HospitalInspections.org

Based on observation, review of records, and interview, the facility's Governing Body failed to ensure all contracted services were provided in a safe and effective manner.

Findings included:

On 6-2-25 at 2:23 PM during a tour of the ICU, an ice machine was observed to have a heavy buildup of white deposits, pale green gelatinous substance and pink residue around the dispense tube. On 6-2-25 at 2:26, the ice machine for the medical unit was observed to have a light buildup of mineral deposits.
On 6-3-25, review of maintenance records revealed a contracted service had cleaned both machines a week prior, on 5-28-25.

Review of the work order showed a "Description" of services as follows:
"Quarterly - Note: Ice machine cleanings will be scheduled with an onsite Supervisor prior to removing from floor. 1) Check operation of ice machine. 2) Clean condenser coil, as required. 3. Inspection ice trays, clean as required (for cleaning refer to manufacturer's procedures) 4) inspect ice bin, replace rubber seal, clean as required. 5) Clean exterior and interior and for proper drainage. 6. Replace water filter(s) before back in service."

The manufacturer's manual was provided and reviewed on 6-3-25. The manual, page 15 stated, "NOTE: A Sanitizing Procedure must be performed after all cleaning procedures have been completed."

Interview with Staff #7 on 6-3-25 confirmed the ice machine had not been effectively cleaned per the instructions in the manufacturer's manual. The ice machine was removed from service and the contracted service provider was called out to clean and sanitize the ice machine.

Contaminated water from ice machines had the potential to cause a life-threatening illness in debilitated patients such as those in the ICU.

On 6-4-25 at 1:49 PM, contracted Staff #22 was observed in room #8 (a contact isolation patient's room) without wearing any Personal Protective Equipment (PPE). Staff #22 was observed to leave the room without washing his hands in the room or in the sink outside of the room. The observation was confirmed with Staff #11.

On 6-4-25, Staff #22's personnel file was reviewed. Staff #22 went through a contractor's orientation on 5-5-2015 with a completed General Hospital Orientation Post Test in his file. The test was observed to include information on PPE and handwashing. Review of Staff #22's personnel file showed that he had not attended annual training required of staff since that time.

Failure to wear PPE while in an infectious patient's room and failure to wash hands at the time of exit of an infectious patient's room could result in the spread of dangerous infections to other patients and staff.

Staff #1, Staff #2, and Staff #12 were asked to provide any evidence of quality indicators or measures that had been used to evaluate contracted services in the past. No such evidence was provided. During interview with Staff #1 and Staff #2 on 6-4-25 at 9:50 AM, it was confirmed that no contract services had been routinely evaluated using measurable quality indicators to ensure services were safe and/or effective.

Based on a chart review and interviews, the facility failed to ensure that the physician documented and signed the blood consent before the patient received information about the risks and benefits of blood prior to signing a consent for blood administration in both patients reviewed, Patient #1 and #12.

Findings included:

A review of the facility policy and procedure, "Consent for Medical and Surgical Procedures," stated, "Policy- Informed consent is the responsibility of the physician and must be obtained by them ... 7. Statement that the procedure was explained to the patient or guardian and name/signature of the person who explained the procedure."

A review of patient #1's chart revealed the patient was ordered 1 unit of packed red blood cells on 5/8/25. The blood consent was signed by the patient and the nurse on 5/8/25 at 1640. The physician did not sign and date the consent until 5/8/25 at 1700.

A review of patient #12's chart revealed that the patient was ordered 1 unit of packed red blood cells on 5/12/25 at 9:50 am. Patient #12 and the nurse both signed the consent on 5/12/25 at 9:50 am. The physician did not sign the consent until 5/12/25 at 1900. There was no documentation in the physician's notes or the history and physical that indicated the patient was informed of the risks and benefits prior to the consent.

An interview was conducted with staff # 13, CNO, on 6/3/25 in the afternoon. Staff # 13 stated the physicians had training on the process and had been calling the patients if they were not in the facility before the consents were signed. Staff #13 confirmed that with patient #1 and #12 charts, the physician had not documented prior to the consent that the risks and benefits were discussed with the patient to allow the patient to make an educated decision.

An interview was conducted with Staff #10 MD on 6/3/25 at 1:46 PM. Staff #10 stated that he will have some more education sent out to the physicians to ensure the documentation is charted appropriately. Staff #10 asked questions and stated that the physicians were not aware that they could document the risks and benefits to the patient before admission or after admission in the History and Physical. Staff #10 stated he would take the issue back to the PI process.

Based on review and interviews, the facility failed to ensure a completed nurse staffing plan was developed, approved by the governing body, and followed to ensure safe staffing was available for safe patient care in 2 of 2(Harlingen and Brownsville) campuses.

Findings included:

A review of the nurse staffing grid revealed the nurse staffing for both campuses. (A nurse staffing grid is a tool used to determine the optimal number and type of nursing staff needed to meet patient care needs. It helps balance patient acuity levels, workload, and available nursing resources to ensure safe and efficient patient care.) The grid was a tool that must address all units and include all staff required at a minimum to maintain patient safety.

A review of the staffing grid revealed that it did not differentiate between the Intensive Care Unit and the Medical Unit. There was no way to determine what staff were required. The grid revealed that if 1 to 8 patients were on a unit, only 1 Registered Nurse (RN) and an unlicensed unit clerk were required. The RN would be left with up to 8 patients on a closed unit with no other licensed personnel, leaving the unit vulnerable.

A review of the policy and procedure, "Nurse Staffing Plan," stated, "POLICY
Solara Specialty Hospital will ensure that a sufficient number and mix of licensed clinical individuals are on site at all times to support safe, quality care, treatment and services offered, there will be adequate numbers of registered Nurses (RNs) Licensed Practical (Vocational) Nurses and other personnel to provide nursing care to all patients. Cornerstone Hospital ensures the nurse executive (CNO/CCO), RNs, and other designated nursing groups have input into the development of nurse staffing plan(s). In addition, it is the policy of Cornerstone Hospital to use data and information to improve the safety and quality of care, treatment, and services. The leaders must provide the resources needed for data and information use, including staff, equipment, and information systems. Also, the hospital will use data and information in decision-making that supports the safety, quality of care, treatment, and services. Lastly, the hospital will evaluate how effectively the data and information are used throughout the hospital ...The staffing plan for each unit (Attachment A0 establishes the minimum staffing levels for that unit."

A review of Attachment A revealed at the top" Staffing Levels for Nursing /Departments (insert specific staffing plans). The plan was blank.

An interview was conducted with Staff #13, CNO-Harlingen campus, on 6/3/25 in the afternoon. Staff #13 stated that the staffing grid was something that came from the corporate office, and it did not fit for her facility. Staff #13 stated that she did not use the corporate grid but had made her own. A review of staff #13's grid revealed 2 separate grids, one for the ICU and one for medical medical-surgical floor. Staff #13 stated that both the Harlingen campus and the Brownsville campus had a joint Nurse Staffing Effectiveness Meeting each quarter, but her grid was not created in the meeting, and it was not approved by the governing body. There was no evidence in the 3/31/2025 Nurse Staffing Committee Meeting minutes that a discussion was held on adequate staffing, any PI process to develop or approve a nurse staffing grid, or how patient needs were considered, how the nurse-sensitive outcomes were measured, and used in developing a safe plan.

An interview was conducted with staff #3 CNO -Brownsville, in the afternoon of 6/4/25. Staff #3 stated that the only grid she had was from the corporate office, and she did not use it. Staff #3 stated that she and the house supervisor decided on the staffing by looking at the patients and their acuities. Staff #3 was asked if she used an acuity tool when making the decisions. Staff #3 provided a blank acuity tool but confirmed she did not use it to make staffing decisions.

A review of the policy and procedure, "Nurse Staffing Plan," stated, "PATIENT CLASSIFICATION TOOL/ACUITY ASSESSMENT stated, "Due to the nature of the LT ACH industry, the average length of stay is about 25 days. Admissions are planned, and there are not the dramatic fluctuations in acuity as seen in short-term acute care hospitals. Therefore, the nurse executive or designee will review classification/acuity at a minimum of daily and PRN. This information is used during the daily assignment of patients and the annual budgeting and planning process to ensure that patient needs are always met and that patient/staff safety remains at the forefront. Due to the nature of our industry and the need to distinguish between licensed and non-licensed duties, this tool takes a unique approach to staffing. This tool specifically addresses the needs of licensed nurses (RN, LVN/LPN). RN Supervisors/Charge RN Nurse will be assigned patients when situations arise and additional licensed nursing staff is called in. The tools attached for the Patient Classification/Acuity is at the discretion of the RN Supervisor/Charge RN and direct patient care nurse to adjust the staffing based on the patient's condition."