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Based on observation, record review, and interview, the facility failed to demonstrate responsibility for the water treatment and dialysate supply systems to protect hemodialysis patients from adverse effects arising from known chemical and microbial (bacteria culture and endotoxin/lal results of all dialysis equipment) contaminates, in that,

there was no quality review for December 2018 and January 2019 for 3 of 6 dialysis machines/equipment that were available for patient use.

(January 2019 missing: Serial #1306115, #4TOS139670, and #4TOS147952; December 2018 missing: #141007, #4TOS139670, and #4TOS147952)

Findings included

During a tour on 3/04/19 ending at 2:26 PM, Personnel #47 was providing Patient #23 with treatment. Patient #23 has 2 hours and 55 minutes left of the treatment. Review of the equipment side books revealed missing monthly (bacteria culture and endotoxin/lal results ) reports. The reports were not present for review for the two (Reverse Osmosis water machine; Serial #1401007 and #1306115) water machines. There was no RO (Reverse Osmosis machine) disinfection (Minnacare) documentation present for review. The water machine form had an area to document the disinfection. There was no indication the disinfection had been completed. There were 4 (Serial #4TOS129744, #4TOS133136, #4TOS139670, and #4TOS147952) dialysis machines available for patient use.

#1401007 - no monthly report for November, October, September, August and July 2018 present for review (previous 6 months)

#1306115 - no monthly report for December or July 2018 present for review

During interview on 3/04/19 ending at 2:26 PM, Personnel #47 reviewed the equipment side books and confirmed the above findings. Personnel #47 was asked about the disinfection documentation. Personnel #47 stated they (biomed) do it on a Sunday. I don't know where they document it. Personnel #47 stated she would have biomed bring the missing reports for each of the 6 machines available for patient use and the disinfection documentation.

During an interview and second tour of the dialysis room on 3/05/19 ending at 11:05 AM, Personnel #4 was asked about the dialysis contract's monthly quality reporting. Personnel #4 stated the documents are reported monthly after she gets it. Personnel #4 was asked about the content of the quality report. Personnel #4 showed the January 2019 and December 2018 reports. Each quality report contained monthly (bacteria culture and endotoxin/lal results ) reports for 3 machines only. Personnel #4 went to the dialysis room and viewed 6 machines available for patient care. The serial numbers were checked against the reports. There were missing monthly reports for 3 machines each month. Personnel #4 indicated she was unaware the provided reports from the dialysis contract did not contain all the information that needed to be reported in hospital quality. Personnel #4 indicated that she does visit the dialysis room often. Personnel #4 was informed the contractor was going to update the equipment side books overnight with all missing reports. Personnel #4 reviewed #1401007's book.

#1401007 - no monthly report for November, October, September, August and July 2018 present for review

The hospital's dialysis quality packet provided by the dialysis contract provider for the months of December 2018 and January 2019 included 3 machines/equipment. The remaining 3 machines/equipment available for patient use were not included in the monthly reporting.

The hospital's quality documentation (Infection Control Meeting) did not contain a review of all 6 machines available for patient use for January 2019 and December 2018.

Based on interview and record review, the facility failed to ensure registered nurses surpervised and evaluated the nursing care for each patient in that, license vocational nurses' (LVNs) shift assessment were completed without evidence of registered nurses' (RNs) supervision and evaluation, citing 2 of 4 patients (Patient #27 and #28) who were discharged from the hospital from 01/28/19 through 02/06/19.

Findings included:

A. Patient #27 was admitted on 01/03/19 for "acute respiratory failure" and subsequently discharged on 01/28/19. On 01/05/19 (night shift) a LVN completed a shift assessment and indicated she would inform the RN supervisor of the findings. There was no evidence that a RN supervised and evaluated the LVN findings for Patient #27 in this particular shift.

On 01/08/19 (morning shift) a LVN completed a shift assessment and indicated she would inform the RN supervisor of the findings. There was no evidence that a RN supervised and evaluated the LVN findings for Patient #27 in this particular shift.

B. Patient #28 was admitted on 01/07/19 for "acute and chronic respiratory failure" and subsequently discharged on 01/29/19. On 01/08/19; 01/09/19; 01/10/19; and 01/12/19 (night shifts) LVNs completed shift assessments and indicated they would inform the RN supervisor of the findings. There were no evidences that RNs supervised and evaluated the LVN findings for Patient #28 in these particular shifts.

During an interview on 03/06/19 at 1:10 PM, Personnel #39 was with the surveyor reviewing Patient #27 and #28 medical records. Personnel #39 confirmed the above findings and was asked to provide a policy and procedure for nursing assessments. At 1:15 PM, Personnel #2 informed the surveyor there was a registered nurse that reviewed patient medical records every 24 hours. Personnel #2 stated the hospital was following the Texas Board of Nursing's minimum requirement for RNs to review LVN findings every 24 hours.

Hospital policy and procedure "Nursing Assessment and Reassessment" reviewed date 01/2019 page 5 required "Re-assessment...B. The routine reassessment of the patient's status includes a system review every shift (12 hours) in the medical surgical unit..."

Obtained on 03/07/19 at 11:03 AM at https://www.bon.texas.gov/practice_bon_position_statements_content.asp#15.27 reflected "The LVN scope of practice is a directed scope of practice and requires appropriate supervision...Supervision is defined as the active process of directing, guiding, and influencing the outcome of an individual's performance of an activity...The LVN collects data and information, recognizes changes in conditions and reports this to the RN supervisor or another appropriate clinical supervisor to assist in the identification of problems and formulation of goals, outcomes and patient-centered plans of care...The LVN cannot perform independent assessments as the LVN has a directed scope of practice under supervision. The LVN participates in the nursing process by appraising the individual patient's status or situation at hand. Also known as a focused assessment, this appraisal may be considered a component of a more comprehensive assessment performed by a RN or another appropriate clinical supervisor."

Based on observation, interviews, and record review, the hospital Director of dietary services failed to ensure safety practices for food handling in the hospital's only kitchen was in compliance with the Texas Food Establishment (October 2015) rules/regulations.

The facility failed to:

1. Keep the Flat Top grill clean and free of spills and grease.
2. Empty and discard old cooking oil in deep fryer.
3. Clean the surrounding surface of deep fryer and stove of splashed grease.
4. Wipe down patient Tray Line shelf.
5. Clean Mixer underneath shelf.
6. Sweep and mop the floor underneath racks in walk-in freezer storeroom.
7. Ensure the cook was wearing beard guard while preparing patient's food.
These failures could affect residents who received their meals from the hospital's only kitchen by placing them at risk for food-borne illness.

Findings included:

Observations of the kitchen on 03/04/19 at 10:30 a.m. revealed the following:

1.The flat top grill was observed to have spilled grease, grime and food residue and crumbs on top.
2.The deep fryer had dark brown cooking oil with surrounding surface covered with crumbs and food debris.
3.The surrounding surface of deep fryer and stove had grease, grime and food residues on the sides.
4. The patient Tray Service Line down shelf was dusty and sticky to touch.
5. The down shelf of the Mixer where the cutting boards were kept was dirty and dusty.
6. The walk-in freezer floor underneath shelf had a dark-brown stain, dirt and food crumps.
7. The cook was observed preparing patient's food and not wearing beard net despite having noticeable long beards.

Interview with the Dietary Manager A on 03/04/19 at 10:47 a.m. revealed she had a cleaning schedule that was not strictly followed. She agreed the flat top grill, the shelf on patient's tray service line, and the deep fryer surface, exterior and interior surface of the stove needed cleaning. She said, "I think I over looked it." She said the walk -in freezer would be cleaned. She stated she would discuss the cleaning schedule with staff and explain the areas to be targeted. She agreed the cook needed to wear a beard net.

An interview with Cook B on 03/04/19 at 10:54 a.m. confirmed the deep fryer grease needed to be changed and the surface and the exterior and interior surfaces of the stove and deep fryer needed cleaning. He said he felt uncomfortable wearing a beard guard and would rather keep it shaved.

Review of the hospital AM/PM -Cook Daily Cleaning Schedule provided by the Dietary Manager on 03/04/19, revealed tasks were initialed by staff members every day during the morning and evening shifts as completed.

Review of the hospital's Policy provided by the Dietary Manager titled "Sanitation and Infection Control" last revised January 2017, revealed " ...sanitation practices are followed to minimize the risk of contamination of food and prevent food borne illness."

The Food and Drug Administration Code 2017, 4-602.13 Nonfood-Contact Surfaces reflected:
"The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests".

The TFER 228.114 (b) ruled indicated, "...The food-contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours..."

Based on interview and record review the facility failed to develop, implement, and enforce policies and procedures to ensure that a sexual assault survivor who presented to the hospital's ED (emergency department) following a sexual assault was provided appropriate care. This deficient practice had the likelihood to cause harm to all sexual assault victims presenting to the ED.

Findings include:

A review of the ED's policy and procedures on 3/05/19, revealed there was no policy for treating a sexual assault victim in the ED.

During an interview on 3/06/19 at 9:50 AM with Personnel #1 he confirmed the hospital did not have a policiy for treating a sexual assault victim in the ED.

Based on record review and interview, the facility failed to ensure rehabilitation services (physical therapy, occupational therapy, and speech therapy) were administered/furnished in accordance with orders of the physician, podiatrist, dentist or other licensed practitioner who is authorized by the medical staff to order the services.

Findings included

Patient #26's record did not reflect a physician order for physical therapy specific to the patient needs.

During an interview on 3/05/19 at 12:52 PM, Personnel #15 was asked about the patient orders. Personnel #15 indicated they have an "eval and treat" order. Personnel #15 was asked if they receive a physician order to treat based on the assessment/recommendation for each patient. Personnel #15 stated no.