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Based on observation, interview, ad record review the facility failed to ensure drugs were distributed according to accepted standards of practice for 2 of 11 sampled patients (ID # 8-C, #9-C) at hospital Outpatient Location C:

Hospital staff was repackaging patients ' home/prescribed medication in different previously used prescription bottles.

Findings include:

Observation on 05-16-12 at 1:35 p.m. of the Medication Room at Outpatient Location C revealed a tray with five (5) paper bags stapled at the top; each bag had a patient's name written in it. Next to the tray, there was a large white plastic bag filled with previously used prescription bottles (approximately 300 bottles). Some of the bottles had partial labels on them that had been torn off.

Interview at this same time with Licensed Vocational Nurse (LVN) ID # 65, she stated the facility saved empty prescription bottles from patients and removed the labels. She went on to say that many of the patients lived at personal care homes and had problems receiving their medications at these homes. LVN # 65 said she put the medications for these patients in the used bottles, placed them in the bags, and sent them home at night with their medication.

Interview on 05-17-12 at 11:30 a.m. with the facility Pharmacy Manager (ID # 67) she stated she was unaware of the practice of LVN ' s at the outpatient C location repacking the patients' medications in used prescription bottles. She went on to say this was not an acceptable practice both from a scope of practice perspective and an infection control/possible allergy issue (drug residue left in bottle). Pharmacy Manager ID # 67 said no medication was to be administered to patients at outpatient facilities (without a doctor ' s order) and nursing should not be placing the medications in any type of containers for the out patients to take home.

Interview by telephone on 05-17-12 at 12:20 p.m. with outpatient location C Administrator ( ID # 64) she stated according to the Director of Nursing (DON) ID # 64, the medications were being done for two(2) patients ( ID # 8-C and 9-C) who lived by themselves and not in a personal care home. In addition, she said that several patients (6) live in group homes and bring a pillbox in which the facility nurse placed their medication.

Review of facility policy titled " medication: use of Patient ' s Own, dated 04/12, read " " .... Misbranding: a drug is considered misbranded if its labeling is false or misleading and if the direction in the bottle cannot be deciphered... "

Based on observation, interview and record review outdated expired drugs were available for patient and staff use at 2 of 3 hospital locations (Location B and Location C):

Findings:

Location B:

On 5/16/2012 at 14:20 PM during a tour of the Medication Room two (2) opened and undated multi-dose vials of Tuberculin (TB) Purified Protein (PPD).were observed in the medication refrigerator.

Review of manufacture instructions on the TB PPD box read: " A vial of Tuberculin PPD which has been entered and in use for 30 days must be discarded. "

Interview with Employee # (B-60) at this same time, she stated the facility no longer used the Tuberculin Purified Protein but she had not yet disposed of the vials. Employee ID # (B-60) went on to say the medication should have been labeled and dated when opened and discarded at 30 days.

Interview on 05/16/2012 at 12:40 of the facility Administrator employee # (B-61), she stated that opened multi dose vials of medication should be labeled when opened and disposed of per facility policy.




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Observation on 05-16-12 at 1:35 p.m. of the Medication Room at Outpatient Location C revealed the following opened and expired vials of insulin:

1-vial of Novolin 70/30 opened and dated 12/2011
1-vial of Novlog insulin, open and dated 01/2012
1-vial of Novolg insulin, open and dated 3/2012

Interview at this same time with LVN # 65, she stated " insulin is good until the expiration date on the bottle. "

Interview on 05-17-12 at 11: 30 a.m with the Pharmacy Manager (ID # 67) she stated insulin was discarded 28 days after opening.

Further observation revealed one (1) vial of opened TB/ PPD Review of manufacture instructions on the TB PPD box read: " A vial of Tuberculin PPD which has been entered and in use for 30 days must be discarded. "

Based on observation and interview, the facility failed to maintain the hospital in a manner to ensure patient safety in 1 of 3 hospital locations (Outpatient Location C):

A housekeeping closet containing hazardous chemicals was unlocked and accessible to patients.

A large amount of water was observed on the floor of a waiting room in front of a freestanding water cooler.

Findings include:

Observation on 05-16-12 during initial tour of Outpatient Location C revealed the following hazardous conditions:

Observation on 05-16-12 at 2:00 p.m revealed in a hallway inside front door of the facility: Housekeeping Closet. The closet was observed unlocked and unattended. I nside the closet were a 1.42 gallon size of bleach and a large bottle of " floor buffer" liquid. Both chemicals were labeled as " hazardous/keep out of reach of children. "

Interview with the facility Administrator (ID # 64) at this same time she stated the closet was always kept locked; she confirmed the chemicals were hazardous and posed a safety issue to the patients.

Continued observation revealed a large Waiting Room inside Building A that contained a free-standing water cooler. A large pool of water (approximately 3 feet in diameter) was observed on the floor in front of the water cooler. Six (6) patients were observed in the room walking near the water cooler and the puddle of water.

Interview with the facility Administrator (ID # 64) at this same time she stated the water was a safety hazard and the cooler would be removed or a rubber mat installed.

Record review of nine (9) sampled patient records for Outpatient Location C revealed all had some degree of cognitive impairment and behavioral issues.

Based on observation, interview, and record review the facility failed to meet applicable NFPA (National Fire Protection Association) standards regarding life safety and storage of oxygen:

The facility failed to store oxygen properly at 2 of 3 hospital locations (main hospital and Outpatient Location C).

Findings include:

Observation on 05-17-12 at 1430 of oxygen storage area in the main hospital revealed 4 oxygen cylinders found lying on the floor. The cylinders were unchained and unsecured.

Interview at the same time with facility Chief Operations Officer(# A-52), he stated he was unaware of the containers being unsecured and confirmed they should be secured in an upright position in the storage stand or secured by a chain in an upright position


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On 05-16-12 at 2:10 p.m observation at Outpatient Location C of a " Janitor ' s Closet " in Building B revealed one(1) large oxygen cylinder located on a shelf with miscellaneous supplies, including clothing. The oxygen cylinder was unsecured in any type of cart and unchained. Also located on this same shelf was a cardboard container of 4 small cylinders of oxygen, also unsecured, unchained, and not in a metal cart.

Interview at this same time with the facility Administrator (ID # 64) she stated she was unaware the oxygen was in the closet and it should not be there.

Review of facility policy titled " Safe Handling of Medical Gases, " dated 05/10, read: " Oxygen Use ... Store oxygen cylinders upright and secured ... "

Based on observation, interview, and record review the facility's infection control officer failed to effectively implement policies to control infections and communicable diseases at 2 of 3 hospital locations.

1. " Clean " items were stored in soiled utility room (plastic bins containing patients ' personal care items (soaps, combs/brushes); towels, blankets, and staff scrub attire).

2. Staff person (MHT # A-55) failed to utilize proper glove use and hand hygiene.

3. Multiple environmental / infection control issues were identified at the main hospital campus: overfull / unlocked biohazard/sharps containers; numerous dirty shower stalls; liquid spill on floor in soiled utility room; cardboard boxes stored directly on the floor.

4. Multiple environmental / infection control issues were identified at the off-site outpatient " C " location: dirty floors; frayed /dirty carpet; torn chairs, stained and torn ceiling tiles, masking-taped baseboards, and boxes and clothing stored directly on floors.

5. Improper storage of dirty linen at the main hospital facility.

Findings include:

Observation on 05-15-12 during initial tour of the main hospital facility revealed the following environmental/ infection control issues:

1.

10:35 a.m: 2nd Floor " Soiled Utility " room: observation was made of a large metal cart that contained 9 plastic bins filled with patients ' personal care items (shampoo, combs, toothbrushes, etc...). Also located on the cart was a stack of " clean " towels and staff scrub attire. Located on the floor of this soiled utility room was a pile of blankets and scrubs.

Interview with MHT # A-55 at this same time she stated the blankets and scrub attire on the floor were " clean. "

Interview with the Interim Chief Nursing Officer (CNO/ ID # 54) on 05-15-12 at 1:35 p.m. , she stated the cart containing ' clean " patient supplies, blankets, and scrubs did not belong in the Soiled Utility room where trash and dirty linen were stored; " clean and dirty should always be stored separately. " She went on to say it was an infection control issue and it would be corrected.

2.

Observation on 05-15-12 at 10:35 a.m. revealed MHT # A-55 in the hallway wearing a pair of exam gloves. While wearing the same gloves, MHT # A-55 was observed pressing the key pad lock to enter the Soiled Utility Room on the 2nd floor.MHT # A-55 exited the Solid Utility room and while wearing the contaminated gloves, pressed the key pad lock and entered the Clean Utility room. MHT # A-55 exited the clean utility room and walked down the hallway. She was observed removing the gloves and kept them in her hand.

Interview on 05-15-12 at 10:45 a.m. with MHT # A55 she stated she was aware she should wash her hands after removing her gloves.

Interview with the Interim Chief Nursing Officer (CNO/ ID # 54) on 05-15-12 at 1:35 p.m. she stated MHT # A-55 should not have been wearing gloves in the hallway. She went on to say the facility policy required handwashing after removal of gloves.

3.

Observation on 05-15-12 at 9:40 a., at the main hospital in the " Intake Area " revealed an overfull wall-mounted biohazard/sharps container. The container was unlocked and accessible. On the floor next to the wall mounted container, a large overfull biohazard/ sharps container was observed.

Interview at this same time with the facility Administrator (ID # 52) he stated the biohazard containers should have been emptied and the wall -mounted container locked. He went on to say this would be immediately corrected.

Observation was made on 05-15-12 between 9: 30 a.m and 11 a.m of the shower stalls in the following occupied patient rooms: 215; 216; 219; 311; 315; 317; 319, and 321. The shower stalls in these rooms contained brown- stained grout and tile; " mold-looking " substances; and soap build up/residue. In occupied room # 215 a wet towel was observed on the shower floor. The towel was covered with rust-colored stains.

Interview on 05-15-12 at 1:50 p.m. with the Maintenance /Housekeeping Director (ID # 63) he stated the rooms / showers were cleaned every day.

Observation on 05-15-12 at 10:35 a.m. revealed a spill of brown colored liquid approximately 1 foot in diameter on the floor of the Soiled Utility Room on the 2nd floor. Unidentified staff member present in the room stated he was unaware of the contents of the spill but said he would clean it up.

Observation during initial tour on 05-15-12 between 9: 30 a.m and 11 a.m revealed cardboard boxes stored directly on the floor in the following areas:

Laboratory (main hospital): Nine (9) boxes
Medication Room (3rd floor): Two (2) boxes

Review of facility form " Environment of Care Survey Tool " read: " ...supplies are stored at least 2 inches off the floor to facilitate cleaning .... "

4.

Observation on 05-16-12 from 1: 15 p.m. to 2:30p.m during initial tour of Outpatient Location C revealed the following environmental/infection control issues:

Building A:

Carpet Dirty and frayed

Multiple vinyl covered chairs split and dirty.

Dirty walls and tile floors.

Storage room: 4 bags of supplies stored directly on floor.

Building B (approximately 2: 10 p.m.):

Women ' s Restroom: dirty, stained floors and sinks

" Clothing Store " Room Observation of multiple ( 8 +) large plastic trash bags on the floor and multiple piles of clothing located on the floor. Interview with ther Administrator (ID # 64) she stated the facility revived recent donations and was the process of going through them.

Four (4) broken /bent window blinds located in the waiting area and hallway.

Baseboards tapped with masking tape.

Stained/ torn ceiling tiles.

Outpatient Services Section: Two (2) large bags of supplies and 2 boxes were observed stored directly on the floor. Staff member stated sister-facility in Missouri City recently closed and sent some of their supplies here.

Interview on 05-16-12 with Administrator (ID # 64) following the tour, she stated she was aware of the environmental issues .She went on to say it was a rental property and several of the issues had been brought to the attention of the landlord to no avail




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5.

During the tour of the adult unit at the main hospital on 5/17/12 at 11:45 am with staff #53, revealed a pile of what appeared to be dirty laundry on the bottom of empty laundry hamper with no laundry bag or lining. This empty hamper was located in a small section near the two seclusion rooms. Interview with staff #53 on 5/17/12 at 12:00pm revealed " the staff is making rounds and will pick them up for laundry pick up " .