HospitalInspections.org

Based on observation, record review and interview the facility failed:

A. to provide written notice to patients filing grievances.

Refer to tag A0123

B. to perform preventative maintenance of patient care equipment, perform the required fire drills, mount alcohol hand sanitizer dispensers in a safe manner and lock and secure the building.

Refer to tag A0144

C. to assure employees had no history of patient abuse and harassment. No background checks were conducted for 13 of 13 employees (staff #1, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25).

Refer to tag A0145

Based on observation, record review, and interview, the facility failed:

A. to maintain its windows so that the facility could be properly secured for patient safety. 15 of 22 ground floor windows (including windows in patient rooms and the operating room) were found unable to be locked.

Refer to tag A0701

B. to maintain agreements with suppliers for gas and water supply during emergencies and disasters.

Refer to tag A0703

C. to conduct the required number of fire drills per year in 2011. The facility conducted only 10 fire drills in 2011. The facility also failed to conduct fire drills on the 7:00pm-7:00am shift during the 2nd and 3rd quarters of 2011.

Refer to tag A0709

D. to assure fire safety by having alcohol hand sanitizer dispensers installed directly above spark sources (light switches) in two locations.

Refer to tag A0716

E. to have preventive maintenance conducted on its electrical equipment within proper time-framed. The facility ' s equipment had no preventive maintenance conducted since September 2010.

Refer to tag A0724

F. to have an equipment performance evaluation (EPE) and preventive maintenance (PM) conducted on its portable x-ray machine within the prescribed time frame. The last EPE and PM were conducted on 7/29/2009. The EPE and PM were due July 2011.

Refer to tag A0537

Based on record review and interview the facility failed to provide a written notice to patients filing grievances.

Review of the document titled " Patient Grievance Policy and Procedure, IV.
Classification of Grievances, 1. In the resolution of all grievance priorities Coxby- Germany Hospital QAQI Coordinator will provide the patient with written notice of the hospital ' s decision, names of hospital contact persons, steps taken on behalf of the patient in the investigation of the grievance, the results of the grievance process, and the date of completion. "

An interview with staff #1 in the employee education room on 03/29/2012 at approximately 1:00PM confirmed the facility was not responding to patients ' grievances with written notices.

Based on observation, record review and interview the facility failed to perform preventative maintenance of patient care equipment, perform the required fire drills, mount alcohol hand sanitizer dispensers in a safe manner and lock and secure the building.

Review of a document, dated 9/15/2010, from the PM company to the facility, revealed that PM was last conducted in September 2010. It further revealed, " The next scheduled inspection is during March 2011. "

Review of the facility ' s fire drill records revealed only 10 fire drills were conducted in 2011. The records also revealed no fire drills on the 7:00pm-7:00am shift during the 2nd and 3rd quarters of 2011.

During a tour of the facility on 3/28/12, two alcohol hand sanitizer dispensers were found installed directly above spark sources (light switches). One was found in room 208 and another in the laboratory. Staff #1 confirmed these findings during the tour.

During a tour of the facility on 3/28/12 at 10:30am, 15 of 22 ground floor windows (including windows in patient rooms and the operating room) were found unable to be locked. This allowed for direct access to patients and patient equipment and rendered the building unsecure.

During an interview on 03/30/2012 at approximately 11:00, Staff #1 confirmed the above findings.

Based on record review and interview, the facility failed to assure employees had no history of patient abuse and harassment. No background checks were conducted for 13 of 13 employees (staff #1, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25).

Findings include:

Review of personnel files revealed no background checks for 13 of 13 employees.

During an interview on 3/30/12 at 10:30am in the conference room, staff #1 confirmed that no background checks had been performed.

The facility provided no further process that assured employees had no history of patient abuse or harassment.

Based on record review and interview the facility failed to develop and follow a consistent practice for granting 6 of 10 medical staff privileges.

A review of 10 medical staff files revealed that 6 of 10 files showed an inconsistent process for granting clinical privileges. Staff #11 credentialing file contained a document titled " Renaissance Hospital Terrell, Clinical Privileges in Pediatrics, " This document showed no evidence the requested privileges made by staff #11, were approved by the Governing Board. The remaining 5 of 10 medical staff files contained a document requesting clinical privileges but the documents were different in format and not consistently the same. None of these five documents contained evidence the requested privileges made by staff #2, #3, #4, #5, #6, #7, #8, #9, #10, were approved by the Governing Board.

An interview with staff #1 in the conference room on 03/30/2012 at approximately 1:00PM confirmed the facility had not developed or followed a consistent practice for granting 6 of 10 medical staff privileges. Staff #1 confirmed the documents used by the facility to request and grant clinical privileges were not consistent.

Based on record review and interview, the facility failed to evaluate competencies for 6 of 6 nursing service employees (staff #1, 17, 19, 22, 24, and 25).

Findings include:

Review of personnel files revealed no competencies for 6 of 6 nursing service employees.

During an interview on 3/30/12 at 10:30am in the conference room, staff #1 confirmed that there were no current competencies for these employees.

Based on record review and interview, the consulting pharmacist failed to evaluate competency for 1 of 1 pharmacy employee (staff #16).

Findings include:

Review of personnel files revealed the consulting pharmacist failed to evaluate competency for 1 of 1 pharmacy employee.

Based on observation and interview, the facility failed to assure expired medications were removed from useable stock. Seven vials of patient medication were found in the pharmacy refrigerator that were either expired or had no documented date opened.

Findings include:

The US Pharmacopeia (USP 2008), General Chapter 797, Pharmaceutical Compounding/ Sterile Preparations, requires multidose vials to be discarded 28 days after initial stopper penetration unless the manufacturer specifies otherwise. The vial should be labeled to reflect the penetration date or the beyond-use date.
-United States Pharmacopeia (USP) 797: Guidebook to Pharmaceutical Compounding - Sterile Preparations. Second Edition, June 1, 2008.

Review of pharmacy policy E-018, " Dating and Initialing Multi-Dose Containers, " revealed the following:
" The containers should be dated on opening and initialed by the person opening it (dating means month, day and year). "

During a tour of the pharmacy on 3/28/12 at 1:00pm, the following expired medications were found in the refrigerator:
-Regular insulin- opened with no date noted
-Lantus- opened and dated 1/13/12 (>28 days)
-Novolin 70/30- opened and dated 12/2011 (>28 days)
-Levemir- opened with no date
-Novolin NPH- opened and dated 12/10/11 (>28 days)
-Novolog- opened and dated 11/9/11 (>28 days)
-Digoxin Immune Fab (Ovine) Digifab 40mg- expired 01/2011

During an interview on 3/28/12 at 1:30pm in the pharmacy, staff #16 confirmed the expired and non-dated medication vials.

Based on record review and interview, the facility failed to have an equipment performance evaluation (EPE) and preventive maintenance (PM) conducted on its portable x-ray machine within the prescribed time frame. The last EPE and PM were conducted on 7/29/2009. The EPE and PM were due July 2011.

Findings include:

A review of PM records for the radiology department revealed that the last EPE and PM for the portable x-ray machine were conducted on 7/29/2009.

During an interview on 3/30/12 at 9:52am in the radiology office, staff #13 confirmed that the last EPE and PM for the portable x-ray machine were conducted on 7/29/2009.
Staff #13 also reported that the EPE and PM were due in July 2011, but were not done.

Based on record review and interview, the facility failed to evaluate competencies for 2 of 2 dietary service employees (staff #20 and 23).

Findings include:

Review of personnel files revealed no competencies for 2 of 2 dietary service employees.

During an interview on 3/30/12 at 10:30am in the conference room, staff #1 confirmed that there were no current competencies for these employees.

Based on observation and interview, the facility failed to maintain its windows so that the facility could be properly secured for patient safety. 15 of 22 ground floor windows (including windows in patient rooms and the operating room) were found unable to be locked.

Findings include:

During a tour of the facility on 3/28/12 at 10:30am, 15 of 22 ground floor windows (including windows in patient rooms and the operating room) were found unable to be locked. This allowed for direct access to patients and patient equipment and rendered the building unsecure.

During an interview on 3/28/12 at 11:05am, Staff #1 and #14 confirmed the ground-floor windows were unsecure.

Based on record review and interview, the facility failed to maintain agreements with suppliers for gas and water supply during emergencies and disasters.

Findings include:

Review of the facility ' s emergency management plans and documents revealed no agreements with suppliers for gas and water supply during emergencies and disasters.

During an interview on 3/29/12 at 1:12pm in the conference room, staff #1 confirmed that the facility had no written agreements with suppliers for gas and water supply during emergencies and disasters.

Based on record review and interviews, the facility failed to conduct the required number of fire drills per year in 2011. The facility conducted only 10 fire drills in 2011. The facility also failed to conduct fire drills on the 7:00pm-7:00am shift during the 2nd and 3rd quarters of 2011.

Findings include:

Texas Hospital Regulation 25 TAC 133.141(g) states the following:
" The hospital shall conduct at least 12 fire drills each year, one fire drill per shift per quarter, which shall include communication of alarms, simulation of evacuation of patients and other occupants, and use of fire-fighting equipment. "

Review of the Risk Management Policy #3-302A, " Fire Drill Schedule, " revealed the following: "The Hospital shall conduct quarterly fire drills, one drill per quarter, per shift. "
Review of the facility ' s fire drill records revealed only 10 fire drills were conducted in 2011. The records also revealed no fire drills on the 7:00pm-7:00am shift during the 2nd and 3rd quarters of 2011.

During an interview on 3/29/12 at 11:00am in the conference room, staff #16 confirmed that only 10 fire drills were conducted in 2011. Staff #16 also confirmed that no fire drills were conducted on the 7:00pm-7:00am shift during the 2nd and 3rd quarters of 2011.

Based on observation and interview, the facility failed to assure fire safety by having alcohol hand sanitizer dispensers installed directly above spark sources (light switches) in two locations.

Findings include:

During a tour of the facility on 3/28/12, two alcohol hand sanitizer dispensers were found installed directly above spark sources (light switches). One was found in room 208 and another in the laboratory. Staff #1 confirmed these findings during the tour.

Based on observation, record review, and interview, the facility failed to have preventive maintenance conducted on its electrical equipment within proper time-framed. The facility ' s equipment had no preventive maintenance conducted since September 2010.

Findings include:

During a tour of the facility on 3/28/12, it was found that stickers located on the electrical equipment throughout the facility noted that preventive maintenance (PM) was due on March 2011.

Review of a document, dated 9/15/2010, from the PM company to the facility, revealed that PM was last conducted in September 2010. It further revealed, " The next scheduled inspection is during March 2011. "

During an interview on 3/29/12 at 3:20pm in the conference room, staff #1 confirmed that the last equipment PM was done in September 2010. Staff #1 reported that the equipment PM was due in March 2011, but was not done.

Based on record review and interview the facility failed to monitor and record the temperature and humidity of the surgical department.
Review of the AORN Perioperative Standards and Recommended Practices, "Temperature should be maintained between 68 degrees F to 73 degrees F." These recommendations apply to both operating rooms and sterile processing areas. A relative humidity level of 30 to 70 percent is acceptable.
" Room temperature, humidity and ventilation of each work area should be monitored and recorded daily. "
Multiple requests were made to review the facility ' s temperature and humidity log for the surgical department. No documents were made available to the surveyor.
An interview with staff #1 in the conference room on 03/30/2012 at approximately 1:00PM confirmed the facility was not monitor and record temperature and humidity of the surgical department.