HospitalInspections.org

29242

Based on observation, record review, and interview, the facility failed to ensure specific patient rights were protected and promoted by providing a safe environment for patients and through implementation of their written policy and procedures that protect and promote each patient's rights for 20 of 20 patients (Patient's #1- #20) reviewed. The facility failed to:

1.) Ensure that access to the post-partum and new born nursery areas were restricted and that facility staff were assigned/ present within the area.

2.) Ensure evidence that Patients were informed of their patient rights orally and in writing, in advance of furnishing patient care, and prior to discharge.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Refer to TAGS A0117 and A0144.

Based on observations, interviews and record reviews, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. The facility failed to:
1.) Ensure a sanitary environment was maintained in the operating room, sterile processing and post-operative staging areas to include the separation of clean and dirty areas, proper facility sanitation/ sterilization, and availability of hand washing sinks.
2.) Ensure that the hospital-wide infection control program data collection was performed by a qualified Registered Nurse.
3.) Ensure the facility physical plant and equipment were maintained in such a manner as to ensure an acceptable level of safety to patients and staff. Cross reference to A0701.
This deficient practice has the potential to affect the facility's ability to accurately identify, track, and prevent infections from occurring, leading to increased risk of infection and adverse patient outcomes for all patients at the facility. Leading up to and including the possibility of death.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Infection Control.


Refer to TAGS A0749 and A0756.

Based on observation and interview the facility failed to ensure out-patient surgical services were consistant in quality with in-patient care. The facility did not have a pre-op room for outpatient surgical patients. Outpatient surgical patients were prepared for surgical services in the hallway of the operating room.
Findings included:
Observation conducted on 11/15/16 at 1:25 p.m. with the Chief Nursing Officer (CNO) revealed the facility did not have a dedicated pre-op area for surgical patients.
In an interview conducted on 11/15/16 at 1:45 p.m., the CNO confirmed that the facility did not have a dedicated pre-op area. She further revealed that in the event of an in-patient surgery, the patient would be triaged and prepared for surgery in their hospital room. Out-patient surgery patients were triaged and prepared for surgery in the hallway of the operating room while staff walked around the stretcher.

Based upon observation, record review, and interview, the facility failed to ensure evidence that 20 of 20 patients reviewed for rights (Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20); were informed of their patient rights orally and in writing, in advance of furnishing patient care, and prior to discharge. Specifically,

1.) Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 medical records did not contain a signed copy of their patient rights or evidence they were informed of their patient rights.

2.) Patient Rights information was not posted or available upon interview at the facility's main registration/admission area, or at the facility's registration area of the Emergency Room (ER) Department.

3.) The required State Law posting to notify patients or patient representatives of the statement of duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language with their right to contact the appropriate complaint line number was not posted at 2 of 2 entrances/waiting areas (Entrance/Main Lobby, and Entrance/Emergency Room Waiting).

Findings included:

Review of the Facility's Patient Bill of Rights, undated, revealed as a patient; you have the right to "be informed of your rights as a [facility] patient, including information about the patient rights policy and the mechanism for resolving patient complaints and grievances."

1.) Record review of Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 medical records revealed there was no evidence or documentation that Patients were given a copy or informed of their Patient's Rights either orally and/or in writing.

During an interview on 11/16/16 at 9:30 AM with the Chief Nursing Officer (CNO) confirmed that Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 medical records did not contain evidence or documentation that Patients were given a copy or informed of their Patient's Rights either orally and/or in writing.

2.) Observations on 11/16/16 at 10:00 AM in the emergency department and hospital admitting areas did not reveal a state required posting regarding patient rights. The facility's Patient Bill of Rights was not available upon request.

Interview on 11/16/16 at 10:00 AM with Staff #4 (Business Office Representative) confirmed that in-patients and observation patients are given a packet of information; that did not include a copy of patient rights.

Interview on 11/16/16 at 10:15 AM with Staff #5 (Emergency Department Admitting Clerk) confirmed that emergency department patients are not given a copy of the patient rights.

3.) Observations on 11/16/16 at 10:00 AM in the emergency department and hospital admitting areas revealed there was not a posting for display readily visible to patients, or patient representatives of the statement of the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language which included the number of the Texas Department of State Health Services (DSHS) patient information and complaint line at (888) 973-0022; in English and Spanish.

Interview on 11/16/16 at 11:07 AM with Staff #6 (Human Resources Representative) confirmed that there is a pending policy on reporting abuse and neglect that needs to go to the facility Policy and Procedure Committee for approval. The HR Representative confirmed there was not a posting in the facility for display readily visible to patients, or patient representatives of the statement of the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language which included the number of the Texas Department of State Health Services (DSHS) patient information and complaint line at (888) 973-0022; in English and Spanish.

Based upon observations and interviews, the facility failed to provide a safe environment for patients. The facility failed to ensure that access to the post-partum and new born nursery areas were restricted and that facility staff were assigned/ present within the area.
The findings were:
Observations conducted on 11/15/16 from 3:00 pm - 4:15 pm of the post-partum/ nursery area with the facility CNO revealed the following:
- The hallway in which the newborn nursey and dedicated post-partum patient care rooms were located was open, with no locked doors to restrict public access. Further observation revealed that the area was approximately 50 feet from the main facility entrance.
- Upon entering the unit, there were no facility nursing staffs present at the nurses station located in the post-partum/ new born nursery area. In addition, no facility staff asked to see the surveyors badge/ credientials, and/or questioned our reason for being on the unit.
-Observations conducted from 11/15/16 through 11/16/16 revealed there was no security guard at or near the main entrance of the facility or main lobby.
In an interview conducted on 11/15/16 at 4:00 pm, the facility CNO confirmed the above findings, and revealed there was a mother and new born infant currently being cared for within the post-partum area. The CNO further stated that new mothers keep their babies in their rooms, while staff preform couplet care (Kangaroo care) for patients. When asked where the nursing staff for the unit were, the CNO stated that the post-partum nursing station is not staffed. Instead, call bells for the post-partum/ new born nursey area ring at the Medical/ Surgical nurse's station (separate unit) and the Med/Surg. nurses either respond to the patient and/or call the labor and delivery nursing staff to respond.

Based on record reviews, observations and record reviews, the facility's governing body failed to ensure the facility quality assessment and performance improvement program (QAPI) reflected all hospital services.

Findings included:

Interview on 11/15/16 with administrative staff during the entrance conference revealed the facility provided outpatient physical therapy services through a contract with a physical therapist on the hospital campus.

Observations on 11/16/16 from 12:58 PM to 1:30 PM of the contracted physical therapy department revealed the following: The wall behind a sink was observed to be open with broken plaster. The carpet was stained with several torn areas. Linen was observed uncovered under one of the physical therapy beds.
Interview on 11/16/16 at 1:15 PM with Physical Therapist # 3 confirmed the facility is responsible for the maintenance of the physical therapy area. He confirmed the linen is received covered but is opened after it is received and stored under the physical therapy bed. Continued interview with the physical therapist revealed that he has contracted with the hospital since 1998. He confirmed that he has not participated in the QAPI meetings in the past year.
Record review of facility QAPI meeting minutes for 2016 and facility governing body meeting minutes for 2016 did not reveal the inclusion of the physical therapy department in these meetings.
Interview on 11/16/16 with the Chief Executive Officer during the exit conference confirmed no formal oversight of contracted services.

Based on observations, record reviews and interview, the facility's pharmaceutical services failed to:
1.) Ensure pharmacy staff conducted daily physical counts of drugs listed in schedules II, III, and V of the Comprehensive Drug Abuse Prevention and Control Act; and
2.) Ensure established hospital policy was followed in order to identify and minimize the risk of medication variances; and
3.) Ensure drugs and biologicals were kept locked and in a secure area; and
4.) Ensure drugs listed in schedules II, III, IV and V of the Comprehensive Drug Abuse Prevention and Control Act were kept locked and under proper security.
This deficient practice placed the facility at increased risk of experiencing serious drug diversions and/or adverse patient outcomes.
The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Pharmaceutical Services.

Refer to TAGS A0491, A0494, A0502 and A0503

Based on record reviews and interviews, the facility failed to ensure the pharmacy and/or drug storage area was administered in accordance with accepted principles. The facility failed to ensure established hospital policy was followed in order to identify and minimize the risk of medication variances.

This deficient practice placed the facility at increased risk of experiencing serious drug diversions and/or adverse patient outcomes.

Findings include:

Record review of the facility Controlled Drug Inventory Records for the dates encompassing 6/2014 to 11/2016 revealed that pharmacy staffs were conducing physical counts/ inventories of narcotic drugs on a 2-3 month basis, which were not witnessed by a second party. Further review revealed the following:
1.) Demerol 25 Milligram (mg) / 1 Milliliter (ml) vials:
- Entry dated 1/14/16: "Nurses station (NS), Late entry as of 9/25/15, -10 vials. Count 180 vials. " Facility staff signed off on the entry and drew an arrow up to the line dated 1/13/16.
2.) Demerol 15 mg/ 1 ml vials (Mependine):
- Entry dated 8/24/14: "Late Entry for 7/26/14, Emergency Room (ER), -10 vials. Count 180. "
(The following entries are in order as they appear on the facility inventory form.)
-Entry dated 5/31/16: "PIC Change, count 40 vials."
-Entry dated 8/17/16: "ER, dispensed 1 vial (-1 vials), count 30 vials."
- Entry dated 9/8/16: "Correct Count 30 vials."
- Entry dated 11/11/16: "Correct Count 30 vials."
3.) Dilaudid Hcl 1mg/ 1 ml vials (Hydromorphone Hcl):
- Entry dated 3/20/15: "Balance brought forward, count 180 vials."
- Review of the next entry on the form, dated 3/20/15: location "Nurses Station" revealed the originally dispensed amount was -10 vials, leaving the pharmacy balance at 170 vials in stock. Twenty Nine (29) subsequent entries were made afterwards starting on 3/22/15 and ending on 5/07/15. The original ending balance on 5/07/15 was stated as 10 vials in stock. However, starting with the entry on 3/20/15, the amount issued was crossed through and changed to show a deduction of an additional 10 vials of medication. The deduction was subtracted for all entries on the form up until 5/07/15 when the count was changed from 10 vials in stock to a count of zero (0). The changes were not signed by the pharmacy personnel making the change, nor was the count verified by a second party.
Record review of the facility Policy entitled: Controlled Substances, effective 5/2010, and revised 6/2016 revealed in part the following:
-Audits:
-At each shift change the on-coming and out-going staffs will record an audit of the controlled drug supply. The remaining balance of each drug is recorded on the audit section of the form in the appropriate time space. Both staff will sign the form verifying the count is correct.
- Discrepancies:
- Any discrepancies in the audit count must be clarified and/or reported to the nurse manager before the out-going staff leave. The pharmacy must be notified of any unresolved discrepancies. Drug testing will be done on all licensed staff on the out-going shift of the discrepancy before they are allowed to leave the premises.

In an interview conducted on 11/15/16 at 1:35 pm, the facility Pharmacy Director confirmed the above findings, and stated that pharmacy staff were only conducting physical counts of the narcotic medications on a monthly basis. These counts were conducted by one staff and not witnessed by a second party. When asked by the surveyor if an investigation had been initiated regarding the discrepancies found on the controlled drug inventory records, the Pharmacy Director stated she had only reported the discrepancies to the remote pharmacist and that no further investigation/action had been taken.

Based on record reviews and interview, the facility failed to ensure pharmacy staff conducted daily physical counts of drugs listed in schedules II, III, IV and V of the Comprehensive Drug Abuse Prevention and Control Act.
This deficient practice placed the facility at increased risk of experiencing drug diversions.

Findings Include:
Record review of the facility Controlled Drug Inventory Records for the dates encompassing 6/2014 to 11/2016 revealed that pharmacy staffs were conducing physical counts/ inventories of narcotic drugs on a 2-3 month basis, which were not witnessed by a second party. Further review revealed the following:
1.) Demerol 25 Milligram (mg) / 1 Milliliter (ml) vials:
- Entry dated 1/14/16: "Nurses station (NS), Late entry as of 9/25/15, -10 vials. Count 180 vials. " Facility staff signed off on the entry and drew an arrow up to the line dated 1/13/16.
2.) Demerol 15 mg/ 1 ml vials (Mependine):
- Entry dated 8/24/14: "Late Entry for 7/26/14, Emergency Room (ER), -10 vials. Count 180. "
(The following entries are in order as they appear on the facility inventory form.)
-Entry dated 5/31/16: "PIC Change, count 40 vials. "
-Entry dated 8/17/16: "ER, dispensed 1 vial (-1 vials), count 30 vials."
- Entry dated 9/8/16: "Correct Count 30 vials. "
- Entry dated 11/11/16: "Correct Count 30 vials. "
3.) Dilaudid Hcl 1mg/ 1 ml vials (Hydromorphone Hcl):
- Entry dated 3/20/15: "Balance brought forward, count 180 vials. "
- Review of the next entry on the form, dated 3/20/15: location " Nurses Station " revealed the originally dispensed amount was -10 vials, leaving the pharmacy balance at 170 vials in stock. Twenty Nine (29) subsequent entries were made afterwards starting on 3/22/15 and ending on 5/07/15. The original ending balance on 5/07/15 was stated as 10 vials in stock. However, starting with the entry on 3/20/15, the amount issued was crossed through and changed to show a deduction of an additional 10 vials of medication. The deduction was subtracted for all entries on the form up until 5/07/15 when the count was changed from 10 vials in stock to a count of zero (0). The changes were not signed by the pharmacy personnel making the change, nor was the count verified by a second party.
Record review of the facility Policy entitled: Controlled Substances, effective 5/2010, and revised 6/2016 revealed in part the following:
-Audits:
-At each shift change the on-coming and out-going staffs will record an audit of the controlled drug supply. The remaining balance of each drug is recorded on the audit section of the form in the appropriate time space. Both staff will sign the form verifying the count is correct.
In an interview conducted on 11/ 15/16 at 1:35 pm, the facility Pharmacy Director stated that pharmacy staff were only conducting physical counts of the narcotic medications on a monthly basis. These counts were conducted by one staff and not witnessed by a second party. When asked by the surveyor which staffs had access to the narcotic drugs, the pharmacy director revealed that in addition to herself, all of her pharmacy technicians had access as well.

In an interview conducted on 11/16/16 at 10:00 am, both the Pharmacy Director and the Chief Nursing Officer confirmed the above findings.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were kept locked and in a secure area on 1 of 1 units (Operating Room).
This deficient practice placed the facility at increased risk of drug diversions and has the potential to cause harm in all patients on these units.

Findings include:
Operating Room:
Observations conducted with the CNO on 11/16/16 at 9:30 am of the operating room revealed a rolling anesthesia cart was being stored in Operating Room #1. The cart did not have a locking mechanism. When the surveyor pulled on the drawers they readily opened. The cart contained vials of propofol and other anesthetic and paralytic agents.

In an interview conducted at the time of discovery, The CNO confirmed the above findings.

Record review of the facility policy entitled: Controlled Substances, effective 5/2010 and revised on 6/2016 revealed in part the following:
- The following medications are classified as controlled substances:
- All DEA classified narcotics
-Propofol
-Nubain

Based on observation, interview, and record review, the facility failed to ensure drugs listed in schedules II, III, IV and V of the Comprehensive Drug Abuse Prevention and Control Act were kept locked and under proper security on 1 of 1 units (Emergency department).
This deficient practice placed the facility at increased risk of drug diversions and has the potential to cause harm in all patients on these units.

Findings include:
Emergency Room:
Observations conducted with the Chief Nursing Officer (CNO) on 11/15/16 at 4:30 pm in the Emergency department revealed a large rolling medication cart was being stored in an open alcove between the main hallway where patients and staff traveled and the nurses station. Further observation revealed that one of the drawers of the cart was hanging open, with no staff present. The drawer readily opened when the surveyor pulled on it, and was found to contain Fentanyl, Ketamine, Valium, Tylenol with Codeine, versed, tramadol, Ativan and ultracet. The drawer did not contain a secondary locking mechanism (not double locked).

In an interview conducted at the time of discovery, the CNO confirmed that the medication cart was open and that the narcotic drawer did not have a secondary lock. She also stated that the cart should have been locked when staff were not physicially present.

Record review of the facility policy entitled: Controlled Substances, effective 5/2010 and revised on 6/2016 revealed in part the following:
- The following medications are classified as controlled substances:
- All DEA classified narcotics
-Propofol
-Nubain

Based on observations, interviews, and record review the facility failed to ensure the condition of the overall hospital environment was maintained for the safety and well-being of the patients. The facility failed to:
-Ensure routine maintenance and preventive maintenance was completed to ensure patient safety.
-To conduct ongoing maintenance inspections that identified equipment and areas in need of repair.
-Ensure the preventive maintenance and condition of the plant was incorporated in the Quality Assurance Performance Improvement (QAPI) plan.

Findings include:

Observations conducted with the facility Chief Nursing Officer (CNO) from 11/15/16 at 2:00 pm to 11/16/16 at 12:00 pm at the facility revealed the following:

Hospital Lobby/ Waiting area:
- The cloth chairs located in the main hospital lobby had numerous white stains. There was also a strong smell of urine present.

Medical/ Surgical unit:
- There were areas of a blackish green substance, which resembled mold, observed on the ceiling tiles and air conditioning vents in the patient rooms throughout the unit. Temperature within the unit was warm and humid, with a strong smell of mold present.

- There was a black substance observed coming up from underneath the linoleum tile flooring next to the unit entrance and the nurse ' s station.

- The A- bed (1st bed) call lights for the patient rooms located on the north side of the unit hallway were not functional. The lights failed to illuminate when the call buttons were pushed.

- The patient care rooms were missing the corner trim which protects the sheet rock. There were also holes and gauges observed in the sheet rock itself.

New Born Nursery:
- The tile counter top in the procedure room, where circumcisions and testing were done, was observed to have been painted. The paint was peeling off in segments, and there was a black substance located along the tile grout lines and the areas where paint was peeling.

- The sink in the procedure room had areas of orange staining both inside the sink and where the sink met the tile countertop.

Radiology:
- Used sheets/ bed linens were thrown on the floor in the CT/ MRI procedure areas.

Record review of the facility maintenance records for the time period of 11/2015 to 11/2016 revealed no evidence that the facility had identified the malfunctioning call lights, mold like growths on the ceiling in the patient care areas, soiled chairs in the lobby, and/or the peeling paint and cleanliness of the new born nursery.

Record review of the facility QAPI for the year of 2016 revealed no evidence that the above areas were discussed and/or addressed.

In an interview on 11/16/16 at 11:00 am, the facility CNO confirmed the above findings.

Based on observations and interview, the facility failed to ensure a sanitary environment was maintained in the operating room, sterile processing and post-operative staging areas to include the separation of clean and dirty areas, proper facility sanitation/ sterilization, and availability of hand washing sinks.
This deficient practice placed all patients receiving treatment in the facility at an increased risk of life threatening infections, leading up to and including the possibility of death.

Findings include:
Observations conducted with the Chief Nursing Officer (CNO) on 11/15/16 from 2:00 pm to 3:30 pm in the facility revealed the following:
Operating Room:
- A biohazard container and open top garbage can were in direct contact with the shelves where sterile medical supplies were stored. Further observation revealed a reddish brown material, which was biological in origin, was located on the packaging of a sterile catheter tray.
- A large container of cidex solution, where contaminated surgical instruments were placed, was being stored on top of a cart which contained sterile surgical supplies.
- A rolling shelving system which contained sterile suture material, was in direct contact with the cart containing the cidex solution, placing it at risk of cross contamination from splash.
- Insects and insect droppings were observed in the fluorescent lighting in the scrub sink area where physicians and nursing staff prep for surgery.
- Bottles of sterile saline were being stored underneath a "dirty" sink, where cord blood processing took place.

Post- Operative area:
- Observations revealed there was no hand washing sink, soap, or paper towels in the post- op area for staff to wash their hands. Further observation revealed the only hand washing sink available to staff was located in the hallway between the post- op area and sonogram room. The sink was unable to be accessed due to portable radiology equipment and geri chairs being stored in the area. In addition, there was no soap or paper towels available at this sink for staff to use.

Sterile Processing:
- The seals on peel packs which contained surgical instruments were not sealed appropriately. There were bubbles, ripples, and visible openings in the packaging.
- There were no biological indicators present in peel packs containing surgical instruments which were processed and ready for use in the operating room.

In an interview conducted on 11/15/16 at the time of discovery, the facility CNO confirmed the above findings.

Based on record review and interview, the facility governing body failed to ensure that the hospital-wide infection control program data collection was performed by a qualified Registered Nurse.
This deficient practice has the potential to affect the facility's ability to accurately identify, track, and prevent infections from occurring, leading to increased risk of infection and adverse patient outcomes for all patients at the facility.

Findings include:
Record review of the facility document entitled Surgical Wound Surveillance, for the dates encompassing 3/22/16 to 11/08/16 revealed that facility Licensed Vocational Nursing Staff (LVN) were conducting wound assessments and infection control monitoring on post-surgical patients.

Record review of the facility Quality Assurance Performance Improvement (QAPI) plan minutes for the years of 2015-2016 revealed no evidence that the facility infection control plan was discussed and/ or identified issues addressed.

In an interview conducted on 11/16/16 at 11:00 AM, the facility Chief Nursing Officer (CNO) confirmed the above findings. She further revealed that a Surgical Services Registered Nurse (RN) was acting as the infection control nurse in addition to her operating room duties. She further revealed that the facility infection control program consisted of the Surgical RN giving the wound surveillance form to the LVN ' s on the medical surgical floor to complete. The RN would then collect the forms, using the LVN ' s assessment of the wound as a basis for infection determination and tracking.