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Based on review of records and interview the facility failed to take effective measures to ensure all policies posted in the hospital's on-line policy files were current for staff use. Two (2) out of 17 policies reviewed were not current policies.

Findings include:

On 12-8-2016 during policy review, it was discovered that two of the policies printed from the on-line policy folder were not the current policies.

The first policy, "St Joseph Regional Health Center Multidisciplinary Patient Care Manual of Policies & Procedures; Policy No. 101; Subject: Consults, Physician; Revised Date: June 2011; Reviewed Date: (blank)", was received initially.

The most current version that was not on line was "CHI St. Joseph Health Regional Hospital Department; Policy No. 101; Patient Care Manual; Title: CONSULTS, PHYSICIAN; Effective Date: January 2016; Supersedes: June 2013.

This indicated that the policy had been updated at least one time in between the first policy received (revised in 2011) and the second policy received (effective in January 2016 that superseded a policy that was dated June 2013).

The second policy, "St Joseph Regional Health Center Multidisciplinary Patient Care Manual of Policies & Procedures; Policy No. 104; Subject: Communication Between Caregivers (SBAR); Revised Date: February 2012; Reviewed Date: (blank)", was received initially.

The most current version that was not on line was "CHI St. Joseph Health Regional Hospital Nursing Services Department; Policy No. 104; Patient Care Manual; Title: COMMUNICATON BETWEEN CAREGIVERS (SBARU); Effective April 2015; Supersedes: February 2012.


Interview was conducted with Staff #3 on 12-8-2016. Staff #3 stated she had printed the policies from the on-line policy files. When asked if this was the same file that nursing staff use to access policies, she answered, "Yes." When asked why the policies were not current, Staff #3 stated, "I don't know. Something happens to the computer system and new policies get replaced with older versions. It's been a problem before."

Staff #10 was interviewed on 12-8-2016. Staff #10 explained that random current policies disappear from the sytem and are replaced with older versions. This problem had been an intermittent problem that did not affect all policies when it happened. Staff #10 stated, "This has been going on for over a year. Some areas of the computer system are affected and others aren't. IT has been working on it, but haven't been able to fix it." When Staff #10 was asked how nursing and other hospital staff could be sure they were using current policies and procedure, ensuring safe care of the patient, Staff #10 replied, "We did a work-around." Staff #10 went on to explain that when a policy is found on the system to be out of date, the nurse managers are notified and must educate their staff on the current policy. When asked if there is any type of ongoing quality or process improvement project to work on this problem and to track policies affected or monitor for errors, Staff #10 stated, "No." Staff #10 explained that the parent corporation was mandating a new policy system to be implemented at some point in the future. Staff #10 could not provide a firm date for implementation. Staff #10 confirmed there was no process for identifying the number of policies affected, how often it was happening, or when it was happening so it could be immediately corrected when it did happen. Staff #10 confirmed that staff could still access and use outdated policy and procedures that could affect safe patient care.

Based on review of records and interview, the hospital failed to ensure a properly executed informed consent form was completed per the hospital policy in 3 out 5 consents reviewed.

Patient #1 and Patient #3's charts were reviewed for consents. Two (2) consents on Patient #1's chart were not signed by the physician prior to the consented procedure.

On 2/16/16, a consent was executed and signed by Patient #1's son. It was witnessed at the time of family consent by the nurse. The statement containing a fill-in-the-blank line, " ...to treat my condition which has been explained to me/us as: __________ " , was left blank. The patient condition was not listed. The patient discharged from the hospital on 2/25/16. They physician electronically signed the consent on 3/4/16.

On 2/20/16, a consent was executed and signed by Patient #1's wife. The consent was witnessed at time of family consent by the nurse. The patient's condition was listed as "Anemic". The statement containing a fill-in-the-blank line, "I (we) understand that the following surgical, medical, and/or diagnostic procedures are planned for me and I (we) voluntarily consent and authorize these procedures ___________", was left blank. No procedures had been listed. The patient discharged from the hospital on 2/25/16. The physician electronically signed the consent on 3/8/16.

On 2/23/16, a consent was executed and signed by Patient #1's wife. The consent was witnessed by a nurse on the same day. However, the nurse had not timed her signature. " ...to treat my condition which has been explained to me/us as: __________ " , was left blank. The patient condition was not listed. The physician signed, dated and timed the consent prior to the procedure.

An interview was conducted with Staff #5 on 12-8-2016. Staff #5 stated, "The policy allows the physician to sign the form at a later date."

Review of "Rules and Regulations of the Medical Staff - St. Joseph Regional Health Center Bryan, Texas; Article X - Informed Consent; 6/22/2016; Part A: Responsibility for Obtaining Informed Consent" was as follows:
"It is the physician's duty to inform patients about risks and alternatives to proposed medical and surgical procedures. Although nurses may assist in preparing the disclosure and consent form and obtaining the necessary signatures, the physician involved must make himself/herself available to the patient to answer question and to discuss the information contained in the form."

Review of "St. Joseph Health System Policy Manual; Subject: Consents, Informed; Number: PC 684; Revision Date(s) November, 2015 revealed the following:

"POLICY STATEMENT: The policy regarding Informed Consent for Medical treatment or surgical procedure is based on the Rules and Regulations of the Medical Staff of St. Joseph Regional Health Center. Consents will be obtained from all patients or their legal guardian prior to performing any procedure or treatment. A surgical consent or medical consent for treatment is a written contract between the physician and the patient or legal guardian of the patient. The consent will specify the patient's condition or illness and specifies the appropriate intervention. The patient/relative/guardian physician will sign, date, and time the consent form. This certifies that the nature, purpose, benefits, risks of and alternatives to the operation/procedure(s) have been discussed. It validates that the patient/relative/guardian fully understands what the physician has explained and answered. The physician obtaining informed consent, using the available clinical evidence and their professional judgment, is responsible for making the determination which risks, benefits, and alternatives will be discussed with the patient. The physician will document informed consent in the patient's hospital medical record. Physician signature, date and time is required on the consent form. It also validates that the physician signature also indicates that the physician understands that the form is only documentation the informed consent process took place in the event that the physician was not present when the patient signed the form. The physician also acknowledges responsibility for having obtained consent from the patient by his/her signature on the Surgical/Procedural consent form.

A properly executed consent form contains the following elements: Name of Hospital where the procedure or other type of medical treatment takes place/ Name of specific procedure, or other type of medical treatment; Name of responsible practitioner who is performing the procedure or administering the medical treatment; statement that the procedure or treatment, including anticipated benefits, risks, and alternative therapies was explained; date, time and signature of the patient or the patient's legal representative; and date, time, and signature of the person witnessing the patient or the patient's representative signing the consent form and date, time and signature of the physician."

Based on observation, review of record, and interview, the facility failed to store linen in a manner that assured cleanliness was maintained in 3 out of 3 units observed.

On the morning of 12-8-2016, Staff #24 was observed preparing for blood administration on the Oncology Unit. Upon entering the clean supply room to obtain supplies, a pillow was observed to be lying uncovered on the supply room floor next to a linen cart. The linen cart cover had been folded up on top of the cart and secured with linen items placed on top of the cover. This left the linen cart open and linen exposed and able to fall off of the cart. Staff #24 was observed to pick the pillow up off the floor and place on a shelf. Staff #2 was advised of this finding and confirmed the linen cart had been left open.

On the afternoon of 12-8-2016, a tour of linen storage was conducted with Staff #2. The following findings were observed:

Staff #26 provided a tour of linen storage on the Orthopedic Unit. The first linen storage closet had linens hanging off of the bottom shelf between the closet door and the floor. The second closet had wire shelves with metal brackets to hold the shelves. The brackets were placed in a manner that created un-level storage shelves. The un-level shelves created a condition for stacks of linens to tumble over and possibly fall to the floor. This was confirmed by Staff #2 and Staff #24.

Staff #27 provided a tour of linen storage on the Pediatric Unit. Pillows and linens were being stored on top of the linen cart in the clean storage room. Two of the pillows on top of the cart were not covered. Two pillows were laying on table in the clean storage area. Staff #27 could not verify that the pillows were clean, as they were not covered. Staff #27 stated that when she returns pillows to clean storage, she wipes them down with disinfecting wipes prior to bringing them into clean storage, then stores them on the linen cart. Staff #27 stated she does not know how housekeeping cleans them.

An interview was conducted with Staff #28 and Staff #29 on the afternoon of 12-8-2016 and the Infection Control Policy for linens reviewed. Staff #28 and Staff #29 both verified that pillows are considered linen and fall under the requirements of "St. Joseph Regional Health Center; Infection Control Policy & Procedures Manual; SJRCH IC 09; Subject: Linen; Reviewed Date: 11/13, as follows:

"Storage
1. Linen should be stored in a manner that prevents contamination. This may be accomplished by storing clean linen in a closet, covered cart or clean supply room.
2. Linen may be removed from the clean supply area and placed on a cart, covered and transported to the patient care area. Linen on this cart is considered clean, provided the cart is covered.
3. Once linen is removed from the clean linen storage area it is considered contaminated and may not be returned to the clean supply area."