Texas Childrens Hospital North Austin Campus

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 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: 33326 Based on observation, interview, and record review, the facility failed to meet the conditions of participation for Dietary Services when; - The facility’s two commercial food steamers had copious amounts of rust on the interior rails, fan, and floor of the steamers, when in use the high- pressure steam can disperse the rust onto the food product. - The facility’s two large convection ovens had burnt food debris and food residue in both ovens. The oven’s interior rails and doors had burned on food debris, which could chip and be dispersed by the oven’s fans onto other foods. - The facility’s bulk food storage bins and clean storage shelf covers had dried food on their surfaces. - The facility’s labeling system, used to determine when items were received, opened, and expired was not being implemented. - The facility’s food slicer had dried food debris on the slicers blade and on the food holding arm. - Floor cleaning chemicals were being stored next to clean food preparation gloves and the dirty dishware were being stored next to clean cooking supplies. Cross refers to: A0619”

“SURGICAL SERVICES CFR(s): 482.51 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 with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 33326 Based on observation, interview, and record review, the facility failed to meet the conditions of participation for Surgical Services when, a.) The facility’s operating room #1 was being maintained at a temperature above the AORN (Association of perioperative Nurses) recommended, 75-degree Fahrenheit; sterile supplies and heat sensitive equipment were being stored in the room. b.) The facility’s surgical staff were not using appropriate hand hygiene, creating an unsanitary environment. c.) The facility was storing opened unprotected sterile supplies, leaving them available for future use. Cross refers to: A0941 Surgical Services”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 33326 Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment for the safe production, and storage of food provided to the hospital’s pediatric, adolescent, and adult patient population, placing all patients at risk of food borne illnesses due to cross contaminated and expired foods. Findings include: Observations made during a tour of the facility’s kitchen on the morning of 6/9/2025 revealed the following: - The facility’s two commercial food steamers had copious amounts of rust on the interior rails, fan, and floor of the steamers, when in use the high- pressure steam can disperse the rust onto the food product. The steamers were still currently being used. - The facility’s two large convection ovens had burnt food debris and food residue in both ovens. The oven’s interior rails and doors had burned on food debris, which could chip and be dispersed by the oven’s fans onto other foods; the ovens were currently in use. - The facility’s bulk food storage bins and clean storage shelf covers had dried food on their surfaces. - The facility’s labeling system, used to determine when items were received, opened, and expired was not being implemented; multiple opened food items that were not dated as to when they were opened or when they would expire. - The facility’s food mixer had food debris to the upper mixing mechanism. - Two food cooking steam cauldron’s had food debris encrusted around the equipments pivoting bolts. - The facility’s food slicer had dried food debris on the slicers blade and on the food holding arm; there was no sign to indicate the slicer required cleaning and the slicer was available for use. - Floor cleaning chemicals were being stored on a shelf next to clean food preparation gloves and dirty dishware were being stored next to clean cooking supplies. During an interview, on the morning of 6/9/2025 in the facility’s kitchen during the tour, Staff #13, Food Services Director was present to confirm the findings. Staff #13 stated in part, the facility had work orders in for the steamers and stated their accrediting organization had mentioned the labels too. Review of the facility provided policy, “Sanitation and Infection Prevention/control” “Cleaning of Food and Nonfood Contact surfaces” (revised 1/25) reflected, “To prevent cross-contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following interruption of operations during which time contamination may have occurred...food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil...Nonfood Contact surfaces of utensils and equipment must be made of materials that are safe, corrosion resistant...and maintained in good condition...nonfood contact surfaces of equipment...shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris.”

“ORGANIZATION OF SURGICAL SERVICES CFR(s): 482.51(a) The organization of the surgical services must be appropriate to the scope of the services offered. This Standard is not met as evidenced by: 33326 Based on observation, interview, and record review, the facility failed to provide surgical services in a safe environment when, a.) The facility’s trauma operating room was being maintained above 75 degrees Fahrenheit placing patient at risk of injury and infections from degraded medical supplies and the medical equipment in the room overheating and malfunctioning from the continued elevated temperatures. b.) The facility’s surgical staff were not using appropriate hand hygiene practices, placing patients at risk of cross contamination and infections. c.) Opened sterile supplies were not being protected from contamination and were left available for use in operating room #2. Findings include: a.) Review of “Guidelines for Perioperative Standards and Recommended Practices.” Association of perioperative Registered Nurses-2019 Perioperative Standards and Recommended Practices, e-AORN, Table 3 reflected, “Temperature should be maintained between 68 degrees F to 75 degrees Fahrenheit (20 degrees to 24 Celsius) within the operating room suite.” An observation, on the morning of 6/10/25, in the facility’s operating room #1 revealed and temperature monitor on the rooms inner wall, the temperature was 80.1 degrees Fahrenheit. During an interview, on the morning of 6/10/25, in the facility’s operating room #1, when asked why the room was so warm, Staff #14 stated, “This is the Pediatric trauma room, we keep it at 80 for emergency cases.” Review of the facility provided Operating Room #1’s temperature logs reflected, from 5/09/25 to 6/10/25, the operating room registered being over 75 degrees Fahrenheit for (12) days, and registered being over 80 degrees Fahrenheit for (17) days. Review of the facility provided policy, “Operating Room Temperature and Humidity Maintenance - Procedure” (undated) reflected the following, “1.2 The recommended temperature range for all ORs is 68-73 degrees Fahrenheit. 1.2.1 ORs may go outside of this design temperature set point based on the needs of the patient and/or occupant’s comfort. 1.2.2 The ORs should be returned to the design set point of 68-73 degrees Fahrenheit as soon as possible or immediately upon room turnover. 1.3 The minimum allowable temperature is 62 degrees Fahrenheit and maximum allowable is 80 degrees Fahrenheit as programmed by facilities.” During an interview on the afternoon of 6/10/25, in the facility conference room, Staff #14 stated in part the facility’s medical staffs had decided the temperature of the room should be at 80 degrees Fahrenheit for Pediatric/Neonatal trauma patients. Staff #12 was not sure if the facility had researched the appropriate equipment and sterile supplies manufacturer’s recommended temperatures for proper storage temperatures. b.) Review of the facility provided policy, “Hand Hygiene Procedure #1959” (undated) reflected, “The following procedure should be utilized in order to comply with Texas Children’s Policy on Hand Hygiene Guidelines. “1. Based on the World Health Organization (WHO) guidelines on hand hygiene in health care, hand hygiene should be performed: ...1.3. Before and after touching a patient regardless of whether or not gloves are used. 1.4. Before clean/aseptic (indwelling urinary catheters, peripheral vascular catheters, or other invasive devices) regardless of whether or not gloves are used ... 1.9. Before and after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. 1.10. Before donning gloves and after removing gloves. 1.11. Before handling medication or preparing food.” Observation made on 06/10/25 in the facility’s Operating room #2 revealed the following: 11:40 AM - Staff #10 doffed gloves, did not perform hand hygiene (HH), touched equipment at head of bed. 11:42 AM - Staff #10 donned new gloves - no HH performed; taped patient mask, touched equipment, touched patient again. 11:43 AM - Staff #8 moved waste bin, doffed gloves, did not perform hand hygiene (HH), touched computer. 11:53 AM - Staff #10 touched computer without gloves, moved chair, walked to corner of room, obtained supplies from cabinet, returned to patient stretcher, touched patient monitor, doffed gloves, no HH performed. 11:56 AM - Staff #10 obtained new gloves and placed them on his computer. 11:58 AM - Staff #10 donned new gloves from computer (no HH performed), touched patient monitor, touched chair, touched patient drape, touched computer, touched scrub pants. 12:00 PM - Staff #10 (same gloves) touched patient bag valve mask (BVM), touched computer, touched patient monitor, touched computer, sat in chair. 12:01 PM - Staff #8 removed gloves, did not perform HH, touched equipment, touched cabinet doors near operating room (OR) door, touched computer. 12:07 PM - Staff #10 (same gloves) touched monitors, touched armrests of chair. 12:09 PM - Staff #10 (same gloves) touched computer. 12:34 PM - Staff #10 doffed and donned new gloves. No HH performed. Touched patient monitor, touched computer, moved across room to supply cabinet, removed supplies, returned to patient bedside, touched computer, returned to chair. 12:40 to 12:50 PM - Staff #10 (same gloves) removed Bair Hugger tubing from blanket covering patient, touched stretcher and equipment, touched patient monitor, obtained medications from cart next to patient stretcher, administered medications, picked something off of floor, administered medication to patient, touched computer, touched patient monitor, touched patient ventilator/oxygen mask, touched patient, held ventilator/oxygen mask to patient face for several minutes while discontinuing patient sedation, placed mask on table, returned to supply cabinet and obtained supplies, returned to computer, touched computer, touched intravenous (IV) solutions hanging from IV pole, touched computer, at head of stretcher while staff #15 removed patient airway and applied oxygen mask, touched computer, touched patient, touched patient monitor, touched airway tubing, touched patient monitor, touched supplies. 12:55 PM - Patient wheeled out of OR by Staff #8 and #10 with same gloves worn while completing tasks at end of procedure. Staff #8 and #10 did not perform HH or don new gloves prior to exiting surgical suite. During an interview on the afternoon of 06/10/2025 with staff #19, #20, and #21, staff stated they (the facility) had “self-identified” issues with clinical staff not following proper hand hygiene policies and procedures. Staff #19, #20, and #21 verified that staff should be performing hand hygiene per their current policy. These same staff denied that their policies and/or procedures prohibited staff from wearing gloves in the halls. However, staff #19, #20, and #21 verified that staff should doff their gloves, perform hand hygiene, and don new gloves before exiting the surgical suite when taking a patient to the Post-Operative Care Unit (PACU). c.) Observations made on the morning of 6/10/25 in the facility’s Operating Room #2 back counter, revealed the following: (7) unused 10 cc syringes attached to intravenous pig tails (used to access and administer fluids and medications into an IV (intravenous) site; both the syringes and pigtails had previously been in separate sterile packaging. (4) unused 3 ml syringes attached to capped needles, both the syringes and the needles had been in sterile packaging. (8) unused 1 ml syringes attached to capped needles, both the syringes and the needles had been in sterile packaging. The supplies were not covered, to prevent contamination, were not on a sterile field, and had been in the room prior to the beginning of the current surgical case and were not used in the current surgical case. During an interview, on the morning of 6/10/25, in the facility’s operating room #2, when shown the opened supplies and asked if that was an acceptable facility practice, Staff #12, Infection Prevention Coordinator confirmed the finding and stated in part, “The supplies should be left in the sterile packaging.” Staff #12 removed the opened supplies.”