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Based on review of documentation and interview with staff, the facility governing body failed to approve medical staff bylaws that are compliant with the requirement that verbal physician orders are authenticated within 48 hours for 30 of 30 patients whose records were reviewed.

Findings were:

The facility RESTATED MEDICAL STAFF RULES AND REGULATIONS, last approved by the Governing Body 7/18/12, state on page 8, #12, that "Verbal orders must be authenticated within ten (10) days." An in-person interview with Staff #25, Corporate Director of Clinical Services, conducted the afternoon of 8/15/12 confirmed this finding in the medical staff rules and regulations. Cross refer to Tag 0457 for more information.




29937

Based on observation, review of documents and interviews with facility staff, the governing body failed to ensure that dietary services performed under contract were provided in a safe and effective manner as food temperature records were not kept in accordance with facility policy. The facility document entitled "Restated Governing Board Bylaws of Cornerstone Hospital of Austin" dated 7/18/12 reflected in part "15. Ensure all contracted services are provided in a safe and effective manner..." Cross refer to A0619 for detailed information.



29937

Based on observation, documentation review and interviews with the facility staff the governing body failed to ensure that the dialysis services performed under contract were provided in a safe and effective manner resulting in the following deficient practice:
1) Quality assessment and performance improvement program. The facility failed to conduct performance improvement on the dialysis acute care department that was under contract. Governing Board Bylaws 15 stated, " the contractor will furnish services in a manner that permits the hospital to comply with all applicable laws and regulations. " Cross refer to A0297 for additional information.
2) Infection Control. The infection control coordinator failed to identify, investigate, report, and monitor the dialysis acute care department at the facility.
In an in-person interview conducted with the infection control coordinator on the morning of 08/14/12, it was confirmed that the coordinator did not monitor the dialysis acute care department. Cross refer to A0749 for additional information.

Based on review of documentation and interview with staff, the Registered Nurse (RN) failed to monitor the outcomes of 1 of 2 patients in restraints.
Findings included:
Review of the medical record for patient #3 revealed the facility restraint form stated " In addition to below the RN must document outcomes per shift in nursing notes ... " Of the 13 restraint orders reviewed for patient #3, 6 were signed by a Licensed Vocational Nurse (LVN) and 4 signature lines were left blank.
The above was confirmed in an interview the morning of 8/14/2012 with staff member #14.

Based on review of documentation and an in-person interview with the director of quality assessment and performance improvement program the facility failed to conduct performance improvement projects on the dialysis acute care department that was under contract.
Findings were:
Review of documentation Patient Focused Functions stated, " The director of quality management shall ensure an on-going systematic process for monitoring, measuring, assessing and improving care delivery processes, clinical outcomes and appropriateness of care provided. Nursing, dietary, environmental, housekeeping, plant operations, laundry, dialysis, rehabilitation, respiratory, pharmaceutical, and case management services shall participate in the on-going performance improvement process.
In an in-person interview with the director of quality on the afternoon of 08/14/12 in the administrative conference room, no documentation was provided indicating the dialysis acute care department had participated in the on-going improvement process.

Based on review of records and interview with staff, the facility failed to ensure that verbal/telephonic orders were dated, timed, and authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of 30 of 30 patients whose records were reviewed.

Findings were:

Review of the medical records of Patients #1 - #30 revealed that all of the records contained telephonic/verbal orders which were not dated, timed, and/or authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patients. For example, Patient #16 ' s record contained a telephonic order given 7/19/12 at 8 am; however the physician did not authenticate the order with a signature, date, or time. Patient #21 ' s medical record contained a telephonic order given on 6/6/12 at 4 pm; it was signed by the physician 8 days later on 6/14/12 at 8 am. Patient #24 ' s medical record had a telephonic order given on 5/4/12 at 3:30 pm that was signed by the physician almost a month later on 6/1/12. These findings were acknowledged by Staff #45, Corporate Director of Clinical Services in an in-person interview the afternoon of 8/15/12.

Based on observation, review of documents and interviews with facility staff, the facility failed to ensure that specific food and dietetic services organization requirements are met as food temperatures were not documented in accordance with facility policy.

The findings were:
The facility policy entitled "Food Temperature Record" policy #17:037:01 dated 10/2005 reflected in part "A Food Temperature Record shall be maintained for prepared foods and beverages by Food Services. The incorrect control of food temperatures can contribute directly to the outbreak of food-borne diseases. To safeguard against the problem, continual testing of prepared foods and beverages will be instituted on a daily basis. 1. The morning and evening cooks will take and document temperatures on all prepared meats, vegetables, starch, soups, salads and deserts. The prepared food temperature form will be used to record the readings."

During a tour of the Dietary Department on 8/13/12 starting at 10:30am, the "Food Production Record-Cook" forms were reviewed for the period from 7/30/12 - 8/12/12. On 8/5/12 and 8/10/12 there were no food temperatures recorded for the breakfast meal. On 7/31/12, 8/3/12, 8/4/12, and 8/9/12 there were no food temperatures recorded for the dinner meal. On 8/2/12 there was no temperatures recorded for the lunch and dinner meal. On 8/6/12 and 8/7/12 there were no food temperatures recorded for the breakfast, lunch and dinner meals. There were no forms found for 8/1/12, 8/11/12, and 8/12/12.

In an interview with staff # 11 on 8/13/12 at 2:00 pm, the missing temperature documentation on the Food Production Record-Cook forms was were shown to her and she agreed that the temperatures were not recorded as listed above. Staff # 11 stated that the cooks should be recording the food temperatures for each meal every day.

Based on review of documentation, and an in-person interview with the infection control coordinator staff # 38, on the morning of 08/14/12 the facility failed to develop a system for identifying, reporting, and investigating the dialysis acute care treatment department and the High Level Disinfection Room.

Findings were:
Review of Infection Prevention and Control Plan, revision date 1/10. II. Infection control stated, " the infection control officer is responsible for the ongoing hospital-wide process to collect and evaluate (through surveillance) information about infections in the hospital. "

During a tour of the "High Level Disinfection Room" the morning of 8/13/2012 with staff member #14, it was confirmed there were no gloves or fluid resistant gowns or aprons in the High Level Disinfection Room which was required. The gloves and the gowns were located in the room next door.

During a tour of the dialysis acute care department on the third floor at the facility on the afternoon of 08/13/12, the floor was observed to be dirty with white powdery substance and black grayish stains appearing to be dried dirty water spots and splashes. 3-4 feet of the wall paper on the lower right wall upon entering the dialysis department was unglued; appearing to have water damage. The dialysis machine located against the left side of the wall was leaking a clear liquid substance on the floor.
The above findings were confirmed by staff # 14 and staff # 22 on the afternoon of 08/13/12. Staff # 14 stated the room is cleaned nightly by environmental services.

During a tour of the dialysis acute care department on the third floor at the facility on the morning of 08/14/12 the surveyor observed that the floor had not been cleaned. The surveyor asked staff # 39, have you performed dialysis care in this room today? Staff # 39 stated no; dialysis care was being performed at the bedside in a contact isolation room. "
The surveyor asked staff # 39 and 23 how do you prevent the possibility of spreading infection from the dialysis machine used at the bedside in the contact isolation room. Staff # 39 and 23 stated, " We clean the machine outside of the storage room in the hall with special wipes. "
The surveyor asked staff 39, where are the clean and dirty sinks and the designated clean and dirty areas? Staff # 39 pointed to an area, stating " this is the clean area and we only have one sink. " The findings were confirmed by staff 39 and staff 46 during the tour.

In an in-person interview conducted with the infection control coordinator on the morning of 08/14/12, it was confirmed that the coordinator did not monitor the dialysis acute care department.

On the afternoon of 08/14/12 in the administrative conference room; staff # 9 stated, " the dialysis acute care department floors are cleaned every afternoon and the white powdery substance on the floor is bicarb; you clean it up and it comes right back. "