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

A. assure that all personnel were licensed as required by regulation. These findings were noted in 4 (#6, #26, #34 and #35) out of 4 (#6, #26, #34 and #35). These findings have the potential to cause harm to all patients receiving care in the facility by the facilities failure to assure the staff have appropriate qualifications and licensure.

Refer to tag A 0023

B. ensure the Medical Staff Credentials Committee failed to recommend to the Governing body the appointments for staff privileges at the facility for 2 (#43, #45) of 4 (#42, #43, #45, #48) physicians (radiologists).

Refer to tag A 0046

C. check the qualifications of the person appointed to be in charge of the facility. Citing 1
(#2) of 1 personnel record reviewed. This deficient practice has the potential to allow an unqualified person to be in charge of the facility.

Refer to tag A 0057

D. ensure that all patients received documentation regarding patient's right including information regarding whom to contact within the facility to file a grievance. This deficient practice has the potential for patient complaints and grievance to not have appropriate follow up.

Refer to tag A 0118

E. ensure that all patients received documentation regarding patient's right including the time frames for the facility review and follow up of the grievance and the provision of a response to the complainant. This deficient practice has the potential for patient complaints and grievances to not have appropriate follow up in a timely manner.

Refer to tag A 0122

F. conduct periodic appraisals for 2 (#43, #45) of 4 (#42, #43, #45, #48) physicians (radiologists) presently working at the facility.

Refer to tag A 0340

G. receive from the Medical Staff Credentials Committee the appointments for staff privileges at the facility for 2 (#43, #45) of 4 (#42, #43, #45, #48) physicians (radiologists).
Refer to tag A 0341
H. properly file and protect all medical records from the elements such as fire, water, and rodents. The records were easily accessible to unauthorized staff. This deficient practice has the potential to patients receiving care at the facility not being able to access their records.

Refer to tag A 0438
I. ensure acceptable professional principles were used with employees working in the pharmacy. One (1) of 2 licensed vocational nurses (Staff #34) provided services outside the scope of their license and education. The facility failed to ensure pharmacy technician working alone was Board approved to be working in the pharmacy and received required training to compound medications, and was compounding under pharmacy supervision.
Refer to tag A 0491
J. ensure the consultant pharmacist was supervising the activities in pharmacy services. The pharmacist failed to supervise staff compounding medications, failed to ensure qualified staff worked in the pharmacy, failed to ensure physician orders were reviewed before medication administration, failed to ensure staff were properly trained to prepare medications, and failed to ensure staff were familiar with pharmacy policies.
Refer to tag A 0501
K. ensure outdated medications were discarded on 2 of 2 nursing units (Medical /Surgical (MS) and emergency department (ED).
Refer to tag A 0505
L. ensure staff had access to information related to drug interactions and drug therapy. The facility allowed the Mediware system to be disconnected for lack of payment and did not implement an alternative system for pharmacy technicians to use.
Refer to tag A 0510
M. have review criteria for staff other than physicians to review the medical necessity for admission and continued stay. This deficient practice has the potential to have cases that are not medically necessary billed to the Medicare and Medicaid system.

Refer to tag A 0656

N. to provide a sanitary environment to avoid a source of infection and safety to the patients being cared for at this facility. Also the facility failed to have a current evacuation plan..

Refer to tag A 701

O. ensure Emergency Department Services were under the direction of a qualified member of the medical staff.

Refer to tag A 1102

P. ensure Physician #19 was immediately available to provide direction and/or direct care to the patients presenting in the emergency room. There were 4 (#36, #47, #17, #48) of 4 patients never seen by physician #19. Patient #48 arrived in the ER at 7:43 AM by ambulance with cardiopulmonary resuscitation (CPR) in progress with no available physician, which resulted in a death in the emergency room.

Refer to tag A 1111

Q. provide a sanitary and safe environment for the patients receiving physical and occupational therapy in the outpatient setting. The water to the building was cut off. No place to wash your hands and the hand sanitizer was expired. There were no functioning bathroom facilities and the phones were disconnected. The Hydrocolator machine containing hot packs for the patient therapy had rust colored water in it. Throughout the building observed chips in the floor tile and the floors were dull, discolored, and dirty.

Refer to tag A 1123

The condition and practices found pose an immediate jeopardy to patient's health and safety.

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

A. ensure Emergency Department Services were under the direction of a qualified member of the medical staff. (Refer to findings A 1102)

B. ensure Physician #19 was immediately available to provide direction and/or direct care to the patients presenting in the emergency room. There were 4 (#36, #47, #17, #48) of 4 patients never seen by physician #19. Patient #48 arrived in the ER at 7:43 AM by ambulance with cardiopulmonary resuscitation (CPR) in progress with no available physician, which resulted in a death in the emergency room.
(Refer to findings A 1111)

C. maintain required qualifications established by Medical Staff Bylaws for 4 (#16, #17, #18, and #19) of 4 physicians working in the emergency room. This has the potential to provide an environment for possible patient harm by not having the properly trained physicians to meet the patients' needs. (Refer to findings A 1112)

D. provide a sanitary environment to avoid a source of infection and safety to the patients being cared for at this facility. The facility also failed to have a current evacuation plan..
(Refer to findings A 701)

E. ensure patient care supplies in the Emergency Room were not expired.
(Refer to findings A 724)

It was determined this deficient practice created an Immediate Jeopardy situation and placed the health and safety of the individuals in serious jeopardy.

Based on observation and interview the facility failed to provide a sanitary and safe environment for the patients receiving physical and occupational therapy in the outpatient setting.


During a tour of the rehabilitation department on 06/06/2013 at approximately 2:00 PM with staff #6 observed:

The rehabilitation department is across the parking lot from the main hospital campus in portable building. Patients are scheduled for therapies in this building Monday through Friday.

1. The water to the building was cut off. No place to wash your hands and the hand sanitizer was expired.

2. There were no functioning bathroom facilities in the building. The sign on the door read out of order.

3. The phones were disconnected.

4. The Hydrocolator machine containing hot packs for the patient therapies had rust colored water in it.

5. One of the rooms in the building had missing ceiling tile and the air conditioner tubing was just blowing out in the open not through a vent.

6. One of the rooms in the building was cluttered with computers, computer parts, loose wiring hanging from the wall, boxes, and trash. Items were on the floor and on shelves in disarray.

7. In the room where the ultrasonic machine was used by physical therapy, observed open electrical outlet with no cover in the wall and upon entrance to the room the floor was uneven.

8. Throughout the building observed chips in the floor tile and the floors were dull, discolored, and dirty.

An interview with the occupational therapist on 06/06/2013 at approximately 2:00 PM stated, "The water has been cut off for 3 weeks and phone too ...I tell the patients if they need to use the bathroom facilities they will have to go to the hospital." The therapist also stated, "I know the water needs to be changed in the Hydrocolator machine."

An interview with staff #3 on 06/04/2013 at 11:00 AM stated, "We don't have anyone that can strip and wax the floors and the administrator will not sign a contract with a cleaning company."

An interview with Interim Nursing Director Staff #6 on 06/06/2013 at approximately 2:00 PM confirmed the findings from above.

Based on record review and interview the facility failed to ensure that all personnel were licensed as required by regulation. These findings were noted in 4 (#6, #26, #34 and #35) out of 4 (#6, #26, #34 and #35) personnel records. These findings have the potential to cause harm to all patients receiving care in the facility by the facility's failure to ensure the staff have appropriate qualifications and licensure.

Findings:

Review of nursing personnel records of staff #6, #26, #34 and #35 revealed that the facility had only verified the nurse's licensure status at the Texas State Board of Nursing web site by searching the nurse's name. The site was not searched by either licensure number or Social Security Number and date of birth in order to verify the nurse working was the same licensed nurse found on the board site. When the site is searched for a nurse by name only, a list of nurses with that name is all that is available to the person running the verification. In order to obtain the nurse's license number the site must be searched by the Social Security Number and date of birth. In review of the hospital records it was observed they were using a black marker to mark out the names that they believed were not the person employed or contracted by the facility.

Review of the Texas Board of Nursing website Texas Nursing Bulletin Volume 39, No 3 dated July 2008 states "After September 1, 2008 nurses and employers should go to the agency website at www.bon.state.tx.us and verify licenses on line. The verification, once printed, will resemble a license and will allow the nurse to have the document laminated for the purpose of carrying the licenses with them."

In an interview on 06/5/2013 at 2:30 p.m. with staff #6 confirmed the hospital did not verify the nurses' licensure status by license number or social security and date of birth. In addition she confirmed the nurses had not been required to show proof of licensure with the license number and correct expiration date as required by the Texas Board of Nursing.

Based on record review and interviews, the Medical Staff Credentials Committee failed to recommend to the Governing body the appointments for staff privileges at the facility for 2 (#43, #45) of 4 (#42, #43, #45, #48) physicians (radiologists).
Findings:
Review on June 5, 2013 of the medical staff bylaws titled "Article VI Clinical Privileges, Section 3 Temporary Privileges, A. New Applicants Pending Medical Staff Review, New Applicants Pending Medical Staff Review" revealed:

"Temporary privileges for new applicants may be granted following submission of a complete
application and while awaiting review and approval by the medical executive committee upon verification of all information required by these Bylaws. Such privileges may be granted for an
initial period of sixty (60) (approved by Governing Board 4/20/2005) days, and may be
renewed for one additional period (approved by the Governing Board 4/20/2005) of sixty (60)
days. At a minimum there must be verification of the following in order for an applicant to be
granted temporary privileges:
*current licensure
*relevant training or experience
*current competence
*ability to perform the privileges requested
*other criteria required by the Bylaws
*NPDB query and evaluation of information
*No current or previously successful challenge to licensure or registration
*No subjection to involuntary termination of medical staff membership at another organization
*No subjection to involuntary limitation, reduction, denial or loss of clinical privileges at another organization."

A review of Physician #43's file revealed that a completed application for medical staff privileges was submitted to the facility, however, pages 11 and 12 (the physician's signature pages) were missing and there was no date on the application. The physician's license expired on 5/31/2013. This physician read X-rays at the facility starting the week of 06/03/2013 and there was no evidence a current medical license was validated and that his record was reviewed by the Chief of the Medical Staff or Governing Body. The signature on the form titled "Medical Staff Membership Approval," by Staff # 2 (Administrator) appeared to be a copy of a signature and not the original. The "from and to period" section on the form was incomplete for the temporary appointment and not dated. There was no evidence the Chief of the Medical Staff approved the temporary appointment as required by the bylaws.

A review of Physician #45's file revealed the physician application was signed and submitted on 05/05/2012. The file revealed Staff #2 (Administrator) gave the physician temporary appointment on 11/15/2012. There was no evidence the Chief of Staff reviewed the file and agreed with the temporary appointment as required by the bylaws.

Review of the radiology call schedule and interview on 06/05/2013 at 2:00 p.m. with the department manager confirmed Physicians #43 and #45 had read X-rays during the week starting 06/03/2013.
In an interview on 06/05/2013 at 2:30 p.m. with Staff #6 (Interim Nursing Director) she confirmed the facility had not corrected the previous deficiencies and the temporary privileges had not been completed as required by the Medical Staff Bylaws. In addition, Staff #6 stated they held a medical staff meeting and governing bodies meeting on May 24, 2013 at 12 noon, but there were no documented minutes. Staff #6 stated, "the re-appointments of medical staff did not take place because Physician #47 would not approve them without the complete application being reviewed prior to the meeting."

Based on record review and interview the facility failed to check the qualifications of the person appointed to be in charge of the facility. Citing 1 (#2) of 1 personnel record reviewed. This deficient practice has the potential to allow an unqualified person to be in charge of the facility.

Findings:

Review of staff # 2's personnel record on 06/06/2013 revealed his application was dated 06/14/2012. The file indicated he attended college #52A and received a diploma degree. There were no dates listed when he attended, received his degree and there was no written indication what type of diploma degree he obtained. Review of his work history revealed he worked as the owner of a television and appliance service form 1/01/1972 through 12/31/1987. In addition the application recorded work history as a manager of a company to oversee the manufacturing division from 1/01/1988 through 4/01/1992. There was no evidence in the file the education and work history had been verified. In addition, there was no evidence they conducted the appropriate back ground check prior to appointment on 06/14/2012.

Review of the 06/14/2012 Governing Body minutes revealed no evidence the Governing Body conducted a background check including verification of education and employment. Review of the Governing Body minutes also revealed "he informed the board he would only be on site one day per week and that newly hired Staff #1, the Director of Nurses\Assistant Administrator, would be on site daily and he would be available by telephone from the corporate office (which is 199 miles away).

In an interview on 06/06/2013 at 1:30 p.m. staff #6 confirmed the administrator was only on site once a week or less. She stated "he was also the Administrator at Hospital #52B." Staff #6 confirmed that was all of Staff #2's personnel file and there was no additional personnel file available. Staff #6 also confirmed that Staff #1 had been out since April 22, 2013 with no expected return and she had been appointed in charge in her absence by Staff #2.

Based on records review and interview the facility failed to ensure that all patients received documentation regarding patient's right including information regarding whom to contact within the facility to file a grievance. This deficient practice has the potential for patient complaints and grievance to not have appropriate follow up.

Findings:

Review of the facility's Patient Rights document titled "Patient Rights", provided to patients on admission, revealed the patient rights document failed to include whom to contact within the facility to file an informal or formal grievance. In addition, the form was in a font level that was not easily readable. The font size was less than a size 6.

During an interview on 06/05/2013 at 2:15 p.m., in the conference room of the facility, staff #6 confirmed there was no evidence the facility provided the above required information. In addition, staff # 6 confirmed the font size on the patient rights document was not easily readable.

Based on records review and interview the facility failed to ensure that all patients received documentation regarding patient's right including the time frames for the facility review and follow up of the grievance and the provision of a response to the complainant. This deficient practice has the potential for patient complaints and grievances to not have appropriate follow up in a timely manner.

Findings:

Review of the facility's patient rights document provided to patients on admission, titled "Patient Rights", revealed the patient rights document failed to include the time frame for the facility grievance process and the length of time a response would take. In addition, the form was in a font level that was not easily readable. The font size was less than a size 6.

During an interview on 06/05/2013 at 2:15 p.m., in the conference room of the facility staff # 6 confirmed there was no evidence the facility provided the above required information. In addition, staff # 6 confirmed the font size on the patient rights document was not easily readable.

Based on record review and interviews the Medical Staff Credentials Committee failed to recommend to the Governing Body the appointments for staff privileges at the facility for 2 (#43, #45) of 4 (#42, #43, #45, #48) physicians (radiologists).
Review of the medical staff bylaws on June 5, 2013 titled, "Article VI Clinical Privileges, Section 3 Temporary Privileges, A. New Applicants Pending Medical Staff Review, New Applicants Pending Medical Staff Review" revealed:

"Temporary privileges for new applicants may be granted following submission of a complete
application and while awaiting review and approval by the medical executive committee upon
verification of all information required by these Bylaws. Such privileges may be granted for an
initial period of sixty (60) (approved by Governing Board 4/20/2005) days, and may be
renewed for one additional period (approved by the Governing Board 4/20/2005) of sixty (60)
days. At a minimum there must be verification of the following in order for an applicant to be
granted temporary privileges:
*current licensure
*relevant training or experience
*current competence
*ability to perform the privileges requested
*other criteria required by the Bylaws
*NPDB query and evaluation of information
*No current or previously successful challenge to licensure or registration
*No subjection to involuntary termination of medical staff membership at another organization
*No subjection to involuntary limitation, reduction, denial or loss of clinical privileges at another organization."

A review of Physician #43's file revealed that a completed application for medical staff privileges was submitted to the facility, however, pages 11 and 12 (the physician's signature pages) were missing and there was no date on the application. The physician's license expired on 5/31/2013. This physician read X-rays at the facility starting the week of 06/03/2013 and there was no evidence a current medical license was validated and that his record was reviewed by the Chief of the Medical Staff or Governing Body. The signature on the form titled, "Medical Staff Membership Approval," by Staff # 2 (Administrator) appeared to be a copy of a signature and not the original. The "from and to period" section on the form was incomplete for the temporary appointment and not dated. There was no evidence the Chief of the Medical Staff approved the temporary appointment as required by the bylaws.

A review of Physician #45's file revealed the physician application was signed and submitted on 05/05/2012. The file revealed Staff #2 (Administrator) gave the physician temporary appointment on 11/15/2012. There was no evidence the Chief of Staff reviewed the file and agreed with the temporary appointment, as required by the bylaws.

Review of the radiology call schedule and interview with the Department Manager on 06/05/2013 at 2:00 p.m. confirmed Physicians #43 and #45 had read X-rays during the week starting 06/03/2013.
Interview with Staff #6 (Interim Nursing Director) on 06/05/2013 at 2:30 p.m. confirmed the facility had not corrected the previous deficiencies and the temporary privileges were not completed as required by the Medical Staff Bylaws. In addition, Staff #6 stated they held a medical staff meeting and governing bodies meeting on May 24, 2013 at 12 noon, but there were no documented minutes. Staff #6 stated "the re-appointments of medical staff did not take place because Physician #47 would not approve them without the complete application being reviewed prior to the meeting."

Based on record review and interviews the Medical Staff Credentials Committee failed to recommend to the Governing body the appointments for staff privileges at the facility for 2 (#43, #45) of 4 (#42, #43, #45, #48) physicians (radiologists).
Review of the medical staff bylaws on June 5, 2013 titled, "Article VI Clinical Privileges, Section 3 Temporary Privileges, A. New Applicants Pending Medical Staff Review, New Applicants Pending Medical Staff Review" revealed:

"Temporary privileges for new applicants may be granted following submission of a complete
application and while awaiting review and approval by the medical executive committee upon
verification of all information required by these Bylaws. Such privileges may be granted for an
initial period of sixty (60) (approved by Governing Board 4/20/2005) days, and may be
renewed for one additional period (approved by the Governing Board 4/20/2005) of sixty (60)
days. At a minimum there must be verification of the following in order for an applicant to be
granted temporary privileges:
*current licensure
*relevant training or experience
*current competence
*ability to perform the privileges requested
*other criteria required by the Bylaws
*NPDB query and evaluation of information
*No current or previously successful challenge to licensure or registration
*No subjection to involuntary termination of medical staff membership at another organization
*No subjection to involuntary limitation, reduction, denial or loss of clinical privileges at another organization."

A review of Physician #43's file revealed that a completed application for medical staff privileges was submitted to the facility, however, pages 11 and 12 (the physician's signature pages) were missing and there was no date on the application. The physician's license expired on 5/31/2013. This physician read X-rays at the facility starting the week of 06/03/2013 and there was no evidence a current medical license was validated and that his record was reviewed by the Chief of the Medical Staff or Governing Body. The signature on the form titled, "Medical Staff Membership Approval," by Staff # 2 (Administrator) appeared to be a copy of a signature and not the original. The "from and to period" section on the form was incomplete for the temporary appointment and not dated. There was no evidence the Chief of the Medical Staff approved the temporary appointment as required by the bylaws.

A review of Physician #45's file revealed the physician application was signed and submitted on 05/05/2012. The file revealed Staff #2 (Administrator) gave the physician temporary appointment on 11/15/2012. There was no evidence the Chief of Staff reviewed the file and agreed with the temporary appointment as required by the bylaws.

Review of the radiology call schedule and interview with the Department Manager on 06/05/2013 at 2:00 p.m. confirmed Physicians #43 and #45 had read X-rays during the week starting 06/03/2013.
In an interview on 06/05/2013 at 2:30 p.m. with Staff #6 (Interim Nursing Director) she confirmed the facility had not corrected the previous deficiencies and the temporary privileges were not completed as required by the Medical Staff Bylaws. In addition, Staff #6 stated they held a medical staff meeting and governing bodies meeting on May 24, 2013 at 12 noon, but there were no documented minutes. Staff #6 stated "the re-appointments of medical staff did not take place because Physician #47 would not approve them without the complete application being reviewed prior to the meeting."

Based on interview and record review the facility failed to ensure nursing provided an ongoing assessment and implement interventions to address labs that were out of the reference ranges and obtain physician ordered lab timely in 2 of 2 patients ( Patient #11 and #16.
This deficient practice had the potential to cause harm in all patients.
Findings include:
1. Review of an emergency department (ED) record on Patient #11 revealed she was a 50 year old female presented to the hospital on 06/02/13 at 2:46 p.m. with chief complaints of "possible seizure."
Review of a "Medication Reconciliation Sheet" dated 06/02/13 revealed orders were written for Patient #11 to be on the anticonvulsant Dilantin Kapseals extended release 500 milligrams by mouth at bedtime.
Physician orders dated 06/2/13 3:45 p.m. revealed a lab order for a Dilantin level. At 11:05 p.m. an order was written for a urinalysis with a culture and sensitivity (UA with C &S).
During an interview on 06/03/13 at 12:55 p.m., Patient #11 reported she was in the hospital for having seizures.
Review of nurses notes dated 06/04/13 revealed Patient #11 was discharged home at 6:15 p.m.
Review of Patient #11's chart on 06/05/13 at 11:21 a.m. revealed no lab results for the Dilantin or the UA with C&S.
During an interview on 06/05/13 at 10:00 a.m., Staff #55 reported she called the lab and the UA with C&S was not done. The results of the Dilantin was pulled off the computer and the following was noted:
Dilantin level low at <0.6 (Reference Ranges 10-20), final report dated 06/04/13 at 11:43 a.m (2 days after it was ordered).
During an interview on 06/06/13 at 10:35 a.m., Staff #29 reported nursing had not signed the UA in on the "Specimen drop off " form in the laboratory. The reason the Dilantin level was late was it had to be sent out to another lab and it was not picked up until 06/03/14.
There was no documentation in the chart of what was done about the Dilantin level or any mention of the UA.

2. Review of an ED record revealed Patient #16 was a 56 year old female who presented to the hospital at 10:47 p.m. on 05/31/13 with a chief complaint of vomiting. Patient #16 had a diagnoses of diabetes mellitus.
Patient #16 had undated verbal physician orders for a complete blood count, complete metabolic panel, fingerstick blood sugar, serum ketone, and a urinalysis.
Review of a "Diabetic flow sheet" revealed on 05/31/13 at 11:34 p.m Patient #16 had a glucose reading that was over the range ( meaning so elevated it would not register on the glucometer); A CMP collected at 11:34 p.m. revealed a glucose level of 604 (Reference range being 70-105). There was no documentation of any insulin being given or ordered.
According to the ED report dated 05/31/13 the physician arrived at 11:45 p.m (almost an hour after Patient #16 presented to the hospital).
Review of a "Diabetic flow sheet" revealed the following :
*06/01/13 at 12:08 midnight the glucose reading was 608 and 10 units of Regular insulin was administered intravenous push (IVP). The first treatment for the elevated blood sugar was administered over 1 hour and 15 minutes after Patient #16 presented to the hospital.
*06/01/13 at 1:20 a.m. the glucose reading was 375 and 2 units of Regular insulin was administered IVP.
*06/01/13 at 2:30 a.m. the glucose reading was 345 and 3 unit of Regular insulin was administered IVP.
*06/01/13 at 3:35 a.m. the glucose reading was 112.
There was no physician orders for the insulin administered for the levels of 375 and 345.
Review of verbal orders on a ED report revealed orders for the FSBS at 0120, 0230, 0335, Regular insulin 10 units IV, 2 liters of normal saline, and Regular insulin 2 units IV. There was no time on the order, no order for 3 units of Regular insulin nor an order for sliding scale insulin.
During an interview on 06/05/13 at 2:25 p.m., Staff #6 confirmed the orders and medications.
During an interview on 06/06/13 at approximately 2:30 p.m., Staff #6 confirmed they needed orders for insulin to address elevated blood sugars on admit.

Based on interview and record review the facility failed to ensure medications were administered as ordered by a physician in 1 of 1 patients (#16).
This deficient practice had the potential to cause harm in all patients.
Findings include:
Review of an ED record revealed Patient #16 was a 56 year old female who presented to the hospital at 10:47 p.m. on 05/31/13 with a chief complaint of vomiting. Patient #16 had a diagnoses of diabetes mellitus.
Patient #16 had undated verbal physician orders for a complete blood count, complete metabolic panel, fingerstick blood sugar, serum ketone, and a urinalysis.
Review of a "Diabetic flow sheet" revealed on 05/31/13 at 11:34 p.m. Patient #16 had a glucose reading that was over the range ( meaning so elevated it would not register on the glucometer); A CMP collected at 11:34 p.m. revealed a glucose level of 604 (Reference range being 70-105). There was no documentation of any insulin being given or ordered.
According to the ED report dated 05/31/13 the physician arrived at 11:45 p.m . (almost an hour after Patient #16 presented to the hospital).
Review of a "Diabetic flow sheet" revealed the following :
*06/01/13 at 12:08 midnight the glucose reading was 608 and 10 units of Regular insulin was administered intravenous push (IVP). The first treatment for the elevated blood sugar was administered over 1 hour and 15 minutes after Patient #16 presented to the hospital.
*06/01/13 at 1:20 a.m. the glucose reading was 375 and 2 units of Regular insulin was administered IVP.
*06/01/13 at 2:30 a.m. the glucose reading was 345 and 3 unit of Regular insulin was administered IVP.
*06/01/13 at 3:35 a.m. the glucose reading was 112.
There was no specific physician orders for the insulin administered for the levels of 375 and 345.
Review of verbal orders on a ED report revealed orders for the FSBS at 0120, 0230, 0335, Regular insulin 10 units IV, 2 liters of normal saline, and Regular insulin 2 units IV. There was no time on the order, no order for 3 units of Regular insulin nor an order for sliding scale insulin.
During an interview on 06/05/13 at 2:25 p.m., Staff #6 confirmed the orders and medications.
During an interview on 06/06/13 at approximately 2:30 p.m., Staff #6 confirmed they needed orders for insulin to address elevated blood sugars on admit.

Based on observation and interview the facility failed to properly file and protect all medical records from the elements such as fire, water, and rodents. The records were easily accessible to unauthorized staff. This deficient practice has the potential for patients receiving care at the facility not being able to access their records.

Finding:

Observation of the facility's off site medical records storage revealed the area was not sprinklered to protect the records from fire. In addition, there were numerous boxes that were just put in the storage area by just piling the boxes in the area as if they were just thrown into the storage area. Many of the box tops were opened and the medical records were lying out. There were boxes that appeared to have water damage and some of them appeared to have been chewed.

In an interview on 06/06/2013 at 3:30 p.m. staff #3 confirmed the condition of the medical records. In an interview on 06/06/2013 at 3:30 p.m. by telephone with Staff # 57 she confirmed she was the Director of Medical Records and stated "her office site was at Hospital #52B", which is 199 miles from this facility. She stated "she was not aware of the condition of the storage of medical records."

Based on observation, interview and record review the pharmacy department failed to:
1. ensure acceptable professional principles were used with employees working in the pharmacy. One (1) of 2 licensed vocational nurses (Staff #34) provided services outside the scope of their license and education. The facility failed to ensure pharmacy technician working alone was Board approved to be working in the pharmacy and received required training to compound medications, and was compounding under pharmacy supervision.
Refer to tag A0491
2. ensure the consultant pharmacist was supervising the activities in pharmacy services. The pharmacist failed to supervise staff compounding medications, failed to ensure qualified staff worked in the pharmacy, failed to ensure physician orders were reviewed before medication administration, failed to ensure staff were properly trained to prepare medications, and failed to ensure staff were familiar with pharmacy policies.
Refer to tag A0501
3. ensure outdated medications were discarded on 2 of 2 nursing units Medical /Surgical (MS) and emergency department (ED).
Refer to tag A0505
4. ensure staff had access to information related to drug interactions and drug therapy. The facility allowed the drug interaction software system to be disconnected for lack of payment and did not implement an alternative system for pharmacy technicians to use.
Refer to tag A0510

Based on observation, interview and record review the facility failed to ensure acceptable professional principles were used in the pharmacy. One (1) of 2 licensed vocational nurses (Staff #34) failed to have State Board approval before working in the pharmacy.
This deficient practice had the potential to cause harm to all inpatients and emergency room patients.
Findings include:
Review of TAC Title 22, Part 15, Chapter 297 of the Texas State Board of Pharmacy Rules the following was documented:
Rule 297.2
"Pharmacy Technician trainee is an individual who is registered with the board as a pharmacy technician trainee and is authorized to participate in a pharmacy's technician training program."
Rule 297.3
"Individuals who are not registered with the Board may not be employed as or perform the duties of a pharmacy technician or pharmacy technician trainee."
Rule 297.5
"(b) A person may be designated as a pharmacy technician trainee for no more than two years and the requirements for registration a pharmacy technician must be completed within a two year period."
Rule 297.6
"(a) Pharmacy technicians and pharmacy technician trainees shall complete initial training as outlined by the pharmacist-in-charge in a training manual. Such training:
(1) shall meet the requirements of subsections (d) or (e) of this section; and
(2) may not be transferred to another pharmacy unless:
(A) the pharmacies are under common ownership and control and have a common training program; and
(B) the pharmacist-in-charge of each pharmacy in which the pharmacy technician or pharmacy technician trainee works certifies that the pharmacy technician or pharmacy technician trainee is competent to perform the duties assigned in that pharmacy.
(b) The pharmacist-in-charge shall assure the continuing competency of pharmacy technicians and pharmacy technician trainees through in-service education and training to supplement initial training.
(c) The pharmacist-in-charge shall document the completion of the training program and certify the competency of pharmacy technicians and pharmacy technician trainees completing the training. A written record of initial and in-service training of pharmacy technicians and pharmacy technician trainees shall be maintained and contain the following information:
(1) name of the person receiving the training;
(2) date(s) of the training;
(3) general description of the topics covered;
(4) a statement that certifies that the pharmacy technician or pharmacy technician trainee is competent to perform the duties assigned;
(5) name of the person supervising the training; and
(6) signature of the pharmacy technician or pharmacy technician trainee and the pharmacist-in-charge or other pharmacist employed by the pharmacy and designated by the pharmacist-in-charge as responsible for training of pharmacy technicians and pharmacy technician trainees.
(d) A person who has previously completed the training program outlined in subsection (e) of this section, a licensed nurse, or physician assistant is not required to complete the entire training program outlined in subsection (e) of this section if the person is able to show competency through a documented assessment of competency. Such competency assessment may be conducted by personnel designated by the pharmacist-in-charge, but the final acceptance of competency must be approved by the pharmacist-in-charge.
(e) Pharmacy technician and pharmacy technician trainee training shall be outlined in a training manual. Such training manual shall, at a minimum, contain the following:
(1) written procedures and guidelines for the use and supervision of pharmacy technicians and pharmacy technician trainees. Such procedures and guidelines shall:
(A) specify the manner in which the pharmacist responsible for the supervision of pharmacy technicians and pharmacy technician trainees will supervise such personnel and verify the accuracy and completeness of all acts, tasks, and functions performed by such personnel; and
(B) specify duties which may and may not be performed by pharmacy technicians and pharmacy technician trainees; and
(2) instruction in the following areas and any additional areas appropriate to the duties of pharmacy technicians and pharmacy technician trainees in the pharmacy:
(A) Orientation;
(B) Job descriptions;
(C) Communication techniques;
(D) Laws and rules;
(E) Security and safety;
(F) Prescription drugs:
(i) Basic pharmaceutical nomenclature;
(ii) Dosage forms;
(G) Drug orders:
(i) Prescribers;
(ii) Directions for use;
(iii) Commonly-used abbreviations and symbols;
(iv) Number of dosage units;
(v) Strengths and systems of measurement;
(vi) Routes of administration;
(vii) Frequency of administration; and
(viii) Interpreting directions for use;
(H) Drug order preparation:
(i) Creating or updating patient medication records;
(ii) Entering drug order information into the computer or typing the label in a manual system;
(iii) Selecting the correct stock bottle;
(iv) Accurately counting or pouring the appropriate quantity of drug product;
(v) Selecting the proper container;
(vi) Affixing the prescription label;
(vii) Affixing auxiliary labels, if indicated; and
(viii) Preparing the finished product for inspection and final check by pharmacists;
(I) Other functions;
(J) Drug product prepackaging;
(K) Written policy and guidelines for use of and supervision of pharmacy technicians and pharmacy technician trainees; and
(L) Confidential patient medication records.
(f) Pharmacy technicians and pharmacy technician trainees compounding non-sterile pharmaceuticals shall meet the training and education requirements specified in the rules for the class of pharmacy in which the pharmacy technician or pharmacy technician trainee is working.
(g) Pharmacy technicians and pharmacy technician trainees compounding sterile pharmaceuticals shall meet the training and education requirements specified in the rules for class of pharmacy in which the pharmacy technician or pharmacy technician trainee is working."

Rule 297.9
"A pharmacy technician or pharmacy technician trainee who only works in the inpatient portion of a Class C pharmacy is not required to publicly display their current registration certification in the pharmacy, provided the pharmacist-in-charge makes and retains a copy of their current registration certificate for inspection by a board representative."
Review of a pharmacy policy "compounding" dated 11/05/11 revealed "All IV admixtures prepared by the technician will then be checked by a pharmacist noting the fluid, additive(s), volume, expiration."

During an observation of the pharmacy on 06/03/13 at 2:15 p.m., Pharmacy staff #34 was observed working in the pharmacy alone. The pharmacy room was found with dirt build-up to the baseboards; supplies had dust build up, medications stored to close to the floor and intravenous bags of medications and fluids stored in bins which were soiled with spills inside and outside. The Hood used to mix medications was found to be soiled with white substance. Staff #34 confirmed it was soiled with antibiotic particles that she could not get clean. Staff #34 reported she had already signed out for the day as cleaning the hood. After reviewing her daily schedule with the surveyor she reported only the front window had been cleaned on the mixing hood. A cabinet with supplies was covered with dust was next to the mixing hood. The monthly cleaning schedule for the room was last signed off in April 2013. Staff #34 said she did not know anything about the inventory sheets used to inspect the drug storage areas. She reported just finding out about them today and she could only find the 2012 sheets. Staff #34 said she did not know the drug recall procedure, stop order policy or the list of what staff could enter the pharmacy. She did know that only RN's could remove medications from the pharmacy. Staff #34 reported there was no way for her to check drug compatibilities because the computer system was down. Sometimes she conducts computer searchs for medication information. A lot of stuff she still does not know and has to ask the other technician. There was no pharmacist in there expect a few hours once per week to supervise her. The other pharmacy technician alternates days with her and they did not work together. Staff #34 did not have her training certificate posted or could not provide one. Staff #34 reported she had not received anything yet and was waiting on approval to test. She had up to a year to get certified.

During an interview on 06/04/13 at 8:25 a.m., Pharmacy staff #34 reported her orientation consisted of 2 weeks with another pharmacy technician who no longer worked there. Pharmacy staff #34 reported she worked in the pharmacy alone a lot and she did not feel comfortable with it. She has been working in the pharmacy since January 2013. Pharmacy staff #34 reported her experience in intravenous therapy was mixing medications as a LVN working in a nursing home. Pharmacy staff #34 reported she had not received any formal intravenous training and was not a certified pharmacy technician. Pharmacy staff #34 reported some of the medications she mixes are Gentamycin, Clindamycin, Primaxin, Zithromax, Zosyn, Protonix and different milligrams of Rocephin. Pharmacy staff #34 reported she adds potassium to fluids and she uses the Laminar Hood to mix her medications. As far as mixing for children the doctor writes the orders in the correct milligrams per kilogram on the floor. Staff #34 reported the pharmacist was not checking her mixtures every time. Staff #34 reported she sent her application off to take the test back in January 2013, but had not received any response yet. She would check her spam e-mail to see if it went there. She could not provide any evidence of being trained by the pharmacy expect for on 05/24/13.
During an interview on 06/04/13 at 3:22 p.m., Staff #34 reported she had checked the Pharmacy board and she had not received approval yet to be a trainee. Staff #34 reported she had just dropped the ball on completing her application. She gave the surveyor a copy of the background check she needed to complete before receiving approval.
Review of the personnel file on Staff #34 revealed she had a hire date of 10/05/2010 as a LVN (licensed vocational nurse). Her job description for pharmacy technician was undated. There was a detailed competency form which explained all items addressed in the pharmacy which were left blank. The first pharmacy competency skills which had general categories were signed off by the pharmacy on 5/24/13 (4 months after Staff #34 started working in the pharmacy). Staff #34 confirmed she could not find anything on 06/04/13 at 8:25 a.m.
During an interview on 06/04/13 at 1:22 p.m., Staff Pharmacist #37 reported he comes to the facility once per week for 2-3 hours per week and on different days. He was contracted labor and did not clock in or out. There was nothing showing how long his visits were. The facility had stop order policies and procedures and they should be in the pharmacy manual. The pharmacist was questioned about the pharmacy technician filling orders and the requirements for supervision. Pharmacist #37 reported he did not know if they needed supervision because they were LVNs and were allowed by the Board of Pharmacy to remove medications from the pharmacy. He could not recall if he had any training for the ladies that mixed intravenous medications. When questioned more about staff training he stated he reported he thought the facility had it wrong about the pharmacy technicians training. He thought they were allowed 6 months instead of 1 year to be trained. Staff #37 reported the training information could be found in a blue book in the pharmacy. He stated "Good luck in finding it because everything is so unorganized over there."
The book was the 2013 Texas Pharmacy Laws and Regulations not a policy and procedure addressing training, staff studies and his supervision requirments.
During an interview on 06/06/13 at approximately 2:30 p.m., Staff #6 confirmed the LVN was not suppose to be mixing medications.

Based on observation, interview and record review the facility failed to ensure pharmacy services were supervised in 1 of 1 pharmacy. The pharmacist failed to supervise staff compounding medications, failed to ensure qualified staff worked in the pharmacy, failed to ensure physician orders were reviewed before medication administration, failed to ensure staff were properly trained to prepare medications, and failed to ensure staff were familiar with pharmacy policies, required resources needed for drug interactions and drug therapy were available.
This deficient practice had the potential to cause harm to all patients.
Findings include:
Review of a pharmacy policy "compounding " dated 11/05/11 revealed "All IV admixtures prepared by the technician will then be checked by a pharmacist noting the fluid, additive {s), volume, expiration "
Review of the Texas Administrative Code (TAC), Title 22, Part 15, Chapter 291 of the Texas State Board of Pharmacy Rules the following was documented:
Rule 291.73
"(a) (2) A Class C pharmacy in a facility with 100 beds or less shall have the services of a pharmacist at least on a part-time or consulting basis according to the need of the facility except that a pharmacist shall be on site at least once every seven days.
(b) (2) Responsibilities. The pharmacist-in-charge shall have the responsibility for, at a minimum, the following:
(A) providing the appropriate level of pharmaceutical care services to patients of the facility;
(B) ensure that drugs and/or devices are prepared for distribution safely, and accurately as prescribed;
(D) providing written guidelines and approval of the procedure to assure that all pharmaceutical requirements are met when any part of preparing, sterilizing, and labeling of sterile preparations is not performed under direct pharmacy supervision.
(F) developing a system to assure that drugs to be administered to patients are distributed pursuant to an original or direct copy of the practitioner ' s medication order;
(K) participating in teaching and /or research programs in the facility. "

Review of TAC Title 22, Part 15, Chapter 297 of the Texas State Board of Pharmacy Rules the following was documented:
Rule 297.2
"Pharmacy Technician trainee is an individual who is registered with the board as a pharmacy technician trainee and is authorized to participate in a pharmacy's technician training program."
Rule 297.3
"Individuals who are not registered with the Board may not be employed as or perform the duties of a pharmacy technician or pharmacy technician trainee."
Rule 297.5
"(b) A person may be designated as a pharmacy technician trainee for no more than two years and the requirements for registration a pharmacy technician must be completed within a two year period."
Rule 297.6
"(a) Pharmacy technicians and pharmacy technician trainees shall complete initial training as outlined by the pharmacist-in-charge in a training manual. Such training:
(1) shall meet the requirements of subsections (d) or (e) of this section; and
(2) may not be transferred to another pharmacy unless:
(A) the pharmacies are under common ownership and control and have a common training program; and
(B) the pharmacist-in-charge of each pharmacy in which the pharmacy technician or pharmacy technician trainee works certifies that the pharmacy technician or pharmacy technician trainee is competent to perform the duties assigned in that pharmacy.
(b) The pharmacist-in-charge shall assure the continuing competency of pharmacy technicians and pharmacy technician trainees through in-service education and training to supplement initial training.
(c) The pharmacist-in-charge shall document the completion of the training program and certify the competency of pharmacy technicians and pharmacy technician trainees completing the training. A written record of initial and in-service training of pharmacy technicians and pharmacy technician trainees shall be maintained and contain the following information:
(1) name of the person receiving the training;
(2) date(s) of the training;
(3) general description of the topics covered;
(4) a statement that certifies that the pharmacy technician or pharmacy technician trainee is competent to perform the duties assigned;
(5) name of the person supervising the training; and
(6) signature of the pharmacy technician or pharmacy technician trainee and the pharmacist-in-charge or other pharmacist employed by the pharmacy and designated by the pharmacist-in-charge as responsible for training of pharmacy technicians and pharmacy technician trainees.
(d) A person who has previously completed the training program outlined in subsection (e) of this section, a licensed nurse, or physician assistant is not required to complete the entire training program outlined in subsection (e) of this section if the person is able to show competency through a documented assessment of competency. Such competency assessment may be conducted by personnel designated by the pharmacist-in-charge, but the final acceptance of competency must be approved by the pharmacist-in-charge.
(e) Pharmacy technician and pharmacy technician trainee training shall be outlined in a training manual. Such training manual shall, at a minimum, contain the following:
(1) written procedures and guidelines for the use and supervision of pharmacy technicians and pharmacy technician trainees. Such procedures and guidelines shall:
(A) specify the manner in which the pharmacist responsible for the supervision of pharmacy technicians and pharmacy technician trainees will supervise such personnel and verify the accuracy and completeness of all acts, tasks, and functions performed by such personnel; and
(B) specify duties which may and may not be performed by pharmacy technicians and pharmacy technician trainees; and
(2) instruction in the following areas and any additional areas appropriate to the duties of pharmacy technicians and pharmacy technician trainees in the pharmacy:
(A) Orientation;
(B) Job descriptions;
(C) Communication techniques;
(D) Laws and rules;
(E) Security and safety;
(F) Prescription drugs:
(i) Basic pharmaceutical nomenclature;
(ii) Dosage forms;
(G) Drug orders:
(i) Prescribers;
(ii) Directions for use;
(iii) Commonly-used abbreviations and symbols;
(iv) Number of dosage units;
(v) Strengths and systems of measurement;
(vi) Routes of administration;
(vii) Frequency of administration; and
(viii) Interpreting directions for use;
(H) Drug order preparation:
(i) Creating or updating patient medication records;
(ii) Entering drug order information into the computer or typing the label in a manual system;
(iii) Selecting the correct stock bottle;
(iv) Accurately counting or pouring the appropriate quantity of drug product;
(v) Selecting the proper container;
(vi) Affixing the prescription label;
(vii) Affixing auxiliary labels, if indicated; and
(viii) Preparing the finished product for inspection and final check by pharmacists;
(I) Other functions;
(J) Drug product prepackaging;
(K) Written policy and guidelines for use of and supervision of pharmacy technicians and pharmacy technician trainees; and
(L) Confidential patient medication records.
(f) Pharmacy technicians and pharmacy technician trainees compounding non-sterile pharmaceuticals shall meet the training and education requirements specified in the rules for the class of pharmacy in which the pharmacy technician or pharmacy technician trainee is working.
(g) Pharmacy technicians and pharmacy technician trainees compounding sterile pharmaceuticals shall meet the training and education requirements specified in the rules for class of pharmacy in which the pharmacy technician or pharmacy technician trainee is working."

Rule 297.9
"A pharmacy technician or pharmacy technician trainee who only works in the inpatient portion of a Class C pharmacy is not required to publicly display their current registration certification in the pharmacy, provided the pharmacist-in-charge makes and retains a copy of their current registration certificate for inspection by a board representative."

During an observation of the pharmacy on 06/03/13 at 2:15 p.m., Pharmacy staff #34 was observed working in the pharmacy alone. The pharmacy room was found with dirt build-up to the baseboards; supplies had dust build up, medications stored to close to the floor and intravenous bags of medications and fluids stored in bins which were soiled with spills inside and outside. The Hood used to mix medications was found to be soiled with white substance. Staff #34 confirmed it was soiled with antibiotic particles that she could not get clean. Staff #34 reported she had already signed out for the day as cleaning the hood. After reviewing her daily schedule with the surveyor she reported only the front window had been cleaned on the mixing hood. A cabinet with supplies was covered with dust was next to the mixing hood. The monthly cleaning schedule for the room was last signed off in April 2013. Staff #34 said she did not know anything about the inventory sheets used to inspect the drug storage areas. She reported just finding out about them today and she could only find the 2012 sheets. Staff #34 said she did not know the drug recall procedure, stop order policy or the list of what staff could enter the pharmacy. She did know that only RN's could remove medications from the pharmacy. Staff #34 reported there was no way for her to check drug compatibilities because the computer system was down. Sometimes she conducted computer searches for medication information. A lot of stuff she still does not know and has to ask the other technician. There was no pharmacist in there expect a few hours once per week to supervise her. The other pharmacy technician alternates days with her and they did not work together. Staff #34 did not have her training certificate posted or could not provide one. Staff #34 reported she had not received anything yet and was waiting on approval to test. She had up to a year to get certified.

During an interview on 06/04/13 at 8:25 a.m., Pharmacy staff #34 reported her orientation consisted of 2 weeks with another pharmacy tech who no longer worked there. Pharmacy staff #34 reported she worked in the pharmacy alone a lot and she did not feel comfortable with it. She has been working in the pharmacy since January 2013. Pharmacy staff #34 reported her experience in intravenous therapy was mixing medications as a LVN working in a nursing home. Pharmacy staff #34 reported she had not received any formal intravenous training and was not a certified pharmacy technician. Pharmacy staff #34 reported some of the medications she mixes are Gentamycin, Clindamycin, Primaxin, Zithromax, Zosyn, Protonix and different milligrams of Rocephin. Pharmacy staff #34 reported she adds potassium to fluids and she uses the Laminar Hood to mix her medications. As far as mixing for children the doctor writes the orders in the correct milligrams per kilogram on the floor. Staff #34 reported the pharmacist was not checking her mixtures every time. Staff #34 reported she sent her application off to take the test back in January 2013, but had not received any response yet. She could not provide any evidence of being trained by the pharmacy expect for on 05/24/13.
During an interview on 06/04/13 at 3:22 p.m., Staff #34 reported she had checked the Pharmacy board and she had not received approval yet to be a trainee. Staff #34 reported she had just dropped the ball on completing her application. She gave the surveyor a copy of the background check she needed to complete before receiving approval.
Review of the personnel file on Staff #34 revealed she had a hire date of 10/05/2010 as a LVN (licensed vocational nurse). Her job description for pharmacy technician was undated. There was a detailed competency form which explained all items addressed in the pharmacy which were left blank. The first pharmacy competency skills which had general categories were signed off by the pharmacy on 5/24/13 (4 months after Staff #34 started working in the pharmacy). Staff #34 confirmed she could not find anything on 06/04/13 at 8:25 a.m.

During an interview on 06/04/13 at 10:55 a.m., Pharmacy staff #31 reported she was a registered /certified pharmacy technician. She had been working in pharmacies since 1989. She did not get to work with Staff #34 and the Pharmacist only comes in once per week. Pharmacy staff #31 reported the pharmacy technicians have to type the orders from the original physician orders, scan the typed information to the pharmacist every morning. The pharmacist never sees the original orders. There was really no actual computerized pharmacy system because it was shut off last fall. One of the other pharmacy technicians quit because of the computer system being down. It was shut down because the facility did not pay the bill. The only way to check drug compatibilities was from the patient's allergies and whatever the pharmacist says.
During an interview on 06/04/13 at 1:22 p.m., Pharmacist #37 reported he comes to the facility once per week for 2-3 hours per week and on different days (not every 7 days as required). He was contracted labor and did not clock in our out. There was nothing showing how long his visits were. Pharmacist #37 was questioned about the pharmacy technician filling orders and the requirements for supervision. He reported he did not know if they needed supervision because they were LVNs and were allowed by the Board of Pharmacy to remove medications from the pharmacy. He could not recall if he had any training for the ladies that mixed intravenous medications. When questioned more about staff training he reported he thought the facility had it wrong about the pharmacy technicians training. He thought they were allowed 6 months instead of 1 year to be trained. Pharmacist #37 reported the information on training could be found in a blue book in the pharmacy. He stated "Good luck in finding it because everything is so unorganized over there."
The book was the 2013 Texas Pharmacy Laws and Regulations not a policy and procedure outlining training, pharmacy tech duties in the facility pharmacy or his supervision requirements.
During an interview on 06/04/13 at 1:22 p.m., Pharmacist #37 reported there was a company that came out to perform drug destruction, but he did not know how often they came. He informed the surveyor to ask Staff #31 who it was. He reported there was no way for staff to check drug compatibilities because the facility stopped paying the bill for the computerized system (Mediware) a couple of months ago. The facility owed about $12,000 dollars. Pharmacist #37 reported he reviews the medications every day before 9:00 a.m. if patients need medication, but he could not see every medication that's prescribed.
On 06/05/13 at 1:05 p.m., Staff #31 provided list of medications for Patients #10, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, and 59 which had been typed. The typed list of medications was not signed off by a physician. The list had the fax attached to prove they had been sent to the pharmacist for review. None of the typed list had the original physician orders attached for the pharmacist to review. Review of the orders revealed the following:
*05/31/13 orders sent at 6:56 a.m. and response from pharmacist received at 8:58 a.m. over 2 hours later.
*06/03/13 orders sent at 7:23 a.m. and response received back over an hour later.
*06/04/13 orders sent at 7:53 a.m. and response received back over 2 hours later.
Review of the orders sent to the pharmacy revealed an incomplete dosage, spelling error on allergy, and spelling error on name of medication.

Review of a "Maintenance Summary" for the computer medication information systems dated 01/01/12 revealed a billing invoice for the drug database which was $ 10, 782.19 owed to the company.
Review of "Pharmacy and Therapeutics Committee" minutes revealed the following:
08/17/12
There were thirty (30) medication errors during the months of April, May and June 2012. It was noted that the plan of correction was to "continue to trend the data, talk with the practitioner in order to receive clarification when confusion in the interpretation of the order is in more than one way, when unfamiliar with the name of a medication-Google it to find other name for medication; staff will take the time read the order completely; check the medications list more carefully, nurse will double check each order".
12/11/12
There was eleven (11) medication errors during July, five (5) during August, two (2) in September and eight (8) in October 2012.
Pharmacist #37 noted that the software the pharmacy had utilized in the past was not functional because of non-payment. This software would assist the Pharmacy Technicians with the medications.
04/15/13
There were seven (7) medication errors during the months of November and December 2012. There were a total of 70 medication errors for 2012 ....
Pharmacist #37 noted that the computer software in the Pharmacy was not working in 2012. It was important for the continuum of care for the patients. The software helps the technicians with drug interactions as well as provides the practitioner with a list of medications at the patient's discharge.
There was no documentation of alternative systems being implemented since the computer system was not functioning.

Based on observation, interview and record review the facility failed to ensure outdated medications were discarded on 2 of 2 nursing units, Medical /Surgical (MS) and Emergency Department (ED).
This deficient practice had the potential to cause harm to all patients.
Findings included:
During observation of the MS unit on 06/03/13 at 12:30 p.m. the following expired medications were found:
*Nursing refrigerator
Two bottles of Humalog insulin expired on 05/02/13;
One bottle of Humulin 70/30 insulin expired on 05/14/13 '
One bottle of Novolin insulin expired on 05/01/13;
One bottle of the respiratory agent, Albuterol sulfate expired 05/2013;
Four packets of the respiratory agent, Levalbuterol hydrochloride which were open, some out of the packet and undated.
According to the instructions on the medication the foil packet should be dated when opened. The unit doses should remain in the foil all the time. Once foil pouch is open, the vials should be used within 2 weeks. Once removed from the foil pouch the vials should be discarded within 1 week.
During an interview on 06/03/13 at 12:30 p.m., Staff #26 confirmed the expired medication.
*During an observation of the after- hour medication cart on 06/03/13 at 1:21 p.m. the following expired medication was found:
A steroid agent Depo Medrol expired on 03/2013;
A steroid agent Methyl Prednisolone expired on 05/2013;
A non-steroidal inflammatory agent Meloxicam expired on 05/2013;
Review of the pharmacy medication inventory sheets for both ED and MS units were dated 2012 and were 2012. There were no inventory sheets for 2013.
During an interview on 06/03/13 at 2:15 p.m., Pharmacy staff #34 said she did not know anything about the inventory sheets used to inspect the drug storage areas. She just found out about them today and could only find the 2012 sheets. These were the only ones she had.


29191

During a tour of the emergency room closet on 06/04/2013 at 4:30 PM with staff #49 expired medications were found in the emergency pediatric portable boxes.

Findings:

Sodium Bicarbonate 4.2% expired 2/1/2013 X 4
Dextrose 50 % expired 6/1/2013 X 2
Calcium chloride 10% 5/1/2012 X 2
Atropine 1 MG expired 2/1/2013 X 2

An interview with staff #49 on 06/04/2013 at 4:30 PM confirmed the expired medications in the pediatric portable boxes.

Based on interview and record review the facility failed to ensure staff had access to information related to drug interactions and drug therapy in 1 of 1 pharmacies.
This deficient practice had the potential to cause harm to all patients.
Findings include:
Review of the Texas Administrative Code (TAC), Title 22, Part 15, Chapter 291 of the Texas State Board of Pharmacy Rules the following was documented:
Rule 291.74 (d) (2) (A)
"(d) Library. A reference library shall be maintained that includes that following in hard-copy or electronic format and that pharmacy personnel shall be capable of accessing at all times:
(2) at least one current or updated reference from each of the following categories:
(A) drug interactions. A reference text on drug interactions, such as Drug Interaction Facts. A separate reference is not required if other references maintained by the pharmacy contain drug interaction information including information needed to determine the severity of significance of the interaction and appropriate recommendations or actions to be taken
(B) a general information reference text, such as:
(i) Facts and Comparisons with current supplements;
(ii) United States Pharmacopeia Dispensing Information Volume I (Drug Information for the Healthcare Provider);
(iii) AHFS Drug Information with current supplements;
(iv) Remington's Pharmaceutical Sciences; or
(v) Clinical Pharmacology;
(3) a current or updated reference on injectable drug products, such as Handbook of Injectable Drugs;
(4) basic antidote information and the telephone number of the nearest regional poison control center;
(5) metric-apothecary weight and measure conversion charts."

During an observation of the pharmacy on 06/03/13 at 2:15 p.m., Pharmacy staff #34 was observed working in the pharmacy alone. The pharmacy room was found with dirt build-up to the baseboards; supplies had dust build up, medications stored to close to the floor and intravenous bags of medications and fluids stored in bins which were soiled with spills inside and outside. The Hood used to mix medications was found to be soiled with white substance. Staff #34 confirmed it was soiled with antibiotic particles that she could not get clean. Staff #34 reported she had already signed out for the day as cleaning the hood. After reviewing her daily schedule with the surveyor she reported only the front window had been cleaned on the mixing hood. A cabinet with supplies was covered with dust was next to the mixing hood. The monthly cleaning schedule for the room was last signed off in April 2013. Staff #34 said she did not know anything about the inventory sheets used to inspect the drug storage areas. She reported just finding out about them today and she could only find the 2012 sheets. Staff #34 said she did not know the drug recall procedure, stop order policy or the list of what staff could enter the pharmacy. She did know that only RN's could remove medications from the pharmacy. Staff #34 reported there was no way for her to check drug compatibilities because the computer system was down. Sometimes she conducted computer searches for medication information. A lot of stuff she still does not know and has to ask the other technician. There was no pharmacist in there expect a few hours once per week to supervise her. The other pharmacy technician alternates days with her and they did not work together. Staff #34 did not have her training certificate posted or could not provide one. Staff #34 reported she had not received anything yet and was waiting on approval to test. She had up to a year to get certified.

During an interview on 06/04/13 at 8:25 a.m., Pharmacy staff #34 reported her orientation consisted of 2 weeks with another pharmacy tech who no longer worked there. Pharmacy staff #34 reported she worked in the pharmacy alone a lot and she did not feel comfortable with it. She has been working in the pharmacy since January 2013. Pharmacy staff #34 reported her experience in intravenous therapy was mixing medications as a LVN working in a nursing home. Pharmacy staff #34 reported she had not received any formal intravenous training and was not a certified pharmacy technician. Pharmacy staff #34 reported some of the medications she mixes are Gentamycin, Clindamycin, Primaxin, Zithromax, Zosyn, Protonix and different milligrams of Rocephin. Pharmacy staff #34 reported she adds potassium to fluids and she uses the Laminar Hood to mix her medications. As far as mixing for children the doctor writes the orders in the correct milligrams per kilogram on the floor. Staff #34 reported the pharmacist was not checking her mixtures every time. Staff #34 reported she sent her application off to take the test back in January 2013, but had not received any response yet. She could not provide any evidence of being trained by the pharmacy expect for on 05/24/13.
During an interview on 06/04/13 at 3:22 p.m., Staff #34 reported she had checked the Pharmacy board and she had not received approval yet to be a trainee. Staff #34 reported she had just dropped the ball on completing her application. She gave the surveyor a copy of the background check she needed to complete before receiving approval.
Review of the personnel file on Staff #34 revealed she had a hire date of 10/05/2010 as a LVN (licensed vocational nurse). Her job description for pharmacy technician was undated. There was a detailed competency form which explained all items addressed in the pharmacy which were left blank. The first pharmacy competency skills which had general categories were signed off by the pharmacy on 5/24/13 (4 months after Staff #34 started working in the pharmacy). Staff #34 confirmed she could not find anything on 06/04/13 at 8:25 a.m.

During an interview on 06/04/13 at 10:55 a.m., Pharmacy staff #31 reported she was a registered /certified pharmacy technician. She had been working in pharmacies since 1989. She did not get to work with Staff #34 and the Pharmacist only comes in once per week. Pharmacy staff #31 reported the pharmacy technicians have to type the orders from the original physician orders, scan the typed information to the pharmacist every morning. The pharmacist never sees the original orders. There was really no actual computerized pharmacy system because it was shut off last fall. One of the other pharmacy technicians quit because of the computer system being down. It was shut down because the facility did not pay the bill. The only way to check drug compatibilities was from the patient's allergies and whatever the pharmacist says.
During an interview on 06/04/13 at 1:22 p.m., Pharmacist #37 reported he comes to the facility once per week for 2-3 hours per week and on different days (not every 7 days as required). He was contracted labor and did not clock in our out. There was nothing showing how long his visits were. Pharmacist #37 was questioned about the pharmacy technician filling orders and the requirements for supervision. He reported he did not know if they needed supervision because they were LVNs and were allowed by the Board of Pharmacy to remove medications from the pharmacy. He could not recall if he had any training for the ladies that mixed intravenous medications. When questioned more about staff training he reported he thought the facility had it wrong about the pharmacy technicians training. He thought they were allowed 6 months instead of 1 year to be trained. Pharmacist #37 reported the information on training could be found in a blue book in the pharmacy. He stated "Good luck in finding it because everything is so unorganized over there."
The book was the 2013 Texas Pharmacy Laws and Regulations not a policy and procedure outlining training, pharmacy tech duties in the facility pharmacy or his supervision requirements.
During an interview on 06/04/13 at 1:22 p.m., Pharmacist #37 reported there was a company that came out to perform drug destruction, but he did not know how often they came. He informed the surveyor to ask Staff #31 who it was. He reported there was no way for staff to check drug compatibilities because the facility stopped paying the bill for the computerized system (Mediware) a couple of months ago. The facility owed about $12,000 dollars. Pharmacist #37 reported he reviews the medications every day before 9:00 a.m. if patients need medication, but he could not see every medication that's prescribed.
On 06/05/13 at 1:05 p.m., Staff #31 provided list of medications for Patients #10, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, and 59 which had been typed. The typed list of medications was not signed off by a physician. The list had the fax attached to prove they had been sent to the pharmacist for review. None of the typed list had the original physician orders attached for the pharmacist to review. Review of the orders revealed the following:
*05/31/13 orders sent at 6:56 a.m. and response from pharmacist received at 8:58 a.m. over 2 hours later.
*06/03/13 orders sent at 7:23 a.m. and response received back over an hour later.
*06/04/13 orders sent at 7:53 a.m. and response received back over 2 hours later.
Review of the orders sent to the pharmacy revealed an incomplete dosage, spelling error on allergy, and spelling error on name of medication.

Review of a "Maintenance Summary" for the computer medication information systems dated 01/01/12 revealed a billing invoice for the drug database which was $ 10, 782.19 owed to the company.
Review of "Pharmacy and Therapeutics Committee" minutes revealed the following:
08/17/12
There were thirty (30) medication errors during the months of April, May and June 2012. It was noted that the plan of correction was to "continue to trend the data, talk with the practitioner in order to receive clarification when confusion in the interpretation of the order is in more than one way, when unfamiliar with the name of a medication-Google it to find other name for medication; staff will take the time read the order completely; check the medications list more carefully, nurse will double check each order".
12/11/12
There was eleven (11) medication errors during July, five (5) during August, two (2) in September and eight (8) in October 2012.
Pharmacist #37 noted that the software the pharmacy had utilized in the past was not functional because of non-payment. This software would assist the Pharmacy Technicians with the medications.
04/15/13
There were seven (7) medication errors during the months of November and December 2012. There were a total of 70 medication errors for 2012 ....
Pharmacist #37 noted that the computer software in the Pharmacy was not working in 2012. It was important for the continuum of care for the patients. The software helps the technicians with drug interactions as well as provides the practitioner with a list of medications at the patient's discharge.
There was no documentation of alternative systems being implemented since the computer system was not functioning.

Based on record review and interview the facility failed to have review criteria for staff other than physicians to review the medical necessity for admission and continued stay. This deficient practice has the potential to have cases that are not medically necessary billed to the Medicare and Medicaid system.

Findings:

Review of the utilization plan for the facility failed to reveal any medical criteria used by Staff #6, a non-physician, who is responsible for the review of the admissions and continued stays.

In an interview on 06/04/2013 at 10:30 a.m., staff #6 confirmed the facility does not have medical criteria for the review. She stated she refers admission and continued stay cases for medical review based on the history of the Medicare and Medicaid denials the facility has received.

Based on observation and interview the facility failed to provide a sanitary environment to avoid a source of infection and safety to the patients being cared for at this facility. Also the facility failed to have a current evacuation plan.

A review of the policy titled "Evacuation Plan" original date 11/5/11 has never been approved. The policy reviewed actually refers to another facility and had been marked through and had crossed out wording throughout the policy.

An interview with the Safety Officer in the administrator office on 06/04/2013 1:30 PM confirmed the facility does not have a current and up to date evacuation plan.


During a tour of the emergency department on 06/05/2013 at approximately 10:00 AM with staff #49 the following was observed:

1. 6 of 6 emergency room stretchers had mattresses that were discolored, torn, cracks and tears were taped, and some stuffing was exposed and not covered with any type of material.

2. The supply carts in the ER room between beds #5, #6, and #7 were rusted and had numerous chipped paint missing.

3. The walls in the trauma room were discolored and had exposed wood due to paint chipping around the door facing and the doors.

4. The floors in the emergency rooms were dirty and discolored with chips noted in the tile floor.

5. The call system for ER rooms #5, #6, and #7 was a front desk bell glued to a clipboard at the bedside. Surveyor rang the bell two different times and there was no response from the nurses working in the ER.

An interview with staff #49 on 06/04/2013 at approximately 4:30 PM confirmed the above findings in the Emergency Department.

During a tour of the radiology department on 06/04/2013 at approximately 9:00 AM with staff #9 the following was observed:

1. In the CT scan room observed patient supplies stored in a rusted cart.

2. The biohazard container sitting on the floor in the CT room had contrast splashed all over the lid.

3. The floors were dull, discolored, and had a dirty appearance in the CT room, ultrasound room, main radiology room, and the office /processing room.

In an interview on 06/04/2013 at approximately 9:00 AM staff #9 stated "the housekeeper never comes in here, we sweep the floors ourselves."

During a tour on 06/06/2013 at approximately 2:00 PM of the rehabilitation department with staff #6 the following was observed:

The rehabilitation department is located across the parking lot from the main hospital campus in a portable building. Patients are scheduled here for therapies in this building Monday through Friday.

1. The water to the building was cut off. There was no place to wash your hands and the hand sanitizer was expired.

2. There were no functioning bathroom facilities. The sign on the door read "out of order".

3. The phones were disconnected.

4. The Hydrocolator machine containing hot packs for the patients had rust colored water in it.

5. In a storage area in the room where physical therapy care is performed, the storage area had missing ceiling tiles and the air conditioner tubing was just blowing out in the open, not through a vent.

6. One of the storage areas in the building was cluttered with computers, computer parts, boxes, trash and loose wiring hanging from the wall. Items were on the floor and on shelves in disarray.

7. In the room where the ultrasonic machine was used by physical therapy an open electrical outlet with no cover in the wall was observed and upon entrance to the room the floor was uneven.

8. Throughout the building chips in the floor tile were observed and the floors were dull, discolored, and dirty.

In an interview on 06/06/2013 at approximately 2:00 PM the occupational therapist stated "the water has been cut off for 3 weeks and phone too ... I tell the patients if they need to use the bathroom facilities they will have to go to the hospital." The therapist also stated "I know the water needs to be changed in the Hydrocolator machine."

In an interview on 06/04/2013 at 11:00 AM staff #3 stated "we don't have anyone that can strip and wax the floors and the administrator will not sign a contract with a cleaning company."

An interview with Interim Nursing Director on 06/06/2013 at approximately 2:00 PM confirmed the findings from above.

Based on interview and record review the facility failed to conduct their required fire drills and or training per facility policy.

A review of policy titled "Fire Drill" dated January 1980 revised 05 08/2001 revealed
"A fire drill is held once a month on alternating shifts, testing each shift on a quarterly basis. Staff performance is evaluated and re-training is conducted by the safety officer at the time of the drill."

Review of the fire drill log revealed for the year 2012 no fire drills for the months March, June, July, August, and December were conducted per policy.

Review of the fire drill log for year 2013 revealed no fire drills for the months of January and February were conducted per policy.

A review of records revealed no training on fire-fighting equipment.

An interview with the Safety Officer in the administrator office on 06/04/2013 10:45 AM, confirmed the above findings.

Based on observation and interview the facility failed to ensure patient care supplies in the facility were not expired.

On 06/05/2013 at approximately 10:00 AM, during a tour of the emergency department with staff #49, expired items in the pediatric box in the ER were observed as follows:

Arterial blood gas kits expired 8/2007 X 2
Nicky heel Incision set expired 8/2006 X 2
Extension set tubing expired 2/2012 X 2
Blood tubes Pediatric (purple) 01/2007 X 3
Syringes 20cc 2/2009 X 1
Syringes 20cc 4/2009 X 1
Syringes 20cc 11/2009 X 1
Syringes 20cc 12/2009 X 1

On 06/04/2013 at approximately 9:00 AM, during a tour of the radiology department with staff #9, five Probe Covers for the intravaginal probe were observed to have expired 4/2011.

On 06/04/2013 at approximately 11:00 AM, during a tour of the medical surgical floor with staff #3, Cidex text strips for Cidex solution was observed to have expired 5/25/2013.


10135

During an observation of the lab on 06/04//13 the following was found:
Review of the instructions for the "Glucotrol-AQ" revealed it was an "assayed glucose control intended for professional use in the verification of the precision and accuracy of the HemoCue B-Glucose analyzer and the HemoCue Glucose 201 analyzer."
"After opening the vial, Glucotrol-AQ is stable for 30 days when properly closed and stored...."
During an observation of the lab on 06/04/13 at 9:55 a.m. the quality control solution for the glucometer was found without an open date recorded. Staff #52 ran quality control checks on both glucometers. Glucometer #1 had high reading of 101 (range being 61-99).
Review of the "HemoCue Glucose 201 Quality Control Log" revealed the solution was logged as being used from 04/29/13-06/04/13 and staff failed to log on the sheet the date it was first opened. According to log on 6/03/13 glucometer number #2 had a high reading of 109 (range being 61-99). There was no documented recheck performed on the glucometer.
During an interview on 06/04/13 at 9:55 a.m., Staff #52 confirmed the quality control solution had not been dated. She reported starting the new June 2013 quality control log and getting the high reading Glucometer #2 on 06/03/13. No follow-up check was recorded for the high reading. Staff #52 reported new solution should have been opened, but she continued with the old solution not knowing when it was opened.

Based on observation, record review, and interview the infection control officer failed to conduct environmental rounds in the Emergency, Radiology, Outpatient Therapy, Medical Surgical Floor, Lab, and Pharmacy departments where patient care is provided.

During a tour of the Emergency department on 06/05/2013 at approximately 10:00 AM with staff #49 observed;

1. The 6 of 6 emergency room stretchers had mattresses that were discolored, torn, cracks and tears were taped, and some stuffing was exposed and not covered with any type of material.

2. The supply carts in the ER room between beds #5, #6, and #7 were rusted and had numerous chipped paint missing.

3. The walls in the trauma room were discolored and had exposed wood due to the paint was chipped around the door facing and the doors.

4. The floors in the emergency rooms were dirty and discolored with chips noted in the tile floor.

An interview with staff #49 on 06/04/2013 at approximately 4:30 PM confirmed the above findings in the Emergency Department.

During a tour of the radiology department on 06/04/2013 at approximately 9:00 AM with staff #9 observed;

1. In the CT scan room observed patient supplies stored in a rusted cart.

2. The biohazard container sitting on the floor in the CT room had contrast splashed all over the lid.

3. The floors were dull, discolored, and had dirty appearance in the CT room, ultrasound room, main radiology room, and the office /processing room.

An interview with staff #9 on 06/04/2013 at approximately 9:00 AM stated, " The housekeeper never comes in here, we sweep the floors ourselves."

During a tour of the Outpatient Therapy department on 06/06/2013 at approximately 2:00 PM with staff #6 observed;

The Outpatient Therapy department is across the parking lot from the main hospital campus in portable building. Patients are scheduled here for therapies in this building Monday through Friday.

1. The water to the building was cut off. No place to wash your hands and the hand sanitizer was expired.

2. There were no functioning bathroom facilities. The sign on the door read out of order.

3. The phones were disconnected.

4. The Hydrocolator machine containing hot packs for the patient had rust colored water in it.

5. In a storage area in the room where physical therapy care is performed, the storage area had missing ceiling tiles and the air conditioner tubing was just blowing out in the open, not through a vent.

6. One of the storage areas in the building was cluttered with computers, computer parts, boxes, trash and loose wiring hanging from the wall. Items were on the floor and on shelves in disarray.

7. In the room where the ultrasonic machine was used by physical therapy observed open electrical outlet with no cover in the wall and upon entrance to the room the floor was uneven.

8. Throughout the building observed chips in the floor tile and the floors were dull, discolored, and dirty.

An interview with the occupational therapist on 06/06/2013 at approximately 2:00 PM stated, "The water has been cut off for 3 weeks and phone too ...I tell the patients if they need to use the bathroom facilities they will have to go to the hospital." The therapist also stated, "I know the water needs to be changed in the Hydrocolator machine."

An interview with staff #3 on 06/04/2013 at 11:00 AM stated, " We don't have anyone that can strip and wax the floors and the administrator will not sign a contract with a cleaning company."

An interview with staff #6 (interim Nursing Director) on 06/06/2013 at approximately 2:00 PM confirmed the findings from above.

On tour of the facility in the Soiled Utility Room near the nurses' station, the surveyor saw a container of Cidex (cold disinfectant solution). The container was used for floor use instruments, emergency instruments, and the ultrasound intravaginal probe from radiology.

Review of Cidex OPA product insert revealed:

"CIDEX OPA Solution may be reused for up to a Maximum of 14 days provided the required conditions of ortho-phthalaldehyde concentration and temperature exist based upon monitoring described in the Direction for use. Do not rely solely on day in use. Concentration of this product during its reuse life must be verified by the CIDEX OPA Solution Test Strips prior to each use to determine that the concentration of ortho-phthalaidehyde is above the MEC of 3%. The Product must be discarded after 14 days. On the bottle of Cidex -OPA test strips the label reads "Caution: Do not use after 90 days of opening the bottle."

Review of the log for checking the concentration of the Cidex revealed that it had been checked by Staff #6 for the cleaning of the instruments on 05/25/2013. On day of the tour (06/04/2013), the Cidex test strips were checked and pulled from the room. The Cidex test strips had expired on 05/25/2013. The test strip bottle stated that the strips were only good for 90 days once the bottle was opened. Subsequent review of the log (on 06/04/2013) revealed that the solution was changed and tested on 05/30/2013 using the Cidex test strips which had expired 05/25/2013 by staff #56.

A review of staff #56 personnel file revealed no documentation that she had been trained on the Cidex test or changing the cidex solution.

An interview with staff #6 on 06/04/2013 at 12:00 confirmed that the Cidex-OPA test strips were expired and staff #56 had used the expired Cidex test strips.

On tour of the facility on 06/05/2013 at 11:00 AM with staff #3 observed the Refrigeration/ Freezer Temperature Log for the patient's nutrients on the medical floor had missing dates for being checked and the signature for the defrosting of the refrigerator was left blank. At the bottom of the form it reads;

"It is the responsibility of the Department or area where unit is located to conduct/perform the daily checks and adjustments. At the end of each month, turn the completed form in to the infection control nurse."

A review of the logs revealed February through May 2013 logs was still attached to the clipboard hanging above the refrigerator.

A review of the Refrigeration/ Freezer Temperature Log for May 2013 were missing dates on 1 of 31:
May 31 and the signature for defrosting the refrigeration was left blank.

A review of the Refrigeration/ Freezer Temperature Log for April 2013 were missing dates on 15 of 30:
April 2,3,11, 12, 13, 14, 16, 17, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30. The signature for defrosting the refrigeration was left blank.

A review of the Refrigeration/ Freezer Temperature Log for March 2013 were missing dates on 12 of 31:
March 1, 5, 6, 11, 14, 15, 16, 17, 19, 20, 25, and 28. The signature for defrosting the refrigeration was left blank.

A review of the Refrigeration/ Freezer Temperature Log for February 2013 were missing dates on 11 of 28:
February 8, 9, 14, 15, 16, 17, 19, 20, 25, 27, and 28. The signature for defrosting the refrigeration was left blank.

A review of the environmental rounds sheets for the Emergency, Medical Floor, and Pharmacy departments did not mention the infection control issues as listed in the above findings. A review of the environmental round sheets revealed no round sheets for Radiology, Outpatient Therapy, and Laboratory departments.

An interview with staff #8 (infection control officer) on 06/05/2013 at 2:00 PM confirmed the findings from above concerning the infection control issues found in the facility.








10135

During an observation of the pharmacy room on 06/03/13 at 2:15 p.m. the following was found:
1. Dirt build-up and loose pills to the baseboards;
2. Supplies and medicines had dust build up;
3. Medications were stored on shelves close to the floor and had dust build-up;
4. Bags of intravenous fluids were stored in bins which were soiled with spills inside and outside.
5. The Laminar hood used to mix medications was found soiled with white substance. Staff #34 confirmed it was soiled with antibiotic particles and she could not get it clean. Staff #34 reported she had already signed out for the day as cleaning the hood. After reviewing her cleaning log with her Staff #34 reported only the front window had been cleaned. A cabinet with supplies covered with dirt and dust build-up was next to the mixing hood.
Review of the monthly cleaning schedule for the room was last signed off in April 2013.
During an interview on 06/03/13 at 3:00 p.m. Staff #34 confirmed the condition of the pharmacy.
During an observation of the M/S unit on 06/03/13 the following was found :
1. At 12:28 p.m. , three packets of blue foam limb protectors were soiled with brown stains. They were in plastic bags and stored as ready to use in the supply room.
2. At 1:00 p.m., the covering of the top edges of the crash cart was cracked and had holes and had areas that were taped. The surface was not sanitizable.
3. At 1:01 p.m., suction equipment and laryngoscopes were stored in a bag that was soiled with dried spills.
During an observation of the lab on 06/04/13 the following was found:
1. At 8:23 a.m., there were specimen cups and tops stored in open plastic bins which were covered with dirt and dust buildup. They were stored on the bottom shelf.
2. At 8:40 a.m., the floor underneath the sink was found to have brown water stains, dirt and a build-up of dust.
During an interview on 06/04/13 at 9:10 a.m., Staff #39 confirmed the observations in the lab.

Based on record review and interview the facility failed to ensure Emergency Department Services were under the direction of a qualified member of the medical staff.

Findings:
Review of the organizational chart for the facility on 06/03/2013 at 1:00 PM in the administrator's office revealed no delineation for Emergency Department Medical Director on the organizational chart for the facility. A review of meetings titled, "Governing Board Meeting" dated July 31, 2012 revealed Physician #18 was reappointed to medical staff with provisional appointment extended for only 6 months (which expired January 31, 2013) due to peer review issues that had transpired in the emergency room. A review of Physician's #18 file revealed Physician #18 was given temporary privileges for 04/22/2013 to 06/22/2013 by the administrator and chief of staff. According to the medical staff bylaws proctor shall complete a report with comments on appointee's performance. The file revealed no proctor documentation or that a proctor had ever been appointed. At the end of the provisional period the appointee must qualify for and be advanced to permanent staff status, or be extended on provisional status for an additional period not to exceed twelve (12) months, at the end of which time he will be reevaluated for advancement per the medical staff bylaws.

A review of record titled, "Medical Staff Bylaws; ARTICLE IV Medical Staff Membership, Section 5, sub-section J. Provisional Status" revealed:

"Provisional Status. All initial appointments to any category of the medical staff shall be provisional for twelve (12) months. Each provisional appointee shall be proctored by one or more appropriate member(s) as determined by the Chief of Staff for the number and type of cases/procedures/treatments approved by the Medical Executive Committee. The care observed shall be relevant to the privileges granted. The purpose of observation is to determine the individual's eligibility for advancement from provisional status and for exercising the clinical privileges provisionally granted. The proctor shall complete a proctoring report with comments on the appointee's performance. Each proctoring report will be evaluated when the case is completed in order to be aware of any undesirable trend/pattern developing. At the end of the provisional period the appointee must qualify for and be advanced to permanent staff status, or be extended on provisional status for an additional period not to exceed twelve (12) months at the end of which time he will be reevaluated for advancement. No member may be on provisional status for a total period longer than twenty-four (24) months. Unless excused for good cause by the Medical Executive Committee and governing board. a practitioner's failure to complete the required number of proctored cases shall be deemed a voluntary relinquishment of privileges and membership: such affected practitioner shall not be entitled to the hearing and appeal rights under these bylaws. A practitioner whose privileges and membership have been deemed to be voluntarily relinquished for failure to complete the required proctoring may petition to appear before either his or her clinical department or the Medical Executive Committee for the sole purpose of establishing good cause This shall not be deemed a hearing pursuant to these bylaws and shall not give rise to any other rights under these bylaws. The decision of the Medical Executive Committee shall be final."

In an interview on 06/05/2013 at 2:30 PM with Staff #6 (Interim Nursing Director) confirmed a meeting was held May 24, 2013 with the medical staff and governing board, both meetings were held at 12 noon, but there were no documented minutes. Staff #6 (Interim Nursing Director) stated, "The re-appointments of medical staff did not take place because physician #47 would not approve them without the complete application being reviewed prior to the meeting."

Based on record review and interview the facility failed to ensure Physician #19 was immediately available to provide direction and/or direct care to the patients presenting in the emergency room. There were 4 (#36, #47, #17, #48) of 4 patients never seen by physician #19. Patient #48 arrived in the ER at 7:43 AM by ambulance with cardiopulmonary resuscitation (CPR) in progress with no available physician, which resulted in a death in the emergency room.

The condition and practices found pose an immediate jeopardy to patient's health and safety.


On 06/02/2013 Physician #19 was on duty in the Emergency Room (ER). A review of the emergency log and patient records dated 06/02/2013 revealed:

1. Patient #36 arrived in the ER at 3:25 AM by ambulance with chief complaint written per nurse of being lethargic-low blood sugar, diagnosis of hypoglycemic, insulin dependent diabetes mellitus, hypertension. Blood sugar on arrival was 57. Physician #19 never came out of the sleep room to see the patient. The patient was not seen until 8:00 AM when physician #15 called at home and arrived in the ER.

2. Patient #47 arrived in the ER at 3:40 AM with chief complaint of generalized pain. Patient left without being seen at 4:55 AM. Physician #19 never came out of the sleep room to see the patient. Patient was never seen by a physician.

3. Patient #17 arrived in the ER at 5:23 AM with complaint of abdominal pain and leg pain. Patient left at 9:45 AM against medical advance. Physician #19 never came out of the sleep room to see the patient. The patient was not seen until after 8:00 AM when physician #15 arrived in the ER.

4. Patient #48 arrived in the ER at 7:43 AM by ambulance with cardiopulmonary resuscitation (CPR) in progress. Physician #19 was still in the sleep room and had not been physically seen since 2:00 AM. The nurses called Physician #19, in the sleep room, to notify her of the patient en route and Physician #19 responded "ok." When the patient arrived a staff nurse went to the sleep room and told the physician that there was a patient in the ER with CPR in progress, the physician responded by saying, "Okay I'm coming." ER Staff #49 called Physician #15 at home at approximately 7:43 AM and reported they had a CPR in progress on a patient and that Physician #19 would not come out of the sleep room. Emergency Room Nursing staff RN and LVN continued the CPR and the staff #50 initiated the 1st line of Advanced Cardiac Life Support medication until the physician #15 arrived in the emergency department. Physician #15 was called at home and arrived in the ER at approximately 7:48 AM to assist with CPR and care for the other patients in the emergency room. Patient #48 expired in the emergency room.

An interview with Staff #25, #49, #50 (all nurses in ER) working with Physician
#19 on the day in question reported they had called the sleep room numerous times from 3:30 AM till 8:00 AM. Physician #19 would say, " Okay. " Staff #49 went down to the sleep room and informed Physician #19 that a patient was in the ER with CPR in progress and Physician #19 stated, "okay I'm coming," so Staff #49 went back to the ER. Physician
#19 never came to the Emergency room. The police were called. Two police officers and Physician #15 escorted Physician #19 to the ER for drug and ETOH testing. Physician #15 relieved Physician #19 of the ER duties.

A review of records show this facility did not have an on-call physicians list for emergencies that occur in the facility.

A review of the Emergency Room physician's schedule revealed the month of June was not available or completed. ER Staff #49 and #50 were questioned on how they would know what ER physician was coming on duty and they responded 'we don't know."

An interview on 06/05/2013 with Physician #18 (Emergency Room Director) stated, " I have not completed the schedule ... there are some days not covered. "On 06/06/2013 Physician #18 was questioned again as to where the schedule was and he stated, "I have not completed the schedule."

In an interview on 06/5/2013 at approximately 4:30 PM Staff #6 (Interim Nursing Director) confirmed the facility does not have any type of physician on-call list or plan if an emergency occurred in the facility, and/or the emergency physician was unavailable. She was unaware that the ER physician schedule for June was not posted nor was it completed.

Based on record review and interview the facility failed to maintain required qualifications established by Medical Staff Bylaws for 4 (#16, #17, #18, and #19) of 4 physicians working in the emergency room. This has the potential to provide an environment for possible patient harm by not having the properly trained physicians to meet the patients' needs.

A review of Physician #16's file revealed no documentation the medical staff and governing board had approved the credentialing application or the delineation of clinical privileges.

A review of Physician #17's file revealed no documentation the medical staff and governing board had approved the credentialing application or the delineation of clinical privileges.

A review of Physician #18's file revealed no documentation the medical staff and governing board had approved the credentialing application or the delineation of clinical privileges. A review of meetings titled, "Governing Board Meeting" dated July 31, 2012 revealed Physician #18 was reappointed to medical staff with provisional appointment extended for only 6 months (which expired January 31, 2013) due to peer review issues that had transpired in the emergency room. A review of Physician's #18 file revealed Physician #18 was given temporary privileges for 04/22/2013 to 06/22/2013 by the administrator and chief of staff dated 04/22/2013. A review of records found no evidence a meeting was held on 04/22/2013 for review of physician #18 provisional status. According to the medical staff bylaws proctor shall complete a report with comments on appointee's performance. The file revealed no proctor documentation or that a proctor had ever been appointed. At the end of the provisional period the appointee must qualify for and be advanced to permanent staff status, or be extended on provisional status for an additional period not to exceed twelve (12) months, at the end of which time he will be reevaluated for advancement per the medical staff bylaws.

A review of Physician # 19's file revealed no documentation of a file existed.

An interview with interim Nursing Director on 06/05/2013 at 2:30 PM confirmed a meeting was held May 24, 2013 with the medical staff and governing board, both meetings were held at 12 noon, but there were no documented minutes. The Nursing Director stated, "The re-appointments of medical staff did not take place because physician #47 would not approve them without the complete application being reviewed prior to the meeting."