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Based on review of documentation and interview, it was determined that the Governing Body failed to procure a contractual agreement concerning pharmaceutical services.

Findings were:

During a review of contractual services provided to Central Texas Hospital on 9/8/11, no valid contractual agreement for pharmaceutical services was made available to the survey team.

In an interview with the Administrator on 9/8/11, it was confirmed that there was no current contractual agreement for pharmaceutical services.

Based on observation and interview, it was determined that the facility was not maintained to assure the safety of staff and patients.

Facility policy entitled " Electrical Safety " stated in part " Electrical devices shall be protected from wet floors. "

Tour of the facility on 9/7/11 revealed the following:

· 2 inch exposed pipes were observed jutting up from the floor of the radiology room creating a fall hazard
· Eight 2 inch long pieces of metal (support pieces that held an x-ray device to the wall in the past) were observed to be hanging from the ceiling in the Radiology Department. These metal pieces protruded from holes in the ceiling tile, creating an entry for vectors.
· The ceilings throughout the facility had stained and missing ceiling tile
· The Physical Therapy Department had cracked and budging plaster on the ceiling.
· In the central supply area, there were several areas on the ceiling where leaks had been apparent. Spots of mold were noted surrounding the old leaks.
· Under the sink in the kitchen, a PVC pipe was noted emptying into a drain. The pipe was not centered over the drain causing dirty water to spill onto the surrounding tile. This tile appeared dirty and swollen. Lying next to the drain and having contact with the water was a corroded extension cord.


In an interview with the Facility Administrator on 9/7/11, the above deficits were confirmed.

Based on observation and interview it was determined that the facility failed to label multi-use medication vials with the date they were opened.

Findings were:

During a tour of the facility on 9/7/11, 6 multi-use medication vials were open and not labeled with the date of opening.

1 multi-use medication vial was open and dated however the date was 5/30/11, exceeding the 30 day time frame.

Facility policy entitled " Policy & Procedure Manual Pharmacy ...Multiple Dose Vial " , reviewed on 9/7/11, stated " The medical personnel that opens the vial shall write the current date, time, and their initials on the container ...Opened vials will be discarded after 30 days " .

The above findings were confirmed with the Chief Nursing Officer during the same tour.