January 10 Health Inspection of Renaissance Hospital Terrell

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING
PRINTED: 01/28/2013 FORM APPROVED
OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED
450683
NAME OF PROVIDER OR SUPPLIER
B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE
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01/10/2013
RENAISSANCE HOSPITAL TERRELL

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG
1551 HWY 34 S
TERRELL, TX 75160
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE
{A 000} INITIAL COMMENTS Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.
{A 000}
An unannounced complaint survey was conducted on site. An entrance conference was held in the Physcian's lounge on 11/13/1012 at 10:00 AM with the Assistant Administrator, Chief Nursing Officer, and Medical Record Director. The purpose and process of the survey was explained and an opportunity was given for questions and discussion.
COMPLAINT: TX 00167549 -SUBSTANTIATED. The condition and deficient practices were identified on 11/15/2012 under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient's health and safety and placed patients at risk of potential harm, serious injury, and possibly subsequent death. 42 CFR 482.13 Patient Rights 42 CFR 482.23 Nursing Servicies 42 CFR 482.42 Infection Control 42 CFR 482.51 Surgical Servicies
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE
(X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: 695E12
Facility ID: 810260
If continuation sheet Page 1 of 219
OMB NO. 0938-0391

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450683
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1551 HWY 34 S
TERRELL, TX 75160
{A 000} Continued From page 1 It was determined that the facility: 1. Failed to ensure nursing provided assessments, nursing interventions, and nursing care to 2 of 2 (#s' 1 and 10) patients which resulted in deaths. This deficient practice caused harm in 2 of 2 (# 1 and #10) patients and had the potential to cause harm to all patients. The facility failed to provide Registered Nurses for supervision and assessment of patient care and provide an RN to be immediately available to the nursing units.The facility failed to ensure nursing provided RN supervision of care to 3 of 3 (#s 10, 12 and 14 ) patients, and nursing staff were competent in the required certifications and annual specialized training in 5 of 5 (# 1, 5, 12, 14, and 16) Emergency Department (ED) and 4 of 4 (# 1, 5, 16,and 25) Intensive care unit (ICU) employee files reviewed. Refer A144, A392, A397 2. Failed to provide surgical services with qualified supervision, a safe and sanitary environment for patients receiving surgery, safe post-opertive care, properly processed supplies and instruments which placed patients at risk for infections and possible death. The Surgical Department had performed 82 cases from 6/6/2012 through 11/12/202012. Refer A144, A942, A944,A956, A957
{A 000}
3. Failed to provide a safe and sanitary environment to prevent infections in the Surgical setting. The facility failed to properly sanitize
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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450683
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1551 HWY 34 S
TERRELL, TX 75160
{A 000} Continued From page 2 invasive instruments used in surgery, ensure sterilization processes were followed according to manufacturer guidelines and facility policy, and failed to ensure surgical equipment was in proper working condition. The facility failed to provide evidence of an Infection Control Program which included a system for identifying, reporting and investigating facility associated infections. Refer to A144, A747
{A 000}
The "Plan of Removal" for the Immediate Jeopardy was received on 11/15/2012 from the facility but the plan had not been fully implemented to effectively remove the Immediate Jeopardy.
Survey findings were presented at an exit conference on 11/15/2012 at 5:30 PM with the facility Assistant Administrator, Chief Nursing Officer, and Medical Record Director who were informed the complaint was substantiated with deficiencies cited.
An opportunity was provided for the facility to provide evidence of compliance with those requirements for which non-compliance had been found during the survey. None was provided.
An unannounced follow-up visit was conducted from 01/07/2013 through 01/10/2013 to determine the compliance status of the hospital particularly those deficient practices cited at
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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450683
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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 000} Continued From page 3 Immediate Jeopardy level during the 11/15/2012 survey. An entrance conference was held with the Administrator and the Director of Nurses in the Physician's Lounge on 01/07/2013 at 9:30 am. The purpose and process of the survey was explained and an opportunity was given for questions and discussion. An exit conference was conducted on 1/10/13 at 2:30 pm in the physician's lounge with the Administrator and the Director of Nurses. The preliminary findings were discussed and an opportunity was given for discussion and to provide additional information.
{A 000}
The following was determined: The facility failed to implement the Plan of Correction that had been provided to remove the Immediate Jeopardy cited on the 11/15/2012 survey. The Immediate Jeopardy deficient practices previously cited during the 11/15.2012 survey were determined unabated for the following Conditions of Participation: 42 CFR 482.13 Patient Rights , 42 CFR 482.23 Nursing Services , 42 CFR 482.42 Infection Control , 42 CFR 482.51 Surgery Services In addition, it was determined that Immediate Jeopardy situation were found on the following Conditions of Participation:
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
TERRELL, TX 75160
{A 000} Continued From page 4 42 CFR 482.12 Governing Body, 42 CFR 482.41 Physical Environment
{A 000}
Based upon the findings of the follow-up survey, the facility was found not in compliance with the following Conditions of Participation: 42 CFR 482.12 Governing Body 42 CFR 482.13 Patient Rights 42 CFR 482.21 QAPI 42 CFR 482.22 Medical Staff 42 CFR 482.23 Nursing Services 42 CFR 482.25 Pharmaceutical Services 42 CFR 482.26 Radiology Services 42 CFR 482.27 Laboratory Services 42 CFR 482.28 Food and Dietetic Services 42 CFR 482.41 Physical Environment 42 CFR 482.42 Infection Control 42 CFR 482.45 Organ, Tissue, Eye Procurement 42 CFR 482.51 Surgical Services 42 CFR 482.52 Anesthesia Services 42 CFR 482.54 Outpatient Services A 023 482.11(c) LICENSURE OF PERSONNEL The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This STANDARD is not met as evidenced by: Based on record review and interview the facility failed to ensure and provide documentation of current annual competencies, annual skills competencies, Cardiopulmonary Resuscitation (CPR), Advance Cardiac Life Support (ACLS), and/or current certifications required for nurses working in the emergency department and other
A 023
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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450683
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1551 HWY 34 S
TERRELL, TX 75160
A 023 Continued From page 5 personnel providing direct patient care. This has the potential to provide an unsafe environment for all patients receiving care at this facility. Citing 22 of 30 personnel files reviewed. ( #'s 3, 4, 5, 11, 14, 17, 24, 25, 30, 31, 32, 34, 36, 37, 38, 41, 42, 44, 45, 46, 50, and 51). Review of personnel records on 1/8/13 and 1/9/13 revealed the following: 1. Staff #3 - No documentation of current annual training including infection control, annual skills competencies, and no certification to work in the emergency room, Pediatric Advanced Life Support (PALS) and/or Trauma Core Nurse Course (TNCC) found. 2. Staff #4- No documentation of current annual training including infection control, annual skills competencies, and/or current certification to work in the emergency room, PALS and /or TNCC found. 3. Staff #5- No documentation of current PALS/TNCC found. 4. Staff #11- No documentation of current annual competencies, infection control, and/or annual skills competencies found. 5. Staff #14- No documentation of current annual skills competencies found. 6. Staff #17- No documentation of current annual competencies and/or annual skills competencies found. 7. Staff #24- No documentation of current
A 023
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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450683
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1551 HWY 34 S
TERRELL, TX 75160
A 023 Continued From page 6 annual training including infection control and/or annual skills competencies found. 8. Staff #25- No documentation of current annual training including infection control, no annual skills competencies, and no certification to work in the emergency room, PALS and/or TNCC found. 9. Staff #30- No documentation of current PALS and/or TNCC. Also Cardiopulmonary Resuscitation (CPR) expired 9/2012. 10. Staff #31- No documentation of annual skills competencies and no documentation of current CPR certification found. 11. Staff #32- No documentation of current annual training including infection control and no annual skills competencies. No documentation of Advances Cardiac Life Support (ACLS) and/or current CPR certification. 12. Staff #34- No documentation of current annual skills competencies found. 13. Staff #36- No documentation of current certifications to work in the emergency room, PALS and/or TNCC. No documentation of current ACLS certification found. 14. Staff #37- No documentation of current annual skills competencies, and no certifications to work in the emergency room, PALS and/or TNCC found. 15. Staff #38- No documentation of current annual skills competencies, and no certification to
A 023
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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450683
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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
A 023 Continued From page 7 work in the emergency room, PALS and /or TNCC found. 16. Staff #41- No documentation of annual skills competencies, and no certification to work in the emergency room TNCC found. 17. Staff #42- No documentation of current certifications PALS and/or TNCC found. 18. Staff #44- No documentation of annual skills competencies found. 19. Staff #45- No documentation that employee signed annual training and/or annual skills competencies. No documentation of a current ACLS certification found. 20. Staff #46- No documentation of skill check off and/or training for use of Cidex to sterilize equipment. No signature and/or date and time on annual skills competencies found. 21. Staff #50- No documentation of annual training including infection control and/or annual skills competencies found. 22. Staff #51- No documentation of job description, application, annual training including infection control, annual skills competencies, and no certification to work in the emergency room, PALS and/or TNCC found. Interview on 1/9/2013 with staff #2 confirmed that the personal files were missing current annual training including infection control, skills competencies, current CPR and ACLS certifications, and current PALS and TNCC
A 023
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
TERRELL, TX 75160
A 023 Continued From page 8 required to work in the emergency department. {A 043} 482.12 GOVERNING BODY The hospital must have an effective governing body legally responsible for the conduct of the hospital as an institution. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body. This CONDITION is not met as evidenced by: Based on documents review and interviews, the governing body: A. Failed to provide Registered Nurses for supervision, assessments and timely interventions of patient care for 4 of 4 patients (#'s 1, 10, 12 and 14) experiencing change in conditions with two incidents resulting in patient deaths (#'s 1 and 10). The facility failed to provide Registered Nurses for supervision and assessment, and be immediately available to the nursing units. Licensed vocational nurses (LVN) were allowed to work the Emergency Department (ED), Intensive care unit (ICU), and Medical-Surgical unit without Registered Nurse supervision. The facility failed to ensure that nursing staff were competent to perform nusring fucntions that required certification and annual specialized training in 5 of 5 (CNO, 5, 12, 14, and 16) Emergency Department (ED) and 4 of 4 (CNO, 5, 16 and 25) Intensive care unit (ICU) employee files reviewed.
A 023 {A 043}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
TERRELL, TX 75160
{A 043} Continued From page 9 Refer to tags A0392 and A0397 B. Failed to provide surgical services with qualified supervision, a safe and sanitary environment for patients receiving surgery, safe post-operative care, properly processed supplies and instruments which placed patients at risk for infections and possible death. The Surgical Department had performed 82 cases from 6/6/2012 through 11/12/202012. Refer to A0941, A0942, A0944, A0956, A0957
{A 043}
C. Failed to provide evidence of an Infection Control Program. The facility failed to provide Infection Control Policies and Procedures, including a system for identifying, reporting and investigating healthcare associated infections. The facility also failed to maintain a log of all reportable diseases. A review was done of the Governing Board Committee Meeting Minutes for January 26, 2012, February 23, 2012, March 29, 2012, April 26, 2012, May 17, 2012, June 21, 2012, July 26, 2012, August 23, 2012 and September 27, 2012 and these documents revealed no Infection Control being reported.
During interviews with CNO (Chief Nursing Officer), who identified himself as the Infection Control Nurse, on 11/14/2012 at 10:00 AM in the Doctor's Lounge, there were multiple requests made of him to provide evidence by way of policy and procedures outlining the facility's Infection Control Program. No policies were provided by CNO. CNO was asked to provide documentation/reports that the facility was
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 043} Continued From page 10 providing infection control training, monitoring infections of patients or employees. CNO confirmed there were no reports. CNO provided a notebook containing lab reports and he confirmed these reports were not being tracked or trended into a report.
{A 043}
D. Failed to ensure the facility had a Quality Assessment Performance Improvement Program (QAPI). The facility was unable to provide evidence of an ongoing, hospital wide, data driven QAPI program.
Requests were made of CNO to provide documentation and/or evidence of a QAPI (Quality Assurance Performance Improvement). No written QAPI plan was provided.
An interview was conducted with CNO on 11/14/2012 at 10:00 AM in the Doctors' Lounge to provide insight into the facility's QAPI Program. CNO confirmed the governing body does not set the frequency and detail of data collected. CNO revealed the department managers make the decisions on the quality indicator's they feel appropriate for their department. The manager chooses one indicator to monitor. The manager monitors the indicators for the length of time they feel appropriate to resolve the issue. CNO confirmed there was no QAPI Committee. CNO revealed if there was a safety issue an incident report would be generated. CNO collects the incident reports once the managers complete the follow up. The incident reports are placed in a notebook/ binder. CNO confirmed once the
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 043} Continued From page 11 incident reports are placed in the binder the incident is closed and the facility has no system in place to track, monitor or analyze the incidents. CNO confirmed there was no evidence the facility was tracking health care associated infections, medication errors or the appropriateness of care and treatment. E. Failed to protect and promote patient's rights by: 1. Not providing patients with RN assessments and RN supervision of their care. Refer to tag A0395 and A0397 2. Not providing the required daily safety checks to cardiac equipment and the required preventative maintenance for patient care equipment. Refer to tag A0724
{A 043}
It was determined during the 01/10/2013 survey that the deficient practices that placed the Governing Body out of compliance with the Condition of Participation remain uncorrected. There was no evidence provided or found that the Governing Body made an attempt to correct the previously cited deficient practices. During the follow-up survey from 01/07/2013 through 01/10/2013, it was determined that the previous deficient practices found remained and have created an Immediate Jeopardy situation. The previous deficiencies were not corrected and additional findings were discovered.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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450683
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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 043} Continued From page 12 During the follow-up visit from 01/7/2013 through 01/10/2012, additional findings were as follows: Based upon observations, records review and interviews, the Board of Directors:
{A 043}
A. Failed to provide an effective governing body. During an interview with the CEO and owner on 01/07/2013 at approximately 4:00 PM in the doctors' lounge, the document titled "Governing Board (Governing Body) Bylaws, Article VI, Section (1)," was reviewed. It was revealed by the CEO and the owner that the bylaws being reviewed were that of a previous owner of the facility. The interview confirmed there were no current bylaws for the facility. An attempt was made to establish who was responsible for the conduct of the hospital. CEO and the owner stated the Governing Body. It was revealed the CEO received the federal document (2567) on 12/11/2012. Nether the CEO or the owner had notified the Governing Board of the previous survey or the cited deficient practices by facility until a called Board Meeting on 01/03/2013. An interview was held with chief of staff/governing board member on 01/09/2013 at approximately 1:00 PM in the Doctors' Lounge revealed that neither the Medical Staff nor the Governing Board had been made aware of the survey findings from 11/15/2012 until 01/03/2013 during a called Governing Board Meeting. It was during this meeting that the board was made aware that the owner and CEO had brought in three nurses from another facility in an attempt to correct the
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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450683
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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 043} Continued From page 13 previously cited problems. B. Failed to provide a safe environment for patients. Refer to tag 0144 C. Failed to provide adequate staffing of registered nurse, to supervise patient care and provide assessments. Refer to tags 0392, 0397 D. Failed to provide repair to radiology equipment. Refer to tag 537 E. Failed to keep specimen logs and establish a look back policy that provides for blood safety. Refer to tag 585,593 F. Failed to provide adequate provisions for dietary consultation for patient receiving Total Parenteral Nutrition. Refer to tags 621,628
{A 043}
G. Failed to provide surgical services with qualified supervision, a safe and sanitary environment for patients receiving surgery, safe post-operative care, properly processed supplies and instruments which placed patients at risk for infections and possible death. The Surgical Department had performed 82 cases from 6/6/2012 through 11/12/202012. Refer to A0941, A0942, A0944, A0956, A0957 H. Failed to provide pharmacy policies that were current and approved by the current medical
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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450683
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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 043} Continued From page 14 staff, a secure place for drugs and biological to be stored, designated individual (by name and title of qualification) to remove drugs from pharmacy when pharmacy is closed or otherwise unavailable to facility staff members, and monitor and report adverse drug reactions to Quality Assessment Performance Improvement Committee. Refer to Tag A502, A506, A508 I. Failed to provide and maintain a safe and clean environment for patient care. Refer to Tag A0701, A0702, A0709, A0713,A0724, A0726 J. Failed to provide Organ Procurement Organization (OPO) written agreements, designated requestor, educate direct care staff in organ issues, and to provide coordination between the facility and the OPO to review death. Refer to Tag A0886, A0889, A0891 and A0892 K. Failed to provide adequate provisions for dietary consultations for patients as needed and ensure nutritional needs were being met for a patient receiving artificial nutrition. Refer to Tag A0621 and A0628 L. Failed to provide security of patient records, medical record entries were dated, timed and appropriately authenticated, ensure consents were properly executed and complete, and ensure medical records contained discharge summaries.
{A 043}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
TERRELL, TX 75160
{A 043} Continued From page 15 Refer to Tag A0442, A0450, A0466, and A0468 A 050 482.12(a)(6) MEDICAL STAFF - SELECTION CRITERIA [The governing body must] ensure that criteria for selection are individual character, competence, training, experience, and judgement. This STANDARD is not met as evidenced by: During the follow-up survey from 1/7/2013 through 1/10/2013 additional findings were as follows: Based on documents review and interviews, the facility failed to enforce established bylaws for categories of Medical Staff, appointment and re-appointment, and the term of the appointment. A review of the document titled, "Medical Staff Bylaws," last amended and approved by the Governing Board 11-28-2007, revealed, Article IV Categories of the Medical Staff, Section 1. The Medical Staff, "The Staff shall be divided into Honorary, Active, Courtesy, Consulting and Emergency Room categories." Article VI, Clinical Privileges, Section 2. Temporary Appointment, "Upon the recommendation of the chairman of a department and the Chief Executive Officer of the Hospital or his designee who is acting on behalf of the Governing Body, temporary privileges may be granted during the application process for the care of specific patient(s) or locum tenens, All such privileges shall be time limited and granted only when sufficient evidence exists that granting of temporary privileges is prudent."
{A 043}
A 050
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
TERRELL, TX 75160
A 050 Continued From page 16 Article V, Procedures for Appointment and Re-Appointment, Section 1. Application for Appointment, "(7) The Medical Staff Services is responsible for obtaining information from the Texas State Board of Medical Examiners and the National Practitioner Data Bank. (8) The application, complete with information sufficient to resolve doubts in any matter, shall be submitted to the administration, who upon receipt of all information, including licensure, education, training, experience and past or present Medical Staff membership at other facilities, shall submit the application and all supporting material to the Medical Executive Committee." Section 3, Appointments- Provisional "A All initial appointments and initial granting of clinical privileges shall be provisional and shall be for one year." "D. At the successful completion of the provisional period the Practitioner's status will be reviewed for advancement to the requested category." Section 4. Re-Appointment Process, "A. The Texas Standardized Application shall be fully completed to assure the availability of data necessary to update the member's medical staff file. The completed re-appointment application should include, but not he limited to the following: (1) request for privileges; (2) documentation of current, valid state license, DEA and DPS certificates (DEA and DPS certificates not required for pathologists);
A 050
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 050 Continued From page 17 (3) continuing training, education and experience since the previous appointment that qualifies the staff member for the privileges sought on re-appointment, or serves as justification for new or expanded privileges; (4) sanctions of any kind imposed or pending by any other health care institution, professional health care organization or licensing authority: changes of any kind in Medical Staff membership(s), or privileges at any other health care institution or professional health care organization; (5) documentation of newly obtained board certification or, as appropriate report on timely progress toward meeting pre-certification requirements; (6) the results of the ongoing monitoring and evaluation of each practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs, shall be available for review in the re-credentialing process; (7) involvement in professional liability actions including letters of intent, final judgments and or settlement; (8) agreement that if the applicant is reappointed, he will continue to abide by the Bylaws, Rules and Regulations of the Medical Staff and Hospital ..... When collection and verification are accomplished, the administration shall transmit the application form and supporting materials to the Medical Executive Committee."
A 050
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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TERRELL, TX 75160
A 050 Continued From page 18 Section 5. Terms of Appointment, "Appointments to the Medical Staff shall be made by the Governing Body of the hospital upon the recommendation of the Medical Executive Committee, Appointments shall be for a period of no more than two years." A review of Medical Staff #8's credentialing files contained a letter dated 03/29/2012, granting Temporary privileges for a period of two years. Staff #8's license expired 12/13/2012. The Temporary privileges and time period did not meet the Medical Bylaws definition. Staff #8 is scheduled weekly in the hospital with the Hospitalist. A review of Medical Staff #9's credentialing files contained a letter dated 01/26/2012, granting Provisional privileges for a period of two years. This file does not contain an updated application, request for privileges, the results of the ongoing monitoring and evaluation of the practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs. The provisional period granted does not meet the Medical Bylaws definition. A review of Medical Staff #26's credentialing files contained a letter dated 01/26/2012, granting Provisional privileges for a period of two years. This file does not contain an updated application, request for privileges, the results of the ongoing monitoring and evaluation of the practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs. The
A 050
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
TERRELL, TX 75160
A 050 Continued From page 19 provisional period granted does not meet the Medical Bylaws definition. The review of Medical Staff #29's credentialing files revealed that the files did not contain an updated application, request for privileges, the results of the ongoing monitoring and evaluation of the practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs. Staff #29's previous re-appointment of 12/17/2010 to 12/17/2012 had expired. Medical Staff #86 was presented as an active staff. Staff made the application on 05/07/2012. The file contains no evidence of granting privileges by Medical Staff or by the Governing Board. This Allied Health Professional's file had no evidence of a supervising Physician. A review of Medical Staff #87's credentialing files contained a letter dated 01/26/2012, granting Provisional privileges for a period of two years. Provisional period granted does not meet the Medical Bylaws definition. A review of Medical Staff #88's credentialing files contained a letter dated 03/26/2012, granting Provisional privileges for a period of two years. Provisional period granted does not meet the Medical Bylaws definition A review of Medical Staff #89's credentialing files contained a letter dated 01/26/2012, granting Temporary privileges for a period of one year. The Temporary privileges and time period did not meet the Medical Bylaws definition. Staff is
A 050
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
TERRELL, TX 75160
A 050 Continued From page 20 scheduled weekly in the hospital with the Hospitalist. On 01/10/2013 at 9:30 AM, an interview was conducted with staff #55 in the credentialing office. Staff #55 revealed she did the credentialing and had not had any formal training by the facility. Staff #55 had picked it up by talking with other staff members. Staff #55 had discovered that some of the information provided by staff was wrong. Staff #55 stated, "Still continuing to learn." Staff #55 was not able to tell the surveyor what the categories were in the Medical Bylaws. Staff #55 had not read the bylaws. Staff #55 stated the Medical Staff's credentialing files, containing the application and all supporting material, were not being submitted to the Medical Executive Committee. Staff #55 was submitting a form listing the required elements. Staff #55 would make check marks beside the elements and the Medical Executive Committee would review that form. During an interview on 01/09/2013 at approximately 1:00 PM in the Doctors' Lounge, Medical Staff #29 revealed that neither the Medical Staff nor the Governing Board had been made aware of the survey findings from 11/15/2012 until 01/03/2013 during a called Governing Board Meeting. It was during this meeting that the board was made aware the owner and CEO had brought in three nurses from another facility in an attempt to correct the previously cited problems. Medical Staff #29 was asked, "are there any problems you have voiced concerns about that have not been addressed by the Board of Directors/Owner?" The response was "yes." Staff #29 reported that there have
A 050
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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450683
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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
A 050 Continued From page 21 been questions about the credentialing process. Staff #29 reported that the owner just put his doctors in here without going through the credentialing process. {A 057} 482.12(b) CHIEF EXECUTIVE OFFICER The governing body must appoint a chief executive officer who is responsible for managing the hospital. This STANDARD is not met as evidenced by: Based on documents review and interviews, the governing body failed to follow the established governing board bylaws for appointing and approving the chief executive officer. The review of the document titled, "Governing Board Bylaws, Article VI Administration" contained the follwing in Section 1. "Chief Executive Officer... shall employ a competent, experienced Chief Executive Officer (CEO) of the Hospital (whose appointment shall be reviewed and approved by the Governing Board) .... The authority and duties of the Chief Executive Officer include: L. Designate, in writing, other individuals by name or position that are, in order of succession, authorized to act for him during any period of his absence from the hospital." A review of the document titled, "Governing Board Committee Meeting Minutes for April 26, 2012" contained the following in Section VII. "New business- A. Administrative Changes: CNO (Chief Nursing Officer) informed the committee that we currently had interim CEO, staff #6, explaining to the members that he is not able to be on-site Monday thru Friday at this time; CNO, staff #3 and staff #4 can contact him at all times
A 050
{A 057}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 057} Continued From page 22 and will be the administrative representatives available at the hospital." There was no evidence in this document of staff #6 being present at the April meeting. Review of the meetings for May 17, June 21, July 26, August 23, September 27 and October revealed no evidence staff #6 was present at these Governing Board Meetings. There was no evidence the Governing Board reviewed or approved the appointment of the interim CEO. No written document was made available for review giving authority to CNO, staff #3 or staff #4 to act on behalf of the CEO (Staff #6). An interview was conducted with the staff #6 (CEO/Interim Administrator) in the Doctor's Lounge on 11/14/2012 at 1:00PM. Staff #6 was asked how often he was in the facility. Staff #6 stated it had been 6 weeks since his last visit to the facility.
{A 057}
During the follow-up survey from 01/07/2013 through 01/10/2013, it was determined that the previous practices found remained and the facility had not implemented a plan of correction.
During an interview with the CEO and owner on 01/07/2013 at approximately 4:00 PM in the doctors' lounge, the document titled "Governing Board (Governing Body) Bylaws, Article VI, Section (1)," was reviewed. It was revealed by the CEO and the owner that the bylaws being reviewed were that of a previous owner of the facility. The interview confirmed there were no current bylaws for the facility. An attempt was made to establish who was responsible for the
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 057} Continued From page 23 conduct of the hospital. CEO and the owner stated the Governing Body. It was revealed the CEO received the federal document (2567) on 12/11/2012. Neither the CEO nor the owner had notified the Governing Board of the previous survey or the cited deficient practices by the facility until a called Board Meeting on 01/03/2013 after the due date of the submitted plan of correction.
{A 057}
An interview was held with chief of staff/governing board member on 01/09/2013 at approximately 1:00 PM in the Doctors' Lounge revealed that neither the Medical Staff nor the Governing Board had been made aware of the survey findings from 11/15/2012 until 01/03/2013 during a called Governing Board Meeting. It was during this meeting the board was made aware the owner and CEO had brought in three nurses from another facility in an attempt to correct the previously cited problems. {A 115} 482.13 PATIENT RIGHTS A hospital must protect and promote each patient's rights. This CONDITION is not met as evidenced by: Based on observations, documents review and interviews, the governing body: A. Failed to provide Registered Nurses for supervision, assessments and timely interventions of patient care for 4 of 4 (#'s 1, 10, 12 and 14) patients experiencing change in conditions with two incidents resulting in patient deaths (#'s 1 and 10).
{A 115}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 115} Continued From page 24 The facility failed to provide Registered Nurses for supervision and assessment and to be immediately available to the nursing units. Licensed vocational nurses (LVN) were allowed to work the Emergency Department (ED), Intensive care unit (ICU), and Medical-Surgical unit without Registered Nurse supervision.
{A 115}
The facility failed to ensure that nursing staff were competent to perform nursing functions with the required certification and annual specialized training in 5 of 5 (CNO, 5, 12, 14, and 16) Emergency Department (ED) and 4 of 4 (CNO, 5, 16 and 25) Intensive care unit (ICU) employee files reviewed. Refer to tag A0385 and A0397 B. Failed to provide surgical services with qualified supervision, a safe and sanitary environment for patients receiving surgery, safe post-operative care, properly processed supplies and instruments which placed patients at risk for infections and possible death. Refer A940, A942, A944, A956, A957 C. Failed to provide the required daily safety checks to cardiac equipment and the required preventative maintenance for patient care equipment. Refer to tag A0724
It was determined that this deficient practice

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 115} Continued From page 25 created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failures had the potential to affect all patients admitted to the facility.
{A 115}
During the follow-up survey from 01/07/2013 through 01/10/2013, it was determined that the deficient practices found previously remained at Immediate Jeopardy level. Based upon records review and interviews, the facility failed to provide adequate staffing. Based on observations, documents review and interviews, the governing body: A. Failed to provide Registered Nurses for supervision, assessments and timely interventions of patient care for 1of 1 (#60 ) patient experiencing changes in condition that resulted in the patient's death. The facility failed to provide Registered Nurses for supervision and assessment and to be immediately available to the nursing units. Licensed vocational nurses (LVN) were allowed to work in Intensive care unit (ICU), and Medical-Surgical unit without Registered Nurse supervision. Refer to Tag 144, 0392, 397 B. Failed to provide and maintain a safe and clean environment for patient care. Refer to Tag 0144 {A 144} 482.13(c)(2) PATIENT RIGHTS: CARE IN SAFE SETTING
{A 144}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 26 The patient has the right to receive care in a safe setting. This STANDARD is not met as evidenced by: Based on observations, interviews, and records review, the facility failed to ensure nursing services provided RN supervision of care to 3 of 3 (#s 10, 12 and 14) patients.
{A 144}
The facility failed to ensure that nursing staff were competent in performing nursing functions that required certifications and annual specialized training in 5 of 5 (CNO, #'s 5, 12, 14, and 16) Emergency Department (ED) and 4 of 4 (CNO, #'s 5, 16, and 25) Intensive care unit (ICU) employee files reviewed.
This deficient practice caused harm in 2 of 2 (#1 and #10) patients and had the potential to cause harm to all patients.
Review of the "MASTER STAFFING PLAN" policy dated March 2007 revealed the following:
*Staffing of each nursing unit/service was developed to provide a sufficient number of personnel. To assure prompt recognition of changes in the patient's condition with appropriate intervention. Staffing was accomplished using Registered Nurses and support staff including, as applicable, Licensed Vocational Nurses, Nurses ' Aides, Unit Secretaries, and other staff classifications as needed based on unit services.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 27
{A 144}
*Staffing will be sufficient to provide for adequate numbers of competent Registered Nurses to provide for initial and ongoing assessments and prompt recognition of any untoward changes in a patient's condition.
1. Review of the Emergency Department (ED) nurses record dated 09/05/12 revealed Patient #1 was a 72 year old male who was admitted at 4:57 p.m. with a chief complaint of aspiration, and a history of CVA (cerebral vascular accident) with Aphasia (inability or difficulty swallowing). Vital signs were 167/81 blood pressure, 126 pulse, 27 respirations, no temperature was documented.
An x-ray report dated 09/05/12 at 6:31 p.m. revealed, "likely atelectasis (collapse of lung) less likely pneumonia. Short interval follow up is recommended to evaluate for resolution."
Review of the ED physician notes dated 09/05/12 revealed Patient #1 had shortness of breath, fever, and decubitus ulcers. On assessment Patient #1 had rales (a sound heard over fluid in the bronchial tubes in the lungs) and was tachycardic (a rapid heart rate.)
Physician orders sent to the medical-surgical floor dated 09/05/12 revealed that Patient #1 had diagnoses of aspiration pneumonia, acute renal failure, dehydration, hypernatremia, and decubitus ulcers. There were orders for an IV
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 28 (intravenous fluids), IV Antibiotics, breathing treatments every 4-6 hours and every 2 hours prn (as needed), aspiration precautions, and gastrostomy tube flush with free water of 150cc every 6 hours.
{A 144}
Review of nursing assessment notes dated 09/05/2012 10:00 p.m. revealed that Patient #1 was received to the medical-surgical floor with no documentation of baseline vital signs on admission to the floor. Further review revealed that Patient #1 had a wet cough and crackles (sounds heard on auscultation of the chest as a result of inflammation) to the right lower lobe. At 11:15 p.m., nursing documentation revealed "Checked the placement for peg tube. Not functioning well. Held free water flush and due meds." The nurse documented that medications were held on 9/5/2012 at 2100. There was no documentation of physician notification or nursing interventions to attempt to resolve G-tube functioning.
A telemetry strip dated 9/5/2012 at 11:57 p.m. showed that Patient #1 had a heart rate of 107 and was Sinus Tachycardia (a steady, rapid heart rate). A telemetry strip dated 09/06/12 at 8:20 a.m. showed that Patient #1 had an increased heart rate of 114 and was Sinus Tachycardia. Further review of the telemetry rhythm strip record revealed, "DC'd off tele" with no time or date it was discontinued. There was no nursing assessment of cardiac/respiratory status documented.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 29 Review of the written statement of the patient's daughter written 9/7/12 revealed that the nurse practitioner was under the impression the patient was still on a heart monitor. She stated, "Sir, you are not monitoring my dad for nothing. He looked at the nurse and asked her, was he on a heart monitor? The nurse stated no. We don't have any at this time they were all on the floor. She left and got one somewhere." Nursing notes documented on 9/8/2012 1130, "put patient on telemetry." No documentation was found on cardiac/respiratory status. No telemetry strips were documented. In an interview on 11/14/2012 at 7:20 p.m. Staff #25 (RN) reported she placed Patient #1 on telemetry but did not remember having any issues.
{A 144}
A review of physician orders dated 09/06/12, 08:30 a.m., revealed orders to obtain an x-ray of the abdomen for G-tube placement, "labs for the am, roll the patient every two hours to prevent bed sores and can have ice chips or popsicles every 6 hours by mouth".
A review of nursing assessment notes dated 09/06/12, 8:30 a.m. RN revealed that the patient had a blood pressure of 178/72, pulse 89, temperature of 97.8. There were no documented respirations or lung sounds. The oxygen was infusing at 3L/NC and the IV was still infusing at 100cc per hour. The only documentation about the G-tube at this time was that it was intact. Review of nursing progress notes dated 09/06/12, 4:30 p.m. revealed that Patient #1 developed a temperature of 100.1, a pulse of 118, respirations 16, blood pressure 120/69 and the doctor was notified. No further assessment or nursing
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 30 intervention was documented.
{A 144}
Review of nursing progress notes dated 9/6/12 at 7:05 p.m. revealed that Jevity feeding was started per G-tube and infusing at 50 ml/hr. via feeding pump. The nurse charted the following: "3cc of stomach content was checked, the G-tube was flushed with 30cc of air with stomach gurgling heard, elevated the head of the patient's bed, stomach content every four hours with less than 5cc stomach content drawn and G-tube flushed with 200cc free water every four hours."
A verbal physician's order was written on 9/6/12 at 8:35 p.m. for Tylenol 10ml every four hours as needed for fever or pain and to start G-tube feeding Jevity 50 ml/hr. The patient was given Tylenol five hours after temperature reading was documented. There was no documentation that patient had been reassessed for fever, cardiac, or respiratory status/interventions. Review of lab results dated 9/7/2012 revealed an elevated white blood cell count of 12.8, indicating an infection.
Review of nursing progress notes dated 9/07/12 at 10:00 a.m. revealed that the patient was suctioned and Jevity was noticed on the side of the bed from the G-tube leaking, tube feedings were stopped and the physician called.
Review of a physician's order dated 9/7/12 at 1:45 p.m. revealed "start Jevity at 25cc/hr., increase to 40cc after 6 hours if he tolerates it, CBC and Chemistry 7 in the AM. Reduce IV fluids
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 31 to 50cc hr. Hospitalist will see patient tomorrow and day after (Saturday and Sunday)."
{A 144}
Review of physician progress notes dated 09/07/12 revealed "patient non communicative. Nurse says peg tube was leaking and was displaced. Patient does not seem to be in pain. Also had fever." Further documentation revealed "Peg tube repositioned and is in stomach. No edema."
Review of nursing assessment notes dated 09/07/12 at 4:30 p.m. revealed "doctor was here and irrigated peg tube with 100cc of water. After repositioning we find that the peg tube was still intact according to physician Staff #29." The doctor gave new orders to decrease the Jevity feedings to 25cc/hr. for 6 hours then increase up to 40cc if patient tolerated it. In addition to this information the nurse documented the patient was suctioned at 0710, 0800, 0830, 1000, 1030, 1215, 1300, 1530, and 1730. However, there was no documentation on why the patient needed to be suctioned or the respiratory status.
Review of nursing progress notes dated 09/07/12 at 7:15 p.m. revealed that the nurse checked the G-tube placement with air, elevated the head of the patient's bed and Jevity was running at 40cc/hr. The nurse documented at 11:30 p.m. that the family was in the room and patient was resting. The nurse also documented that vital signs were checked and the patient's temperature had increased to 100.4 and that the patient was suctioned. At 11:55 p.m., the RN documented the
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
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{A 144} Continued From page 32 patient began showing signs of pain and agitation. There was no documentation of an assessment of the pain intensity or location, G-tube placement, or when feedings were increased. There were no nursing interventions documented.
{A 144}
Review of nursing progress notes dated 09/07/12 at 11:55 p.m. revealed that the family requested pain meds, so the nurse called the doctor. New orders were obtained for Vicodin 5/500mg. Vicodin and Ativan were administered per G-tube. Documentation revealed "patient temperature rechecked 100.4 noticed patient is grimacing and making small noise. Given Tylenol 650mg and Vicodin 5/500 as per order." There was no assessment of the location or intensity of the pain. Further review revealed that there was no documentation of an assessment of the patient's pain from 09/07/12 11:55 p.m. until 09/08/12 at 10:45 a.m.
Review of nursing progress notes dated 09/08/12 at 11:00 a.m. revealed that Staff #8 (NP) was notified that the family was requesting to see him. On 09/08/12 at 11:15 a.m., the nurse documented Staff #8 (NP) was talking to the family about the patient's disease process and new orders to put the patient on telemetry. There was documentation the patient was put on telemetry at 11:30 a.m. but no documentation or assessment of cardiac or respiratory status was found.
Review of nursing progress notes dated 09/8/12

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 33 at 1:00 p.m. revealed that the patient suddenly was having breathing difficulties, respirations were at 26, oxygen saturation was 81%, blood pressure 108/100, pulse 148, temperature 98.9 with mild perspirations. At 1:08 p.m., Staff #8 (NP) was called and came to the patient's room. New orders were received to move the patient to ICU. There were no interventions documented on the cardiac or respiratory status and no telemetry readings were documented.
{A 144}
In an interview on 11/14/2012 at 7:20 p.m., Staff #25 (RN) stated "I worked the 7:00 p.m.-7:00 a.m. shift on 9/7/2012. I had no relief the next morning 9/8/2012 at 7:00 a.m. CNO (Chief Nursing Officer) told me to stay another shift due to no relief and I could go home around 4:00 p.m. if it was slow. He said he was unable to find coverage for me and my LVN. I was the only RN for the Medical surgical floor and the ICU was closed due to no staff."
A physician's order dated 09/08/12, Staff #8 (NP) documented "Transfer patient to ICU stat, ABG's now, CT to the head without contrast, CT of the chest without contrast, C.E. and (ineligible word) EKG (electrocardiogram ) per protocol, need todays labs ASAP, CBC, CMP (comprehensive metabolic panel) and BNP(basic metabolic panel) at 1600 hours and call results. Stat D-Dimer (used to see if a blood clot is present) Consult cardiology with Dr. -. "
In an interview on 11/15/2012 at 8:54 a.m., Staff #8 (NP) stated "I had seen Patient #1 earlier that
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 34 morning around 11:00 a.m. and talked with the family. I felt the patient was not critical enough to go to ICU. I spent a good length of time talking with the family and the patient was stable at that time. The patient had a change in vitals and respiratory status on second visit sometime after 12:00 p.m. I wrote orders to move the patient to ICU for closer observation. I'm not always secure with the knowledge that the current nursing staff has enough experience to let me or the other doctors know when a patient is declining. I did know there was no nursing staff available for ICU and there would be a delay in transferring the patient. I left the facility to go to another hospital but had instructed the nursing staff to let ER physician or the on call hospitalist know if there was a change in condition on the patient. I didn't know the patient had expired until the next day."
{A 144}
Review of nursing progress notes dated 09/08/12 at 1:10 p.m., revealed respiratory therapy had been called to intervene and perform ABG's (arterial blood gas). At 1:15 p.m. ABGs were collected and oxygen was increased to 4L per nasal cannula. At 1:25 p.m. the patient was transferred to ICU and report was given to the ICU nurse (CNO).
Review of nursing progress notes dated 09/08/12, at 1:02 p.m. revealed, "patient arrived in ICU. Lying in supine position, labored breathing @ 40 respiration rate. Blood pressure 62/40, pulse 141, respirations 40, temp 96.9, Oxygen saturation 83%, sinus tachycardia at 141, lethargic, skin w/d, will continue to monitor." At 1:30 p.m. CNO documented that he spoke with the family about
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 35 "DNR, (do not resuscitate) or full code status. Will continue to monitor. Tube feeding and IV running." There were no nursing or respiratory interventions documented on respiratory status. At 2:00 p.m. CNO documented "patient turned to left side by nurse tech suctioned small amount of clear secretion orally. Blood pressure 74/38, pulse 144, respirations 42, Oxygen sats 96% and temp 97.2. Will continue to monitor."
{A 144}
Review of nursing progress notes dated 09/08/12 2:38 p.m., revealed that patient #1's blood pressure was 68/36 and Dopamine 5meq/ kg/min started at 1:30 p.m. CNO documented that he called Staff #10 (Dr.) from the ER to assist with care and Staff #29 (Dr.) had been called twice with no response. At 3:30 p.m., CNO increased the Dopamine drip to 10meq and documented patient #1's blood pressure as 72/31, pulse 152, respirations 40, and temperature 97.0. Review of the physician's orders revealed no documentation for the order of Dopamine. There was no further nursing documentation noted on this chart.
Review of the physician progress notes dated 09/08/12 at 5:25 p.m. revealed that Staff #10 (Dr.) responded to the code and documented "the patient had stopped breathing and had no pulse." Further review revealed that Staff # 11 (Dr.) had already responded, intubated the patient, and initiated ACLS (advanced cardiac life support). Patient #1 was in a Pulseless Electrical Activity rhythm (has a heart rhythm with no pulse.); pupils were fixed with no reaction and he was placed on a ventilator. The patient continued to decline and had a femoral blood pressure of 34/13. A
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 36 Dopamine bolus was given. Patient #1 continued to deteriorate and expired at 5:24 p.m. Staff #10 (Dr.) discussed the patient's situation with the family and the patient was then removed from the ventilator. Staff #10 documented cause of death was "Aspiration pneumonia, lead to respiratory arrest, then cardiac arrest and cerebral anoxia."
{A 144}
In an interview with CNO on 11/14/2012 at 9:20 a.m., he stated "I do not remember this patient. I just heard about him yesterday." He was then given the patient's chart to review. Upon reviewing the nurse's notes he stated. "Oh yes, I remember this patient. The patient was transferred to ICU because of a breathing problem. We were short staffed so the ICU was closed. I was notified by Staff #25 that she had ICU orders. I had to take on the role of ICU nurse because I had absolutely no one that would come in and work. I tried calling everyone. The NP had written orders for ICU and he had left. I didn't know physician Staff #29 (Dr.) was out of town and that Staff #8 (NP) was covering."
The CNO was asked if he remembered the family asking to put the patient on the ventilator. CNO stated, "I don't recall that". CNO was asked where the order was for the Dopamine he had started in the ICU and what physician gave him the order. CNO stated, "I did call the nurse practitioner and I tried to call Staff # 29 (Dr.) twice but he did not answer. Then I had to call the ER doctor. I know there was an order it must be missing."
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 37 Further review of the medical record revealed the CNO's nursing notes ended at 3:30 p.m. The patient did not expire until 5:24 p.m. CNO stated "the nurse's notes from 3:30 p.m. on must be missing, I am sure I wrote more". Upon further questioning CNO stated, "I didn't document on nurses notes past 1530." CNO stated, "I was trying to get the family to tell me if they wanted to make their father a DNR. It was very confusing and difficult to get them to make a decision."
{A 144}
When the CNO was questioned about the possibility of transferring the patient to a higher level of care, CNO stated, "a transfer was never discussed and it is frowned upon by administration." CNO was questioned on what interventions he performed to save this patient. He paused for a long period of time and shrugged his shoulders. He became emotional and tearful. CNO shook his head no. He stated, "I realize this is a horrible mess. I did not do everything I could to help this patient."
Review of the CNO's personnel files reveale a hire date of 04/22/11, did not have a current ACLS (Advanced Cardiac LIfe Support) certification and there were no current nursing or Intensive Care Nnursing competencies .
2. Review of the emergency department (ED) nurses record revealedthat Patient #10 was a 55 year old male who presented to the ED 10/30/12 at 6:46 p.m. with complaints of sore feet. The triage notes revealed the patient had a pain level
Event ID: 695E12
Facility ID: 810260
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{A 144} Continued From page 38 of 1 out of a scale of 1-10 and vital signs of 138/96 blood pressure, 92 pulse, 16 respirations and an oral temperature of 98.7.
{A 144}
Review of an ED physician assessment dated 10/30/12 revealed that the initial clinical impression on Patient #10 was an "abnormal EKG (echocardiogram), leg pain, Non ST (myocardial infarction) and congestive heart failure." The patient was complaining of "hurting".
Review of an ED physician history and physical dated 10/30/12 revealed that the "patient appeared uncomfortable. He is lying in the floor in the ER complaining that his feet are hurting." He had "bilateral basal rales to his mid chest. He looked anxious and was dry. His extremities had "2+ edema."
There was no documentation of any medications administered or nursing interventions put into place to address the anxiety or pain.
Review of the ED nurses record dated 10/30/12 at 8:50 p.m., revealed that Patient #10 was discharged to the medical-surgical floor and was documented as being improved and stable.
Review of nursing progress notes dated 10/30/12, 8:57 p.m. revealed that the patient was moved to a room closer to the nursing station because "he was yelling out and going to others rooms." There was documentation he had "bilateral pedal
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 39 edema, patient refused to go to bed, sitting in the floor, laying under the bed, continuing to yell out and refused the exam."
{A 144}
Review of a Registered Nurse admission assessment dated 10/30/12, 9:00 p.m. revealed that the patient had "anxiety, complained of shortness of breath and had diminished breath sounds." He complained of "abdominal pain, hypoactive bowel sounds and distended abdomen." Patient #10 was "complaining of hurting all over his body." There was documentation at the bottom of the assessment that the physician was notified at 9:00 p.m. There was no documentation why physician was notified. There were no nursing interventions implemented to address the pain, shortness of breath nor the anxiety.
Review of a physician's order dated 10/30/12 at 9:11 p.m. revealed that Patient #10 was being admitted with diagnoses of congestive heart failure exacerbation, non ST- myocardial infarction, acute renal failure and hypernatremia. There were physician orders for pain medication agent Demerol 12.5 milligrams (mgs) intravenously (IV) every 4- 6 hours prn and anti-anxiety agent Ativan 1mgs IV every 4-6 hours prn, diuretic agent Lasix 40 mg IV BID (twice a day), respiratory treatments, and Duonebs every 4-6 hours. There were no orders for oxygen therapy listed.
Review of nursing progress notes dated 10/30/12 written by Staff #28 (LVN) revealed the following:
Event ID: 695E12
Facility ID: 810260
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{A 144}
*At 10:30 p.m. the patient was "given Ativan 1mg IV due to him yelling for 30 minutes."
*At 11:30 p.m. the patient was put "back to bed with assist."
*At 11:34 p.m. the patient was "back on the floor."
*At 1:30 a.m. the patient was "incontinent of feces and back into the floor."
*At 2:10 a.m. the patient was given "Ativan 1mg IV, was yelling out occasionally and very uncooperative."
*At 3:10 a.m. the patient was "put back to bed twice." Staff documented they "watched the patient for 5 minutes and he crawled back to the floor twice, was rolling on the floor and then slept. He would yell out occasionally and would not stay in bed."
*At 6:00 a.m. the patient was "back on the floor and refused to stay in bed. "
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 41 *At 6:10 a.m. the patient "verbally refused vital signs and blood draw."
{A 144}
*At 6:50 a.m. the patient was "on the floor foaming from the mouth" and the doctor was notified.
There was no documentation of a continued nursing assessment of vital signs, pain, abdominal status or respiratory by nursing after admission. There was no documentation of nursing interventions that were attempted, no notification to the physician, no pain medication administered, and no documentation that Staff #28(LVN) reported to an RN of the patient's condition, between 10:30 pm, 10/30/12, and 6:50 am, 10/31/12.
Review of nursing progress note dated 10/31/12 which was written by Staff #30 revealed the following:
*At 0700 a.m. "the patient lying in the floor, moving from side to side, non-verbal, grunting and was foaming at the mouth. He was placed back into the bed with assist and the doctor was called". There was no documentation of a nursing assessment of vital signs, pain, abdominal status or respiratory status.
*At 7:40 a.m. (40 minutes later),"the patient's blood pressure was 140/112, heart rate was 121, unable to get the oxygen saturation, and
Event ID: 695E12
Facility ID: 810260
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{A 144} Continued From page 42 respiratory called. Treatment and oxygen placed on, patient suctioned, Lasix 40 mg IV given, Catapress patch ordered and placed on and his sister was called." Review of respiratory notes dated 10/31/12 timed 7:50 a.m. confirmed the information about the oxygen saturation, breathing treatments and suctioning.
{A 144}
*At 8:15 a.m. the patient's "sister arrived and talked to the patient who was still turning from side to side and trying to get up, Foley catheter was placed after Lasix given, respiratory treatments, oxygen and suctioning still going on. Patient stopped breathing and sister stated she wanted no intervention. Patient was pronounced dead by the doctor."
Review of the medication administration record for 10/30/12 and 10/31/12 revealed no pain medication was administered to the patient during the hospitalization. There was no nursing assessment of his pain level documented after the initial nursing assessment at 9:00 p.m. on 10/30/12.
During an interview on 11/20/12 at 8:35 a.m., Staff #28 reported he was the patient's nurse when he got to the floor on 10/30/12. The patient was "up and down, refusing care and I did not know what was wrong with him. Other staff was telling me that was how the patient usually acted when he was a patient here before." Staff #25 "had not passed the information onto me that the patient was having pain. I did not give him any pain medication during my shift. When I was
Event ID: 695E12
Facility ID: 810260
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{A 144} Continued From page 43 giving report to Staff #30 we found the patient in the floor, not responding, incontinent and foaming at the mouth. We put him back to bed and I went and called the doctor. Afterwards Staff #30 took over the patient's care."
{A 144}
During an interview on 11/15/12 at 4:35 p.m., Staff #30 reported that she relieved Staff #28 at 6:45 a.m. on 10/31/12. "While taking report we found the patient laying on the floor and grunting. Something was wrong with him. We put him back to bed and called respiratory. Respiratory could not get oxygen saturation." Staff #30 confirmed "none of the patient's pain medication had been administered."
During an interview on 11/15/12 at 4:25p.m., the CNO reported "I knew about the incident. The patient was up and down all night and complaining of pain. The staff should have done more than just put him back to bed." CNO reported "I was just looking into the incident this week (which occurred two weeks prior), but could not do any investigation because the surveyors were in the building."
Review of a death summary dated 10/31/12 revealed that the patient had an "acute cardiopulmonary arrest and was in respiratory distress." The doctor documented that "Early morning, I came in to see the patient. He was out of the bed and not cooperating. He was desaturating to 60 percent. He was put on Duoneb treatment and suctioned, he improved to 70 percent, but he was with a thick secretion. He
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 44 never regained consciousness, never talked to me and he was agitated and belligerent. I contacted the family members including the sister and discussed resuscitation plan. At 8:50 a.m. the patient was pronounced deceased".
{A 144}
During the follow-up survey from 1/7/2013 through 1/10/2013 additional findings were as follows: Based on observations, records review, and interviews, the facility failed to provide and maintain a safe and clean environment for patient care.
During observation tour of the facility with staff #42 on 1/8/2013 and staff #46 on 1/9/2013, observed the following:
Patient Rooms 100 Hallway Room 116--Observed a 4 inch gap between the wall and the floor, the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. In this room, a large tear (hole) in the vinyl upholstery of the sleep chair was observed. There were dust particles in the air conditioner/heating unit. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission. Room 115--Observed a 4 inch gap between the wall and the floor, the molding was falling off the
Event ID: 695E12
Facility ID: 810260
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{A 144} Continued From page 45 wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. This room was available for patient admission. Room 114-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. There were dust particles and insects in air conditioner/heating unit. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission. Room 113-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. This room was available for patient admission. Room 112-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor, the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found. Room 111-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. This room was
{A 144}
Event ID: 695E12
Facility ID: 810260
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{A 144} Continued From page 46 available for patient admission. Room 110-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed was found. Room 109-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found. Room 108-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found. Room 107-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance
{A 144}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 47 sticker. No preventive maintenance sticker on the patient bed was. This room was available for patient admission. Room 105-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed was found. Observed a dead mouse on the floor. This room was available for patient admission. Room 104-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found. Room 103-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed. The floor had missing tile. This room was available for patient admission. Patient Rooms 200 Hallway Isolation Room 213 -- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room.
{A 144}
Event ID: 695E12
Facility ID: 810260
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{A 144} Continued From page 48 There was a patient next door to the isolation room. There was no negative air flow for the isolation room. There were blood specimen tubes that had expired in 5/2012 found the cart at the entrance of the isolation room found . This room ws available for patient admission. Room 214 Dialysis Room-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The hoses for water treatment and the drain hoses were routed thru the wall and into the bathroom where it drained into the bathtub. The cover for the air conditioner/heating unit was off and the electrical wiring was showing with dust and dirt. This room was available for patient admission. Room 215--Patient being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. There were dust particles and trash observed in the air conditioner/heating unit. No preventive maintenance sticker on the patient bed was found. Room 217-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission.
{A 144}
Event ID: 695E12
Facility ID: 810260
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{A 144} Continued From page 49 Room 219-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed was found. The electrical outlet on the wall had plaster missing around the electrical outlet. This room was available for patient admission. Room 221-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall.The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. There were several chips in the ceiling tile and stains observed in the patient room. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission. An interview with staff #46 on 1/9/2013 at 2:00 PM stated "the facility has a foundation problem and the gap between the walls and floor can increase due to change in the weather conditions." Staff #46 confirmed all the findings found during the facility tour on 1/9/2012.
{A 144}
Based on documents review and interviews, the facility failed to provide registered nurses to supervise patient care and to provide assessments. These actions created an unsafe environment for patients. A review of the documents titled "Assignment
Event ID: 695E12
Facility ID: 810260
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{A 144} Continued From page 50 Sheets" revealed 4 dates, (12/24/2012, 12/25/2012, 12/27/2012, 12/28/2012), on the 7 PM till 7 AM where there were no RNs scheduled to be immediately available to the Intensive Care Unit to supervise LVN staff and patient care. An attempt was made to review the Assignment Sheets for the dates of 12/09/2012, 12/29/2012 and 12/30/2012 for the 7 AM till 7 PM shift to verify the RN staffing, but the facility did not have these staffing sheets available for review by the surveyors. An interview on 01/08/2013 at approximately 11:30 AM with staff #42 and staff #57 confirmed that there were 19 dates on the Assignment Sheets for the Medical Unit where there was no RN coverage. The interview also confirmed the 4 dates in question where there was no RN coverage in the Intensive Care unit. A review of patient #60's medical record revealed the admission diagnosis of acute exacerbation of COPD and shortness of breath. Review of the assignment sheet revealed that patient #60 was assigned to staff #33, an LVN. The patient was admitted from the ER to the medical unit on 12/24/2012 at 10:00 PM. The Admission Record was completed by staff #33, at 2:00 AM. There was no evidence of an RN assessment. The Admission Orders read, "take vital signs every 4 hours, oxygen saturations every 4 hours, Intravenous fluid of normal saline" ( no rate was ordered). No clarification order was found for the normal saline rate. The Nursing Progress Note
{A 144}
Event ID: 695E12
Facility ID: 810260
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{A 144} Continued From page 51 dated 12/24/2012 and timed 10:00 PM, documented "Received patient from the ER with labored breathing." Respiratory was called to give a breathing treatment. The Respiratory Therapy Chart Sheet at 10:00 PM on 12/24/2012 documented that a breathing treatment was given and the patient was on oxygen at 2 liter per nasal cannula. No order to place the patient on oxygen was found. The next time documented in the Nursing Progress Note was not legible. The following entries were at 2:00 AM, 2:10 AM, 4:00 AM and no oxygen saturation was documented. The next entry was at 6:15 AM and the documentation revealed, "patient in bed, awake and hyperventilating, short of breath with an oxygen saturation of 84%. Called respiratory and called MD. MD said transfer to ICU." The next entry at 6:30 read, "pt. transfer to ICU #4 at this time." Report was given to staff #38. Staff #38 was the only RN scheduled for the medical unit and ICU during that 7 PM till 7 AM shift. A review of the ICU document titled "Nursing Observation/ Action/ Results" (ICU note), revealed that staff #38 assumed care of patient #60 at 6:35 AM the morning of 12/25/2012. At 7:00 AM, staff #38 documented giving the patient Rocephin 1 gram by IV and Solumedrol 60 milligrams IV. No order for these medications was found, nor evidence of communication with the MD. At 7:15 AM, staff #38 documented giving report and turning over the care of the patient to staff #40, an LVN that works in the surgical department.
{A 144}
Event ID: 695E12
Facility ID: 810260
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{A 144} Continued From page 52 On 12/25/2012 at 7:30 AM, staff #40 documented in the ICU that MD was in the patient's room. At 8:00 AM staff #40 documented that patient #60 was placed on Bi-Pap (Bi-Pap is a continuous positive airway pressure used to assist a patient with breathing). At 9:00 AM, staff #40 documented that patient #60 was attempting to remove the Bi-Pap mask and soft wrist restraint was placed on the right wrist. No documentation was noted that the MD was notified of the use of the restraint. There was not a signed doctor's order dated 12/25/2012 for the use of restraints. At 2:00 PM staff # 40 documented the patient was intubated and placed on a ventilator (life support). A review of a written document by consulting staff #57 revealed, "On 12/26/2012, After a tour of the facility an immediate recommendation to close the ICU was made ....An intense interview with the CNO was conducted and he verbalized understanding of the following: 1. Immediate closing of the ICU .... Upon returning to the facility on 12/27/2012 the ICU not only remained open but more patients were admitted to the unit. During personnel record review it was found that the nursing staff did not have competencies, job descriptions, proper certifications and only one nurse was qualified to work in ICU. An intense interview was again conducted with the CNO who verbalized understanding of the following: 1. An immediate need to close down ICU ....HOWEVER: items remained unchanged throughout the three day stay. 12/28/2012 ... ... A final meeting was then held with the CNO and the following recommendations were made: 1. Close ICU ....."
{A 144}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 144} Continued From page 53 An interview with consultant #57 on 01/07/2013 at 11:30 AM revealed, when we left the facility the evening of 12/28/2012 there were still patients in the ICU. Review of a nursing policy, "MASTER STAFFING PLAN", dated 03/2007 revealed the following: "Staffing will be sufficient to provide for adequate numbers of competent Registered Nurses to provide for initial and ongoing assessment and prompt recognition of any untoward changes in a patient's condition. " "At least one (1) Registered Nurse will be on duty on each unit for each operational shift. Operational shift is defined as the hours of shifts during which the unit is open and available for patient care. A Licensed Vocational Nurse may assume responsibility for the unit with a Registered Nurse immediately available to the unit." Review of the documents titled, "Assignment Sheets" revealed 19 dates (11/16/2012, 11/17/2012, 11/22/2012, 11/23/2012, 11/26/2012, 11/29/2012, 11/30/2012, 12/01/2012, 12/02/2012, 12/03/2012, 12/04/2012, 12/05/2012, 12/08/2012, 12/12/2012, 12/13/2012, 12/25/2012, 12/27/2012, 12/30/2012) on the 7 PM till 7 AM shift, and on 12/7/2012 7 AM till 7 PM shift where there were no RNs scheduled to be immediately available to the medical unit to supervise LVN staff and patient care. Review of the documents titled, "Assignment Sheets", revealed 4 dates (12/24/2012,
{A 144}
Event ID: 695E12
Facility ID: 810260
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{A 144} Continued From page 54 12/25/2012, 12/27/2012, 12/28/2012) on the 7 PM till 7 AM shift where there were no RNs scheduled to be immediately available to the Intensive Care Unit to supervise LVN staff and patient care. Review of the documents titled, "Assignment Sheets", revealed 3 dates (11/15/2012, 11/18/2012, and 12/9/2012) for the 7 AM till 7 PM shift and on 11/16/2012 for the 7 PM till 7 AM shift where there were no RNs scheduled to be immediately available to the Emergency Room to supervise LVN staff and patient care. An attempt was made to review the Assignment Sheets for the dates of 12/09/2012, 12/29/2012 and 12/30/2012 for the 7 AM till 7 PM shift to verify the RN staffing, but the facility did not have these staffing sheets available for review by the surveyors. During an interview on 01/08/13 at 8:20 a.m., Staff #57 (consultant) confirmed that the assignment sheets for the Medical/Surgical Unit, Intensive Care Unit, and Emergency Room did not have RN coverage for these areas of the hospital. 2. Review of the emergency department (ED) nurse record revealed Patient #49 was a 74 year old male who presented to the ED on 01/05/13 at 8:40 a.m. with complaints of his left arm being limp. Review of the ED physician assessment dated 01/05/13 revealed the initial clinical impression on Patient #49 was "weakness to the left upper arm and resolving TIA" (Transient ischemic attack).
{A 144}
Event ID: 695E12
Facility ID: 810260
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{A 144} Continued From page 55 Review of the ED nurses record dated 01/05/13 at 11:45 a.m. revealed that Patient #49 was being admitted to the medical-surgical floor. Review of a nursing "admission record", dated 01/5/13, revealed that Patient #49 was received to the floor at 2:00 p.m. Staff #16 (LVN) performed the admitting assessment and documented that Patient #49 had a blood pressure of 152/86 and weakness to his left arm. On the same assessment, Staff #16 documented Patient #49's neurological status was within normal limits. There was an assessment category for recent onset of weakness/paralysis within the "Rehabilitative medicine" section which was left blank. Instructions on the form directed the nurse, "If one or more is checked, referral required." There was no documented physical therapy referral by Staff #16. Review of the nursing "admission record" revealed that an RN was supposed to complete the assessment within 12 hours of admission. There was no RN signature on the form. Review of admission physician orders dated 01/05/13 revealed that staff was to perform neurological checks every 2 hours for 12 hours and then every 4 hours. Review of nurse's notes and logs dated 01/05/13 revealed no documentation of an assessment of neurological checks every two hours as ordered. A neurological assessment sheet was started the next day on 01/06/13 at 8:00 p.m. and continued until 01/07/13 at 4:00 p.m. with every 4 hour checks.
{A 144}
Event ID: 695E12
Facility ID: 810260
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{A 144} Continued From page 56 Review of physician orders from 01/05-01/08 revealed no documentation of the neurological checks being discontinued. {A 263} 482.21 QAPI The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital's governing body must ensure that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.
{A 144}
{A 263}
This CONDITION is not met as evidenced by: Based on interviews, the governing body failed to ensure that a hospitalwide Quality Assessment Performance Improvement Program (QAPI) was implemented. The facility was unable to provide evidence of an ongoing, hospital wide, data driven QAPI program. Requests were made of CNO to provide documentation and/or evidence of a QAPI Program. No written QAPI plan was provided. An interview was conducted with CNO (Chief Nursing Officer) on 11/14/2012 at 10:00 AM in the
Event ID: 695E12
Facility ID: 810260
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{A 263} Continued From page 57 Doctor's Lounge to provide insight into the facility's QAPI Program. CNO confirmed that the governing body does not set the frequency and detail of data collection. CNO revealed that the department managers make the decisions on the quality indicator's they feel appropriate for their department. The manager chooses one indicator to monitor. The manager monitors the indicators for the length of time they feel appropriate to resolve the issue. CNO confirmed there was no QAPI Committee. CNO revealed if there was a safety issue an incident report would be generated. CNO collects the incident reports once the managers complete the follow up. The incident reports are place in a notebook/ binder. CNO confirmed once the incident reports are placed in the binder the incident is closed and the facility has no system in place to track, monitor or analyze the incidents. CNO confirmed there was no evidence the facility was tracking health care associated infections, medication errors or the appropriateness of care and treatment.
{A 263}
During the follow-up survey from 1/7/2013 through 1/10/2013, it was determined that the facility had not implemented the plan of correction proposed from the 11/15/12 survey and the Condition of Participation remains out of compliance. Based on interviews, the governing body failed to ensure that a hospitalwide Quality Assessment Performance Improvement Program (QAPI) was implemented. The facility was unable to provide evidence of an ongoing, hospital wide, data
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 263} Continued From page 58 driven QAPI program during the survey. An interview was conducted with Consultant #57 on 1/8/12 in the doctor's lounge. The Consultant reported that the facility had not implemented a QAPI program at this time. A 338 482.22 MEDICAL STAFF The hospital must have an organized medical staff that operates under bylaws approved by the governing body and is responsible for the quality of medical care provided to patients by the hospital. This CONDITION is not met as evidenced by: During the follow-up survey from 1/7/2013 through 1/10/2013 additional findings were as follows:
{A 263}
A 338
Based on documents review and interviews, the facility failed to enforce the established bylaws for categories of Medical Staff, appointment and re-appointment, and the term of the appointment. A review of the document titled "Medical Staff Bylaws" last amended and approved by the Governing Board 11-28-2007, revealed Article IV Categories of the Medical Staff, Section 1. The Medical Staff, "The Staff shall be divided into Honorary, Active, Courtesy, Consulting and Emergency Room categories."
Article VI, Clinical Privileges, Section 2. Temporary Appointment, "Upon the recommendation of the chairman of a department and the Chief Executive Officer of the Hospital or
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A 338 Continued From page 59 his designee who is acting on behalf of the Governing Body, temporary privileges may be granted during the application process for the care of specific patient(s) or locum tenens, All such privileges shall be time limited and granted only when sufficient evidence exists that granting of temporary privileges is prudent."
A 338
Article V, Procedures for Appointment and Re-Appointment, Section 1. Application for Appointment, "(7) The Medical Staff Services is responsible for obtaining information from the Texas State Board of Medical Examiners and the National Practitioner Data Bank. (8) The application, complete with information sufficient to resolve doubts in any matter, shall be submitted to the administration, who upon receipt of all information, including licensure, education, training, experience and past or present Medical Staff membership at other facilities, shall submit the application and all supporting material to the Medical Executive Committee."
Section 3, Appointments- Provisional "A All initial appointments and initial granting of clinical privileges shall be provisional and shall be for one year." "D. At the successful completion of the provisional period the Practitioner's status will be reviewed for advancement to the requested category."
Section 4. Re-Appointment Process,
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A 338 Continued From page 60 "A. The Texas Standardized Application shall be fully completed to assure the availability of data necessary to update the member's medical staff file. The completed re-appointment application should include, but not he limited to the following: (1) request for privileges; (2) documentation of current, valid state license, DEA and DPS certificates (DEA and DPS certificates not required for pathologists); (3) continuing training, education and experience since the previous appointment that qualifies the staff member for the privileges sought on re-appointment, or serves as justification for new or expanded privileges; (4) sanctions of any kind imposed or pending by any other health care institution, professional health care organization or licensing authority: changes of any kind in Medical Staff membership(s), or privileges at any other health care institution or professional health care organization; (5) documentation of newly obtained board certification or, as appropriate report on timely progress toward meeting pre-certification requirements; (6) the results of the ongoing monitoring and evaluation of each practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs, shall be available for review in the re-credentialing process;
A 338
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A 338 Continued From page 61 (7) involvement in professional liability actions including letters of intent, final judgments and or settlement; (8) agreement that if the applicant is reappointed, he will continue to abide by the Bylaws, Rules and Regulations of the Medical Staff and Hospital ..... When collection and verification are accomplished, the administration shall transmit the application form and supporting materials to the Medical Executive Committee."
A 338
Section 5. Terms of Appointment, "Appointments to the Medical Staff shall be made by the Governing Body of the hospital upon the recommendation of the Medical Executive Committee, Appointments shall be for a period of no more than two years."
A review of Medical Staff #8's credentialing files contained a letter dated 03/29/2012, granting Temporary privileges for a period of two years. Staff #8's license expired 12/13/2012. The Temporary privileges and time period did not meet the Medical Bylaws definition. Staff #8 is scheduled weekly in the hospital with the Hospitalist.
A review of Medical Staff #9's credentialing files contained a letter dated 01/26/2012, granting Provisional privileges for a period of two years. This file did not contain an updated application, request for privileges, the results of the ongoing monitoring and evaluation of the practitioner's
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 338 Continued From page 62 patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs. The provisional period granted does not meet the Medical Bylaws definition.
A 338
A review of Medical Staff #26's credentialing files contained a letter dated 01/26/2012, granting Provisional privileges for a period of two years. This file did not contain an updated application, request for privileges, the results of the ongoing monitoring and evaluation of the practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs. The provisional period granted does not meet the Medical Bylaws definition.
The review of Medical Staff #29's credentialing files revealed that the files did not contain an updated application, request for privileges, the results of the ongoing monitoring and evaluation of the practitioner's patient outcomes and general practice patterns, as identified through the established quality assurance and risk management programs. Staff #29's previous re-appointment of 12/17/2010 to 12/17/2012 had expired.
Medical Staff #86 was presented as an active staff. Staff made the application on 05/07/2012. The file contained no evidence of privileges granted by the Medical Staff or by the Governing Board. This Allied Health Professional's file had no evidence of a supervising Physician.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 338 Continued From page 63
A 338
A review of Medical Staff #87's credentialing files contained a letter dated 01/26/2012, granting Provisional privileges for a period of two years. Provisional period granted did not meet the Medical Bylaws definition.
A review of Medical Staff #88's credentialing files contained a letter dated 03/26/2012, granting Provisional privileges for a period of two years. Provisional period granted does not meet the Medical Bylaws definition
A review of Medical Staff #89's credentialing files contained a letter dated 01/26/2012, granting Temporary privileges for a period of one year. The Temporary privileges and time period did not meet the Medical Bylaws definition. Staff is scheduled weekly in the hospital with the Hospitalist.
On 01/10/2013 at 9:30 AM, an interview was conducted with staff #55 in the credentialing office. Staff #55 revealed that she did the credentialing and had not had any formal training by the facility. Staff #55 had picked it up by talking with other staff members. Staff #55 had discovered that some of the information provided by staff was wrong. Staff #55 stated, "Still continuing to learn." Staff #55 was not able to tell the surveyor what the categories were in the Medical Bylaws. Staff #55 had not read the bylaws. Staff #55 stated the Medical Staff's credentialing files, containing the application and
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 338 Continued From page 64 all supporting material, were not being submitted to the Medical Executive Committee. Staff #55 was submitting a form listing the required elements. Staff #55 would make check marks beside the elements and the Medical Executive Committee would review that form. During an interview on 01/09/2013 at approximately 1:00 PM in the Doctors' Lounge, Medical Staff #29 revealed the neither the Medical Staff nor the Governing Board had been made aware of the survey findings from 11/15/2012 until 01/03/2013 during a called Governing Board Meeting. It was during this meeting that the board was made aware that the owner and CEO had brought in three nurses from another facility in an attempt to correct the previously cited problems. Medical Staff #29 was asked, "are there any problems you have voiced concerns about that have not been addressed by the Board of Directors/Owner?" The response was "yes." Staff #29 reported that there have been questions about the credentialing process. Staff #29 reported that the owner just put his doctors in here without going through the credentialing process. {A 385} 482.23 NURSING SERVICES The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This CONDITION is not met as evidenced by: Based on observations, interviews and records review, the facility failed to provide Registered Nurses for supervision, assessments and timely interventions of patient care for 4 of 4 (#'s 1, 10,
A 338
{A 385}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 385} Continued From page 65 12, and 14) patients experiencing change in conditions with two incidents resulting in patient deaths (#'s 1 and 10).
{A 385}
The facility failed to provide Registered Nurses for supervision and assessment and to be immediately available to the nursing units. Licensed vocational nurses (LVN) were allowed to work the Emergency Department (ED), Intensive care unit (ICU), and Medical-Surgical unit without Registered Nurse supervision.
The facility failed to ensure that nursing staff were competent in performing nursing functions that required certification and annual specialized training in 5 of 5 (CNO, 5, 12, 14, and 16) Emergency Department (ED) and 4 of 4 (CNO, 5, 16 and 25) Intensive care unit (ICU) employee files reviewed.
Refer to tag A0392 and A0397 for additional information.
It was determined that this deficient practice created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failures had the potential to affect all patients admitted to the facility.
During the follow-up survey from 1/7/2013 through 1/10/2013, the Immediate Jeopardy
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 385} Continued From page 66 previously cited on the Conditions of Participation for Nursing Services was found to remain at the Immediate Jeopardy level. Additional findings were as follows:
{A 385}
Based on interviews and records review, the facility failed to ensure that nursing services provided RN supervision of care provided to 7 of 7 (#'s 35, 37, 39, 41, 44, 49 and 58) patients. Refer to A-397 {A 392} 482.23(b) STAFFING AND DELIVERY OF CARE The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient. This STANDARD is not met as evidenced by: Based on documents review and interviews, the facility failed to provide Registered Nurses for supervision and assessment of patient care and be immediately available to the nursing units. Review of the document titled, Master Staffing Plan, revealed: 1."At least one (1) Registered Nurse will be on duty on each unit for each operational shift. Operational shift is defined as the hours of shifts during which the unit is open and available for patient care. A Licensed Vocational Nurse may assume responsibility for the unit with a Registered Nurse immediately available to the unit. "
{A 392}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 392} Continued From page 67 Observational tour of the facility was conducted on 11/13/2012 at approximately 11:15 AM with CNO, who was functioning as the Chief Nursing Officer (CNO) and House Supervisor. While in the Emergency Room the nurse staffing was one Registered Nurse (RN) and one Licensed Vocational Nurse (LVN). CNO was asked, "if the RN has to leave the ER unit for any reason, for example take a lunch break, triage a patient presenting to the ER, go to the bathroom, or go with a patient to X-ray, how do you ensure that a RN is immediately available to the LVN/ER unit?" CNO responded, he would be the backup RN. While touring the Medical Surgical Unit, CNO was asked if LVNs were left in charge of the unit. CNO confirmed the unit was staffed with only LVNs at times and the House Supervisor would be available if the unit needed an RN. CNO confirmed LVNs were also staffed in the Intensive Care Unit (ICU) with the House Supervisor being available to the unit. CNO confirmed the House Supervisor, who is always a RN is the person that would be available to the units staffed with LVNs. At the end of the tour in the Doctor's Lounge in an attempt to confirm the findings, CNO was asked, "when using LVNs to staff the ICU and Medical Surgical Units the facility considers the House Supervisor to be the RN immediately available to these units along with being the backup RN for the ER?" CNO reported this was true up until October but the owner discontinued the use of a House Supervisor at night. During the complaint investigation on 09/13/2012, an attempt was made to establish who was staffed in the facility on 09/08/2012. A review was
{A 392}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 392} Continued From page 68 done of the monthly staffing schedule for the Medical Surgical unit and the monthly staffing schedule for the House Supervisors. The monthly schedules were then compared to the daily staffing schedules. The daily schedules indicate that staff #25 and staff #33 both worked 24 hour shifts starting on 09/07/2012 at 7PM and was scheduled through 09/08/2012 at 7PM. On 09/08/2012 there was not a House supervisor scheduled for the 7 AM till 7 PM shift. On 11/15/2012 at 8:54 AM, an interview was conducted with Medical Staff #8 in the Doctor's Lounge. Staff #8 confirmed that the ICU and Medical Surgical units were often staffed with LVNs and no RN supervision. Staff #8 voiced concerns that LVNs were not qualified to care for patients in the ICU. The LVNs lack of assessment skills and critical thinking were questioned by staff #8 along with the ability of the LVNs to identify changes in the patient before they became critical. Staff #8 revealed that the LVN staff has voiced their concern of feeling uncomfortable being staffed as the primary nurse in the ICU. An interview was conducted with staff #25 on 11/14/2012 at 6:40 PM. Staff #25 was asked about her nursing experience. Staff #25 had been a nurse for 1 years. During the interview it was established that staff #25 had worked 24 hours on 09/07/2012 to 09/08/2012. Staff #25 was scheduled to work on 09/07/2012 from 7apm to7aam. Staff #25 was told at the end of her scheduled shift the morning of 09/08/2012 by CNO that there was no relief and staff #25 had to work the next shift. Staff #25 established that she would often be the only nurse in ICU and would
{A 392}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 392} Continued From page 69 have more than one patient. Staff #25 reported there have been times when she was the only nurse staffed on the Medical Surgical Floor as well. An interview was conducted with CNO on 11/14/2012 at 11:45 on the Medical Surgical Unit in regards to the House Supervisors Schedule for the date of 09/08/2012. The interview was conducted to confirm the inconsistencies with the daily staffing schedules. CNO was shown the daily schedule for the date of 09/08/2012 the 7 AM till 7 PM shift. CNO confirmed there was no House Supervisor scheduled for that date and shift. CNO was asked if he covered that day and shift as the House Supervisor. CNO stated, "No." An interview with staff #16 on 11/15/2012 at approximately 3:00 PM reported she is a LVN (Licensed Vocational Nurse) who works in Surgery, ICU (Intensive Care Unit), Emergency Room, and the Medical /Surgical Unit wherever she is assigned. Staff # 16 was questioned is she ever worked in the Intensive Care Unit without a Registered Nurse? Staff #16 responded, "yes, but I make sure there are no ventilation patients." A review was done of the employee time sheets to determine staffing for 09/07/2012 through 09/08/2012. The employee time sheets did not correlate with the daily staffing schedules. Due to the inconsistencies between the employee time sheets and the monthly staffing schedules, inconsistencies in information reported in interviews, and lack of documentation, it was determined the facility failed to provide adequate staffing for the dates of 09/07/2012 through
{A 392}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 392} Continued From page 70 09/08/2012.
{A 392}
During the follow-up survey from 01/07/2013 through 01/10/2013, it was determined: Based on documents review and interviews, the facility failed to provide Registered Nurses for supervision and assessment of patient care and provide an RN to be immediately available to the nursing units. Review of the document titled, Master Staffing Plan, revealed: 1."At least one (1) Registered Nurse will be on duty on each unit for each operational shift. Operational shift is defined as the hours of shifts during which the unit is open and available for patient care. A Licensed Vocational Nurse may assume responsibility for the unit with a Registered Nurse immediately available to the unit. " A review of the documents titled, Assignment Sheets revealed 19 dates (11/16/2012, 11/17/2012, 11/22/2012, 11/23/2012, 11/26/2012, 11/29/2012, 11/30/2012, 12/01/2012, 12/02/2012, 12/03/2012, 12/04/2012, 12/05/2012, 12/07/2012, 12/08/2012, 12/12/2012, 12/13/2012, 12/25/2012, 12/27/2012, 12/30/2012), on the 7 PM till 7 AM where there were no RNs scheduled to be immediately available to the medical unit to supervise LVN staff and patient care. A review of the documents titled, Assignment Sheets revealed 4 dates, (12/24/2012, 12/25/2012, 12/27/2012, 12/28/2012), on the 7 PM till 7 AM where there were no RNs scheduled to be immediately available to the Intensive Care Unit to supervise LVN staff and patient care.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 392} Continued From page 71 An attempt was made to review the Assignment Sheets for the dates of 12/09/2012, 12/29/2012 and 12/30/2012 for the 7 AM till 7 PM shift to verify the RN staffing, but the facility did not have these staffing sheets available for review by the surveyors. An interview on 01/08/2013 at approximately 11:30 AM with staff #42 and staff #57 confirmed that there were 19 dates on the Assignment Sheets for the Medical Unit where there was no RN coverage. The interview also confirmed the 4 dates in question where there was no RN coverage in the Intensive Care unit. A review of patient #60's medical record revealed the admission diagnosis of acute exacerbation of COPD and shortness of breath. Review of the assignment sheet revealed patient #60 was assigned to staff #33, an LVN. The patient was admitted from the ER to the medical unit on 12/24/2012 at 10:00 PM. The Admission Record was completed by staff #33, at 2:00 AM. There was no evidence of an RN assessment. The Admission Orders read, "take vital signs every 4 hours, oxygen saturations every 4 hours, Intravenous fluid of normal saline" ( no rate was ordered). No clarification order was found for the normal saline rate. The Nursing Progress Note, dated 12/24/2012 and timed 10:00 PM, documented, "Received patient from the ER with labored breathing." Respiratory was called to give a breathing treatment. The Respiratory Therapy Chart Sheet at 10:00 PM on 12/24/2012
{A 392}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 392} Continued From page 72 documented a breathing treatment was given and the patient was on oxygen at 2 liter per nasal cannula. No order to place the patient on oxygen was found. The next time documented in the Nursing Progress Note was not legible. The following entries were at 2:00 AM, 2:10 AM, 4:00 AM and no oxygen saturation was documented. The next entry was at 6:15 AM and the documentation revealed, "patient in bed, awake and hyperventilating, short of breath with an oxygen saturation of 84%. Called respiratory and called MD. MD said transfer to ICU." The next entry at 6:30 read, "pt. transfer to ICU #4 at this time." Report was given to staff #38. Staff #38 was the only RN scheduled for the medical unit and ICU during that 7 PM till 7 AM shift. A review of the ICU document titled, "Nursing Observation/ Action/ Results" (ICU note), revealed that staff #38 assumed care of patient #60 at 6:35 AM the morning of 12/25/2012. At 7:00 AM, staff #38 documented giving the patient Rocephin 1 gram by IV and Solumedrol 60 milligrams IV. No order for these medications was found, nor evidence of communication with the MD. At 7:15 AM, staff #38 documented giving report and turning over the care of the patient to staff #40, an LVN that works in the surgical department. On 12/25/2012 at 7:30 AM, staff #40 documented in the ICU that MD was in the patient's room. At 8:00 AM staff #40 documented that patient #60 was placed on Bi-Pap (Bi-Pap is a continuous
{A 392}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 392} Continued From page 73 positive airway pressure used to assist a patient with breathing). At 9:00 AM staff #40 documented that patient #60 was attempting to remove the Bi-Pap mask and soft wrist restraint was placed on the right wrist. No documentation was noted that the MD was notified of the use of the restraint. There was not a signed doctor's order dated 12/25/2012 for the use of restraints. At 2:00 PM staff # 40 documented the patient was intubated and placed on a ventilator (life support). A review of a written document by consulting staff #57 revealed, "On 12/26/2012, after a tour of the facility an immediate recommendation to close the ICU was made ....An intense interview with the CNO was conducted and he verbalized understanding of the following: 1. Immediate closing of the ICU .... Upon returning to the facility on 12/27/2012 the ICU not only remained open but more patients were admitted to the unit. During personnel record review it was found that the nursing staff did not have competencies, job descriptions, proper certifications and only one nurse was qualified to work in ICU. An intense interview was again conducted with the CNO who verbalized understanding of the following: 1. An immediate need to close down ICU ....HOWEVER: items remained unchanged throughout the three day stay. 12/28/2012 ... ... A final meeting was then held with the CNO and the following recommendations were made: 1. Close ICU ..... " An interview with consultant #57 on 12/07/2013 at 11:30 AM revealed, when we left the facility the evening of 12/28/2012 there were still patients in the ICU. {A 397} 482.23(b)(5) PATIENT CARE ASSIGMENTS
{A 392}
{A 397}
Facility ID: 810260
Event ID: 695E12
OMB NO. 0938-0391

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{A 397} Continued From page 74 A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. This STANDARD is not met as evidenced by: Based on observations, interviews, and records review, the facility failed to ensure nursing serevices provided RN supervision of care provided to 3 of 3 (#s 10, 12 and 14) patients.
{A 397}
The facility failed to ensure that nursing staff were competent in performing nursing functions that required certifications and annual specialized training in 5 of 5 (CNO, #'s 5, 12, 14, and 16) Emergency Department (ED) and 4 of 4 (CNO, #'s 5, 16, and 25) Intensive care unit (ICU) employee files reviewed.
This deficient practice caused harm in 2 of 2 (#1 and #10) patients and had the potential to cause harm to all patients.
Review of the "MASTER STAFFING PLAN" policy dated March 2007 revealed the following:
*Staffing of each nursing unit/service was developed to provide a sufficient number of personnel. To assure prompt recognition of changes in the patient's condition with appropriate intervention. Staffing was accomplished using Registered Nurses and
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 75 support staff including, as applicable, Licensed Vocational Nurses, Nurses' Aides, Unit Secretaries, and other staff classifications as needed based on unit services.
{A 397}
*Staffing will be sufficient to provide for adequate numbers of competent Registered Nurses to provide for initial and ongoing assessments and prompt recognition of any untoward changes in a patient's condition.
1. Review of the Emergency Department (ED) nurses record dated 09/05/12 revealed that Patient #1 was a 72 year old male who was admitted at 4:57 p.m. with a chief complaint of aspiration, and a history of CVA (cerebral vascular accident) with Aphasia (inability or difficulty swallowing). Vital signs were 167/81 blood pressure, 126 pulse, 27 respirations, no temperature was documented.
An x-ray report dated 09/05/12 at 6:31 p.m. revealed "likely atelectasis (collapse of lung) less likely pneumonia. Short interval follow up is recommended to evaluate for resolution."
Review of the ED physician notes dated 09/05/12 revealed Patient #1 had shortness of breath, fever, and decubitus ulcers. On assessment, Patient #1 had rales (a sound heard over fluid in the bronchial tubes in the lungs) and was tachycardic (a rapid heart rate.)
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 76 Physician orders sent to the medical-surgical floor dated 09/05/12 revealed that Patient #1 had diagnoses of aspiration pneumonia, acute renal failure, dehydration, hypernatremia, and decubitus ulcers. There were orders for an IV (intravenous fluids), IV Antibiotics, breathing treatments every 4-6 hours and every 2 hours prn (as needed), aspiration precautions, and gastrostomy tube flush with free water of 150cc every 6 hours.
{A 397}
Review of nursing assessment notes dated 09/05/2012 10:00 p.m. revealed that Patient #1 was received to the medical-surgical floor with no documentation of baseline vital signs on admission to the floor. Further review revealed that Patient #1 had a wet cough and crackles (sounds heard on auscultation of the chest as a result of inflammation) to the right lower lobe. At 11:15 p.m. nursing documentation revealed "Checked the placement for peg tube. Not functioning well. Held free water flush and due meds." The nurse documented that medications were held on 9/5/2012 at 2100. There was no documentation of physician notification or nursing interventions to attempt to resolve G-tube functioning.
A telemetry strip dated 9/5/2012 at 11:57 p.m. showed Patient #1 had a heart rate of 107 and was Sinus Tachycardia (a steady, rapid heart rate). A telemetry strip dated 09/06/12 at 8:20 a.m. showed Patient #1 had an increased heart rate of 114 and was Sinus Tachycardia. Further review of the telemetry rhythm strip record revealed, "DC'd off tele" with no time or date it
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 77 was discontinued. There was no nursing assessment of cardiac/respiratory status documented.
{A 397}
Review of the written statement of the patient's daughter written 9/7/12 revealed the nurse practitioner was under the impression the patient was still on a heart monitor. She stated, "Sir, you are not monitoring my dad for nothing. He looked at the nurse and asked her was he on a heart monitor? The nurse stated no. We don't have any at this time they were all on the floor. She left and got one somewhere." Nursing notes documented on 9/8/2012 1130, "put patient on telemetry." No documentation was found on cardiac/respiratory status. No telemetry strips were documented. In an interview on 11/14/2012 at 7:20 p.m. Staff #25 (RN) reported she placed Patient #1 on telemetry but did not remember having any issues.
A review of physician orders dated 09/06/12, 08:30 a.m., revealed orders to obtain an x-ray of the abdomen for G-tube placement, "labs for the am, roll the patient every two hours to prevent bed sores and can have ice chips or popsicles every 6 hours by mouth".
A review of nursing assessment notes dated 09/06/12, 8:30 a.m. revealed that the patient had a blood pressure of 178/72, pulse 89, temperature of 97.8. There were no documented respirations or lung sounds. The oxygen was infusing at 3L/NC and the IV was still infusing at 100cc per hour. The only documentation about the G-tube at this time was that it was intact.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 78 Review of nursing progress notes dated 09/06/12, 4:30 p.m. revealed Patient #1 developed a temperature of 100.1, a pulse of 118, respirations 16, blood pressure 120/69 and the doctor was notified. No further assessment or nursing intervention was documented.
{A 397}
Review of nursing progress notes dated 9/6/12 at 7:05 p.m. revealed a Jevity feeding was started per G-tube and infusing at 50 ml/hr. via feeding pump. The nurse charted the following: "3cc of stomach content was checked, the G-tube was flushed with 30cc of air with stomach gurgling heard, elevated the head of the patient's bed, stomach content every four hours with less than 5cc stomach content drawn and G-tube flushed with 200cc free water every four hours."
A verbal physician order was written on 9/6/12 at 8:35 p.m. for Tylenol 10 ml every four hours as needed for fever or pain and to start G-tube feeding Jevity 50 ml/hr. The patient was given Tylenol five hours after a temperature reading was documented. There was no documentation that patient had been reassessed for fever, cardiac, or respiratory status/interventions. Review of laboratory results dated 9/7/2012 revealed an elevated white blood cell count of 12.8, indicating an infection.
Review of nursing progress notes dated 9/07/12 at 10:00 a.m. revealed that the patient was suctioned and Jevity was noticed on the side of the bed from the G-tube leaking, tube feedings were stopped and the physician called.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397}
Review of a physician's order dated 9/7/12 at 1:45 p.m. revealed "start Jevity at 25cc/hr., increase to 40cc after 6 hours if he tolerates it, CBC and Chemistry 7 in the AM. Reduce IV fluids to 50cc hr. Hospitalist will see patient tomorrow and day after (Saturday and Sunday)."
Review of physician progress notes dated 09/07/12 revealed "patient non communicative. Nurse says peg tube was leaking and was displaced. Patient does not seem to be in pain. Also had fever." Further documentation revealed, "Peg tube repositioned and is in stomach. No edema."
Review of nursing assessment notes dated 09/07/12 at 4:30 p.m. revealed "doctor was here and irrigated peg tube with 100cc of water. After repositioning we find that the peg tube was still intact according to physician Staff #29." The doctor gave new orders to decrease the Jevity feedings to 25cc/hr. for 6 hours then increase up to 40cc if patient tolerated it. In addition to this information, the nurse documented the patient was suctioned at 0710, 0800, 0830, 1000, 1030, 1215, 1300, 1530, and 1730. However, there was no documentation on why the patient needed to be suctioned or respiratory status.
Review of nursing progress notes dated 09/07/12 at 7:15 p.m. revealed that the nurse checked the G-tube placement with air, elevated the head of the patient's bed and Jevity was running at
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 80 40cc/hr. The nurse documented at 11:30 p.m. that the family was in the room and patient was resting. The nurse also documented that vital signs were checked and temperature had increased to 100.4 and that the patient was suctioned. At 11:55 p.m., the RN documented the patient began showing signs of pain and agitation. There was no documentation of an assessment of pain intensity or location, G-tube placement, or when feedings were increased. There were no nursing interventions documented.
{A 397}
Review of nursing progress notes dated 09/07/12 at 11:55 p.m. revealed that the family requested pain meds, so the nurse called the doctor. New orders were obtained for Vicodin 5/500mg. Vicodin and Ativan were administered per G-tube. Documentation revealed "patient temperature rechecked 100.4 noticed patient is grimacing and making small noise. Given Tylenol 650mg and Vicodin 5/500 as per order." There was no assessment of the location or intensity of the pain. Further review revealed no documentation of an assessment of the patient's pain from 09/07/12 11:55 p.m. until 09/08/12 at 10:45 a.m.
Review of nursing progress notes dated 09/08/12 at 11:00 a.m. revealed that Staff #8 (NP) was notified that the family was requesting to see him. On 09/08/12 at 11:15 a.m., the nurse documented Staff #8 (NP) was talking to the family about the patient's disease process and new orders to put the patient on telemetry. There was documentation the patient was put on telemetry at 11:30 a.m. but no documentation or assessment of cardiac or respiratory status was
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 81 found.
{A 397}
Review of nursing progress notes dated 09/8/12 at 1:00 p.m. documented that the patient suddenly was having breathing difficulties, respirations were at 26, oxygen saturation was 81%, blood pressure 108/100, pulse 148, temperature 98.9 with mild perspirations. At 1:08 p.m., Staff #8 (NP) was called and came to the patient's room. New orders were received to move the patient to ICU. There were no interventions documented on cardiac or respiratory status and no telemetry documentation.
In an interview on 11/14/2012 at 7:20 p.m., Staff #25 (RN) stated "I worked the 7:00 p.m.-7:00 a.m. shift on 9/7/2012. I had no relief the next morning 9/8/2012 at 7:00 a.m. CNO (Chief Nursing Officer) told me to stay another shift due to no relief and I could go home around 4:00 p.m. if it was slow. He said he was unable to find coverage for me and my LVN. I was the only RN for the Medical surgical floor and the ICU was closed due to no staff."
A physician's order dated 09/08/12, Staff #8 (NP) documented "Transfer patient to ICU stat, ABG's now, CT to the head without contrast, CT of the chest without contrast, C. E. and (ineligible word) EKG (electrocardiogram ) per protocol, need todays labs ASAP, CBC, CMP (comprehensive metabolic panel) and BNP(basic metabolic panel) at 1600 hours and call results. Stat D-Dimer (used to see if a blood clot is present) Consult
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 82 cardiology with Dr. -. "
{A 397}
In an interview on 11/15/2012 at 8:54 a.m., Staff #8 (NP) stated "I had seen Patient #1 earlier that morning around 11:00 a.m. and talked with the family. I felt the patient was not critical enough to go to ICU. I spent a good length of time talking with the family and the patient was stable at that time. The patient had a change in vitals and respiratory status on second visit sometime after 12:00 p.m. I wrote orders to move the patient to ICU for closer observation. I'm not always secure with the knowledge that the current nursing staff has enough experience to let me or the other doctors know when a patient is declining. I did know there was no nursing staff available for ICU and there would be a delay in transferring the patient. I left the facility to go to another hospital but had instructed the nursing staff to let ER physician or the on call hospitalist know if there was a change in condition on the patient. I didn't know the patient had expired until the next day."
Review of nursing progress notes dated 09/08/12 at 1:10 p.m., revealed that respiratory therapy had been called to intervene and perform ABG's (arterial blood gas). At 1:15 p.m., ABGs were collected and oxygen was increased to 4L per nasal cannula. At 1:25 p.m., the patient was transferred to ICU and report was given to the ICU nurse (CNO).
Review of nursing progress notes dated 09/08/12, at 1:02 p.m. revealed "patient arrived in ICU. Lying in supine position, labored breathing @ 40
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 83 respiration rate. Blood pressure 62/40, pulse 141, respirations 40, temp 96.9, Oxygen saturation 83%, sinus tachycardia at 141, lethargic, skin w/d, will continue to monitor." At 1:30 p.m. CNO documented that he spoke with the family about "DNR, (do not resuscitate) or full code status. Will continue to monitor. Tube feeding and IV running." There were no nursing or respiratory interventions documented on respiratory status. At 2:00 p.m., CNO documented "patient turned to left side by nurse tech suctioned small amount of clear secretion orally. Blood pressure 74/38, pulse 144, respirations 42, Oxygen sats 96% and temp 97.2. Will continue to monitor."
{A 397}
Review of nursing progress notes dated 09/08/12 2:38 p.m. revealed documentation that patient #1's blood pressure was 68/36 and Dopamine 5meq/ kg/min started at 1:30 p.m. CNO documented he called Staff #10 (Dr.) from the ER to assist with care and Staff #29 (Dr.) had been called twice with no response. At 3:30 p.m., CNO increased the Dopamine drip to 10 meq and documented patient #1's blood pressure as 72/31, pulse 152, respirations 40, and temperature 97.0. Review of the physician's orders revealed no documentation for the order of Dopamine. There was no further nursing documentation noted on this chart.
Review of the physician progress notes dated 09/08/12 at 5:25 p.m. revealed that Staff #10 (Dr.) responded to the code and documented "the patient had stopped breathing and had no pulse." Further review revealed that Staff # 11 (Dr.) had already responded, intubated the patient, and
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 84 initiated ACLS (advanced cardiac life support). Patient #1 was in a Pulseless Electrical Activity rhythm (has a heart rhythm with no pulse.); pupils were fixed with no reaction and he was placed on a ventilator. The patient continued to decline and had a femoral blood pressure of 34/13. A Dopamine bolus was given. Patient #1 continued to deteriorate and expired at 5:24 p.m. Staff #10 (Dr.) discussed the patient's situation with the family and the patient was then removed from the ventilator. Staff #10 documented cause of death was "Aspiration pneumonia, lead to respiratory arrest, then cardiac arrest and cerebral anoxia."
{A 397}
In an interview with CNO on 11/14/2012 at 9:20 a.m., he stated "I do not remember this patient. I just heard about him yesterday." He was then given the patient's chart to review. Upon reviewing the nurse's notes he stated. "Oh yes, I remember this patient. The patient was transferred to ICU because of a breathing problem. We were short staffed so the ICU was closed. I was notified by Staff #25 that she had ICU orders. I had to take on the role of ICU nurse because I had absolutely no one that would come in and work. I tried calling everyone. The NP had written orders for ICU and he had left. I didn't know physician Staff #29 (Dr.) was out of town and that Staff #8 (NP) was covering."
The CNO was asked if he remembered the family asking to put the patient on the ventilator. CNO stated, "I don't recall that". CNO was asked where the order was for the Dopamine he had started in the ICU and what physician gave him the order. CNO stated "I did call the nurse
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 85 practitioner and I tried to call Staff # 29 (Dr.) twice but he did not answer. Then I had to call the ER doctor. I know there was an order it must be missing."
{A 397}
Further review of the medical record revealed the CNO's nursing notes ended at 3:30 p.m. The patient did not expire until 5:24 p.m. CNO stated "the nurse's notes from 3:30 p.m. on must be missing, I am sure I wrote more". Upon further questioning CNO stated, "I didn't document on nurses notes past 1530." CNO stated "I was trying to get the family to tell me if they wanted to make their father a DNR. It was very confusing and difficult to get them to make a decision."
When the CNO was questioned about the possibility of transferring the patient to a higher level of care, he stated "a transfer was never discussed and it is frowned upon by administration."
CNO was questioned what interventions he performed to save this patient. He paused for a long period of time and shrugged his shoulders. He became emotional and tearful. CNO shook his head no. He stated "I realize this is a horrible mess. I did not do everything I could to help this patient."
Review of the CNO's personnel files revealed a hire date of 04/22/11, did not have a current ACLS (Advanced Cardiac LIfe Support) certification and there were no current nursing or
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 86 Intensive Care competencies .
{A 397}
2. Review of the emergency department (ED) nurses record revealed that Patient #10 was a 55 year old male who presented to the ED 10/30/12 at 6:46 p.m. with complaints of sore feet. The triage notes revealed the patient had a pain level of 1 out of a scale of 1-10 and vital signs of 138/96 blood pressure, 92 pulse, 16 respirations and an oral temperature of 98.7.
Review of an ED physician assessment dated 10/30/12 revealed the initial clinical impression on Patient #10 was an "abnormal EKG (echocardiogram), leg pain, Non ST (myocardial infarction) and congestive heart failure." The patient was complaining of "hurting."
Review of an ED physician history and physical dated 10/30/12 revealed the "patient appeared uncomfortable. He is lying in the floor in the ER complaining that his feet are hurting." He had "bilateral basal rales to his mid chest. He looked anxious and was dry. His extremities had "2+ edema."
There was no documentation of any medications administered or nursing interventions put into place to address the anxiety or pain.
Review of the ED nurses record dated 10/30/12

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Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 87 at 8:50 p.m., revealed that Patient #10 was discharged to the medical-surgical floor and was documented as being improved and stable.
{A 397}
Review of nursing progress notes dated 10/30/12, 8:57 p.m. revealed that the patient was moved to a room closer to the nursing station because "he was yelling out and going to others rooms." There was documentation he had "bilateral pedal edema, patient refused to go to bed, sitting in the floor, laying under the bed, continuing to yell out and refused the exam."
Review of a Registered Nurse admission assessment dated 10/30/12, 9:00 p.m. revealed that the patient had "anxiety, complained of shortness of breath and had diminished breath sounds." He complained of "abdominal pain, hypoactive bowel sounds and distended abdomen." Patient #10 was "complaining of hurting all over his body." There was documentation at the bottom of the assessment that the physician was notified at 9:00 p.m. There was no documentation why physician was notified. There were no nursing interventions implemented to address the pain, shortness of breath nor the anxiety.
Review of a physician's order dated 10/30/12 at 9:11 p.m. revealed that Patient #10 was being admitted with diagnoses of congestive heart failure exacerbation, non ST- myocardial infarction, acute renal failure and hypernatremia. There were physician orders for pain medication agent Demerol 12.5 milligrams (mgs)
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 88 intravenously (IV) every 4- 6 hours prn and the anti-anxiety agent Ativan 1mgs IV every 4-6 hours prn, the diuretic agent Lasix 40 mg IV BID (twice a day), respiratory treatments, and Duonebs every 4-6 hours. There were no orders for oxygen therapy listed.
{A 397}
Review of nursing progress notes dated 10/30/12 written by Staff #28 (LVN) revealed the following: *At 10:30 p.m. the patient was "given Ativan 1mg IV due to him yelling for 30 minutes."
*At 11:30 p.m. the patient was put "back to bed with assist."
*At 11:34 p.m. the patient was "back on the floor."
*At 1:30 a.m. the patient was "incontinent of feces and back into the floor."
*At 2:10 a.m. the patient was given "Ativan 1mg IV, was yelling out occasionally and very uncooperative."
*At 3:10 a.m. the patient was "put back to bed twice." Staff documented they "watched the patient for 5 minutes and he crawled back to the
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 89 floor twice, was rolling on the floor and then slept. He would yell out occasionally and would not stay in bed."
{A 397}
*At 6:00 a.m. the patient was "back on the floor and refused to stay in bed."
*At 6:10 a.m. the patient "verbally refused vital signs and blood draw."
*At 6:50 a.m. the patient was "on the floor foaming from the mouth" and the doctor was notified.
There was no documentation of a continued nursing assessment of vital signs, pain, abdominal status or respiratory status by nursing staff after admission. There was no documentation of nursing interventions attempted, no notification to the physician, no pain medication administered, and no documentation that Staff #28(LVN) reported to an RN of the patient's condition, between 10:30 pm, 10/30/12, and 6:50 am, 10/31/12.
Review of nursing progress note dated 10/31/12 which was written by Staff #30 revealed the following:
*At 0700 a.m. "the patient lying in the floor, moving from side to side, non-verbal, grunting and was foaming at the mouth. He was placed
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 90 back into the bed with assist and the doctor was called". There was no documentation of a nursing assessment of vital signs, pain, abdominal status or respiratory status.
{A 397}
*At 7:40 a.m. (40 minutes later),"the patient's blood pressure was 140/112, heart rate was 121, unable to get the oxygen saturation, and respiratory called. Treatment and oxygen placed on, patient suctioned, Lasix 40 mg IV given, Catapress patch ordered and placed on and his sister was called." Review of respiratory notes dated 10/31/12 timed 7:50 a.m. confirmed the information about the oxygen saturation, breathing treatments and suctioning.
*At 8:15 a.m. the patient's "sister arrived and talked to the patient who was still turning from side to side and trying to get up, Foley catheter was placed after Lasix given, respiratory treatments, oxygen and suctioning still going on. Patient stopped breathing and sister stated she wanted no intervention. Patient was pronounced dead by the doctor."
Review of the medication administration record for 10/30/12 and 10/31/12 revealed no pain medication was administered to the patient during the hospitalization. There was no nursing assessment of his pain level documented after the initial nursing assessment at 9:00 p.m. on 10/30/12.
During an interview on 11/20/12 at 8:35 a.m.,

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 91 Staff #28 reported he was the patient's nurse when he got to the floor on 10/30/12. The patient was "up and down, refusing care and I did not know what was wrong with him. Other staff was telling me that was how the patient usually acted when he was a patient here before." Staff #25 "had not passed the information onto me that the patient was having pain. I did not give him any pain medication during my shift. When I was giving report to Staff #30, we found the patient in the floor, not responding, incontinent and foaming at the mouth. We put him back to bed and I went and called the doctor. Afterwards Staff #30 took over the patient's care."
{A 397}
During an interview on 11/15/12 at 4:35 p.m., Staff #30 reported that she relieved Staff #28 at 6:45 a.m. on 10/31/12. "While taking report we found the patient laying on the floor and grunting. Something was wrong with him. We put him back to bed and called respiratory. Respiratory could not get oxygen saturation." Staff #30 confirmed "none of the patient's pain medication had been administered."
During an interview on 11/15/12 at 4:25p.m., the CNO reported "I knew about the incident. The patient was up and down all night and complaining of pain. The staff should have done more than just put him back to bed." CNO reported "I was just looking into the incident this week (which occurred two weeks prior), but could not do any investigation because the surveyors were in the building."
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 92 Review of a death summary dated 10/31/12 revealed the patient had an "acute cardiopulmonary arrest and was in respiratory distress." The doctor documented that "Early morning, I came in to see the patient. He was out of the bed and not cooperating. He was desaturating to 60 percent. He was put on Duoneb treatment and suctioned, he improved to 70 percent, but he was with a thick secretion. He never regained consciousness, never talked to me and he was agitated and belligerent. I contacted the family members including the sister and discussed resuscitation plan. At 8:50 a.m. the patient was pronounced deceased".
{A 397}
During the follow-up survey from 01/07/2012 through 01/10/2013, additional findings were as follows: Based on interviews and records review, the facility failed to ensure thatv nursing services provided RN supervision of care provided to 7 of 7 (#'s 35, 37, 39, 41, 44, 49 and 58) patients. This deficient practice had the potential to cause harm in all patients. 1. Review of a nursing policy, "MASTER STAFFING PLAN", dated 03/2007 revealed the following: "Staffing will be sufficient to provide for adequate numbers of competent Registered Nurses to provide for initial and ongoing assessment and prompt recognition of any untoward changes in a patient's condition. "
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 93 "At least one (1) Registered Nurse will be on duty on each unit for each operational shift. Operational shift is defined as the hours of shifts during which the unit is open and available for patient care. A Licensed Vocational Nurse may assume responsibility for the unit with a Registered Nurse immediately available to the unit. " Review of the documents titled, "Assignment Sheets" revealed 19 dates (11/16/2012, 11/17/2012, 11/22/2012, 11/23/2012, 11/26/2012, 11/29/2012, 11/30/2012, 12/01/2012, 12/02/2012, 12/03/2012, 12/04/2012, 12/05/2012, 12/08/2012, 12/12/2012, 12/13/2012, 12/25/2012, 12/27/2012, 12/30/2012) on the 7 PM till 7 AM shift, and on 12/7/2012 7 AM till 7 PM shift where there were no RNs scheduled to be immediately available to the medical unit to supervise LVN staff and patient care. Review of the documents titled, "Assignment Sheets", revealed 4 dates (12/24/2012, 12/25/2012, 12/27/2012, 12/28/2012) on the 7 PM till 7 AM shift where there were no RNs scheduled to be immediately available to the Intensive Care Unit to supervise LVN staff and patient care. Review of the documents titled, "Assignment Sheets", revealed 3 dates (11/15/2012, 11/18/2012, and 12/9/2012) for the 7 AM till 7 PM shift and on 11/16/2012 for the 7 PM till 7 AM shift where there were no RNs scheduled to be immediately available to the Emergency Room to supervise LVN staff and patient care.
{A 397}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 94 An attempt was made to review the Assignment Sheets for the dates of 12/09/2012, 12/29/2012 and 12/30/2012 for the 7 AM till 7 PM shift to verify the RN staffing, but the facility did not have these staffing sheets available for review by the surveyors. During an interview on 01/08/13 at 8:20 a.m., Staff #57 (consultant) confirmed that the assignment sheets for the Medical/Surgical Unit, Intensive Care Unit, and Emergency Room did not have RN coverage for these areas of the hospital. 2. Review of the emergency department (ED) nurse record revealed that Patient #49 was a 74 year old male who presented to the ED on 01/05/13 at 8:40 a.m. with complaints of his left arm being limp. Review of the ED physician assessment dated 01/05/13 revealed the initial clinical impression on Patient #49 was "weakness to the left upper arm and resolving TIA" (Transient ischemic attack). Review of the ED nurses record dated 01/05/13 at 11:45 a.m. revealed that Patient #49 was being admitted to the medical-surgical floor. Review of a nursing "admission record", dated 01/5/13, revealed that Patient #49 was received to the floor at 2:00 p.m. Staff #16 (LVN) performed the admitting assessment and documented Patient #49 had a blood pressure of 152/86 and weakness to his left arm. On the same assessment, Staff #16 documented that Patient #49's neurological status was within normal limits. There was an assessment
{A 397}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 95 category for recent onset of weakness/paralysis within the "Rehabilitative medicine" section which was left blank. Instructions on the form directed the nurse, "If one or more is checked, referral required." There was no documented physical therapy referral by Staff #16. Review of the nursing "admission record" revealed that an RN was supposed to complete the assessment within 12 hours of admission. There was no RN assessment on record. Review of admission physician orders dated 01/05/13 revealed that staff was to perform neurological checks every 2 hours for 12 hours and then every 4 hours. Review of nurse's notes and logs dated 01/05/13 revealed no documentation of an assessment of neurological checks every two hours as ordered. A neurological assessment sheet was started the next day on 01/06/13 at 8:00 p.m. and continued until 01/07/13 at 4:00 p.m. with every 4 hour checks. Review of physician orders from 01/05-01/08 revealed no documentation of the neurological checks being discontinued. During an interview on 01/08/13 at 2:05 p.m., Staff #83 (LVN) checked Patient #49's record and confirmed that she could not find any neurological checks for every 2 hours on 01/05/13 or neurological checks for every 4 hours after 01/07/13 at 4:00 p.m. Staff #83 confirmed that the physician order was not discontinued. Staff #83 reported that she had not been given the information in report to continue the neurological
{A 397}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 96 checks when she got to work this morning at 7:00 a.m. Staff #83 confirmed an RN was supposed to complete the admission assessment. During an interview on 01/08/13 at 2:15 p.m., Staff #57 (RN consultant) reported they were having trouble getting the RNs to perform the assessments. They were unwilling to take care of their patients and then perform admission assessments on the LVN's patients. 3. Review of an "admission record" revealed that Patient # 35 was a 57 year old female admitted on 01/05/13 with diagnoses of atrial fibrillation. Review of the nutritional screen revealed problems with swallowing, diabetes, and HIV/AIDS were checked by nursing. According to the nutritional screen directive, if one or more categories were checked, nursing was supposed to make a referral. Nursing made no documentation of an attempt to make a referral. 4. Review of an "admission record" revealed that Patient #37 was a 64 year old female admitted on 01/04/13 with diagnoses of congestive heart failure, chest pain and hypertension. Review of the nutritional screen revealed diabetes and clinically obese were checked by nursing. According to the nutritional screen directive, if one or more categories were checked, nursing was supposed to make a referral. Nursing documented that no referral was made. Review of the rehabilitative medicine screen revealed that recent onset of weakness/paralysis and difficulty in walking were checked. According to the rehabilitative medicine screen directive, if one or more category was checked a referral was required. Nursing documented that no referral
{A 397}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 97 was made. 5. Review of the emergency department (ED) nurse record revealed that Patient #58 was a 93 year old female who presented to the ED on 01/03/13 at 1:50 p.m. with complaints of a fall. Patient #58 had a pain level of 10 (out of a scale from 0 meaning no pain to 10 meaning severe pain) in the left hand. Review of the initial ED assessment tool, dated 01/03/13, consisted of two pages. Nursing completed one page of the assessment and failed to complete the other. The second page consisted of actions taken, additional notes, medications given, procedures, vital signs, intake and outputs, property, and discharge disposition. All of these categories were not completed by nursing. There was no indication as to what happened to the patient. 6. Review of "nursing interventions" assessment, dated 12/24/12, revealed that Patient #44 was a 37 year old female admitted on 12/22/12. Acccording to the assessment sheets, LVN's (Staff #33, #83 and # 91) and a GN (# 92) completed the assessments from 12/24-26/12. There was a place on the assessments for a RN to sign, but this was not done. 7. Review of a "24 hour nursing flow record" revealed that Patient #39 was a 75 year old male admitted on 11/26/12 with diagnoses of pneumonia and congestive heart failure. Review of a "24 hour nursing flow record", dated 11/27/12, revealed documentation that Patient #39 had a cough, shortness of breath and
{A 397}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 98 generalized weakness. This assessment was signed off by Staff #83 (LVN). According to the flow sheet a RN was suppose to sign off on the assessment and this was not done. 8. Review of an "admission record", dated 11/17/12, revealed that Patient #41 was a 63 year old female admitted on 11/17/12 with diagnoses of dizziness and hypertension. Review of the "admission record" dated 11/17/12 revealed that the entire assessment was completed by Staff #90 (LVN). According to the "admission record" a RN was to perfom the assessment, but this was not done. Staff #90 (LVN) signed her name on the RN signature line. Review of the nutritional screen on the "admission record" form revealed that Patient #41 followed a special diet at home, had problems with chewing, and had cancer. According to the nutritional screen directive, if one or more categories were checked, nursing was supposed to make a referral. Nursing left the referral category blank. There was no documentation of a referral being made. According to the high risk assessment for fall category, Patient #41 had an unsteady gait. Review of the rehabilitative medicine screen section revealed no documentation by nursing of an assessment of the unsteady gait. There was a category on the screen for nursing to check difficulty in walking, but this was not done. According to the rehabilitative medicine screen directive, if one or more category was checked, a referral was required. Nursing left the referral category blank.
{A 397}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 397} Continued From page 99 Review of physician orders dated 11/17/12 revealed neuro checks were to be performed every 2 hours on Patient #41. There was no documentation in the nurses' notes or progress notes showing they were done. A 442 482.24(b)(3) SECURITY OF MEDICAL RECORDS [Information from or copies of records may be released only to authorized individuals,] and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. This STANDARD is not met as evidenced by: Based on observations and interviews, the facility failed to ensure the security of patient records in the emergency department.
{A 397}
A 442
During the tour of the emergency department on 1/7/2013, a filing cabinet storing patient records was observed unlocked and unattended by facility staff. The cabinet could be accessed by any unauthorized persons.
Interview with staff #42 on 1/7/2013 confirmed that the patient charts located in the hallway of the emergency department were not secure and could be accessed by any unauthorized persons.
Review of Policies and Procedure Manual for medical records revealed the following:
Subject: Policy for Confidential/Security of Patient

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A 442 Continued From page 100 Health Information Revised: March 1,2010 I. To assure safety, security, and confidentiality of all medical records maintained by Renaissance Hospital in an organized and readily accessible environment. II. The health record is the property of Renaissance Hospital and shall be maintained to serve the patient, the health care provider, and the institution in accordance with legal, accrediting and regulatory agency requirements. The information contained in the health record belongs to the patient, and the patient is entitled to the protected right of information. All patient care information shall be regarded as confidential and available only to authorized users. IV. Storage: A. All primary heath records shall be housed in physically secure areas. B. Secondary records, indices or other individually identifiable patient health information maintained by the institution are subject to the stated policies for maintenance of confidentiality of patient health information. F. When in use within the institution, health records should be kept in secure areas at all times. Health records should not be left unattended in areas accessible to unauthorized individuals. A 450 482.24(c)(1) MEDICAL RECORD SERVICES All patient medical record entries must be legible,
A 442
A 450
Event ID: 695E12
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A 450 Continued From page 101 complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This STANDARD is not met as evidenced by: Based on records review and interviews, the facility failed to ensure all medical record entries were dated, timed, and appropriately authenticated by the person who is responsible for ordering, providing, or evaluating the service provided. Citing 8 of 30 records reviewed. (#8, 32, 39, 40, 42, 45, 47, and 48)
A 450
Review of medical records on 1/9/2013 and 1/10/2013 revealed the following: 1. Patient record #39- no physician signature on history and physical transcribed on 11/26/2012. No physician signature and/or date found on discharge summary transcribed 11/29/2012. 2. Patient record #40- no physician signature and/or date on progress notes date 11/22/2012 and 11/28/2012. 3. Patient record #32- no physician signature and/or date on history and physical transcribed 11/26/2012. No signature and/or date on discharge summary transcribed on 11/28/2012. 4. Patient record #42- no physician signature and/or date on discharge summary transcribed on 11/23/2012. 5. Patient record #45- no physician signature
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 450 Continued From page 102 and/or date on history and physical transcribed on 11/25/2012. 6. Patient record #48- no physician signature and/or date on history and physical transcribed on 11/21/2012. 7. Patient record #47- no physician signature and/or date on history and physical transcribed on 11/15/2012. 8. Patient record #8- no physician signature and/or date on history and physical dated 11/13/2012. Interview with staff #42 on 1/10/2013 confirmed the findings for medical records #8, 32, 39, 40, 42, 45, 47, and 48. A 466 482.24(c)(2)(v) CONTENT OF RECORD INFORMED CONSENT [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This STANDARD is not met as evidenced by: Based on records review and interviews, the facility failed to ensure that consent forms were properly executed and complete. Citing 3 of 30 medical records reviewed. (#8, 42, and 47).
A 450
A 466
Review of patient medical record on 1/9/2013 and 1/10/2013 revealed the following:
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 466 Continued From page 103 1. Chart #42- patient name missing on consent for treatment dated 11/23/2012. 2. Chart #8- no physician signature and/or date and time on consent for blood transfusion patient received on 11/13/2012. No consent found for blood transfusion patient received on 11/14/2012. 3. Chart #47- No patient signature and/or witness signature on consent for treatment dated 11/15/2012. Interview with staff #42 on 1/10/2013 confirmed the findings for charts #8, 42, and 47. A 468 482.24(c)(2)(vii) CONTENT OF RECORD DISCHARGE SUMMARY [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This STANDARD is not met as evidenced by: Based on records review and interviews, the facility failed to ensure that all patient medical records contained a discharge summary. Citing 4 of 30 patient charts reviewed. (#8, 40, 41, and 48.) Review of medical records on 1/9/2013 revealed the following: 1. Patient chart #8- Patient discharged on 11/15/2012- no discharge summary found. 2. Patient chart #48- Patient discharged on 11/23/2012- no discharge summary found.
A 466
A 468
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 468 Continued From page 104 3. Patient chart #41- Patient discharged on 11/20/2012- no discharge summary found. 4. Patient chart #40- Patient discharged on 11/17/2012- no discharge summary found. Interview with staff #42 on 1/9/2013 confirmed the findings for charts #8, 40,41, and 48. A 490 482.25 PHARMACEUTICAL SERVICES The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital's organized pharmaceutical service. This CONDITION is not met as evidenced by: Based on records review, observations, and interviews, the facility's pharmacy: A. Failed to provide pharmacy policies that were current and approved by the current medical staff . A review of the pharmacy policies revealed that the policies were dated and approved in 2007 by the previous management/owner of the facility. Pharmacy services were not integrated into the hospital wide Quality Assessment and Performance Improvement Program.
A 468
A 490
B. Failed to provide a secure place for drugs and biological to be stored.

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 490 Continued From page 105 Refer to Tag A502
A 490
C. Failed to provide designated individual (by name and title of qualification) to remove drugs from pharmacy when pharmacy is closed or otherwise unavailable to facility staff members. Nine of nine signatures on the "Pharmacy Entry Log" were not designated individuals to remove drugs from the pharmacy. The facility staff members and pharmacist failed to complete the "Pharmacy Entry Log" with the required documentation per the facility policy. Refer to Tag A506
D. Failed to monitor and report adverse drug reactions to Quality Assessment and Performance Improvement Committee. Refer to Tag A508 A 502 482.25(b)(2)(i) SECURE STORAGE All drugs and biologicals must be kept in a secure area, and locked when appropriate. This STANDARD is not met as evidenced by: Based on observations, records review, and interviews, the facility failed to provide a secure place for drugs and biological to be stored.
A 502
Observed on tour of the facility on 1/9/2012 with staff #58 at approximately 10:00 AM, the medication cart in the nurses' medication room
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 502 Continued From page 106 which contains patient's individual medication was unlocked with the keys left in the lock.
A 502
An interview with Staff #58 on 1/9/2012 at approximately 10:00 AM, confirmed the keys were left in the medication cart which is stored in the nurses' medication room. A 506 482.25(b)(4) AFTER-HOURS ACCESS TO DRUGS When a pharmacist is not available, drugs and biologicals must be removed from the pharmacy or storage area only by personnel designated in the policies of the medical staff and pharmaceutical service, in accordance with Federal and State law. This STANDARD is not met as evidenced by: Based on observations, records review, and interviews, the facility failed to designate individuals (by name and title of qualification) to remove drugs from pharmacy when pharmacy is closed or otherwise unavailable to facility staff members.
A 506
Nine of nine signatures on the "Pharmacy Entry Log" were not designated individuals to remove drugs from the pharmacy. The facility staff members and pharmacist failed to complete the "Pharmacy Entry Log" with the required documentation per the facility policy.
A review of policy titled "Subject: DISPENSING: OBTAINING DRUGS OR BIOLOGICALS WHEN THE PHARMACY IS
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 506 Continued From page 107 CLOSED OR OTHERWISE UNAVAILABLE" revealed:
A 506
"POLICY: When drugs are not available from the patient's supply or other stocks, they shall be obtained from the pharmacy. A pharmacist shall be contacted if needed. When the pharmacy is closed or otherwise unavailable, drugs shall be removed in accordance with the following procedure.
REMOVING DRUGS FROM THE PHARMACY PREPACKAGED DRUGS: Drugs that have been prepackaged (by the manufacturer or pharmacy) shall be removed when available. If drugs are not prepackaged, the person making the withdrawal shall take the entire bulk container. Doses shall be removed from the container as needed and the container shall remain at the patient care area until retrieved by the pharmacy staff. AMOUNT OF DRUGS TO REMOVE: Only amounts of drugs sufficient for immediate therapeutic needs may be removed from the pharmacy. The amount removed may extend beyond a single dose, but should not exceed an amount to last until a pharmacist is available. RESTRICTIONS ON LABELING AND TRANSFERRING DRUGS: Non-pharmicists shall not label drugs or transfer drugs from one container to another. This is a dispensing function reserved for pharmacists.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 506 Continued From page 108 WHO MAY REMOVE DRUGS FROM PHARMACY: Only designated individuals (by name and title of qualification) shall remove drugs from the pharmacy. These individuals shall be oriented to the removal of drugs from the pharmacy. REVIEW OR REMOVALS BY A PHARMACIST: A licensed pharmacist shall review all orders for drugs removed from the pharmacy. RECORDING THE REMOVAL: The person who removes a drug from the pharmacy shall record the following: Time and date of removal Location and name of the patient Drug name, strength and dosage form Dose prescribed Quantity taken and (amount removed) Signature of person making the removal Signature of pharmacist who verified the removal Date and time of pharmacist verification" Review of the record titled "Pharmacy Entry Log" revealed 9 different nurse's signatures on the "Pharmacy Entry Log" (sign out record for drugs being removed from the pharmacy by nursing staff after the pharmacy is closed.) Review of records titled "Pharmacy Entry and Pass code Rules" for the year 2012 revealed 9 of 9 staff members signing out drugs from the pharmacy after the pharmacy was closed, had not signed the "Pharmacy Entry and Pass code Rules" record. A review of the record titled "Pharmacy Entry Log"
A 506
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 506 Continued From page 109 from 11/1/2012 thru 1/5/2013 revealed missing information from the log; Time and Date of removal----15 of 35 were missing Location and name of the patient----6 of 35 were missing Drug name, strength and dosage form----15 of 35 were missing Dose prescribed---- 35 of 35 (sign out form does not have documentation for the dose prescribed) Quantity taken and (amount removed) ----20 of 35 were missing Signature of person making the removal----21 of 35 were missing Signature of pharmacist who verified the removal----35 of 35 were missing Date and time of pharmacist verification ----35 of 35 were missing
A 506
A review of the record titled "Pharmacy Entry and Pass code Rules" revealed no documentation that the pharmacist had checked what the nursing staff was removing from the pharmacy after it was closed per the facility policy.
An interview with Staff #48 on 1/9/2013 at approximately 3:00 PM, confirmed that the staff members signing out drugs after the pharmacy is
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 506 Continued From page 110 closed were not designated individuals to have authority to remove drugs from the pharmacy per the facility policy. Staff #48 and #58 confirmed the "Pharmacy Entry Log" had missing documentation per the facility policy. A 508 482.25(b)(6) REPORTING ADVERSE EVENTS Drug administration errors, adverse drug reactions, and incompatibilities must be immediately reported to the attending physician and, if appropriate, to the hospital-wide quality assurance program. This STANDARD is not met as evidenced by: Based on observations, records review, and interviews, the facility's pharmacy failed to monitor and report adverse drug reactions to the Quality Assessment and Performance Improvement Committee.
A 506
A 508
A review of record titled, "Department of Pharmacy Services Quarterly Quality Improvement Third Quarter 2012" revealed adverse drug reaction monitoring was documented on the report as a "-1, (# of Response -1, Threshold % -1, % of Outcome-1, and Remarks Poor documentation by nursing department.)."
An interview with staff #57 on 1/8/2013 at approximately 5:00 PM confirmed that the facility does not have Quality Assessment and Performance Improvement (QAPI) committee or QAPI data to be submitted to a committee.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 508
An interview with staff #58 on 1/9/2013 at 2:00 PM revealed that if the pharmacy finds a medication error with nursing services, a verbal report is given to the Director of Nursing. Staff #58 was questioned if an occurrence report is completed and she stated "No, I just report the medication error to the Director of Nursing and the Pharmacist."
An interview with staff #48 on 1/9/2013 at 3:00 PM stated that "the nursing staff does not report to the pharmacy when a patient has had a drug reaction and we realize this is a problem." Staff #48 reported that he has not attended any type of QAPI meeting and the last Pharmacy meeting was October 2012. A 528 482.26 RADIOLOGIC SERVICES The hospital must maintain, or have available, diagnostic radiological services. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications. This CONDITION is not met as evidenced by: Based on records review and interviews, the facility failed to have an ongoing process of Quality Assessment and Performance Improvement (QAPI) program that measures, analyzes, and tracks adverse patient events, infection control and other aspects of performance improvement for the radiology department.
A 528
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 528 Continued From page 112 While reviewing the radiology departments documentation of QAPI activity on 1/8/2013, there was evidence of documentation that staff members had taken responsibility for collecting data for discussion at department director meetings. No documentation found to validate that it was taken forward for review by the QAPI program.
A 528
Interview with staff #50 on 1/8/2013 confirmed that at this time the facility has no organized QAPI program in which the radiology department can participate . . A 537 482.26(b)(2) PERIODIC EQUIPMENT MAINTENANCE Periodic inspection of equipment must be made and hazards identified must be promptly corrected. This STANDARD is not met as evidenced by: Based on records review and interviews, the facility failed to ensure preventative maintenance was current on equipment used in radiology.
A 537
During the tour of the radiology department on 1/9/2013, surveyor observed no preventative maintenance sticker on the x-ray table in room #2. Model # 46-27538258.
Interview with staff #50 confirmed no preventative maintenance had been done in years in the
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 537 Continued From page 113 radiology department. Staff #50 reported she had been employed since 2009. Was advised the physicist comes yearly to perform his routine checks. Staff #50 also advised, "I can't remember the last time the x-ray table had it's routine preventative maintenance." A 576 482.27 LABORATORY SERVICES The hospital must maintain, or have available, adequate laboratory services to meet the needs of its patients. The hospital must ensure that all laboratory services provided to its patients are performed in a facility certified in accordance with Part 493 of this chapter. This CONDITION is not met as evidenced by: Based on records review and interviews, the facility: A. Failed to provide an ongoing process of the Quality Assurance and Performance Improvement (QAPI) program that measures, analyzes, and tracks adverse patient events, infection control and other aspects of performance improvement for the laboratory department. While reviewing the laboratory departments documentation of QAPI activity on 1/8/2013, there was no evidence of documentation that any staff member had taken responsibility for collecting, measuring, analyzing, or tracking performance improvement in the laboratory department for the facility. Interview with staff #19 on 1/8/2013 confirmed that at this time the facility has no organized QAPI program program in which the laboratory
A 537
A 576
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 576 Continued From page 114 department can participate and no data had been collected.
A 576
B. Failed to adopt, implement, and enforce policies and procedures for receipt and reporting of tissue specimens. Refer to tag A0585 C. Failed to adopt, implement, and enforce policies and procedures for general blood safety issues concerning look back activities. Refer to tag A0586 A 585 482.27(a)(3) WRITTEN PROTOCOL FOR TISSUE SPECIMENS The laboratory must make provisions for the proper receipt and reporting of tissue specimens. This STANDARD is not met as evidenced by: Based on records review and interviews, the facility failed to adopt, implement, and enforce policies and procedures for receipt and reporting of tissue specimens. On 1/9/2013 while reviewing the Policy and Procedure Manual for the laboratory department, no Policies and Procedure were found for instructions for the collection, preservation, transportation, receipt, and reporting of tissue specimen results in the laboratory department. Interview with Director of Laboratory on 1/9/2013 confirmed that the department did not have any policies and procedures concerning tissue specimens. The Director of Laboratory also
A 585
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 585 Continued From page 115 advised, "The laboratory department received the tissue specimens and they were sent out to another facility for processing." A 593 482.27(c) GENERAL BLOOD SAFETY ISSUES General blood safety issues. For lookback activities only related to new blood safety issues that are identified after August 24, 2007, hospitals must comply with FDA regulations as they pertain to blood safety issues in the following areas: (1) Appropriate testing and quarantining of infectious blood and blood components. (2) Notification and counseling of recipients that may have received infectious blood and blood components. This STANDARD is not met as evidenced by: Based on records review and interviews, the facility failed to adopt, implement, and enforce policies and procedures for general blood safety issues concerning look back activities. On 1/9/2013 while reviewing the Policy and Procedure Manual for the laboratory department, no Policies and Procedure were found for blood safety issues concerning notification and counseling of recipients that may have received infectious blood and blood products. (Look Back Policy) Interview with Director of Laboratory on 1/9/2013 confirmed that the department did not have any policies and procedures concerning look back policy. The Director of Laboratory also advised that the laboratory department received paperwork from Carter Blood Bank for the
A 585
A 593
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 593 Continued From page 116 follow-up of a possible exposure and the follow-up was done. A 618 482.28 FOOD AND DIETETIC SERVICES The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This CONDITION is not met as evidenced by: Based on records review and interviews, the facility: A. Failed to have an ongoing process of Quality Assurance and Performance Improvement (QAPI) program that measures, analyzes, and tracks adverse patient events, infection control, and other aspects of performance improvement for the dietary department. While reviewing the dietary departments documentation of QAPI activity on 1/8/2013, there was no evidence that any staff member had taken responsibility for collecting, measuring, analyzing, or tracking performance improvement in the dietary department for the facility.
A 593
A 618
B. Failed to ensure adequate provisions for dietary consultation that meets the needs of the
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 618 Continued From page 117 patients when the dietician is not available.
A 618
Refer to tag A0621
C. Failed to ensure the nutritional needs were being met for patient receiving artificial nutrition.
Refer to tag A0628 A 621 482.28(a)(2) QUALIFIED DIETITIAN There must be a qualified dietitian, full-time, part-time, or on a consultant basis. This STANDARD is not met as evidenced by: Based on records review and interviews, the facility failed to ensure adequate provisions for dietary consultation that meets the needs of the patients when the dietician is not available. Citing 3 of 30 patient medical records reviewed. (#36, 41, and 45).
A 621
Review of the dietician schedule on 1/8/2013 revealed availability every Tuesday for 6-8 hours.
Review of patient records on 1/9/13 and 1/10/13 revealed the following:
1. Patient #45 was admitted to facility on 11/25/2012. Registered Nurse (RN) assessment dated 11/25/2012 revealed a referral for a dietary consult. No documentation that a dietary consult was conducted.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 621
2. Patient #36 was admitted to facility on 1/4/2013. RN assessment dated 1/04/2013 revealed a referral for a dietary consult due to patient on Total Parenteral Nutrition (TPN). No documentation that a dietary consult was conducted.
3. Patient #41 was admitted 11/17/2012. Patient was started on Potassium replacement therapy. No documentation of referral to dietician for consult and education found. No documentation that a dietary consult was done.
Interview with staff #75 on 1/8/2013 confirmed that she only work every Tuesday for 6-8 hours. Staff #75 confirmed that the previous Director of Dietary left sometime in 11/2012. Staff #75 also confirmed that staff #52 had recently been appointed to the position and was currently being oriented and trained. Advised that she reviewed the menu request forms received daily from the nurses station and frequently went out to the nurses station and reviewed patient charts to see if patient's needed dietary consult and education. Staff #75 also stated,"I'm available by phone if staff have any questions."
Interview with staff #42 on 1/10/2012 confirmed the findings for patient medical records, #36, 41, and 45. A 628 482.28(b) DIETS Menus must meet the needs of the patients.
A 628
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 628 Continued From page 119 This STANDARD is not met as evidenced by: Based on records review and interviews, the facility failed to ensure that the nutritional needs for patient receiving artificial nutrition were being met. Citing 1 (#36)of 30 patient medical records reviewed.
A 628
Review of patient records on 1/9/2013 and 1/10/2013 revealed the following:
Patient #36 was admitted on 1/4/2013 and Total Parenteral Nutrition was initiated. Documentation reveals that a nutritional assessment was completed by the Registered Nurse (RN) and the patient had a referral initiated for a consult by the dietician. No documentation that a dietary consultation and/or evaluation was done.
Interview with staff #42 on 1/101/2013 confirmed the findings for patient #36. A 700 482.41 PHYSICAL ENVIRONMENT The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This CONDITION is not met as evidenced by: Based on observations, records review, and interviews, the facility:
A 700
A. Failed to provide and maintain a safe and

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 700 Continued From page 120 clean environment for patient care. Refer to Tag A701
A 700
B. Failed to provide adequate fuel in the storage tank that runs the facility generator and the underground storage tank had not been inspected by the Texas Commission on Environmental Quality. Refer to Tag A702
C. Failed to provide fire drills on evenings and night shift for the facility staff members. Also, the facility failed to have the fire extinguishers inspected. Refer to Tag A709
D. Failed to dispose of trash and bio-hazard waste. The facility also failed to store Hazmat supplies in a clean area. Refer to Tag A713
E. Failed to ensure preventative maintenance was being done for patient care equipment. Refer to Tag 724 F. Failed to monitor temperature and humidity in the surgical suites and the sterile processing room where supplies are stored. Refer to Tag A726
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 701 482.41(a) MAINTENANCE OF PHYSICAL PLANT The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This STANDARD is not met as evidenced by: Based on observations, records review, and interviews, the facility failed to provide and maintain a safe and clean environment for patient care.
A 701
During observation tour of the facility with staff #42 on 1/8/2013 and staff #46 on 1/9/2013, observed the following:
Emergency Room During observation on 01/07/13 at 12:02 p.m., the sink in Treatment Room #2 (Emergency Room) was found with two basins stored underneath the pipes. The inside of the basins were stained brown from water leakage. The floor beneath the sink had buckled and the particle board underneath could be seen. During observation on 01/08/13 at 8:51 a.m., the entrance door to the Emergency Biohazard room was found with 2 approximate one inch holes and 1 two inch hole above the door knob. There was a sign on the outside of the door that read "Warning Biohazard" and the room was unlocked. Inside the room there were three bags of trash stored on the floor, two portable toilet seats, and
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 701 Continued From page 122 a box of open biohazard trash. Inside the biohazard box was a used basin and urinal which were not bagged. The cabinet underneath the sink had a missing door and front panel. Stored under the sink were two containers of biohazard treatment solution Isolyser. On the wall, at the entry of the room was an exposed electrical junction box.
A 701
Patient Rooms 100 Hallway Room 116--Observed a 4 inch gap between the wall and the floor, the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. In this room, a large tear (hole) in the vinyl upholstery of the sleep chair was also observed. There were dust particles in air conditioner/heating unit. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission. Room 115--Observed a 4 inch gap between the wall and the floor, the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. This room was available for patient admission. Room 114-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 701 Continued From page 123 entire length of the patient's room. There were dust particles and insects in air conditioner/heating unit. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission. Room 113-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. This room was available for patient admission. Room 112-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor, the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found. Room 111-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. This room was available for patient admission. Room 110-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed was
A 701
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 701 Continued From page 124 found. Room 109-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found. Room 108-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found. Room 107-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission. Room 105-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive
A 701
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 701 Continued From page 125 maintenance sticker on the patient bed. There was a dead mouse on the floor. This room was available for patient admission. Room 104-- Patient was being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Infusion pump being used had no preventive maintenance sticker. No preventive maintenance sticker on the patient bed was found. Room 103-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed. The floor had missing tile. This room was available for patient admission. Patient Rooms 200 Hallway Isolation Room 213 -- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. There was a patient next door to the isolation room. There was no negative air flow for the isolation room. There were blood tubes that had expired in 5/2012 found in the isolation cart at the entrance of the isolation room. This room was available for patient admission. Room 214 Dialysis Room-- Observed a 4 inch gap between the wall and the floor and the
A 701
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 701 Continued From page 126 molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The hoses for the water treatment and the drain hoses were routed thru the wall and into the bathroom where it drained into the bathtub. The cover for the air conditioner/heating unit was off and the electrical wiring was showing with dust and dirt. This room was available for patient admission. Room 215--Patient being cared for in this room. Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. Dust particles and trash observed in the air conditioner/heating unit. No preventive maintenance sticker on the patient bed was found. Room 217-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission. Room 219-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. No preventive maintenance sticker on the patient bed was found. The electrical outlet on the wall had plaster missing from around the electrical outlet. This room was available for patient admission.
A 701
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 701 Continued From page 127 Room 221-- Observed a 4 inch gap between the wall and the floor and the molding was falling off the wall. The gap was large enough that you can see into the next patient's room. The gap was the entire length of the patient's room. There were several chips in the ceiling tile and stains observed in the patient room. No preventive maintenance sticker on the patient bed was found. This room was available for patient admission. During the tour of the main hallway, the floor was dirty and stained. This hallway with patient rooms was used for pediatric and adult patients. There was large hole in the wall beside some type of call system with electrical wiring exposed and maintenance cover was missing from the cabinet in the soiled utility room on hallway 200. There was large hole in the ceiling observed in the equipment room on hallway 200. This was the room where cleaned patient equipment was stored. The floor in the equipment room was dirty and stained. There was computers, numerous cords, and trash on the floor in the electrical room on hallway 200. Decontamination Room During the tour with staff #2 on 1/7/2013 at 10:00 AM, the bottom cabinet 2 shelves were observed to have brown substance (appears to be rust and dirt). This cabinet had surgical instrument trays stored on the shelf.
A 701
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 701 Continued From page 128 Oxygen Tank Storage Area During the tour of the storage area on 1/9/2013 at 9:00 AM 4 (H- cylinders large oxygen tanks) and 11(E-cylinders small oxygen tanks) were observed lying on the ground and/or standing without being secured. Purchasing Department During the tour of the purchasing department 1/9/2013 at 1:00 PM with staff #51, there were card board boxes stored on shelves above the sterile supplies. The shelves where sterile supplies were being stored were dusty. The purchasing room opens up to the back dock where supplies are bought in from the outside vendors and this door was open. During the tour, it was observed in the purchasing department numerous opened card board boxes. Questioned why the boxes were still present? Staff #51 stated "the dumpster is full and has not been emptied in 3 months." Medical Records Storage During the tour of the medical record storage area with staff #46 on 1/9/2013, there were medical records piled on the floor approximately 3 feet high without any type of shelving.
A 701
Boiler Room
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 701 Continued From page 129 During the tour of the boiler room with staff #46, there was a fan on the floor connected to electrical outlet by a long extension cord. The fan was blowing air on the boiler motor.
A 701
Air conditioner Unit
During an interview on 1/10/2013 at 10:00 AM, staff #46 reported that the air conditioner unit was not functioning properly and has not functioned properly for 2 years. Staff #46 stated that "The heating wires were pulled from the unit 2 years ago. The unit has to be manually turned on and off by going on top of the roof. The unit will only blow cold air and there is no regulating the temperature. If it is cold outside then the unit just has to be turned off manually by going to the roof top of the building."
Staff #46 confirmed that this air conditioner unit supplies air flow and regulates the temperature for the Emergency room, Kitchen, Gastrointestinal Lab, Day Surgery, Medical/Surgical Floor, Front Office, Medical Records, and Sterilization where sterile supplies and instruments are stored. This Air conditioner unit supplies air flow to half the facility.
An interview with staff #46 on 1/9/2013 at 2:00 PM stated that "the facility has a foundation problem and the gap between the walls and floor can increase due to change in the weather
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 701 Continued From page 130 conditions."
A 701
Staff #46 confirmed there is bio-hazard waste and trash that needs to emptied, storage areas need to be cleaned and repaired, areas in the facility need repair work along with infection control issues, and the isolation room does not have negative air flow.
Staff #46 confirmed all the findings found during the facility tour on 1/9/2012.
A review of records titled "Safety Committee Meeting" revealed the last safety committee meeting was held December 2, 2010.
An interview with the safety officer on 1/10/2013 at 10:00 AM confirmed the facility last held safety meeting was December 2, 2010. A 702 482.41(a)(1) EMERGENCY POWER AND LIGHTING There must be emergency power and lighting in at least the operating, recovery, intensive care, and emergency rooms, and stairwells. In all other areas not serviced by the emergency supply source, battery lamps and flashlights must be available. This STANDARD is not met as evidenced by: Based on records review, observatiosn, and interviews, the facility failed to provide adequate fuel in the storage tank that runs the facility
A 702
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 702 Continued From page 131 generator and the underground storage tank had not been inspected by the Texas Commission on Environmental Quality.
A 702
During the tour of the facility generator on 1/9/2013 at 9:00 AM with staff #46, the low fuel alarm was alarming on the panel and the print showed low fuel in the tank that supplies the generator for emergency lighting and power. Also observed on the wall beside the alarm panel was a delivery certificate for petroleum storage tank program which expired the last day of September 2012.
A review of the Delivery Certificate revealed "for the specific time period and the Underground Storage tanks (USTs) indicated, this certificate verifies self-certification by the tank owner or operator of compliance with TCEQ rule requirements listed at TAC Sec. 334.8 (c)(3) (D). [regarding tank registration, payment registration fees, UST financial responsibility (e.g., insurance), and technical standards (release detection, spill/over fill prevention, corrosion protection & variances issued by the agency to any of these standards)]. The Texas Water Code Sec. 26.346 requires the tank owner or operator to accurately complete the parts of the registration and self-certification form pertaining to the self-certification of compliance with UST administrative requirements and technical standards. Expires last day of September 2012."
An interview with staff #46 on 1/9/2013 at 9:00 AM confirmed that the the alarm on the fuel tank
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 702 Continued From page 132 is recording low fuel and the "Delivery Certificate" for petroleum storage tank program had expired the last day of September 2012. A 709 482.41(b) LIFE SAFETY FROM FIRE Life Safety from Fire This STANDARD is not met as evidenced by: Based on records review, observations, and interviews, the facility failed to conduct fire drills on evenings and night shift for the facility staff members. Also, the facility failed to have the fire extinguishers inspected.
A 702
A 709
A review of 11 fire drill records revealed that there were no fire drills held on the evening or night shifts for the staff members of the facility.
A review of records and observation revealed that 2 fire extinguishers had not been inspected since 2010, 12 fire extinguishers had not been inspected since 2011 and 8 fire extinguishers had not been inspected since 2012.
An interview with staff #46 on 1/9/2013 at 1:00 PM confirmed that there were no fire drills held on evening or night shifts for staff members and the fire extinguishers in the facility had not been inspected. A 713 482.41(b)(6) DISPOSAL OF TRASH The hospital must have procedures for the proper routine storage and prompt disposal of trash. This STANDARD is not met as evidenced by:
A 713
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 713 Continued From page 133 Based on observations, records review, and interviews, the facility failed to dispose of trash and bio-hazard waste appropriately. The facility also failed to store Hazmat supplies in a clean area.
A 713
During a tour of the facility on 1/9/2013 at 11:00 AM with staff #46, there were card board boxes stacked up on the dock where supplies come in to the facility in the purchasing department area. Staff #46 was questioned why the boxes were not placed in the trash dumpster and Staff #46 stated, "The dumpster is full and it will not hold any more trash." Staff #46 was questioned why the dumpster has not been emptied and Staff #46 stated, "The dumpster has not been emptied in 3 months because the vendor has not been paid and the service will not come until paid."
During a tour of the facility on 1/9/2013 at 11:30 AM with staff #46, there were 2 carts full sharps containers (45 full bio-hazard sharp containers) in the hallway of the facility. When Staff #46 was questioned why the bio-hazard had not been picked up, Staff #46 stated, "The vendor has not been paid and will not pick up the containers until paid."
During a tour of the facility on 1/9/2013 at 12:00 PM with staff #46 of a room where the red bags of bio-hazard are stored, there was equipment, trash, sharp containers, intravenous infusion pumps, boxes, computers, numerous wires on the ground, and at the very back of the room was a large amount of Hazmat supplies for a disaster.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 713
A review of policy titled "Hazardous Waste Management Plan" "AUTHORITY AND RESPONSIBILITY The Chief Executive Officer(CEO) has final legal and moral authority and responsibility for the assurance at a compressive, flexible and integrated Hazardous Waste Management Program. The CEO is responsible for providing financial support necessary for the specific services, equipment and personnel required to maintain the hazardous waste management program The CEO delegates authority and accountability for the Hazardous Waste Program to the Safety Officer."
A review of records titled "Hazardous Waste Policy and Procedure Manual 2001" revealed the policies had not been updated or reviewed since 2001.
An interview with Director of Nurses on 1/9/2013 at 2:00 PM was unaware that the dumpster had not been emptied for 3 months and sharp containers (45) had not been picked up due to vendors not being paid. {A 724} 482.41(c)(2) FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.
{A 724}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 724} Continued From page 135 This STANDARD is not met as evidenced by: Based on observations, documents review, and interviews, the facility: A. Failed to enforce the established police for daily check of crash carts. A review of the nursing policy titled, Crash Carts, revealed "Crash carts will be checked daily on the units during hours of operation." A review of the documents titled, "Resuscitation Cart Checklist" (Crash Cart), revealed that the crash carts were not being checked daily to ensure the carts in working order and ready if an emergency occurred. The Surgical Crash Cart was not checked as required for the months of: July not checked 28 days of the required 31 days. August not checked 2 days of the required 31 days. September not checked 10 days of the required 30 days. October not checked 24 days of the required 31 days. November not checked 10 days of the required 15 days. The Intensive Care Crash Cart was not checked as required for the months of: May not checked 13 days of the required 31 days.
{A 724}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 724} Continued From page 136 No documentation for the month of June. No documentation for the month of July. August not checked 27 days of the required 31 days. September not checked 2 days of the required 30 days. October not checked 6 days of the required 31 days. November not checked 7 days of the required 15 days. The Medical Surgical Unit housed two adult crash carts. For the purpose of the report the carts will be labeled Crash Cart #1 and Crash Cart #2. The Medical Surgical Unit's Crash Cart #1 had all the required checks. The Medical Surgical Unit's Crash Cart #2 did not have the required checks for the months of: June not checked 5 of the required 30 days. July was checked 31days of the required 31 days. August was checked 31 days of the required 31 days. September not checked 2 days of the required 30 days. No documentation the cart was checked for the
{A 724}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 724} Continued From page 137 month of October. No documentation the cart was being checked for the month of November. B. Failed to ensure preventative maintenance was being done for patient care equipment. During tours of the facility and throughout the investigation conducted on 09/13/2012 until 09/15/2012, random equipment was checked for preventative maintenance. During observations on 11/13/12 the following equipment did not have current preventative maintenance checks: Medical Surgical Unit 11:20 a.m., Two adult defibrillator/monitor on the crash cart #1 and #2 were due for inspection. Operating Room 11:22 a.m., a defibrillator/monitor on the crash cart was due an inspection 07/12. 11:30 a.m., a heart monitor was due to be inspected 10/11 Day Surgery Room 12:00 p.m., intravenous pump was due an inspection 07/12 and a heart monitor in the same room was due an inspection 07/12. 12:05 p.m., a heart monitor was due an inspection 07/12.
{A 724}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 724} Continued From page 138 12:07 p.m., a heart monitor was due an inspection 07/12. During an interview on 11/13/12 at 12:05 p.m., CNO (Chief Nursing Officer) said the company who did the inspections on the equipment came out every 3 months or every 6 months. He was not really sure. Respiratory equipment storage room At 1:45 p.m. a Bi-PAP machine was due an inspection 07/12. Emergency Room During observations on 11/15/12 the following equipment did not have current preventative maintenance checks: At 9:10 a.m. a defibrillator/monitor was on the crash cart in Treatment room #2 and was due an inspection 07/12. At 9:15 a.m. a defibrillator/monitor was on the crash cart in Treatment room #1 and was due an inspection 07/12. At 9:35 a.m., an intravenous pump in Treatment room #2 had an inspection sticker dated 01/11. Interviews and review of emails with the Bio Medical Company that provides the preventative maintenance revealed the facility owes $2706.25 for services rendered and will not provide any other service for the facility until payment is made.
{A 724}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 724}
During the follow-up survey from 1/7/2013 through 1/10/2013 additional findings were as follows: Based on observation, record review, and interview the facility failed to ensure a safe and sanitary environment for patients. Emergency Room Pediatric infusion pump #HEC107 due by 03/2011; Pediatric infusion pump #HEC207 due by 10/2011; Examining lights #2119141 and 2119142 over the beds were due by 7/2012. During an observation on 01/07/13 at 12:02 p.m., an Ambu bag was found in a ripped plastic bag. The Ambu bag was stored on the crash cart in Treatment room #2 in ED ready for use. During an interview on 01/07/13 at 1:14 p.m., Staff #57 (RN Consultant) reported the respiratory department had discarded the Ambu bag in the dumpster, but someone had brought it back into the facility. The respiratory department was cutting the bags before discarding them to show they were no longer to be in use. Radiology During observation on 01/07/13 at 12:30 p.m., a portable x-ray machine was found in the
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 724} Continued From page 140 Emergency Room with an approximate 10 centimeter hole in metal covering. The hole was covered with clear plastic tape. Decontamination Room Alcohol bottle (opened and not dated) - expired 1/2012 Cricothyroid kit - expired 6/2012
{A 724}
Ruhhof-Biocide solution for cleaning - dated expired 5/4/2011(the bottle was empty; observed black substance in the bottom of the bottle)
Gastrointestinal Lab Pentax EPK -1000 Laparoscopic processing machine and camera had preventive maintenance due 7/2012 Anesthesia Machine was last inspected 11/10/2010 and was due for inspection 5/2011
Day Surgery Intravenous pump # 0125 had no preventive maintenance sticker Intravenous pump # 0076 preventive maintenance due 10/2011 Quick Pace Pads-expired 1/28/2012 (x 1) During a tour of the Day Surgery Unit with staff #2
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 724} Continued From page 141 on 1/7/2013, the Cardiac Monitor was beeping continuously and when turned on showed device error service required.
{A 724}
Day Surgery Supply Closet Green Cap blood tubes- expired 11/2012- (x 11) Butterfly expired- 08/2012- (x 1) Punch box-4 mm- expired 10/12/2012- (x 20) Punch box-6 mm- expired 10/22/2012- (x 22) Disposable Derma Curette- expired 11/2012 (x 25) Sterile Gauze- 2x3- expired 6/2008 (x 8) Sterile Gauze- 3x8- expired 7/2008 (x 2) Sterile Gauze- 3x4- expired 7/2008 (x 2) During a tour of the Day Surgery Unit with staff #2 on 1/7/2013, there was a dead cricket hanging on the wall of the Day Surgery Supply Closet above the sterile supplies. Sterile Processing Room Stapler TL90- expired 12/2012 (x 1) Hemodialysis Catheter (14.5) -expired 11/2012(x 1) One-Step Prep-Dura Prep- expired 5/2012 (x 1)
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 724} Continued From page 142 Stapler Reload-35 mm - expired 4/2012 (x 4) Retrieval System- expired 08/2012 (x 5) Burr- 4.0 expired 5/2012 (x 2)
{A 724}
Resector- 4.0 expired 9/2012 (x 2) Guide wire .35 expired 5/2012 (x 1) Thoracic Catheter (36) expired 08/2012 (x 1) Punch Biopsy- 3 mm -expired 11/2012 (x 4) Punch Biopsy- 6 mm -expired 11/2012 (x 2) Punch Biopsy- 4 mm -expired 11/2012 (x 2) First Pass Needle and Suture Capture- expired 09/2012 Wound Reservoir Drain (Hemovac) - expired 07/2012 (x 3) Supply Closet in Surgery Glycine 3000cc bag X 1 expired 11/2012 on the shelf. Intravenous catheter Jelco #16- expired 2012 (x4) During a tour 1/7/2013 at 4:30 PM with staff #5, there were card board boxes found on the shelves in the supply closet, dust and insects found on shelves in the sterile supply room, and dust on the floors in the surgical suite. Recovery Room
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 724} Continued From page 143 Insulted needle-expired 09/2012- (x 43) Epidural pumps X 2 no preventive maintenance sticker Interview with staff #5 on 1/7/2013 at 4:30 PM confirmed Gastrointestinal Lab, Day Surgery, Sterile Processing Room, Decontamination Room, Recovery Room, and the supply closet in the surgery suite had expired supplies, broken equipment and preventive maintenance inspections that were not current on surgical equipment. Supplies and equipment were available for patient use and the surgery areas were contaminated with insects and dust. A 726 482.41(c)(4) VENTILATION, LIGHT, TEMPERATURE CONTROLS There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This STANDARD is not met as evidenced by: Based on observations, records review, and interviews, the facility failed to monitor temperature and humidity in the surgical suites and the sterile processing room where supplies are stored.
{A 724}
A 726
Review of the facility's Surgery policies revealed that there was no policy on monitoring temperature and humidity in the area where sterile supplies are stored.
Review of the AORN (Association of

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 726 Continued From page 144 periOperative Registered Nurses) Standards and Recommended Practices revealed, "Temperature should be maintained between 68 degrees F to 73 degrees F." These recommendations apply to both operating rooms and sterile processing areas. A relative humidity level of 30 to 70 percent is acceptable. "Room temperature, humidity, and ventilation of each work area should be monitored and recorded daily." Review of record with the temperature and humidity recorded revealed the following: Operating Room #1 December --no recording of temperature/humidity being recorded January 2013 -- 8 of 8 days temperature were out of range
A 726
Operating Room #2 December --no recording of temperature/humidity being recorded January 2013 -- 8 of 8 days temperature were out of range
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 726
Sterilization Room December --no recording of temperature/humidity being recorded January 2013 -- 7 of 10 days temperature were out of range
During a tour on 1/10/2013 at approximately 11:00 AM with staff #46, it was noted that the temperature was 81 degrees in the Sterilization Processing Room. Sterile instruments and supplies are stored in this area.
An interview with Staff #46 on 1/10/2013 at 10:00 AM reported that the air conditioner unit is not functioning properly and has not functioned properly for 2 years. Staff #46 stated, "The heating wires were pulled from the unit 2 years ago. The unit has to be manually turned on and off by going on top of the roof. The unit will only blow cold air and there is no regulating the temperature. If it is cold outside then the unit just has to be turned off manually by going to the roof top of the building."
Interview with staff #57 confirmed temperatures and humidity were not being recorded daily for Operating Room #1, #2, #3, or the sterilization room and no policy for temperature/humidity if recorded out of range. {A 747} 482.42 INFECTION CONTROL
{A 747}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 146 The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on documents review and interviews, the facility failed to provide evidence of an Infection Control Program. The facility failed to provide Infection Control Policies and Procedures, including a system for identifying, reporting and investigating healthcare associated infections. The facility also failed to maintain a log of all reportable diseases. The Governing Board Committee Meeting Minutes for January 26, 2012, February 23, 2012, March 29, 2012, April 26, 2012, May 17, 2012, June 21, 2012, July 26, 2012, August 23, 2012 and September 27, 2012 were reviewed. These documents revealed no Infection Control being reported. During a tour of the Scope Procedure Room on 11/13/2012 at 11:00 AM with CNO (Chief Nursing Officer) and staff # 2, the endoscopy scopes were observed hanging in the endoscopy cabinet touching the floor of the cabinet. On the floor of the scope cabinet was a green towel where brown substance had leaked onto the towel from the scope. Also observed on the scope processing machine was a bottle of water that supplies the water irrigation to the scope during the procedure. The bottle was still present from the endoscopy procedure done on 11/9//2012. The sterile water irrigation bottle that replenishes
{A 747}
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 147 the water in the bottle on the machine had expired 10/15/2012.
{A 747}
The endozyme instrument brush for cleaning the scopes was found stored in a cabinet where the scopes are cleaned. The scope brushes had all expired. One brush expired 5/2010, ten brushes expired 6/2010, and six brushes expired 8/2010. The container holding all the brushes had approximately 4 used brushes in with the expired bushes. There were no endozyme sponges used to clean scopes, found in the processing room.
Interview with staff #2 on 11/13/2012 at 12:30 confirmed that leak testing of the scopes was not being done, brushes that were expired and used brushes had been reused to clean scopes, and there were no available sponges for cleaning the scopes.
During a tour,there was a pan of Cidex OPA (Cidex solution) for high disinfection of the endoscopy scopes in the Processing Room,. Staff #2 was not able to produce the CIDEX OPA Solution Test Strips that are needed for checking the concentration of ortho-phthalalldehyde in the Cidex solution. There was no log documenting the Cidex was being checked and/or monitored.
Review of the manufacturer's recommendation for use of the Cidex revealed, "CIDEX OPA Solution may be reused for up to a Maximum of 14 days provided the required conditions of ortho-phthalaldehyde concentration and
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 148 temperature exist based upon monitoring described in the Direction for use. Do not rely solely on day in use. Concentration of this product during its reuse life must be verified by the CIDEX OPA Solution Test Strips prior to each use to determine that the concentration of orto-phthalaidehyde if above the MEC of 3%. The product must be discarded after 14 days."
{A 747}
Staff #2 was interviewed throughout the tour of the Surgical Department on 11/13/2012. Staff #2 confirmed there was no log being maintained for the monitoring of when the Cidex was being tested for the effectiveness of the concentration . Staff #2 reported that the active ingredient ortho-phthalaldehyde in the Cidex solution was not being monitored because the facility had not purchased the required Cidex OPA Solution Test Strips in over 2 months. When questioning Staff #2 about the log for testing the Cidex solution, he stated "I did not know that a monitoring log of the Cidex solution had to be kept." Staff #2 confirmed the last endoscopy procedure was done on 11/09/2012 and the endoscopy scope was processed in the Cidex solution that had never been tested for the effectiveness of concentration. There were 18 completed scheduled endoscopy cases done in the facility from June 18, 2012 thru November 9, 2012 without the Cidex solution being tested for the effectiveness of the concentration.
Interview with Staff #2 on 11/13/2012 at 12:00 PM confirmed no processing of the scopes prior to the surgical procedure.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
TERRELL, TX 75160
{A 747} Continued From page 149 Review of the Association of periOperative Registered Nurses (AORN) "2009 Peri-Operative Standards and Recommended Practices", revealed that flexible endoscopes be reprocessed before use if unused for more than 5 days.
{A 747}
Staff #2 was questioned during the tour if scopes are reprocessed prior to the surgical procedure. Staff #2 reported that scopes are cleaned after the procedure and hung back on the endoscopy cabinet till the next scheduled case. No prior cleaning is done before the case. Review of operating log /register and interview with Staff #2 revealed scheduled cases for the last 6 months have been (6) in June, ( 1) in July, (1) in August, (8) in September, (1) in October, (1 ) in November in which confirms storage of the scopes have been longer than 7 days between cases.
During the tour with CNO and #2 on 11/13/2012 at 12:00 PM, there were expired supplies, broken equipment, and equipment with preventive maintenance inspections due 7/12/2012 observed.
Gastrointestinal Lab Bite block expired 8/2011 Endoscopy tubing 10/2012 Pentax EPK -1000 Laparoscopic processing machine and camera had preventive
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
TERRELL, TX 75160
{A 747} Continued From page 150 maintenance due 7/2012 Anesthesia Machine had preventive maintenance due 7/2012, observed on the anesthesia machine tubing with brown substance and along the base of anesthesia machine was a brown splattered substance.
{A 747}
Day Surgery Intravenous pump had preventive maintenance due 7/2012 #1 Heart Monitor had preventive maintenance due 7/2012 #2 Heart Monitor had preventive maintenance due 7/2012 Cardiac Monitor was broken and the defibrillator paddles were missing Open circumcision tray was lying on top of the crash cart #1 Suction canister was found with dried pink substance at the bottom of it which appeared to be sputum, and a clear plastic bag covering it with tubing attached. #2 Suction canister was found with dried brown substance at the bottom of it which appeared to be sputum, and a clear plastic bag covering it with tubing attached.
Sterile Processing Room

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 151 Two large card board boxes filled with various types of expired surgical supplies (available to staff for patient use) Supply Closet in Surgery Sterile water 3000cc bag X 2 expired 10/2012 on the shelf. Sterile water 3000cc bag X 1 expired 10/2012 found in the warmer. Card board boxes were found in the supply closet in the surgery suite.
{A 747}
Interview with CNO on 11/13/2012 at 1:00 PM confirmed Gastrointestinal Lab, Day Surgery, Sterile Processing Room, and the supply closet in surgery had expired supplies, broken equipment and preventive maintenance inspections that were not current on equipment, and dirty supplies available to staff for patient use.
During a tour of the facility, the washer for the instruments had a graph showing if the washer reached a certain water temperature for proper cleaning was observed. The graph had been left there without being replaced. The red circle was a solid red circle with no elevated lines showing the water temperature of the washer. Staff #2 was questioned why the graph paper was never changed and he reported the facility did not have any more graph paper.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 152 Interview with staff #2 on 11/14/2012 at 2:00 PM confirmed that the autoclave inspection labels read July 2012 on both autoclaves and the graph paper has not been changed in the washer due to insufficient supplies by the facility. Staff #2 confirmed that he has no idea if the washer is reaching the water temperature recommended by the manufacture.
{A 747}
Review of facility policy titled "Decontamination, Sorting, and Sterilization of Contaminated Instruments and Equipment:"
PROCEDURE: PACKAGING. WRAPPING, STERILIZATION AND STORAGE OF SURGICAL INSTRUMENTS. 1. Assembles instrument sets according to established lists. 2. Places sterilization indicators in densest area of the package. 3. Wraps/contains instruments using nonwoven CSR wrap (two layers), peel pouches, or rigid case. 4. Labels package with name of instrument or set, tags with load lot number and records on autoclave load record.
Review of record titled "3M Attrest load list and Process Monitor Documentation System" revealed sterilization log did not include load
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 153 identification, indicator results, and identification of the contents of the load when using the autoclave in the Surgery Department. In the sterile processing room surveyor observed a tray with instruments and numerous sterilization strips that had not been recorded in the "3M Attrest Load List and Process Monitor Documentation System.
{A 747}
Interview with staff #2 on 11/14/2012 at 2:00 PM confirmed, the improper use of the sterilization log would cause a problem in identifying contaminated instruments from a load not logged properly. Staff #2 also confirmed the sterilization log was not being done on all loads of surgical instruments being processed.
During a tour of the decontamination area on 11/14/2012 at 2:00 PM, there were contaminated instruments sitting on the counter top, in the sink, and in the cart (the cart is used to carry clean instruments to the surgical suite from sterile processing area). The cart was found in the decontamination area with sterile and contaminated instruments inside it. The decontamination room had contaminated instruments that remained in the same place during the survey for 3 consecutive days. Survey dates were 11/13-15/2012. The last surgical case was completed on 11/12/2012.
The washer for the instruments has a graph showing if the washer reaches a certain water temperature for proper cleaning. The graph had been left there without being replaced. The red
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 154 circle was a solid red circle with no elevated lines showing the water temperature of the washer. Staff #2 was questioned why the graph paper was never changed and he reported the facility did not have any more graph paper.
{A 747}
Interview with staff #2 on 11/14/2012 at 2:00 PM confirmed the contaminated instruments have been sitting in the decontamination room since 11/12/2012 when the case was completed. Staff #2 also confirmed the graph paper has not been changed in the washer due to insufficient supplies by the facility. Staff #2 confirmed that he has no idea if the washer is reaching the water temperature recommended by the manufacture.
Review of the facility's Surgery policies revealed that there was no policy on recording temperature and humidity in the area where sterile supplies are stored.
Review of the AORN (Perioperative Standards and Recommended Practices) revealed, "Temperature should be maintained between 68 degrees F to 73 degrees F. These recommendations apply to both operating rooms and sterile processing areas. A relative humidity level of 30 to 70 percent is acceptable. Room temperature, humidity, and ventilation of each work area should be monitored and recorded daily." Review of record with the temperature and humidity recorded revealed the following:
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 155 Operating Room #1 July--21 of 31 days temperature/humidity was not monitored August --20 of 31 days temperature/humidity was not monitored September--19 of 30 days temperature/humidity was not monitored October--26 of 31 days temperature/humidity was not monitored November --10 of 15 days temperature/humidity was not monitored
{A 747}
Operating Room #2 July--20 of 31 days temperature/humidity was not monitored August --22 of 31 days temperature/humidity was not monitored September--22 of 30 days temperature/humidity was not monitored October--26 of 31 days temperature/humidity was not monitored November --10 of 15 days temperature/humidity was not monitored
Operating Room #3
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 156 The months July through November 15th the temperature/humidity was never monitored for operating room #3.
{A 747}
Sterilization Room The months July through November 15th the temperature/humidity was never monitored and there was no documented record that the sterilization room was ever monitored.
Interview with staff #2 confirmed temperatures and humidity was not being recorded daily for Operating Room #1, #2, #3, and/or the sterilization room.
During interviews with CNO, who identified himself as the Infection Control Nurse, on 11/14/2012 at 10:00 AM in the Doctor's Lounge, there were multiple requests made of him to provide evidence by way of policy and procedures outlining the facility's Infection Control Program. No policies were provided by CNO. CNO was asked to provide documentation/reports that the facility was providing infection control training, monitoring infections of patients or employees. CNO confirmed there were no reports. CNO provided a notebook containing lab reports and he confirmed these reports were not being tracked or trended into a report. It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failed practices
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 157 had the potential to affect all patients admitted to the facility.
{A 747}
During the follow-up survey from 1/7/2013 through 1/10/2013, the Immediate Jeopardy cited on the Conditions of Participation for Infection Control were found to remain at the Immediate Jeopardy level. Additional findings were as follows:
Based on documents review, observations, and interviews, the facility: A. Failed to have evidence of an Infection Control Program. The facility failed to provide Infection Control Policies and Procedures, including a system for identifying, reporting and investigating healthcare associated infections. The facility also failed to maintain a log of all reportable diseases. A review of records titled "Governing Board Meeting" for January 26, 2012, February 23, 2012, March 29, 2012, April 26, 2012, May 17, 2012, June 21, 2012, July 26, 2012, August 23, 2012, September 27, 2012 and January 3, 2013 revealed no Infection Control being reported. There was no documentation of any infection committee or meetings held at this facility. A review of the record titled "Medical Center at Terrell Infection Control Manual 2004" revealed the only infection control manual for the facility and has not been updated since 2004. An interview with Staff #57 on 1/10/2013 at 12:00 PM confirmed there was no infection control
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 158 program or committee. B. Failed to ensure a sanitary environment to prevent infections in the surgical setting.
{A 747}
During a tour of the Scope Procedure Room on 1/7/2013 at 12:00 PM with staff #2, there was a bottle of water that supplies the water irrigation to the scope during the procedure. The bottle was still present from the endoscopy procedure done on 11/9//2012.
During a tour on 1/7/2013 at 4:30 PM with staff #5 in the Process cleaning room, there were expired endoscopy brushes that were stored in a cabinet. Three brushes expired 11/2009, three brushes expired 2/2010, three brushes expired 6/2010, and five brushes expired 8/2010. Observed in the cabinet of the process cleaning room were brushes for Olympus scopes and the facility has Pentax scopes. Question to staff #5, which supply brushes are used for cleaning the facility scopes? Staff #5 had no knowledge of which brush should be used nor was staff #5 able to tell the surveyor which brand of scopes the facility was using.
Interview with staff #5 on 1/7/2013 at 4:30 PM, confirmed brushes were expired and the facility had the wrong brand of brushes to be used for cleaning the Pentax scopes.
A review of the "Daily Disinfection Record" revealed that staff #2 had been using the Cidex solution to disinfect the endoscopy scopes. A
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 159 review of #2 personnel file revealed no training on the use of Cidex solution.
{A 747}
A review of the "Daily Disinfection Record" revealed that staff #78 had been using the Cidex solution to disinfect transvaginal probe used in the radiology department for vaginal sonograms. A review of #78 personnel file revealed no training on the use of Cidex solution.
An interview with staff #57 on 1/8/2013 at 5:00 PM confirmed that staff #2 and #78 had not had any training on the use of Cidex solution.
During the tour with Staff #2 on 1/7/2013 at 12:00 PM, tehre were expired supplies, broken equipment, and equipment with preventive maintenance inspections due 7/12/2012 observed.
Observed in the decontamination room on a stool were 2 containers with washing solution for the washer. Staff #2 was questioned why the containers were on the stool and staff #2 reported that the dispenser for the instrument washer was broken and staff #2 just pours solution in the instrument washer.
Decontamination Room Alcohol bottle (opened and not dated) - expired 1/2012
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 160 Cricothyroid kit - expired 6/2012 Ruhhof-Biocide solution for cleaning - expired 5/4/2011(the bottle was empty; observed black substance in the bottom of the bottle)
{A 747}
Day Surgery Intravenous pump # 0125 had no preventive maintenance sticker Intravenous pump # 0076 preventive maintenance due 10/2011 Quick Pace Pads-expired 1/28/2012 (x 1)
During a tour of the Day Surgery Unit with staff #2 on 1/7/2013, the Cardiac Monitor was beeping continuously and when turned on showed device error service required.
Day Surgery Supply Closet Green Cap blood tubes- expired 11/2012- (x 11)
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 161 Butterfly catheter expired- 08/2012- (x 1) Punch biopsy-4 mm- expired 10/12/2012- (x 20) Punch biopsy-6 mm- expired 10/22/2012- (x 22) Disposable Derma Curette- expired 11/2012 (x 25) Sterile Gauze- 2x3- expired 6/2008 (x 8) Sterile Gauze- 3x8- expired 7/2008 (x 2) Sterile Gauze- 3x4- expired 7/2008 (x 2)
{A 747}
During a tour of the Day Surgery Unit with staff #2 on 1/7/2013, there was a dead cricket hanging on the wall of the Day Surgery Supply Closet above the sterile supplies.
Sterile Processing Room Stapler TL90- expired 12/2012 (x 1) Hemodialysis Catheter (14.5) -expired 11/2012(x 1) One-Step Prep-Dura Prep- expired 5/2012 (x 1) Stapler Reload-35 mm - expired 4/2012 (x 4) Retrieval System- expired 08/2012 (x 5) Burr- 4.0 expired 5/2012 (x 2)
Resector- 4.0 expired 9/2012 (x 2)

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 162 Guide wire .35 expired 5/2012 (x 1) Thoracic Catheter (36) expired 08/2012 (x 1) Punch Biopsy- 3 mm -expired 11/2012 (x 4) Punch Biopsy- 6 mm -expired 11/2012 (x 2) Punch Biopsy- 4 mm -expired 11/2012 (x 2) First Pass Needle and Suture Capture- expired 09/2012 Wound Reservoir Drain (Hemovac) - expired 07/2012 (x 3)
{A 747}
Supply Closet in Surgery Glycine 3000cc bag X 1 expired 11/2012 on the shelf. Intravenous catheter Jelco #16- expired 2012 (x 4)
During a tour on 1/7/2013 at 4:30 PM with staff #5, there were card board boxes found on the shelves in the supply closet, dust and insects found on shelves in the sterile supply room, and dust on the floors in the surgical suite.
Recovery Room Insulated needle-expired 09/2012- (x 43)
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 163 Epidural pumps X 2 no preventive maintenance sticker
{A 747}
Interview with staff #5 on 1/7/2013 at 4:30 PM confirmed Gastrointestinal Lab, Day Surgery, Sterile Processing Room, Decontamination Room, Recovery Room, and the supply closet in the surgery suite had expired supplies, broken equipment and preventive maintenance inspections that were not current on surgical equipment. Supplies and equipment were available for patient use and the surgery areas were contaminated with insects and dust.
C. Failed to provide and maintain an environment for apprpriate sterile processing of surgical instruments with a qualified staff member over the sterilization department, proper use of external chemical indicators and biological testing, recording of sterilization logs, and continued education and training for the staff on sterilization of supplies. The Surgical Department has performed 82 cases from 6/6/2012 thru 11/12/2012.
Review of records revealed no supervision of the sterile processing room.
Interview with Staff #5 on 1/7/2013 at 4:30 PM confirmed there was no one over the sterilization room with any training or experience to oversee the processing was done according manufacturer's guidelines.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 164 Review of the personnel file for staff #2 revealed no documentation of training on the sterilization of supplies and/or processing of endoscopy scopes. The personnel file dated 9/27/2011 revealed a job description on which the evaluator writes that staff #2 needs to "look at continuing education to enhance knowledge in sterile processing through certification program" (this is the only record in the file written by the evaluator). The employee wrote, "There is a lot of space for improvement regarding new methods of packing, sterilizing, education which can be done with frequent orientation." The personnel file revealed no education or training in the sterilization area or the processing of the endoscopy scopes.
{A 747}
Observed on tour of the sterile processing room on 11/14/2012 at 2:00 PM with staff #2, the autoclave was out of service waiting on a part to arrive to the facility. Last inspection of the autoclave was on July 2012. The autoclave in the Surgery department last inspection was also July 2012.
An interview with staff #5 on 1/7/2013 at 4:30 PM reported that all the surgical instruments would have to be redone due to the autoclave was not reaching the temperature according to the manufactures' guidelines for the last 3 months.
Interview with Director of Nursing on 1/7/2013 at approximately 5:00 PM confirmed that staff #2 and Staff #5 had not taken any type of education courses on sterilization of supplies and
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 165 equipment since being hired at the facility. Director of Nurses also confirmed education courses for sterilization of supplies had not been provided by the facility.
{A 747}
Interview with staff #2 on 1/7/2013 at 12:00 PM confirmed that the autoclave inspection labels read July 2012 on both autoclaves and the main autoclave in the sterilization room was broken. Staff #2 confirmed the washer dispenser was broken and he had no knowledge of how much washing solution was recommended by the manufacturers' guideline.
Review of the facility's Surgery policies revealed no policy on recording temperature and humidity in the area where sterile supplies are stored.
Review of the AORN (Perioperative Standards and Recommended Practices) revealed, "Temperature should be maintained between 68 degrees F to 73 degrees F." These recommendations apply to both operating rooms and sterile processing areas. A relative humidity level of 30 to 70 percent is acceptable. "Room temperature, humidity, and ventilation of each work area should be monitored and recorded daily." Review of record with the temperature and humidity recorded revealed the following: Operating Room #1 December --no recording of temperature/humidity
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 166 being recorded January 2013 -- 8 of 8 days temperature were out of range
{A 747}
Operating Room #3 December 2012 --no recording of temperature/humidity being recorded January 2013 -- 8 of 8 days temperature were out of range
Sterilization Room December 2012--no recording of temperature/humidity being recorded January 2013 -- 8 of 8 days temperature were out of range
During a tour on 1/10/2013 of the Sterilization Room with staff # 46 it was noted the temperature was 81 degrees.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 747} Continued From page 167 An interview with Staff #46 on 1/10/2013 at 10:00 AM reported that the air conditioner unit was not functioning properly and had not functioned properly for 2 years. Staff #46 stated "the heating wires were pulled from the unit 2 years ago. The unit has to be manually turned on and off by going on top of the roof. The unit will only blow cold air and there is no regulating the temperature. If it is cold outside then the unit just has to be turned off manually by going to the roof top of the building."
{A 747}
Interview with staff #57 confirmed temperatures and humidity were not being recorded daily for Operating Room #1, #2, #3, or the sterilization room and no policy for temperature/humidity if recorded out of range.
D. Failed to provide and maintain a safe and clean environment for patient care. Refer to Tag 701 A 884 482.45 ORGAN, TISSUE, EYE PROCUREMENT Organ, Tissue and Eye Procurement This CONDITION is not met as evidenced by: Based on interview and record review, the facility failed to ensure that the facility have a written agreement with an Organ Procurement Organization (OPO) which addressed how donor issues would be handled with patients. This deficient practice was found in 7 of 30 (#s 35, 36, 53, 56, 57, 58, and 59) charts reviewed. The facility failed to ensure that there was a
A 884
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 884 Continued From page 168 trained Organ Procurement Organization representative or requestor. The facility failed to ensure patient care staff were trained in donation issues. The facility failed to ensure policies and procedures were in place to ensure coordination between an Organ Procurement Organization (OPO) and the facility to review death records. Refer to tags A0886, A0889, A0891 and A0892 for additional information. A 886 482.45(a)(1) OPO AGREEMENT Incorporate an agreement with an OPO designated under part 486 of this chapter, under which it must notify, in a timely manner, the OPO or a third party designated by the OPO of individuals whose death is imminent or who have died in the hospital. The OPO determines medical suitability for organ donation and, in the absence of alternative arrangements by the hospital, the OPO determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the hospital for this purpose; This STANDARD is not met as evidenced by: Based on interview and review record, the facility failed to ensure that the facility have a written agreement with an Organ Procurement Organization (OPO) which addressed how donor issues would be handled with patients. This deficient practice was found in 7 of 30 (#s 35, 36, 53, 56, 57, 58, and 59) charts reviewed.
A 884
A 886
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 886
Review of the facility's "ORGAN/TISSUE DONATION PROTOCOL" dated 03/01/10 revealed the following:
"For all deaths/potential deaths, a mandatory referral" would be made to an Organ Procurement Organization," allowing as much time prior to death as possible." The Organ Procurement Organization would "notify the eye/tissue bank."
"The Emergency Department Physician and Nursing personnel in the Emergency Department will be responsible for the mandatory routine referral when receiving victims of accident or trauma who are dead on arrival or are near death."
"Nursing personnel caring for an inpatient that is near death or expires will notify the" Organ Procurement Organization "for further instructions as to the patient being a potential donor."
There was an OPO and tissue bank listed on the protocol as who to make referrals to.
Review of the protocol revealed no information about a written signed agreement for services between the OPO and the facility.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 886 Continued From page 170 Review of a facility admit packet revealed an "admit record" which was one of the initial assessment tools used by nursing. There was a section on the tool which asked if the patient was an organ donor.
A 886
Review of a facesheet on Patient #35 revealed he was a 68 year old male admitted to the facility on 12/28/12 at 2:45 p.m. with a diagnosis of "flu like symptoms."
Review of emergency room (ED) nursing assessments on Patient #35 revealed no documentation of his organ donation status. Review of a death report dated 12/28/12 revealed that Patient #35 expired on 12/28/12 at 6:15 p.m.. Review of ED nurses notes dated 12/28/12 at 7:23 p.m. revealed that the OPO was called at this time over an hour after the death.
Review of charts on Resident #s 36, 53, 56, 57, 58, and 59 revealed no documentation of staff obtaining information about organ donation status.
During an interview on 01/08/13 at 10:38 a.m., Staff #5 reported that she could not find any agreements with an OPO. There was no agreement addressing immiment death, timely notification, medical suitability for organ donation, designated requestor training program, maintaining organ viablity, and permitting the OPO access to the hospital death record.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 886 Continued From page 171 Staff #5 provided an unusual event report dated 01/08/13 indicated they needed to meet with the OPO "concerning their protocol, paperwork and QI." A 889 482.45(a)(3) DESIGNATED REQUESTOR The individual designated by the hospital to initiate the request to the family must be an organ procurement representative or a designated requestor. A designated requestor is an individual who has completed a course offered or approved by the OPO and designed in conjunction with the tissue and eye bank community in the methodology for approaching potential donor families and requesting organ or tissue donation. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure that there was a trained Organ Procurement Organization representative or requestor.
A 886
A 889
Review of the facility's "ORGAN/TISSUE DONATION PROTOCOL" dated 03/01/10 revealed no information outlining who the trained representive or requestor would be for the facility. There was no documentation about the formal training required for the donor request process. Review of the protocol revealed no written signed agreement for services between the OPO and the facility which outlined training for the donor requestor. During an interview on 01/08/13 at 10:38 a.m.,
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 889 Continued From page 172 Staff #5 reported that she could not find any agreements with an OPO. There was no agreement addressing the designated requestor training program. Staff #5 reported they did not have a trained requestor. As of 12/28/12, her and two other staff members were handling it, but no one had any formal training. Before 12/28/12 Staff #1 the previous (Chief Nursing Officer) took care of the program. Staff #5 provided an unusual event report dated 01/08/13 indicated they needed to meet with the OPO "concerning their protocol, paperwork and QI." Staff #5 reported they needed to assign someone to be the contact person for the OPO and their facility and they needed the OPO to "come to their facility and have an in-service." A 891 482.45(a)(5) STAFF EDUCATION Ensure that the hospital works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues; This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure that patient care staff were trained in donation issues. This deficient practice had the potential to cause harm to all patients. Review of the facility's "ORGAN/TISSUE DONATION PROTOCOL" dated 03/01/10 revealed no information outlining the training staff needed and that was in cooperation with the OPO and tissue bank. Review of the protocol revealed no written signed
A 889
A 891
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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A 891 Continued From page 173 agreement for services between the OPO and the facility which outlined staff training. During an interview on 01/08/13 at 10:38 a.m., Staff #5 reported she could not find any agreements with the OPO. There was no agreement addressing the designated requestor training program or staff training. Staff #5 reported that she could find no documentation of staff being trained. Staff #5 provided an unusual event report dated 01/08/13 indicated they needed to meet with the OPO "concerning their protocol, paperwork and QI." Staff #5 reported they needed to assign someone to be the contact person for the OPO and their facility and they needed the OPO to "come to their facility and have in-service." A 892 482.45(a)(5) DEATH RECORD REVIEWS Ensure that the hospital works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on ...] reviewing death records to improve identification of potential donors, and This STANDARD is not met as evidenced by: Based on interview and review record the facility failed to ensure policies and procedures were in place to ensure coordination between an Organ Procurement Organization (OPO) and the facility to review death records.
A 891
A 892
Review of the facility's "ORGAN/TISSUE DONATION PROTOCOL" dated 03/01/10 revealed no direction on how the facility would coordinate with the OPO on reviewing death records. There was no directive on how they
Event ID: 695E12
Facility ID: 810260
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A 892 Continued From page 174 would improve identification of potential donors. There was no directive on how confidentialty would be maintained between the facility and the OPO. Review of the protocol revealed no written signed agreement for services between the OPO and the facility which outlined how to handle death record reviews. During an interview on 01/08/13 at 10:38 a.m., Staff #5 reported she could not find any agreements with the OPO. There was no agreement addressing immiment death, timely notification, medical suitability for organ donation, designated requestor training program, maintaining organ viablity, and permitting the OPO access to the hospital death record. Staff #5 reported she could provide no evidence of charts reviewed by the OPO. Staff #5 provided an unusual event report dated 01/08/13 indicated they needed to meet with the OPO "concerning their protocol, paperwork and QI." They needed to assign someone to be the contact person for the OPO and their facility and they needed the OPO to "come to their facility and have in-service." Staff #5 reported she could provide no evidence of chart reviewed by the OPO. {A 940} 482.51 SURGICAL SERVICES If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality
A 892
{A 940}
Event ID: 695E12
Facility ID: 810260
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{A 940} Continued From page 175 with inpatient care in accordance with the complexity of services offered. This CONDITION is not met as evidenced by: During the follow-up survey from 1/7/2013 through 1/10/2013, the Immediate Jeopardy cited on the Conditions of Participation for Surgical Services was found to remain at the Immediate Jeopardy level. Additional findings were as follows:
{A 940}
Based on record review, observation, and interview the facility:
A. Failed to provide a sanitary environment to prevent infections in the surgical setting.
During a tour of the Scope Procedure Room on 11/13/2012 at 11:00 AM with CNO (Chief Nursing Officer) and staff # 2, the endoscopes were observed hanging in the endoscopy cabinet touching the floor of the cabinet. On the floor of the scope cabinet was a green towel where brown substance had leaked onto the towel from the scope. Also observed on the scope processing machine was a bottle of water that supplies the water irrigation to the scope during the procedure. The bottle was still present from the endoscopy procedure done on 11/9//2012. The sterile water irrigation bottle that replenishes the water in the bottle on the machine had expired 10/15/2012.
An interview and record review of the cleaning

Event ID: 695E12
Facility ID: 810260
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{A 940} Continued From page 176 process of the endoscopes with staff #2 revealed that leak testing of the scopes was not done. The endozyme instrument brush for cleaning the scopes was found stored in a cabinet where the scopes are cleaned. The scope brushes had all expired. One brush expired 5/2010, ten brushes expired 6/2010, and six brushes expired 8/2010. The container holding all the brushes had approximately 4 used brushes in with the expired bushes. There were no endozyme sponges found in the processing room.
{A 940}
Interview with staff #2 on 11/13/2012 at 12:30 p.m. confirmed that leak testing of the scopes was not being done, brushes that were expired and used brushes had been reused to clean scopes, and there were no available sponges for cleaning the scopes.
During a tour of the Processing Room, there was a pan of Cidex OPA (Cidex solution) for high disinfection of the endoscopy scopes. Staff #2 was not able to produce the CIDEX OPA Solution Test Strips that are needed for checking the concentration of ortho-phthalalldehyde in the Cidex solution. There was no log documenting the Cidex was being checked and/or monitored.
Review of the manufacturer's recommendation for use of the Cidex revealed, "CIDEX OPA Solution may be reused for up to a Maximum of 14 days provided the required conditions of ortho-phthalaldehyde concentration and temperature exist based upon monitoring described in the Direction for use. Do not rely
Event ID: 695E12
Facility ID: 810260
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{A 940} Continued From page 177 solely on day in use. Concentration of this product during its reuse life must be verified by the CIDEX OPA Solution Test Strips prior to each use to determine that the concentration of orto-phthalaidehyde if above the MEC of 3%. The product must be discarded after 14 days."
{A 940}
Staff #2 was interviewed throughout the tour of the Surgical Department on 11/13/2012. Staff #2 confirmed that there was no log being maintained for the monitoring of when the Cidex was being tested for the effectiveness of the concentration . Staff #2 reported that the active ingredient ortho-phthalaldehyde in the Cidex solution was not being monitored because the facility had not purchased the required Cidex OPA Solution Test Strips in over 2 months. When Staff #2 was questioned about the log for testing the Cidex solution, he stated "I did not know that a monitoring log of the Cidex solution had to be kept." Staff #2 confirmed that the last endoscopy procedure was done on 11/09/2012 and the endoscope was processed in the Cidex solution that had never been tested for the effectiveness of concentration. There were 18 completed scheduled endoscopy cases done in the facility from June 18, 2012 thru November 9, 2012 without the Cidex solution being tested for the effectiveness of the concentration.
Interview with Staff #2 on 11/13/2012 at 12:00 PM confirmed no processing of the scopes prior to the surgical procedure.
Review of the Association of periOperative

Event ID: 695E12
Facility ID: 810260
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{A 940} Continued From page 178 Registered Nurses (AORN) "2009 Peri-Operative Standards and Recommended Practices", revealed that flexible endoscopes be reprocessed before use if unused for more than 5 days.
{A 940}
During the tour, staff #2 was questioned if scopes are reprocessed prior to the surgical procedure. Staff #2 reported scopes are cleaned after the procedure and hung back on the endoscopy cabinet till the next scheduled case. No prior cleaning is done before the case. Review of operating log/register and interview with Staff #2 revealed scheduled cases for the last 6 months have been (6) in June, (1) in July, (1) in August, (8) in September, (1) in October, (1) in November in which confirms storage of the scopes have been longer than 7 days between cases.
During the tour with CNO and Staff #2 on 11/13/2012 at 12:00 PM, there were expired supplies, broken equipment, and equipment with preventive maintenance inspections due 7/12/2012 observed.
Gastrointestinal Lab Bite block expired 8/2011 Endoscopy tubing 10/2012 Pentax EPK -1000 Laparoscopic processing machine and camera had preventive maintenance due 7/2012 Anesthesia Machine had preventive maintenance
Event ID: 695E12
Facility ID: 810260
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{A 940} Continued From page 179 due 7/2012, observed on the anesthesia machine tubing with brown substance and along the base of anesthesia machine was a brown splattered substance.
{A 940}
Day Surgery Intravenous pump had preventive maintenance due 7/2012 #1 Heart Monitor had preventive maintenance due 7/2012 #2 Heart Monitor had preventive maintenance due 7/2012 Cardiac Monitor was broken and the defibrillator paddles were missing Open circumcision tray was lying on top of the crash cart #1 Suction canister was found with dried pink substance at the bottom of it which appeared to be sputum, and a clear plastic bag covering it with tubing attached. #2 Suction canister was found with dried brown substance at the bottom of it which appeared to be sputum, and a clear plastic bag covering it with tubing attached.
Sterile Processing Room Two large card board boxes filled with various types of expired surgical supplies (available to
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940} Continued From page 180 staff for patient care usage)
{A 940}
Supply Closet in Surgery Sterile water 3000cc bag X 2 expired 10/2012 on the shelf. Sterile water 3000cc bag X 1 expired 10/2012 found in the warmer. Card board boxes were found in the supply closet in the surgery suite.
Interview with CNO on 11/13/2012 at 1:00 PM confirmed that Gastrointestinal Lab, Day Surgery, Sterile Processing Room, and the supply closet in surgery had expired supplies, broken equipment and preventive maintenance inspections that were not current on equipment, and dirty supplies available to staff for patient use.
B. Failed to provide and maintain an environment for appropriate sterile processing of surgical instruments with a qualified staff member over the sterilization department, proper use of external chemical indicators and biological testing, recording of sterilization logs, and continued education and training for the staff on sterilization of supplies. The Surgical Department has performed 82 cases from 6/6/2012 thru 11/12/2012.
Review of records revealed no supervision of the sterile processing room.

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940}
Interview with CNO and Staff #2 on 11/14/2012 at 3:00 PM confirmed that there was no one over the sterilization room with any training or experience to oversee the processing was done according manufacturer's guidelines.
Review of personnel record for staff #2 revealed no documentation of education on sterilization of supplies and/or processing of scopes. The personnel record dated 9/27/2011 of the job description and the only record in the file is written by the evaluator that staff #2 needs to "look at continuing education to enhance knowledge in sterile processing through certification program." The employee wrote, "there is a lot of space for improvement regarding new methods of packing, sterilizing, education which can be done with frequent orientation." The personnel file reveals no education or training in the sterilization area or the processing of the endoscopy scopes.
Interview with CNO on 11/15/2012 at 3:30 PM confirmed that he had not taken any type of education courses on sterilization of supplies and equipment since being hired at the facility. CNO also confirmed education courses for sterilization of supplies had not been provided by the facility.
During a tour of the sterile processing room on 11/14/2012 at 2:00 PM with staff #2, it was observed that the last inspection of the autoclave was on July 2012. The autoclave in the Surgery
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940} Continued From page 182 department last inspection was also July 2012.
{A 940}
The washer for the instruments has a graph showing if the washer reaches a certain water temperature for proper cleaning. The graph had been left there without being replaced. The red circle was a solid red circle with no elevated lines showing the water temperature of the washer. Staff #2 was questioned why the graph paper was never changed and he reported that the facility did not have any more graph paper.
Interview with staff #2 on 11/14/2012 at 2:00 PM confirmed that the autoclave inspection labels read July 2012 on both autoclaves and the graph paper had not been changed in the washer due to insufficient supplies by the facility. Staff #2 confirmed that he had no idea if the washer was reaching the water temperature recommended by the manufacturer.
Review of facility policy titled, "Decontamination, Sorting, and Sterilization of Contaminated Instruments and Equipment:"
PROCEDURE: PACKAGING. WRAPPING, STERILIZATION AND STORAGE OF SURGICAL INSTRUMENTS. 1. Assembles instrument sets according to established lists. 2. Places sterilization indicators in densest area of the package.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940} Continued From page 183 3. Wraps/contains instruments using nonwoven CSR wrap (two layers), peel pouches, or rigid case. 4. Labels package with name of instrument or set, tags with load lot number and records on autoclave load record.
{A 940}
Review of record titled, "3M Attrest load list and Process Monitor Documentation System" revealed sterilization log did not include load identification, indicator results, and identification of the contents of the load when using the autoclave in the Surgery Department. In the sterile processing room, surveyor observed a tray with instruments and numerous sterilization strips that had not been recorded in the "3M Attrest Load List and Process Monitor Documentation System."
Interview with staff #2 on 11/14/2012 at 2:00 PM confirmed that the improper use of the sterilization log would cause a problem in identifying contaminated instruments from a load not logged properly. Staff #2 also confirmed the sterilization log was not being done on all loads of surgical instruments being processed.
During a tour of the decontamination area on 11/14/2012 at 2:00 PM, there were contaminated instruments sitting on the counter top, in the sink, and in the cart (the cart is used to carry clean instruments to the surgical suite from sterile processing area). The cart was found in the
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940} Continued From page 184 decontamination area with sterile and contaminated instruments inside it. The decontamination room had contaminated instruments that remained in the same place during the survey for 3 consecutive days. Survey dates were 11/13-15/2012. The last surgical case was completed on 11/12/2012.
{A 940}
The washer for the instruments has a graph showing if the washer reaches a certain water temperature for proper cleaning. The graph had been left there without being replaced. The red circle was a solid red circle with no elevated lines showing the water temperature of the washer. Staff #2 was questioned why the graph paper was never changed and he reported the facility did not have any more graph paper.
Interview with staff #2 on 11/14/2012 at 2:00 PM confirmed that the contaminated instruments have been sitting in the decontamination room since 11/12/2012 when the case was completed. Staff #2 also confirmed that the graph paper had not been changed in the washer due to insufficient supplies by the facility. Staff #2 confirmed that he had no idea if the washer was reaching the water temperature recommended by the manufacturer.
Review of the facility's Surgery policies revealed no policy on recording temperature and humidity in the area where sterile supplies are stored. Review of the AORN (Perioperative Standards and Recommended Practices) revealed,
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940} Continued From page 185 "Temperature should be maintained between 68 degrees F to 73 degrees F." These recommendations apply to both operating rooms and sterile processing areas. A relative humidity level of 30 to 70 percent is acceptable. "Room temperature, humidity, and ventilation of each work area should be monitored and recorded daily." Review of record with the temperature and humidity recorded revealed the following: Operating Room #1 July--21 of 31 days temperature/humidity was not monitored August --20 of 31 days temperature/humidity was not monitored September--19 of 30 days temperature/humidity was not monitored October--26 of 31 days temperature/humidity was not monitored November --10 of 15 days temperature/humidity was not monitored
{A 940}
Operating Room #2 July--20 of 31 days temperature/humidity was not monitored August --22 of 31 days temperature/humidity was not monitored
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940} Continued From page 186 September--22 of 30 days temperature/humidity was not monitored October--26 of 31 days temperature/humidity was not monitored November --10 of 15 days temperature/humidity was not monitored
{A 940}
Operating Room #3 The months July through November 15th the temperature/humidity was never monitored for operating room #3.
Sterilization Room The months July through November 15th the temperature/humidity was never monitored and there was no documented record that the sterilization room was ever monitored.
Interview with staff #2 confirmed temperatures and humidity was not being recorded daily for Operating Room #1, #2, #3, and/or the sterilization room.
C. Failed to ensure that the organizational chart within the Surgical Department delegates the authority and responsibility of running the Surgery Department. Refer to A0941
Event ID: 695E12
Facility ID: 810260
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{A 940}
D. Failed to provide operating room supervision. Refer to A0942
E. Failed to ensure supervision by an experienced surgical registered nurse in the surgical cases being performed at this facility. There were 4 of 5 (CNO, #5, #16, #20, and #22) nurses that have worked in the Surgery Department without experience or competencies in surgery. One (#16) of 4 (CNO, #5, #20, and #22) was a Licensed Vocational Nurse. Refer to A0944
F. Failed to provide preventative maintenance (safety inspections) on the equipment in the operating room suites while surgical cases were being performed. The cardiac monitor had not been checked daily per the facility policy. Refer to A0956
G. Failed to provide available staff, equipment, supplies, and clean space for postoperative patient care area. Refer to A957
H. Failed to provide an ongoing process of the QAPI (quality assessment and performance improvement) program that measures, analyzes,
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940} Continued From page 188 and tracks adverse patient events, infection control, and other aspects of performance improvement for the surgical department.
{A 940}
Review of meetings titled, "P&T, Infection Prevention & Control & Employee Health Quality Report" dated February 21, 2012 thru September 12, 2012 revealed no evidence of routine collection, organization, follow-up, and evaluation of data being processed from the surgical department for quality assurance.
There was no evidence of documentation that any staff member had taken responsibility for collecting, measuring, analyzing, or tracking performance improvement in the surgical department for the facility.
An interview with CNO and Staff #2 on 11/15/2012 at approximately 2:30 PM confirmed no QAPI had been collected, measured, analyzed, or tracked in the surgical department for the facility.
It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failed practices had the potential to affect all patients admitted to the facility.
During the follow-up survey from 1/7/2013 through 1/10/2013, the Immediate Jeopardy
Event ID: 695E12
Facility ID: 810260
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{A 940} Continued From page 189 previously cited were found to remain at the Immediate Jeopardy level. Additional findings were as follows:
{A 940}
Based on record review, observation, and interview the facility:
A. Failed to provide a sanitary environment to prevent infections in the surgical setting. During a tour of the Gastrointestinal Lab on 1/7/2013 at 12:00 PM with staff #2, there was a bottle of water that supplies the water irrigation to the scope during the procedure on the scope processing machine. The bottle was still present from the endoscopy procedure done on 11/9/2012.
Observed on 1/7/2013 at 4:30 PM with staff #5 in the process cleaning room were expired endoscopy brushes that were stored in a cabinet. Three brushes expired 11/2009, three brushes expired 2/2010, three brushes expired 6/2010, and five brushes expired 8/2010. Observed in the cabinet of the process cleaning room were brushes for Olympus scopes, though the facility has Pentax scopes. Staff #5 was asked which supply brushes were used for cleaning the facility scopes. Staff #5 had no knowledge of which brush should be used nor was staff #5 able to tell the surveyor which brand of scopes the facility was using.
Interview with staff #5 on 1/7/2013 at 4:30 PM,

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940} Continued From page 190 confirmed brushes were expired and the facility had the wrong brand of brushes to be used for cleaning the Pentax scopes.
{A 940}
A review of the "Daily Disinfection Record" revealed staff #2 had been using the Cidex solution to disinfect the endoscopy scopes. A review of staff #2's personnel file revealed no training on the use of Cidex solution.
A review of the "Daily Disinfection Record" revealed staff #78 had been using the Cidex solution to disinfect transvaginal probes used in the radiology department for vaginal sonograms. A review of staff #78's personnel file revealed no training on the use of Cidex solution.
During an interview on 1/8/2013 at 5:00 PM, staff #57 confirmed that bstaff #2 and #78 had not had any training on the use of disinfectant (Cidex) solution.
Observed during the tour with Staff #2 on 1/7/2013 at 12:00 PM were expired supplies, broken equipment, and equipment with preventive maintenance inspections due 7/12/2012.
Observed in the decontamination room on a stool were 2 containers with washing solution for the washer. Staff #2 was asked why the containers were on the stool and staff #2 reported the solution dispenser for the instrument washer was
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940} Continued From page 191 broken and he just pours solution in the instrument washer.
{A 940}
Decontamination Room Alcohol bottle (opened and not dated) - expired 1/2012 Cricothyroid kit - expired 6/2012 Ruhhof-Biocide solution for cleaning - expired 5/4/2011(the bottle was empty; observed black substance in the bottom of the bottle)
Day Surgery Intravenous pump # 0125 had no preventive maintenance sticker Intravenous pump # 0076 preventive maintenance due 10/2011 Quick Pace Pads-expired 1/28/2012 (x 1)
On tour of the Day Surgery Unit with staff #2 on

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940} Continued From page 192 1/7/2013, the Cardiac Monitor was beeping continuously and when turned on showed device error service required.
{A 940}
Day Surgery Supply Closet Green Cap blood tubes- expired 11/2012- (x 11) Butterfly catheter expired- 08/2012- (x 1) Punch biopsy-4 mm- expired 10/12/2012- (x 20) Punch biopsy-6 mm- expired 10/22/2012- (x 22) Disposable Derma Curette- expired 11/2012 (x 25) Sterile Gauze- 2x3- expired 6/2008 (x 8) Sterile Gauze- 3x8- expired 7/2008 (x 2) Sterile Gauze- 3x4- expired 7/2008 (x 2)
Observed on tour of the Day Surgery Unit with staff #2 on 1/7/2013 was a dead cricket hanging on the wall of the Day Surgery Supply Closet above the sterile supplies.
Sterile Processing Room Stapler TL90- expired 12/2012 (x 1) Hemodialysis Catheter (14.5) -expired 11/2012(x 1)
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940} Continued From page 193 One-Step Prep-Dura Prep- expired 5/2012 (x 1) Stapler Reload-35 mm - expired 4/2012 (x 4) Retrieval System- expired 08/2012 (x 5) Burr- 4.0 expired 5/2012 (x 2)
{A 940}
Resector- 4.0 expired 9/2012 (x 2) Guide wire .35 expired 5/2012 (x 1) Thoracic Catheter (36) expired 08/2012 (x 1) Punch biopsy- 3 mm -expired 11/2012 (x 4) Punch biopsy- 6 mm -expired 11/2012 (x 2) Punch biopsy- 4 mm -expired 11/2012 (x 2) First Pass Needle and Suture Capture- expired 09/2012 Wound Reservoir Drain (Hemovac) - expired 07/2012 (x 3)
Supply Closet in Surgery Glycine 3000cc bag X 1 expired 11/2012 on the shelf. Intravenous catheter Jelco #16- expired 2012 (x 4)
During a tour on 1/7/2013 at 4:30 PM with staff #5, there were card board boxes found on the
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940} Continued From page 194 shelves in the supply closet, dust and insects were found on shelves in the sterile supply room, and dust was found on the floors in the surgical suite.
{A 940}
Recovery Room Insulated needle-expired 09/2012- (x 43) Epidural pumps X 2 no preventive maintenance sticker
During an interview with staff #5 on 1/7/2013 at 4:30 PM, staff #5 confirmed that the Gastrointestinal Lab, Day Surgery, Sterile Processing Room, Decontamination Room, Recovery Room, and the supply closet in the surgery suite had expired supplies, broken equipment and preventive maintenance inspections that were not current on surgical equipment. Supplies and equipment were available for patient use and the surgery areas were contaminated with insects and dust.
B. Failed to provide and maintain an environment for appropriate sterile processing of surgical instruments with a qualified staff member over the sterilization department, proper use of external chemical indicators and biological testing, recording of sterilization logs, and continuing education and training for the staff on sterilization of supplies. The Surgical Department has performed 82 cases from 6/6/2012 thru 11/12/2012.
Event ID: 695E12
Facility ID: 810260
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{A 940} Continued From page 195 Review of records revealed no supervision of the sterile processing room.
{A 940}
During an interview on 1/7/2013 at 4:30 PM, Staff #5 confirmed there was no one over the sterilization room with any training or experience to oversee that processing was done according manufacturers' guidelines.
Review of the personnel file for staff #2 revealed no documentation of training on the sterilization of supplies and/or processing of endoscopy scopes. The personnel file dated 9/27/2011 revealed a job description on which the evaluator writes that staff #2 needs to "look at continuing education to enhance knowledge in sterile processing through certification program"(this is the only record in the file written by the evaluator). The employee wrote, "There is a lot of space for improvement regarding new methods of packing, sterilizing, education which can be done with frequent orientation." The personnel file revealed no education or training in the sterilization area or the processing of the endoscopy scopes.
Observed on tour of the sterile processing room on 11/14/2012 at 2:00 PM with staff #2, the autoclave was out of service waiting on a part to arrive to the facility. The last inspection of the autoclave was on July 2012. The autoclave in the Surgery department was last inspected July 2012 also.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940} Continued From page 196 During an interview on 1/7/2013 at 4:30 PM, staff #5 reported that all the surgical instruments will have to be re-done because the autoclave had not been reaching the temperature required by the manufactures' guidelines for the last 3 months.
{A 940}
During an interview on 1/7/2013 at approximately 5:00 PM, the Director of Nursing confirmed staff #2 and staff #5 had not completed any education courses on sterilization of supplies and equipment since being hired at the facility. Director of Nurses also confirmed education courses for sterilization of supplies had not been provided by the facility.
During an interview on 1/7/2013 at 12:00 PM, staff #2 confirmed the autoclave inspection labels read July 2012 on both autoclaves and the main autoclave in the sterilization room was broken. Staff #2 confirmed the washer dispenser was broken and he had no knowledge of how much washing solution was recommended by the manufacturer's guideline.
Review of the facility's surgery policies revealed no policy on recording temperature and humidity in the area where sterile supplies are stored. Review of the AORN (Perioperative Standards and Recommended Practices) revealed, "Temperature should be maintained between 68 degrees F to 73 degrees F." These recommendations apply to both operating rooms and sterile processing areas. A relative humidity
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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TERRELL, TX 75160
{A 940} Continued From page 197 level of 30 to 70 percent is acceptable. "Room temperature, humidity, and ventilation of each work area should be monitored and recorded daily." Review of temperature and humidity logs revealed the following: Operating Room #1 December --no recording of temperature/humidity January 2013 -- 8 of 8 days temperatures were out of range
{A 940}
Operating Room #2 December --no recording of temperature/humidity January 2013 -- 8 of 8 days temperatures were out of range
Operating Room #3 December --no recording of temperature/humidity January 2013 -- 8 of 8 days temperatures were out of range
Sterilization Room December --no recording of temperature/humidity January 2013 -- 7 of 10 days temperatures were out of range
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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{A 940}
During a tour on 1/10/2013 at approximately 11:00 AM with staff #46, it was noted the temperature was 81 degrees in the Sterilization Processing Room. Sterile instruments and supplies are stored in this area.
During an interview on 1/10/2013 at 10:00 AM, staff #46 reported that the air conditioner unit was not functioning properly and has not functioned properly for 2 years. Staff #46 stated"The heating wires were pulled from the unit 2 years ago. The unit has to be manually turned on and off by going on top of the roof. The unit will only blow cold air and there is no regulating the temperature. If it is cold outside then the unit just has to be turned off manually by going to the roof top of the building."
Staff #57 confirmed temperatures and humidity were not being recorded daily for Operating Rooms #1, #2, #3, and the sterilization room. Staff #57 reported that there was no policy for out of range temperature/humidity.
C. Failed to ensure the organizational chart within the Surgical Department delegates the authority and responsibility of running the Surgery Department. Refer to A0941
D. Failed to provide operating room supervision.

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
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{A 940} Continued From page 199 Refer to A0942
{A 940}
E. Failed to ensure supervision by an experienced surgical registered nurse in the surgical cases being performed at this facility. Refer to A0944
F. Failed to provide preventative maintenance (safety inspections) on the equipment in the operating room suites while surgical cases were being performed. The cardiac monitor had not been checked daily per the facility policy. Refer to A0956
G. Failed to provide staff, equipment, supplies, and clean space for the postoperative patient care area. Refer to A957
H. Failed to provide an ongoing process of the QAPI program that measures, analyzes, and tracks adverse patient events, infection control, and other aspects of performance improvement for the surgical department.
Review of meetings titled, "P&T, Infection Prevention & Control & Employee Health Quality Report," dated February 21, 2012 thru September 12, 2012, revealed no evidence of routine
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 940} Continued From page 200 collection, organization, follow-up, and evaluation of data being processed from the surgical department for quality assurance.
{A 940}
There was no evidence of documentation that any staff member had taken responsibility for collecting, measuring, analyzing, or tracking performance improvement in the surgical department for the facility.
An interview with staff #57 on 1/8/2013 at approximately 4:00 PM confirmed no QAPI (Quality Assurance Performance Improvement) had been collected, measured, analyzed, or tracked in the surgical department for the facility. {A 941} 482.51(a) ORGANIZATION OF SURGICAL SERVICES The organization of the surgical services must be appropriate to the scope of the services offered . This STANDARD is not met as evidenced by: Based on records review and interviews, the facility failed to ensure that the organizational structure within the Surgical Department delineates who has the authority and responsibility of running the surgery Department.
{A 941}
Review of records revealed no surgical organizational chart for the department delegating who was responsible the running of the Surgical Department.
Review of the personnel file for CNO (Chief

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 941} Continued From page 201 Nursing Officer) revealed a job description for a Chief Nursing Officer with no signature and no surgical competencies for the Surgery Department and no documented experience of ever working in a Surgery Department. Personnel file revealed no documentation of current Advanced Cardiac Life Support which is required by facility.
{A 941}
Interview with CNO on 11/14/2012 at 3:00 PM confirmed that the Director of Surgery left in June 2012. CNO reported he was responsible for the Surgery Department at this time.
During the follow-up survey from 1/7/2013 through 1/10/2013, additional findings were as follows:
Based on records review and interviews, the facility failed to ensure that the organizational structure within the Surgical Department delegated who has the authority and responsibility of running the Surgery Department.
Review of records revealed no surgical organizational chart for the department delegating who was responsible the running of the Surgical Department.
Review personnel file for staff #5 (who was named the Operating Room Director by the Director of Nursing) revealed a job description for
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 941} Continued From page 202 an Emergency Room Nurse. Further review of the personnel file revealed that staff #5 had no surgical competencies for the Surgery Department and no documented experience of ever working in a Surgery Department.
{A 941}
During an interview on 1/8/2013 at approximately 3:00 PM, the Director of Nursing confirmed the Operating Room Director was staff #5 and her personnel file had no documentation of competencies or experience for working in a Surgery Department. The Director of Nursing stated, "staff #5 was the only staff member working in the facility with any knowledge of Surgery, because I have no experience in Surgery." {A 942} 482.51(a)(1) OPERATING ROOM SUPERVISION The operating rooms must be supervised by an experienced registered nurse or a doctor of medicine or osteopathy. This STANDARD is not met as evidenced by: Based on records review and interviews, the facility failed to provide operating room supervision.
{A 942}
Review of records revealed one scrub technician for the surgical department. This was the only staff member for the Surgery Department. The Surgery Department does not have a Director of Surgery, the last Director left in June 2012.
Review of records and interview with CNO (Chief Nursing Officer) and #2 on 11/14/2012 at 3:00 PM
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 942} Continued From page 203 revealed the staff members used in the surgical department was pulled from different units in the facility.
{A 942}
Interview with CNO on 11/14/2012 at 3:00 PM, confirmed surgical department consisted of one scrub technician. CNO reported the Director of Surgery left in June 2012. CNO confirmed the nurses working in surgery are part-time from the other units in the facility and do not have experience or competencies in surgery.
Based on records review and interviews, the facility failed to provide qualified operating room supervision.
Review of records revealed one scrub technician for the surgical department. This was the only staff member for the Surgery Department. The Surgery Department had an Operating Room Director (staff #5) appointed by the Director of Nursing. The personnel file for staff #5 revealed a job description for an Emergency Room Nurse. Further review of the personnel file revealed that staff #5 had no surgical competencies for the Surgery Department and no documented experience of ever working in a Surgery Department. Further review of records revealed
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
TERRELL, TX 75160
{A 942} Continued From page 204 staff #5 also works in the Emergency Room.
{A 942}
During an interview on 1/8/2013 at approximately 3:00 PM, the Director of Nursing confirmed the Operating Room Director was staff #5, and her personnel file contains no documentation of competencies for surgery or experience working in a Surgery Department. {A 944} 482.51(a)(3) OPERATING ROOM CIRCULATING NURSES Qualified registered nurses may perform circulating duties in the operating room. In accordance with applicable State laws and approved medical staff policies and procedures , LPNs and surgical technologists may assist in circulatory duties under the supervision of a qualified registered nurse who is immediately available to respond to emergencies. This STANDARD is not met as evidenced by: Based on records review and interviews, the facility failed to ensure that there was supervision by an experienced surgical registered nurse in the surgical cases being performed at this facility. There were 4 of 5 (CNO, #5, #16, #20, and #22) nurses that have worked in the Surgery Department without experience or competencies in surgery. One (#16) of 4 (CNO, #5, #20, and #22) was a Licensed Vocational Nurse.
{A 944}
Review of records revealed one scrub technician full time and no Registered Nurse in the Surgery Department.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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TERRELL, TX 75160
{A 944} Continued From page 205 Review of record titled, "Register of Operations" from June 2012 thru November 2012 revealed 5 different nurses as the circulator nurse in the operating room. One of the 5 was a Licensed Vocational Nurse (#16) and the other 4 Registered Nurses (CNO, #5, #20, and #22) revealed no documented surgical job description or surgical competencies for working in the Surgery Department.
{A 944}
Review personnel file of the CNO (Chief Nursing Officer) revealed a job description for a Chief Nursing Officer with no signature and no surgical competencies for the Surgery Department. There was no documented experience of ever working in a Surgery Department. Personnel file revealed no documentation of current Advanced Cardiac Life Support which was required by facility.
Review personnel file for Staff #5 revealed a job description for the Emergency Department and Medical /Surgical Unit with no signature and no competencies/orientation for the Surgical Department or experience of ever working in a Surgery Department.
Review personnel file for Staff #16 revealed a signed job description for LVN/ Medical/Surgical Unit with no date. There was no documented competencies for the Surgery Department or experience of ever working in a Surgery Department. The file revealed no documented training for the procedure for processing scopes using Cidex. Staff #16 was a Licensed Vocational Nurse. There was no documentation
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 944} Continued From page 206 of current Advanced Cardiac Life Support or CPR (Cardiopulmonary resuscitation) which was required by the facility.
{A 944}
Review personnel file for Staff #20 revealed a job description for the Emergency Department and Medical /Surgical Unit with no signature. There was no competencies/orientation for the Surgery Department. No documented experience of ever working in a Surgery Department.
Review personnel file for Staff #22 revealed a job description for the Emergency Department and Recovery RN with no signature. There was no documented competencies/orientation for the Surgery Department. The file revealed no documented experience of ever working in a Surgery Department.
Interview with CNO on 11/13/2012 at 11:00 AM, confirmed that the surgical department consisted of one scrub technician. CNO reported the Director of Surgery left in June 2012. CNO confirmed that the nurses working in surgery are part-time, pulled from other units in the facility, and do not have experience/competencies in surgery.
Based on records review and interviews, the

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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450683
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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 944} Continued From page 207 facility failed to ensure that there was a supervision by an experienced surgical Registered Nurse in the surgical cases being performed at this facility.
{A 944}
Review of records revealed one full-time scrub technician and no full-time Registered Nurse in the Surgery Department for circulating duties.
During an interview on 1/8/2013 at approximately 3:00 PM, the Director of Nursing stated "there is no OR team, all we have is staff #5 (Operating Room Director) who also assist with staffing the Emergency Room and 1 surgical technician." {A 956} 482.51(b)(3) REQUIRED OPERATING ROOM EQUIPMENT The following equipment must be available to the operating room suites: call-in system, cardiac monitor, resuscitator, defibrillator, aspirator, and tracheotomy set. This STANDARD is not met as evidenced by: Based on records review, observations, and interviews, the surgical department failed to provide preventative maintenance (safety inspections) on the equipment in the operating room suites while surgical cases were being performed. The cardiac monitor had not been checked daily per the facility policy.
{A 956}
Observed on tour of the surgical suite on 11/13/2012 at 11:00 AM, the cardiac monitor and defibrillator safety checks were last completed on 7/12/2012. Observed in the equipment storage
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 956} Continued From page 208 area the surgical equipment being used during the surgical cases has not had safety inspections since 7/2012. The facility have a new piece of equipment for Laparoscopic cases (the set-up, which is composed of air insufflator, camera processor, and printer) with no evidence that it was inspected by a Bio-Medical company before use.
{A 956}
The Surgical Department has performed 61 surgical cases from 7/13/2012 thru 11/12/2012 without the preventative maintenance inspections being completed.
Interview on 11/14/2012 at 2:00 PM with Staff #2, confirmed that the cardiac monitor, defibrillator, and operating room equipment had not had preventive maintenance (safety inspections) since 7/12/2012. The new piece of Laparoscopic equipment had never been inspected by the Bio-Medical company.
Review of the record titled, "Resuscitation Cart Checklist" (the log for checking the emergency crash in the surgery department) revealed the cart had not been checked daily per facility policy.
* July cart had not been checked 28 of 31 days * August cart had not been checked 2 of 31 days * September cart had not been checked 15 of 30 days
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
TERRELL, TX 75160
{A 956} Continued From page 209 * October cart had not been checked 24 of 31 days * November cart had not been checked 10 of 15 days
{A 956}
Review of facility policy titled "Crash Carts" revealed:
PURPOSE: To provide standards for use in stocking, checking, and securing hospital emergency (crash) carts. To ensure that all crash carts are ready for use for all cardiac or respiratory arrests.
POLICY: 1. The crash carts and Broselow pediatric crash cart are inspected, secured controlled, and restocked according to the following procedure. These activities shall he documented on the "Crash Cart Check List." 2. The crash carts and Broselow pediatric crash cart are checked daily and as needed. 3. Each department that maintains a crash cart has a designated staff member check the cart daily as appropriate. If the department is closed it must be noted on the appropriate date and the cart moved from accessibility.
4. Crash carts contents will not be added to or

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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1551 HWY 34 S
TERRELL, TX 75160
{A 956} Continued From page 210 deleted from the standardized crash carts without the approval of the Code Blue Committee and the appropriate Medical Staff. 5. Crash cart locks are issued by the Pharmacy. Each time the crash cart is opened a new lock is issued and a new medication drawer, if utilized. 6. A locked Standardized Adult crash cart will be available for use in the following patient care areas of the hospital:
{A 956}
Day Surgery unit OR holding area Emergency Room ICU Med/Surg 200 Hall Med/Surg Peds Med/Surg 100 Hall Labor and Delivery
Daily: 1. Crash carts will be checked daily on the units during hours of operation. 2. Supplies on top side of the Adult and Pedi crash carts, and the oxygen tank level (designated areas) will be checked for availability, expiration date, and documented (see emergency Cart- Daily Check list) each morning by the Charge Nurse and after each restocking by nursing personnel. 3. Inspect the physical condition of defibrillator/monitor for foreign substance,
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 956} Continued From page 211 damage or cracks, low battery connect to AC power messages, and service indicator message. 4. Inspect power source for: AC power connector plugged into unit and AC power source LED is lit. Battery charged LED is lit. 5. Press ON button and CHARGE defibrillator to 200 joules and discharge SHOCK button. Assure the 200 joules were delivered. 6. Check EKG printer for adequate paper supply and ability to print. 7. Verify that the lock is intact. Record lock number on daily checklist form. 8. Initial the daily checklist.
{A 956}
Interview on 11/14/2012 at 2:00 PM with Staff #2 confirmed the cardiac monitor had not been checked daily per the facility policy.
Based on records review, observations, and interviews, the facility failed to provide preventative maintenance (safety inspections) on the equipment in the operating room suites.
Observed on tour of the surgical suite on 1/7/2013 at 4:30 AM, the cardiac monitor and
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

______________________
450683
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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 956} Continued From page 212 defibrillator safety checks were last completed on 7/12/2012. Observed in the equipment storage area, the surgical equipment being used during the surgical cases has not had safety inspections since 7/2012. The facility had received a new piece of equipment for laparoscopic cases (the set-up, which is composed of air insufflator, camera processor, and printer) which had never been inspected by a bio-medical company. Anesthesia machines in operating rooms #1,#2, and #3 had there last service inspection on 11/10/2010 and were due to be inspected on 5/2011.
{A 956}
During an interview on 1/7/2013 at 4:30 PM, staff #5 confirmed that the cardiac monitor, defibrillator, and operating room equipment had not had preventive maintenance (safety inspections) since 7/12/2012. The new piece of laparoscopic equipment had never been inspected by the bio-medical company and the anesthesia machines in operating rooms #1, #2, and #3 had there last service inspection on 11/10/2010 and were due to be inspected on 5/2011.
An interview with the Director of Nursing on 1/8/2013 at approximately 3:00 PM confirmed there was no documentation that a bio-medical group had inspected the facility equipment. {A 957} 482.51(b)(4) POST-OPERATIVE CARE
{A 957}
Facility ID: 810260
Event ID: 695E12
OMB NO. 0938-0391

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1551 HWY 34 S
TERRELL, TX 75160
{A 957} Continued From page 213 There must be adequate provisions for immediate post-operative care. This STANDARD is not met as evidenced by: Based on records review, observations, and interviews, the facility failed to provide qualified staff, equipment, supplies, and clean space for postoperative patient care area.
{A 957}
Review of personnel files for nurses that have worked in the surgical department according to the record titled, "Register of Operations" revealed that there were 5 different nurses that have worked in the surgical department since the Director of Surgery left.
One of the 5 staff members was a Licensed Vocational Nurse (#16) and the other 4 Registered Nurses (CNO, #5, #20, and #22) have no signed job descriptions for working in the Recovery Room, Recovery Room competencies, or experience in working in a Recovery Room.
Review personnel file of the CNO (Chief Nursing Officer) revealed a job description for a Chief Nursing Officer with no signature. There was no competencies for the Recovery Room. No documented experience of ever working in a Recovery Room. File revealed no documentation of current Advanced Cardiac Life Support which is required by facility.
Review personnel file for Staff #5 revealed a job

Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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450683
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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 957} Continued From page 214 description for the Emergency Department and Medical /Surgical Unit with no signature. There was no documented competencies for the Recovery Room. File revealed no documented experience of ever working in a Recovery Room.
{A 957}
Review personnel file for Staff #16 revealed a signed job description for LVN/ Medical/Surgical Unit with no date. There was no documented competencies for the Recovery Room or documented experience of ever working in a Recovery Room. Staff #16 was a Licensed Vocational Nurse. File revealed no documentation of current Advanced Cardiac Life Support or CPR (Cardiopulmonary resuscitation) which was required by facility.
Review personnel file for Staff #20 revealed a job description for the Emergency Department and Medical/Surgical Unit with no signature. There was no documented competencies for the Recovery Room. File revealed no documented experience of ever working in a Recovery Room.
Review personnel file for Staff #22 revealed a job description for the Emergency Department and Recovery Room with no signature. There was no documented competencies for the Recovery Room. File revealed no documented experience of ever working in a Recovery Room.
Interview with the CNO on 11/13/2012 at 3:00 PM, confirmed that the 5 nurses (CNO,#5, #16, #20, and #22) had no job descriptions for the
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

______________________
450683
R-C
01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 957} Continued From page 215 Recovery Room, experience, or competencies for working in the Recovery Room area in this facility.
{A 957}
During a tour of the Recovery Room area on 11/13/2012 at 12:00 PM, there was a bag that contained Ambu bags (resuscitation equipment) and suction tubing on the floor of the recovery room in the 1st bay area where patients are to be cared for. The CNO and staff #2 were questioned on why the bag was on the floor and neither staff member could give an explanation why the bag of supplies was on the floor. The cardiac monitor in the recovery room area was due to have preventative maintenance on 10/2011. Intravenous pump at the 1st bay area was due to have preventative maintenance on 7/2012.
The Recovery Room warmer was filled with intravenous fluids x 10 and irrigation solutions x 5 without being dated as to how long the fluids had been in the warmer.
Review of the "Association for Professionals in Infection Control" recommendations revealed that fluids were not to be stored more than 14 days in the warmer if dated and the temperature less than 104 degrees.
An interview with CNO and staff #2 on 11/13/2012 at 12:00 PM revealed they did not know how long the fluids had been in the warmer.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

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450683
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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 957} Continued From page 216 In the 3rd bay of the recovery room area, a stack of papers (approximately 3 inches thick) was observed which consisted of infection control sheets, patient lab reports, and patient occurrence reports. The CNO was questioned why these papers were laid out on the patient care bedside table and CNO reported that the Infection Control Nurse left in May 2012 and no one has looked at those papers since she left.
{A 957}
The CNO reported on an interview on 11/13/2012 at 12:00 PM that the Recovery Room was in disarray, and he had not looked at the original paperwork of lab reports, occurrence reports, or the infection control sheets since the Infection Control Nurse left in May 2012.
A tour of the Recovery Room area on 1/7/2013 at 4:30 PM revealed equipment had not had preventive maintenance checks and expired supplies were available in the patient care area.
An interview with staff #5 on 1/7/2013 at 4:30 PM confirmed that the Recovery Room was in disarray, equipment had not had preventive maintenance checks, expired supplies were available in the patient care area, and, at present, there was no available or trained staff to work in the postoperative patient care area.
Event ID: 695E12
Facility ID: 810260
OMB NO. 0938-0391

______________________
450683
R-C
01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
{A 957}
An interview with Director of Nursing on 1/7/2013 at 5:00 PM confirmed the postoperative patient care area did not have available or trained staff for patient care, if a surgery case was performed. A1000 482.52 ANESTHESIA SERVICES If the hospital furnishes anesthesia services, they must be provided in a well-organized manner under the direction of a qualified doctor of medicine or osteopathy. The service is responsible for all anesthesia administered in the hospital. This CONDITION is not met as evidenced by: Based on records review and interviews, the facility failed to provide an organized Anesthesia Service. Administration was requested to provide documentation of a policy and procedure manual for Anesthesia Service. No type of documentation was provided for Anesthesia Service. The facility does not have a staff member to provide information on Anesthesia Services. A review of record titled "Anesthesiology Service Agreement Coverage Agreement" revealed that neither the facility's Administration staff nor the Anesthesiology Service had signed the agreement. An interview on 1/7/2013 at approximately 5:00 PM with staff #5 stated, "there is no Anesthesia policy manual or an employee of the Anesthesia Service to provide information" A1076 482.54 OUTPATIENT SERVICES
A1000
A1076
Facility ID: 810260
Event ID: 695E12
OMB NO. 0938-0391

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01/10/2013

1551 HWY 34 S
TERRELL, TX 75160
A1076 Continued From page 218 If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice. This CONDITION is not met as evidenced by: Based on records review and interviews, the facility failed to provide an ongoing process of the QAPI program that measures, analyzes, and tracks adverse patient events, infection control, and other aspects of performance improvement for out patient services. While reviewing out-patient services for documentation of QAPI activity on 1/8/2013, there was no evidence of documentation that any staff member had taken responsibility for collecting, measuring, analyzing, or tracking performance improvement for out patient services. Interview with staff #57 on 1/8/2013 confirmed that at this time the facility has no organized QAPI program and no data had been collected.
A1076
Event ID: 695E12
Facility ID: 810260

January 10 Health Inspection of Renaissance Hospital Terrell

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January 10 Health Inspection of Renaissance Hospital Terrell

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

RENAISSANCE HOSPITAL TERRELL

Event ID: 695E12

Facility ID: 810260

If continuation sheet Page 1 of 219

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OMB NO. 0938-0391

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

RENAISSANCE HOSPITAL TERRELL

Event ID: 695E12

Facility ID: 810260

If continuation sheet Page 2 of 219

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

RENAISSANCE HOSPITAL TERRELL

Event ID: 695E12

Facility ID: 810260

If continuation sheet Page 3 of 219

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OMB NO. 0938-0391

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

RENAISSANCE HOSPITAL TERRELL

Event ID: 695E12

Facility ID: 810260

If continuation sheet Page 4 of 219

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

RENAISSANCE HOSPITAL TERRELL

Event ID: 695E12

Facility ID: 810260

If continuation sheet Page 5 of 219

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

RENAISSANCE HOSPITAL TERRELL

Event ID: 695E12

Facility ID: 810260

If continuation sheet Page 6 of 219

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

RENAISSANCE HOSPITAL TERRELL

Event ID: 695E12

Facility ID: 810260

If continuation sheet Page 7 of 219

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

RENAISSANCE HOSPITAL TERRELL

Event ID: 695E12

Facility ID: 810260

If continuation sheet Page 8 of 219

PRINTED: 01/28/2013 FORM APPROVED

OMB NO. 0938-0391

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

RENAISSANCE HOSPITAL TERRELL

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 695E12