DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11IOSI2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) PROMIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- WING 1or1sr2015 NAME OF PROVIDER DR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (x5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CRoss- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) . A 398(Continued from Page 43) A 398 1 Continued From page 43 A 398i . for calibrating the Myron - D-1 Meter used for I checking conductivity. Furtherinterview with i Registered Nurse KK revealed she works with a company that in contracted with the hospital. Review of the facility's Myron - 0-1 Meter Log revealed the last date calibration was done on the Myron - D-1 Meter was dated January 11, 2015. Review of the facility's Myron - Meter Log revealed documentation which indicated the facility's dialysis unit has three Myron - D-1 Meters, serial numbers 302232, 303334 and 302235 for checking of dialysate conductivity. Review ofthe log revealed documentation which indicated that all three meters were last calibrated on own/2015. Review of the Man ufacturer's Instructions for Myron - D-1 Meter direct users as follows: "The Conductivity Standard Solutions and pH Buffers below are used for factory calibration. Regular use Of these solutions is recommended to ensure specified instrument accuracy. Frequency of conductivity recalibration depends upon use, but once every month should be sufficient for an instrument used daily." Review of the facility's current policy and procedure on Calibrating the Myron- D-1 Meter directs users as follows: "This procedure should be performed before once every month for an instrument that is used daily (as per manufacturer's requirement)" During an interview on 10/13/2015, at 10:41 am, with the Facility?s Chief Biomedical Technician for dialysis, he said it was the responsibility Of the nurses who provide dialysis to patients to calibrate the Myron 0-1 Meter. Monitoring and Tracking procedures that will . ?be implemented to ensure that the plan of correction is effective: Monitoring and tracking of the verification of conductivity and PH ofthe dialysate solution is included on the dialysis flowsheet and is part of ithe ongoing review oftreatments by the SJMC assigned supervising RN. calibration of Meters is monitored through the use of the Preventive Maintenance Review Form (Exhibit lc-2) and verified by the SJMC assigned :supervising RN. 1Ol151?2015 The results, recommendations, and actions taken is reported by the ICU Director/designee, not less than quarterly to ICC, QMOC, PIC, MEC, and GB. Title of person responsible: .Chief Nursing Of?cer, Director of ICU, Director of Quality Management FORM Previous Versions Obsolete Event ID: 272U11 Facility ID: 810020 If Continuation sheet Page 44 of 83 PRINTED: 11/06/2015 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 450035 WING 10/15/2015 NAME OF PROVIDER OR SUPPLIER CITY, STATE. CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) in 3 SUMMARY STATEMENT OF DEFICIENCIES i ID PROVIDERS PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL i pREFix ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) I TAG REFERENCED To THE APPROPRIATE DATE I A 398 I Continued From page 44 A 398i I I I Verification of dialysate composition Interview on 10/13/2015, at 10:30 am, with the facility's Chief Biomedical Technician for dialysis revealed the facility had 4 new Fresenius 2008T hemodialysis machines in use in the facility for hemodialysis treatment Of patients. Review of manufacturer's recommendations for i Fresenius 2008T hemodialysis machines direct ITHIS PAGE LEFT INTENTIONALLY BLANK users as follows: i "The Machine must be labeled to indicate the i type of concentrate for which it is con?gured. I Check the composition (LeH003 and pH) of the dialysate solution afterthe machine is installed or after the machine is modified for different concentrate type." "Check the conductivity and appropriate pH of the I dialysate solution with an independent device 3 before initiating dialysis." i Observation on 10/13/2015, at 2:40 pm, revealed hemodialysis machine #3 41, 42 and 43 were observed in the dialysis equipment room of the facility. Tags on the machines indicated they I were ready for usage. One machine was tagged i as out of service. I I Interview on 10/13/2015, at 2:40 pm. with the facility's Chief Biomedical Technician for dialysis revealed four Fresenius 2008 hemodialysis machines were put into service in January 2015 and were being used for hemodialysis treatment of patients. He said he did not validate the dialysate composition with a laboratory after the machines were installed. i Interview with the facility's Chief Biomedical FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 45 of 83 PRINTED: 1130619015 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8: MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (XI) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBERS COMPLETED A. BUILDING 450035 B. WING NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTONJ TX 77002 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 398 Continued From page 45 A 398 Technician for dialysis revealed he works with a company that is contracted to the facility. Registered Nurses Qualifications Registered Nurse KK On 1011312015, at 10:10 am, Registered Nurse KK was observed in the dialysis unit of the facility providing care and services to Patient #28 who was receiving hemodialysis treatment. Review of Registered Nurse KK's Job description titled: "St Joseph Contract Employee Addendum - Dialysis Revised 10/02/2015, and signed on 10/07/2015, by Registered Nurse (KK) revealed the following "This job has special vision requirement check all that apply. Color vision ability to identify and distinguish colors)" The I requirementto identify and distinguish colors was lchecked. Review of Registered Nurse KK's personnel and health records revealed no indication that a test 1 was perform to determine the Registered Nurse's I ability to detect and distinguish colors. I Registered Nurse II I On 10/1 312015, at 2:40 pm. Registered Nurse was observed in the dialysis unit of the facility providing care and services to Patient #72 who was receiving hemodialysis treatment. I Review of Registered Nurse ll's Job description titled "St Joseph Contract Employee Addendum - THIS PAGE LEFT INTENTIONALLY BLANK FORM Previous Versions Obsolete Event D2272U11 Facility ID: 810020 If continuation sheet Page 46 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 450035 B. WING 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES I ID PROVIDERS PLAN OF CORRECTION (EACH (x5) I (EACH DEFICIENCY MUST BE PRECEDED BY FULL I PREFIX CORRECTIVEACTION SHOULD BE CROSS- TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE I I DEFICIENCY) A 3598] Continued From page 46 A 398 i Dialysis Revised 10/02/2015, and Signed on . 10/08/2015, by Registered Nurse revealed the I following "This job has Special Vision requirement Check all that apply. Color Vision ability to 7 identify and distinguish colors)" The requirement to identify and distinguish colors was Checked. Review of Registered Nurse Il's personnel and health records revealed no indication that a test was perform to determine the Registered Nurse's ability to detect and distinguish colors. Registered Nurse AM On 10/14/2015, at 10:25 am, Registered Nurse AM was observed in the dialysis unit of the facility providing care and services to Patient#28 who was receiving hemodialysis treatment. Review of Registered Nurse AM's Job description titled "St Joseph Contract Employee Addendum - Dialysis Revised 10/02/2015, and signed on 10/07/2015, by Registered Nurse AM revealed the following: "This job has special Vision - requirement check all that apply. Colorvision ability to identify and distinguish colors") The requirement to identify and distinguish colors was Checked. Review of Registered Nurse personnel and health records revealed no indication that a test was perform to determine the Registered Nurse's ability to detect and distinguish colors. THIS PAGE LEFT INTENTIONALLY BLANK FORM Previous Versions Obsolete Event lDz272U11 Facility ID: 810020 If continuation sheet Page 47 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) Ixz) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 I3. WING 10,15,2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID i PROVIDERS PLAN OF CORRECTION (EACH (x5; pREle (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX I CORRECTIVEACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE . DEFICIENCY) A 398 Continued From page 47 A 398 Interview on 10/14/2015, at 1:10 pm, with the Registered Nurse in Charge ofthe dialysis unit, the Surveyors requested documentation that tests were conducted to determine the nurse's ability to to detect and distinguish colors. He said they were not performed on the nurses. Observation on the Surgical Intensive Care Unit (ICU) on 10/13/2015, between the hours of 9:30 am and 10:40 am, revealed the following information: Patient(# 63). Patient was Observed in bed receiving hemodialysis treatment via a temporary intravenous catheter. He was receiving his hemodialysis with a Fresenius 160 dialyzer, dialysate flow rate (DFR) at 800 and blood ?ow rate (BFR) at 350. Review of the physician's orders dated 10/13/2015, revealed no orders for a dialyzer. Further review of physician orders, progress notes and dialysis treatment ?ow sheets revealed Patient 63 started hemodialysis treatment on 10/10/2015. Review of Physician orders dated 10/10/2015, and 10/14/2015, revealed the orders did not include a dialyzer. The use of a dialyzer for hemodialysis treatment require a physician's order. THIS PAGE LEFT INTENTIONALLY BLANK FORM Previous Versions Obsolete Event ID: 272U11 Facility ID: 810020 If continuation Sheet Page 48 of 83 PRINTED: 11/06/2015 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIEs (X1) (x2) MULTIPLE CONSTRUCTION {x3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDWG COMPLETED 450035 3- WING 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY HOUSTON, TX 77002 ST JOSEPH MEDICAL CENTER (x4) ID 1 SUMMARY STATEMENT OF DEFICIENCIES ID I PLAN OF CORRECTION (EACH (x5) I (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CRoss? COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCED To THE APPROPRIATE DATE . DEFICIENCY) I i I A 398 Continued From page 48 A 308I Review Of the treatment records for 10/10/2015, revealed dialyzer Fresenius 160 was used to dialyze the patient without a physician's order. On 10/11/2015. and 10/12/2015, the orders did not include blood flow rate or dialysate flow rate. Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR) are a component of the patient's i hemodialysis prescription and requires a physician's order. I Review ofthe treatment records for 10/11/2015, THIS LEFT BLANK . i revealed the patient was dialyzed at a dialysate i flow rate of 300 mls/hr without an order. there was no documentation of what the DFR was. i I i I During an interview on 10/13/2015, at 10:15 am, with Staff II. who was providing the hemodialysis treatment for the patient, he stated the hemodiaiysis orders are standing orders. Review of hemodialysis treatment record dated 10/10/2015 through 10/13/2015, revealed no documentation that the patient had a pre or post . dialysis weight necessary to determine the amount of fluid to be removed during the treatment and determine the effectiveness of the hemodialysis treatment post dialysis. During an interview on 10/13/2015, at 10:25 am, with the Nurse Managerfor the unit regarding weights and physician orders for hemodialysis patients. She stated. staffs are required to weigh 1 the patients pre?dialysis. She stated the orders were incomplete. Patient 49 Review of the Patient# 49's treatment sheets FORM Previous Versions Obsolete Event IDI272U11 Facility ID: 810020 If continuation sheet Page 49 0183 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 450035 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 10/15/2015 NAME OF PROVIDER OR SUPPLIER ST JOSEPH MEDICAL CENTER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY HOUSTON, TX 77002 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS- REFERENCEDTO THE APPROPRIATE DEFICIENCY) COMPLETION DATE A 398 Continued From page 49 revealed no documented evidence that a pre-treatment dialysis weight was obtained prior to initiation of hemodialysis treatment on the I patient. 1. 10/08/2015 2. 10/09/2015 I 3. 10/10/2015 14.10/12/2015 Interview on 10/14/2015, at 08:45 am. with Registered Nurse WV revealed that she is one ofthe dialysis nurses from the Contracted Services. The Surveyor notified her ofthe missing weight priorto treatment of Patient #49 and said "Yes. we are supposed to weigh them before each treatment, I do not know why the other I nurses don't do that." Review of personnel ?les for Staff #3 WV, WW, and revealed the staff did not 5 have documentation that a color blind test was conducted on these staff. Review of St Joseph Medical Center Job Description titled "St. Joseph Contract Employee Addendum-Dialysis states the following information: "This job has special vision requirements. Color Vision (ability to identify and distinguish colors)". MEDICAL RECORD SERVICES A 450 All patient medical record entries must be legible, 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 A3985 I A A 450: MEDICAL RECORD SERVICES iTheplan for correcting the specific 'deficienc cited: CBH leadership reviewed and/or i revised the '1 1/16/2015 gfollowing poiicies/procedures/Medical Staff Rules: FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 50 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11i06t2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF IDENTIFICATION NUMBER: A BUILDING COMPLETED 450035 B. WING 1011512015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVEACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) I TAG A 450 Continued: A 450 Continued From page 50 i A 450 - Speciai Precautions Monitoring (Revised) rocedures I (EXhibit I Faii Prevention Program (Revised) (Exhibit E-2) This STANDARD is not met as evidenced by: Based on interview and review of medical records of patients, it was determined that entries in the medical records were not complete, lacked dating when required, and were not consistent with hospital policies and procedures. Further, the facility failed to ensure complete medical records when physician orders were not signed, Special Precautions, although being done, were not . ordered, and treatment ptans on the behavioral health units were not individualized, did not include individualized goals or outcomes in 10 of 10 records reviewed on two units. Patient #3 1, 2 3, 4, 12, 13, 14, 19, 52, and 53. Findings were: I I Patient #3 Review of Patient #3's medical history and i physical record revealed a 61 year old, female, I admitted on 10i1/15. Reason for admission: The patient was found with her bra wrapped around her neck in the bathroom and a bottle of pills by I her hand. She was unconscious. Review of Patient Physician Orders - Behavioral Medicine General Admission form dated 10f2i15, timed at 10:00 am, revealed I there were no precautions ordered. The Physician Orders were not signed by a physician. Review of Patient#3's lnterdisciplinaryAdult Plan of Care (undated) reflected an admission date of 10/3/15. The Plan of Care reflected fall Risk and interventions per fall Risk Assessment tool was a General Rules and Regulations of the Medical Staff regarding physician orders (Reviewed) - interdiscipiinary Assessment and Treatment Pians (Revised) (Exhibit - Revised policiesiprocedures will be forwarded to the GB for review and leadership implemented the following iactions: 11/2/2015 lnstituted a new process of flagging incomplete physician orders by the night shift nurses. Education was provided to physicians on a 1:1 basis by the CBH clinical leaders in Chart Checks (Exhibit E-6) every shift to I ensure compietion of all required documentsi11i2/2015 (consents, assessments, treatment plans, orders, precautions) -- Special Precautions sticker (Exhibit E-T) prompting the physician to review special Tug/2015 precaution orders and their continuation or discontinuation daily 1: Implemented a fall risk assessment tool I specific to behavioral health. This tool is used by staff to facilitate the process for obtaining desired outcomes and goals, as well as to integrate fall risk levels into the new individualized treatment plan a Revised comprehensive behavioral health treatment planning process, which addresses medical and behavioral health problems, is patient-centered and individualized, includes interventions, outcomes and goals, and involves the patient in the treatment plan process. 11/16t2015 I11/13i2015 FORM Previous Versions Obsolete Event ID1272U11 Facility ID: 810020 If continuation sheet Page 51 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 checked. There were no desired outcome/goals I written or checked for the Safety Fall Risk. Further review revealed patient 3's treatment plan Suicide risk was not a part ofthe treatment plan; her admitting reason for admission indicated a suicide risk. 3 During an interview on 10/12/15, on the 8th floor unit, StaffW, Registered Nurse (RN), when asked how the fall interventions are determined she stated the Fall Risk Assessment tool is completed on admission. StaffW stated, "The facility uses a Fall Risk Assessment Form." She was unable to provide the form or evidence that the form had been completed on Patients 4, or 5. During an interview on 10/12/15, on the 8th floor Medical] unit Staff, RN stated, "The unit is new and the fall form has not been implemented yet. She stated,"The staffs check on the patients frequently. Patient#4 Review of Patient#4's medical history and physical record revealed a 63 year old, female, admitted on 10/10/15. Reason for admission: The patient was delusional, threatening to kill her brother and herself with a knife and apparently, she was running down the street naked. Review of Patient #4's Physician Orders - Behavior Medicine General Admission form dated 10/11/15 at 12:30 am. revealed Precautions: Fall was checked. Suicide Precautions was not checked; her admitting reason for admission indicated a suicide risk. STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 450035 8- 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, Tx 77002 (X4) SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING IN FORMATION) . TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TAG A 450 Continued: A 450 Continued From page 51 A 450 iThe plan for improving the processes that led to the deficiency cited. including how the hospital is addressing improvements in its Systems in order to prevent the likelihood of Irecurrence of the deficient practice: 1A new process of ?agging incomplete physician torders was implemented. Night shift nurses are fresponsible for this process with oversight being performed by CBH leadership. 11/2/2015 The Special Precautions Poi/cy/Procedure 51 1/16/2015 (Exhibit E-3) was revised and delineates that all I assessments and reassessments are reviewed in the process of initiating precautions. The policy now includes a self?harm risk assessment based on risk level. Nursing is responsible for I contacting the physician for orders speci?c to the risk level assigned. In addition, patients on special precautions are clearly communicated on the unit?s communication whiteboard, reviewed during change of shift report, as well as in Treatment Team meetings. The Fa/i Prevention Program Po/r'cy (Exhibit E-2) 1 1/16/2015 and assessment tool speci?c to behavioral health was revised. This tool is used by staff to facilitate the process of obtaining and documenting desired outcomes and goals, as well as integrating fall risk into the new individualized treatment plan. Comprehensive Behavioral Health Treatment 11/13/2015 Pianning Process was revised and implemented, which addresses medical and behavioral health problems, is individualized for FORM Previous Versions Obsolete Event ID: 272U11 Facility ID: 810020 If continuation sheet Page 52 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 1110612015 FORM APPROVED OMB NO. 0938-0391 Review of patient#4?s Interdisciplinary Adult Plan of Care (undated) reflected an admission date of 10110/15. The Plan of Care reflected fall Risk and interventions per fall Risk Assessmenttool was checked. There was no desired outcomeigoals written or checked for the Safety Fall Risk. Risk of injury to self/others was checked as a problem, therapeutic communication was an intervention, there were no further interventions and there were no desired OutcomeSI?Goals recorded. Patient #5 Review of Patient#5's medical history and physical record revealed a 63 year old, female, admitted on 10118115. Reason for admission: acting abnormal, having hallucinations, and supposedly a seizure disorder. I Review of Patient Physician Orders - Behavior Medicine General Admission form dated 10i9I?15, at 12:30 am, revealed Precautions: Elopement and Fall were checked off. Further review revealed patient 5?s treatment plan Seizure risk was not a part Of the treatment plan; her admitting reason for admission indicated a Seizure precaution. During an interview on 10/12115, at4:00 pm, on the Medical! unit, Staff W, RN stated, "If orders are missing for suicide precautions the I nurse should call the physician tO obtain the I order." POLICY: Review ofthe facility provided Special Precautions Monitoring Policy CBH. 32 (dated 619/2015) revealed: STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B. WING 1011512015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) i . I TAG A 450 Continued A 450 Continued From page 52 A 450 .each patient, includes interventions, outcomes and goals, and involves the patient in the treatment plan process. in addition, a treatment planning schedule: was revised and implemented on all units for facilitating days times 1 participants in treatment team. Procedures for implementing the acceptable plan of correction for each deficiency cited: The clinical director has educated physicians relative to completion of orders, including authentication and the new flagging process. In addition, a physician newsletter (Exhibit E-8) was published for members of the medical staff re? educating them on the requirements of completing medical recordSIi orders. The night shift nurses were educated on the new order flagging process. 10(30/2015 iPatients on special precautions are now included as a daily agenda item in the CBH leadership team?s ?daily flash meeting?. I I IAII behavioral health team members responsible forI the identification of special precautions (nurses, 111/30/2015 Isocial workers, activity therapists, and physicians) will receive education and training relative to the policy change, use of sticker (Exhibit E-7), and importance of appropriate use of precautions. Education and training will be completed for CBH :11130/2015 staff on the Fail Prevention Program (Exhibit E-2) and assessment tool Specific to behavioral health. Clinical staff at CBH began receiving education on 1012212015 relative to the development of a patient-I centered individualized comprehensive treatment 12/1/2015 plan. This education is ongoing and will be incorporated into orientation and annual education of staff. FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 53 0183 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/069015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 SWING 10115/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) in SUMMARY STATEMENT OF DEFICIENCIEs in I PROVIDERS PLAN OF CORRECTION (EACH (x5) pREFix (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE CRoss- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE - DATE DEFICIENCY) A 450 Continued From page 53 The purpose of the assessment for suicide, homicide and self-harm is to provide guidelines for the safe management of patients with suicidal I ideations and to minimized self?harming acts by all patient admitted to the facility's Center for Behavioral Health. DEFINITIONS: A. "Suicidal Patient" is one who has recently made an attempt in the last 12 months B. "Risk Factors" for suicide or or environmental factors PROCEDURE: An order for suicide precautions is written by a physician, or by a registered nurse as an Independent nursing intervention. A physician's order must be Obtained within 1 hour of the nursing order. The order must include reason. Review Of the facility provided policy for MEDICAL RECORDS (undated) revealed: E. Physician Orders 1. All orders for treatment shall be in writing, dated, and timed. I 2. Persons receiving dictated orders will sign the order, read back, verify, and confirm with the practitioner's name! the transcriber's name. Following dictated order, the responsible I practitioner must authenticate such order by signature as soon as possible. I On behavioral health: I Review of the medical record Of patient hypertension was noted as a problem for this TAG A 450 Continued: A 450 Monitoring and Tracking procedures that willi the implemented to ensure that the plan of Icorrection is effective: The Executive Director and Nursing Director Of CBH is providing oversight to the formal ;1 1/16/2015 monitoring and evaluation process, which will inciude a review of the: - CBH physician orders to ensure completiong including authentication; - Number and appropriateness of patients on special precautions, during daily flash meetings; - Completion of the fall risk assessment tool with appropriate identi?cation and treatment planning for those patients identi?ed as high risk for fall. Random sample of 20 cases per month is included in this review. a All patient treatment plans are being reviewed for the next 90 days. Any identifiedi deficiency is corrected with education provided to the staff member. These real time reviews are conducted with the clinical team members that are actively engaged in the care of the patient at the time and changes made as needed. iResults, recommendations and actions are reported not less than quarterly to QMOC, PIC, MEC, and GB. Title of personts) responsible: Executive Director Behavioral Health, Nursing Director Behavioral Health, Behavioral Health Medical Director, Chief Nursing Of?cer FORM Previous Versions Obsolete Eyent Facility ID: 810020 If continuation sheet Page 54 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: i1i?061?2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE CONSTRUCTION (xsi DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B.WING 10l15l2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY. STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH Ixsi DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVEACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAO REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) I . A 4501 Continued From page 54 A 450' patient. However, there was no mention of hypertension in the patient?s individualized treatment plan, nor were there any modalities described for interventions for this medical issue. Further review of this patient?s record revealed, Insulin-sliding scale - was ordered by the physician. Insulin is usually prescribed for the treatment of diabetes and the dosage is dependent on the blood sugar level result per the I sliding scale order. There was no mention of i diabetes in the patient's individualized treatment plan. Interview with the nurse on the unit I indicated that the insulin was not being administered to this patient secondary to the fact that the patient was refusing "finger sticks" to test his blood sugar levels, and that the patient himself was denying that he had a diabetic . condition. Again, there was no mention of diabetes, nor the modalities Of blood sugar measurements or administration of insulin i mentioned in the patient's individualized treatment plan. There was no indication that the patient participated in the development and . implementation of his own treatment plan. - In review Ofthe medical record of patient the initial physician's assessment and admitting orders were accomplished via the use Of telemedicine. There was no indication that the patient was involved in the development and implementation of his treatment plan. in review of the medical records of patients #12, #13, #14, and #52, there were no dates in the space provided for the dates (with the word "date" under the line or space provided) after the staff signatures, so that it could not be ascertained if THIS PAGE LEFT INTENTIONALLY BLANK FORM Previous Versions Obsolete Event Facility 810020 If continuation sheet Page 55 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11(06/2015 FORM APPROVED OMB NO. 0938-0391 (ii) ls responsible for daily management of the dietary services; and ls qualified by experience or training. This STANDARD is not met as evidenced by: Based on observation, interview and record review the facility?s Dietary Director failed to maintain an organized and sanitary kitchen and show evidence for the daily management of dietary services. Findings included: Observation on 10/12/15, at 2:00 pm, in the facility?s kitchen revealed: - A 55 gallon white plastic trash bag filled with i food and garbage and liquid refuse sitting on the kitchen floor. The plastic bag was leaking onto the kitchen floor. STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- WING 10(1512015 NAME OF PROVIDER OR SUPPLIER CITY, STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON. TX 77002 pet) to SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH pREFix (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVEACTION SHOULD BE COMPLETION TAG RECULATORYOR IDENTIFYING TAG REFERENCEO TO THE APPROPRIATE DATE DEFICIENCY) A 450 Continued From page 55 A 450 the staff members Signed the treatment plan prior to or after the patient. 3 In review ofthe medical record of patient #19 and i #53 there was no patient signature and no dates by the staff signatures even though a space was I provided for the date with the word "date" under the line of space provided. I I A 6203 DIRECTOR OF DIETARY I A 620 A 620 DIRECTOR OF DIETARY SERVICES I ISERVICES I I Ideficiency cited: Serves as director of the food and dietetic i SGWICGSJ ?Hospital Administration, along with Infection .10i12/2015 Prevention, Clinical Dieticians, Director of Nutrition Services, Quality Management took immediate actions during the survey to address (the issues identi?ed including: 10l1512015 :0 Contracting with an outside Company to I clean and sanitize the kitchen; 10/12/2015 in Floors were pressure washed; 10/13/2015 -- Cutting boards were discarded and new ones purchased and placed into use; 10i13/2015 .0 Kitchenware was inspected and replaced if it could not be cleaned adequately; mfg/2015 - Ceiling and air vents were cleaned; .1 Dim/2015 Dish machine was de-Iimed and Cleaning was implemented following each meal service In addition, this team developed and implemented a detailed action plan (Exhibit A-t) and Cleaning schedule (Exhibit A2) for maintaining an organized and sanitary kitchen. This action plan addressed surveyors Speci?c findings as follows: FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 56 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES {x1} (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) TAG A 620 Continued: A 620 Continued From page 56 A 620 1. Purchased four 50 gallon rolling trash - Five staff handwashing sinks did not have trash receptacles to dispose Of used hand towels - The dry storage room had shelves with shipping boxes stored over open disposable food supplies. - The dietary floors were dirty and sticky throughoutthe department, creating an environmentfor pests and bacterial growth. - There were multiple cracked and chipped baseboards and tiles making the area not Cleanable; there was built-up dirt and debris in the I 3 cracks. I - There were (4) boxes Of Chocolate Pretzels and (1) box of Cheddar crackers stored on the floor of an of?ce, making them accessible to pests and other contaminants. - There was a can Of WAD40, chemical to oil mechanical objects, stored with food items, I creating a possible chemical ingestion. I - There was a smoke alarm, several ceiling and air vents with dust and dirt residue over food items and in the food preparation areas. - A metal can of Sesame Seed oil with (2) puncture holes was sitting on the spice rack and was accessible for use. - There was food debris on the Buffalo Chopper, electric food Slicer, large floor mixer, and on various walls throughout the department. - The facility?s (2) deep fat fryers had spilled oil on the bottom Shelves, and old food debris in the containers with lids attached. Staff is instructed i to empty soiled trays into these containers and when bags are full, they are then rolled to the trash wagons and transferred into those for transport to the dumpster area. i2. Placed ?ve foot activated trash receptacles by each of the hand washing stations, with four additional foot-activated receptacles ordered and placed by all prep areas in the kitchen. I3. Placed plastic shelf covers on the top and lower shelves in storage room to eliminate any debris falling from the top storage to the products below. Clerks are responsible for maintaining cleanliness of the Shelf covers. 4. Floors throughout the kitchen and storage areas were power washed and scrubbed with hand brushes. An outside company was ?contracted to power wash the floors Sx/week iuntil FTE's are hired. An outside company was contracted to resurface the base molding/color and coat with epoxy to allow for effective and efficient Cleaning. 1 6. All products stored on the ?oor in the i1 0/1 52015 procurement office were removed and relocated to appropriate store rooms. Staff instructed that no storage allowed in office. 7. Can of was immediately removed and 10/13/2015 staff retrained on the proper storage of chemicals. 11/12/2015 10/12/2015 10/12/2015 10/15/2015 511/1512015 FORM Previous Versions Obsolete EventlD:272U11 Facility ID: 810020 If continuation sheet Page 5? Of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- WING 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (st DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) TAG A 620 Continued: A 620 Continued From page 57 A 620 fryer baskets. - Four (4) plastic food cutting boards had multiple deep gouges, making them dif?cult to Clean. The cutting boards had a dark residue in the gouges and were accessible for use. i - Staff S, the Dietary Manager was Chewing gum in the kitchen creating possible saliva transfer to prepared foods. Further observation of the facility kitchen on 10/12/15, at 3:00 pm, revealed the facility's large dishwashing machine had food debris floating in . the wash tanks and the water was dirty. There was a built-up lime deposit on the inner doors. The lunch dishes had been completed and the dish machine had not been drained and cleaned. During an interview on 10/12/15, at 2:40 pm, Staff 8, the Dietary Manager when asked by the surveyor how often does the dish machine get the night. During an interview on 10/12/15, at 3:00 pm, Staff V, a Dietary Aide, stated he does not empty and clean the dish machine after each meal, it is emptied at the end Of the night. StaffV stated that sometimes if the water gets too bad, then he will change the water out. Observation on 10/13/15, at 11 :40 am, in the facility?s kitchen revealed two (2) large 55 gallon cleaned and the water get Changed, he stated the 1 dish machine is drained and cleaned at the end of 8. The smoke alarms, along with sprinkler heads 10/20/2015 were cleaned by an outside company and all ceiling tiles replaced in food preparation area. Vents were taken down, cleaned, and repainted in the designated areas. Two back pack 10,152015 vacuums were purchased and are being utilized to maintain the cleaning of the vents, ceiling 10/20/2015 tiles, smoke alarms and sprinkler heads. E1 on 2/2015 9. Sesame Seed Oil was immediately discarded and staff was retrained on the storage procedures forfOOd products. 1019/2015 10. The buffalo chopper, electric food slicer, large floor mixer were disassembled and 10/13/2015 terminally cleaned/sanitized and placed back 10/14/2015 into service. Walls cleaned by kitchen staff with food debris removed. Walls have been added to? the cleaning schedule. ,11. All fryers were degreased and power washed?10/1 5/2015 Ito remove debris and residual grease. i 512. Cutting boards were disposed of, new 0/13/2015 icutting boards purchased and placed into use. 513. Staff instructed that Chewing gum is strictly 3/2015 forbidden in the dietary area and disciplinary action will be taken for non-compliance. 14. Dish Washing Machine: Staff was re- educated on the procedure and documentation for cleaning the dish machine in between each 10/132015 meal period according to the Hobart Instruction Manual. The dish machine is de-limed three I times per week on Monday, Wednesday and I Friday, paying Close attention to the doorjams and outside Of machine. will provide additional education on the proper maintenance 11/303015 ofthe dish machine during November. FORM Previous Versions Obsolete Event ID: 272U11 Facility ID: 810020 ii continuation sheet Page 58 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11l06!2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERIOLIA (X2) MULTIPLE CONSTRUCTION 023) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 450035 SWING 10r15i2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY. STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4; ID SUMMARY STATEMENT OF DEFICIENCIEs ID PROVIDERS PLAN OF CORRECTION (EACH pREFix (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAO REFERENCED TO THE APPROPRIATE DATE TAG A 620 Continued: A 620 Continued From page 58 A 620 white plastic trash bags filled with food and The for ImprOVInq the processes that garbage and liquid refuse sitting on the kitchen 19d t0 the defiCienCieS Cited. floor. There was a large pool of pink milky the hospital is addressing improvements in substance on the kitchen ?oor under the leaking its systems in order to prevent the likelihood plastic bags. Iof reoccurrence of the deficient practice: Developed and implemented a detailed action plan (Exhibit A-1) and cleaning schedule (Exhibitm/ml2015 REVIEW 0f the provided for maintaining an organized and sanitary CLEAN UP PROCEDURE (undated) reflected: kitchen This action plan inciudes; How Often: End Of shift and/ or end Of day. 2 - Daily checklist Of cleaning activities by 10/25/2015 I dietary staff to maintain an organized and Review of the facility provided Hobart FTQOO sanitary kitchen; (Exhibit A-3) 21111152015 Series Dishwasher Manufacturer's Operation I Twice deep/terminal cleaning of the manual (dated Oct. 2007) reflected, kitchen; 210,128,120? a Purchase Of new equipment to be utilized CLEANING for Cleaning: backpack vacuums, The dishwasher MUST be thoroughly cleaned at powerwasmng resmratlon, ?oor maChme I the end of each working shift or after each meal. I and a ?oor aup?SCIUbber' 11/15/2015 0 Approved addItIon of 4 FTEs to clean (Using contracted company to powenNash I Open all front access doors. Drain the machine ?oors after hours until FTES are hired and and clean the curtains the trained); interior and all tanks shelves using a good hose . Oversight by Infection Control Manager to all debris toward the strainers Remove include bi~weekly environmental audit end caps. Clean wash arms. Remove, clean and validation in the kitchen area in . replace the strainers_ I collaboration the department director; 5- lnfection Control staff are scheduled to 12/3/2015 During the tour of the Facility's kitchen Staff T, the I attend the Food Safety Manager i facility's Infection Control Director, confirmed the i Tram'ng cemf'camn I above Procedures for implementing the acceptable A 747 I 482'42 INFECTION CONTROL A 747 plans of correction for each deficiency cited: The hospital must provide a sanitary environment Staff meetings were held to reeducate on the to avoid sources and transmission of infections requirements for trash disposal? cleaning, and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases. 10/13/2015 sanitizing equipment, food storage, labelIng, handwashing, Chewing gum, proper cleaning I of the dish machine, reporting of broken or equipment in need of replacement; FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 59 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 11i06f2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (x3; DATE AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 450035 B. WING 101?1 512015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (X4) in SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (st (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TAG A 620 Continued: A 747? Continued From page 59 A 747 - Implemented daily staff huddles to review and 10/19/2015 5 This CONDITION is not met as evidenced by: reinforce the procedures necessary to maintain Based on observation, interview, and record an orgamz?d and 530m? k'tChen' . th d. .I Re-education of all dietary staff to Safe Food rewewt 30' "act ?@513 3' to Handling Practices (Exhibit A-4) and the :1 1 [30,2015 remove gloves and wash/sanitize hands after maintenance of an organized and sanitary . direct contact with contaminated items and kitchen. Education to be 100% complete by patients In 9 random observations in the facility's November 30, 2015. This education will also intensive care unit, hemodialysis unit, new born '?C'Ufje? nursery. RR AM HH and ?ve random Sanitation and cleaning of Kitchenware physician; i -Dish Machine Cleaning and sanitizing I0 To re-enforce prior training, EcoLab will Failed to ensure physicians' orders were obtained pmde regardm ff for insertion of Foley catheters and monitored for Dimer mamtenance 0; to 3? Sta appropriateness of continued use of Foley 0 are ass'gned wt 8 '8 was mg' Egaeiers 122:": W'th Monitoring and Trackinq procedures that will be ers a ?an 8 an implemented to ensure that the plan of :correction is effective: Failed to maintain a clean and sanitary It?? enVIrO-nm-ent In the faCIlIty's community kitchen, I. An audit tool (ExhibitAa) was developed and 101262015 1 units, and surgical . Cross refer impgemented to ensure compliance of dietary to A 0620, 0749, and A 0951. staff. Cleaning calendar (Exhibit A-2) was A 749; INFECTION CONTROL PROGRAM A 74st developed that ls completed and monitored by The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the facility's direct care staff failed to remove gloves and washfsanitize hands after direct contact with contaminated items and patients in 9 random observations in the facility's intensive care unit, hemodialysis unit, new born nursery; ll, RR, AM HH and five random the Director of Dietary Services. The Infection Control Manager in collaboration with the COO will conduct bi-weekly audit validation in the kitchen area and give feedback to the Director of Dietary Services, I which is included with his audit results. i 11i1?12015 These activities are reported not less than quarterly to the E00, ICC, QMOC, PIC, MEC and the GB. Title of personfs) responsible: IDirector, Dietary Services, Chief Operating Of?cer Infection Control Manager, Director of Quality Management TAG A 747 INFECTION CONTROL The plan for correcting the specific deficiency cited: FORM CM S?2567t02?99) Previous Versions Obsolete Event ID1272U11 Facility ID: 810020 If continuation sheet Page 60 Of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11i?06i'2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 5- WING 1011512015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY. STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) (0 SUMMARY STATEMENT OF DEFICIENCIES (D PROVIDERS PLAN OF CORRECTION (EACH (st (EACH DEFICIENCY MUST BE PRECEDED BY FULL pREFix CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) TAG A 747 Continued: A 749 Continued From page 60 A 749 A comprehensive hand hygiene awareness 12K15f2015 physicians. Failed to ensure physicians' orders were Obtained for insertion of Foley catheters and monitored for appropriateness of continued use of Foley catheters in 2 Of6 Patients monitored with Foley . catheters Patient #8 63 and 65 . Failed to maintain a Clean and sanitary environment in the facility's community kitchen units and surgical suites . 1 Findings: Review of the Facility's Policy and Procedure on Universal Blood and Body Fluid Precautions Obtained from the hemodialysis Policy Manual, section direct staff as follows: "Hand and other skin surface must be washed immediately (or as soon as possible) with soap and water if contaminated with blood or any other body fluid. . Hands will be washed immediately after gloves are removed and upon leaving the work area." "Gloves must be worn during all venous and arterial punctures. Sterile gloves will be worn when necessary." Patient #3 26 and 27. Registered Nurse HH On 10/13/2015, at 1:55 pm, Registered Nurse HH was Observed wearing a pair Of gloves while pushing patient 26's bed into the dialysis unit from the outside of the unit. On entering the unit, Registered Nurse HH repositioned the patient in bed, and handed over the patient to the dialysis nurse. After handing the campaign and education on the apprOpriate use of PPE was initiated by Infection control for all hospital; staff (Exhibit D-1). - A risk assessment for placement of hand I hygiene dispensers in the CBH was performed; dispensers will be installed in designated areas. - CBH unit secretaries were reeducated on ensuring adequate amounts of portable hand sanitizer are ordered and available for staff. 0 Comprehensive education on hand hygiene, appropriate glove use, and responding to i environmental infection control issues will be i provided to CBH staff by 11I20i15. A Frequently Asked Questions tool will be developed as a resource for behavioral health based on feedback during training. a Hand hygiene monitoring for dialysis specifically includes appropriate glove use during venous and arterial punctures and the use of sterile gloves when necessary. '0 Charge nurses were re-educated on i addressing the need for concurrent staff redirection for performing hand hygiene before and after entering patient rooms and after every patient interaction. A multidisciplinary team was formed with representatives from IC Manager, Corporate IC Director, Quality Director and ICU Directorto implement process improvements for Foley Catheter use. 0 A process for daily CAUTI rounds was revised and implemented to ensure that all Foleys have an appropriate physician order, and indications for use are identi?ed. Validation audits by IC Manager are conducted a minimum Of twice weekly - The team developed a sticker (Exhibit D43) ??11?2015 tO document the need for continuing or discontinuing Foley catheters per physician's order 11/11/2015 FORM Previous Versions Obsolete Event Facility ID: 810020 if continuation sheet Page 61 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY. STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (x5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE I I DEFICIENCY) I I A 747 Continued: A 749 Continued From page 61 A 749 patient over, Registered Nurse HH continued to wear the contaminated gloves that she had used to transfer the patient. Registered Nurse HH placed her contaminated gloved hands in her pocket and retrieved two syringes and ampoules with medication from her pocket. The Registered Nurse then walked over to the computer terminal, verified the physician's order and pulled up medication from the ampoules containing medication. She continued wearing the contaminated gloves she had used to transport the patient. Registered Nurse walked over to Patient #27, who was in an adjacent bed receiving hemodialysis treatment. She administered intravenous medication to Patient#27 using the contaminated gloves she had used to transfer Patient Registered Nurse HH did not remove her gloves and wash/ sanitize her hands aftertransferring the patient from the unit. Interview on 10/13/2015, at 2:15 pm, with I Registered Nurse HH, the Surveyor notified the Registered Nurse that she had used the same gloves that she used to transfer Patient 26 with to administer Patient#27's intravenous medication. Registered Nurse HH stated "Shuck, Just now I thought about it." PATIENT #72 Registered Nurse II On 10/13/2015, at 2:30 pm, Registered Nurse II was observed on the hemodialysis unit, at the bedside of Patient 72. Observation revealed The plan for improving the processes that led' to the deficiency cited, including how the hospital is addressing improvements in its systems in order to prevent the likelihood of recurrence of the deficient practice: Staff was educated to raise awareness among .co-workers to perform hand hygiene. - ?Stop and Wash" signage will be posted above each hand hygiene dispenser outside patient rooms as a visual prompt I - Hospital Leadership, Infection Control, and Quality will monitor hand hygiene performance while performing daily rounds and dispense washed my hands" stickers for positive reinforcement. Stickers can be exchanged for tokens and used to purchase items in the cafeteria. ,0 Hand hygiene scores will be posted for department every month in break rooms, communication board, and other staff areas 1 so everyone can see how each unit is ranked. A Hand Hygiene Campaign notification email will be sent to all medical staff and information about the campaign will be routinely included in the hospital Friday Facts weekly communication. a The charge nurse will review orders and is 11/1112015 responsible for placing sticker (Exhibit D-6) on the physician order sheet. A checklist (Exhibit D-2) was developed and is utilized for the daily CAUTI rounding and evaluation - of sticker. The CAUTI Team will assure sticker is on chart and that completion of the sticker includes indications, discontinuation, and reasons for continuation. 11/20/2015 11/20/2015 Procedures for implementing the acceptable plans of correction for each deficiency cited: Daily and weekly departmental speci?c checklists (Exhibits and F-1) were developed to support ongoing review and analysis of 10/26/15 FORM Previous Versions Obsolete Event ID1272U11 Facility ID: 810020 If continuation sheet Page E32 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: FORM APPROVED OMB NO. 0938-0391 STATEMENT OF (x1) PROVIDERISUPPLIERJCLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B. WING 10i15i2015 NAME OF OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH I (st PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TAG A 747 Continued: A 749. Continued From page 62 A 749 Registered Nurse II donned a pair of gloves, pulled up the side rails on the patient's bed . reset the settings on the patient's hemodialysis machine, removed his gloves. The Registered Nurse did not wash or sanitize his contaminated hands. Registered Nurse ll walked over to the . clean glove box located at the nurses station and picked up Clean gloves with his contaminated I hands. Observation on 10/132015. at 2:40 pm, revealed Registered Nurse II was Observed at the bedside of Patient #72. The Registered Nurse - was observed initiating hemodialysis treatment on Patient #72. Registered Nurse ll applied a gown and a mask to his face. While securing the disposable mask around his neck, the Registered Nurse directly touched the back of his neck and head. The Registered Nurse did not wash/sanitize his hands. He then picked up clean gloves from the box Of gloves, with his contaminated hands he had used to touch his neck and head. He then donned the glove and proceeded to clean Patient #72'3 vascular access. After cleaning the patient's vascular access located on the patient's left lower arm, Registered Nurse II retrieved the stethoscope from his neck and examined the patient's chest and back, touching the Patient's chest and back with his gloved hands. Registered Nurse then cannulated the patient's vascular access wearing the same gloves he used to examine the patients chest and back. I During an interview on 10/132015, at2:45 the Surveyor informed registered Nurse II that he I did not wash/sanitize his hands after touching his environmental and workplace activities for reducing infection risk and evaluating compliance with current healthcare regulatory Sstandards. Oversight of this checklist process is performed by IC staff, who will validate ,departmental findings twice weekly on a rotating :department basis via formal schedule (Exhibit D-i i4), with the exception of dietary, where validation' irounds are performed weekly. ICU Nursing and physician staff were educated through daily huddles and on a one-tO-One basis 12/15/2015 lregarding the use of the sticker. The sticker was {initially trialed in ICU for a period of 3 weeks and jevaluated through CAUTI rounds. Compliance Ereached 100% and the team has determined that implementation be house wide. House wide education Ofthe nursing and physician staff will ,be conducted through daily huddles, one-on-one ?education, physician newsletter, and physician [department meetings.(Exhibit D-S) I Monitoring and Tracking procedures that will be implemented to ensure that the plan of correction is effective: Monitoring is accomplished through daily CAUTI rounds utilizing the Foley catheter data collectionI?I ?1 1/2015 scorecard (Exhibit D-2) on 100% of patients with I Foley catheters. Infection control validation rounds performed twice weekly and rounds by leadership and quality will also include hand hygiene and PPE use surveillance. Results, recommendations, and actions of monitoring and evaluation are reported to the ICC, QMOC, PIC, MEC and the GB not less than quarterly. FORM Previous Versions Obsolete Event ID: 272U11 Facility ID: 810020 If continuation sheet Page 63 Of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11i06i2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 10i15i20?l5 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, Tx 77002 (x4) SUMMARY STATEMENT OF DEFICIENCIES JD PLAN OF CORRECTION (EACH (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TAG A 747 Continued: A 749 Continued From page 63 A 749 neck and head and that he used the same I gloves that he had used to examine the patient's neck and chest to cannulate the Patient's vascular access. Registered Nurse (ll) stated agree." Patient 28 Registered Nurse AM On 10/14/2015, at 10.50 am, Registered Nurse AM was observed in the dialysis unit at the chair?side of Patient #28. Registered Nurse AM reset the patient's hemodialysis machine wearing one hand ofa glove to her right hand. After resetting the patient?s contaminated hemodialysis I machine, Registered Nurse AM entered I information on the patient's treatment sheet while wearing her contaminated glove. She then walked over to the nurse' station with her contaminated gloved hand picked up the clean glove box from the nurses? station with her contaminated gloved hands. Registered Nurse AM did not remove her contaminated glove and wash/sanitize her hands after touching patient #5 28 contaminated hemodialysis machine. During an interview on 10/14i2015, at 10:55 am, the Surveyor notified Registered Nurse AM that she had reset the panel on the patient's hemodialysis machine with her gloves, that she had contaminated everything at the nurses station by wearing her contaminated glove to the station and touched items at the nurses' station. Registered Nurse AM responded "yes" On 10/14/2015, at 11:05 am, Registered Nurse AM donned a pair of gloves and pulled the contaminated biohazard box from across the room to the bedside of Patient #28. She touched the inside of the opened lined carton with her Responsible Personis): Infection Control Manager, Director of Quality Management, Nursing Directors. i A 749 INFECTION CONTROL IPROGRAM .Hospital Administration, along with Infection IPrevention, Corporate Infection Control, and Quality to review the overall Infection control and prevention program and plan. The team reviewed the Infection Control Pian, Sanitation of Operating Room Suites and Equipment and Cieaning and Storage of Non-Criticai Reusabie Patient Equipment Poiicies and determined no revisions were needed. This group determined that additional proactive oversightisupervision of program implementation and adherence to lestablished policiesiprocedures was needed Ispeci?cally in the areas of roles/responsibilities of IIC staff, environmental rounding, and sanitation of :dietary and OR suites and equipment. {The corrective actions below pertain to hospital iwide initiatives and encompass speci?c ,departments mentioned in the statement of deficiency: dietary, CBH Intake, hemodialysis, and surgical services. 10/19/2015 The_plan for correcting the Specific deficiency cited: The Governing Board has approved the following as it relates to the Infection Control Program at SJMC: 2 additional FTEs to ensure that SJMC maintains a robust and proactive infection control program; 11i16/2015 FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 64 or 83