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1. Based on reviews of committee reports, inspections/observations, staff files and personal interviews Dimmit Regional Hospital's Governing Body failed to maintain responsibility over the quality assessment/ performance improvement program, infection control program, surgical services department and its staff.
The findings included:
a. Reviews of committee reports revealed issues identified from the quality assessment performance improvement program (QAPI) were not reported to the governing body for 2013 and 2014.
b. The infection control coordinator failed to identify and implement strategies to ensure a sanitary environment throughout the entire hospital.
c. Inspection of surgical services revealed outpatient pre-operative surgery services did not meet the same standards as inpatient surgical services.

1. Based on observations, reviews of policies and procedures, and staff interviews the hospital failed to enforce infection control policies and procedures.
The findings were:
1. On 5/27/14, Tour of the Ultrasound room revealed the ultrasound bed had two tears on it, exposing the foam and weave fabric inside.
2. On 5/27/14 Tour of the patients rooms 118 and 121 revealed the ceiling tiles had water damage and was rusty where the ceiling met the wall. Bathrooms contained rust stains around the faucet and on the basin of the sink. Around the sink, there was no caulking. The walls behind the bed had scratched and peeling paint, exposing the sheetrock. The lamps at the head of the bed did not work.
3. On 5/28/14 Tour of the peri-operative services revealed:
a. A colonoscopy tray in the scrub sink.
b. The floors in the OR hallway and OR room #1 were dirty and scuffed with black marks.
c. The base boards around the OR hallways were dirty and peeling from the wall.
d. In the Sterile Processing room, the wall behind the sink had water damage, peeling paint which exposed the sheet rock. When the DON touched the sheet rock, the sheet rock crumbled.
e. In the Sterile Processing room, there was three holes in the wall next to the drying rack, which contained clean, packaged instruments. One hole was approximately one inch diameter and one hole was approximately two inches in diameter. Both holes the surveyor could look into and see into the next room. One hole was approximately one inch diameter, the hole did not go through the wall. It stopped about mid way and was filled with a brown, rusty substance.
f. Tour of the Recovery Room revealed around the room where the ceiling meets the wall contained rust all around the room.
During the tour, the Director of Nursing confirmed the findings.

1. Based on observation and interview the facility failed to ensure outpatient surgical services were offered in quality with inpatient care. The facility did not have a pre-op room for outpatient surgical patients. Outpatient surgical patients were prepared for surgical services in the lobby/hallway of the operating room.
The findings were:
a. Observation on 5/28/14 at 10:20 a.m. with the surgical services revealed there was no pre-op area for surgical patients.
b. Interview on 5/28/14 at 10:25 a.m. with the facility Director of Nurses (DON) revealed they did not use a pre-op room. The DON revealed if the patient was going to be admitted to the hospital, then the patient was triaged and prepared for surgery in their hospital room. The DON further revealed if the patient was at the facility for outpatient surgery, then the patient was triaged and prepared for surgery in the lobby/hallway of the operating room and the staff would just walk around the stretcher.

1. Based upon observations, interviews, and reviews of policies and procedures the facility failed to provide a safe environment for patients.
The findings were:
a. Observations while touring the facility on 5/27/2014, at 12:15 p.m., with the facility CEO it was observed the door to the new born nursery was not locked. There were two new born babies in the nursery.
b. Observation on 5/27/14 at 3:00 p.m. revealed the door was still unlock. When surveyors opened the door to the newborn nursery, staff did not ask to see the surveyors ' badges nor asked who the surveyors were.
c. Further observation revealed the door to the newborn nursery was approximately 50 feet from the main facility entrance.
d. Observations from 5/27/14 through 5/28/14 revealed there was no security guard at or near the main entrance of the facility entrance or main lobby.
a. Interview with staff #11 on 5/27/14 at 3:10 p.m. with staff #12 revealed there were two newborn babies in the nursery. Staff also revealed they have had up to 7 newborn babies at one time. Staff also revealed that the newborn nursery door is never locked unless the nursery is empty, then the door is locked.
b. Interview on 5/27/14 at 3:45 p.m. with the facility Director of Nurses (DON) revealed the nursery door should have been locked at all times.

a. Record review of the policy titled Patient Care: Code Pink or Child Abduction, not dated, states " the door to the nursery has a lock " .

1. Based on record review and interview, the facility's governing body failed to review the facility's quality assurance performance improvement (QAPI) program.

Findings included:

a. Record review of Quality Assurance Performance Improvement Plan Policy and Procedure, last reviewed 11/2009, revealed but was not limited to the following: " The QAPI Plan is a process that will encompass all functions of patient care and support services provided within this organization, including any form of contracted service. Through the support of the Board of Trustees (designated Governing Body for this facility) and the Chief of Staff, all mangers, medical staff and support staff will participate in performance improvement activities. The Board of Trustees has the responsibility to oversee and support performance improvement activities. The Board shall require, receive, consider, and where necessary, act on the findings and recommendations emanating from the activities of the Performance Improvement Committee. The Performance Improvement Director shall participate in and coordinate the development and implementation of the performance improvement. Specific functions will include but not be limited to the following: report outcomes of performance improvement efforts to medical staff and governing body."

b. Record review of Governing Body Monthly Minutes from 04/25/13 to 05/21/14 failed to reveal a discussion of QAPI activities.

a. Interview on 05/28/14 with Chief of Nursing confirmed that she was the facility's Performance Improvement Director. She confirmed the Governing Body Monthly Minutes did not contain QAPI information.

1. Based on Inspections/observations and staff interviews the Dimmit Regional Hospital failed to ensure outdated medications were removed from patient care areas and opened multi-dose vials were labeled incorrectly.
The findings were:
a. Observation on 5/27/14 at 2:55 p.m. of the medication cart located in the medication room of the medical surgical area revealed 2 boxes of expired Diazepam Injection 10 mg/2 ml which expired on 1/1/2014. Further observations revealed 12 containers of Chloral Hydrate Oral Solution 500 mg/5 ml which expired on 4/2013.
Interview on 5/27/14 at 3:00 p.m. with staff members confirmed the medications were expired. Staff revealed it is the pharmacist's job to remove all expired medications from patient use. Further interviews revealed it is also the nurses ' job to remove expired medications if they see it.
b. Observation 5/28/14 at 10:45 a.m. of the facility operating room suite #1 revealed there was an open multi-dose vial of Ketamine 500 mg/10 ml. There was no date documenting when the vial was opened.
Interview on 5/28/14 at 10:45 a.m. with the Certified Registered Nurse Anesthetist (CRNA) revealed the multi -dose vial of Ketamine was opened within the past 30 days.
Interview on 5/28/14 at 10:47 a.m. with the facility DON revealed the CRNA she could not provide evidence of compliance with acceptable standards of practice or established hospital policies and procedures.

1. Based on interview and record review, the facility failed to ensure the Infection Control Nurse had documented training in the area of infection control.

Findings included:

a. Interview with Nurse #15 on 05/27/14 at 2:35 PM revealed she was the designated Infection Control Officer. She stated that her training's consisted of computer training's from the Centers for Disease Control and Prevention (CDC) and she attended infection control training in San Antonio, Texas.

b. Record review on 05/28/14 of Nurse #15 's personnel record did not reveal any documented training in the area of infection control.

c. Interview with the Chief Nursing Officer (CNO) on 05/28/14 at 2:00 PM confirmed there was no documentation in Nurse #15 's personnel record regarding her infection control expertise.