The Texas Department of State Health Services cited Hickory Trail Hospital for multiple issues following an unannounced re-certification survey of the facility. The facility’s governing body was issued citations for failing to ensure that its contracted dietary services were provided in a safe and sanitary environment. The Department found many sanitation and cleanliness issues, including the storage of dietary and food items along with syringes, enemas, and wound supplies. The Department found that “this practice placed patients at risk for developing and/or acquiring infections while residing in the hospital.” The facility also violated general care and treatment requirements (mandated by the state) by not ensuring that one of its medical doctors had the demonstrated competencies. The doctor was authorized to perform evaluations of restrained and/or secluded patients, but records show that he did not have the appropriate training or the demonstrated competencies to properly assess these patients. Specifically, his training records revealed no competency for identifying facility-approved restraints, identifying the behavioral criteria for the discontinuation of restraint/seclusion, or recognizing how different factors (age, weight, gender, ethnicity, level of development or functioning, and history of sexual or physical abuse, etc.) may affect the way in which an individual reacts to physical contact. An interview with a facility staff member revealed that if the physician competency documentation was not included in the training record files, “then it was not done.” The Department also cited the facility because it “failed to provide adequate nursing staff to ensure the safety of the facility’s patients and staff.” The Department determined that the facility failed to meet staffing ratios during 46 shifts from 2/22/12 – 3/5/12. Minutes from the Nursing Staffing committee meeting in July 2011 also reflected inadequate staffing concerns; it states in part, that a staff member “had concerns about the lack of flexibility of the grid to provide adequate staffing when acuity changes from unit to unit.” Nursing Staffing Committee Meeting minutes from January 2012 also revealed that staffing concerns remained an issue. It states in part, “We currently do not have an acuity tool…At times the acuity on the units make it necessary to increase tech support. Supervisors consider reviewing the acuity of the patient on each unit from shift to shift and make appropriate adjustments. Current issues have been on Adult 1 where 1 nurse and 1 tech are not safely able to meet the needs of patients…” As a result, the facility was required to submit a plan of correction to address its cited deficiencies.