| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 670067 | (X3) Date Survey Completed 04/24/2013 |
| Name of Provider or Supplier Baylor Scott And White Orthopedic And Spine Hospi | Street Address, City, State 707 Highlander Blvd, Arlington, TX | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| A0000 | An unannounced validation survey was conducted on site. An entrance conference was held with the administrative representatives at 1300 on 04/22/13 to explain the purpose and process of the survey. The hospital representatives were informed that the survey would be conducted under the authority of Section 3240 of the State Operations Manual 42CFR482 - Hospital Conditions of Participation. Survey findings were presented at an exit conference on 04/24/13 with the facility representatives. They were informed the survey findings would be forwarded to CMS. |
| A0749 | INFECTION CONTROL OFFICER RESPONSIBILITIES CFR(s): 482.42(a)(1) 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 hospital did not ensure that the infection control policies were implemented and enforced. Infection control practices were not adhered to by: A) 2 of 3 physicians (anesthesiologist) in the postoperative unit; B) 2 of 3 circulators in the OR (operating room); and C) 1 of 1 employee who worked in the surgical department and was wearing disposable shoe covers in the cafeteria. Findings included: During a tour on 04/23/13 in the postoperative unit with the facility's CNO (Chief Nursing Officer/ Personnel #1) the following were observed: A) 1. At approximately 9:12 AM in the postoperative unit/bay #5 Physician #19 had a mask hanging around his neck which was previously worn in the OR. Physician #19 was conversing with a postoperative nurse (Personnel #24). The CNO was informed of the above findings. She confirmed the findings. 2) At approximately 9:54 AM Physician #20 was observed to come out from OR #1 with the OR circulator rolling the patient on the gurney towards the postoperative unit. Physician #20 was wearing a mask previously worn in the OR. He was observed talking to the postoperative nurse then proceeded to go to the nursing station and use a computer. Physician #20 still had his mask on while using the computer. The CNO was informed of the findings and she confirmed the findings. B) 1. At approximately 9:51 AM in OR #4 Personnel #23 (the OR circulator) took off her soiled gloves and stepped out of the OR. She came back with a small sterile package and opened the sterile package for the scrub technician. Personnel #23 did not wash her hands or apply alcohol rub after taking off her gloves. The CNO was informed of the above findings and confirmed the findings. 2) At approximately 10:00 AM in OR #6 Personnel #25 (the OR circulator) was assisting the physician in repositioning the "Hanna table." Personnel #25 laid the "Hanna table" on the floor. She proceeded to open a sterile package for the scrub technician. She did not wash her hands or apply alcohol rub after repositioning the "Hanna table" on the floor. C) At 11:19 AM in the cafeteria Personnel #25 was observed wearing blue scrubs (top and bottom) and disposable blue shoe covers. Personnel #25 was asked for his name and the department he worked. The CNO was informed of the above findings. After verification of policy and AORN guidelines (Association of Perioperative Nurses) which the facility had adopted, the CNO confirmed the findings. The Provisions of Care policy and procedure #35: "surgical Attire" reviewed 2/2013 required "4...Shoe covers should be removed before leaving the OR suite...6...Masks are to be removed before leaving the OR suite. Masks are not to be saved by hanging around the neck..." The Infection Control policy and procedure #11: "Hand Hygiene" required "Procedure: A. Indications for use...4. Before and after using gloves...9. After touching contaminated surfaces..." |
| K0000 | This STANDARD is not met as evidenced by: A life safety code (LSC) survey was conducted on site on 04/24/2013. An entrance conference was held for the hospital ' s administrator and plant engineer on the morning of 04/24/2013 to discuss the purpose of the LSC survey and the survey process were explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital ' s compliance. An LSC exit conference was conducted on 04/24/2013 in the hospital. In attendance were the hospital ' s administrator and plant engineer. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. 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. |
| K0106 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Hospitals, and nursing homes and hospices with life support equipment, have a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. This STANDARD is not met as evidenced by: Facility failed to maintain essential electrical system in accordance with the Standard for Health Care, NFPA (National Fire Protection Association) 99. Findings included the following: Surveyor observed between 11 and 11:30 am on 4/24/13 that electrical room containing switch gear did not have task battery lighting in accordance with NFPA 99: 3-4.2.2.2. |