HospitalInspections.org

Based on document review the Governing Body failed to:
A. approve policies and procedures for Rehabilitation, Cardiopulmonary, Radiology, Emergency Department, Surgical Department and the Anesthesia Department.
A review of the meeting minutes for the Governing Board/ Board of Directors (GB) dated June 30, 2015, July 14, 2015, July 21, 2015, July 28, 2015, August 4th, 2015 and August 25, 2015 revealed policies and procedures for Rehabilitation, Cardiopulmonary, Radiology, Emergency Department, Surgical Department and the Anesthesia Department had not been approved.
An interview with Staff #1 on 8/25/2015 in Class Room #2 confirmed the above mentioned policies and had not been approved by the GB.



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B. provide adequate numbers of licensed registered nurses to be physically present and immediately available on each patient care unit.

Refer to tag A0392

C. provide 24 hour nursing services furnished or supervised by a registered nurse in all areas of the hospital on 37 of 46 Medical/Surgical (M/S) floor shifts (two 12 hour shifts per day) for the period of August 1, 2015 until August 23, 2015.

Refer to tag A0393

D. provide a registered nurse to supervise and evaluate the nursing care of each patient on 17 of 46 Medical/Surgical (M/S) floor shifts (two 12 hour shifts per day) for the period of August 1, 2015 until August 23, 2015.

Refer to tag A0395



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E. have a Quality Assessment Process Improvement program that 1) incorporated the Infection Control Program as part of the facilities QAPI, 2) ensure all departments of the hospital had QAPI indicators and 3) provide documentation the Governing Board had approved the QAPI program.
Refer to tag 263

F. ensure the facility's Infection Control Professional had specific training in infection control.
Refer to tag A 0748

G. ensure all hospital staff participated in the infection control program since June 1, 2015.
Refer to tag A 0749

H. ensure the Infection Control Program had been approved by the Governing Body prior to implementation.
Refer to tag A 0756

Based on interview and document review the facility failed to have a Quality Assessment Process Improvement program that 1) incorporated the Infection Control Program as part of the facilities QAPI and 2) ensure all departments of the hospital had QAPI indicators and 3) provide documentation the Governing Board had approved the QAPI program.

On 8/25/2015 at 10:00 a.m. in the conference room staff #1 confirmed the Governing Board (GB) had not meet to approve all components of the Quality program. Staff #1 further confirmed the GB was scheduled to meet on 8/26/2015 and the Infection Control Plan was on the agenda.

On 8/25/2015 during a tour of the dietary department, the staff #14 confirmed there was no specific department focused infection control indicator they were following and submitting to the infection control program for review.

On 8/26/2015 during a tour of the Outpatient Rehabilitation program, staff #21 stated they cleaned all surfaces with Sani wipes but that she did not know of a specific infection control identifier the department was focused on.

On 8/27/2015 during a tour of the plant operations department, an interview with Staff #15 confirmed there was no specific infection control indicator the department was aware of.

On 2/26/2015 at 11:00 a.m. interview with staff #3 confirmed all departments of the hospital had not established quality indicators

On 8/27/2015 an attempt to review the GB meeting minutes revealed at the time of the survey exit 2:00 p.m., the meeting minutes had not been provided. The facility had no evidence the QAPI program and its components had been approved.

Based on record review and interviews the facility failed to:

A. provide the types and numbers of licensed nursing personnel to provide nursing care to all areas of the hospital on 37 of 46 Medical/Surgical (M/S) floor shifts (two 12 hour shifts per day) for the period of August 1, 2015 until August 23, 2015.

Refer to tag A0386

B. provide adequate numbers of licensed registered nurses to be physically present and immediately available on each patient care unit.

Refer to tag A0392

C. provide 24 hour nursing services furnished or supervised by a registered nurse in all areas of the hospital on 37 of 46 Medical/Surgical (M/S) floor shifts (two 12 hour shifts per day) for the period of August 1, 2015 until August 23, 2015.

Refer to tag A0393

D. provide a registered nurse to supervise and evaluate the nursing care of each patient on 17 of 46 Medical/Surgical (M/S) floor shifts (two 12 hour shifts per day) for the period of August 1, 2015 until August 23, 2015.

Refer to tag A0395

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

A. the facility's Infection Control Professional failed to have specific training in infection control since June 1, 2015.

Refer to tag A 0748

B. ensure all hospital staff participated in the infection control program since June 1, 2015.

Refer to tag A 0749

C. ensure the Infection Control Program had been approved by the Governing Body prior to implementation.

Refer to tag A 0756

Based on document review and interview the facility failed to provide the required Anesthesia consent to 3 of 3 (Patient #2, #3, #17) patients reviewed.

A review of the document titled Consent for Anesthesia for patients #2, #3, and #17 revealed the facility did not use the required Consent for Anesthesia.

A review of the document titled Texas Administrative Code, Title 25 Health Services, Part 7 Texas Medical Disclosure Panel, Chapter 601 Informed Consent:

Rule 601.2 Procedures Requiring Full Disclosure of Specific Risks and Hazards--List A

(a) Anesthesia.

(1) Epidural.
(A) Nerve damage.
(B) Persistent back pain.
(C) Headache.
(D) Bleeding/epidural hematoma.
(E) Infection.
(F) Medical necessity to convert to general anesthesia.
(G) Brain damage.
(H) Chronic pain.

(2) General.
(A) Permanent organ damage.
(B) Memory dysfunction/memory loss.
(C) Injury to vocal cords, teeth, lips, eyes.
(D) Awareness during the procedure.
(E) Brain damage.

(3) Spinal.
(A) Nerve damage.
(B) Persistent back pain.
(C) Bleeding/epidural hematoma.
(D) Infection.
(E) Medical necessity to convert to general anesthesia.
(F) Brain damage.
(G) Headache.
(H) Chronic pain.

(4) Regional block.
(A) Nerve damage.
(B) Persistent pain.
(C) Bleeding/hematoma.
(D) Infection.
(E) Medical necessity to convert to general anesthesia.
(F) Brain damage.

(5) Monitored Anesthesia Care (MAC) (conscious sedation).
(A) Permanent organ damage.
(B) Memory dysfunction/memory loss.
(C) Medical necessity to convert to general anesthesia.
(D) Brain damage.
Rule 601.9 Disclosure and Consent Form for Anesthesia and//or Perioperative Pain Management (analgesia) revealed:

The Texas Medical Disclosure Panel adopts the following form which shall be used to provide informed consent to a patient or person authorized to consent for the patient of the possible risks and hazards involved in anesthesia and/or perioperative pain management (analgesia). Providers shall have the form available in both English and Spanish language versions ....

An interview on 8/26/2015 at approximately 2:00PM with staff #35 confirmed the facility was not using the required anesthesia consent.

Based on record review and interviews the facility failed to provide the types and numbers of licensed nursing personnel to provide nursing care to all areas of the hospital on 37 of 46 Medical/Surgical (M/S) floor shifts (two 12 hour shifts per day) for the period of August 1, 2015 until August 23, 2015.

Review of the records titled "Daily Assignments" dated August 1, 2015 through August 23, 2015, revealed a staffing matrix (a guide to provide the ratio of nursing staff, Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs) to the number of patients requiring nursing care) with the following information:

"MATRIX
7 or less = D 1-1 N 1-1
8 to 14 = D 2-1 N 2-1
15 to 21 = D 3-2 N 3-2
22 to 28 = D 4-2 N 4-2
29 or more = D 5-3 N 5-3"

According to the facility's staffing matrix and the records titled "Daily Assignments" dated August 1, 2015 through August 23, 2015, the M/S floor was short 1 licensed nurse on 37 of 46 shifts.

An interview with staff #31 confirmed the validity of the above findings. Staff #31 revealed the facility's administration was aware of the staff shortage and had not given approval to hire another licensed nurse.

An interview with staff #1, Chief Nursing Officer (CNO) confirmed that the facility's administration was aware of the staff shortage and had not approved the hiring of another licensed nurse. Staff #1 stated, "I am aware of the RN shortage. It is not a first priority but, it is on my list." Further interview with staff #1 revealed the facility had not completed their nursing services policies.

Based on record review and interviews the facility failed to provide adequate numbers of licensed registered nurses to be physically present and immediately available on each patient care unit.

Review of the facility's records titled "Daily Assignments" dated August 1, 2015 through August 23, 2015, the Medical/Surgical (M/S) floor was short 1 licensed registered nurse on 17 of 46 shifts.

The "Daily Assignments" revealed 10 night shifts (7 p.m. until 7 a.m.) with an average patient census of 2.9 patients were staffed with 1 LVN.
In addition, 7 night shifts with an average patient census of 4.9 patients were staffed with 2 LVNs.

An interview with staff #31 confirmed the validity of the above findings. Staff #31 revealed the facility's administration was aware of the staff shortage and had not given approval to hire another licensed registered nurse.

An interview with staff #1, Chief Nursing Officer (CNO) confirmed that the facility's administration was aware of the staff shortage and had not approved the hiring of another licensed registered nurse. Staff #1 stated, "I am aware of the RN shortage. It is not a first priority but, it is on my list." Further interview with staff #1 revealed the facility had not completed their nursing services policies.

Based on record review and interviews the facility failed to provide 24 hour nursing services furnished or supervised by a registered nurse in all areas of the hospital on 37 of 46 Medical/Surgical (M/S) floor shifts (two 12 hour shifts per day) for the period of August 1, 2015 until August 23, 2015.

Review of the facility's records titled "Daily Assignments" dated August 1, 2015 through August 23, 2015, the Medical/Surgical (M/S) floor was short 1 licensed registered nurse on 17 of 46 shifts.

The "Daily Assignments" revealed 10 night shifts (7 p.m. until 7 a.m.) with an average patient census of 2.9 patients were staffed with 1 LVN. No RN was assigned to the unit for supervision of the nursing care provided by the LVN.
In addition, 7 night shifts with an average patient census of 4.9 patients were staffed with 2 LVNs. No RN was assigned to the unit for supervision of the nursing care provided by the LVNs.

An interview with staff #31 confirmed the validity of the above findings. Staff #31 revealed the facility's administration was aware of the staff shortage and had not given approval to hire another licensed registered nurse.

An interview with staff #1, Chief Nursing Officer (CNO) confirmed that the facility's administration was aware of the staff shortage and had not approved the hiring of another licensed registered nurse. Staff #1 stated, "I am aware of the RN shortage. It is not a first priority but, it is on my list." Further interview with staff #1 revealed the facility had not completed their nursing services policies.

Based on record review and interviews the facility failed to provide a registered nurse to supervise and evaluate the nursing care of each patient on 17 of 46 Medical/Surgical (M/S) floor shifts (two 12 hour shifts per day) for the period of August 1, 2015 until August 23, 2015.

Review of the facility's records titled "Daily Assignments" dated August 1, 2015 through August 23, 2015, the Medical/Surgical (M/S) floor was short 1 licensed registered nurse on 17 of 46 shifts.

The "Daily Assignments" revealed 10 night shifts (7 p.m. until 7 a.m.) with an average patient census of 2.9 patients were staffed with 1 LVN. No RN was assigned to the unit for supervision of the nursing care provided by the LVN.
In addition, 7 night shifts with an average patient census of 4.9 patients were staffed with 2 LVNs. No RN was assigned to the unit for supervision of the nursing care provided by the LVNs.

An interview with staff #31 confirmed the validity of the above findings. Staff #31 revealed the facility's administration was aware of the staff shortage and had not given approval to hire another licensed registered nurse.

An interview with staff #1, Chief Nursing Officer (CNO) confirmed that the facility's administration was aware of the staff shortage and had not approved the hiring of another licensed registered nurse. Staff #1 stated, "I am aware of the RN shortage. It is not a first priority but, it is on my list." Further interview with staff #1 revealed the facility had not completed their nursing services policies.

Based on interview and document review the facility's Infection Control Professional failed to have specific training in infection control.

On 8/25/2015 in the conference room at 10:30 a.m. the Chief Nursing Officer confirmed the Infection Control Officer had not attended specific infection control training.

On 8/27/2015 at 10:00 a.m. in a class room the Infection Control Officer indicated she was registered for her training but would not be in attendance until September 2015.

On 8/27/2015 at 10:30 a.m. in the class room the personnel record for the Infection Control Officer confirmed there was no record of specific initial or on-going infection control training to support her position of Infection Control Officer..

Based on interview and document review the facility failed to ensure all hospital staff participated in the infection control program from June 2015 through August 2015.

On 8/27/2015 at 9:00 a.m. in the hallway interview with staff #3 confirmed not every department had chosen infection control indicators yet.

On 8/25/2015 during a tour of the dietary department, the staff #14 confirmed there was no specific department focused infection control indicator they were following and submitting to the infection control program for review.

On 8/26/2015 during a tour of the Outpatient Rehab program staff #21 stated they cleaned all surfaces with Sani wipes but that she did not know of a specific infection control identifier the department was focused on.

On 8/27/2015 during a tour of the plant operations department, an interview with Staff #15 confirmed there was no specific infection control indicator the department was aware of.

Based on observation, document review and interview the facility failed to follow the recommended standard of practices related to coverage of hair in the surgical areas.

While touring the surgical department on 8/26/2015 male employees were observed wearing surgical skull caps. Multiple female staff was observed wearing personal, reusable head coverings.

A review of the document titled AORN Recommended Practices, Implementing AORN Recommended Practices for Surgical Attire:
Recommendation IV

All personnel should cover their head and facial hair when in the semirestricted and restricted areas.1(p62) Hair coverings should cover facial hair, sideburns, and the nape of the neck. Perioperative nurses can help minimize the risk of surgical site infections by covering head and facial hair, which prevents skin squames and hair shed from the scalp from falling onto the sterile field.17,18 Skull caps are not recommended because they do not completely cover the wearer ' s hair and skin; they fail to cover the side hair above and in front of the ears and the hair at the nape of the neck ....

Personal, reusable head coverings are acceptable for perioperative personnel to wear if they are covered with a single-use disposable head covering or if they are laundered daily in a health care-accredited laundry facility.19

An interview on 8/26/2015 at approximately 4:00PM with staff #35 confirmed the facility was allowing the use of skull caps in the surgical department. Staff #35 confirmed the facility did not have an approved policy for Personal, reusable head coverings and the use of skull caps.

Based on document review the facility failed to provide medical supervision to the certified registered nurse anesthetist (CRNA) that provided anesthesia to 3 of 3 (Patient #2, #3, #17). Patient #2, #3, #17 had anesthesia consents on their medical records with the statement: "Nurse Anesthetists are NOT medically directed".
A review of the document titled Consent for Anesthesia for patients #2, #3, and #17 revealed the statement: "Nurse Anesthetists are NOT medically directed."
A review of the document titled TEX OC. CODE ANN. 157.058 : Texas Statutes - Section 157.058: DELEGATION TO CERTIFIED REGISTERED NURSE ANESTHETIST:
(a) In a licensed hospital or ambulatory surgical center, a physician may delegate to a certified registered nurse anesthetist the ordering of drugs and devices necessary for the nurse anesthetist to administer an anesthetic or an anesthesia-related service ordered by the physician.
(b) The physician's order for anesthesia or anesthesia-related services is not required to specify a drug, dose, or administration technique.
(c) Pursuant to the physician's order and in accordance with facility policies or medical staff bylaws, the nurse anesthetist may select, obtain, and administer those drugs and apply the medical devices appropriate to accomplish the order and maintain the patient within a sound physiological status.
(d) This section shall be liberally construed to permit the full use of safe and effective medication orders to use the skills and services of certified registered nurse anesthetists.

A review of the document titled Opinion No. JC-0117 Re: Whether the Board of Nurse Examiners may regulate the selection and administration of anesthesia and the care of an anesthetized patient by certified registered nurse anesthetist, and related questions. .....Consequently, section 157.058 does not require that a physician's directly supervise a CRNA's selection and administration of the anesthesia. Rather the extent of physician's involvement is left to the physician's professional judgement in light of the relevant federal and state laws, facility policies, medical staff bylaws, and ethical standards. See id. 157.001,.007,.058. For example, federal regulations limiting medicare coverage and conditioning hospital participation in medicare and medicaid programs currently require a CRNA to be supervised by the operating physician when the CRNA administers anesthesia ...

Based on interview and document review the facility failed to ensure the Infection Control Program had been approved by the Governing Body prior to implementation.

On 8/25/2015 at 10:00 a.m. in the conference room staff #1 confirmed the Infection program was written and the infection control officer had been given the program but the program had not been approved by the Governing Board at the present. The Governing Board was scheduled to meet the evening of 8/26/2015.

On 8/27/2015 request was made for the Governing Board meeting minutes for the purpose of establishing approval of the Infection Control Plan. No meeting minutes were presented. The facility did not have an infection Control plan approved by the Governing Board.