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Based on record review and interview, the facility ' s governing body failed to review and approve the policies and procedures being carried out by the contracted rehabilitation service, Peoplefirst Rehabilitation.

Findings include:

Review of facility policy LD-10.00, " Policy & Procedure Development, " revealed the following: " The hospital shall develop and maintain policies and procedures which comply with state and federal regulations, standards, and the practices of the hospital. "

Review of facility policy LD-4.00, " Contracted services, " revealed the following: " Policies and procedures that relate to, or that are developed by a contracted service, should be adapted to the specific needs of our facility and should follow the format and appropriate approval mechanism and signatures as established by our facility. "

Review of the Peoplefirst policy and procedure manual revealed no approval/signature page signifying that the manual had been approved by the facility ' s governing body.

Review of the contract entitled, " Therapy Service Agreement, " revealed the following: " THIS THERAPY SERVICE AGREEMENT (the " Agreement " ) is entered into and effective as of the 1st day of March, 2011 (the " Effective Date " ), by and between Kindred Rehab Services Inc., a Delaware corporation, d/b/a Peoplefirst Rehabilitation ( " Peoplefirst" ) and the facility. "

During an interview on 8/16/2011 at 1:44pm in the rehabilitation department, staff #11 confirmed that Peoplefirst began providing services in the facility on March 1, 2011. Staff #11 also reported that she was unsure if the Peoplefirst policy and procedure manual had been approved by the facility ' s governing body.

During an interview on 8/16/2011 at 2:39pm in the conference room, staff #12 reported that the Peoplefirst policy and procedure manual had not been approved by the facility ' s governing body.

Based on record review and interview the facility failed to document facility orientation and/ or competency assessment for contract Acute Dialysis staff. Citing 12 of 14 personnel files(#25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, and 38) reviewed.

Findings:
Policy Review: Title: Human Resource File Information Requirements
#HR 06 Manual: Human Resources Effective Date: 09/01/2006 Revise Date: 03/01/2009; 01/21/20211
Scope: Contract Employees, Volunteers, and Students Reference: J C Standard H.R.1.20
Purpose: To define the information needed on file for all contract employees, volunteers, and students who work or intern in the hospital.
Policy: The Human Resources office is required to maintain file information on the above affected individuals.
Procedure: 1. The following items must be collected, prepared or performed and given to Human Resources and maintained in a file before or upon arrival of any contract employee, volunteer or student, as applicable:
a. Verification of current license, registration or certification.
b. Job description
c. Proof of criminal background check.
d. Copy of CPR/ACLS
e. Proof of competency assessment
f. Proof of PPD
g. Completed Hospital Orientation or Fast Track Orientation
h. Contracts with schools assigning students to do clinical rotations in the hospital.

Review of personnel files on 8/16/2011 for contract staff revealed:
Staff # 25, 27, 28, 29, 30, 31, 32, 33, 35, 36, 37, and 38 had no documentation of facility orientation and/or competency assessment.

Interview with staff #12 on 8/16/2011 confirmed there was no documentation of orientation and/or competency assessment for contract staff #25, 27, 28, 29, 30, 31, 32, 33, 35, 36, 37, and 38.

Based on record review, the facility failed to assure medical records were complete within 30 days of patient discharge in 2 of 30 records (#9 and 12).


Findings include:

Review of facility policy RC.01.01, " Completion/Delinquency of Medical Records, " revealed the following: " All medical records shall be completed within 30 days following discharge. "

Review of facility policy RC.01.08, " Timeliness of Documentation in the Medical Record, " revealed the following: " Upon discharge, the medical record should be completed by 30 days. "

A review of patient charts revealed 2 that were incomplete greater than 30 days after discharge, as follows:
-Chart #9- The patient was discharged on 7/7/11 and the chart was incomplete as of 8/16/11. There was no discharge summary on the chart.
-Chart #12- The patient was discharged on 6/21/11 and the chart was incomplete as of 8/16/11. There was no discharge summary on the chart.

Based on record review, the facility failed to assure physician signatures, dates, and/or times were affixed to documents and progress notes on 11 of 30 patient charts (#2, 5, 6, 7, 9, 10, 11, 13, 14, 18, and 25). Based on record review and interview, the facility also failed to assure nurses ' signatures and titles were legible on 3 of 30 patient charts (#22, 27, and 28).

Findings include:

Review of patient charts revealed the following physician signatures, dates, and/or times missing on medical record documents:

-Chart #2- No signature, date, or time on admission guidelines
-Chart #5- No time on history and physical and no time on progress notes on 4/23/11 and 5/1/11
-Chart #6- No time on admission guidelines
-Chart #7- No time on history and physical and no time on admission guidelines
-Chart #9- No time on history and physical, no time on admission guidelines, and no time on progress notes on 5/26/11 and 5/27/11
-Chart #10- No time on progress note on 5/22/11
-Chart #11- No time on history and physical and no time on progress note on 6/19/11
-Chart #13- No time progress notes on 6/26/11 and 6/28/11
-Chart #14- No time progress note on 7/6/11
-Chart #18- No time on progress note on 7/18/11
-Chart #25- No time on history and physical and no time on progress notes on 7/30/11 and 8/8/11

Review of patient charts revealed nurses ' signatures and titles were illegible on 3 of 30 patient charts (#22, 27, and 28).

During an interview on 8/16/2011 at 2:00pm in the conference room, staff #6 and #14 confirmed that nurses ' signatures and titles were illegible on nurses ' progress notes on charts #22, 27, and 28.

Based on record review, the facility also failed to assure written orders were timed in 13 of 30 charts (#2, 5, 6, 7, 10, 11, 13, 14, 16, 18, 20, 21, and 25). The facility also failed to assure the ordering physician countersigned verbal orders in 7 of 30 charts (#16, 18, 19, 20, 22, 23, and 28).


Findings include:

A review of patient charts revealed the following times missing on physician orders (Chart # x number of missing times in the chart):

Chart #2 x 2
Chart #5 x 2
Chart #6 x 2
Chart #7 x 4
Chart #10 x 1
Chart #11 x 1
Chart #13 x 3
Chart #14 x 1
Chart #16 x 1
Chart #18 x 2
Chart #20 x 1
Chart #21 x 2
Chart #25 x 2


Review of medical records revealed 7 charts where verbal orders were not countersigned, as follows (Chart# x number of verbal orders not countersigned):

Chart #16 x 1
Chart #18 x 1
Chart #19 x 1
Chart #20 x 1
Chart #22 x 2
Chart #23 x 1
Chart #28 x 2

Based on record review, the facility failed to assure verbal orders were authenticated by the ordering physician within 48 hours in 14 of 30 charts (#2, 4, 6, 8, 9, 13, 16, 18, 19, 20, 21, 22, 23, and 28).


Findings include:

Review of facility policy RC.01.07, " Telephone Orders, " revealed the following: " 4. All other orders for medications and biologicals shall be authenticated and dated by the attending physician within forty-eight (48) hours. "

Review of medical records revealed 14 charts where the verbal order countersignature had not been dated; therefore, the facility could not assure the orders had been countersigned within 48 hours, per regulation. Findings were as follows (Chart# x number of undated verbal order countersignatures):

Chart #2 x 1
Chart #4 x 3
Chart #6 x 1
Chart #8 x 2
Chart #9 x 1
Chart #13 x 2
Chart #16 x 1
Chart #18 x 1
Chart #19 x 1
Chart #20 x 1
Chart #21 x 1
Chart #22 x 2
Chart #23 x 1
Chart #28 x 2

Review of medical records revealed 7 charts where verbal orders were not countersigned, as follows (Chart# x number of verbal orders not countersigned):

Chart #16 x 1
Chart #18 x 1
Chart #19 x 1
Chart #20 x 1
Chart #22 x 2
Chart #23 x 1
Chart #28 x 2

Based on record review, the facility failed to assure a history and physical (H&P) examination was completed and placed on patients ' charts within 24 hours of admission in 9 of 30 charts (#3, 9, 13, 14, 16, 17, 19, 21, and 28).


Findings include:

Review of facility policy RC.01.05, " History and Physical Documentation, " revealed the following: " The History and Physical must be performed and documented in the medical record for all patients within 24 hours of admission. "

Review of facility policy RC.01.08, " Timeliness of Documentation in the Medical Record, " revealed the following: " A complete History and Physical must be completed within 24 hours of all admissions. Handwritten History and Physicals are acceptable if legible. "

A review of patient charts revealed nine history and physical notes were placed in the medical record more than 24 hours after admission (charts #3, 9, 13, 14, 16, 17, 19, 21, and 28). In all cases, the history and physical note was transcribed greater than 24 hours after the patient ' s admission and no handwritten history and physical note could be found.

Based on observation and documentation review the facility failed to administer services in accordance with professional principles in 3 of 3 incidences recorded.


On 8/16/2011 at 11:00 AM in the 3rd floor medication room, an individual patient storage unit was observed to contain Triamcinolone cream for topical use, 4% lidocain for wound care anesthetic, and injectable insulin. All observed medications had been previously opened for multi-dose use in a single patient.

Texas administrative Code Title 22 part 15, chapter 291, sub-chapter D rule 291.74 page #4 General Requirements Item (G) The institutional pharmacy shall store antiseptics, other drugs for external use, and disinfectants separately from internal and injectable medications

Further observation revealed Chlorhexadine Gluconate 0.12% for patient #22 was observed to be labeled as follows "PO 3 x daily." A review of the manufacturer label revealed the drug was an oral antiseptic intended for rinse and spit, not to be swallowed.

Texas Administrative Code Title 22, part 15, chapter 291, sub-chapter B Rule 291.33 (A) (7) Labeling (vii) Instructions for use that is printed in an easily readable font size .....

An interview on 8/16/2011 at 11:30 AM with staff # 15 revealed the labels were printed with PO instructions and could be changed to read rinse and spit. Staff #15 also confirmed the information on the label did not meet required labeling standards.

Further review revealed reconstituted liquid Erythromycin, trade name Eryped, 400 mg had a dispense date of 8/14/2011 but no expiration or use by date on the label.

Texas Administrative Code Title 22, part 15, chapter 291, sub-chapter B Rule 291.33 (xv) Effective June 1, 2010,....Unless otherwise specified by the manufacturer the beyond-use-date shall be one (1) year from the date the drug was dispensed or the manufacturers date which ever is earlier.. The beyond-use-date may be placed on the prescription label or on a flag attached to the bottle.

Based on document review and interview the facility failed to insure 2 physicians participated in the utilization review committee in 2 of 2 committee opportunities.


On 8/17/ 2011 at 11:00 AM, an interview with staff #12 and staff #4 revealed the Utilization Review Committee (URC) had not been able to meet during the 1st and 2nd quarter because the 2 contracted physicians had not participated in the meetings. It was recommended by the remaining URC participants to restructure the committee and utilize physicians from within the facility. The URC recommendation had been scheduled to be presented to the Governing Body (GB) at their next scheduled meeting. The committee had not met pending GB approval.

Staff #12 and staff #4 confirmed there were no distinct URC meeting minutes for review.

Based on record review and interview, the facility failed to assure the quality of its contracted linen service. The linen services did not report to the hospital ' s Organizational Improvement Committee (OIC).

Findings include:

Review of the hospital ' s OIC minutes from January 2011 to July 2011 revealed that the linen service was not reporting to the committee.

During an interview on 8/17/2011 at 10:30am in the conference room, staff #12 confirmed that linen service was not reporting to the OIC.

Based on document review and observation the facility did not enforce hand washing policies in 9 of 9 patients observed.

On 8/17/2011 at 12:00 PM, on the second floor, during the delivery of patient meal trays staff # 21, 22, 23, & 24 ( 2 Personal Care Technicians, a nurse and unit secretary) were observed. All staff delivered trays into patients' rooms. No staff was observed to use alcohol hand sanitizer prior to entry into the patient room. Only staff #23 was observed to enter the room of a patient in contact isolation and use alcohol hand sanitizer upon exiting the room, however, no Personal Protective Equipment was donned by staff #23 prior to entering the room and setting up the patient's meal tray. After exiting the contact isolation room, staff #23 was observed entering another patient's room to deliver the meal tray.

On 8/17/2011 at 1:00 PM, the facility policy # IC-5.00 Hand Washing Hygiene Program was reviewed and revealed the following: Procedure; A) The facility considers hand washing the single most important procedure for preventing the spread of infection. Routine hand washing before and after patient care and as otherwise indicated, will be part of the healthcare workers repertoire. B) The hospital will ensure that when hand washing facilities are not readily available an antiseptic hand cleanser is provided to use as a temporary measure only.

Alcohol foam dispensers were observed outside each patient's room.

A review of hospital policy # IC-6.00 Standard Precautions/ Isolation Precautions Isolation guidelines Tier 1 and 2. A.) 4. Gloves are worn when touching blood, body fluids, secretions, excretions, non-intact skin, mucous membranes, or contaminated items after each patients contact. Gloves should be removed and hands washed immediately after each patient contact.

Facility staff did not utilize gloves while delivering and setting up trays in a contact isolation room and did not follow the facility hand washing policy when entering and exiting patients rooms during meal tray delivery.