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Based upon observation, record review and interview, the facility failed to

A. 1. set up quality control procedures to ensure ongoing conformance to policies and procedures regarding dialysate quality. These deficient practices had the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to unsafe dialysate.

2. ensure permanent records of batches of bicarbonate were maintained to include the concentrate formula produced, the volume of the batch, lot number(s) of powdered concentrate packages, the manufacturer of the powdered concentrate, date and time of mixing, test results, person performing mixing, and expiration date (if applicable).

3. log the number of bags or weight of powder added thus exposing patients to unsafe dialysate.

4. label the mixing tank to clearly indicate the fill and final volumes required to correctly dilute the powder.

5. ensure the staff performed conductivity and PH reading with an independent device before each dialysis treatment and compare them to the dialysis machine reading. The facility also failed to ensure the 1st level verification was conducted.

6. ensure that all samples for cultures and endotoxins were drawn from the water treatment systems and dialysis machines, exposing patients to harmful bacteria.

7. ensure all samples for chlorine/chloramines testing were drawn when the water treatment system had been operating for at least 15 minutes, thus potentially exposing patients to harmful chlorine and chloramines chemicals. Citing 6 out of 6 RO's (reverse osmosis water systems) including the main RO and 5 portable RO's.


8. offer and administer Hepatitis B vaccinations to susceptible staff whose antibodies were less than 10 mIU (Mill International Unit); or test the staff for antibodies to determine the need for immunizations. Also, a review of records indicated the Engerix vaccine was not given as recommended by the Engerix guidelines. The facility failed to follow its own policy and that of the Centers for Disease Control. The following employee records were reviewed: 15 (#12, #14, #15, #16 #17, #25, #26, #36, #53, #67, #71, #73, #75, # 80 and #104) of 19 (#11, #12, #13, #14, #15, #16 #17, #21, #24, #25, #26, #36, #53, #67, #71, #73, #75, # 80 and #104).

9. ensure the required chemical analysis of the product water was conducted every 6 months as required.

10. ensure the storage tank and the water systems were disinfected.

11. test the water softeners at the end of the day to verify their capacity to treat a sufficient volume of water to supply the facility for the entire treatment day.

12. ensure the water system which was located on another floor was continuously monitored during patient treatment and was guarded by audible and visual alarms. The alarms must be seen and heard in the dialysis treatment area should water quality drop below specific parameters.

13. ensure the dialysis machines were checked according to manufacture instructions. Citing 7 out of 8 dialysis machines reviewed.

14. ensure that each major water system was labeled in a manner that identified the device; described its function, how performance was verified and actions to be taken in the event performance was not within an acceptable range.

15. ensure the Medical Director of Dialysis Unit and the Hospital Quality Improvement Meeting reviewed the results of the water quality testing and, when indicated, directed corrective action. In addition, there was no evidence the reports of equipment testing were trended and analyzed over time through the hospital's Quality Improvement meeting. Citing 5 months (January- May 31, 2015 out of 5 months (January-May 2015) of equipment and laboratory report results reviewed.

Refer to tag A0144 for additional information

B. have a patient representative make informed decisions regarding his or her care. The facility failed to involve the patient in requesting or refusing treatment. The facility failed to provide consent for treatment, to ensure proper evaluation to determine if a patient is of sound mind to enter into a voluntary admission contract. The facility failed to ensure the patient was on a mental health warrant if the patient was a danger to self or others, or unable to make sound decisions for his or her mental healthcare in 6 out of 6 (#20, #21, #22, #23, #24, and #40) records reviewed.

Refer to tag A0131 for additional information

C. ensure there was a sufficient number of nurses and patient care technicians on duty to provide care at all times. They failed to ensure their nurse staffing numbers set by their staffing matrix included licensed vocational nurses which were being used. This deficient practice was found in 3 of 3 units (Oncology, Ortho-Neuro, and Medical-Surgical unit).

Refer to tag A0392 for additional information.
D. ensure registered nurses evaluated patients with head injuries, increased pain levels, and with infections. They failed to ensure nursing staff initiated physician orders timely. This deficient practice was found in 3 of 3 patients (Patient #s' 11, 12 and 15).
Refer to tag A0395 for additional information.
E. to ensure they had physician orders for blood administration and failed to ensure vital signs were checked as required. They failed to ensure staff documented they were checking for reactions during blood administration. The facility failed to ensure blood was administered timely after receiving lab results on high risk patients. This deficient practice was found in 3 of 3 patients (Patient #s' 10, 27 and 40).
Refer to tag 0409 for additional information.
F. ensure narcotics (Fentanyl, Hydrocodone, Morphine, and Hydromorphone) were accurately logged and accounted for at all times in 1 of 1 medication room (Kilgore Emergency Center).
Refer to tag A0494 for additional information.
G. ensure medication preparation and mixing were performed in an area which minimized potential contamination. This was found in 1 of 1 emergency rooms (Kilgore Emergency Center).
Refer to tag A0501 for additional information.
H. monitor cold disinfectant, the procedures according to manufacturer guidelines and facility policy were not followed. Also, the facility failed to train 3 (#33, #49, and # 113) of 3 staff members on cold disinfection solution procedures and monitor the scope process. The facility failed to follow their policy for monitoring the fluids in the warming cabinet and cleaning of the 5 sterilizers. Also, the temperature and humidity were not recorded or monitored for the Surgery, Labor and Delivery, and Cath lab departments where sterile instruments were stored. Further review revealed the facility failed to provide a sanitary environment for pre-op area, holding area, surgical area, sterilization area, post anesthesia area, and sterile supply storage area.

Refer to tag A0749 for additional information
Refer to tag A0940 for additional information

2. ensure the patient had a current or updated history and physical on the chart prior to the surgical procedure on 3 ( #40, #46, and #54) of 10 ( #40. 46, 47, 48, 49, 50, 51, 52, 53, and 54) patients.

Refer to tag A0952 for additional information

3. provide adequate post-operative care areas for the patients receiving surgical procedures.
Refer to tag A0957 for additional information

4. ensure the patient's record had an operative report on the chart after the procedure was completed on 1 ( #54) of 10 ( #40. 46, 47, 48, 49, 50, 51, 52, 53, and 54) patients.

Refer to tag A0959 for additional information

Based upon observation, record review and interview, the facility failed to

A. provide ongoing assessment, document a patient neurological assessments following multiple psychotropic medications and following a fall, offer alternative interventions, or justification before the administration of a chemical restraint for agitation and anxiety in 1(#39) of 3 patients reviewed.
Refer to Tag A160

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, potential for harm, serious injury, impairment and/or subsequent death.



B. to ensure the physician conducted and documented the 1 hour face-to-face medical and behavioral evaluation after ordering physical restraints for violent behavior for 1 (#39) of 3 patients reviewed.
Refer to Tag A178, A184
C. 1. set up quality control procedures, to ensure ongoing conformance to policies and procedures, regarding dialysate quality. These deficient practices have the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to unsafe dialysate. Citing 5 (#4, #5, #6, #7, and #8) out of 5 (#4, #5, #6, #7, and #8) medical records reviewed. Citing 3 months (March 1-May 31, 2015 and June 1-13 2015) out of 3 months of logs reviewed.

2. ensure permanent records of batches of bicarbonate were maintained to include the concentrate formula produced, the volume of the batch, lot number(s) of powdered concentrate packages, the manufacturer of the powdered concentrate, date and time of mixing, test results, person performing mixing, and expiration date (if applicable).

3. log the number of bags or weight of powder added. These deficient practices have the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to unsafe dialysate. Citing 3 months (March 1-May 31, 2015 and June 1-13 2015) out of 3 months of logs reviewed.

4. label the mixing tank to clearly indicate the fill and final volumes required to correctly dilute the powder. These deficient practices have the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to unsafe dialysate. Citing 3 months (March 1-May 31, 2015 and June 1-13 2015) out of 3 months of logs reviewed.

5. ensure the staff preformed conductivity and PH reading with an independent device before each dialysis treatment and compare them to the dialysis machine reading. The facility also failed to ensure the 1st level verification was conducted. These deficient practices have the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to unsafe dialysate. Citing 5 (#4, #5, #6, #7, and #8) out of 5 (#4, #5, #6, #7, and #8) medical records reviewed and 1 out of 2 Phoenix meters reviewed.

6. ensure that all samples for cultures and endotoxins were drawn from the water treatment systems and dialysis machines. These deficient practices have the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to harmful bacteria. Citing 6 out of 6 RO's including the main RO and 5 portable RO's. In addition 1 out of 1 bicarbonate mixing systems were not collected.

7. ensure that all samples for chlorine/chloramines testing were drawn when the water treatment system had been operating for at least 15 minutes. These deficient practices have the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to harmful chlorine and chloramines chemicals. Citing 6 out of 6 RO's including the main RO and 5 portable RO's. ensure the staff preformed conductivity and PH reading with an independent device before each dialysis treatment and compare them to the dialysis machine reading. The facility also failed to ensure the 1st level verification was conducted. Citing 5 (#4, #5, #6, #7, and #8) out of 5 (#4, #5, #6, #7, and #8) medical records reviewed and 1 out of 2 Phoenix meters reviewed.

8. offer and administer Hepatitis B vaccinations to susceptible staff whose antibodies were less than 10 mIU (Mill International Unit); or test the staff for antibodies to determine the need for immunizations. Also, a review of records indicated the Engerix vaccine was not given as recommended by the Engerix guidelines. The facility failed to follow its own policy and the Center for Diseases Control. The following employee records were reviewed: 15 (#12, #14, #15, #16 #17, #25, #26, #36, #53, #67, #71, #73, #75, # 80 and #104) of 19 (#11, #12, #13, #14, #15, #16 #17, #21, #24, #25, #26, #36, #53, #67, #71, #73, #75, # 80 and #104).

9. ensure the required chemical analysis of the product water was conducted every 6 months as required.

10. ensure the storage tank and the water systems were disinfected.

11. test the water softeners at the end of the day, to verify their capacity to treat a sufficient volume of water, to supply the facility for the entire treatment day.

12. ensure the water system which was located on another floor was continuously monitored during patient treatment and be guarded by audible and visual alarms. The alarms must be seen and heard in the dialysis treatment area should water quality drop below specific parameters.

13. ensure the dialysis machines were checked according to manufacture instructions. Citing 7 out of 8 dialysis machines reviewed.

14. ensure that each major water system was labeled in a manner that identifies the device; describes its function, how performance is verified and actions to take in the event performance is not within an acceptable range.

15. ensure that the Medical Director of Dialysis Unit and the Hospital Quality Improvement Meeting reviewed the results of the water quality testing and directed corrective action, when indicated. In addition, there was no evidence the reports of equipment testing was trended and analyzed over time through the hospitals Quality Improvement meeting. Citing 5 months (January- May 31, 2015) out of 5 months (January-May 2015) of equipment and laboratory report results reviewed.

These deficient practices posed an Immediate Jeoparday due to the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to unsafe dialysate, unsafe and contaminated water, hepatitis B, lack of trained staff, and failure to maintain equipment. The facility provided a plan of removal for the IJ related to the hemodialysis unit. The facility transferred patients to other acute care facilities and discontinued hemodialysis services until corrective measures could be accomplished. The facility's decision to close the hemodialysis unit abated the Immediate Jeopardy as it related to hemodialysis, however, the findings remained condition level due to lack of a plan to correct the processes currently in place.

16. provide a clean and safe environment for patients to receive care. Tours of the facility revealed unsanitary patient rooms, unsanitary environment where sterile patient care supplies were being stored. The facility failed to maintain the patient care areas, food preparation areas and areas where clean and dirty linens were being stored.
Refer to A0144.
D. have a patient representative make informed decisions regarding his or her care. The facility failed to involve the patient in requesting or refusing treatment. The facility failed to provide consent for treatment, to ensure proper evaluation to determine if a patient is of sound mindto enter into a voluntary admission contract. To ensure the patient is on a mental health warrant if the patient is a danger to self or others, or unable to make sound decisions for his or her mental healthcare in 6 out of 6 (#20, #21, #22, #23, #24, and #40) records reviewed.
Refer to Tag A0131

E. obtain the patient or patient representatives wishes on advance directives in 1 of 1(#40) charts reviewed.
Refer to Tag A0132

F. safeguard patient personal information, to provide patients with physical privacy during an examination by a nurse or physician, and during discussions of clinical issues and treatments for 1 of 1 patient's observed in the ER.

Refer to Tag A0143

Based on document review the facility failed to promote patient safety, identify opportunities for improvement, and review the data collected by the Environment of Care Program (EOC). The Infection Prevention Risk Assessment 2015 was approved by the Quality Assurance and Performance Improvement Program (QAPI) with the "Potential for transmission of infection related to procedures, medical equipment, and medical devices as determined by appropriate storage, cleaning, disinfection, sterilization, reuse and/or disposal of supplies and equipment being rated as high for inpatients." Surveillance data was collected by the EOC rounding team and was not reported to the Infection Prevention Committee. The Quality Assurance and Performance Improvement Committee (QAPI) and the responsible Administration and Management team failed to implement the planned mission and vision for a systematic approach to assure safety, quality driven, and patient centered care.

A review of the document titled Quality Assurance and Performance Improvement Program (QAPI) revealed the following:

"Purpose
To develop, implement, and maintain an effective, ongoing, system-wide, data-driven quality assessment and performance improvement program.
This plan reflects the mission, vision and strategic focus to establish a planned, systematic approach to assuring safe, quality driven, patient centered care.

Program Goals and Functions
The goal of the QAPI plan is to continually and systematically assess, plan, design, measure and improve processes of care resulting in quality patient outcomes. To achieve safe and quality driven care, each entity will:
Identify opportunities for improvement and establish performance goals that are measurable and outcome focused .....
... Use process standardization to promote safety and excellence.
Provide a systematic mechanism for multidisciplinary collaboration towards quality improvement, risk reduction and patient safety through education and feedback communication ....

Authority and Responsibility
Governing Body
The Governing Body authorizes the establishment of this performance improvement program. The Governing Body is responsible for assuring:
.... That the organization-wide quality assessment and performance improvement efforts address priorities for improved quality of care, and patient safety and that all improvement actions are evaluated
That clear expectations for safety are established ....

Administration and Management
The Governing Body also delegates the development, implementation and evaluation of this program to the organization's Administration and Management team.
Administration and Management are responsible for improving the quality of care, safety and service provided by organization staff.

Collecting Data on Performance
Scope of Data Collection
At a minimum, the organization will review and collect data in the following areas:
..... Processes as defined in the organizations Infection Prevention Program,
Environment of Care Program, and Patient Safety Program ...

Detail of Data Collection
By approval of this program, the Governing Body has determined that data shall be collected in sufficient detail to provide the user of that data with sufficient information to make timely, accurate, and data-driven decisions.

Aggregation and Analysis of Data
Purpose
The purpose of data aggregation and analysis is to:
· Establish a baseline level of performance
· Determine the stability of processes
· Determine the effectiveness of a process or desirability of an outcome as compared to internal or external targets (benchmarks)
· Identify opportunities for improvement
· Identify the need for more focused data collection
· Determine whether improvement has been achieved and/or sustained

Analysis of Data
Data on performance measures will be analyzed to:
· Monitor the effectiveness and safety of services and quality of care
· Identify opportunities for improvement and changes that will lead to improvement"

A review of the document titled "INFECTION PREVENTION RISK ASSESSMENT FOR 2015" revealed the results of the facility's identified areas of risk for infections and their assigned risk levels of low, medium or high. The document revealed as part of its commitment to quality care and service, (the facility name), conducts a periodic assessment of the risk(s) for transmission and acquisition of infectious agents. This risk assessment incorporates an analysis of the following:

1. The geographic location and community environment of the organization, the programs and services provided, and the characteristics of the population served,
2. Analysis of surveillance activities and the results of the organization's infection prevention and control data.
3. The care, treatment, and services provided ....

PROCESS
The risk analysis is conducted and/or reviewed at least annually and whenever there is a significant change in any of the above factors, The assessment is facilitated by the Infection Prevention Department and presented to the Infection Prevention and Quality Committee for review and approval.

Once risks are identified, the organization prioritizes those risks that are of epidemiological significance. Certain risks are automatically prioritized based on their nature, scope, and impact on the care, treatment, and services provided. These risks are outlined on this document as well.

Specific strategies are developed and implemented to address the prioritized risks. These strategies may take the form of policy and procedure establishment, surveillance and monitoring activities, education and training programs, environmental and engineering controls, or combinations thereof. Strategies may differ in approach, form, scope, application, and/or duration depending on the specific risk issue, the care setting(s), and environment involved.

ASSESSMENT FINDINGS/MITIGATION STRATEGIES
The table below outlines the prioritized risks identified as the result of the assessment; provides a brief description of those risks, assigns a risk level (low, medium, or high) based on the care setting, outlines - in summary form - actions that have been or will be taken by the organization to address the risks, and how the organization will evaluate the effectiveness of actions taken.

This information was taken from the above mentioned "table below".

Prioritized Risk Description: (The following risk assessment for inpatients was rated as "high")

Potential for transmission of infection related to procedures, medical equipment, and medical devices as determined by appropriate storage, cleaning, disinfection, sterilization, reuse and/or disposal of supplies and equipment (was rated as high for inpatients).

Summary of Risk Mitigation Strategy:
Reconvene all depts. reprocessing scopes/probes,
EOC rounds weekly
Develop re-education (identification/accountability) to ensure department based equipment and WOW's are sanitized.

A review of the Infection Prevention Committee Meeting Minutes for January 20, 2015 and April 21, 2015 revealed no evidence of the EOC reporting the hazards identified during the EOC rounds. The meeting minutes revealed no evidence the Committee was monitoring or evaluating the EOC data or the area of risk identified by the Infection Prevention Risk Assessment for 2015.

A review of the documents titled Environmental Tours revealed:

Purpose: To identify the areas and equipment subject to required safety inspections or surveys .... Environmental tours are conducted by a multi-disciplinary team that includes Safety Management, Plant Operations and Maintenance, Infection Prevention, Environmental Services, Biomed and Occupational Injury Management.

A review of the documents titled Environmental Hazard Assessment (EOC Rounds, Environmental Tours or Environmental Rounds), dated 4/10/2014, revealed 58 hazards in Labor and Delivery unit by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/14/2014, revealed 25 hazards in A200 unit by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/17/2014, revealed 18 hazards in the Dietary Department by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/17/2014, revealed 11 hazards in the Pulmonary Department by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/24/2014, revealed 25 hazards in the A300 unit by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/24/2014, revealed 9 hazards in the A300 Antepartum unit by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/24/2014, revealed 3 hazards in the A300 Perinatal unit by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/24/2014, revealed 5 hazards in the A300 Unit SANE Exam Room by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 5/1/2014, revealed 36 findings in the unit A400 by the persons performing the inspections. An area of the document provided for "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

Interviews on 6/17/2015 at approximately 3:00 PM with staff #89 revealed Environmental Rounds were to be made weekly. Staff #89 confirmed the above documented rounds were the only rounds that were done.

A review of the document titled Quality Improvement Council Minutes revealed for
January 19, 2015, February 19, 2015, March 16, 2015, April 20, 2015 and May 18, 2015 Infection Prevention did not report on the surveillance data collected by the EOC for high risk areas for patients seeking care at the facility. Infection Prevention Risk Assessment 2015 identified "Potential for transmission of infection related to procedures, medical equipment, and medical devices as determined by appropriate storage, cleaning, disinfection, sterilization, reuse and/or disposal of supplies and equipment as a high risk for inpatients".

A review of the document titled Quality Improvement Council Minutes revealed for
January 19, 2015, February 19, 2015, March 16, 2015, April 20, 2015 and May 18, 2015 the EOC did not report the surveillance data collected during the EOC Rounds.

An interview on 6/16/2015 with staff #115 revealed the issues with the flooring, the unfinished wood, had been reported over and over with no response of action, and "we don't report it anymore."

An interview on 6/17/2015 with staff #115 revealed the reports generated from the Environmental Round were to be given to the Safety Officer. The Safety Officer would give the reports to the Division Directors for an Action Plan. Staff #1 revealed there were "holes in the system and we don't get feedback".

An interview on 6/17/2015 at approximately 9:30AM with staff #1 revealed Data was being collected but was not being trended. Interview confirmed there was a problem with getting Quality information back to the staff/units.

Based on observation, interview and record review the facility failed to:
A. ensure there was a sufficient number of nurses and patient care technicians on duty to provide care at all times. They failed to ensure their nurse staffing numbers set by their staffing matrix included licensed vocational nurses which were being used. This deficient practice was found in 3 of 3 units (Oncology, Ortho-Neuro, and Medical-Surgical unit).
Refer to tag A0392 for additional information.
B. ensure registered nurses evaluated patients with head injuries, increased pain levels, and with infections. They failed to ensure nursing staff initiated physician orders timely. This deficient practice was found in 3 of 3 patients (Patient #s' 11, 12 and 15).
Refer to tag A0395 for additional information.
C. to ensure they had physician orders for blood administration and failed to ensure vital signs were checked as required. They failed to ensure staff documented they were checking for reactions during blood administration. The facility failed to ensure blood was administered timely after receiving lab results on high risk patients. This deficient practice was found in 3 of 3 patients (Patient #s' 10, 27 and 40).
Refer to tag 0409 for additional information.

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

A. clean patient rooms between patients. The facility also failed to ensure the cleanliness of patient care areas and preventative maintenance of equipment and furnishings. The flooring was not maintained and was chipped and broken making it impossible to clean and sanitize. The facility had unfinished wood throughout the facility that could not be sanitized. The facility identified hazards throughout the facility and did not provide repairs.

Refer to tag A701

B. provide a safe and sanitary environment housing laundry services in a manner which protected the safety of the worker and patients.

Refer to tag A 724

A. monitor cold disinfectant and the procedures were not followed according to the manufacturer guidelines and the facility's policy. Also, the facility failed to train 3 (#33, #49, and # 113) of 3 staff members on cold disinfection solution procedures and monitor the scope process.

Refer to Tag A0749

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, potential for harm, serious injury, or subsequent death.


B. follow their policy for monitoring the fluids in the warming cabinet and cleaning of the 5 sterilizers. The temperature and humidity were not recorded or monitored for the Surgery, Labor and Delivery, and Cath lab departments where sterile instruments were stored. Further review revealed the facility failed to provide a sanitary environment for pre-op area, holding area, surgical area, sterilization area, post anesthesia area, and sterile supply storage area.

Refer to Tag A0749


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C. provide a clean and safe environment for patients to receive care.
D. Follow and implement the Infection Prevention Plan established and approved for the year of 2015. The areas of high risk for patients seeking care at facility and identified in the Infection Prevention Risk Assessment for 2015 were not monitored, assessed and evaluated by the Infection Control Committee. The Infection Control Committee did not address, monitor, assess or evaluate the findings reported by the Environment of Care Rounding Team. The facility did not provide evidence of adherence to the recommendations of the World Health Organization (WHO) or to the recommendations of the Centers for Disease Control (CDC).

Refer to Tag A0749

Based on observation, record review, and interview, the facility failed to:
A. ensure the cold disinfectant solution was monitored and the procedures were followed according to the manufacturer guidelines and the facility's policy. Also, the facility failed to train 3 (#33, #49, and # 113) of 3 staff members on cold disinfection solution procedures and monitor the scope process. Review of 8 (#55, #56, #57, #58, #59, #60, #61, and #62) of 8 patients revealed the instruments used for the patient's procedures had been cleaned with expired disinfection solution.

Findings:
Surgery Solution Testing Log Sheet For: Metricide OPA Plus:
A review of the log titled, "Solution Testing Log Sheet For: Metricide OPA Plus" (cold disinfectant) for April, May, and June 1-12, 2015 revealed the following:
A review of the log for April 2015 revealed the test strip bottle was documented as opened on 12/2/2016 and do not use after date of 3/2/2015. Also, on the log the quality control test date was documented performed "12/2/2015", the person that performed the test was left blank. The quality control test was to be performed when the bottle of test strips was opened to make sure the test strips were good. The test strip bottle was used until 4/9/2015, but should have been discarded on 3/2/2015. Test strip bottles are only good for 90 days once the bottle is opened. Further review of the log showed the cold disinfectant had not been checked daily as required on 4/4, 4/5, 4/11, 4/12, 4/18, 4/19, 4/25, and 4/26. The log indicated the solution was opened and activated on 3/11/2015 and was documented expired on 12/2016. The log indicated the solution was opened and activated on 4/9/2015 and was documented expired on 12/2016. In checking the April log, for two (2) days the date "4/28/2015" was documented as if the solution was changed, but then the log went back to the solution being activated on 4/9/2015. Again the Metricide OPA Plus is only good for 14 days once the cold disinfectant has been activated.
Further review of the April log showed the cold disinfectant solution (Metricide OPA Plus) was mixed 3/11/2015. The solution was not mixed again until 4/9/2015, which was 15 days past the due date 3/25/2015. Next time the solution was changed was 5/13/2015, which was 34 days past the due date of 4/23/2015. There were 8 (#55, #56, #57, #58, #59, #60, #61, and #62) patients that had procedures that had utilized instruments or glide scopes for those procedures that had been soaked in the expired solution.
A review of the May 2015 log showed the cold disinfectant solution (Metricide OPA Plus) was activated 4/9/2015 and was documented expires 12/2016. Again the Metricide OPA Plus is only good for 14 days once the cold disinfectant has been activated. Further review of the log showed the cold disinfectant had not been checked daily as required on 5/8 5/9, 5/10, 5/17, 5/18, 5/23, 5/24, 5/25, 5/30, and 5/31.
A review of the June 2015 log showed the cold disinfectant solution (Metricide OPA Plus) was mixed 5/27/2015 and not mixed again until 6/12/2015 which was 2 days past the due date of 6/10/2015. There was 1 (#63) patient that had procedures that had utilized instruments or glide scopes for those procedures that had been soaked in the expired solution.
An interview with Staff #33 was conducted on 6/19/2015 at approximately 10:00AM. Staff #33 was asked if he/she knew how to perform the quality control test for the test strips. Staff #33 stated, "I have no idea what you are talking about, all I do is test the solution with the strip." Surveyor showed the log to Staff #33 to verify it was his initial that showed he had done the quality control testing. Staff #33 stated, "Those are my initials, but I don't do the quality testing."
A review of the April, May, and June 1-12, 2015 logs did not show the quality control testing staff member until 5/13/2015.
An interview with Staff #31 on 6/19/2015 at approximately 9:30 AM confirmed the cold disinfectant was to be tested daily.
A review of the manufacturer guidelines for Metricide OPA PLUS revealed the following:
"The product must be discarded after 14 days, even if the Metricide OPA PLUS Test Strip indicates a concentration above the MRC (minimum recommended concentration) of 0.3%.
Once the Metricide OPA PLUS gallon container is opened it is only good for 75 days."
A review of the manufacturer guidelines for Metricide OPA PLUS Solution Test Strips revealed the following:
"1. Quality control test for the test strips:
Testing of positive and negative controls must be performed on each newly opened bottle of Metricide OPA PLUS Solution Test Strips. Always note the date the bottle was opened and "do not use after" date in the space provided on the bottle. Test strips once opened are good for 90 days."
An interview with Staff #31 on 6/19/2015 at approximately 10:30 AM confirmed the above findings.
Cardio-Pulmonary:
During a tour of the Cardio-Pulmonary department on 6/16/2015 at approximately 3:00 PM Staff #49 was observed processing a TEE (Trans-Esophageal Echocardiogram) scope. Staff #49 wore no personal protective equipment. Staff #49 and #113 were asked if he/she knew the how to perform the quality control test for the test strips. Both staff members described checking the solution of the Metricide OPA PLUS. Neither Staff #49 or #113 knew how to perform the Quality control test for the test strips.

A review of the policy titled, "Care and Cleaning of Scopes and Probes- Use of CPA Plus" effective date 9/2014 revealed the following:

"PURPOSE:
To guide personnel in the care and cleaning of reusable scopes/probes and in the proper use of Metricide Ortho-Phthaladehyde to provide high level disinfection (HLD).

RESPONSIBILITY:
Scopes and probes shall be reprocessed by competent personnel in a manner consistent with infection prevention, safety, regulatory and manufacturer ' s recommendations.

CLEANING PROCEDURE:
*Follow manufacturer's instructions.
*Transport used scopes/probes to the soiled area in a biohazard bin and in a manner that avoids cross contamination.
*Wipe with a damp cloth or gauze immediately after use to avoid drying of organic materials.
*Avoid bending or coiling.
*Only immerse parts as per instructions.
*Perform leak test on scopes as per manufacturer's instructions.
BEGIN DISINFECTION PROCESS USING METRICIDE OPA
Supportive Data:
1. Metricide CPA Solution is a high level disinfectant for semi-critical level devices when used or reused, according to Directions for Use, at or above its Minimum Effective Concentration (MEC) of 0.6% as determined by the Metricide CPA Solution Test Strips, at 20° C (68° F).
2. Efficacy of this product during its use-life must be verified by the Metricide CPA
Solution Test strips and testing temperature prior to use.
3. Metricide CPA can be re-used for up to 14 days.
4. Opened, but unused Metricide CPA Solution in original container can be used for up to 75 days once opened and must be dated.
5. Metricide CPA Solution should be used only in a location pre-apptoved by Infection Prevention or in a designated reprocessing area.
6. PRECAUTIONS/WARNING:
a. Avoid contact with eyes, on skin or clothing. Metricide CPA will stain gray, wear PPE
b. Use nitrile gloves.
c. Use in well-ventilated area in closed containers with tight fitting lids.
d. In case of contact, immediately flush eyes or skin with plenty of water for at least 15 minutes. For exposure to eyes, proceed to Emergency department.
e. Contaminated reusable devices MUST BE THOROUGHLY CLEANED prior to disinfection.
f. User must adhere to Directions for Use. Modifications to the Directions for Use may affect safety and effectiveness of germicide.
g. No activation is required.
h. Dispose/Discard Metricide CPA in accordance with hospital and/or local laws or regulations.

Procedure for disinfection using Metricide OPA Metricide CPA is used for high level disinfection (HLD)
1. No activation is required when using Metricide CPA
2. The following Personal Protective Equipment will be used:
a. Protective safety goggles with side shield protection or face shield
b. Disposable nitrile gloves are preferred
c. Fluid resistant gowns
3. When opening the original Metricide CPA container, label with the date it is opened if entire contents of the container are not used immediately. The solution remaining in the container can be used for up to 75 days (providing the 75 days does not extend past the expiration date printed on the container). Ctherwise, if entire contents are transferred to a soak container, properly dispose of the empty original container.
4. Open clean soak container and carefully pour solution, avoiding splashing.
a. Record the date the solution was poured out of the original container into the secondary container, lot number and the new expiration date (14 days from date poured) on a label affixed to the secondary container. The expiration date of 14 days is effective as long as the concentration of the Metricide CPA is above the Minimum Effective Concentration (MEC) as indicated by the Metricide CPA Solution Test Strip.

Testing:
Upon opening of a new container of Metricide CPA Test Strips, a Quality Control (QC) test shall be performed as follows:
1. Verify the expiration date on the Metricide CPA solution and test strips.
2. Full strength Metricide CPA solution may be used as the positive control.
3. Prepare a negative control by diluting 1 part full strength Metricide CPA Solution (10mI) with 1part water (15 ml)-use plastic bowl or denture cup.
4. Label each solution.
5. Dip 3 test strips into each of the prepared solutions one at a time for 2 full seconds.
a. Tap test strip to remove excessive solution.
b. Hold strip horizontally.
6. Check for the test result after 60 seconds
a. Positive control solution strips should appear completely PINKIMAGENTA.
b. Negative control solution strips should either remain YELLOW or exhibit an incomplete change to pink. (Refer to color chart on bottle to interpret).
c. If the results of the QC test indicate the test strip is not functioning properly, discard the remaining strips.
7. Container of strips must be kept clean, dry and closed.
8. The Metricide CPA solution during its ' useful life must be verified using Metricide CPA Solution Test Strips prior to each cycle to determine concentration.
9. This solution must be discarded after 14 days even if the Metricide CPA Solution test Strip indicates a concentration above the MEC. Also, if after visual inspection, precipitates are in the solution it must be discarded. A neutralizer for Metricide CPA Solution IS NCT required prior to disposal. Discard solution into the drain. Flush drain thoroughly with water."

An interview with Staff #49 and #113 on 6/18/2015 at approximately 3: 00 PM confirmed the facility policy was not followed.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

B. follow their policy for monitoring the fluids in the warming cabinet and cleaning of the 5 sterilizers. Also, the temperature and humidity were not recorded or monitored for the Surgery, Labor and Delivery, and Cath lab departments where sterile instruments were stored. Further review revealed the facility failed to provide a sanitary environment for pre-op area, holding area, surgical area, sterilization area, post anesthesia area, and sterile supply storage area.

Fluid Warming Cabinet:
A review of the log titled, "Warming cabinet temperature log: Heating of Fluids, and/or Solutions: Acceptable Range for heating = 86-104 degrees" revealed a temperature of 140 degrees on June 1, 2015 at 0030. In the corrective action column it was written "turned down to low." There was no further follow up to know if the warming cabinet was working properly. The cabinet contains intravenous and irrigation fluids that are used on patients during a surgical procedure. This had the likelihood to cause a safety hazard.
A review of the policy titled, "Temperature Setting for Warming Cabinets Policy" revealed the following:
"Purpose: To ensure safe and effective temperature settings for warming cabinets. Allowing Digital Warming Cabinets to reach excessive temperatures is unacceptable.

When heating fluids and/or solutions warming cabinet temperatures should be maintained no higher than 104° Fahrenheit.

Allowing the temperature to rise above the specified ranges is a safety hazard to patients, visitors and employees.

Employee Responsibility:
1. Monitor warming cabinet temperature gauge and ensure that temperature stays at 104° when being utilized to heat fluids, and/or solutions.
2. Fluids that are placed into a warming cabinet will be rotated on a regular basis.
Note: Fluids cannot be " rewarmed " once removed. All bags must be labeled and dated when at first placed in the warmer to indicate initial warming Reference " Guidelines for Storage and Stability of Sterile IV and Topical Irrigation Solutions "
3. IV solutions and irrigation bottles may be stored up to 28 days in the warmer, unless otherwise specified by the manufacturer.
4. If the warming cabinet temperature exceeds acceptable temperature, check the gauge and adjust as necessary.
5. Recheck temperature in one hour, if temperature continues out of range, contact maintenance for evaluation and repair. Move contents to a properly functioning warmer.
6. Units with warming cabinets that contain IV fluids and irrigation solutions will maintain a temperature log and daily temperature quality checks.
7. Occurrences of a warming cabinet's temperature exceeding the acceptable temperature mandate corrective action."

An interview with Staff #31 on 6/16/2015 at 9:30 AM confirmed the one hour recheck was not recorded as per the facility policy.

Sterilizers:

A review of the log titled, "Stream Sterilizer Cleaning Schedule Log" revealed sterilizers #1, #2, #3, #4, and #5 had not been cleaned since 6/15/2013. It was written on the log per Staff #1 to discontinue the service and Biomedical would provide the service. A review of emails dated April 23, 2013, May 30, 2013, and May 31, 2013 revealed the cleaning would start 6/15/2013. There was no documentation that the cleaning of the sterilizers was ever started. The observation of sterilizer #1 revealed green corrosion and rust build-up.

A review of the policy titled, "Cleaning of Sterilizers (effective date 4/1/2013)" revealed the following:

"Purpose: To define the process used in maintaining the sterilizers within the department.
Policy Statement: Routine cleaning will be performed on all sterilizers to maintain the units in optimum condition.

Content:
Steam sterilizers will be cleaned on a weekly schedule to remove scale deposits and rust from the chamber.
The exterior surfaces of the steam sterilizers will be wiped down using a germicidal solution on a weekly basis.
The steam drain strainer will be cleaned on each steam sterilizer on a daily basis. The drain must be maintained free of all debris to ensure correct processing.
The low temperature sterilizer chambers will be cleaned and exterior surfaces wiped down on a weekly basis.
The manufacturer ' s instructions will be followed when cleaning each of the sterilizer units. Staff should consult the manual for any questions.
PPE will be worn by all personnel when performing the cleaning duties.
A cleaning log will be maintained by the staff and document date of cleaning.
All preventative maintenance/ repairs are completed by Biomed department."

An interview with Staff #31 on 6/17/2015 at approximately 2:00 PM confirmed the sterilizers had not been cleaned since 2013 and the facility policy was not followed.

Temperature and Humidity:

A review of the log titled, "Surgery Temperature-Humidity Log" for the following departments of Surgery (14 rooms), Sterile Storage (4 areas), Labor and Delivery (4 areas), and Cath lab (4 areas) revealed the following:

A review of the temperature-humidity log for the month of April 2015 for Surgery, Labor and Delivery, and Cath lab revealed the following:

215 Temperatures were not recorded.

318 Humidities were not recorded.

391 Temperatures were out of range.

5 Humidities were out of range.

A review of the temperature and humidity log for the month of April 2015 revealed 810 slots for staff to record the readings. During this time frame there were 606 temperatures and 68 humidity readings that were either omitted or out of range.

A review of the temperature-humidity log where remarks were to be documented revealed "thermometers/humidity removed from operating rooms 1-9" as the the only documented remarks. There was no documentation of the out of ranges or omitted recordings.

A review of the temperature-humidity log for the month of May 2015 for Surgery, Labor and Delivery, and Cath lab revealed the following:

165 Temperatures were not recorded.

304 Humidities were not recorded.

313 Temperatures were out of range.

9 Humidities were out of range.

A review of the temperature and humidity log for the month of May 2015 revealed 837 slots for staff to record the readings. During this time frame there were 478 temperatures and 313 humidity readings that were either omitted or out of range.

A review of the temperature-humidity log where remarks were to be documented revealed no documentation of the out of ranges or omitted recordings for temperatures or humidity.

A review of the temperature-humidity log for the month of June1-15, 2015 for Surgery, Labor and Delivery, and Cath lab revealed the following:

55 Temperatures were not recorded.

103 Humidities were not recorded.

197 Temperatures were out of range.

10 Humidities were out of range.

A review of the temperature and humidity log for June 1-15, 2015 revealed 405 slots for staff to record the readings. During this time frame there were 252 temperatures and 113 humidity readings that were either omitted or out of range.


A review of the temperature-humidity log where remarks were to be documented revealed no documentation of the out of ranges or omitted recordings for temperatures or humidity.

Review of the AORN Perioperative Standards and Recommended Practices noted, "Temperature should be maintained between 68 degrees F to 73 degrees F (20 degrees to 23 C) within the operating room suite and general work areas in sterile processing.
Relative humidity should be maintained between 30% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, instrument processing areas, and sterilizing areas and should be maintained below 70% in sterile storage areas.
Low humidity increases the risk of electro static charges, which pose a fire hazard in an
oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed.

Humidity should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system.

Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system."

An interview with Staff #44 on 6/19/2015 at approximately 11:30 AM confirmed the Cath Lab personnel had never monitored the humidity where sterile instruments were being stored.

An interview with Staff #31 was conducted on 6/19/2015 at approximately 10:30 AM. Staff #31 was asked do you monitor the temperature and humidity of the operating rooms. Staff #31 stated, "It is the responsibility of the plant operations personnel."

An interview with Staff #34 on 6/19/2015 at approximately 12:00 PM confirmed the plant operations department records the temperature and humidity for Surgery, Labor and Delivery, and Cath Lab. Staff #34 stated, "Operating rooms #1-9 are on a computerized auto monitoring system. If the system records an out of range temperature or humidity it will adjust the control to regulate the temperature which will in turn regulate the humidity. Rooms #10-14 are manually regulated. One of the staff members has to manually go to the room and read the temperature and humidity. If the plant operations staff member goes to the room and a surgical case was being performed the temperature and humidity is not recorded." Staff #34 was asked how the rooms (#10 -14) were regulated if the temperature or humidity is out of range. Staff #34 stated, "A staff member has to manually go into the room and through the ceiling tile to open or close the air conditioner damper which will adjust the temperature and humidity."

The process of monitoring the temperature and humidity for the operating rooms where surgical cases are being performed have different standards of care for rooms #1-9 and rooms #10-14. In rooms #10-14, the room is manually controlled by a staff member. In rooms' #1-9 the system is computerized and automatically controlled. This process has the likelihood to cause outbreaks of surgical site infections.


Patient #47 followed through the surgery departments:

The following observations of Patient #47 on 6/17/2015 starting at 9:30 AM and continued from the time the patient entered the pre-surgical area until Patient #47 was discharged from the Same Day Surgery.

Same Day Surgery Area:

In the room where Patient #47 was being prepped, dust particles and what appeared to be rodent pellets were observed in the drawer where patient supplies were kept.

In the patient/public bathroom on the back hallway of the "Same Day Surgery" the commode had an extra support system for larger patients; the support system was made of metal and was covered with numerous rust spots. The bathroom had an unclean appearance.

Surgery Holding Area:

The light fixture over Patient #47's bed had insects and the appearance of dark spots inside the covering.

The patient's bathroom cord was pulled by the surveyor and there was no audible alarm signal. Approximately 2 minutes went by before anyone responded to the bathroom flashing signal.

Operating room:

In the operating room where Patient #47's procedure was performed, the arm cushions on the surgery table were split with exposed foam showing through the vinyl covering. Patient #47's arms were placed directly on the vinyl cushions.

Postoperative Area:

The bedside table had a hole in the top of the table about the size of a fifty cent piece. Porous wood was showing where the patient was being cared for. One of the patient care areas in the postoperative area was being used for storage of wheelchairs and other equipment.

Surgical Tour

Surgery Holding Area:

Six (6) cardboard outside shipping boxes of Cathlon epidural needles stored with the sterile supplies in the cabinet.

Surgery:

Vinyl chair/stool was sitting in the hallway of the surgery department with an 8 inch split in the seat of the cushion.

In operating Room #13 there were 3 outside cardboard shipping boxes inside the operating room. Also, observed in the room was unfinished wood on the cabinets and observed a Nellcor pulse oximetry which had expired 12/2014. In the lithotripsy room was a large cardboard box sitting on the floor full of equipment pieces.

In the hallway in front of operating rooms #10, #11, #12, and #13, the baseboards were laying over in the floor.

Surgery Sterile Supply Storage Area:

In the sterile supply storage area where open sterile supplies were stored was a wooden pallet (4x4 in size). The pallet was stacked with outside shipping cardboard boxes approximately 6 feet high. The employees were observed opening and breaking down the cardboard boxes in the room with the open sterile supplies. The sterile supplies were within a foot of where cardboard boxes were being torn down. There was a portable metal table being used for paperwork and drink items while the employees worked. The floor was dirty with dust particles, plastic, and paper trash. Also, the caster wheels of the wire racks were observed to be covered in sticky paper, trash, and dust particles. The sterile supply room had a very unclean and disarray appearance. The outside shipping cardboard boxes were being brought into the room from a back hallway with a lift that comes in from the outside. The process was to drop the wooden pallet directly in the sterile supply room with the open sterile supplies.

The hallway outside the sterile storage area was where dirty instruments from other departments were brought, stored, and logged. The instruments were kept there until ready to be processed by the sterilization department. The floor under the carts was dirty in appearance with trash and dust particles. The light fixtures along the hallway were full of bugs, yellowish in color, and had a dull lighting appearance.

Anesthesia Care area (PACU)

During a tour of the surgical area 14 functional operating rooms were observed. In the postoperative care unit there were only 12 post anesthesia patient care areas. One of the patient care areas was being used for storage of wheelchairs and other equipment. The monitoring, suctioning, and oxygen supplies had been removed from the patient care area. The post anesthesia care area only had 11 functional bay areas.

An interview with Staff #31 on 6/16/2015 at approximately 11:45 PM confirmed the above findings in the surgical area.


Cath Lab Area:

In Cath Lab #2 the wire rack that was full of sterile supplies did not have a barrier that would prevent dust particles and wet mop splatters from contaminating the sterile supplies.

There was a blue wedge cushion used for positioning patients that was worn with exposed foam.

In the cabinet where sterile supplies were stored, observed 3 of 3 peel packages with water stains. One of the water stained packages noted a sterilization date of 2008.

A review of the log titled, "Surgery Temperature and Humidity Log" from April through June 15, 2015 revealed the humidity had never been checked in the Cath Lab Rooms #1, #2, and #3. During the tour of the Cath Lab observed numerous sterile instruments that were being stored in all 3 rooms.

An interview with Staff #44 on 6/16/2015 at approximately 2:45 PM confirmed the above findings in the Cath Lab area.

Obstetric Area:

In the C-section room a stainless steel back table and mayo table was observed which had rusted caster wheels. The Fetal Heart tone cabinet could not been cleaned due to exposed porous wood.

An interview with the Director of Obstetric on 6/19/2015 at approximately 11:06 AM confirmed the above findings in the Obstetric area.


C. ensure the patient had a current or updated history and physical on the chart prior to the surgical procedure on 3 ( #40, #46, and #54) of 10 ( #40. 46, 47, 48, 49, 50, 51, 52, 53, and 54) patients.

Refer to Tag: A952

D. provide adequate post-operative care areas for the patients receiving surgical procedures.
Refer to Tag: A957

E. ensure the patient's record had an operative report on the chart after the procedure was completed on 1 ( #54) of 10 ( #40. 46, 47, 48, 49, 50, 51, 52, 53, and 54) patients.

Refer to Tag: A959

F. ensure the patient had a post-operative anesthesia evaluation on 1 (#54) of 10 ( #40. 46, 47, 48, 49, 50, 51, 52, 53, and 54) patients.
Refer to Tag: A1005

Based on chart reviews, interviews, and policy and procedures the facility failed to have a patient representative make informed decisions regarding his or her care. The facility failed to involve the patient in requesting or refusing treatment. The facility failed to provide consent for treatment, the facility failed to ensure proper evaluation to determine if a patient was of sound mind to enter into a voluntary admission contract. The facility failed to ensure the patient was on a mental health warrant if the patient was a danger to self or others or unable to make sound decisions for his or her mental healthcare in 6 out of 6 (#20, #21, #22, #23, #24, and #40) records reviewed.
1.) Review of patient #21's chart revealed an arrival date and time to the ER of 6/1/2015 at 16:27 (4:27PM). Review of the Emergency Room Physician Documentation revealed the patient was a 46 year old male that resided in a local Nursing Home. The patient was sent to the ER for Medical clearance.
Physician's note dated 6/1/2015 at 17:45(5:45PM) stated, "46 y/o male comes to Kilgore ED for medical clearance. Pt states that he became aggressive with the nursing home staff and also tried to hit one of the nurses. 17:54 (5:54PM) Patient presents with denies suicidal ideation, denies homicidal ideation, aggressive behavior towards nursing home staff. Onset: The symptoms/episode began/occurred today. Severity of symptoms: At worst the symptoms were very mild, in the emergency department the symptoms improved. Disposition Summary: 6/1/2015 at 1900 (7:00PM). Transferred ordered to specialty hospital. Diagnosis are Acute Exacerbation of Chronic Dementia, Acute Psychosis- with aggressive behavior."
Review of patient #21's chart revealed there was no screening from the accepting facility or from a mental health authority to determine the need for a geriatric psychiatric facility admission. There was no information found if patient #21 requested to be in a Geriatric Psychiatric facility. There was a Memorandum of Transfer (MOT) for the patient to transfer from the ER to the Geriatric Psychiatric facility. There was no information found of who transferred the patient and how the patient arrived at the Geriatric Psychiatric facility. Review of the MOT "next of kin notified" was blank. There was no warrant found for psychiatric hold.
Review of patient #21's chart had no consents for treatment found. Requested consents for treatment multiple times from administration but none were received.
2.) Review of patient #24 revealed the patient came to the Kilgore ER for medical clearance on 6/1/2015 at 16:33 (4:33PM). Review of the physician notes stated, "Patient presents with suicidal ideation. Patient does have a plan to carry out suicide attempt - PT HAS THOUGHT TO TAKE PILLS OR CUT HERSELF. Patient reports they are taking prescription psych meds. Patient has had previous suicide attempts. PT HAS HAD NUMEROUS ATTEMPTS IN SUICIDE Patient has had previous inpatient hospitalization. PT STATES SHE HAS BEEN HOSPITALIZED FOR SUICIDAL ATTEMPTS, depression. Onset: The symptoms/episode began/occurred today. Severity of symptoms: At worst the symptoms were very mild, in the emergency department the symptoms improved. The patient has experienced similar episodes in the past, multiple times. Physician's Note: 46 YO FEMALE COMES TO ED FOR MEDICAL CLEARANCE. PT STATES SHE HAS BEEN HAVING SUICIDAL THOUGHTS AND DOES HAVE A PLAN TO ATTEMPT. PT HAS THOUGHT OF TAKING PILLS OR CUTTING HERSELF BUT HAS HAD NEITHER MATERIAL AVAILABLE TO DO SO. PT HAS BEEN DIAGNOSED AS BIPOLAR."
Review of patient #24's chart revealed there was no screening from the accepting facility or from a mental health authority to determine the need for a geriatric psychiatric facility admission. There was no information found if patient #24 requested to be in a Geriatric Psychiatric facility. There was a Memorandum of Transfer (MOT) for the patient to transfer from the ER to the Geriatric Psychiatric facility. There was no information found of who transferred the patient and how the patient arrived at the Geriatric Psychiatric facility. Review of the MOT "next of kin notified" was blank. There was no warrant found for psychiatric hold.
Review of patient #24's chart had no consents for treatment found. Requested consents for treatment multiple times from administration but none were received.
3.) Review of patient #23's chart revealed an arrival date and time to the ER of 6/16/2015 at 16:40 (4:40PM). Review of the physician documentation stated, "06/16 18:11 this 62 yrs old Caucasian Female presents to ED via Unassigned with complaints of Medical Clearance. 19:22 This 62 yrs old Caucasian Female presents to ED via Walk-in with complaints of Medical Clearance. 18:12 MEDICAL CLEARANCE. Onset: The symptoms/episode began/occurred just prior to arrival. Severity of symptoms: At worst the symptoms were very mild, in the emergency department the symptoms are unchanged. The patient has not recently seen a physician. The patient has not experienced similar episode(s) in the past. Physician's Note: 62 YO FEMALE IS BROUGHT TO ED FOR MEDICAL CLEARANCE FOR ALLEGIANCE. PT STATES THAT SHE PUNCHED HER ROOMMATE AT THE NH BECAUSE SHE CUSSED HER OUT. THE NH NOW WANTS HER TO BE PLACED IN A FACILITY FOR ANGER MANAGEMENT. PTS ONLY COMPLAINT IS HER BACK ITCHING."
Review of patient #23's chart revealed there was no screening from the accepting facility or from a mental health authority to determine the need for a geriatric psychiatric facility admission. There was no information found if patient #23 requested to be in a Geriatric Psychiatric facility. There was a Memorandum of Transfer (MOT) for the patient to transfer from the ER to the Geriatric Psychiatric facility. There was no information found of who transferred the patient and how the patient arrived at the Geriatric Psychiatric facility. Review of the MOT "next of kin notified" was blank. There was no warrant found for psychiatric hold.
Review of patient #23's chart had no consents for treatment found. Requested consents for treatment multiple times from administration but none were received.
4.) Review of patient #20's chart revealed an arrival date and time to the Kilgore ER was 6/1/2015 at 16:40 (4:02PM). Review of the physician documentation stated, "06/01 15:37 This 64 yrs old Caucasian Female presents to ED via Wheelchair with complaints of Medical Clearance. 15:39 Patient presents with grandiose delusions, auditory hallucinations. Onset: The symptoms/episode began/occurred 6 month(s) ago. Also reports CONFUSION, AGITATION, ANGER AND INCOHERENT THOUGHTS. Severity of symptoms: At worst the symptoms were mild, in the emergency department the symptoms are unchanged. Physician's Note: PT PRESENTS FOR MEDICAL CLEARANCE. HUSBAND STATES THAT FOR THE PAST 6 MONTHS PT HAS BEEN CONFUSED, DELUSIONAL, HAVING INCOHERENT THOUGHTS, AGITATED, AND ANGER OUTBURST. HUSBAND STATES THAT PT IS ARGUING ABOUT THINGS THAT HAVEN'T HAPPENED. BELIEVES THAT HER HUSBAND IS PLACING HER IN A HOME SO HE CAN HAVE AN AFFAIR. PT ISN'T MAKING SENSE WITH HER CONVERSATIONS AND THEN BECOMES ANGRY WHEN SHE IS QUESTIONED ABOUT WHAT SHE IS TALKING ABOUT. NO OTHER SX ARE NOTED CURRENTLY. Transfer ordered to Allegiance Specialty Hospital. Diagnoses are Acute Psychosis, Acute UTI."
Review of patient #20's chart revealed there was no screening from the accepting facility or from a mental health authority to determine the need for a geriatric psychiatric facility admission. There was no information found if patient #20 requested to be in a Geriatric Psychiatric facility. There was a Memorandum of Transfer (MOT) for the patient to transfer from the ER to the Geriatric Psychiatric facility. There was no information found of who transferred the patient and how the patient arrived at the Geriatric Psychiatric facility. Review of the MOT "next of kin notified" was blank. There was no warrant found for psychiatric hold.
Review of patient #20's chart had no consents for treatment found. Requested consents for treatment multiple times from administration but none were received.
5.) Review of patient #22's chart revealed an arrival date and time to the Kilgore ER was 6/1/2015 at 19:04 (7:04PM). Review of the ER physician documentation stated, "06/01 19:22 This 56 yrs old Caucasian Male presents to ED via Walk-in with complaints of Medical Clearance. 19:22 Patient presents with suicidal ideation. Patient does not have a plan to carry out suicide attempt. WANTED TO HURT OTHERS. Onset: The symptoms/episode began/occurred today. Also reports no other symptoms. Severity of symptoms: At worst the symptoms were very mild, in the emergency department the symptoms improved. Physician ' s Note: 56 YO MALE COMES TO ED FOR MEDICAL CLEARANCE. PT STATES THAT HE BECAME AGGRESSIVE WITH NURSING HOME STAFF AND ATTEMPTED TO HIT THEM. PT ALSO STATES HE HAS HAD SUICIDAL THOUGHTS EARLIER TODAY."
Review of patient #22's chart revealed there was no screening from the accepting facility or from a mental health authority to determine the need for a geriatric psychiatric facility admission. There was no information found if patient #20 requested to be in a Geriatric Psychiatric facility. There was a Memorandum of Transfer (MOT) for the patient to transfer from the ER to the Geriatric Psychiatric facility. There was no information found of who transferred the patient and how the patient arrived at the Geriatric Psychiatric facility.
Review of patient #22's chart had no consents for treatment found. Requested consents for treatment multiple times from administration but none were received.
An interview was conducted with staff #53 on 6/17/2015 at 11:00AM. Staff #53 revealed the psychiatric hospital would send a screening they performed and a voluntary consent signed by the patient at the time of a medical clearance. Staff #53 denied having the screenings and consents as part of the patient's chart. Staff #53 stated, "It just didn't occur to me we needed to scan the screenings in the medical record."
An interview conducted with staff #44 on 6/17/15 at 2:30PM revealed she was not aware the screenings and voluntary forms were not being scanned into the system. Staff #44 called the Geriatric Psychiatric Facility and obtained the screenings and voluntary forms. On review of the forms it was brought to her attention the forms were not completed. The screenings were not completed with multiple blanks and conflicting information. Staff #44 reported the mental health authority sees the patients in the main ER but the geriatric psychiatric facility sends their own people and they were trusting in them to make all the necessary arrangements.
Review of patient #40's chart revealed he was brought to the Emergency Room (ER) unconscious and was not able to sign admission consents. Review of the patient's consent for treatment stated, "I have read and understand the information in this consent to treat? Patient admission acknowledgement and agree to its conditions". On the line for the patient responsible party signature an unidentifiable signature was found. In the relationship to the patient it stated, "RN" Dated 6-2-15 at 2:00AM Under "reason patient unable to sign, AMS/LOC " (altered mental status/loss of consciousness).
Review of patient #40's chart revealed consent to perform a "Cardiac Catherization with Percutaneous Coronary Intervention (PCI) and Temporary External Pacemaker Bilateral." At the top of the consent it required a physician signature. A printed name of the surgeon was found with the time 5:07AM but no date. Patient #40's mother signed the consent but there was no date or time. Below the signature was a section on consent for resuscitation. The section was blank on "do" or "do not" resuscitate.

Review of patient charts and policy and procedures the facility failed to obtain the patient or patient representative's wishes on advance directives in 1 of 1(#40) charts reviewed.
Review of patient #40's chart revealed he was brought to the Emergency Room (ER) unconscious and was not able to sign admission consents. Review of the patient's consent for treatment stated, "I have read and understand the information in this consent to treat? Patient admission acknowledgement and agree to its conditions". On the line for the patient responsible party signature an unidentifiable signature was found. In the relationship to the patient it stated, "RN" Dated 6-2-15 at 2:00 AM under reason patient unable to sign,"AMS/LOC" (altered mental status/loss of consciousness). The Patient's Rights/Advanced Directives section was left blank. There was no further evidence of patient directives reviewed or clarified.
Review of patient #40's chart revealed consent to perform a "Cardiac Catherization with Percutaneous Coronary Intervention (PCI) and Temporary External Pacemaker Bilateral ". At the top of the consent it required a physician signature. A printed name of the surgeon was found with the time 5:07 AM but no date. Patient #40's mother signed the consent but there was no date or time. Below the signature was a section on consent for resuscitation. The section was blank on "do" or "do not" resuscitate.

Based on observation and interviews the facility failed to safeguard patient personal information, to provide patients with physical privacy during an examination by a nurse or physician, and during discussions of clinical issues and treatments.

A tour was conducted on 6/16/15 of the main campus Emergency Room (ER). During the tour patients were observed on stretchers in the hallways. The stretchers were considered "hall beds". A patient was observed lying in hall bed "J". The patient was an older white male who had come to the ER due to a car accident. The patient did not have on a shirt, socks or shoes. He was only wearing shorts. Two female residents were examining the patient. The patient was not covered by a sheet or screen to give any kind of privacy during the exam.

Due to the patient's hard of hearing condition the residents were asking personal medical questions in a loud tone. Other patients in hall beds and visitors standing in the hall were watching the patient receive a physical exam. A visitor was looking over the residents shoulder during the exam.

During the exam, staff # 54 confirmed the patient was not given privacy during the exam. Staff #54 stated, " maybe we can have curtains put around the beds." Staff #54 confirmed multiple patients a day were placed in hall beds due to ER saturation.

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

A. set up quality control procedures to ensure ongoing conformance to policies and procedures regarding dialysate quality. These deficient practices had the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to unsafe dialysate. Citing 5 (#4, #5, #6, #7, and #8) out of 5 (#4, #5, #6, #7, and #8) medical records reviewed. Citing 3 months (March 1-May 31, 2015 and June 1-13 2015 out of 3 months of logs reviewed.

B. ensure permanent records of batches of bicarbonate were maintained to include the concentrate formula produced, the volume of the batch, lot number(s) of powdered concentrate packages, the manufacturer of the powdered concentrate, date and time of mixing, test results, person performing mixing, and expiration date (if applicable).

C. log the number of bags or weight of powder added. These deficient practices had the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to unsafe dialysate. Citing 3 months (March 1-May 31, 2015 and June 1-13 2015) out of 3 months of logs reviewed.

D. label the mixing tank to clearly indicate the fill and final volumes required to correctly dilute the powder. These deficient practices had the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to unsafe dialysate. Citing 3 months (March 1-May 31, 2015 and June 1-13 2015) out of 3 months of logs reviewed.

E. ensure the staff performed conductivity and PH reading with an independent device before each dialysis treatment and compare them to the dialysis machine reading. The facility also failed to ensure the 1st level verification was conducted. These deficient practices had the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to unsafe dialysate. Citing 5 (#4, #5, #6, #7, and #8) out of 5 (#4, #5, #6, #7, and #8) medical records reviewed and 1 out of 2 Phoenix meters reviewed.

F. ensure that all samples for cultures and endotoxins were drawn from the water treatment systems and dialysis machines. These deficient practices had the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to harmful bacteria. Citing 6 out of 6 RO's including the main RO and 5 portable RO's. In addition 1 out of 1 bicarbonate mixing systems were not collected.

G. ensure that all samples for chlorine/chloramines testing were drawn when the water treatment system had been operating for at least 15 minutes. These deficient practices had the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to harmful chlorine and chloramines chemicals. Citing 6 out of 6 RO's including the main RO and 5 portable RO's. The facility failed to ensure staff performed conductivity and PH readings with an independent device before each dialysis treatment and compare them to the dialysis machine reading. The facility also failed to ensure the 1st level verification was conducted. Citing 5 (#4, #5, #6, #7, and #8) out of 5 (#4, #5, #6, #7, and #8) medical records reviewed and 1 out of 2 Phoenix meters reviewed.

H. offer and administer Hepatitis B vaccinations to susceptible staff whose antibodies were less than 10 mIU (Mill International Unit); or test the staff for antibodies to determine the need for immunizations. Also, a review of records indicated the Engerix vaccine was not given as recommended by the Engerix guidelines. The facility failed to follow its own policy and that of the Center for Disease Control. The following employee records were reviewed: 15 (#12, #14, #15, #16 #17, #25, #26, #36, #53, #67, #71, #73, #75, # 80 and #104) of 19 (#11, #12, #13, #14, #15, #16 #17, #21, #24, #25, #26, #36, #53, #67, #71, #73, #75, # 80 and #104).

I. ensure the required chemical analysis of the product water was conducted every 6 months as required.

J. ensure the storage tank and the water systems were disinfected.

K. test the water softeners at the end of the day, to verify their capacity to treat a sufficient volume of water, to supply the facility for the entire treatment day.

L. ensure the water system which was located on another floor was continuously monitored during patient treatment and was guarded by audible and visual alarms. The alarms must be seen and heard in the dialysis treatment area should water quality drop below specific parameters.

M. ensure the dialysis machines were checked according to manufacturer instructions. Citing 7 out of 8 dialysis machines reviewed.

N. ensure that each major water system was labeled in a manner that identified the device; described its function, how performance was verified and actions to be taken in the event performance was not within an acceptable range.

O. ensure the Medical Director of Dialysis Unit and the Hospital Quality Improvement Meeting reviewed the results of the water quality testing and, when indicated,directed corrective action. In addition, there was no evidence the reports of equipment testing was trended and analyzed over time through the hospital's Quality Improvement meeting. Citing 5 months (January- May 31, 2015 out of 5 months (January-May 20150 of equipment and laboratory report results reviewed.

These deficient practices had the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to unsafe dialysate, unsafe and contaminated water, hepatitis B, lack of trained staff, and failure to maintain equipment.

P. provide a clean and safe environment for patients to receive care. Tours of the facility revealed unsaitary patent rooms, unsanitary enviornment where sterile patient care supllies were being stored. The facility failed to mantain the patient care areas, food preperation areas and areas where clean and dirty linens were being stored.

Findings:

A-E. Observation in the dialysis unit on 06/16/2015 at 10:30 a.m., the dialysis mixer was observed to not be marked with a line to indicate the amount of water to be added. There also wasn't a line to indicate the final fill volume after adding the bicarbonate to the mixer.

The individual single dose bicarbonate was out of the carton and placed on two shelves. This practice allows the different lot numbers of bicarbonate to be mixed together and increases the chance that more than one lot number will be mixed together.

In review of the Naturallyte 4000 bicarbonate manufactures instructions the instruction stated "add 7.7 liter of RO water to a container and add 1 box of powder, place lid on container and gently agitate the container a sufficient number of times to dissolve powder. NOTE: Vigorous mixing can drive carbon dioxide from the solution and is not recommended. Check conductivity and PH of dialyzing fluid before starting treatment and each time solution is added."

Review of 5 out of 5 (#4, #5, #6, #7, and #8) medical record revealed there was no evidence the facility checked the conductivity and PH with an independent meter prior to the start of any treatment. In an interview with staff # 7 on 06/17/2015 at 10:30 a.m., he stated the facility had not been checking conductivity until May 27, 2015. The facility also failed to check the second first level calibration on the phoenix meter on June 9, 2015.

Review of the mixing logs for March 1, 2015-June 13, 2015 revealed there was no recorded information on the logs for the numbers of bags or weight of the bicarbonate (bicarb) used when mixing. The logs for the months of March 1, 2015-May 31, 2015 did not contain the lot numbers of the bicarb used.

A review of the facilities policies and procedures revealed they failed to have a policy for the mixing of bicarbonate, acid, checking conductivity and PH with an independent meter.

In an interview with staff #10 and #14 on 06/16/2015 at 10:30 a.m. they stated they mix 12 containers of powder and 25 gallons of water to the mixer and mix it for 20 to 30 minutes. When asked how long they mixed it 20 or 30 minutes, staff # 14 stated 30 minutes. Staff #14 also confirmed she had spiked the acid to bring the potassium content up to the ordered amount. Staff # 14 is a Patient Care Technician and only licensed trained staff are allowed to spike acid.

In an interview with the manufacture of Naturallyte 4000, #18, on 07/17/2015 at 11:30 a.m., she confirmed the Naturallyte 4000 was made for mixing of individual containers and not for mixing in a mixer. She stated they cannot tell the provider not to mix it in a mixer but would recommend mixing in a container. When she was informed the facility mixed the bicarbonate solution for 30 minutes and she stated that was way too long.

Review of the training records for staff #10, #11, #12, #13, #14 and #17 revealed the facility had not conducted the training that included for the safe operation of the main RO and the five portable RO's and the quality testing, risks and hazards of improperly prepared concentrate and bacterial issues.
Interview with staff #7 and #9 on 06/17/2015 at 10:30 a.m. confirmed there was no training for staff #10, #11, #12, #13, #14 and #17 for the above operation of the water and dialysate preparation and disinfection. Staff #7 confirmed the patient care technician (PCT) was adding potassium to the container to increase the concentration.

F. Machines and the RO's culture and endotoxin reports for January thru June 11, 2015 were reviewed. These reports did not identify each machine by its unique serial number. The reports identified the machines with three separate numbers, that was affixed to each machine with removable adhesive. There were also 3 numbers used on the portable RO's and other equipment. Without a unique identifying number on the lab reports, it was impossible to determine which cultures and endotoxin tests were taken from which machines without going to each piece of equipment and writing all members down.

The water records January 2015 through June 11, 2015 were reviewed for the main RO and the 5 portable RO # 105085, 202369, 115451, 202584, and 20583.

Review of the main RO revealed the endotoxins were not collected from the incoming distribution piping from January 1, 2015 through May 31, 2015 and for June 2015 11, 2015 when the other specimens were collected.

Review of the portable RO # 105085 revealed the endotoxins were not collected from January 1, 2015 through April 30, 2015 and for June 2015 11, 2015 when the other specimens were collected.

Review of the portable RO # 202369 revealed the endotoxins were not collected from January 1, 2015 through April 30, 2015 and for June 11, 2015 when the other specimens were collected.

Review of the portable RO # 115451 revealed the endotoxins were not collected from January 1, 2015 through May 31, 2015.

Review of the portable RO #202584 revealed the endotoxins were not collected from January 1, 2015 through April 30, 2015 and for June 11, 2015 when the other specimens were collected.

Review of the portable RO #202583 revealed the endotoxins were not collected from January 1, 2015 through April 30, 2015 and for June 11, 2015 when the other specimens were collected.

Review of the bicarbonate mixing systems revealed the cultures and endotoxins were no collected from January 2015 through May 31, 2015.

Review of 9 out of 9 dialysis machine records revealed the facility did not collect endotoxins from January-April 2015. They failed to collect endotoxins in May for 6 dialysis machines. These 6 machines had also not been collected from Jan-April 2015.

In an interview with staff #9 on 06/18/2015 at 11:30 a.m. he confirmed the facility had not documented collected the required specimens as required. He stated he did not know until the end of May the endotoxins were required and that the bicarbonate mixing system needs the cultures and endotoxins done.

G. Review of the water records March through June 13 for the main RO and the 5 portable RO # 105085, 202369, 115451, 202584, and 202583; there was no indication the ROs were allowed to run for 15 minutes prior to taking the samples. There was no recorded time the RO's were turned on prior to the collection of the test.

In an interview with staff #7 on 06/16/2015 at 11:30 a.m. he confirmed the facility had not documented the ROs had been running for 15 minutes prior to collecting the test.

H. A review of the employee health files for Staff #12, #14, #15, #25, #36, #53, #67, #71, #73, #75, #80, and #104 revealed there was no proof of immunization and no antibody titer to indicate if the staff members were immune or had been notified per the facility policy.
A review of employee #16's health file revealed the facility failed to give the immunization correctly. The immunizations were given on 04/09/2012, 07/25/2012 and 01/17/2013. There was no evidence the employee's antibodies had converted to indicate the employee was not protected or immune, nor had the employee been notified per the facility policy.
A review of employee #17's health file revealed the facility failed to give the immunization correctly. The immunizations were given on 04/22/2010 and on 06/3/2010. There was no evidence the employee completed the series as required by facility policy.
A review of employee #26's health file revealed the Hepatitis B 1ST series was given 8/23/1988, 9/30/1988 and 3/6/1989 which was incorrect. Staff #26's antibody status indicated he was not immune and had less than 9 antibodies. A booster injection was given 6/2/1994 after an exposure. There was no evidence in the file to determine if the employee had ever had positive titer after the booster was given. The employee continues to work with a less than 9 antibodies to this day as a perfusion technician in surgery without returning to the employee health office and receiving a complete second series as required by facility policy.

A review of the manufacturer guidelines for Engerix B administration is as follows:

"Engerix B dosage for adults: A series of 3 doses given as a single injection on a schedule of 3 doses on 0, 1 and 6 month."

A review of the policy titled, "Post-vaccination testing for Hepatitis B Vaccine:
Effective date 03/13/2007 " revealed the following:

" It is the policy of the facility to offer testing, at no cost to the employee, to test immunological status for persons who have completed the hepatitis B vaccine status.

1. Post-vaccination testing will be available at the employee ' s discretion from two to six months after completion of the vaccine series. Post vaccination immunological status may also be confirmed per post exposure protocol.

Employee will be informed of the opportunity to receive post-vaccination testing at the time of the last hepatitis B vaccine injection. A letter, along with a lab requisition, will be sent informing the employee to have post-vaccination testing performed in the hospital lab or Acuity lab.

2. Persons who do not respond to the primary vaccine series should complete a second 3-dose vaccine series.

3. Post vaccine testing for immune status verification will be done on a one-time basis following verification of immunological protection."

A review of policy titled, " Guidelines for Vaccination Preventable Diseases, Effective Date September 1, 2012" revealed the following:


I. Policy Purpose: The purpose of this policy is to protect the health and safety of patients,
employees, patient and employee family members, and the community as a whole from vaccine preventable diseases and to comply with Texas state law.

II DEFINITIONS:
V a. Senate Bill 7- Part of Texas Health code with new provision requiring that all hospitals
implement a policy specifying vaccines requited for direct care providers.

b. Covered individuals - An employee or volunteer of the healthcare facility or an individual
granted privileges (active or affiliated) to provide care to include direct care staff, physicians,
students, residents and LIP ' s.

c. Direct care - Staff who has patient contact, hands on care, those who handle or reprocess
equipment, clean or support patient areas, deal with food/dietary

Covered individuals working at the facility include employees of facility, individuals providing direct patient care under a contract with facility, and individuals to whom facility has granted
privileges to provide direct patient care. Proof of vaccination is required if vaccination occurs at location other than facility. The facility has adopted procedures on enforcement of this policy, including designation of persons responsible for enforcement.

d. The facility requires that a covered individual, based on the level of risk the individual presents to patients by the individual ' s routine and direct exposure to patients must receive vaccine or prove immunity to Measles, Mumps, Rubella, Varicella (chickenpox), Tetanus, Diphtheria, Pertussis (whooping cough), Influenza AND Meningococcal (Microbiology). Covered individuals will monitor their health status and comply with appropriate infection prevention standards.


e. Record will be maintained of all compliance/exemption documentation and must be completed and verified prior to employment or patient care at the facility.

f. Forms will be provided for medical or religious exemption and must be completed by a personal physician or clergy and returned within a month of request.

g. Noncompliance may result in suspension and/or termination; however the facility will not discriminate or take retaliatory action against any individual with a valid medical or religious exemption."

Center for Disease Control
MMWR December 8, 2006 / 55(RR16); 26-29
" Unknown or Uncertain Vaccination Status
· A reliable vaccination history is defined as a written, dated record (e.g., personal, school, physician, or immunization registry) of each dose of a complete series.
· In the majority of clinical practice settings, providers should accept only written and dated records as evidence of vaccination. Although vaccinations should not be postponed if records cannot be located, providers should try to locate missing records by contacting previous health-care providers and asking patients to search for personally held records. Persons whose records cannot be located should be considered susceptible and started or continued on the age-appropriate vaccine schedule.
Testing after vaccination is recommended only for the following persons whose subsequent clinical management depends on knowledge of their immune status:
Health-care workers and public safety workers at high risk for continued percutaneous or mucosal exposure to blood or body fluids (e.g., acupuncturists, dentists, dental hygienists, emergency medical technicians, first responders, laboratory technologists/technicians, nurses, nurse practitioners, phlebotomists, physicians, physician assistants, and students entering these professions), to determine the need for revaccination and to guide post exposure prophylaxis. Testing persons at low risk for continued mucosal or percutaneous exposure to blood or body fluids (e.g., public safety workers and health-care workers without direct patient contact) is not likely to be cost effective. Health-care and public safety workers who have written documentation of a complete vaccine series but who have never had post vaccination testing do not need serologic testing for anti-HBs unless they have a percutaneous or mucosal exposure to blood or body fluids. "
I. Review of the water analysis records revealed the facility only conducted the water analysis once in the year of 2014. There was no evidence the chemical analysis was done for the main plant reverse osmosis (RO) and 5 portable RO # 105085, 202369, 115451, 202584, and 202383. The only analysis was conducted in 11/2014 and was not repeated in May 2015.

J. Review of the main water system record revealed there was no evidence the facility disinfected the water system at least monthly. The records indicated the system was only disinfected on 01/19/2014, 05/16/2014 and 11/11/2014. There was also no indication the main RO was checked for clearance of the disinfections. Review of the water logs for the main RO revealed there was no evidence the storage tank was disinfected. The facility provided a separate log from a water technologies company that they contracted with to conduct periodic disinfection of their water system. The disinfection was to include the water tank. The log indicated that the RO and loop was only disinfected on 01/19/2014, 05/16/2015, and 11/16/52014 and it did not list the storage tank.
In an interview with staff # 9 on 06/18/2015 at 2:30 p.m., he confirmed the above records were all the records they had regarding disinfection and checking for clearance of chemicals after disinfection.
Review of the portable schedule revealed they were to be disinfected weekly. Review of the operation record for RO's #202584 revealed there was no evidence the system was disinfected between 02/24/2015 and 03/04/2015.

In review of the logs for RO 105085 there was no evidence it was check for clearance of the chemicals following disinfections on 03/17/2015.

Review of the policies and procedures revealed there were no policies for the operation of the water system.
In an interview with staff # 7 on 06/17/2015 at 10:30 a.m. he confirmed the above findings.

K .Review of the main RO start up record for April 27, 2015 through June 13, 2015 revealed the hardness test for the water softener was collected on start up each day and not at the end of the day as required.

In an interview with staff # 9 on 06/07/2015 at 10:30 a.m. he confirmed the test were collected on start up each morning.

L. Observation on the treatment floor on 06/17/2015 the green visual light on the water system to indicate the water was of good quality was not on.
In an interview with staff # 7 and # 8 at 11:00 a.m., confirmed the green light was out.

M. Review of the table of content for the dialysis unit revealed there was no policy to direct the staff for proper maintenance of the dialysis machines, the operation of the water system, the preparation of the dialysate, chemical and microbial contaminates that may be found in the water system and preparation of the dialysate.

Review of dialysis machine 2K0SB565 maintenance records for this dialysis machine revealed the quarterly check was conducted on 08/05 (no year recorded) the hours were recorded at 31656. The next quarterly check was not done until 02/18; (no year recorded) the hours were recorded at 32702. The next check was recorded as an annual and was conducted on 05/16, (no year recorded); the hours on the maintenance record had rolled backward to 31,428. There was no documented way to know when the checks on the machines were actually done as required.

Review of dialysis machine 2K0SB577 maintenance records for this dialysis machine revealed the quarterly check was conducted on 09/17/2014 the hours were recorded at 31758. The next quarterly check was done on 03/04/2015 the hours were recorded at 32561. The next quarterly check was conducted on 06/11, (no year recorded); the hours on the maintenance record had rolled backward to 31,382. There was no documented way to know when the checks on the machines was actually done as required on 06/04/2015 or if the records provided were from another year.

Review of dialysis machine 2K0SB347G maintenance records for this dialysis machine revealed the annual check was conducted on 08/29/2014 the hours were recorded at 12503. The next check was recorded as an annual check was done 09/05; (no year recorded) the hours were not recorded. The next check documented as a 6 month check on 02/09/2015, the hours on the maintenance record had rolled backward to 14,000. There was no documented way to know when the checks on the machines were actually done. There was no evidence the quarterly check was done in January 2015 and again in April as required.

Review of dialysis machine 2K0SB559 maintenance records for this dialysis machine revealed there were only two maintenance records provides one was dated 05/27 (no year recorded) and documented as a quarterly check. The hours recorded are listed at 33,978. The second check was dated 05/29 (no year recorded) it was documented as being a quarterly check and the hours were recorded at 32,277. The hours reported from 05/27 to 05/29 indicated the machine hours had gone backwards. There was no evidence the quarterly check and annual checks on this machine had been done as required.

Review of dialysis machine 5K0SB395 maintenance records for this dialysis machine revealed the quarterly check was conducted on 07/02 (no year recorded) the hours were 14, 054. The next check documented as a 6 month check on 01/16 the hours on the maintenance record had was listed as 14,554. There was no documented way to know which year the checks on the machines were actually done. There was no evidence the annual check had been done as required.

Review of dialysis machine 2K0SB572 maintenance records for this dialysis machine revealed the Quarterly check was performed on 07/10 (no date recorded) the hours was listed as 29,711. The next maintenance record revealed it was done on 10/30 (no year recorded) the hours was listed as 30202. The Next record was a quarterly check don on 0//16 (no year recorded. The hours were listed as 31402. The next maintenance record indicted it was an annual and it was recorded on 04/27 (no year recorded). The hours listed indicated the machine hours had rolled backward to 28,697, there was no documented way to know when the checks on the machines was actually done. There was no evidence the Annual check was done other on a record indicating the hours had rolled back.

Review of dialysis machine 2K0SB559 maintenance records for this dialysis machine revealed the quarterly check was conducted on 08/01 (no year recorded) the hours were recorded at 32,616. The next record indicated it was an annual check done on 11/18 (no year recorded). The hours are listed as 33,074. The next record indicated it was a quarterly check done on 02/23 (no year recorded) the hours are listed at 33,410. There was no documented way to know when the checks on the machines was actually done as required or it the required maintenance was done in the month of May 2015.

Review of the 2008 Fresenius dialysis machine manufactures instructions revealed the machine maintenance schedule should include a quarterly preventative maintenance schedule and a more comprehensive annual preventative maintenance check.

In an interview with staff # 9 on 06/17/2015 at 1030 a.m. he confirmed the above findings. He stated he did not know the complete dates of maintenance records provided for the dialysis machines. He could not explain the appearance of the hours of the machines rolling backwards and the lack of required maintenance. He stated he would look for additional records. No additional records were provided. He also confirmed the RO were not disinfected as required and there were no policies regarding the water system. Review of the table of content for the dialysis unit revealed there was no policy to direct the staff for proper maintenance of the dialysis machines. In an interview with staff # 7 and 9 on 06/17/2015 at 10:30 a.m. they also confirmed there was no policy for the preventative maintenance schedule for the dialysis machines.

N. Observation in the water room on 06/16/2015 revealed the gauges and major operating parameters were not labeled to indicate how the performance is verified and actions to take in the event performance is not within an acceptable range.

In an interview with staff # 7 and 8 they confirmed the parts were not labeled to indicate how performance is verified and actions to take in the event performance is not within an acceptable range.

O. Review of the Quality Improvement Committee minutes for the months of January 1, -May 31, 2015 revealed that there was no evidence the machine cultures and endotoxin's tests were reviewed over time and analyzed by the committee for the dialysis machines, 6 portable RO's and Bicarbonate mixing machine. In addition, there was no evidence that the dialysis unit conducted monthly Quality Improvement meetings to review the operation of the unit.

An interview with Staff 1, 5 and # 6 on 10/27/2017 at 2:30 p.m. confirmed there was no evidence of the review by the Medical Director. In addition, staff #1, # 5 and # 6 confirmed there was no evidence this information was presented to the Quality Improvement Committee. In addition, staff # 1 confirmed the Medical Director was not a member of the Quality Improvement Committee and there was not a Quality Improvement committee for the dialysis unit that included at least the Medical Director, Dialysis biomedical staff, and Dialysis Nurse Manager. In an interview with staff # 1 she also confirmed the lack of infection control reports to the Infection control committee concerning the dialysis unit.



29762

P. A tour of the facility was conducted on 6/16/2015 with staff #87 and staff #112. The tour was started on the 6th floor of the West tower. A request was made of the staff to only tour rooms that were clean and ready to receive patients. During the tour of this patient care unit the following observations were made:
The tour of room 1618 revealed the drawer pulls were made of a plastic/resin material. Several of the drawer pulls were broken and had sharp jagged edges. The pulls were broken into two pieces and dangling loosely. One would have to hold onto one of these broken pieces with sharp jagged edges and risk injuring themselves in order to open these drawers.
The bathroom floors and shower had the appearance of being dirty and un-kept. A handful of white toilet paper was taken and whipped on the bathroom floor and the paper revealed hair and a gray fibrous material with the appearance of built up dust. The procedure with the toilet paper was repeated in the shower with the same results, hair and a gray fibrous material with the appearance of built up dust. At the point where the walls and the bathroom floors and the shower floors meet, the floors had a darker coloration that becomes brighter/ cleaner towards the center of the room. This darker color protrudes out about 8 inches from the wall and has the appearance of being dirty/ un-kept.
The tour of room 1612 revealed the drawer pulls were made of a plastic/resin material. Several of the drawer pulls were broken and had sharp jagged edges. The pulls were broken into two pieces and dangling loosely. One of the pulls had been taped together with a white silk tape. The tape was stained and discolored. The tape was porous and could not be disinfected. One would have to hold onto one of these broken pieces with sharp jagged edges and risk injuring themselves to open these drawers.
The bathroom floors and shower had the appearance of being dirty and un-kept. A handful of white toilet paper was taken and whipped on the bathroom floor and revealed hair and a gray fibrous material with the appearance of built up dust. The procedure with the toilet paper was repeated in the shower with the same results, hair and a gray fibrous material with the appearance of built up dust. At the point where the walls and the bathroom floors and the shower floors meet the floors had a darker coloration that becomes brighter/ cleaner towards the center of the room. This darker color protrudes out from the wall about 8 inches and had the appearance of being dirty/ un-kept. The base boards were cracked with pieces missing leaving voids/holes that could not be cleaned and disinfected.
The clean equipment/supply room in this patient care area was toured. The room was filled and cluttered with equipment and carts. The floors had the appearance of being dirty/ un-kept. Visible clumps of dust had gathered in to corners and along the edges of the floor where it met the walls. Upon wiping the hand on the cabinet tops, once the clutter was removed, a visible amount of dust was collected. The clumping of the dust was so great it fell from the hand and could be seen floating in the air. The track of the hand was seen on the cabinet top. A look inside the cabinet revealed sterile supplies with a coating of dust. Reaching to the back of the cabinet and wiping the hand along the shelf revealed a collection of dust that could be rolled between three fingers and made into a fibrous ball. A cart that was said to be a procedure cart and would be taken to the bedside for procedures was observed. The open

Based on record reviews and interviews, the facility failed to provide ongoing assessment, document a patient neurological assessments following multiple psychotropic medications and following a fall, offer alternative interventions, or justification before the administration of a chemical restraint for agitation and anxiety in 1 (#39) of 3 patients reviewed.
Review of patient chart #39 revealed he was received in the main campus emergency room (ER) on 6/16/2015 at 6:00 AM via ambulance. Review of the ER nurse documentation on 6/15/15 at 6:01 AM stated, "patient seeing eagles in the front yard. EMS (Emergency Medical Services) stated pt grabbed a 380 caliber pistol and shot randomly throughout the house. LPD (local police department) states when they arrived on scene the patient was loading the pistol with 38 caliber shells and trying to fire them. LPD talked the patient into lower the gun and coming into the hospital for mental evaluation. LPD and EMS deny any aggressive behavior. 6:02 AM patient is shaking erratically, pt is very respectful to staff. Pt states he is at GSMC in Longview. Pt states he is seeing eagles as we talk and they are telling him to be careful."

A review of patient #39's chart for physician orders showed an order for Geodon was entered on 6/15/15 at 7:33 AM (before the patient was seen by the physician). Review of the physician notes revealed the patient was not examined by a physician until 6/15/15 at 7:57 AM.

Review of the nurses notes revealed the patient was administered the Geodon 20 mg IM in the right deltoid on 6/5/15 at 7:57 AM.

Review of the ER physician documentation on 6/15/15 at 10:36 AM revealed the patient was resting comfortably. There was no further physician documentation until 12:45 PM. Physician documented 6/15/15 at 12:45 PM, "I have reviewed the scribe documentation and agree. ED course Ativan given for anxiety/agitation." There was no scribe documentation found. There was no documentation found of anxiety or agitation that would require Ativan order in physician or nursing notes.

Review of the nurses notes dated 6/16/15 stated, "06/15 08:00 Nurse Notes: PT OBSERVED RESTING ON STRETCHER WITH NO SIGNS OF DISTRESS, RESP
EVEN AND UNLABORED AT 20, PT REQUESTING "A BAG OF FLUIDS BECAUSE HE FEELS LIKE HE IS DEHYDRATED DUE TO HIS URINE "LOOKING DARK ", Staff #115 (MD) NOTIFIED AND GIVEN ORDER FOR A NS 1000 ML BOLUS, PT'S FAMILY AT BEDSIDE AND SITTER OUTSIDE PT'S DOOR".

10:20 Nurse Notes: PT REQUESTING TO SPEAK TO HIS NURSE, PT INFORMED NURSING STAFF THAT THE NOISE IN THE HALLWAY WAS "MESSING WITH HIS HEAD", INSTRUCTED SITTERS TO MINIMIZE NOISE IN HALLWAY AREA AROUND ROOM, PT ALSO "REQUESTING A BACKGROUND CHECK ON EVERYONE WHOM HAS ENTERED HIS ROOM " ,WHEN STAFF ASKED PT WHAT HE MEANT BY THAT, PT STATES HE CAN'T TALK RIGHT NOW AND REQUESTED TO HAVE THE DOOR CLOSED, PT INFORMED THAT THE DOOR WOULD NOT BE ABLE TO BE CLOSED AT THIS TIME DUE TO PROTOCOLS AND SAFETY REASONS, PT THEN AGREED TO SPEAK TO STAFF WITH ANOTHER STAFF MEMBER PRESENT AND UPON ARRIVAL TO PT'S ROOM PT REFUSED TO TALK TO NURSING STAFF AND STATED , 'HE WOULD TALK TO ME LATER".

11:10 AM Nurse Notes: PT AMBULATED TO BATHROOM WITH SITTER ESCORT.

12:15 PM Nurse Notes: CHC (local mental health authority) IN ED TO EVALUATE PT.

13:11 (1:11 PM) Drug Ativan 1 mg Route IVP; Infused over two minutes.

16:03 (4:03 PM) Patient is resting quietly, eyes closed, respirations even and unlabored.
visited by significant other.

18:52 (5:52 PM) Nurse Notes: PATIENT IS ASKING FOR SOMETHING FOR HIS HEADACHE. DOCTOR NOTIFIED.

21:23 ( 9:23 PM) Patient is resting quietly.

21:56 (9:56 PM) Patient is resting quietly.

21:56 (9:56 PM) Nurse Notes: PATIENT PACING AROUND THE ROOM. TALKING WITHOUT VERBAL UNDERSTANDING AND ASKING TO GO SMOKE.

23:10 ( 11:10 PM) Patient appears restless.

Nurse documented on 6/15/15 at 21:56 (9:56 PM) patient #39 was resting quietly and in another entry at the same time that the patient was pacing the room. There was no clarification in the nursing documentation on what or how the patient was acting to justify the statement "appears restless."

The following psychotropic medication orders given and administered to patient #39 on 6/15/15:

1. 06/15 20:42 (8:42 PM) Order name: Ativan (anti-anxiety) 1 mg lM once.

2.) 06/15 22:29 (10:29 PM) Order name: Geodon (anti-psychotic) 20 mg IM once.

3.) 06/15 22:29 (10:29 PM) Order name: Ativan (anti-anxiety) 1 mg IM once.

Review of patient #39's physician and nurses notes revealed no information or justification of why the above psychotropic meds were ordered or administered. There was no documentation found of patient receiving any nutrition or oral fluids. There was no documentation found of a neurological exam after the patient had been given multiple psychotropic medications.

There was no physician documentation found of patient assessment or observation from 6/15/15 at 2:59 PM until 6/15/15 at 11:22 PM, a total of 8 hours. At 23:22 (11:22 PM) the physician documented, " ED COURSE PT PSYCHOTIC. WAS SHOOTING PISTOL. WAS ACCEPTED BY MENTAL HEALTH FACILITY AFTER DISCUSSION WITH STAFF #115 (MD) HOWEVER MENTAL HEALTH FACILITY IS UNABLE TO ACCOMODATE DUE TO STAFFING ISSUES."

Review of the physician notes revealed staff #116 (MD) took over patient #39's care. Staff #116 (MD) documented, "06/16 01:15 ED course PT BECOMING MORE AGITATED AND EXPRESSING MORE PSYCHOTIC BEHAVIOR. PT GIVEN IM MEDS AND MORE CALM AND RELAXED.

03:12 ED course PT PACING IN ROOM. CONTINUES TO HAVE CONVERSATIONS WITH PEOPLE NOT IN ROOM. HAVE TRIED TO REDIRECT PT TO REMAIN IN BED BUT PT NOT LYING IN BED.

WHILE PACING IN ROOM WITH BED REMOVED AND MATTRESS ONLY IN ROOM - HE TRIPPED AND HIT HEAD ON WALL. PT ASSISTED TO BED AND RESTRAINED. AFTER MULTIPLE MEDS PT STILL AGITATED AND TALKING WITH PEOPLE WHO ARE NOT IN ROOM.

WHILE IN BED RESTRAINED PT FIGHTING AGAINST RESTRAINTS, SITTING UP IN BED AND ATTEMPTING TO THROW HIMSELF OUT OF BED AS WELL AS BITE STAFF. LOW DOSE KETAMINE ORDERED. "

The following psychotropic medications were ordered;

1.) 6/16/15 at 1:10 AM Haldol (Anti-psychotic)10mg IM once.

2.) 6/16/15 at 1:55 AM Ativan (Anti-anxiety) 2 mg IM once.

3.) 6/16/15 at 2:34 AM Benadryl (antihistamine) 50 mg IM once.

4.) 6/16/15 at 3:12 AM Haldol (anti-anxiety) 10mg IM once.

5.) 6/16/15 at 3:21 AM Ketamine (anesthetic) 50mg IM once.

Review of the nursing notes dated 6/16/15 stated, "00:04 Patient appears restless.

00:38 Patient appears restless. Nurse Notes: PATIENT IS PULLING AT THE BLANKET CONTINUOUSLY, PUTTING HIS HAND IN THE SHARPS CONTAINER AND TRYING TO PULL OFF THE SOAP DISPENSER.

01:04 Patient is resting quietly. Nurse Notes: PATIENT IS THREATENING TO THROW THE CHAIR AT THE SITTER. CHAIR AND STOOL REMOVED FROM ROOM. PHYSICIAN NOTIFIED. NEW ORDERS RECEIVED AND INITIATED. TRYING TO LAY ON THE FLOOR. PATIENT IS TALKING TO HIMSELF, BUT HE ISN T MAKING ANY VERBAL SENSE.

01:30 Patient appears restless. Nurse Notes: PATIENT IS TRYING TO WALK OUT OF ROOM STATING HE DOESN'T HAVE TO STAY HERE. PATIENT IS LOOKING UNDER THE BED AND REMOVING THE GREEN SHIRT. PATIENT STATES WE ARE NOT GIVING HIM ANY OF HIS MEDICATIONS. THE POLICE OFFICER IS BY PATIENTS ROOM.

01:36 Patient appears restless. Nurse Notes: PATIENT IS PACING AROUND THE ROOM SAYING HE DIDN'T GET ANY FOOD AND THAT HE WANTED TO SMOKE.

02:01 Patient is resting quietly.

02:09 Patient appears restless. Nurse Notes: PATIENT STATES HE IS LOOKING FOR HIS CIGARETTES. PATIENT IS LOOKING UNDER THE BED AND PUTTING HIS HAND IN THE SHARPS CONTAINER. THE POLICE OFFICER IS OUTSIDE THE ROOM.

02:14 Nurse Notes: PATIENT IS LAYING ON THE BED, CALMLY, HAVING A CONVERSATION WITH HIMSELF.

02:31 Patient appears restless. Nurse Notes: PATIENT STANDING UP ASKING TO GO SMOKE AND SOMETHING TO EAT. PATIENT STATES HE NEEDS SOMETHING TO EAT BECAUSE WE HAVEN'T GIVEN HIM ANY LUNCH OR DINNER. I TRIED TO EXPLAIN THAT HE WAS GIVEN DINNER AND HE SAYS
"WHY ARE YA'LL LYING TO ME".

There was no earlier documentation that the patient was offered any food. There was no documentation that the patient was offered anything to eat when he requested.

02:51 Patient appears restless. Nurse Notes: PATIENT STANDING UP TRYING TO PULL THE SHARPS CONTAINER OFF THE WALL. PATIENT CONTINUES TO TRY TO LEAVE THE ROOM AND THEN PULL THE SOAP DISPENSER OFF THE WALL. SITTER, 2 NURSE AND POLICE OFFICER ARE AT BEDSIDE TRYING TO TALK TO PATIENT AND HAVE HIM LAY BACK IN BED PATIENT CONTINUOUSLY TRYING TO GET UP.

03:16 Nurse Notes: PATIENT TRIPPING OVER THE BED AND HIT HIS HEAD ON THE CABINET DOOR. 2 NURSES AND POLICE OFFICER WAS TRYING TO PUT PATIENT BACK IN THE BED AND THE PATIENT BEGAN TO FIGHT, HIT AND BITE. BACK UP WAS CALLED AND 2 MORE OFFICERS AND 2 MORE NURSES WAS HAVING TO HOLD PATIENT DOWN WHILE ANOTHER NURSE ADMINISTERED MEDICATION. PATIENT CONTINUED TO YELL, TRY TO BITE,SCRATCH AND HIT THE NURSES AND OFFICERS.

Physician documented at 3:12 AM that patient #39 tripped over mattress in floor and fell hitting his head against the wall.) There was no documentation of a neurological check after patient injured his head in the nursing or physician notes.

On 6/16/15 at 3:12 AM a physician order for restraints was found that stated, " Order name: Restrain - up to 4 hours (Adult> 17 years of age) Violent and Self Destructive; Complete Time: 03:25." There was no further order to address what type of restraint, how to restrain, or length of time or release criteria found.

There was no documentation that a physician face to face was performed within 1 hour of the restraint application.

A review of the nurses notes on 6/16/15 at 3:15 PM revealed the nurse applied leather wrist and ankle restraints. The nurse continued to document the patient was kicking, hitting, biting at staff. Patient was agitated and "continuing to come out of bed" while in four point restraints.

Review of the physician orders revealed patient #39 was ordered Ativan 4mg IVP once. There was no physician documentation that the patient had been observed by the physician from 3:12 AM to 7:25 AM a total of 4 hours.

Review of the physician notes on 6/16/15 stated, "07:25 ED course PT STILL AGITATED AND NON COOPERATIVE. PT TACHYCARDIC TO THE 130's AND OCCASIONALLY 150's. PT THRASHING IN BED AND WILL NOT CALM DOWN WHEN TALKED TO. WILL CONTINUE RESTRAINT ORDER. CONTINUE FLUIDS AND ADMIT PATIENT.
PT IN RHABDO AND I AM CONCERNED THAT THIS WILL WORSEN IF PATIENT DOES NOT CALM DOWN. ALL MEDS GIVEN HAVE NOT CONTROLLED HIS EXCITED DELIRIUM. POTENTIALLY INTUBATE PATIENT TO CONTROL HIS DELIRIUM.

08:16 ED course PT STILL PSYCHOTIC AND COMBATIVE. DECISION MADE TO INTUBATE PATIENT SO HE CAN BE KEPT CALM AND RHABDO TREATED. PT ADMITTED TO THE ICU."

Patient #39 was intubated on 6/16/15 at 8:33 AM. Patient was admitted to ICU.

Review of the policy and procedure Restraint and Seclusion: Least Restrictive Devices effective date 5/26/2015 stated, "Chemical Restraint: A drug or medication when used as a restriction to manage patient behavior or restrict patient freedom of movement and is not a standard treatment or dosage for patient's condition. Medications that comprise a patient's medical regimen including PRN medications are not considered chemical restraints if:

a. Approved by United States Food and Drug Administration (USFDA) and used
in accordance with approved indications and label instructions, including listed
dosage parameters

b. Use follows national practice standards established or recognized by medical
community and/or professional medical association or organization; and

c. Used to treat specific patient's clinical condition and is based on that patient's
symptoms, overall clinical situation, and on Physician/Licensed Independent
Practitioners (LIP's) knowledge of that patient's expected and actual response.

Note: The standard use of a psychoactive medication to treat a patient's condition
enables the patient to more effectively or appropriately function in the world than would
be possible without the use of the medication, is not considered a chemical restraint.

Chemical restraint is not a recognized form of patient management in the state of
Texas."

Review of patient #39's chart revealed a history and physical dated 6/16/2015. The physician documented, "Home medications: Klonopin (Benzodiazepine) 1 mg p.o. twice a day, BuSpar 15 mg p.o. twice daily (Spiro compound to treat anxiety), Hydroxyzine (H1 antagonist, Analgesic for anxiety) 50 mg p.o. every six hours, and Citalopram (selective serotonin reuptake inhibitor, Serotonin reuptake inhibitor for anxiety) 20 mg p.o. daily."

There was no documentation found of home medications offered to patient #39 during the emergency room stay. Patient #39 does not take Geodon, Ativan, Ketamine or Haldol as a standard treatment for a medical or psychiatric condition, and that resulted in restricting the patient's freedom of movement causing the psycotropic drugs ordered to be used as a restraint.

An interview was conducted on 6/19/2015 at 1:55 PM with staff # 61 (RN House Supervisor). Staff #61 reported if a nurse needed to restrain a patient they were to call the House Supervisor for the restraints (restraints were kept with the house Supervisor). Staff #61 reported the physician was to do the 1 hour face to face. When questioned about the chemical restraints and how they are reported staff # 61 stated, "We don't do chemical restraints here." Staff #61 was shown an order on patient #39 for chemical restraints. Staff #61 stated, "its against the law to do chemical restraints. We do not do those here."

An interview was conducted with staff #38 (RN) on 6/19/15 at 3:00PM. Staff #38 was asked how you would report chemical restraints and how you would document. Staff #38 hesitated and stated, "it depends on how the order is written but we don't do chemical restraints." Staff #38 was shown an order from patient #39 for chamical restraints. Staff #38 stated, "I guess I really don't understand it."

Based upon record review and interview, the facility failed to ensure the physician conducted the 1 hour face-to-face medical and behavioral evaluation after ordering physical restraints for violent behavior for 1 (#39) of 3 patients reviewed.
Review of patient chart #39 revealed he was received in the main campus emergency room (ER) on 6/16/2015 at 6:00 AM via ambulance. Review of the ER nurse documentation on 6/15/15 at 6:01 AM stated, "patient seeing eagles in the front yard. EMS (Emergency Medical Services) stated pt grabbed a 380 caliber pistol and shot randomly throughout the house. LPD (local police department) states when they arrived on scene the patient was loading the pistol with 38 caliber shells and trying to fire them. LPD talked the patient into lower the gun and coming into the hospital for mental evaluation. LPD and EMS deny any aggressive behavior. 6:02 AM patient is shaking erratically, pt is very respectful to staff. Pt states he is at GSMC in Longview. Pt states he is seeing eagles as we talk and they are telling him to be careful."

Review of the physician notes revealed staff #116 (MD) took over patient #39's care. Staff #116 (MD) documented, "06/16 01:15 ED course PT BECOMING MORE AGITATED AND EXPRESSING MORE PSYCHOTIC BEHAVIOR. PT GIVEN IM MEDS AND MORE CALM AND RELAXED.

03:12 ED course PT PACING IN ROOM. CONTINUES TO HAVE CONVERSATIONS WITH PEOPLE NOT IN ROOM. HAVE TRIED TO REDIRECT PT TO REMAIN IN BED BUT PT NOT LYING IN BED.

WHILE PACING IN ROOM WITH BED REMOVED AND MATTRESS ONLY IN ROOM - HE TRIPPED AND HIT HEAD ON WALL. PT ASSISTED TO BED AND RESTRAINED. AFTER MULTIPLE MEDS PT STILL AGITATED AND TALKING WITH PEOPLE WHO ARE NOT IN ROOM.

WHILE IN BED RESTRAINED PT FIGHTING AGAINST RESTRAINTS, SITTING UP IN BED AND ATTEMPTING TO THROW HIMSELF OUT OF BED AS WELL AS BITE STAFF. LOW DOSE KETAMINE ORDERED. "

The following psychotropic medications were ordered;

1.) 6/16/15 at 1:10 AM Haldol (Anti-psychotic)10mg IM once.

2.) 6/16/15 at 1:55 AM Ativan (Anti-anxiety) 2 mg IM once.

3.) 6/16/15 at 2:34 AM Benadryl (antihistamine) 50 mg IM once.

4.) 6/16/15 at 3:12 AM Haldol (anti-anxiety) 10mg IM once.

5.) 6/16/15 at 3:21 AM Ketamine (anesthetic) 50mg IM once.


On 6/16/15 at 3:12 AM a physician order for restraints was found that stated, "Order name: Restrain - up to 4 hours (Adult> 17 years of age) Violent and Self Destructive; Complete Time: 03:25." There was no further order to address what type of restraint, how to restrain, or length of time or release criteria found.

There was no documentation that a physician face to face was performed within 1 hour of the restraint application.

Review of the nurses notes on 6/16/15 at 3:15 PM revealed the nurse applied leather wrist and ankle restraints. The nurse continued to document the patient was kicking, hitting, biting at staff. Patient was agitated and "continuing to come out of bed" while in four point restraints.

Review of the policy and procedure "Restraint and Seclusion: Least Restrictive Devices" effective date 5/26/2015 revealed a section titled "Special Assessment Requirement Specific to Violent/Self-Destructive Behavior Patients (Face to Face Evaluation)":

A. When restraint/seclusion is used to manage violent or self-destructive behavior, physician/LIP (Licensed Independent Practitioner) must conduct a face to face patient evaluation in person within one hour after restraint/seclusion initiated. A telephone call or telemedicine method is not permitted. If patient's violent or self-destructive behavior resolves and restraint/seclusion is discontinued before practitioner arrives to perform face to face evaluation, practitioner is still required to see patient face to face and conduct evaluation within one hour after restraint/seclusion initiated.
B. The patient must be seen face to face within one hour after the initiation of the intervention to evaluate:
1) The patient's immediate siutuation;
2) The patient's reaction to the intervention;
3) The patient's medical and behavioral condition;
a. Review of the systems
b. Patient's history, drugs, and medications, and most recent lab tests
c. Review for other causes such as drug interactions, electrolyte imbalance, hypoxia, sepsis, etc.
4) The need to continue or terminate the restraint or seclusion.

Review of the physician orders revealed patient #39 was ordered Ativan 4mg IVP once at 7:35 AM on 6/16/15. There was no physician documentation the patient had been observed by the physician from 3:12 AM to 7:25 AM, a total of 4 hours.

Review of the physician notes on 6/16/15 stated, "07:25 ED course PT STILL AGITATED AND NON COOPERATIVE. PT TACHYCARDIC TO THE 130's AND OCCASIONALLY 150's. PT THRASHING IN BED AND WILL NOT CALM DOWN WHEN TALKED TO. WILL CONTINUE RESTRAINT ORDER. CONTINUE FLUIDS AND ADMIT PATIENT.
PT IN RHABDO AND I AM CONCERNED THAT THIS WILL WORSEN IF PATIENT DOES NOT CALM DOWN. ALL MEDS GIVEN HAVE NOT CONTROLLED HIS EXCITED DELIRIUM. POTENTIALLY INTUBATE PATIENT TO CONTROL HIS DELIRIUM.

08:16 ED course PT STILL PSYCHOTIC AND COMBATIVE. DECISION MADE TO INTUBATE PATIENT SO HE CAN BE KEPT CALM AND RHABDO TREATED. PT ADMITTED TO THE ICU."

Patient #39 was intubated on 6/16/15 at 8:33 AM. Patient was admitted to ICU.

An interview was conducted on 6/19/2015 at 1:55 PM with staff # 61 (RN House Supervisor). Staff #61 reported if a nurse needed to restrain a patient they were to call the House Supervisor for the restraints (restraints are kept with the house Supervisor). Staff #61 reported the physician was to do the 1 hour face to face.

Based upon record review and interview, the physician failed to document the 1 hour face-to-face medical and behavioral evaluation after ordering physical restraints for violent behavior for 1 (#39) of 3 patients reviewed.
Review of patient #39s chart revealed he was received in the main campus emergency room (ER) on 6/16/2015 at 6:00 AM via ambulance. Review of the ER nurse documentation on 6/15/15 at 6:01 AM stated, "patient seeing eagles in the front yard. EMS (Emergency Medical Services) stated pt grabbed a 380 caliber pistol and shot randomly throughout the house. LPD (local police department) states when they arrived on scene the patient was loading the pistol with 38 caliber shells and trying to fire them. LPD talked the patient into lower the gun and coming into the hospital for mental evaluation. LPD and EMS deny any aggressive behavior. 6:02 AM patient is shaking erratically, pt is very respectful to staff. Pt states he is at GSMC in Longview. Pt states he is seeing eagles as we talk and they are telling him to be careful."

Review of the physician notes revealed staff #116 (MD) took over patient #39's care. Staff #116 (MD) documented, "06/16 01:15 ED course PT BECOMING MORE AGITATED AND EXPRESSING MORE PSYCHOTIC BEHAVIOR. PT GIVEN IM MEDS AND MORE CALM AND RELAXED.

03:12 ED course PT PACING IN ROOM. CONTINUES TO HAVE CONVERSATIONS WITH PEOPLE NOT IN ROOM. HAVE TRIED TO REDIRECT PT TO REMAIN IN BED BUT PT NOT LYING IN BED.

WHILE PACING IN ROOM WITH BED REMOVED AND MATTRESS ONLY IN ROOM - HE TRIPPED AND HIT HEAD ON WALL. PT ASSISTED TO BED AND RESTRAINED. AFTER MULTIPLE MEDS PT STILL AGITATED AND TALKING WITH PEOPLE WHO ARE NOT IN ROOM.

WHILE IN BED RESTRAINED PT FIGHTING AGAINST RESTRAINTS, SITTING UP IN BED AND ATTEMPTING TO THROW HIMSELF OUT OF BED AS WELL AS BITE STAFF. LOW DOSE KETAMINE ORDERED. "

The following psychotropic medications were ordered;

1.) 6/16/15 at 1:10 AM Haldol (Anti-psychotic)10mg IM once.

2.) 6/16/15 at 1:55 AM Ativan (Anti-anxiety) 2 mg IM once.

3.) 6/16/15 at 2:34 AM Benadryl (antihistamine) 50 mg IM once.

4.) 6/16/15 at 3:12 AM Haldol (anti-anxiety) 10mg IM once.

5.) 6/16/15 at 3:21 AM Ketamine (anesthetic) 50mg IM once.


On 6/16/15 at 3:12 AM a physician order for restraints was found that stated, "Order name: Restrain - up to 4 hours (Adult> 17 years of age) Violent and Self Destructive; Complete Time: 03:25." There was no further order to address what type of restraint, how to restrain, or length of time or release criteria found.

There was no documentation that a physician face to face was performed within 1 hour of the restraint application.

Review of the nurses notes on 6/16/15 at 3:15 PM revealed the nurse applied leather wrist and ankle restraints. The nurse continued to document the patient was kicking, hitting, biting at staff. Patient was agitated and "continuing to come out of bed" while in four point restraints.

Review of the policy and procedure "Restraint and Seclusion: Least Restrictive Devices" effective date 5/26/2015 revealed a section titled "Special Assessment Requirement Specific to Violent/Self-Destructive Behavior Patients (Face to Face Evaluation)":

A. When restraint/seclusion is used to manage violent or self-destructive behavior, physician/LIP (Licensed Independent Practitioner) must conduct a face to face patient evaluation in person within one hour after restraint/seclusion initiated. A telephone call or telemedicine method is not permitted. If patient's violent or self-destructive behavior resolves and restraint/seclusion is discontinued before practitioner arrives to perform face to face evaluation, practitioner is still required to see patient face to face and conduct evaluation within one hour after restraint/seclusion initiated.
B. The patient must be seen face to face within one hour after the initiation of the intervention to evaluate:
1) The patient's immediate siutuation;
2) The patient's reaction to the intervention;
3) The patient's medical and behavioral condition;
a. Review of the systems
b. Patient's history, drugs, and medications, and most recent lab tests
c. Review for other causes such as drug interactions, electrolyte imbalance, hypoxia, sepsis, etc.
4) The need to continue or terminate the restraint or seclusion.


Review of the physician orders revealed patient #39 was ordered Ativan 4mg IVP once at 7:35 AM on 6/16/15. There was no physician documentation the patient had been observed by the physician from 3:12 AM to 7:25 AM, a total of 4 hours.

Review of the physician notes on 6/16/15 stated, "07:25 ED course PT STILL AGITATED AND NON COOPERATIVE. PT TACHYCARDIC TO THE 130's AND OCCASIONALLY 150's. PT THRASHING IN BED AND WILL NOT CALM DOWN WHEN TALKED TO. WILL CONTINUE RESTRAINT ORDER. CONTINUE FLUIDS AND ADMIT PATIENT.
PT IN RHABDO AND I AM CONCERNED THAT THIS WILL WORSEN IF PATIENT DOES NOT CALM DOWN. ALL MEDS GIVEN HAVE NOT CONTROLLED HIS EXCITED DELIRIUM. POTENTIALLY INTUBATE PATIENT TO CONTROL HIS DELIRIUM.

08:16 ED course PT STILL PSYCHOTIC AND COMBATIVE. DECISION MADE TO INTUBATE PATIENT SO HE CAN BE KEPT CALM AND RHABDO TREATED. PT ADMITTED TO THE ICU."

Patient #39 was intubated on 6/16/15 at 8:33 AM. Patient was admitted to ICU.

An interview was conducted on 6/19/2015 at 1:55 PM with staff # 61 (RN House Supervisor). Staff #61 reported if a nurse needed to restrain a patient they were to call the House Supervisor for the restraints (restraints are kept with the house Supervisor). Staff #61 reported the physician was to do the 1 hour face to face.

Based on interview and record review the facility failed to ensure there was a sufficient number of nurses and patient care technicians on duty to provide care at all times. They failed to ensure their nurse staffing numbers set by their staffing matrix included licensed vocational nurses which were being used. This deficient practice was found in 3 of 3 units (Oncology, Ortho-Neuro, and Medical-Surgical unit).
This deficient practice had the likelihood to cause harm to all presenting and in-patients in the hospital.
Findings include:
Review of the facility "Care ware" staffing system and staffing grids revealed the following:
Oncology unit
Review of the staffing grid revealed for a patient census of 17 there was an allowance for 5 licensed nurses.
From the time frames of 06/10-17/2015 there was an average patient census of 14-17 on both shifts. Every day except for 06/11/2015 the census increased up to 17 patients.
Review of "Care ware" revealed there were four licensed nurses working on both shifts during this entire timeframe.
The facility was short one nurse during this timeframe.
Review of the staffing grid revealed for a patient census of 16-17 there was an allowance for 1.5 -2.0 patient care technicians.
Review of "Care ware" revealed there was one patient care tech working on one or both shifts during this entire timeframe of June 11th, 12th, 13th, and the14th.
The facility was short 0.5-1.0 patient care technicians during this timeframe.
During an interview on 06/18/2015 after 3:40 p.m., Staff #63 confirmed the staff shortages.
Ortho-Neuro unit
Review of the facility staffing grid called for 2-3 patient care technicians.
From the time frames of 06/09-18/2015 revealed
On 06/16/2015 the average patient census was 19-21 and "Care ware" revealed there were 1-2 patient care technicians working.
The facility was short one patient care technician.
On 06/09/2015 the average patient census was 22 and "Care ware" revealed there were 2 patient care technicians working both shifts.
Review of the facility staffing grid called for 3 patient care technicians from 7:00 a.m. -11:00 p.m..
The facility was short one patient care technician.
During an interview on 06/19/2015 after 11:00 a.m., Staff #63 confirmed they had a shortage of one patient care technician.

Medical-Surgical unit
From the timeframe of 06/10-18/2015 the average patient census was 22.0-24.38. on the 7:00 a.m.-7:00 p.m. shift.
Review of "Care ware" revealed during this timeframe there were 5-6 licensed nurses working.
Review of facility staffing grid called for 5.5 registered nurses (RN) when there were 5 nurses working and 6.5 registered nurses when there were 6 nurses working. On 7 of 9 of the days there was a licensed vocational nurse included in the number of nurses working. Review of the facility staffing grid did not call for LVNs to be used interchangeably for RNs.
From the timeframe of 06/10-18/2015 the average patient census was 19.0-24.0. on the 7:00 p.m.-7:00 a.m shift.
Review of "Care ware" revealed during this timeframe there were 4-5 licensed nurses working. On 9 of 9 days a LVN was included in this number of licensed staff. Review of the facility staffing grid called for 5 RNs and did not allow for LVNs to be used interchangeably for RNs.
From the timeframe of 06/10-18/2015, the facility staffing grid called for 3 patient care techs on the 7:00 a.m.-7:00 p.m. shift. On 06/16, 06/15, 06/14, 06/13, and 06/11/2015 the unit was short one patient care technician.
From the timeframe of 06/10-18/2015, the facility staffing grid called for 2 patient care techs on the 7:00 p.m.-7:00 a.m. shift. On 06/14 and 06/12 there was one patient care technician working and on 06/13/2015 there was none.
During an interview on 06/19/2015 after 2:00 p.m., Staff #44 confirmed the staffing shortage and the usage of LVNs for staffing. Staff #44 reported the patients were being held a long time in the emergency room because of the staffing struggles on the units due to a lot of nurses leaving recently.
Review of the facility policy named "Hospital Nursing Safe Staffing Plan" dated April 2014 revealed the following:
PURPOSE:
The Hospital Safe Staffing Law (Senate Bill 47) was passed in Texas in order to assure that the hospital nurse staffing plan protects patients, supports greater retention of registered nurses and promotes adequate nurse staffing....
OBJECTIVES:
3. Develop and recommend a unit - and shift-based staffing plan to guide the hospital-wide assignment of nurses based on patien care needs in order to provide an adequate number and skill mix of nurses to meet varying levels of care.
Review of the policy named "Boarding of Admitted and Observation Patients in the Emergency Department" dated February 2007 revealed the following:
Policy Statement: Optimal utilization of the Emergency Department (ED) include the timely evaluation, management, and Stabilization of all patients. The ED should not be utilized as an extension of inpatient units for admitted patients or patients placed in observation status, because this practice can adversely affect quality of care and access to care.
Staffing patterns applicable to all other specialized areas/ units of the hospital shall apply equaly to the ED to assure that boarding patients receive a consistent standard of care within the organization.
If ED capacity, Inpatient capacity, and ED boarding patients begin to exceed available resources, Diversion may be considered per policy.
Refer to tag A0395 for additional information.

Based on observation, interview and record review the facility failed to ensure registered nurses evaluated patients with head injuires, increased pain levels, and with infections. They failed to ensure nursing staff initiated physician orders timely. This deficient practice was found in 3 of 3 patients (Patient #s' 11, 12 and 15).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:
Review of the clinical record of Patient #11 revealed she was a 91 year old female who presented to the Emergency Department (ED) on 06/14/2015 at 11:03 p.m. Patient #11 was triaged at 11:13 p.m. and was given an Acuity level of 3 (urgent). Nursing staff documented Patient #11 had an elevated temperature of 101.2 degrees Fahrenheit, oxygen saturation on room air of 91 percent and a pain level of 8 out of 10 (0 indicating no pain and 10 indicating severe pain). There was documentation Patient #11 had a positive sepsis screening. There was no documentation of what was done about the elevated pain level.
At 12:09 a.m. Tylenol 650 milligrams and Ibuprofen 600 milligrams was administered. There was no documentation of the rationale or results afterwards for the medication administration.
At 1:07 a.m. there was documentation Patient #11 required admission.
An "Emergency Department Holding Orders" set was found dated 06/15/2015, but there was no time on the orders to indicate when they were written. There was documentation on the orders that they expired in 4 hours after arrival to the inpatient unit.
Review of physician history and physical revealed Patient #11 had diagnoses of Acute Pyelonephritis and Acute Dehydration.
Review of the clinical record revealed Patient #11 was discharged from the ED to the Medical-surgical unit in the hospital at 3:10 a.m. (4 hours later). There was no documentation of staff assessing Patient #11's temperature again during the ED stay.


Review of the clinical record on Patient #12 revealed she was an 88 year old female who presented to the ED on 06/15/2015 at 10:53 a.m. Diagnoses documented were acute intractable pain, acute fall, acute pelvic fracture, acute closed head trauma, acute scalp laceration, acute hand contusion, acute foot contusion, acute hand laceration and acute community acquired pneumonia.
At 10:55 a.m.,nursing documented neuro checks were performed and Patient #12 also had a pain level of 6 out of 10. There was no documentation of what nursing did to address the pain. At this time Patient #12 was given an Acuity level of 3 (urgent). There was documentation of neuro exam by the physician at 11:10 a.m. and by nursing again at 11:17 a.m.
At 12:55 p.m., Emergency Department Holding Orders revealed an order for the intravenous fluids Dextrose 5 percent normal saline with 20 milliequvalent of Potassium chloride at 100 cc per hour.
At 1:07 p.m., admit ordered by the MD (medical doctor).
At 1:36 p.m. (2 hours after complaining of pain) there was documentation of Patient #12 receiving the pain medication Morphine 4 milligrams intravenous push (IVP). There was no documentation of an assessment of where the pain was or level that warranted administering the pain medication nor follow-up pain level.
At 2:52 p.m., and 7:27 p.m. Morphine 4 milligrams IVP was administered again . There was no documentation of an assessment of the pain level that warranted administering the pain medication nor follow-up pain level.
At 9:02 p.m (10 hours after presenting to the ED), Patient #12 was admitted to the Ortho/Neuro floor. This was the next time Patient #12's pain level was mentioned since 10:55 a.m.. There were no other documentation of neuro checks since 11:17 a.m.. There was no documentation that Patient #12 was given the intravenous fluids that were ordered at 12:55 p.m.


Review of the clinical record of Patient #15 revealed she was a 29 year old female who presented at 9:55 p.m. with complaints of lower back pain. A triage assessment was performed at 10:34 p.m. and there was documentation of Patient #15 having lower back pain. There was no assessment of the level of pain. At 10:42 p.m. a non urgent medical screen was performed and it was noted the pain level was 10 out of 10. Patient #15 was discharged from the facility at 11:06 p.m. and there was never any documentation of staff addressing the pain.

During an interview on 06/19/2015 after 2:00 p.m, Staff #44 confirmed the missing pain and neuro assessment, condition of physician orders and medication administration problems. A request was made for a policy addressing nurses assessing neuro signs and Staff #44 reported they did not have one for addressing this type of patient.


Review of a policy named "Pain Management Protocol" dated 02/02/2013 revealed the following:
4. Patients are assessed and reassessed for their level of comfort"
5.Pain medication should not be withheld for fear of addiction or respiratory depression. The patient should be kept as comfortable as possible.
Assessment
a.On admission, assess the patient's pain history to include:
a) Use of a Pain Scale:Number, FLACC, Faces, Other
c)Location
d) Description(acute, chronic, burning, cramping crashing, dull, sharp, generalized, radiating, throbbing or tender)
e)Intensity of pain (0-10)
f) Duration
g) Functional Pain Goal


Review of a policy named "Emergency Triage Protocol" dated 02/28/2011 revealed the following:
"Medication Reconciliation will be the responsibility of the assigned primary nurse."

Based on interview and record review the facility failed to ensure they had physician orders for blood administration and failed to ensure vital signs were checked as required. They failed to ensure staff documented they were checking for reactions during blood administration. The facility failed to ensure blood was administered timely after receiving lab results on high risk patients. This deficient practice was found in 3 of 3 patients (Patient #s' 10, 27 and 40).
This deficient practice had the likelihood to cause harm in all patients who received blood transfusions in the facility.
Findings include:
Review of the clinical record on Patient #10 revealed she was a 67 year old female admitted to the hospital on 06/09/2015 with a diagnosis of problems with her gastric outlet. On 06/10/2015 Patient #10 had an exploratory laporatomy and a complete total gastrectomy.
Review of ICU (Intensive care unit) admit physician orders dated 06/10/2015 (not timed by physician) revealed the following:
H/H (hemoglobin/hematocrit) at 3 p.m.;
If Hgb (hemoglobin) < 7 give 1 unit of PRBC (packed red blood cells);
If INR(international normalized ratio) > 1.5 give 2 units of FFP (fresh frozen plasma)
The only INR that could be found was dated 06/09/2015 at 12:12 p.m. and the result was 1.05. These lab results did not warrant a blood transfusion be administered according to the physician orders.
Review of transfusion records on Patient #10 dated 06/10/2015 revealed 2 units of FFP was administered on 06/10/2015 and both units were started before 12:00 p.m.. On the second unit, nursing failed to document if there was a reaction from the transfusions.
On 06/10/2015 at 12:00 p.m. there was a physician order to give 2 units of FFP. This telephone physician order was written after the blood was administered.
On 06/10/2015 (no time)a physician order was written to get an H/H now. If HGB <7.0 give 1 unit of PRBC.
Review of lab results dated 06/10/2015 revealed the Hgb results ranged from 9.4 and 9.9.
Review of lab results dated 06/11/2015 received at 5:12 a.m. revealed a Hgb decrease of 5.2 with reference ranges being 11.4-14.4. According to documentation on the lab results, notification was made to the nursing unit at 7:50 a.m (over 2 hours later).
On 06/11/2015 (no time written by physician) the following order was written:
"Transfuse 2 units PRBC for Hgb 5.2
H/H at 3p.m. If Hgb < 7 give 1 unit PRBC
AM CBC, Basic
2 units FFP"
Review of the transfusion records dated 06/11/2015 revealed the first unit of red blood cells was started at 8:30 a.m. (over 3 hours after the results were received in the lab). Documentation on the first unit did not show vital signs that were taken prior to the administration. The vitals were taken at the same time the transfusion started.
Nursing failed to document on both units of red blood cells and both units of FFP if there was a reaction during the transfusions.
Review of lab results dated 06/11/2015 at 3:08 p.m., Patient #10's Hgb decreased to 4.6, and lab called the nursing unit with the results at 3:29 p.m.
On 06/11/2015 (no time written) the following physician order was written :
Transfuse 4 units PRBC
H/H afterwards
If Hgb<7 give 1 unit of PRBC
Review of transfusion records revealed 1 unit of RBC was given at 4:48 p.m.. Nursing failed to document if there was a reaction. Review of another transfusion record revealed a transfusion was started at 6:00 p.m. and Patient #10 was transferred to the operating room.
On 06/11/2015 at 6:00p.m, another physician order was written for 2 units FFP to OR (operating room).
Review a transfusion record revealed a unit of FFP was started at 7:40 p.m. on 06/11/2015 and two nurses failed to sign as checking the blood. According to instructions on the transfusion record "Two nurses from patient care must verify patient name, DOB, hospital ID number and blood bank arm band at the patient's bedside."
On 06/11/2015 at 11:06 p.m. a telephone order was written for the following:
"Please give (2 was marked through) 1 unit PRBC x 1 now and 2 units platelets
Give 25 milligrams of Benadryl x 1 now
100 mg hydrocortisone x 1 now"
Review of transfusion records revealed 2 units of RBC were administered. There was no start time or end time documented on the form for the first unit. Documentation on the form showed the vital signs started at 10:15 p.m and stopped at 10:50 p.m.
Another unit of RBC was issued by lab at 11:18 p.m and the lab technician failed to sign the form. According to the transfusion form the blood was started and ended at the same time. There was documentation on the same form showing the vital signs started at 11:30 p.m and ended at 12 45 a.m.
During an interview on 06/18/2015 after 8:40 a.m., Staff #114 confirmed the physician orders and the missing assessments on the blood forms and chart.
Review of the clinical record of Patient #27 revealed she was a 74 year old female who presented to the ED for a chief complaint of low Hbg per md (medical doctor) and blood pressure problems. Patient #27 presented on 06/17/2015 at 1:40 p.m and was given a triage level of 3 (urgent).
Review of a history and physical dated 06/17/2015 at 2:27 p.m. revealed Patient #27 presented with a low Hbg. Patient #27 had her blood drawn and was told her Hgb was 5.1 and she needed to go to the ED. Associated symptoms were generalized weakness and a history of ovarian cancer.
Review of physician orders revealed three different orders for blood administration:
On 06/17/2015 at 2:27 p.m. there was an order to give 4 units of PRBCs.
On 06/17/2015 at 3:40 p.m. Emergency Department Holding orders revealed staff were to Recheck the H/H after 2 unit of PRBC. The order was not complete with instructions on how to proceed.
Review of 23 hour observation orders which were not timed or dated revealed an order to Type and Cross, 3 units PRBC, give 2 units and repeat if hgb is <8.5, give third unit. The 23 hour observation orders were matched up against computer orders and there was documentation the physician wrote them on 06/18/2015. The blood order for 3 units of PRBCs was not on the computer orders for 06/18/2015.
Review of nurse's notes dated 06/17/2015 at 3:02 p.m. revealed a notification value received for a low hgb/hct 5.1 and 17.0. At 3:51 p.m. an admit ordered written by the MD. According to the nurses notes the blood was administered as follows: 1st unit on 06/17/2015 at 5:00 p.m.(3 hours and 20 minutes after presenting to the ED) and 2nd unit at 8:20 p.m.. On 06/18/2015 the 3rd unit was given at 2:35 a.m.
Review of the blood transfusion records revealed 3 units of blood were administered. There was no order discontinuing the 4th unit of blood.
On 06/18/2015 at 1:58 p.m. the inpatient bed had been assigned and at 2:24 p.m. patient #27 departed from the ED (transferred to oncology unit).




32143

Review of #40' s Emergency Room (ER) physician notes revealed he was ordered 2 units of blood on 6/2/15 at 1:54AM in the ER computer system. A written transfuse order sheet was found to transfuse 2 units of "Red Blood Cells." The written order had the ER physician's signature but no date and time. The nurse signature was blank but had a time of 4:19AM on 6/2/15. Blood consent was signed by patient #40's mother on 6/2/2015 at 4:10AM. There was no further documentation of blood administration or an order to discontinue the transfusion found.
Review of an undated facility policy named "Blood Products Administration" revealed the following:
ALERT
The single most important function of the nurse concerning blood product administration is verification of the patient and blood product(s) according to the organization's practice. Most major fatal transfusion reacation result from clerical error, administration of blood to the wrong patient, or incorrect identification of the blood component.
Transfusion reactions can be life threatening and occur with exposure to even a small amount of blood; therefore, transfusion should be started slowly unless the patient's condition requires a rapid, life-sustaining transfusion. Baseline vital signs should be obtained before initiation of the transfusion and should be reassessed at the end of the first 15 minutes and periodically through the transfusion.
Review of an undated policy named "Blood Products: Administering v.14" revealed the following:
5. Prior to initiation of the blood product, two licensed caregivers(one of them must be the transfusionist), at the patient's side, will verify the blood unit to be administered (clerical check) at the bedside by checking patient armband, Unit Crossmatch card on the unit, the blood product label and the Unit Issue/Transfusion for the following ...
Assessment and Preparation
2. Assess and document vital signs, including blood pressure, heart rate, respiratory rate, and temperature on transfusion record.
Preparation
Check physician's order for type of blood component, amount to be infused and when to infuse. Send a copy of the physician's order to the Blood Bank via the tube system.
Procedures
General Principles
Vital Signs:
15 minutes x 2 after each unit of blood has been initiated (Look for signs and symptoms of a transfusion reaction as described in Transfusion Reaction Section including fever, (2 degrees Fahrenheit rise in temperature, chills or nausea)
Then every 30 minutes throughout transfusion.
One addition set of VS (vital signs) 30 minutes following the infusion of each unit of blood. (If multiple units are given this VS can be obtained during the transfusion of the next unit).

Based on observation and interview the facility failed to protect closed patient records stored at the remote location from risk of destruction by fire from January 2015 through June 2015.

On 6/19/2015 at 1:00 p.m., accompanied by the Director of Health Information Management (HIM), the remote site where closed medical records were stored was toured. Documents, too numerous to count, of closed patient records were observed stored in a warehouse with a wooden ceiling and no sprinkler system in place. One fire extinguisher was identified. Records nearing destruction date were observed boxed and stacked. Some boxes were observed on shelves and others were observed stacked on top of each other. Recently discharged patient records were observed in name file order on shelves designed for easy retrieval. Records for all the Hospitals remote locations were observed at the off site warehouse also.

On 6/19/2015 at 11:00 a.m. an interview with the HIM Director in the Medical Records Department confirmed the remote location for storage of closed patient records was not protected from fire with a sprinkler system.

Based on interview and record review the facility failed to ensure physician orders were signed, dated and timed. They failed to ensure physician orders were complete and failed to ensure verbal orders were signed off timely. This was found in 5 of 5 patients reviewed. (Patient #s' 10, 11, 12, 17, 18, 19, 25, and 27). This deficient practice had the likelihood to cause harm in all patients.
Findings include:
Review of the clinical record on Patient #10 revealed she was a 67 year old female admitted to the hospital on 06/09/2015 with a diagnosis of problems with her gastric outlet. On 06/10/2015 Patient #10 had an exploratory laporatomy and a complete total gastrectomy.
Review of ICU (Intensive care unit) admit physician orders dated 06/10/2015 (not timed by physician) revealed the following:
H/H (hemoglobin/hematocrit) at 3 p.m.;
If Hgb (hemoglobin) < 7 give 1 unit of PRBC (packed red blood cells);
If INR(international normalized ratio) > 1.5 give 2 units of FFP(fresh frozen plasma)
The only INR that could be found was dated 06/09/2015 at 12:12 p.m. and the results were 1.05. These lab results did not warrant a blood transfusion be administered according to the physician orders.
Review of transfusion records on Patient #10 dated 06/10/2015 revealed 2 units of FFP was administered on 06/10/2015 and both units were started before 12:00 p.m.. On the second unit nursing failed to document if there was a reaction from the transfusions.

On 06/10/2015 at 12:00 p.m. there was a physician order to give 2 units of FFP. This telephone physician order was written after the blood was administered.

On 06/10/2015 (no time) a physician order was written to get an H/H now. If HGB <7.0 give 1 unit of PRBC.

On 06/11/2015 (no time written by physician) the following order was written:
Transfuse 2 units PRBC for Hgb 5.2
H/H at 3p.m. If Hgb < 7 give 1 unit PRBC
AM CBC, Basic
2 units FFP
On 06/11/2015 (no time written ) the following physician order was written :
Transfuse 4 units PRBC
H/H afterwards
If Hgb<7 give 1 unit of PRBC
During an interview on 06/18/2015 after 8:40 a.m., Staff #114 confirmed the physician orders and the missing assessments on the blood forms and chart.

Review of the clinical record of Patient #27 revealed she was a 74 year old female who presented to the ED for a chief complaint of low Hbg per md (medical doctor) and blood pressure problems. Patient #27 presented on 06/17/2015 at 1:40 p.m and was given a triage level of 3 (urgent).

Review of physician orders revealed a set of 23 hour observation orders which were not timed or dated revealed an order to Type and Cross, 3 units PRBC, give 2 units and repeat if hgb if <8.5 give third unit.

Review of clinical record on Patient #25 revealed he was a 82 year old male who was admitted to the hospital on 06/09/2015 for a wound infection.
Review of physician orders dated 06/18/2015 revealed orders for lab, blood transfusion and intravenous fluids. The physician wrote to "transfuse now." There was no time on the orders.

Review of the clinical record of Patient #11 revealed she was a 91 year old female who presented to the Emergency Department on 06/14/2015 at 11:03 p.m.. Patient #11 was triaged at 11:13 a.m. and was given an Acuity level of 3 (urgent).
Review of physician orders revealed telephone orders for medications and treatments which had not been signed off by the physician on the following days:
06/15 (one);
06/16 (one);

Review of physician orders revealed telephone orders for medications and treament which were signed by the physician, but were not timed.
06/15/2015 (two) and 06/17/2015 (one)

Review of the clinical record on Patient #12 revealed she was an 88 year old female who presented to the ED on 06/15/2015 at 10:53 a.m. Diagnoses documented at the top of the nurses notes were acute intractable pain, acute fall, acute pelvic fracture, acute closed head trauma, acute scalp laceration, acute had contusion, acute foot contusion, acute hand laceration and acute community acquired pneumonia.
Review of the clinical record revealed a telephone order medications dated 06/15/2015 that was not signed off by the physician.
Review of six telephone orders dated 06/16/2015 for medications and treatment revealed the physician signed off on the orders, but failed to date them.



32143

Review of patient# 40's chart revealed the patient was ordered the following drugs per telephone or verbal orders;

1.) Pepcid (histamine-2 blockers) 20 mg intravenously daily. A telephone order was taken on 6/3/15 at 4:53 AM. The physician did not electronically sign order until 11 days later on 6/14/15.

2.) "Continue medications per TMORF" ( patients medication record) a telephone order was taken on 6/4/2015 at 9:40 AM. The medication order was electronically signed by the physician 9 days later on 6/13/15.

3.) "Propofol (anesthetic) gtt now per protocol titrate for sedation" telephone order taken on 6/2/15 at 10:45 AM. The physician signed electronically 13 days later on 6/14/15.

4.) A Hemodialysis order was taken by telephone on 6/3/15 at 10:00 AM. The patient was to receive Epogen injections and Normal Saline intravenously. The physician signed the order electronically, fifteen days later, on 6/18/2015 at 1:13 PM.

Review of patient #19's "Discharge Order Medication Profile" revealed the Order was signed by the physician but has no date or time. Review of ER holding order revealed physician signed the order with a date but no time.

Review of patient #17's chart revealed he was admitted on 6/14/2015. Review of a telephone medication order "Warfarin Dosing Orders for Adults" revealed the RN signature with no date or time. No physician signature, date, or time noted.

Review of patient #17's chart revealed a telephone order "Lexiscan in am." Physician signed order with no time or date.

Review of patient #18's chart revealed an order written for "Levaquin 500mg po daily." Order was dated 6/14/15 with no time. Order written on 6/16/2015 to switch patient to by mouth Protonix with no time.

Based on chart reviews the facility failed to have a History and Physical completed and documented prior to surgery in 1 (#40) of 1 (#40) charts reviewed.

A review of Patient #40's chart revealed the patient was a 61 years old admitted to the Emergency Room (ER) for altered mental status and bradycardia. Patient arrived via helicopter to the ER on 6/2/15 at 12:51 AM (after midnight). The History and Physical written by Physician's #107 and #108 revealed there was no date or time of the physical exam. Physician #107's History and Physical was dictated on 6/2/15 at 11:08 AM (after the surgical procedure) and Physician #108's History and Physical was dictated on 6/3/15 at 2:14 PM (the following day).

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

A. ensure narcotics (Fentanyl, Hydrocodone, Morphine, and Hydromorphone) were accurately logged and accounted for at all times in 1 of 1 medication room (Kilgore Emergency Center).
Refer to A0494 for additional information.

B.ensure medication preparation and mixing were performed in an area which minimized potential contamination. This was found in 1 of 1 Emergency rooms (Kilgore Emergency Center).
Refer to A0501 for additional information.

Based on observation, interview and record review, the facility failed to ensure narcotics were accurately logged and accounted for at all times in 1 of 1 medication room (Kilgore Emergency Center).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:
During an observation and interview on 06/17/2015 after 9:10a.m., Staff #53 confirmed there was a locked medication room at the facility. Staff #53 reported they, as nurses, did not have any access to the room. Only the Pharmacist and pharmacy technicians had access to the room. Staff #53 reported observations could not be made on the medication room until the pharmacist (Staff #45) came with the key.
During an observation on 06/17/2015 after 10:00 a.m., the medication room was unlocked by Staff #45. Narcotics were found locked in a safe in the medication room. A random count was performed with Staff #45 and the following was found:
*Thirteen vials (13) of Fentanyl were on hand and the inventory sheet listed 18 should be left (last audit 05/14/2015);
*Thirty (30) tablets of Hydrocodone 10/325 milligrams were on hand and the inventory sheet listed 50 should be left (last audit 06/10/2015);
*One hundred and six (106) vials of Hydromorphone were on hand and the inventory sheet listed 313 should be left (last audit 06/10/2015);
*One hundred and ninety four (194) syringes of Morphine sulfate 4 milligrams/cc on hand and the inventory sheet listed 225 should be left (last audit 06/10/2015).
During an interview on 06/17/2015 after 10:00 a.m., Staff #45 confirmed the narcotic counts. Staff #45 reported he had not logged the narcotics on the inventory sheet when he removed them and restocked the Pyxis.
Review of a policy named "Controlled Drugs: Diversion and Prevention" dated 06/2014 revealed the following:
Pharmacy is charged with purchasing, storing, securing, distributing and monitoring drugs classified as controlled substances by the Drug Enforcement Agency and /or controlled by the applicable Board of Pharmacy.
Monitoring Use
1.The pharmacy shall maintain a perpetual inventory of all controlled substances. This inventory is kept by the Pyxis C-11Safe and is verified by physical inventory monthly.
Review of a policy named "Controlled Drugs: Distribution and Accountability" dated 04/20/2014 revealed the following:
Documentation
The Director of Pharmacy, acting as the facility's agent, shall ensure that the distribution and administration of controlled drugs are documented adequately by pharmacy, nursing service and other involved services or personnel in accordance with federal laws and the laws of this state.

Based on observation, interview and record review the facility failed to ensure medication preparation and mixing were performed in an area which minimized potential contamination. This was found in 1 of 1 Emergency rooms (Kilgore Emergency Center).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

During an observation on 06/17/2015 after 10:00 a.m., the room used for mixing medication was checked. Nursing staff were using a room which did not have a door and which lead to the nurses station. Medication mixing was performed on a counter in the corner just as you enter the room. On top of the counter was the fax machine and next to the counter was a sink. Also inside the room was the Pyxis used for storage of medications, open biohazard containers and the copier. The mixing area was located directly underneath the ceiling air vent. There were no barriers in place to prevent contamination from splashes from the sink and from traffic in the room.
During an interview on 06/17/2015, Staff #53 and #45 confirmed staff were mixing medications in the area. Staff #45 provided a list of medications that were being mixed.
During an interview on 06/19/2015 after 1:00 p.m., Staff #30 reported he was correcting the problems with the mixing areas by putting up plexi glass areas that could be sanitized and prevent splashing.
Review of pharmacy staff meeting minutes for this emergency room dated 04/04/2013 revealed the following:
3) Per (their accrediting agency), a dedicated area for preparation of immediate use CSPs (Compounded Sterile Products) must be designated in the medication area. The area must be kept as clean as possible for all preparations. Proper barrier garb should be worn and sterile technique used in preparation of all medication.
Review of an undated policy named "Immediate Use CSP Risk Assessment" revealed the following:
Aseptic Technique must be followed
Must Follow Proper Hand Hygiene
Designated Preparation area must be cleaned with 70 percent isopropyl alcohol or Purple top wipe.
Must allow area to dry
Must maintain constant supervision of product
Must be done in an designated area to minimize exposure to contaminated surfaces.

Based on observation, document review and interview the facility failed to clean patient rooms between patients. The facility also failed to ensure the cleanliness of patient care areas and preventative maintenance of equipment and furnishings. The flooring was not maintained and was chipped and broken making it impossible to clean and sanitize. The facility had unfinished wood throughout the facility that could not be sanitized. The facility identified hazards throughout the facility and did not provide repairs.

A tour of the facility was conducted on 6/16/2015 with staff #87 and staff #112. The tour was started on the 6th floor of the West tower. A request was made of the staff to only tour rooms that were clean and ready to receive patients. During the tour of this patient care unit the following observations were made:
The tour of room 1618 revealed the drawer pulls were made of a plastic/ resin material. Several of the drawer pulls were broken and had sharp jagged edges. The pulls were broken into two pieces and dangling loosely. One would have to hold onto one of these broken pieces with sharp jagged edges and risk injuring themselves in order to open these drawers.
The bathroom floors and shower had the appearance of being dirty and un-kept. A handful of white toilet paper was taken and used to wipe across the bathroom floor, the paper revealed hair and a gray fibrous material with the appearance of built up dust. The procedure with the toilet paper was repeated in the shower with the same results, hair and a gray fibrous material with the appearance of built up dust. At the point where the walls and the bathroom floors and the shower floors met the floors had a darker coloration that becams brighter/ cleaner towards the center of the room. This darker color protruded out about 8 inches from the wall and had the appearance of being dirty/ un-kept.
The tour of room 1612 revealed the drawer pulls were made of a plastic/ resin material. Several of the drawer pulls were broken and had sharp jagged edges. The pulls were broken into two pieces and dangling loosely. One of the pulls had been taped together with a white silk tape. The tape was stained and discolored. The tape was porous and could not be disinfected. One would have to hold onto one of these broken pieces with sharp jagged edges and risk injuring themselves to open these drawers.
The bathroom floors and shower had the appearance of being dirty and un-kept. A handful of white toilet paper was taken and used to wipe across the bathroom floor and revealed hair and a gray fibrous material with the appearance of built up dust. The procedure with the toilet paper was repeated in the shower with the same results, hair and a gray fibrous material with the appearance of built up dust. At the point where the walls and the bathroom floors and the shower floors met the floors had a darker coloration that became brighter/ cleaner towards the center of the room. This darker color protruded out from the wall about 8 inches and had the appearance of being dirty/ un-kept. The base boards were cracked with pieces missing leaving voids/holes that could not be cleaned and disinfected.
The clean equipment/supply room in this patient care area was toured. The room was filled and cluttered with equipment and carts. The floors had the appearance of being dirty/ un-kept. Visible clumps of dust had gathered into corners and along the edges of the floor where it met the walls. Upon wiping the hand on the cabinet tops, once the clutter was removed, a visible amount of dust was collected. The clumping of the dust was so great it fell from the hand and could be seen floating in the air. The track of the hand was seen on the cabinet top. A look inside the cabinet revealed sterile supplies with a coating of dust. Reaching to the back of the cabinet and wiping the hand along the shelf revealed a collection of dust that could be rolled between three fingers and made into a fibrous ball. A cart that was said to be a procedure cart and would be taken to the bedside for procedures was observed. The open area on the top of the cart appeared to be without dust but when the items/supplies around the top were moved visible dust was revealed. The dust collected on the finger when the top was wiped. Upon opening the drawers small particles of unidentified debris was observed collected in the multiple compartments within the drawer. The drawer/compartments had the appearance of being dirty.
As the tour continued through the patient care unit an observation revealed the rolled flooring was laid so it would roll and continue up the wall approximately 6 inches providing the baseboard. The rolled flooring that doubled as the baseboard was then topped with a metal trim. This metal trim was observed in multiple areas throughout the halls pulled away from the wall and protruding into the hall. These protruding areas had sharp corners that could cause injuries/cut to patients or visitors in the hospital. At multiple points though out the hallways areas of the flooring were chipped and broken leaving porous concrete exposed. These broken chipped areas of the flooring could not be sanitized.
The tour of room 1609 revealed un-kept floors. Tape residue was observed throughout the room on fixtures and on the walls making these areas difficult to disinfect. The bathroom floors and shower had the appearance of being dirty and un-kept. A handful of white toilet paper was taken and used to wipe across the bathroom floor and revealed hair and a gray fibrous material with the appearance of built up dust. The procedure with the toilet paper was repeated in the shower with the same results, hair and a gray fibrous material with the appearance of built up dust. At the point where the walls and the bathroom floors and the shower floors met the floors had a darker coloration that became brighter/ cleaner towards the center of the room. This darker color protruded out from the wall about 8 inches and had the appearance of being dirty/ un-kept. The base boards were cracked with pieces missing leaving voids/ holes that could not be cleaned and disinfected.
The tour of room 1602 revealed tape residue throughout the room on fixtures and on the walls making these areas difficult to disinfect. The bathroom floors and shower had the appearance of being dirty and un-kept. A handful of white toilet paper was taken and used to wipe across the bathroom floor and revealed hair and a gray fibrous material with the appearance of built up dust. The procedure with the toilet paper was repeated in the shower with the same results, hair and a gray fibrous material with the appearance of built up dust. At the point where the walls and the bathroom floors and the shower floors met the floors had a darker coloration that became brighter/ cleaner towards the center of the room. This darker color protruded out from the wall about 8 inches and had the appearance of being dirty/ un-kept. The base boards were cracked with pieces missing leaving voids/ holes that could not be cleaned and disinfected.
The facility tour continued to the 5th floor, the Medical Intensive Care Unit Ward. In the ICU Ward a corner bed was revealed to be clean and ready to receive a patient. While standing at the end of the bed, to the right of the bed lying on the floor was the patient monitoring cables were observed. On the right side of the bed in the corner on the floor was a buildup of loose particles of what appeared to be dust and dirt. At the point where the walls and the floors met, the floors had a darker coloration that became brighter/ cleaner towards the center of the room. This darker color protruded out from the wall about 8 inches and has the appearance of being dirty/ un-kept. To the left of the bed lying on the floor was a wadded up tissue and what appeared to be a used alcohol pad. There was a sink mounted into a cabinet to the left of the bed. Upon opening the cabinet doors under the sink a strong musty/ mold order was smelled. The Formica laminate on the bottom shelf of the sink cabinet was peeling and appeared to have been exposed to large amounts of water. The left wall of the cabinet had become dislodged and appeared to be falling apart. At the foot of the bed was the nurses' desk and the baseboard surrounding the desk was chipped, broken and tattered. The baseboard was in disrepair and was a focal point of the unit.

The tour continued to the 4th floor. An observation of the clean utility room revealed two sets of scales used to weigh patients. The scales were found to be dirty. The platform area patients' stand was covered in what appeared to be sand and dirt. The lift scales appeared dirty and soiled with fingerprints left in the dust. Dust and lint was in the corners of the room. Lying next to an IV pole was a dead bug and remnants of tape on the floor. Staff #43 confirmed the findings. A tour of room 1402 on the Oncology floor revealed a room ready to receive a patient. On the wall that held the windows was an area that appeared to have water damage. The wall was bubbled up and the paint appeared to be peeling. Staff #112 inspected the area and revealed it looked like moisture damage. In the same area of the moisture damage sat a table and lamp. When the table and lamp was moved to inspect the moisture damage a large amount of bugs, too numerous to count, were observed lying on the floor. A small sofa sitting next to the table was moved and under the sofa was a large amount of built up dust and lint that could be seen moving from the breeze created. A cabinet was observed with three drawers. The cabinet and the fronts of the drawers were covered with a Formica laminate. The drawers were opened and unfinished wood drawers were observed. Unfinished wooden surfaces are porous and cannot be sanitized.
Upon arriving to the 3rd floor, wall paper was observed separating at a seam. The wall paper was rolling on both sides of the seam exposing a porous wall underneath. Porous surfaces cannot be sanitized. A tour of room 1313 revealed a large amount of dust collecting in the corners of the room and on counters. It was observed to be dirty under the sink and in need of cleaning.
The tour continued to room 1381. The bathroom had a bathtub shower combination. The shower head was missing. Only a metal pipe was protruding from the wall. In the bottom of the tub were blue strips of rubber tape. The tape and tub were discolored with a black residue. The tape appeared to be molded. Hair and dust were observed on the floor under the trash can. Staff #35 confirmed the findings.
The tour continued to the Pediatric unit located on the 2nd floor. Upon entering room 1252 a plastic toy was observed hanging on the wall. The toy had a plastic replica of a steering wheel affixed to it with a metal bolt and nut. The interior workings of the toy steering wheel were missing. The toy flopped loosely and had an opening between the steering wheel and the metal bolt and nut. The opening was large enough the surveyor could place a finger in. Staff #87 and staff #112 confirmed the toy posed a safety risk to children. Under the sink was a plastic drain cover that had fallen apart and exposed sharp edges that posed a pinching or cutting risk to patients or visitors. The bed had a wooden headboard and a wooden footboard. Both the footboard and the headboard had areas that were worn and splintered. The exposed splinters posed a risk of injury to patient, visitors and employees. The worn wood was porous and could not be sanitized. A vinyl covered chair was observed to be torn at a seam and had staples exposed. The points of the staples were sharp and positioned in a way that they were pointing outward and could cause injury.
Room 1252 revealed under the sink was a plastic drain cover that had fallen apart with exposed sharp edges that posed a pinching or cutting risk to patients or visitors. The bed had a wooden headboard and a wooden footboard. Both the footboard and the headboard had areas that were worn and splintered. The exposed splinters posed a risk of injury to patient, visitors and employees. The worn wood was porous and could not be sanitized.

At the time of the tour on 6/16/2015 the findings were verified by staff #87 and staff #112.

During a tour of the facility the following infection control issues were found:
A tour of the North Campus Emergency Room was conducted on 6/16/15, the following was found:
Seven patient rooms, that had been identified as "clean" rooms ready to receive patients, had trash in the trash cans, stretchers were soiled, equipment dirty and dusty, biohazard trash cans in various rooms contained blood filled syringes, bloody bandages and bed pads, and soiled disposable vaginal speculums. The Pyxis Medstation was dusty on the inside bottom shelves and soiled. The outside of the station was splattered with a dried brown liquid. In a clean supply room a red cart with clean supplies was found with a bloody hemostat lying on top of the cart. Blood gas supplies dated 4/15 were found expired in the crash cart.
Staff #56 and #57 accompanied surveyors on the tour and confirmed the infection control problems at the North Campus ER.
A tour of the Main Campus Emergency Room was conducted on 6/16/15, the following was found:
A cast cart was found in the Minor ER with expired supplies dated 10/2010. The cart was soiled with dust and debris. Room #3 and #5 were " clean " and ready to receive patients. Room #3 ' s walls had mildew, dirt, and debris present. The curtain was soiled and ripped, the floor was soiled with dirt and dried liquids, the stretcher had metal and plastic jagged edges on the frame and the frame was rusted under the mattress and was soiled with dirt and hair. Room #5 had trash in the trash can, veneer was missing from the cabinets exposing bare wood, the mattress on the stretcher was torn and soiled.
In the Minor ER, the "soiled" biohazard room had the following issues: Multiple urine samples were found sitting on top of a counter, the counter was soiled with dried urine, brown stains and dust, cleaning supplies were under the counter.
A cabinet was found in the Minor ER nurses station full of shipping boxes and an electrical fan covered with dust. A computer jack was dislodged from the wall in the main ER triage room. Sheet rock and wires were exposed. The cabinets in the triage room were filled with employee cups, medical supplies, papers, and scrubs. An EKG machine was found soiled with dust and sticky tape on the top, sides, and handles.
In the Main ER, the electronic scales for infants did not have a preventive maintenance sticker (PM) and was dusty. A venipuncture tray holding supplies was soiled with old tape, dust, debris, and opened 2x2 dressings. The monitor used to view patient's vital signs were covered in dust and debris in the triage room. Trash was visible in the hallway next to the patient beds. Trash had a pungent smell. Multiple areas of sheet rock were exposed on the walls. Floor tiles were cracked and soiled. The floor in the clean supply room was soiled with dust and debris. Multiple ceiling tiles were damaged with water stains or broken. A crash cart in the main hallway was dusty and had opened cups, bandages, trays, and paper tossed in the bottom of the cart. A patient medical supply cart was sitting next to two bags of soiled patient laundry. Expired medical items were found: Uricath expired 2/15, Hi-Lo vac expired 11/14, and 3 nasopharyngeal airways having expired on 11/14 and 2/12.
A tour was conducted in the Kilgore ER on 6/17/15 with the following findings:
The entrance to the Kilgore ER had a sliding glass door. The floor tiles in front of the door were missing, chipped, and buckled. In the corner of the threshold were multiple dead bugs, dirt, and mud. Clean patient supplies were found on a bottom shelf uncovered in a clean supply room. The supplies consisted of bed pans that were covered with dust and debris. A cast saw was found uncovered and dusty. The saw had no PM sticker. The floor was dusty and compacted dust and debris was found in the corners of the room.
Trauma rooms #3 and #5 were the designated negative pressure rooms. The rooms were equipped with alarms and pressure monitors. Both monitors were showing .02 inches of water and the alarms were in red showing the room was not holding a negative pressure. Staff #53 confirmed the negative air flow in the rooms was not functioning properly. The oxygen and air regulators in trauma rooms #3 and #5 were on a metal column coming down from the ceiling approximately 6 feet high above the ground. The surveyor was unable to reach the gauges and needed assistance in turning the oxygen on. The column and gauges were dusty. The stretcher in Trauma #3 had hair, trash and dust on the frame and under the mattress, the frame was missing a bolt and was rusted.
The room used by the nursing staff for mixing medications did not have a door and was the area that entered into the nursing station. Medication mixing was performed on a counter in the corner just as you enter the room. On top of the counter was the fax machine and next to the counter was a sink. Also inside the room was the Pyxis, used for storage of medications, open biohazard containers and the copier. The mixing area was located directly under the ceiling air conditioner vent. There were no barriers in place to prevent contamination from splashes from the sink and from traffic in the room.
A tour of the main campus nursing units was conducted on 6/17/15 and 6/18/15 with the following findings:
Tour of the Surgical Intensive Care Unit revealed there were no patients at the current time. Soiled dirty laundry was found in the soiled linen bags next to patient beds. Staff #29 confirmed the dirty laundry had been there a couple of days. In patient room #11, the door to the room was being held open by a soiled string which was wrapped around the handle at one end and by a piece of broken plastic from the threshold at the other end. Multiple countertops and bedside tables were noted with laminate missing or broken with exposed wood in patient care areas. Multiple chairs were found with the vinyl torn and foam exposed. Surgical packs and patient medical supplies were soiled and found stored ready for patient use. Packets of expired dressings, infant tube feeding catheter, needles and syringes that expired in 2013 and 2014 were stored as ready for use. The crash cart was found with debris and dust in the bottom of the drawers. A venipuncture tray with IV supplies was found to be dusty and soiled with debris. An open one pound bag of beef jerky was found in the nurse's station cabinet and the medication crusher had a buildup of dust and rust. Five (5) bottles of potassium solution, one bottle of disinfectant, one bottle of bleach, and one bottle of vinegar were found in a cabinet across from a patient care area. The bottles were sitting in a white dried substance, were all opened and had no open date or discard date recorded. The hallway floor leading to the Surgical Intensive Care Unit had missing and torn safety strips that were heavily soiled.

Tour of the Progressive Care Unit (A600) revealed the ceiling in the waiting room was leaking and standing water was in a trash can underneath the leak as well as on the floor. Patient room with contact isolation supplies at the entrance of the patient room had no gloves in the isolation supplies. Clear containers which contained medical supplies were found in the medication preparation area. The drawers in the clear containers were soiled with debris, dust and unknown dried substances. In a cabinet on A600, several yellow plastic bins were found with room numbers on them. The bins contained patient medications that were not kept in the Pyxis system. Under the medications in 12 bins were old stickers, layers of dust, and debris.
The Pyxis on A600 was found to be soiled with debris and dust on the inside bottom shelf and drawers. Paint was missing in spots on the bottom shelf and could not be sanitized in this condition. Dead bugs were found in two of the bins containing medications. The patient refrigerator was soiled with liquid spills and food crumbs. The patient coffee maker was soiled with dust and food debris. The top of the coffee maker was mildewed. The coffee pot was stained and had debris in the handle that was sticky. Containers holding clean supplies were found to be soiled with dust, hair, old stickers and tape. A vacuum tube system was found on A600. Staff confirmed that labs were sent in the tube system. The inside and outside of the tube system was soiled and dusty. The sides of the tube door were cracked and discolored. The tube capsules had foam in them to protect the samples. The foam was soiled and smelled of urine. A food cart to retrieve dirty trays was soiled with dried liquids, dust, debris, and hair.
In other areas of the facility, The Medical Surgical Unit (S400) Pyxis machine was found to have dust and a dead insect in one of the bins holding medications. A patient room confirmed by staff to be clean and ready for a new patient revealed a rusted and soiled bed frame with dust, hair, and debris. A medication crusher was found with a buildup of dirt, dust, debris and medication residue.
Patient Room 1455 on the Oncology floor was confirmed as a clean room ready for patient use. The floor grout was soiled and mildewed in the bathroom. The tile flooring behind the commode had a buildup of hair and dust. The shower curtain was mildewed and stained. The drain in the shower had a buildup of hair and debris.
In the NICU (Neonatal Intensive Care Unit), a scale was found to be dusty and debris found in the bottom section. The sink area had exposed sheet rook on the back splash. An infant bouncer, ready for patient use, was found sitting on the soiled and dusty floor. A privacy screen was soiled, stained and covered in dust.
On Ortho/Neuro floor (E200), a bed frame in a clean patient room was found to be rusted and paint missing. A supply cart in the clean medical supply room was found to be dusty and soiled with a dried liquid on the bottom. The Pyxis Medstation was found to have dust and dead bugs in the trays holding patient medications. Patient Room #2213 was a negative pressure room. The door had been closed for an allotted time to allow the monitors to set. The monitor continued to show the room was not in a negative pressure state.


A review of the documents titled Environmental Tours revealed Purpose: To identify the areas and equipment subject to required safety inspections or surveys .... Environmental tours are conducted by a multi-disciplinary team that includes Safety Management, Plant Operations and Maintenance, Infection Prevention, Environmental Services, Biomed and Occupational Injury Management.


A review of the documents titled Environmental Hazard Assessment (EOC Rounds, Environmental Tours or Environmental Rounds), dated 4/10/2014, revealed 58 hazards in Labor and Delivery unit by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/14/2014, revealed 25 hazards in A200 unit by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/17/2014, revealed 18 hazards in the Dietary Department by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/17/2014, revealed 11 hazards in the Pulmonary Department by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/24/2014, revealed 25 hazards in the A300 unit by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/24/2014, revealed 9 hazards in the A300 Antepartum unit by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/24/2014, revealed 3 hazards in the A300 Perinatal unit by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 4/24/2014, revealed 5 hazards in the A300Unit, SANE Exam Room by the persons performing the inspections. An area of the document provided for documentation of "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

A review of the documents titled Environmental Hazard Assessment, dated 5/1/2014, revealed 36 findings in the unit A400 by the persons performing the inspections. An area of the document provided for "Action Taken / Follow up Required". No follow up was documented on the Environmental Hazard Assessment.

The EOC rounds reviewed for 4/10/2014, 4/14/2014, 4/17/2014, 4/24/2014 and 5/1/2014 were not conducted by the required multi-disciplinary team that included Safety Management, Plant Operations and Maintenance, Infection Prevention, Environmental Services, Biomed and Occupational Injury Management.

A review of the documents titled "Environment of Care Committee" meeting minutes dated 1/20/2015, 2/172015, 3/17/2015, 4/21/2015 and 5/19/2015 revealed the environmental hazards identified by the Environmental Hazard Assessment were not reported or evaluated by the Environment of Care Committee.

An interview on 6/18/2015 with staff #89 confirmed the hazards of the EOC rounds. Staff #89 revealed there was not a process to follow up that would ensure the findings/ hazards were addressed.

An interview on 6/17/2015 with staff #115 revealed the reports generated from the Environmental Round were to be given to the Safety Officer. The Safety Officer would give the reports to the Division Directors for an Action Plan. Staff #1 revealed there were "holes in the system and we don't get feedback".

Based on observation and interview the facility failed to provide a safe and sanitary environment housing laundry services in a manner which protected the safety of the worker and patients.

On 6/18/2015 in the afternoon the laundry department was toured with the plant operations manager. During this tour the following observations were made on the soiled linen side:
A short narrow hallway opened into a large concrete room. The lighting was dim compared to the clean linen side. The ceiling was very high and pipes and air conditioning (AC) ductwork were observed crossing the ceiling. The silver moisture barrier that wrapped the AC duct work was observed in disrepair and actually appeared to be shredded in places with fist size holes in the wrappers and pockets of torn foam insulation visible. The AC held the room at a cool temperature, however the force of cool air entering the soiled linen side of the room kept lint, dust and particulate matter circulating. Heavy lint was observed on pipes which ran across the ceiling. Pipes which traveled down the walls were observed with shredded wrapping of insulation. Insulated pipes near commercial washers were observed torn nearly completely off. There was heavy lint on the cage which covered the fan pulling inside air to vent to the outside. The floor was bare concrete. A concrete wall separated the soiled linen side from the clean linen side. The wall did not rise to the ceiling but stopped approximately 2 feet to allow piping to cross from the soiled side to the clean side. The walls of the soiled linen side were not painted or if they were painted they were faded and chipped. The soiled linen side of the room appeared dirty and uncared for. Two staff worked on the soiled linen side. There were multiple large deep bin carts, stacked well above the sides of the carts which held soiled linen.

The clean linen side of the concrete room was much brighter. Upon entrance to the room a large pipe behind the first dryer was observed head high (5.6 feet). The fiberglass insulation was visible from a large hole where the protective wrapper was torn and appeared to have been taped back up and that had torn as well. A heavy layer of lint was accumulated behind the dryers. There was 4 feet of space between the dryers and the back wall. Large hard wrapped pipes crossed the ceiling. These pipes had a small layer of lint. The AC duct work was again wrapped with silver moisture barrier and the wrappers were shredded and torn. A random laundry worker was interviewed and was asked what was their greatest concern working in the laundry. That worker replied "that this stuff is gonna fall on us".

At the completion of the tour the plant operation manager confirmed the vapor wrapping was in poor condition and would be replaced as well as general pipe insulation that was in disrepair. He also confirmed both the clean and the dirty sides of the laundry work area needed to have heavy lint removed. The plant operations manager also called a department co-worker to observe the findings. The co-worker confirmed he was aware of the working conditions but had stopped reporting them when no improvements were attempted.

C. ensure the cold disinfectant solution was monitored and the procedures were followed according to the manufacture guidelines and the facility policy. Also, the facility failed to train 3 (#33, #49, and # 113) of 3 staff members on cold disinfection solution procedures and monitor the scope process. The facility failed to follow their policy for monitoring the fluids in the warming cabinet and cleaning of the 5 sterilizers. Also, the temperature and humidity was not recorded or monitored for the Surgery, Labor and Delivery, and Cath lab departments where sterile instruments were stored. Further review revealed the facility failed to provide a sanitary environment for pre-op area, holding area, surgical area, sterilization area, post anesthesia area, and sterile supply storage area.
Findings:
Surgery Solution Testing Log Sheet For: Metricide OPA Plus:
A review of the log titled, "Solution Testing Log Sheet For: Metricide OPA Plus" (cold disinfectant) for April, May, and June 1-12, 2015 revealed the following:
A review of the log for April 2015 revealed the test strip bottle was documented as opened on "12/2/2016" and do not use after date of 3/2/2015. Also, on the log the quality control test date was documented performed "12/2/2015" and the person that performed the test was left blank. The quality control test is to be performed when the bottle of test strips is opened to make sure the test strips are good. The test strip bottle was used until 4/9/2015, but should have been discarded on 3/2/2015. Test strip bottles are only good for 90 days once the bottle is opened. Further review of the log showed the cold disinfectant had not been checked daily as required on 4/4, 4/5, 4/11, 4/12, 4/18, 4/19, 4/25, and 4/26. The log indicated the solution was opened and activated on 3/11/2015 and was documented expired on "12/2016". In checking the April's log, for two (2) days the date "4/28/2015" was documented as if the solution was changed, but then the log went back to the solution being activated on 4/9/2015. Again the Metricide OPA Plus is only good for 14 days once the cold disinfectant has been activated.
Further review of the April log showed the cold disinfectant solution (Metricide OPA Plus) was mixed 3/11/2015. The solution was not mixed again until 4/9/2015, which was 15 days past the due date 3/25/2015. Next time the solution was changed was 5/13/2015, which was 34 days past the due date of 4/23/2015. There were 8 (#55, #56, #57, #58, #59, #60, #61, and #62) patients that had procedures that had utilized instruments or glide scopes for those procedures that had been soaked in the expired solution.
A review of the May 2015 log showed the cold disinfectant solution (Metricide OPA Plus) was activated 4/9/2015 and was documented expires "12/2016". Again the Metricide OPA Plus is only good for 14 days once the cold disinfectant has been activated. Further review of the log showed the cold disinfectant had not been checked daily as required on 5/8 5/9, 5/10, 5/17, 5/18, 5/23, 5/24, 5/25, 5/30, and 5/31.
A review of the June 2015 log showed the cold disinfectant solution (Metricide OPA Plus) was mixed 5/27/2015 and not mixed again until 6/12/2015 which was 2 days past the due date of 6/10/2015. There was 1(#63) patient that had a procedure that utilized glide scopes for the procedure that had been soaked in the expired solution. The solution was activated 6/12/2015 with a solution expiration date of "3/2017". Again the MetriCide OPA Plus is only good for 14 days once the cold disinfectant has been activated.
An interview with Staff #33 was conducted on 6/19/2015 at approximately 10:00AM. Staff #33 was asked if he/she knew how to perform the quality control test for the test strips. Staff #33 stated, "I have no idea what you are talking about, all I do is test the solution with the strip." Surveyor showed the log to Staff #33 to verify it was his initial that showed he had done the quality control testing. Staff #33 stated, "Those are my initials, but I don't do the quality testing."
A review of the April, May, and June 1-12, 2015 logs did not show the quality control testing staff member until 5/13/2015.
An interview with Staff #31 on 6/19/2015 at approximately 9:30 AM confirmed the cold disinfectant was to be tested daily.
A review of the manufacture guidelines for Metricide OPA PLUS revealed the following:
"The product must be discarded after 14 days, even if the Metricide OPA PLUS Test Strip indicates a concentration above the MRC (minimum recommended concentration) of 0.3%.
Once the Metricide OPA PLUS gallon container is opened it is only good for 75 days."
A review of the manufacture guidelines for Metricide OPA PLUS Solution Test Strips revealed the following:
"1. Quality control test for the test strips:
Testing of positive and negative controls must be performed on each newly opened bottle of Metricide OPA PLUS Solution Test Strips. Always note the date the bottle was opened and "do not use after" date in the space provided on the bottle. Test strips once opened are good for 90 days."
An interview with Staff #31 on 6/19/2015 at approximately 10:30 AM confirmed the above findings.
Cardio-Pulmonary:
During a tour of the Cardio-Pulmonary department on 6/16/2015 at approximately 3:00 PM Staff #49 was observed processing a TEE (Trans-Esophageal Echocardiogram) scope. Staff #49 wore no personal protective equipment. Staff #49 and #113 were asked if he/she knew how to perform the quality control test for the test strips. Both staff members described checking the solution of the Metricide OPA PLUS. Neither Staff #49 or #113 knew how to perform the Quality control test for the test strips.

A review of the policy titled, "Care and Cleaning of Scopes and Probes- Use of CPA Plus" effective date 9/2014 revealed the following:

"PURPOSE:
To guide personnel in the care and cleaning of reusable scopes/probes and in the proper use of Metricide Ortho-Phthaladehyde to provide high level disinfection (HLD).

RESPONSIBILITY:
Scopes and probes shall be reprocessed by competent personnel in a manner consistent with infection prevention, safety, regulatory and manufacturer's recommendations.

CLEANING PROCEDURE:
*Follow manufacturer's instructions.
*Transport used scopes/probes to the soiled area in a biohazard bin and in a manner that avoids cross contamination.
*Wipe with a damp cloth or gauze immediately after use to avoid drying of organic materials.
*Avoid bending or coiling.
*Only immerse parts as per instructions.
*Perform leak test on scopes as per manufacturer ' s instructions.
BEGIN DISINFECTION PROCESS USING METRICIDE OPA
Supportive Data:
1. Metricide CPA Solution is a high level disinfectant for semi-critical level devices when used or reused, according to Directions for Use, at or above its Minimum Effective Concentration (MEC) of 0.6% as determined by the Metricide CPA Solution Test Strips, at 20° C (68° F).
2. Efficacy of this product during its use-life must be verified by the Metricide CPA
Solution Test strips and testing temperature prior to use.
3. Metricide CPA can be re-used for up to 14 days.
4. Opened, but unused Metricide CPA Solution in original container can be used for up to 75 days once opened and must be dated.
5. Metricide CPA Solution should be used only in a location pre-apptoved by Infection Prevention or in a designated reprocessing area.
6. PRECAUTIONS/WARNING:
a. Avoid contact with eyes, on skin or clothing. Metricide CPA will stain gray, wear PPE
b. Use nitrile gloves.
c. Use in well-ventilated area in closed containers with tight fitting lids.
d. In case of contact, immediately flush eyes or skin with plenty of water for at least 15 minutes. For exposure to eyes, proceed to Emergency department.
e. Contaminated reusable devices MUST BE THCROUGHLY CLEANED prior to disinfection.
f. User must adhere to Directions for Use. Modifications to the Directions for Use may affect safety and effectiveness of germicide.
g. No activation is required.
h. Dispose/Discard Metricide CPA in accordance with hospital and/or local laws or regulations.

Procedure for disinfection using Metricide OPA Metricide CPA is used for high level disinfection (HLD)
1. No activation is required when using Metricide CPA
2. The following Personal Protective Equipment will be used:
a. Protective safety goggles with side shield protection or face shield
b. Disposable nitrile gloves are preferred
c. Fluid resistant gowns
3. When opening the original Metricide CPA container, label with the date it is opened if entire contents of the container are not used immediately. The solution remaining in the container can be used for up to 75 days (providing the 75 days does not extend past the expiration date printed on the container). Ctherwise, if entire contents are transferred to a soak container, properly dispose of the empty original container.
4. Open clean soak container and carefully pour solution, avoiding splashing.
a. Record the date the solution was poured out of the original container into the secondary container, lot number and the new expiration date (14 days from date poured) on a label affixed to the secondary container. The expiration date of 14 days is effective as long as the concentration of the Metricide CPA is above the Minimum Effective Concentration (MEC) as indicated by the Metricide CPA Solution Test Strip.

Testing:
Upon opening of a new container of Metricide CPA Test Strips, a Quality Control (QC) test shall be performed as follows:
1. Verify the expiration date on the Metricide CPA solution and test strips.
2. Full strength Metricide CPA solution may be used as the positive control.
3. Prepare a negative control by diluting 1 part full strength Metricide CPA Solution (10mI) with 1part water (15 ml)-use plastic bowl or denture cup.
4. Label each solution.
5. Dip 3 test strips into each of the prepared solutions one at a time for 2 full seconds.
a. Tap test strip to remove excessive solution.
b. Hold strip horizontally.
6. Check for the test result after 60 seconds
a. Positive control solution strips should appear completely PINKIMAGENTA.
b. Negative control solution strips should either remain YELLOW or exhibit an incomplete change to pink. (Refer to color chart on bottle to interpret).
c. If the results of the QC test indicate the test strip is not functioning properly, discard the remaining strips.
7. Container of strips must be kept clean, dry and closed.
8. The Metricide CPA solution during its ' useful life must be verified using Metricide CPA Solution Test Strips prior to each cycle to determine concentration.
9. This solution must be discarded after 14 days even if the Metricide CPA Solution test Strip indicates a concentration above the MEC. Also, if after visual inspection, precipitates are in the solution it must be discarded. A neutralizer for Metricide CPA Solution IS NCT required prior to disposal. Discard solution into the drain. Flush drain thoroughly with water."

An interview with Staff #49 and #113 on 6/18/2015 at approximately 3: 00 PM confirmed the facility policy was not followed.

These deficient practices were determined to posed an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or death.



Fluid Warming Cabinet:
A review of the log titled, "Warming cabinet temperature log: Heating of Fluids, and/or Solutions: Acceptable Range for heating = 86-104 degrees" revealed a temperature of 140 degrees on June 1, 2015 at 0030. In the corrective action column it was written "turned down to low." There was no further follow up to know if the warming cabinet was working properly. The cabinet contains intravenous and irrigation fluids that are used on patients during a surgical procedure. This had the likelihood to cause harm to all patients who would receive overheated fluids. A review of the policy titled, "Temperature Setting for Warming Cabinets Policy" revealed the following:
"Purpose: To ensure safe and effective temperature settings for warming cabinets. Allowing Digital Warming Cabinets to reach excessive temperatures is unacceptable.

When heating fluids and/or solutions warming cabinet temperatures should be maintained no higher than 104° Fahrenheit.

Allowing the temperature to rise above the specified ranges is a safety hazard to patients, visitors and employees.

Employee Responsibility:
1. Monitor warming cabinet temperature gauge and ensure that temperature stays at 104° when being utilized to heat fluids, and/or solutions.
2. Fluids that are placed into a warming cabinet will be rotated on a regular basis.
Note: Fluids cannot be "rewarmed" once removed. All bags must be labeled and dated when at first placed in the warmer to indicate initial warming. Reference "Guidelines for Storage and Stability of Sterile IV and Topical Irrigation Solutions".
3. IV solutions and irrigation bottles may be stored up to 28 days in the warmer, unless otherwise specified by the manufacturer.
4. If the warming cabinet temperature exceeds acceptable temperature, check the gauge and adjust as necessary.
5. Recheck temperature in one hour, if temperature continues out of range, contact maintenance for evaluation and repair. Move contents to a properly functioning warmer.
6. Units with warming cabinets that contain IV fluids and irrigation solutions will maintain a temperature log and daily temperature quality checks.
7. Occurrences of a warming cabinet ' s temperature exceeding the acceptable temperature mandate corrective action."

An interview with Staff #31 on 6/16/2015 at 9:30 AM confirmed the one hour recheck was not recorded as per the facility policy.

Sterilizers:

A review of the log titled, "Stream Sterilizer Cleaning Schedule Log" revealed sterilizer #1, #2, #3, #4, and #5 had not been cleaned since 6/15/2013. It was written on the log per Staff #1 to discontinue the service and Biomedical would provide the service. A review of emails dated April 23, 2013, May 30, 2013, and May 31, 2013 revealed the cleaning will start 6/15/2013. There was no documentation that the cleaning of the sterilizers was ever started. The observation of sterilizer #1 revealed green corrosion and rust build-up.

A review of the policy titled, "Cleaning of Sterilizers (effective date 4/1/2013)" revealed the following:

"Purpose: To define the process used in maintaining the sterilizers within the department.
Policy Statement: Routine cleaning will be performed on all sterilizers to maintain the units in optimum condition.

Content:
Steam sterilizers will be cleaned on a weekly schedule to remove scale deposits and rust from the chamber.
The exterior surfaces of the steam sterilizers will be wiped down using a germicidal solution on a weekly basis.
The steam drain strainer will be cleaned on each steam sterilizer on a daily basis. The drain must be maintained free of all debris to ensure correct processing.
The low temperature sterilizer chambers will be cleaned and exterior surfaces wiped down on a weekly basis.
The manufacturer ' s instructions will be followed when cleaning each of the sterilizer units. Staff should consult the manual for any questions.
PPE will be worn by all personnel when performing the cleaning duties.
A cleaning log will be maintained by the staff and document date of cleaning.
All preventative maintenance/ repairs are completed by Biomed department."

An interview with Staff #31 on 6/17/2015 at approximately 2:00 PM confirmed the sterilizers had not been cleaned since 2013 and the facility policy was not followed.

Temperature and Humidity:

A review of the log titled, "Surgery Temperature-Humidity Log" for the following departments of Surgery (14 rooms), Sterile Storage (4 areas), Labor and Delivery (4 areas), and Cath lab (4 areas) revealed the following:

A review of the temperature-humidity log for the month of April 2015 for Surgery, Labor and Delivery, and Cath lab revealed the following:

215 Temperatures were not recorded.

318 Humidities were not recorded.

391 Temperatures were out of range.

5 Humidities were out of range.

A review of the temperature and humidity log for the month of April 2015 revealed 810 slots for staff to record the readings. During this time frame there were 606 temperatures and 68 humidity readings that were either omitted or out of range.

A review of the temperature-humidity log where remarks were to be documented revealed "thermometers/humidity removed from operating rooms 1-9" were the only documented remarks. There was no documentation to the out of ranges or omitted recordings.

A review of the temperature-humidity log for the month of May 2015 for Surgery, Labor and Delivery, and Cath lab revealed the following:

165 Temperatures were not recorded.

304 Humidities were not recorded.

313 Temperatures were out of range.

9 Humidities were out of range.

A review of the temperature and humidity log for the month of May 2015 revealed 837 slots for staff to record the readings. During this time frame there were 478 temperatures and 313 humidity readings that were either omitted or out of range.

A review of the temperature-humidity log where remarks were to be documented revealed no documentation to the out of ranges or omitted recordings for temperatures or humidity.

A review of the temperature-humidity log for the month of June1-15, 2015 for Surgery, Labor and Delivery, and Cath lab revealed the following:

55 Temperatures were not recorded.

103 Humidities were not recorded.

197 Temperatures were out of range.

10 Humidities were out of range.

A review of the temperature and humidity log for June 1-15, 2015 revealed 405 slots for staff to record the readings. During this time frame there were 252 temperatures and 113 humidity readings that were either omitted or out of range.

A review of the temperature-humidity log where remarks were to be documented revealed no documentation to the out of ranges or omitted recordings for temperatures or humidity.

Review of the AORN Perioperative Standards and Recommended Practices noted, "Temperature should be maintained between 68 degrees F to 73 degrees F (20 degrees to 23 C) within the operating room suite and general work areas in sterile processing.
Relative humidity should be maintained between 30% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, instrument processing areas, and sterilizing areas and should be maintained below 70% in sterile storage areas.
Low humidity increases the risk of electro static charges, which pose a fire hazard in an
oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed.

Humidity should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system.

Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system."

An interview with Staff #44 on 6/19/2015 at approximately 11:30 AM confirmed the Cath Lab personnel have never monitored the humidity where sterile instruments are being stored.

An interview with the Staff #31 on 6/19/2015 at approximately 10:30 AM was conducted. Staff #31 was asked do you monitor the temperature and humidity of the operating rooms. Staff #31 stated, "It is the responsibility of the plant operations personnel."

An interview with Staff #34 on 6/19/2015 at approximately 12:00 PM confirmed the plant operations department records the temperature and humidity for Surgery, Labor and Delivery, and Cath Lab. Staff #34 stated, "Operating rooms #1-9 are on a computerized auto monitoring system. If the system records an out of range temperature or humidity it will adjust the control to regulate the temperature which will in turn regulate the humidity. Rooms #10-14 are manually regulated. One of the staff members has to manually go to the room and read the temperature and humidity. If the plant operations staff member goes to the room and a surgical case was being performed the temperature and humidity is not recorded." Staff #34 was asked how the rooms (#10 -14) were regulated if the temperature or humidity is out of range. Staff #34 stated, "A staff member has to manually go into the room and through the ceiling tile to open or close the air conditioner damper which will adjust the temperature and humidity."

The process of monitoring the temperature and humidity for the operating rooms where surgical cases are being performed have different standards of care for rooms #1-9 and rooms #10-14. In rooms #10-14, the room is manually controlled by a staff member. In rooms' #1-9 the system is computerized and automatically controlled. This process has the likelihood to cause outbreaks of surgical site infections.


Patient #47 followed through the surgery departments:

The following observations of Patient #47 on 6/17/2015 starting at 9:30 AM and continued from the time the patient entered the pre-surgical area until Patient #47 was discharged from the Same Day Surgery.

Same Day Surgery Area:

In the room where Patient #47 was being prepped, it was observed in the drawer where patient supplies were kept dust particles and what appeared to be rodent pellets.

In the patient/public bathroom on the back hallway of the "Same Day Surgery" the commode had an extra support system for larger patients; the support system was made of metal and was covered with numerous rust spots. The bathroom had an unclean appearance.

Surgery Holding Area:

The light fixture over Patient #47's bed had insects and the appearance of dark spots inside the covering.

The patient's bathroom cord was pulled by the surveyor and there was no audible alarm signal. Approximately 2 minutes went by before anyone responded to the bathroom flashing signal.

Operating room:

In the operating room where Patient #47 procedure was performed, the arm cushions on the surgery table were split with exposed foam showing through the vinyl covering. Patient #47's arms were placed directly on the vinyl cushions.

Postoperative Area:

The bedside table had a hole in the top of the table about the size of a fifty cent piece. Porous wood was showing where the patient was being cared for. One of the patient care areas in the postoperative area was being used for storage of wheelchairs and other equipment.

Surgical Tour

Surgery Holding Area:

Six (6) cardboard outside shipping boxes of Cathlon epidural needles stored with the sterile supplies in the cabinet.

Surgery:

Vinyl chair/stool was sitting in the hallway of the surgery department with an 8 inch split in the sit of the cushion.

In operating Room #13 there was 3 outside cardboard shipping boxes inside the operating room. Also, observed in the room was unfinished wood on the cabinets and observed a Nellcor pulse oximetry which had expired 12/2014. In the lithotripsy room was a large cardboard box sitting on the floor full of equipment pieces.

In the hallway in front of operating rooms #10, #11, #12, and #13, the baseboards were laying over in the floor.

Surgery Sterile Supply Storage Area:

In the sterile supply storage area where open sterile supplies were stored was a wooden pallet (4x4) in size, and was stacked with outside shipping cardboard boxes approximately 6 feet high. Observed were the employees opening and breaking down the cardboard boxes in the room with the open sterile supplies. The sterile supplies were within a foot of where cardboard boxes were being torn down. There was a portable metal table being used for paperwork and drink items while the employees worked. The floor was dirty with dust particles, plastic, and paper trash. Also, observed the caster wheels of the wire racks were covered in sticky paper, trash, and dust particles. The sterile supply room had a very unclean and disarray appearance. The outside shipping cardboard boxes were being brought into the room from a back hallway with a lift that comes in from the outside. The process was to drop the wooden pallet directly in the sterile supply room with the open sterile supplies.

The hallway outside the sterile storage area was where dirty instruments from other departments were brought, stored, and logged. The instruments were kept there until ready to be processed by the sterilization department. The floor under the carts was dirty in appearance with trash and dust particles. The light fixtures along the hallway were full of bugs, yellowish in color, and had a dull lighting appearance.

Anesthesia Care area (PACU)

During a tour of the surgical area, 14 functional operating rooms were observed. In the postoperative care unit there were only 12 post anesthesia patient care areas. One of the patient care areas was being used for storage of wheelchairs and other equipment. The monitoring, suctioning, and oxygen supplies had been removed from the patient care area. The post anesthesia care area only had 11 functional bay areas.

An interview with Staff #31 on 6/16/2015 at approximately 11:45 PM confirmed the above findings in the surgical area.


Cath Lab Area:

In Cath Lab #2 the wire rack that was full of sterile supplies did not have a barrier that would prevent dust particles and wet mop splatters from contaminating the sterile supplies.

There was a blue wedge cushion used for positioning patients that was worn with exposed foam.

In the cabinet where sterile supplies were stored, observed 3 of 3 peel packages with water stains. One of the water stained packages noted a sterilization date of 2008.

A review of the log titled, "Surgery Temperature and Humidity Log" from April through June 15, 2015 revealed the humidity had never been checked in the Cath Lab Rooms #1, #2, and #3. During the tour of the Cath Lab observed numerous sterile instruments that were being stored in all 3 rooms.

An interview with Staff #44 on 6/16/2015 at approximately 2:45 PM confirmed the above findings in the Cath Lab area.

Obstetric Area:

In the C-section room observed a stainless steel back table and mayo table which had rusted caster wheels. The Fetal Heart tone cabinet could not been cleaned due to exposed porous wood.

An interview with the Director of Obstetric on 6/19/2015 at approximately 11:06 AM confirmed the above findings in the Obstetric area.







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Based on observation, record review, and interview, the facility failed to:
A. provide a clean and safe environment for patients to receive care. Tours of the facility revealed unsanitary patient rooms, unsanitary environment where sterile patient care suplies were being stored. The facility failed to maintain the patient care areas, food preparation areas and areas where clean and dirty linens were being stored.

A tour of the facility was conducted on 6/16/2015 with staff #87 and staff #112. The tour was started on the 6th floor of the West tower. A request was made of the staff to only tour rooms that were clean and ready to receive patients. During the tour of this patient care unit the following observations were made:
The tour of room 1618 revealed the drawer pulls were made of a plastic/ resin material. Several of the drawer pulls were broken and had sharp jagged edges. The pulls were broken into two pieces and dangling loosely. One would have to hold onto one of these broken pieces with sharp jagged edges and risk injuring themselves in order to open these drawers.
The bathroom floors and shower had the appearance of being dirty and un-kept. A handful of white toilet paper was taken and used to wipe across the bathroom floor, the paper revealed hair and a gray fibrous material with the appearance of built up dust. The procedure with the toilet paper was repeated in the shower with the same results, hair and a gray fibrous material with the appearance of built up dust. At the point where the walls and the bathroom floors and the shower floors met the floors had a darker coloration that becams brighter/ cleaner towards the center of the room. This darker color protruded out about 8 inches from the wall and had the appearance of being dirty/ un-kept.
The tour of room 1612 revealed the drawer pulls were made of a plastic/ resin material. Several of the drawer pulls were broken and had sharp jagged edges. The pulls were broken into two pieces and dangling loosely. One of the pulls had been taped together with a white silk tape. The tape was stained and discolored. The tape was porous and could not be disinfected. One would have to hold onto one of these broken pieces with sharp jagged edges and risk injuring themselves to open these drawers.
The bathroom floors and shower had the appearance of being dirty and un-kept. A handful of white toilet paper was taken and used to wipe across the bathroom floor and revealed hair and a gray fibrous material with the appearance of built up dust. The procedure with the toilet paper was repeated in the shower with the same results, hair and a gray fibrous material with the appearance of built up dust. At the point where the walls and the bathroom floors and the shower floors met the floors had a darker coloration that became brighter/ cleaner towards the center of the room. This darker color protruded out from the wall about 8 inches and had the appearance of being dirty/ un-kept. The base boards were cracked with pieces missing leaving voids/holes that could not be cleaned and disinfected.
The clean equipment/supply room in this patient care area was toured. The room was filled and cluttered with equipment and carts. The floors had the appearance of being dirty/ un-kept. Visible clumps of dust had gathered into corners and along the edges of the floor where it met the walls. Upon wiping the hand on the cabinet tops, once the clutter was removed, a visible amount of dust was collected. The clumping of the dust was so great it fell from the hand and could be seen floating in the air. The track of the hand was seen on the cabinet top. A look inside the cabinet revealed sterile supplies with a coating of dust. Reaching to the back of the cabinet and wiping the hand along the shelf revealed a collection of dust that could be rolled between three fingers and made into a fibrous ball. A cart that was said to be a procedure cart and would be taken to the bedside for procedures was observed. The open area on the top of the cart appeared to be without dust but when the items/supplies around the top were moved visible dust was revealed. The dust collected on the finger when the top was wiped. Upon opening the drawers small particles of unidentified debris was observed collected in the multiple compartments within the drawer. The drawer/compartments had the appearance of being dirty.
As the tour continued through the patient care unit an observation revealed the rolled flooring was laid so it would roll and continue up the wall approximately 6 inches providing the baseboard. The rolled flooring that doubled as the baseboard was then topped with a metal trim. This metal trim was observed in multiple areas throughout the halls pulled away from the wall and protruding into the hall. These protruding areas had sharp corners that could cause injuries/cut to patients or visitors in the hospital. At multiple points though out the hallways areas of the flooring were chipped and broken leaving porous concrete exposed. These broken chipped areas of the flooring could not be sanitized.
The tour of room 1609 revealed un-kept floors. Tape residue was observed throughout the room on fixtures and on the walls making these areas difficult to disinfect. The bathroom floors and shower had the appearance of being dirty and un-kept. A handful of white toilet paper was taken and used to wipe across the bathroom floor and revealed hair and a gray fibrous material with the appearance of built up dust. The procedure with the toilet paper was repeated in the shower with the same results, hair and a gray fibrous material with the appearance of built up dust. At the point where the walls and the bathroom floors and the shower floors met the floors had a darker coloration that became brighter/ cleaner towards the center of the room. This darker color protruded out from the wall about 8 inches and had the appearance of being dirty/ un-kept. The base boards were cracked with pieces missing leaving voids/ holes that could not be cleaned and disinfected.
The tour of room 1602 revealed tape residue

Based on record review, observation, and interview, the facility failed to ensure the patient had a current or updated history and physical on the chart prior to the surgical procedure on 3 (#40, #46, and #54) of 10 ( #40. 46, 47, 48, 49, 50, 51, 52, 53, and 54) patients.
A review of Patient #46's record revealed the patient was a 37 year old admitted for Laser Lithotripsy procedure and arrived at the "Same Day Surgery" area on 6/16/2015 at 8:15 AM. The history and physical was from Physician #107's office dated 6/10/2015. The facility stamp used to update the History and Physical was stamped as, "There have been no changes in the patient's physical history" dated and timed by Physician #107 on 6/16/2015 at 7:00 AM prior to the patient arriving to the facility.
An interview with Patient #46 on 6/16/2015 at approximately 10:00 AM in the holding area confirmed the patient had not spoken with the physician.
A review of Patient #54's record revealed the patient was a 62 year old female admitted for ICD (implantable cardioverter-defibrillator) malfunction. The history and physical was dated 6/15/2015, but there was no time noted if the history and physical was conducted prior to surgery.
An interview with Staff #44 on 6/19/2015 after 12:00 PM confirmed the above findings.


32143

A review of Patient #40's chart revealed the patient was a 61 year old admitted to the Emergency Room (ER) for altered mental status and bradycardia. Patient arrived via helicopter to the ER on 6/2/15 at 12:51 AM (after midnight). The History and Physical written by Physician #107 and #108 revealed there was no date or time of the physical exam. Physician #107's History and Physical was dictated on 6/2/15 at 11:08 AM (after the surgical procedure) and Physician #108's History and Physical was dictated on 6/3/15 at 2:14 PM (the following day).

Based on record review, observation, and interview, the facility failed to provide adequate post-operative care areas for the patients receiving surgical procedures.
During a tour of the surgical area, 14 functional operating rooms were observed. In the postoperative care unit there were only 12 post anesthesia patient care areas. One of the patient care areas was being used for storage of wheelchairs and other equipment. The monitoring, suctioning, and oxygen supplies had been removed from the patient care area. The post anesthesia care area only had 11 functional bay areas.

The recommendations and standards of practice by the American Society of Anesthesiologist recommended the following:

"The appropriate number of PACU bed slots will vary with the surgical case mix, the length of the cases (e.g., will first cases likely be discharged from the PACU before second cases are finished?) and the usual turnover time of both the OR and PACU beds. A high turnover of outpatients or a significant number of long-stay ICU patients will create a need for more PACU bed slots. In the past, the suggested guideline was that the number of PACU bed slots should equal the number of rooms in the OR suite. This idea has been replaced by a newer algorithm that recommends there should be one and a half to two PACU slots for each room in the OR suite. The factors described above and any other unusual issues for that particular PACU could impact such calculations. The important point is to involve all relevant personnel and departments (including support services, such as respiratory therapy and housekeeping) very early in the decision-making process. Their input can impact the decision as to how many bed slots to build."
The recommendations and standards of practice by the Facility Guidelines Institute; September 15, 2014 revealed the following:

"Operating Room Requirements for 2014 and Beyond

The number of Phase I (PACU or post-anesthetic care unit) patient care stations required in both inpatient and outpatient settings has been defined as 1.5 per OR. If that calculation yields a fraction, the number of patient care stations provided is to be rounded up to the next whole number. As explained in the definition of patient care areas, a patient care station can be a single-patient room or a bay or cubicle in a room with spaces for multiple patients."
An interview with Staff #31 on 6/17/2015 at approximately 2:00 PM confirmed the above findings.

Based on record review and interview, the facility failed to ensure the patient's record had an operative report on the chart after the procedure was completed on 1 ( #54) of 10 ( #40. 46, 47, 48, 49, 50, 51, 52, 53, and 54) patients.
A review of Patient #54's record revealed the patient was a 62 year old female admitted for lCD (implantable cardioverter-defibrillator) malfunction. The record revealed the start time of the procedure was 1:58 PM. A review of Patient's #54's post procedure progress note dated 6/15/2015 and timed 1:30 PM was written before the patient's procedure was performed.

An interview with Staff #44 on 6/19/2015 after 11:00 AM confirmed the above findings.

Based on record review, observation, and interview, the facility failed to ensure the patient had a post-operative anesthesia evaluation on 1 (#54) of 10 ( #40. 46, 47, 48, 49, 50, 51, 52, 53, and 54) patients.
A review of Patient #54's record revealed the patient was a 62 year old female admitted for ICD (implantable cardioverter-defibrillator) malfunction. The post-operative anesthesia evaluation note was left blank on the form. Patient was discharged at 3:06 PM from the facility.
An interview with Staff #44 on 6/19/2015 after 12:00 PM confirmed the above findings.