, exposed liquid. Crushed medication/pills were left on top of pyxis. Floor was covered in dust and pieces of trash.

b. Further observations outside the medication room, behind the nurses' station, revealed the countertop at the nurses' station had pieces of the laminate missing - leaving wood exposed. A stainless steel wheeled cart where a community patient oral thermometer was kept, was dirty. Ceiling tiles had large brown stains. AC vents in the ceiling were rusty and had dusty cobwebs.
Floor was dirty.


c. Observations in the facility supply room revealed the shelves, that carried cleaned supplies, were dirty and dusty. A dried liquid substance was dried on the shelves. An opened Suplena Supplement, that was leaking, was discovered in the supply room.


d. Observations in a "clean" patient room, identified as room 9, revealed patient call bell with large piece plastic missing exposing internal components of call bell, bedside monitor, that was identified as clean, was dusty. Under the sink in the patient room, the floor was coming up. The back splash at the wall was missing caulk, there was a gap between the backsplash and wall. The bedside remote was dusty.


e. Observation in patient room 33 revealed a chunk was missing from the wall above the headboard. The missing chunk was approximately 3 inches by 2 inches, exposing sheet rock. Further observation outside of room 33 revealed the handwashing sink was dirty and no caulking at the baseboard and wall. Cracks and gaps were exposed.


f. Continued observations in the intensive care unit revealed, the medication room handwashing sink was dirty, rusty, caulking was missing between baseboard and wall revealing cracks and gaps. Wall behind the handwashing sink was dirty. The pill crusher in the medication room was cracked and broke, the air conditioning vents in the medication room was rusty and dusty. Ceiling tiles had large stains. Observations on the floor by the Pyxis system was dirty dusty and had food crumbs.


g. The floors in the intensive care unit, the baseboards were peeling from the walls, exposing the walls which were dirty. Trash was on the floor.


h. Intensive care unit (ICU) room 39, revealed the seams at the floor were pulled up with gaps and missing laminate.


i. Observation of the physical therapy room revealed the desk had exposed plywood, no laminate. Cannot be wiped down. The ceiling tiles had large brown stains. The bathroom in the therapy room, the laminate was coming up off the floor revealing huge gaps, which could result in a trip/fall hazard, and the drain cover had black tape over it. The facility staff revealed the black tape was to cover the smell of the sewer. Further observations revealed a drawer handle was covered with tape, and a black stool had a tear at the scene exposing the fabric.


Interview on 6/7/21 at 04:20 p.m. with the HS- Staff #2 during the observations confirmed the above findings.


Interview on 6/7/21 at 4:30 p.m. with the Plant Operations (Ops) Director stated, he conducted weekly Environment of Care (EOC) rounds with the facility's Quality Coordinator (QC). The Plant Ops Director stated, he had a running list in progress and had just began creating a "work order system." The Plant Ops Director stated, he was contracted through (Hospital and Housekeeping Systems) HHS and that any maintenance repairs that will cost money or another contractor, must go through the Chief Executive Officer (CEO) for approval. The Plant Ops Director stated, if the issue was a "life-safety" concern that he would push for it to get corrected. The Plant Ops Director stated, he does not go into the Therapy rooms often and was not aware of the concerns identified by the surveyor in the PT room. The Plant Ops Director also stated that "medication rooms were off limits" to him and would not be aware of any maintenance issues in the medication rooms.


3.) Facility B- (Harlingen) observations on June 8, 2021, toured facility with the Director of Plant Ops then joined by HHS Integrated Facility Manager from 11:00am - 1:30pm:

a. Kitchen/Dining area: observed mold/dirt in lighting area, stained, and chipped ceiling tiles, dust around ceiling vents

b. Observed CT mobile trailer: Holes in tables on mobile trailer. Radiology Lead Technician was in attendance during this observation

c. Observed ICU area on June 8, 2021, bathroom being used as temporary storage area. Clean and dirty equipment being stored in the bathroom. The bathroom was unlocked. Sewer smell coming through the floor drain pipes. Facilities Director of Plant Ops stated that staff must turn on air blowers in room and run water in this bathroom sink to reduce/minimize the smell coming from the floor drains.

d. Observed some cracks in wall near sink near room 139. Notice some crack in wall from COVID walls recently taken down.

e. Observed in soil linen room soil linen in bags hanging on edge of carts edge when they should have been properly stored inside of cart.

f. observed in clean linen room. Clean linen covered in linen bags some were open and exposed to environment. There was no external covering draped over all the clean linen this poses an infection control risk.

g. Continued Observations on 6/8/21 with the facility CNO revealed the Medication refrigerator which had dirty shelves. The AC vents were observed to be rusty.

h. Further observations in the nurses' station revealed the counter tops were chipped, exposing wood. The hand washing sink backsplash at nurse's station without sealant had dirt build up and staining. A cart that held patient records was covered in dust.

i. Observations in the hallway revealed tape residue on floor in patient room #112. The residue was covered with dirt.

j. Observations in a clean, empty room 119, revealed the window blinds had cobwebs. The counter tops at the patient sink was missing laminate which exposed wood. Behind the sink in the patient room, was missing caulk/sealant where gaps were exposed between backsplash and the wall.

k. Further observations of the "30's hallways" revealed the baseboards/ co-base was pulling away from walls in hallway outside of patient rooms. Dirt was accumulating where the baseboard/cobase was not attached to the wall.

l. Observations of the storage room where clean supplies for the patients were kept was found to have dust and dirt build up in bins and shelving. Further observations revealed snacks, drinks, cell phone and other personal belongings stored unlocked at Nurses Station (hallway 30). A chair at the nurses' station was worn, with fabric fibers closed. A bedside table behind the nurses station was covered in tape around all four edges.

m. A chair at the nurses' station was worn, with fabric fibers closed. A bedside table behind the nurses station was covered in tape around all four edges.

n. Continued observations revealed dust and rust noted on many ceiling vents and ceiling tiles with brown water stains.

o. Observations in the ICU revealed a Janitor closet was kept unlocked and HVAC vent was rusted, floor was dirty.

p. Observations in the ICU medication room had both clean patient supplies and dirty items mixed in drawers, the drawers were dirty with dust and dirt. The floor was dusty and dirty, the medication sink had dirt buildup and trash around the counter and back of ice machine. The back of the ice machine revealed an exposed power strip, which was plugged in, that was covered with dust. Bins with patient supplies had dust, Pyxis had dirt on the edges of the
machine.

q. Further observations revealed unused bathroom, that had an odor of sewage, that was used as a temporary storage room. Both clean and dirty equipment were stored together next to the toilet.

Interview on 6/8/21 at 1:30 p.m. with the Plant Ops Director confirmed the above findings during the overall facility observations from11:00 am - 1:30 pm.

Review of the facility's Infection Control and Prevention Plan Policy ICP.01.01 last reviewed 2/2021 revealed the following, in part;

Prevention of Infection included: Preventive surveillance, and controlling procedures related to the inanimate hospital environment, including: disinfecting practices, laundry, engineering and maintenance, food sanitation, and waste management, all of which are contracted services. These procedures are evaluated on a continuing basis and revised as necessary.

Based on observation, interview, and record review, the hospital failed to ensure equipment was maintained to ensure an acceptable level of safety and quality.

Specifically, the dish washing machine was not working for at least two weeks without a plan or approval for repair.

Findings included:

Observation in Kitchen/Dining room in facility- A at Brownsville: On June 9, 2020, at 11:20 am, while conducting a walkthrough of the kitchen area of dietary services with the interim Quality Director observed the following:

The dish washing machine was currently out of order and had not been used for at least two weeks due to leaking water.

The patients as of the week of June 7-10, 2021, were using paper plates and disposable utensils.

Interviewed the Hospital & Houskeeping Systems (HHS) Integrated Facility manager at 11:50 am on June 9, 2021, who was aware of the issue and as of current trying to find a means to pay for contractor services to repair the dishwasher.

Review of the 2021 Capitol Expense plan the dishwasher was not included on this plan. The chief executive officer of the Brownsville facility was aware of the dishwasher being out of order.

Based on observations, interviews with facility staff, and record reviews, the facility failed to maintain a clean, sanitary, and safe physical environment in order to prevent and control the transmission of infections within the hospital.

Findings included:

1.) Observations of Facility A (Brownsville) on 6/7/21 at 03:38 p.m. during rounds of facility with House Supervisor (HS)- Staff #2 present revealed the following:

a. Medication Room revealed - Pill crusher chipped and cracked, handwashing sink at medication room rusted, handwashing sinks back splash at the wall dirty, missing caulk- exposed cracks and gaps between wall and counter tops. Medication refrigerator with a dirty and stained mat, plastic liner on top of refrigerator/under clean supplies was dirty and had a dry residue on it, liquid waste container was dirty with dried, exposed liquid. Crushed medication/pills were left on top of pyxis. Floor was covered in dust and pieces of trash.

b. Further observations outside the medication room, behind the nurses' station, revealed, the countertop at the nurses' station had pieces of the laminate missing - leaving wood exposed. A stainless steel wheeled cart where a community patient oral thermometer was kept, was dirty. Ceiling tiles had large brown stains. AC vents in the ceiling were rusty and had dusty cobwebs. Floor was dirty.

c. Observations in the facility supply room revealed, the shelves, that carried cleaned supplies, were dirty and dusty. A dried liquid substance was dried on the shelves. An opened Suplena Supplement, that was leaking, was discovered in the supply room.

d. Observations in a "clean" patient room, identified as room 9, revealed, patient call bell with large piece plastic missing exposing internal components of call bell, bedside monitor, that was identified as clean, was dusty. Under the sink in the patient room, the floor was coming up. The back splash at the wall was missing caulk, there was a gap between the backsplash and wall. The bedside remote was dusty.

e. Observation in patient room 33 revealed, a chunk was missing from the wall above the headboard. The missing chunk was approximately 3 inches by 2 inches, exposing sheet rock. Further observation outside of room 33 revealed the handwashing sink was dirty and no caulking at the baseboard and wall. Cracks and gaps were exposed.

f. Continued observations in the intensive care unit revealed, the medication room handwashing sink was dirty, rusty, caulking was missing between baseboard and wall revealing cracks and gaps. Wall behind the handwashing sink was dirty. The pill crusher in the medication room was cracked and broke the air conditioning vents in the medication room was rusty and dusty. Ceiling tiles had large stains. Observations on the floor by the Pyxis system was dirty dusty and had food crumbs.

g. The floors in the intensive care unit, the baseboards were peeling from the walls, exposing the walls which were dirty. Trash was on the floor.

h. Intensive care unit (ICU) room 39, revealed, the seams at the floor were pulled up with gaps and missing laminate.

i. Observation of the physical therapy (PT) room revealed, the desk had exposed plywood, no laminate. Cannot be wiped down. The ceiling tiles had large brown stains. The bathroom in the therapy room, the laminate was coming up off the floor revealing huge gaps, which could result in a trip/fall hazard, and the drain cover had black tape over it. The facility staff stated, the black tape was to cover the smell of the sewer. Further observations revealed, a drawer handle was covered with tape, and a black stool had a tear at the scene exposing the fabric.

Interview on 6/7/21 at 04:20 p.m. with the HS- Staff #2 during the observations confirmed the above findings.

Interview on 6/7/21 at 4:30 p.m. with the Plant Operations (Ops) Director stated, he conducted weekly Environment of Care (EOC) rounds with the facility's Quality Coordinator (QC). The Plant Ops Director stated, he had a running list in progress and had just began creating a "work order system." The Plant Ops Director stated, he was contracted through (Hospital and Housekeeping Systems) HHS and that any maintenance repairs that will cost money or another contractor must go through the Chief Executive Officer (CEO) for approval. The Plant Ops Director stated, if the issue was a "life-safety" concern that he would push for it to get corrected. The Plant Ops Director stated, he does not go into the Therapy rooms often and was not aware of the concerns identified by the surveyor in the PT room. The Plant Ops Director also stated that "medication rooms were off limits" to him and would not be aware of any maintenance issues in the medication rooms.


2.) Facility B- (Harlingen) observations on June 8, 2021, toured facility with the Director of Plant Ops then joined by HHS Integrated Facility Manager from11:00am - 1:30pm:

a. Kitchen/Dining area: observed mold/dirt in lighting area, stained and chipped ceiling tiles, dust around ceiling vents

b. Observed CT mobile trailer: Holes in tables on mobile trailer. Radiology Lead Technician was in attendance during this observation

c. Observed ICU area on June 8, 2021, bathroom being used as temporary storage area. Clean and dirty equipment being stored in the bathroom. The bathroom was unlocked. Sewer smell coming through the floor drain pipes. Facilities Director of Plant Ops stated that staff must turn on air blowers in room and run water in this bathroom sink to reduce/minimize the smell coming from the floor drains.

d. Observed in soil linen room, soiled linen in bags hanging on edge of carts edge when they should have been properly stored inside of cart.

e. observed in clean linen room. Clean linen covered in linen bags, some were open and exposed to environment. There was no external covering draped over all the clean linen this poses an infection control risk.

f. Continued Observations on 6/8/21 with the facility CNO revealed, the Medication refrigerator had dirty shelves. The AC vents were observed to be rusty.

g. Further observations in the nurses' station revealed, the counter tops were chipped, exposing wood. The hand washing sink backsplash at nurse's station without sealant had dirt build up and staining. A cart that held patient records was covered in dust.

h. Observations in the hallway revealed tape residue on floor in patient room #112. The residue was covered with dirt.

i. Observations in a clean, empty room 119, revealed, the window blinds had cobwebs. The counter tops at the patient sink was missing laminate which exposed wood. Behind the sink in the patient room, was missing caulk/sealant where gaps were exposed between backsplash and the wall.

j. Further observations of the "30's hallways" revealed the baseboards/ co-base was pulling away from walls in hallway outside of patient rooms. Dirt was accumulating where the baseboard/cobase was not attached to the wall.

k. Observations of the storage room where clean supplies for the patients were kept was found to have dust and dirt build up in bins and shelving. Further observations revealed snacks, drinks, cell phone and other personal belongings stored unlocked at Nurses Station (hallway 30). A chair at the nurses' station was worn, with fabric fibers closed. A bedside table behind the nurses station was covered in tape around all four edges.

l. A chair at the nurses' station was worn, with fabric fibers closed. A bedside table behind the nurses station was covered in tape around all four edges.

m. Continued observations revealed, dust and rust noted on many ceiling vents and ceiling tiles with brown water stains.

n. Observations in the ICU revealed, a Janitor closet was kept unlocked and HVAC vent was rusted, floor was dirty.

o. Observations in the ICU medication room had both clean patient supplies and dirty items mixed in drawers, the drawers were dirty with dust and dirt. The floor was dusty and dirty, the medication sink had dirt buildup and trash around the counter and back of ice machine. The back of the ice machine revealed an exposed power strip, which was plugged in, that was covered with dust. Bins with patient supplies had dust, Pyxis had dirt on the edges of the machine.

p. Further observations revealed unused bathroom, that had an odor of sewage, that was used as a temporary storage room. Both clean and dirty equipment were stored together next to the toilet.

Interview on 6/8/21 at 1:30 p.m. with the Plant Ops Director confirmed the above findings during the overall facility observations from11:00 am - 1:30 pm.


3.) Observations conducted at Facility B on 6/9/21 at 12:08 PM of a non-sampled patient receiving hemodialysis (HD) that is contracted, revealed the following: machine lines of machine #159 were draped across the overflowing trashcan with dirty gowns on top of the lines. The Dialysis Registered Nurse (RN) - Staff #9 was seen touching the dirty machine without gloves, while donning and doffing gloves. No hand hygiene was performed. Patient was touched with dirty gloves, open pack of gauze sitting open next to patient in the bed for use post treatment.

Review of the Machine Logs for HD machine #159 revealed, the machine had not been disinfected (bleach) for the Month of June 2021; 6/1/21 to 6/9/21.

Review of the HD contracted policy titled, Infection Control Policy 736 for Cleaning and Disinfecting - Delivery System revealed that; 4. The Chemical/Rinse program should be used when disinfecting the hydraulic system using corrosive chemicals, such as bleach or peracetic-acid-based disinfectants. The Chemical/Rinse program will be done at least once every seven (7) days.

Interview with Dialysis RN- Staff #9 and Dialysis RN- Staff #10 on 6/9/21 at 12:10 confirmed that machine #159 that the unsampled patient was being dialyzed on during surveyor inspection had not been bleached for more than 7 days according to the documentation of the machine log.


4.) Observation in Kitchen/Dining room in facility-A (Brownsville): On June 9, 2020, at 11:20 am, while conducting a walkthrough of the kitchen area of dietary services with the interim Quality Director revealed, the dish washing machine was currently out of order and had not been used for at least two weeks due to leaking water.

The patients, as of the week of June 7-10, 2021, were using paper plates and disposable utensils.

Interviewed the HHS Integrated Facility manager at 11:50 am on June 9, 2021 who was aware of the issue and as of current trying to find a means to pay for contractor services to repair the dishwasher.

Review of the 2021 Capitol Expense plan revealed the dishwasher was not included on this plan. The chief executive officer of the Brownsville facility was aware of the dishwasher being out of order.

Review of the facility's Infection Control and Prevention Plan Policy ICP.01.01 last reviewed 2/2021 revealed the following, in part;

Prevention of Infection included: Preventive surveillance, and controlling procedures related to the inanimate hospital environment, including: disinfecting practices, laundry, engineering and maintenance, food sanitation, and waste management, all of which are contracted services. These procedures are evaluated on a continuing basis and revised as necessary.