HospitalInspections.org

Cross refer to:

A0619

A0756

Cross Refer to:

A0119

A0505

A0144

Cross refer to:

A0144

A0386

A00502

Cross refer to:

A0438

A0454

Cross refer to:

A0749

A0756

Based on a review of facility documentation and staff interviews, the facility's governing body failed to appoint and/or reappoint members of the active medical staff in 7 of 7 credentialing files reviewed (Credentialed Staff #6-13).

Findings were:

A review of the appointment/reappointment forms for the active medical staff and mid-level providers for El Paso LTAC Hospital (Credentialed Staff #6-13) revealed no signature of approval by the "Governing Body Chair." The line for this signature was blank on each individual's form. The oldest of these appointments was signed by the physician on 7/28/14 (Credentialed Staff #8).

In an interview with Administrative Staff #1 on the afternoon of 5/30/16 in the facility conference room, Governing Body minutes for 2015 and 2016 were requested. Minutes provided were for the Limited Partnership of El Paso LTAC Hospital for the following dates:
o 8/26/15
o 11/4/15
o 3/31/16
These meeting minutes included no discussion of medical staff appointments or reappointments.

Medical Executive Committee minutes were reviewed for 2015. Minutes were provided for only two dates: 1/28/15 and 7/29/15. The minutes included no discussion of appointment or reappointment of active medical staff members despite 6 of 8 of them (Credentialed Staff #6 and #9-13) requiring review in 2015.

In a subsequent interview with Administrative Staff #1 on the afternoon of 5/31/16, he stated that no meeting minutes existed for the facility's true governing body for 2015 and 2016. When asked exactly who the facility's governing body was, he stated, "It's not the Limited Partners, it's the General Partners. The General Partnership is the hospital's governing body. They own 100% of the hospital operations. The Limited Partners are the financial side. I sit in on those meetings [of the General Partners], but I'm not a voting member. The voting membership is really only two people, well basically one. And I've repeatedly requested she [the one voting member] make those appointments..." When asked for the exact date when he started as CEO of the facility, he stated it was 9/24/15. When it was pointed out that he was listed as present at the meeting of the Limited Partners on 8/26/15, he could provide no explanation for this. He stated, "I don't know what happened there. I wasn't here at that time." He repeated that no minutes existed for the actual governing body meetings for 2015 or 2016.

Facility Medical Staff Bylaws & Rules & Regulations, no effective date, included the following:
"Membership on the Medical Staff, including assignment to a staff category, is granted by the Governing Body following recommendation of the Medical Staff ...
Article VII Appointment and Privileging
Section I Application for Appointment of Privileges
All applications for membership or privileges must be in writing, signed by the applicant, and submitted on a form prescribed by the Hospital, with submission to Governing Body for final the [sic] approval ...
D. Notice of Recommendation and Subsequent Action. Upon receipt of the Executive Committee's recommendation, the Applicant shall be notified of the nature of the recommendation ...The recommendation will be forwarded to the Governing Body for final action ..."

These findings were confirmed in a final interview with the facility CEO and other administrative staff on the afternoon of 5/31/16 in the facility conference room.

Based on record review and interview, the facility's governing body failed to approve and be responsible for an effective grievance process and procedure which provided for the documentation of the existence, submission, investigation and disposition of patients' written or verbal grievances.

Findings were:

In an interview with Nursing Staff #1 on the afternoon of 5/31/16, the facility's patient grievance policy was requested. In response, he provided a policy entitled Conflicts - Resolution Of, effective date January, 2008, which appeared to address conflict resolution between and among facility employees. Nursing Staff #1 stated no other patient grievance policy existed for El Paso LTAC Hospital.

Facility policy entitled Patient Rights, effective January 2008, included the following:
"Complaint Resolution Guidelines
The patient can expect that facility will have established guidelines for handling complaints of patient, physicians, family members, visitors, or facility staff. The patient can also expect that he/she will have the right to have complaints heard, and reviewed ... "

In a final interview with the facility CEO and other administrative staff on the afternoon of 5/31/16 in the facility conference room, it was confirmed that no patient grievance process was in place at the hospital.

Based on observation, interview and record review the facility failed to provide care in a safe environment when housekeeping chemicals, respiratory supplies, medications and the wound care supplies were stored in unlocked areas.

Findings Include:

During a tour of the facility's nursing unit on 5/30/16 in the afternoon revealed the housekeeping room on the "High Side Unit" (name of the nursing unit) was unlocked and unattended. there was an opened gallon container of Lemon Delight Disinfectant, Comet cleaner and surface cleaning solutions on the cart. The room was accessible to confused ambulatory patients, placing them at risk of for accidental poisoning.

During a tour of the facility's Respiratory room on 5/31/16 in the morning revealed an unlocked, unattended room. An unsanitary opened endotracheal tube and empty 10cc syringe was left open on one of the shelves and was available for use. An unsanitary, used double blade disposable razor was on a cart in the room and was available for use. The room contained multiple portable oxygen containers in rolling carts. The room was accessible to confused ambulatory patients, placing them at risk for opening the valves and inadvertently causing a fire.

During a tour of the facility's Wound Care room on 5/31/16 revealed signage on the door "Keep door closed at all times". The door was opened and unattended. The Wound Care Cart was stored in the room; the cart unlocked and unattended. The cart contained opened tubes of physician prescribed medications and wound care products and supplies. The room was accessible to confused ambulatory patients, placing the patients at risk of consuming the medications or contaminating the supplies.
Observation on 5/31/16 at 10:15 a.m. revealed the patient's prescribed medication cart, sitting in the patient hallway; the cart was unlocked and unattended and was accessible to unauthorized individuals. The floor nurse IC (Infection Control) Staff #1, LVN was informed. IC Staff #1, Licensed Vocational Nurse (LVN) locked the cart and stated, "The cart is supposed to be locked."
Observations on the 5/31/16 at 11:05 a.m. and again at 12:00 p.m. revealed the patient's prescribed medication cart, sitting in the patient hallway. The cart was unlocked and unattended. The cart was accessible to unauthorized individuals and posed a risk of tampering, removal of medications or accidental ingestion of medications by confused ambulatory patients.

An observation on 5/31/16, in the afternoon on the "Low Side" (name of the nursing unit) in-patient unit revealed IC Staff#9, House Keeper was observed in IC Patient #3's room; IC Patient #3 was on Contact Isolation Precautions for MRSA. IC Staff #8 was changing out the, Patient use, soap dispenser; she was not wearing gloves. There was a sign on the door reflecting the need for personal protective equipment, including gloves. IC Staff #8 touched the patient surfaces; left the room, but did not wash her hands, potentially transferring microorganisms to other patients and surfaces.

Review of the facility provided document Isolation Precaution (dated 1/2008) reflected; "Handwashing ...Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other staff, patients or environments. 3. Hands must be washed between tasks and procedures on the same patient to prevent cross-contamination. 4. Use an approved antimicrobial soap for routine handwashing. ...Gloves must be removed promptly after use, before touching non contaminated items and environmental surfaces, and before going [sic] contact with another patient. Wash hands immediately to avoid transfer of microorganisms to other patient or environments ...."
During an interview in the afternoon of 5/31/16 at 5:30 p.m., in the conference room, IC Staff #8, Environmental Services Director confirmed the finding and stated, "Staff #8 should have been wearing gloves and washed her hands after removing the gloves; the facility does not have a policy for storing the chemicals but they should be kept secured."

Based on a review of hospital documentation and staff interviews, the hospital failed to conduct performance improvement projects.

Findings were:

In an interview with Quality Assessment Staff #1 on the morning of 5/31/16 in his office, he provided a nursing plan which he stated was the facility's performance improvement project. Upon review, the project appeared to be an operational plan for the facility which included suggestions about how to go about improving patient care, but did not include documentation of projects conducted, the reason for not conducting a project, nor measurable improvement on a project.

While the facility was following a number of patient care indicators, no other documented evidence of a performance improvement project was provided for surveyor review.

These findings were confirmed during an interview with Administrative Staff #1 on the afternoon of 5/31/16 in his office. He stated he was aware of performance indicators being reviewed, but did not believe the facility had a current hospital-wide performance improvement project.

They were again confirmed in an exit interview with the CEO and other administrative staff on the afternoon of 5/31/16 in the facility conference room.

Based on a review of hospital documentation and staff interviews, the hospital failed to ensure that the hospital-wide improvement actions were consistently evaluated, and also failed to annually determine the number of distinct performance improvement projects.

Findings were:

In an interview with Quality Assessment Staff #1 on the morning of 5/31/16 in his office, he provided a nursing plan which he stated was the facility's performance improvement project. Upon review, the project appeared to be an operational plan for the facility which included suggestions about how to go about improving patient care, but did not include all the components of a hospital-wide quality assessment and performance improvement plan.

While the facility was following a number of patient care indicators, no other documented evidence of a performance improvement project was provided for surveyor review.

In an interview with Administrative Staff #1 on the afternoon of 5/31/16, he confirmed that no meeting minutes existed for the facility ' s governing body for 2015 and 2016. Thus, the hospital governing body did not ensure that the hospital-wide improvement actions were consistently evaluated, and also failed to annually determine the number of distinct performance improvement projects.

These findings were confirmed in an interview with the CEO and other administrative staff on the afternoon of 5/31/16 in the facility conference room.

Based on a review of documentation and an interview with staff, the medical staff failed to adopt and enforce bylaws to carry out its responsibilities .

Findings were:

Based on a review of documentation and an interview with staff, the hospital failed to maintain a promptly completed medical record for each patient.
Findings were:

During a review of medical records for patients treated by 5 credentialed medical staff members (credentialed staff #1, #6, #7, #8 and #9) 1 of the 5 staff (#1) was responsible for 49 incomplete, delinquent medical records. The 49 patients had admission dates ranging from 7-13-15 to 4-28-16 and discharge dates ranging from 7-13-15 to 4-28-16.

Based on an interview with health information management staff #2, the records were incomplete due to the need for physician authentication on progress notes, consultations and orders.

During an interview with health information management staff #1, the staff member was asked if privileges for credentialed staff #1 had been suspended. Health information staff #1 stated that privileges had not been suspended.

The clinical records remained incomplete at the completion of the survey.

"El Paso LTAC Hospital Medical Staff Bylaws & Rules and Regulations" state, in part:
"ARTICLE V, CLINICAL PRIVILEGES
...
Section 2, Qualifications
The following constitute continuing qualification for the exercise of privileges at the Hospital. Each member and applicant for membership and each clinical practitioner and applicant for clinical privileges shall:
Q. COMPLIANCE WITH RULES: Abide by the terms, conditions and procedures of the Bylaws and the governing documents and policies of the Hospital.
...
S. RECORDS: Complete all required patient care records in a thorough, professional timely fashion.
ARTICLE VIII, MATTERS AFFECTING MEMBERSHIP AND PRIVILEGES: CORRECTIVE ACTION
...
Section 4, Automatic Sanctions
A. DELINQUENT MEDICAL RECORDS. For failure to complete medical records within the time limits established by the Medical Staff Rules and Regulations for Medical Records and hospital policies, the practitioner's clinical privileges (except with respect to his/her patients already in the Hospital) and his/her right to admit patients and to provide any other provisional services shall be suspended as approved by the Governing Body in accordance with the Medical Staff Rules and Regulations.
...
RULES AND REGULATIONS, HOSPITAL MEDICAL STAFF
...

RULE 20
The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. This record shall include identification data, medical history, psychological needs, physical needs, physical examination, planned course of action, diagnostic and therapeutic orders, progress notes with clinical observations and results of therapy, special reports such as consultation, procedures, tests, laboratory, radiology, pathology, final diagnoses and procedures, discharge summary and autopsy report when performed.
...
RULE 25
All clinical entries in the patient's medical record shall be accurately dated and authenticated. The parts of the medical record that are the responsibility of the medical practitioner are authenticated by the practitioner. The medical record must be clear, concise, complete and current.
...
Rule 27
...Any chart incomplete after thirty (30) days post-discharge shall be considered delinquent."

The above was confirmed in an interview with the CEO, CNO/COO, HIM Director and IC Director on the evening of 5-31-16 in the facility conference room.

Based on observation, interview and record review the facility failed to ensure that policies governing prevention, control and surveillance of infections and communicable diseases are developed, implemented and enforced when;
a.) Nursing staffs handled items with contaminated gloves and did not wash their hands after removing the contaminated gloves;

b.) The facility's Glucometer was not being disinfected between multiple patient uses; and

c.) A Certified Nursing Assistant, (CNA) did not provide adequate patient Perineal (Personal Hygiene) care.

Findings include:

a.) At 9:30 a.m., IC Staff #3, Registered Nurse (RN), the facility Wound Care Nurse, was on the "High Side" hallway preparing medications for a wound treatment; Staff #3 did not wash her hands before donning gloves, mask and a gown. Staff #3 stated, "IC Patient #1 was on Contact Isolation for C-Difficile (a highly infectious bacterial infection causing severe diarrhea) and Methicillin-resistant Staphylococcus aureus (MRSA, a virulent staph infection)." Staff #3 rubbed a cream on IC Patient #1's right buttock and inner thighs. Staff #3 removed her gloves then left the room. Staff #3 did not wash her hands with soap and water.

IC Staff #4, CNA was assisting in positioning Patient #1. IC Staff #4, CNA was wearing gloves and touching the patients exposed legs and thighs and buttock. Staff #4, CNA left the room wearing the contaminated gloves and returned, wearing the same gloves, with a camera that had been stored in the wound care cart. She did not wash her hands with soap and water.

Further observation revealed at 9:45 a.m., Staff #3, RN prepared medications IC Patient #2's wound treatment; Staff #3, RN did not wash her hands before donning gloves and entering room 339. Staff #3 removed a soiled dressing from IC Patient #2's left ankle and leg wounds; she changed gloves but did not wash or sanitize her hands before putting on new gloves.

IC Staff#1, LVN entered Patient #2's room wearing a mask, gloves and gown. IC Staff #1, LVN touched Patient#3's arm and handled the patient's IV tubing. IC Staff reached into his uniform pocket, under the protective gown, with a contaminated glove, and pulled out a prefilled normal saline syringe. IC Staff#1's inner uniform pocket contained multiple prefilled Saline flushes and documents. The potentially contaminated Saline flushes and documents were not discarded prior to leaving the room.

During an interview on the morning of 5/31/16, in the Infection Control Nurse's office stated, "The staff should wash their hands using soap and water after coming in contact with a patient with C-difficile ...the staff clean the glucometers with a germicidal wipe ..."

Review of the facility provided document Isolation Precaution (dated 1/2008) reflected; "Handwashing ...Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other staff, patients or environments. 3. Hands must be washed between tasks and procedures on the same patient to prevent cross-contamination. 4. Use an approved antimicrobial soap for routine handwashing.
...Gloves must be removed promptly after use, before touching non contaminated items and environmental surfaces, and before going [sic] contact with another patient. Wash hands immediately to avoid transfer of microorganisms to other patient or environments ...."

Review of the facility provided document World Health Organization Glove Use (dated August 2009) reflected; " ...Pathogens may gain access to the caregivers' hands via small defects in gloves or by contamination of the hands during glove removal. Hand hygiene by rubbing or washing remains the basic to guarantee hand decontamination after glove removal ..."

b.) Review of the facility provided policy Bedside Blood Glucose Monitor (dated 102008) reflected; " ...Remove gloves and ...wash hands thoroughly with soap and water ...." The policy does not include the cleaning of the Monitor.

Review of the facility provided document Manufacturer's " ...To disinfect the meter, dilute 1 ml of household bleach (5%-6% sodium hypochlorite solution) in 9 ml of water to achieve a 1:10 dilution final concentration of 0.5% -0.6% sodium hypochlorite) ...." Commercially available 1:10 bleach wipes ...."

Observations made during a tour of the facility's in-patient nursing unit on the morning of 5/31/16 revealed IC Staff #5, CNA performing capillary blood glucose (CBG) checks on the "Low Side" in-patient unit. Staff#5, CNA was observed performing a CBG on IC Patient #3; IC Patient #3 was on Contact Isolation Precautions for MRSA. Staff #5, CNA cleaned the glucometer with an alcohol wipe following the use of the meter. Staff #5, CNA removed his gloves and did not wash his hands before moving on to the next patient.

Further observation revealed Staff #5, CNA placed the glucometer on top of IC Patient #4's, linen covered, stomach; IC Patient #4 was on Contact Isolation for MRSA. Staff #5, CNA cleaned the glucometer with an alcohol wipe following the use of the meter. Staff #5, CNA removed his gloves and did not wash his hands before moving on to the next patient.

c.) Observations made on 5/31/16 at 12:10 p.m. on the patient unit revealed IC Staffs #
6 and 7 performing Perineum Care in patient room 310. The female patient was incontinent of bowel and had a Foley Catheter. IC Staff #6 and 7 placed the patient on her back. IC Staff #6 took a soapy, wet hand towel and wiped the inner thighs and then wiped down the front of the patient's mons pubis (Small bump of flesh on the pubic bone). IC Staff #6 did not separate the labia to expose the urethral meatus and vaginal orifice. IC Staff #6 used a clean wet hand towel and squeezed water down the front of the patient's mons pubis and wiped the inner thighs and pons pubis with the towel; IC Staff #6 rinsed the used towel in a water filled basin, and repeated the process. IC Staff #6 did not change towels, and did not clean the Foley catheter tubing. IC Staff #6 did not dry the patient from the front to back.


During an interview on 5/31/16, in the afternoon, when asked how she cleans the Foley catheter IC Staff #6 stated, "I just check for poop".

Review of the facility provided policy Nursing Standards of Practice (dated 1/2008) reflected; The DON ...utilizes the Potter's & Perry's current Edition Manual on Nursing Clinical Skills & Techniques ...."

Review of the Potter's & Perry's current Edition Manual on Nursing Clinical Skills & Techniques (Copyright 2006) reflected ...If a client is totally dependent, ...in side lying position to raise leg as perineum is bathed ....Gently separate labia with non-dominant hand to expose urethral meatus and vaginal orifice ....wash downward from pubic area toward rectum in one smooth stroke.. Use separate section of cloth for each stroke ....Cleanse thoroughly around labia minora, clitoris, and vaginal orifice. ( ...clients with indwelling catheters, cleanse with cotton balls.) ..."Rinse area thoroughly ...Dry thoroughly, using front-to-back method ..."

Based on a review of documentation and an interview with staff, the facility failed to maintain a promptly completed medical record for each patient.

Findings were:

Based on a review of documentation and an interview with staff, the hospital failed to maintain a promptly completed medical record for each patient.
Findings were:

During a review of medical records for patients treated by 5 credentialed medical staff members (credentialed staff #1, #6, #7, #8 and #9) 1 of the 5 staff (#1) was responsible for 49 incomplete, delinquent medical records. The 49 patients had admission dates ranging from 7-13-15 to 4-28-16 and discharge dates ranging from 7-13-15 to 4-28-16.

Based on an interview with health information management staff #2, the records were incomplete due to the need for physician authentication on progress notes, consultations and orders.

During an interview with health information management staff #1, the staff member was asked if privileges for credentialed staff #1 had been suspended. Health information staff #1 stated that privileges had not been suspended.

The clinical records remained incomplete at the completion of the survey.

"El Paso LTAC Hospital Medical Staff Bylaws & Rules and Regulations" state, in part:
"ARTICLE V, CLINICAL PRIVILEGES
...
Section 2, Qualifications
The following constitute continuing qualification for the exercise of privileges at the Hospital. Each member and applicant for membership and each clinical practitioner and applicant for clinical privileges shall:
Q. COMPLIANCE WITH RULES: Abide by the terms, conditions and procedures of the Bylaws and the governing documents and policies of the Hospital.
...
S. RECORDS: Complete all required patient care records in a thorough, professional timely fashion.
ARTICLE VIII, MATTERS AFFECTING MEMBERSHIP AND PRIVILEGES: CORRECTIVE ACTION
...
Section 4, Automatic Sanctions
A. DELINQUENT MEDICAL RECORDS. For failure to complete medical records within the time limits established by the Medical Staff Rules and Regulations for Medical Records and hospital policies, the practitioner's clinical privileges (except with respect to his/her patients already in the Hospital) and his/her right to admit patients and to provide any other provisional services shall be suspended as approved by the Governing Body in accordance with the Medical Staff Rules and Regulations.
...
RULES AND REGULATIONS, HOSPITAL MEDICAL STAFF
...

RULE 20
The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. This record shall include identification data, medical history, psychological needs, physical needs, physical examination, planned course of action, diagnostic and therapeutic orders, progress notes with clinical observations and results of therapy, special reports such as consultation, procedures, tests, laboratory, radiology, pathology, final diagnoses and procedures, discharge summary and autopsy report when performed.
...
RULE 25
All clinical entries in the patient's medical record shall be accurately dated and authenticated. The parts of the medical record that are the responsibility of the medical practitioner are authenticated by the practitioner. The medical record must be clear, concise, complete and current.
...
Rule 27
...Any chart incomplete after thirty (30) days post-discharge shall be considered delinquent."

The above was confirmed in an interview with the CEO, CNO/COO, HIM Director and IC Director on the evening of 5-31-16 in the facility conference room.

Based on review of medical records, review of facility documents, and interview, the facility failed to ensure verbal orders were authenticated promptly.

Findings included:
Review of discharged patient #3's medical record revealed that discharged patient #3 was discharged on 8/13/15. The following verbal orders were unsigned by credentialed staff #5 at the time of the survey on 5/31/16:
· Order dated 08/07/15 at an unknown time
· 2 orders dated 08/11/15 at 5:00 am
· Order dated 08/11/15 at 7:55 am
· Order dated 08/12/15 at 5:22 pm
· Order dated 08/13/15 at 12:00 pm

Review of discharged patient #6's medical record revealed that discharged patient #6 was discharged on 9/20/15. 36 out of 41 verbal orders dated from 8/26/15 to 9/20/15 were unsigned by three out of five physicians (credentialed staff number 2, 3 and 4) at the time of the survey on 5/31/16.

Facility pharmacy policy titled "Verbal and telephone orders" stated in part "verbal/telephone orders of medication shall be received and recorded by the Pharmacist or licensed nurse into Meditech [the electronic medical record system]. The prescriber shall co-sign the order ... The prescribing practitioner must sign the written record of the verbal/telephone order."

Medical staff bylaws and rules and regulation stated in part, "Rule 11: Verbal/telephone orders are acceptable when dictated to and transcribed by duly authorized personnel and shall be authenticated by the responsible medical practitioner. An attending physician may sign/authenticate verbal/telephone orders provided by a covering physician. Verbal/telephone orders entered by an Allied Health Practitioner shall be authenticated by Supervising Physician at time of physician oversight visit."

The above was verified with health information management staff #1 and nursing staff #1 on the afternoon of 5/31/16.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals are stored in a manner to prevent unauthorized access when the patient's prescribed medications were left in an unlocked, unattended medication cart, in a public hallway.

Findings Include:

Observations made during a tour of the facility's "Low Side" (name of the patient unit) in-patient unit on the morning of 5/31/16 revealed:

Observation on 5/31/16 at 10:15 a.m. revealed the patient's prescribed medication cart, sitting in the patient hallway; the cart was unlocked and unattended and was accessible to unauthorized individuals. The floor nurse IC (Infection Control) Staff #1, LVN was informed. IC Staff #1, Licensed Vocational Nurse (LVN) locked the cart and stated, "The cart is supposed to be locked."

Observations on the 5/31/16 at 11:05 a.m. and again at 12:00 p.m. revealed the patient's prescribed medication cart, sitting in the patient hallway. The cart was unlocked and unattended. The cart was accessible to unauthorized individuals and posed a risk of tampering, removal of medications or accidental ingestion of medications by confused ambulatory patients.

During an interview on the morning of 5/31/16, in the conference room, IC Staff #2, Director of Nursing confirmed the finding.

Based on observation and interview, it was determined that the facility failed to ensure that outdated biologicals were available for patient use.

Findings were:

During a tour of the facility on the afternoon of 5/30/2016, the following observations were made:
· Nurses Station Crash Cart:
IV Cath 20G 1.1 X 25 mm expired 07/2015
IV Cath 20G 1.1 X 25 mm expired 09/2015
Two (2) Nasopharyngeal Airway 28 Fr. expired 01/2016
Pro-Vent Arterial Blood Sampling Kit with Dry Lithium Heparin for Gases and Electrolytes expired 04/2015
Two (2) Endotracheal Tube Cuffed PVC 7.5 mm 30 Fr. expired 03/2016
Endotracheal Tube - Tubo Endotruqueal Murphy W/Cuff and Stylette 8.5 mm Fr. 34
expired 04/2012

During a tour of the facility on the afternoon of 5/31/2016, the following observations were made:
· Medication Room #1
Two (2) IV Cath 20G 1.1 x 25 mm expired 03/2016
IV Cath 20G 1.1 X 25 mm expired 12/2015

· Medication Room #2
Ten (10) Red lab top tubes expired 04/2016
Five (5) Purple lab top tubes expired 02/2016
Fourteen (14) Blue lab top tubes expired 02/2016
Purple lab top expired 09/2015
Two (2) IV Cath 20G expired 03/2016
IV Cath 18G expired 10/2010
23G x 1'' 3cc syringe opened package
Latex Surgical Gloves 7.5 expired 01/2014
Culture swab expired 01/2016
Three (3) Bacti Swab expired 03/2015
60cc Lues Lock tip syringe opened package
· Wound Care Room
Urethral Catheter expired 08/2014


The above findings were confirmed during the same tour with the facility's Infection Control Nurse and the Chief Executive Officer.

Based on observation, interview and record review the facility failed to provide an organized dietary service when;

- Raw and cooked food items were stored uncovered, unlabeled and dated;
- Food items were not dated when opened;
- Staff removed soiled gloves and did not wash their hands.

Findings include:

Review of the facility provided documents Food Storage (dated 2010) reflected: " ...Scoops are not to be stored in food ...all foods should be covered, labeled and dated ..."

Review of the facility provided documents Food Temperatures (dated 2010) reflected:
"...all hot food items must be ...held and served at a temperature of at least 135 degrees Fahrenheit ...."

Review of the facility provided documents Bare Hand Contact with Food and Use of Plastic Gloves (dated 2010) reflected: "... remember gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed ....Wash hands after removing the gloves ...."

Observations during a tour on 5/30/16 at 2:20 p.m. of the facility's kitchen revealed:

The Walk-in freezer revealed a bag of raw, pre-cooked, and breaded chicken in plastic bags; there were also multiple bags of frozen mixed vegetables. The bags were removed from the original packaging and were not labeled or dated; to ensure proper rotation of food products, and the facility policy required.

The Walk-in refrigerator revealed a pan of (4) each 5 lb. raw ground beef in plastic tubes (removed from the original packaging), unlabeled and dated; one of the 5 pound tubes of ground beef had a 6 inch cut in the packaging that was not covered or dated when opened, exposing it to possible cross contamination from other sources.

Containers of Pimentos, Blueberries, cooked fish, Mayonnaise, Fat Free Mayonnaise, Pickles, Orange Juice, and Lemonade were not labeled and dated when opened, possibly exposing patients to spoiled food products.

A watermelon was cut in half and was sitting directly below food trays on open shelving; the watermelon was uncovered, exposing it to cross contamination from items above.

The Dry storage area revealed large containers each of flour and rice with plastic scoop handles in the food product, exposing the food products to the contaminated handle.

A cooked hamburger patty and bun was wrapped in foil and was sitting on the steamtable at room temperature; the temperature at which bacteria will grow and multiply, and was available for consumption.

A dietary staff member was observed in the dishwashing area wearing plastic gloves; handling dirty dishes, remove the gloves, and then did not wash their hands before handling cooked food items with her unwashed bare hands, as the facility policy dictates.


During an interview on 5/30/16 in the facility kitchen, Dietary Staff #1, Kitchen Manager, confirmed the findings.

Based on a review of documentation, a tour of the facility and staff interviews, the facility failed to ensure:

A. Significance of HAI surveillance results were compared to nationally recognized infection rates for a comparable type and size of facility.

B. A sanitary and well-maintained environment which avoided all sources and transmission of infections and communicable diseases.

C. Patient instruments were sterilized in accordance with regulatory requirements for sterile processing for hospitals in the State of Texas as delineated in 25 TAC (Texas Administrative Code) §133.41(v). The facility failed to follow established policies and procedures for sterilization, failed to ensure that the staff member responsible for sterile processing had completed appropriate training in the method and techniques for the sterilization of instruments and patient care equipment, and failed to follow nationally recognized standards of practice for the sterilization of instruments.

Findings were:

These deficient practices placed all patients at risk for infection.

Findings were:

A. A review of facility patient infection rates for 2015 and the first quarter of 2016 revealed an expected non-infected rate for catheter-related urinary tract infections (CAUTIs) and central line associated blood stream infections (CLABSIs) of 80% or higher.

In an interview with Infection Control Staff #2, the Infection Control Director, on the afternoon of 5/31/16, she was asked to provide the rationale for the facility's expected infection rate and how it compared with other long-term acute care hospitals. She stated, "I don't know how that was decided. It was just the hospital's standard...I think our infection rate may be a little high." With no reference to standaradized infection rates, there was no basis for the facility to ascertain whether its infection control program was functioning in range of national, state or local healthcare standards or expectations.

Facility policy #IC 1.0 entitled Infection Control Plan, effective date December 2014, included the following:
"B. Description of IC Standards
IC.1.10 ...include systematically identifying risks for acquiring or transmitting infectious agents, determining where actions can be taken based on current science and resources, and taking action to reduce the risks either through prevention or control ...
3. El Paso LTAC Hospital ' s infection control program is planned and focused based on:
The demographics of the organization and the characteristics of the population served ...
The care, treatment and services provided ...
IC.2.10 El Paso LTAC Hospital uses case findings and identification of demographically important nosocomial infection information gathered through surveillance data to identify risk for acquisition and transmission of infection on an ongoing basis ...
B. At El Paso LTAC Hospital, the Infection Control Practitioner (ICP) will select the surveillance programs to be utilized in infection control. Criteria considered include:
Rationale for selecting a specific surveillance approach or combination of approaches ...

B. During a tour of the facility with the chief executive officer on the morning of 5/31/16, the following items were observed:

Patient Rooms:
- Room 309: Layer of dust on high horizontal surfaces
- Room 320:
* Chip in linoleum of patient bedside table making it impossible to clean.
* Unknown substance particles noted in drawer of bedside table which appeared to be pieces of food. The room was identified as clean and ready for patient use by the CEO. He stated he believed the particles looked "like some kind of food."
* Dirt in corner of the room

East Hall:
- Outside light shining through East hall emergency exit door
- East hall wood banister with chipping paint, making it impossible to clean

Wound Care Room:
- A silver-topped canister half full of a brown liquid. The canister was unlabeled and the substance cound not be identified by staff.
- 7 bottles of enzymatic cleaner and 5 bottles of distilled water were stored under the sink.

Soiled Utility Room:
- A hole approximately 24" x 10" under the sink which opened into the space behind the wall. This allowed for entry of pests, debris and dirt.
- In the anteroom to the soiled utility room directly opening into the west hallway of patient rooms, there was a mop bucket half-full of dirty water.

West Hall:
- A closed external door revealed outdoor light shining into the hallway. This allowed for entry of pests into the patient hallway.

East Hall:
- A closed external door revealed a large amount of outdoor light shining into the hallway. This allowed for entry of pests into the patient hallway.

C. Patient instruments were not sterilized in accordance with regulatory requirements for sterile processing for hospitals in the State of Texas as delineated in 25 TAC §133.41(v).

1. 25 TAC §133.41(v)(1): The sterilization of all supplies and equipment shall be under the supervision of a person qualified by education, training and experience.

A review of the personnel record for infection control staff #3, the individual identified as responsible for sterile processing for the facility, revealed this employee had not completed any recent specialized training for the sterile processing of instruments.

In an interview with infection control staff #3 on the morning of 5/31/16 in her office, she stated she had received minimal training on how to use the autoclave "maybe 7 years ago when I started working here. Then 3 to 4 years ago, a company rep came and showed me how to use a sterilizer, but it was on a different machine that we don't use anymore." She also stated, "I should probably get some more current training. I get online sometimes and I look at the manual, but that's about it."

2. 25 TAC §133.41(v)(2)(b): Written policies and procedures for the decontamination and sterilization activities performed shall be adopted, implemented and enforced. Policies shall include the receiving, cleaning, decontaminating, disinfecting, preparing and sterilization of reusable items, as well as those for the assembly, wrapping, storage, distribution and quality control of sterile items and equipment.

In an interview with Infection Control Staff #3 on the morning of 5/31/16 in her office, policies related to sterile processing for the facility were requested. Infection Control Staff #3 stated she would look for the policies.

In an interview with Administrative Staff #1 and Nursing Staff #1 on the afternoon of 5/31/16 in the corridor outside the office of Administrative Staff #1, they stated no such policies existed.

A general policy related to sterile processing was located by the surveyor. Facility policy #IC 1.0 entitled Infection Control Plan, effective date December 2014, included the following:
"B. Description of IC Standards
IC.1.10 ...include systematically identifying risks for acquiring or transmitting infectious agents, determining where actions can be taken based on current science and resources, and taking action to reduce the risks either through prevention or control ...
3. El Paso LTAC Hospital's infection control program is planned and focused based on:
The demographics of the organization and the characteristics of the population served ...
The care, treatment and services provided ...
IC.2.10 El Paso LTAC Hospital uses case findings and identification of demographically important nosocomial infection information gathered through surveillance data to identify risk for acquisition and transmission of infection on an ongoing basis ...
B. At El Paso LTAC Hospital, the Infection Control Practitioner (ICP) will select the surveillance programs to be utilized in infection control. Criteria considered include:
Rationale for selecting a specific surveillance approach or combination of approaches ...
4. Each department that performs decontamination and sterilization activities has procedures that are consistent in intent and application throughout the organization. The content of these policies address the following elements of infection control:
A. The receiving, decontaminating, cleaning preparing, and disinfecting or sterilization of reusable items.
B. The assembling, wrapping, storage, distribution, and quality control of sterile equipment and medical supplies.
C. The use of sterilization process monitors, including temperature and pressure recordings, and use and frequency of appropriate chemical indicator...for all sterilizers ... "

No further policies related to the sterile processing of instruments at El Paso LTAC Hospital were made available for surveyor review.

3. 25 TAC §133.41(v)(2)(G)(i): (i) External chemical indicators, also known as sterilization process indicators, shall be used on each package to be sterilized, including items being flash sterilized to indicate that items have been exposed to the sterilization process.

In an interview with Infection Control Staff #3, the individual responsible for the facility's sterile processing, during a tour of the hospital on the morning of 5/31/16 she was asked if chemical indicators were used to ensure proper sterilization of instruments was achieved. She said they were not.

Facility policy #IC 1.0 entitled Infection Control Plan, effective date December 2014, included the following:
"4. Each department that performs decontamination and sterilization activities has procedures that are consistent in intent and application throughout the organization. The content of these policies address the following elements of infection control: ...C. The use of sterilization process monitors, including temperature and pressure recordings, and use and frequency of appropriate chemical indicator...for all sterilizers ... "

The Centers for Disease Control and Prevention Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, states in part, "Chemical indicators are affixed on the outside of each pack to show that the package has been processed through a sterilization cycle, but these indicators do not prove sterilization has been achieved. Preferably, a chemical indicator also should be placed on the inside of each pack to verify sterilant penetration. Chemical indicators usually are either heat-or chemical-sensitive inks that change color when one or more sterilization parameters (e.g., steam-time, temperature, and/or saturated steam; ETO-time, temperature, relative humidity and/or ETO concentration) are present. Chemical indicators have been grouped into five classes based on their ability to monitor one or multiple sterilization parameters ...If the internal and/or external indicator suggests inadequate processing, the item should not be used... "

4. 25 TAC §133.41(v)(2)(M): Preventive maintenance of all sterilizers shall be performed according to individual adopted, implemented and enforced policy on a scheduled basis by qualified personnel, using the sterilizer manufacturer's service manual as a reference.

A review of the Biomega BioClave Operations Manual V 1.0, revealed preventive maintenance required on a daily, weekly and annual basis. The facility could provide no documented evidence of such required preventive maintenance being performed.

In an interview with Infection Control Staff #3, the individual responsible for the sterile processing of instruments at the facility, on the morning of 5/31/16 in her office, she stated she was cleaning the sterilizer, "but that's it and it's not documented. "

The above findings were confirmed in an interview with the facility CEO and other administrative staff on the afternoon of 5/31/16 in the facility conference room.

Based on observation, interview and record review the facility's QAPI and training programs failed to educate staffs on the principles and practices for preventing the transmission of infectious agents within the hospital and failed to revise corrective actions as needed when;

a.) Nursing staffs handled items with contaminated gloves and did not wash their hands after removing the contaminated gloves inspite of training;

b.) The facility's Glucometer was not being disinfected between multiple patient uses; and

c.) A Certified Nursing Assistant, (CNA) did not provide adequate patient Perineal (Personal Hygiene) care.

Findings include:

a.) At 9:30 a.m., IC Staff #3, Registered Nurse (RN), the facility Wound Care Nurse, was on the "High Side" hallway preparing medications for a wound treatment. IC Staff #3 did not wash her hands before donning gloves, mask and a gown and entering the room. IC Staff #3 stated, "IC Patient #1 was on Contact Isolation for C-Difficile (a highly infectious bacterial infection causing severe diarrhea) and Methicillin-resistant Staphylococcus aureus (MRSA, a virulent staph infection)." IC Staff #3,RN rubbed a cream on IC Patient #1's right buttock and inner thighs. IC Staff #3,RN removed her gloves then left the room. IC Staff #3 did not wash her hands with soap and water.

IC Staff #4, CNA was assisting in positioning IC Patient #1. IC Staff #4, CNA was wearing gloves and touching the patients exposed legs, thighs and buttock. IC Staff #4, CNA left the room wearing the contaminated gloves and returned wearing the same gloves, with a camera that had been stored in the wound care cart. When IC Staff #4 CNA finished assisting, she removed her contaminated gloves; she did not wash her hands with soap and water

Further observation revealed at 9:45 a.m. on the "Low Side" hall, IC Staff #3, RN prepared medications for IC Patient #2's wound treatment; IC Staff #3, RN did not wash her hands before donning gloves and entering room 339. IC Staff #3, RN removed a soiled dressing from IC Patient #2's left ankle and leg wounds; she changed gloves but did not wash or sanitize her hands before putting on new gloves.

IC Staff#1, LVN entered IC Patient #2's room wearing a mask, gloves and gown. IC Staff #1, LVN touched IC Patient#2's arm and handled the patient's IV tubing. IC Staff #1 reached into his uniform pocket, under the protective gown, with a contaminated glove, and pulled out a prefilled normal saline syringe. IC Staff#1's inner uniform pocket contained multiple prefilled Saline flushes and documents. The potentially contaminated Saline flushes and documents were not discarded prior to IC Staff #1 leaving the room.

During an interview on the morning of 5/31/16, in the Infection Control Nurse's office stated, "The staff should wash their hands using soap and water after coming in contact with a patient with C-difficile ...the staff should clean the glucometers with a germicidal wipe ..."
"We have targeted hands washing as an area of improvement." "We will have one good month, then the compliance goes back down." "I don't know what else to do."

Review of the facility provided document Isolation Precaution (dated 1/2008) reflected; "Handwashing ...Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other staff, patients or environments. 3. Hands must be washed between tasks and procedures on the same patient to prevent cross-contamination. 4. Use an approved antimicrobial soap for routine handwashing. ...Gloves must be removed promptly after use, before touching non contaminated items and environmental surfaces, and before going [sic] contact with another patient. Wash hands immediately to avoid transfer of microorganisms to other patient or environments ...."

Review of the facility provided document World Health Organization Glove Use (dated August 2009) reflected; " ...Pathogens may gain access to the caregivers' hands via small defects in gloves or by contamination of the hands during glove removal. Hand hygiene by rubbing or washing remains the basic to guarantee hand decontamination after glove removal ..."

b.) Review of the facility provided policy Bedside Blood Glucose Monitor (dated 102008) reflected; " ...Remove gloves and ...wash hands thoroughly with soap and water ...." The policy does not include the cleaning of the Monitor.

Review of the facility provided document Manufacturer's " ...To disinfect the meter, dilute 1 ml of household bleach (5%-6% sodium hypochlorite solution) in 9 ml of water to achieve a 1:10 dilution final concentration of 0.5% -0.6% sodium hypochlorite) ...." Commercially available 1:10 bleach wipes ...."

Observations made during a tour of the facility's in-patient nursing unit on the morning of 5/31/16 revealed IC Staff #5, CNA performing capillary blood glucose (CBG) checks on the "Low Side" in-patient unit. IC Staff#5, CNA was observed performing a CBG on IC Patient #3; IC Patient #3 was on Contact Isolation Precautions for MRSA. IC Staff #5, CNA cleaned the glucometer with an alcohol wipe following the use of the meter. Staff #5, CNA removed his gloves and did not wash his hands before moving on to the next patient.

Further observation revealed IC Staff #5, CNA placed the glucometer on top of IC Patient #4's, linen covered, stomach; IC Patient #4 was on Contact Isolation for MRSA. IC Staff #5, CNA cleaned the glucometer with an alcohol wipe following the use of the meter. IC Staff #5, CNA removed his gloves and did not wash his hands before moving on to the next patient.

c.) Observations made on 5/31/16 at 12:10 p.m. on the patient unit revealed IC Staffs #
6 and 7 performing Perineum Care in patient room 310. The female patient was incontinent of bowel and had a Foley Catheter. IC Staff #6 and 7 placed the patient on her back. IC Staff #6 took a soapy, wet hand towel and wiped the inner thighs and then wiped down the front of the patient's mons pubis (Small bump of flesh on the pubic bone). IC Staff #6 did not separate the labia to expose the urethral meatus and clean the vaginal orifice or the catheter tubing. IC Staff #6 used a clean wet hand towel and squeezed water down the front of the patient's mons pubis and wiped the inner thighs and pons pubis with the towel. IC Staff #6 rinsed the used towel in a water filled basin, and repeated the process. IC Staff #6 did not change towels, and did not clean the Foley catheter tubing. IC Staff #6 did not dry the patient from the front to back.

During an interview on 5/31/16, in the afternoon, when asked how she cleans the Foley catheter IC Staff #6 stated, "I just check for poop on the tube." IC Staff #6 did not provide any further directions.

Review of the facility provided policy Nursing Standards of Practice (dated 1/2008) reflected; The DON ...utilizes the Potter's & Perry's current Edition Manual on Nursing Clinical Skills & Techniques ...."

Review of the Potter's & Perry's current Edition Manual on Nursing Clinical Skills & Techniques (Copyright 2006) reflected ...If a client is totally dependent, ...in side lying position to raise leg as perineum is bathed ....Gently separate labia with non-dominant hand to expose urethral meatus and vaginal orifice ....wash downward from pubic area toward rectum in one smooth stroke.. Use separate section of cloth for each stroke ....Cleanse thoroughly around labia minora, clitoris, and vaginal orifice. ( ...clients with indwelling catheters, cleanse with cotton balls.) ..."Rinse area thoroughly ...Dry thoroughly, using front-to-back method ..."

During an interview on 5/31/16, in the afternoon, in the conference room, IC Staff #2, Director of Nursing confirmed the finding.