HospitalInspections.org

Based on observations, document reviews and interviews with facility staff, the governing body failed to be responsible for ensuring that hospital policies and procedures were implemented and followed by hospital staff resulting in the following deficient practices:

1. Patient's Rights to privacy were violated according to hospital policy & procedure titled
"Release of Patient Information/Access to Medical Records" because electronic patient information boards displayed clinical information; Cross refer to A0115.

2. A dialysis patient was restrained without a physician's order in violation of hospital policy and procedure titled "Medical/Surgical Restraints"; Cross refer to A0115.

3. Behavioral health clinical records lacked completed consent forms for psychoactive medications in violation of hospital policy and procedure "Patient Consent for Psychoactive Medications". Cross refer to A0115.

4. The hospital failed to implement a hospital-wide quality assessment and performance improvement program in violation of hospital policy and procedure titled "Quality Review Committee"; Cross refer to A0263.

5. Medical records were not completed or not completed in a timely manner.

(a) Behavioral health clinical records lacked completed consent forms for psychoactive medications, surgical consent forms were signed by someone other than the patient, and suicide prevention monitoring was not documented appropriately for one patient in violation of hospital policies and procedures, "Patient
Consent for Psychoactive Medications", "Policy #RA 07 titled "Informed Consent", and "Suicide Precautions"; Cross refer to A0466.

(b) Hospital failed to enforce policy and procedure" Medical Staff Bylaws - Covenant
Medical Center/Covenant Lakeside" and ensure medical records were completed 30 days after discharge. Cross refer to A0469

6. The hospital failed to ensure medication was kept in a secure location and locked when necessary in various areas throughout the facility in violation of hospital policy and procedure # RX 4.77 entitled "Drug Storage"; Cross refer to A502.

7. The hospital failed to maintain the physical environment to ensure the safety and well-being of patients and staff in violation of hospital policy and procedure, "Management of the Environment of Care ...Policy #EC.8.0"; Cross refer to A0701.

8. The hospital failed to maintain facilities, supplies, and equipment to ensure an acceptable polices and procedures "Stored Gas Policy #EC.3.7", "Code Blue " #PC 08", "Stocking and Cleaning Emergency Department" #270.0" Cross refer to A0724.

9. The hospital failed to ensure that dietary staff were competent in their duties, which included following the hospitals policies and procedures for cleaning the kitchen to ensure a sanitary environment for the preparation, service and storage of food in violation of hospital policies and procedures "Infection Control - Food Service", "Sanitation" ; and "Cleaning Schedule for Dry Storage and Cold Vaults" ; Cross refer to A0622.

10. The hospital failed to enforce hospital policies and procedures "Prevention Guidelines for
Transmission of Blood Borne Pathogens" ; "Glutaraldehyde, Use and Monitoring"; "Environmental Service Policy and Procedure Manual" ; "General Cleaning of Operating Rooms" ; "Infection Control - Food Service" ; and "Cleaning Schedule for Dry Storage and Cold Vaults" thus failing to ensure a sanitary environment. Cross refer to A0747

Based on a review of available documentation, observations in the facility, and staff interviews, the facility failed to ensure that each patient's rights were protected and promoted.

Findings were:

The facility did not ensure that patients were cared for in a safe environment, patients were denied the right to privacy, the right to confidentiality of medical information, the right to make informed decisions regarding his or her care, and failed to ensure that patient restraints were properly ordered by a physician.

1. Based on a review of documentation, patients were denied the right to make informed decisions regarding his or her care. Cross refer to: A0131

2. Based on a review of hospital policy and medical record review, the hospital failed to follow policy to ensure the safety of patients. Cross refer to: A0142

3. Based on observation and an interview with staff, the hospital failed to follow policy to ensure the right of the patient to personal privacy was observed. Cross refer to: A0143.

4. Based on observation and document review, the hospital failed to guarantee the right of the patient to the confidentiality of his or her clinical record. Cross refer to A0147.

5. Based on observation, a tour of the facility, and review of documentation the facility failed to correctly identify a restraint as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Cross refer to A0159.

6 Based on observation, a tour of the facility, and review of documentation, the facility failed to utilize restraint in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient according to hospital policy. Cross refer to A0168

Based on a review of documentation, patients were denied the right to make informed decisions regarding his or her care.

Findings were:

1. Review of the hospital "Policy #RA 07 titled, "Informed Consent", revealed the following:
"Adults. Incapacitated means lacking the ability based on reasonable medical judgment to understand and appreciate the nature and consequences of the treatment decision, including the significant benefits and risks and any reasonable alternative. It is ultimately the physician's responsibility to decide capacity for the purposes of consent. For adult patients who are comatose, incapacitated or incapable of communication, and no Medical Power of Attorney exist, the following persona in order of priority are deemed surrogate decision-makers ...i. the patient's spouse ...An explanation of the person ' s relationship to the patient should be written on the consent form when someone other than the patient has signed the form. Enter this information on the line provided in the signature section of the permit."

During a review of six surgical charts (patients #1 through #6), two of six clinical records (patient # 1 & patient #2) contained surgical consent forms signed by someone other than the patient.

? The clinical record of patient #1 revealed three surgical consent forms signed by the patient's wife. The clinical record contained no documentation that the patient was incapacitated in any way. There was no documentation in the record reflecting a physician ' s determination of capacity, nor was there any documentation on the consent form providing an explanation of the surrogate decision-maker ' s relationship to the patient, per facility policy.

? The clinical record of patient #2 revealed two surgical consent forms signed by the patient's husband (in addition to three surgical consent forms signed by the patient). The clinical record contained no documentation that the patient was incapacitated in any way. There was no documentation in the record reflecting a physician ' s determination of capacity, nor was there any documentation on the consent form providing an explanation of the surrogate decision-maker ' s relationship to the patient, per facility policy.

2. Review of hospital policy, " Patient Consent for Psychoactive Medications " stated " Statement of Purpose: To protect patient ' s right to consent to treatment with psychoactive medications ... a psychoactive medication is a medication prescribed for the treatment of symptoms of psychosis or other severe mental or emotional disorder and is used to exercise an effect on the central nervous system to influence and modify behavior, cognition or affective state when treating symptoms of mental illness ...

Informed consent is the responsibility of the treating psychiatrist ...Informed consent for the administration of psychoactive medication will be evidenced by a completed copy of the " Consent For Treatment With Psychoactive Medication form that: Is signed by the patient or their legal representative ...

Patient's refusal to receive or withdrawal of consent for treatment with psychoactive medications will require that the patient again sign a consent form in order to be treated with the refused psychoactive medication."

During a review of eleven behavioral health clinical records (patients #7 through #17), six records (# 9, #12, #13, #14, #15, and #16) lacked completed consent forms for psychoactive medications, including one patient administered medication after documenting that he/she declined consent to receive the medication.

? The clinical record for patient #9 lacked signed consent forms for Trazodone and Melatonin (also used as a sedative-hypnotic). Documentation reveals that both drugs were administered to the patient.

? The clinical record for patient #12 lacked signed consent forms for Trazodone.
Documentation reveals that the drug was administered to the patient.

? The clinical record for patient #13 lacked signed consent for Vistaril, and the word " refuse" is documented on the consent for Klonopin. Documentation reveals that both drugs were administered to the patient.

? The clinical record for patient #14 lacked signed consent for Vistaril. Documentation reveals that the drug was administered to the patient.

? The clinical record for patient #15 lacked signed consent for Trazodone. Documentation reveals that the drug was administered to the patient.

? The clinical record for patient #16 lacked signed consent for Effexor. Documentation reveals that the drug was administered to the patient.

Based on a review of documents, the hospital did not ensure the safety of patients.

Findings were:

During a review of eleven behavioral health clinical records (patients #7 through #17), one of eleven records (patient #10) lacked documentation that the patient was properly monitored while on suicide precautions.

? The hospital ' s "Suicide Precautions" policy states, in part, "I.: F. " Nursing staff checks the patient randomly no less than 15 minutes apart keeping in mind that a patient can commit suicide in less than 5 minutes. The times and staff member monitoring the patient will be documented on the precautions flow sheet."

? The clinical record of patient #10 revealed that the patient was placed on suicide precautions by the physician (necessitating checks every 15 minutes by a staff member) on 1-20-12 and that the suicide precautions were discontinued on 1-31-12. Although the patient was properly monitored every 15 minutes from 1-20-12 through 1-23-12, he was only monitored on an hourly basis from 1-24-12 through 1-31-12.

Based on observation and an interview with staff, the right of the patient to personal privacy was not observed.

Findings were:

Review of facility policy, "Release of Patient Information/Access to Medical Records" stated, "Information Boards are in use in some patient care areas. Covenant Health System - Lubbock will ensure that patient information will be protected from disclosure in utilizing these boards.
1. Patient diagnoses or any clinical information will not be associated with patient name.
2. Patient names will not appear on "No Information" Patients."

During a tour on 2/7/12 and 2/8/12, patient information boards were displayed in the nurses station which were visible to staff, patients, and their visitors. Patient's first and last names, age, and medical information were displayed on the boards, including medications patients were taking (which constitutes "medical information"), insurance information, and other confidential information were displayed. This was confirmed in interview with the Chief Nursing Officer on 2/8/12.

Based on observation, the hospital failed to guarantee the right of the patient to the confidentiality of his or her clinical record.

Findings were:

Review of facility policy, "Release of Patient Information/Access to Medical Records" stated, "Information Boards are in use in some patient care areas. Covenant Health System - Lubbock will ensure that patient information will be protected from disclosure in utilizing these boards.
1. Patient diagnoses or any clinical information will not be associated with patient name.
2. Patient names will not appear on "No Information" Patients."

During a tour of the facility on 2-7-12 and 2-8-12, 12 out of 15 nursing units had electronic patient information boards at the nurses ' station that were visible to the public. These electronic patient information boards included the following patient information: full patient name, age, isolation precautions (constitutes medical information), comments, and attending physician.

Based on observation, a tour of the facility, and review of documentation the facility failed to correctly identify a restraint as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

Findings were:

Facility policy & procedure titled " Medical/Surgical Restraints " stated, in part,
" 1. The definition of restraint is as follows:
? A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. "

During a tour of the dialysis unit on 2-7-12 at 0900, Patient # 45 was observed with a soft restraint immobilizing his left wrist. In an interview, the staff nurse stated the patient ' s wrist was restrained, " because he ' s confused and tries to pull on his site. " During observation, Patient #45 appeared calm and cooperative, making no attempt to disrupt his dialysis access site. No physician order was present for this medical restraint in the patient ' s medical chart on 2-7-12. On 2-8-12, the medical chart for Patient # 45 was again reviewed and no physician order was present for the medical restraint.

In an interview with the chief nursing officer, Staff Member # 133 on 2-8-12, she stated that restraint of a patient ' s extremity during dialysis was considered using a " medical immobilization device " and was not a " medical restraint requiring physician order. "

This inappropriate use of restraint confirmed in an interview with chief nursing officer on 2-8-12.

Based on observation, a tour of the facility,and review of documentation, the facility failed to utilize restraint in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient according to hospital policy.

Findings were:

Review of the hospital policy & procedure titled "Medical/Surgical Restraints" revealed the following procedure to be followed whenever the use of patient restraints was required for acute medical or surgical patients:

"10. Restraint of an acute medical or surgical patient is used only with an LIP patient-specific order authorizing the use of restraints. The LIP may delegate this task to his/her physician assistant or nurse practitioner."

"11. If a licensed independent practitioner is not available to issue such an order, a registered nurse based on appropriate assessment initiates restraint use of the patient.
a. In this case, the attending LIP is notified as soon as possible, not to exceed 12 hours, of the initiation of restraint and a verbal, telephone, or written order if obtained and entered into the patient's medical record"

"c. A written order based on an examination of the patient by a LIP or his designee, is entered into the patient's medical record within 24 hours of the initiation."

? During a tour of the dialysis unit on 2-7-12 at 0900, Patient # 45 was observed with a soft restraint immobilizing his left wrist.

? In an interview, the staff nurse stated the patient's wrist was restrained, "because he's confused and tries to pull on his site."

? During observation, Patient #45 appeared calm and cooperative, making no attempt to disrupt his dialysis access site.

? Based on review of Patient # 45's medical chart on 2-7-12, there was no physician order for this medical restraint documented in the patient's medical chart.

? On 2-8-12, the medical chart for Patient #45 was again reviewed and no physician order was documented for the medical restraint applied to patient on 2-7-2012.

During an interview with the chief nursing officer (CNO), Staff Member #133, on 2-8-12, the CNO stated that restraint of a patient's extremity during dialysis was considered using a medical immobilization device," and was not a "medical restraint requiring physician order."

This use of restraint without an order from a physician or other licensed independent practitioner was confirmed in an interview with the CNO on 2-8-12.

Based on a review of available documentation and interviews, the facility failed to develop, implement and maintain an effective, on-going, hospital-wide, data-driven quality assessment and performance improvement program that involved all hospital departments and services.

Findings were:

Review of the hospital policy & procedure titled "Quality Review Committee" revealed the following procedures for implementing a hospital wide quality assessment and performance improvement program :

"The Quality Review Committee will integrate medical Staff/Cross-Functional Quality Activities as follows: ...Coordinate and prioritize Quality Improvement efforts between all Medical Staff, Departments, Sections, and combined Hospital/Medical Staff committees to minimize duplication efforts; ... Annually evaluate quality utilization, and risk management programs for effectiveness, and revise as appropriate; ...

Meeting: The Quality Review Committee will meet monthly."

Documentation of Quality Review Committee Meetings provided by the facility was a copy of minutes for a meeting held on 12-6-11 this included a " Quality Annual Report ". There was no other documentation of Quality Review Committee Meetings or Quality Assessment Performance Improvement (QAPI) provided for review by the hospital.

Based on review of the minutes of the meeting held on 12-6-11, 8 hospital departments involved in the meeting that provided Function Reports included:
1. Blood Usage/lab Functioning,
2. Cardiac,
3. Environmental Safety,
4. Infection Control,
5. Perfect Care,
6. Risk Management,
7. Medical Records, &
8. JACC.

Based on review of the minutes of the meeting held on 12-6-11, the following 21 hospital departments did not participate:
1. Pharmacy,
2. OR & Endoscopy,
3. Case Management,
4. Radiation Safety,
5. Cath Lab/EP Lab,
6. Standards/Regulatory,
7. Interventional Radiology,
8. Respiratory,
9. Behavioral Health,
10. Women 's Services,
11. Adult ED,
12. ICU & Code Blue,
13. Trauma, Rehab,
14. Counseling Clinic,
15. Dialysis, Home Infusion Center & OP Infusion,
16. JACC Breast Center and Mobile Unit,
17. Neuro Institute, Sleep Lab,
18. Southwest medical Center,
19. Community Health Education,
20. Covenant Transplant Clinic, &
21. Gamma Knife.

Review of the hosiptal policy & procedure titled " Patient Safety Program Plan" revealed the following procedures:
"Q. continual evaluation of the Patient Safety Program is a function of the Committee for Clinical Excellence (CCE) through review of clinical quality, patient safety, and outcome data. Recommendations for modifications to performance improvement action plans are provided by the CCE on an ongoing basis as needed.

The Committee for Clinical Excellence (CCE)
1. Membership ...
o. Vice Presidents and Directors from the following areas:
i. Nursing
ii. Pharmacy
iii. Lab
iv. Radiology
v. Rehab/Therapy
vi. Patient Safety/Risk Management
vii. Quality Management
vii. Patient Experience
ix. Joint Commission/Regulatory
x. Dietary
xi. Transportation
xii. Environmental Services
xiii. Medical Records
xiv. Case Management
xv. Performance Improvement
xvi. Infection Prevention
xvii. Emergency Department
xviii. Surgical Services/OR/PACU
xix. Behavioral Health
xx. Cardiovascular Service Line
xxi. Women ' s Services
xxii. Ambulatory Services
xxiii. Other discipline representatives as appropriate
xxiv. Covenant Specialty Hospital. "

R. Evaluation of the overall effectiveness of the Patient Safety Program will be facilitated through the development of the annual report by Quality Management and /or Patient Safety/Risk Management for the review of the Board of Directors. The report will also be reviewed by the Quality and Patient Safety Committee of the Board, HS, and CCH Executive Committee, and Quality Review Committees, and other groups of individuals as determined appropriate by the CCE."

In an interview with Staff Member # 117 on 2-7-12, the staff member stated that the following departments do not participate in the quality assessment/performance improvement program:
1. Dialysis, Wound Care,
2. Home Infusion,
3. Gamma Knife,
4. Dental Clinic,
5. Community Clinic,
6. Diabetes Education Center,
7. Sleep Lab,
8. South West Occupational Therapy and Physical Therapy Clinic.

The lack of participation in the hospital-wide QAPI program by all departments of the hospital was again confirmed in an interview with Staff Members #117 and 118 on 2-8-12.

Based on a review of documentation, the facility failed to follow their own policies and failed to ensure that patients were allowed to exercise the right to make informed decisions regarding his or her care, including documentation of informed consent for medical treatment, and documentation of informed consent for psychoactive medications.

Findings were:

During a review of six surgical charts (patients #1 through #6), two of six clinical records (patient #1 and patient #2) contained surgical consent forms signed by someone other than the patient. Neither of the two clinical records designated anyone other than the patient as the legally authorized representative.

Review of facility policy "Informed Consent" stated "B. Who May Consent: the following persons are legally authorized to consent:

1. Adults-
a. An adult is any person 18 years or older or any person male or female who is or has been legally married and has not been legally declared incompetent or insane with a guardian appointed."

"c. Incapacitated means lacking the ability based on reasonable medical judgment to understand and appreciate the nature and consequences of the treatment decision, including the significant benefits and risks and any reasonable alternative.

It is ultimately the physician's responsibility to decide capacity for the purposes of consent...An explanation of the person's relationship to the patient should be written on the consent form when someone other than the patient has signed the form. Enter this information on the line provided in the signature section of the permit."

The clinical record of patient #1 revealed three surgical consent forms signed by the patient's wife. The clinical record contained no documentation that the patient was incapacitated in any way. There was no documented evidence on the consent form of a reason another person signed the consent form or an explanation of the person's relationship to the patient.

The clinical record of patient #2 revealed two surgical consent forms signed by the patient ' s husband (in addition to three surgical consent forms signed by the patient). The clinical record contained no documentation that the patient was incapacitated in any way. There was no documented evidence on the consent form of a reason another person signed the consent form or an explanation of the person's relationship to the patient.


Based on a review of documentation, the facility did not follow their own policy nor ensure patient ' s right to give or withhold informed consent to treatment with psychoactive medication.

Findings were:

Facility policy, " Psychoactive Medications, Consent Form " stated that, " Statement of Purpose: To protect patient ' s right to consent to treatment with psychoactive medications ...Informed consent is the responsibility of the treating psychiatrist ...Informed consent for the administration of psychoactive medication will be evidenced by a completed copy of the " Consent For Treatment With Psychoactive Medication " form that: 1. Is signed by the patient of [sic] their representative. "

During a review of eleven behavioral health clinical records (patients #7 through #17), six of eleven (patient #9, patient #12, patient #13, patient #14, patient #15, and patient #16) records lacked completed consent forms for psychoactive medications, including one patient administered medication after documenting that he/she declined consent to receive the medication.

? The clinical record for patient #9 lacked signed consent forms for Trazodone and Melatonin (also used as a sedative-hypnotic). Documentation reveals that both drugs were administered to the patient.
? The clinical record for patient #12 lacked signed consent forms for Trazodone. Documentation reveals that the drug was administered to the patient.
? The clinical record for patient #13 lacked signed consent for Vistaril, and the word " refuse" is documented on the consent for Klonopin. Documentation reveals that both drugs were administered to the patient.
? The clinical record for patient #14 lacked signed consent for Vistaril. Documentation reveals that the drug was administered to the patient.
? The clinical record for patient #15 lacked signed consent for Trazodone. Documentation reveals that the drug was administered to the patient.
? The clinical record for patient #16 lacked signed consent for Effexor. Documentation reveals that the drug was administered to the patient.

Based on review of available documentation and staff interviews, the facility failed to ensure that medical records were completed within 30 days of patient discharge.

Findings were:

Review of the "Medical Staff Bylaws - Covenant Medical Center/Covenant Lakeside" revealed the following requirement:

"Any chart will be delinquent when ...Any portion of the chart is incomplete fifteen (15) days after the date of discharge ...If a physician does not complete all delinquent medical records within sixty (60) days of continuous suspension, his Medical Staff membership and clinical privileges will be terminated ..."

The Director of Health Information Management provided documentation of 1190 incomplete/delinquent patient charts over 30 days post discharge during an interview on 2/8/12 in the nursing conference room. Average monthly discharges for the last 12 months were 836.

Based on observation, review of documentation, and interview with staff, it was determined the facility failed to ensure medications were kept secure and locked in accordance with hospital policy.

Findings were:

During a tour of the Main Campus on 2/6/12, the following was observed:
? Operating Room #220 - An anesthesia cart containing medications was found unlocked, unattended and out of direct visual observation of staff. For example: Atropine, Benadryl, Epinephrine, Narcan, and Phenergan were some examples of the medications found in the cart.
? Operating Room #220 - A physician medication case was found on floor unlocked, with medications, unattended and out of direct visual observation of staff. For example: Atropine, Benadryl, Epinephrine, Narcan, and Phenergan were some examples of the medications found in the case.
? Post Anesthesia Care Unit #24 - A vial of Zofran was found in an unlocked drawer, which was unattended and out of direct visual observation of staff.

During a tour of the Endoscopy Department - Main Campus on 2/8/12, the following was observed:
? Exam room 7 - An anesthesia cart containing medications was found unlocked, unattended and out of direct visual observation of staff. For example: Atropine, Benadryl, Epinephrine, Narcan, and Phenergan were some examples of the medications found in the cart.
? Exam room 8 - An anesthesia cart containing medications was found in the locked position, however the cart easily opened as if it were unlocked. This cart was unattended and out of direct visual observation of staff. For example: Atropine, Benadryl, Epinephrine, Narcan, and Phenergan were some examples of the medications found in the cart.

Facility policy # RX 4.77 entitled "Drug Storage" stated on page 1, "Scope & Applicability ...This is an organization-wide policy. As such, it applies to all services and settings in which medication is used." The policy further stated on pages 2 and 3, "Medication storage areas will be secured (locked) when unattended by - or not under the direct visual observation of - authorized staff."

The Chief Medical Officer and Director of Nursing confirmed the above findings during the tours.

Based on observation throughout both kitchens during tours with hospital staff, the facility failed to ensure that staff maintained a sanitary environment for patient food preparation and storage in accordance with assigned duties and facility policies

Findings were:

Facility policy entitled "Cleaning Schedule for Dry Storage and Cold Vaults" stated,
"Proper sanitation procedure must be followed to keep clean and sanitary food and non food items from becoming contaminated before use.
? Dry storage area must be swept and scrubbed regularly.
? Walls, ceiling, floor shelves, light fixtures and racks require cleaning on a daily basis ...
? Walls, ceiling, floor, shelves, light fixtures and racks all must be cleaned to ensure proper storage procedures. "

Facility policy entitled "Infection Control - Food Service "stated, "It is the policy of the Food and Nutrition Department at Covenant Health System to contribute to the health maintenance of patients and employees alike, by preventing infection and disease transmission.

Food Products and Storage:
...Food must be stored sufficiently above floor level and away from walls in accordance with local health and safety standards. This facilitates cleaning of floors and corners, and protects against contamination by the cleaning process itself and accidental flooding from any source.

Housekeeping:
? Ranges and grills should be cleaned daily
? All work surfaces, utensils, and equipment should be cleaned and sanitized after each use. All counters should be cleaned daily and as needed.
? All floor surfaces must be wet-mopped daily and as needed
? Storage facilities for raw and cooked food must be cleaned and sanitized on a fixed schedule. "

Controls on the System: Periodic prevalence walks should be conducted by the nurse epidemiologist and the food Service director."

Facility policy entitled "Infection Control - Food Service" stated in part "It is the policy of the Food and Nutrition Department at Covenant Health System to contribute to the health maintenance of patients and employees alike, by preventing infection and disease
transmission...

Facility policy entitled "Sanitation" stated in part "The food service department maintains a sanitation program which meets all applicable health regulations.
? All equipment and furnishings and interior walls and windows are cleaned by an acceptable method.
? The department is clean and tidy
? Cleaning schedules are posted
? In-service training is given to employees about sanitation and cleaning."


During a tour of the kitchen area, the following items were observed in an unsanitary condition:
? On observation, the top shelf where the condiments were stored was covered with dust and the outside of the condiment jars felt sticky which indicated a lack of cleaning and potential for contamination of food products.
? On observation, the soda mixing devices and connected tubing were covered in dust. This indicated a lack of cleaning and the potential for dust to contaminate the soda when the syrup or air lines require routine changing.
? On observation, the tops of ALL freestanding coolers and freezers had an accumulation of dust and dirt/debris when touched by surveyors, which indicated a lack of cleaning and the potential for dust or dirt/debris to fall into the cooler, freezer, or food when doors are opened and food is removed or inserted.
? On observation, the top of the Vulcan oven had an accumulation of dust and dirt when touched by surveyors, which indicated a lack of cleaning and the potential for dust or dirt to fall into patient food when being placed into or removed from this oven.
? On observation, the wall areas behind the stoves had a large accumulation of grease and dust, and electrical cords were covered with grease and dust. The floor under and behind all large equipment (stoves, coolers, hot and cold holding units and freezers) had a large accumulation of grease and debris. The top of the exposed motor in back of one of the units had a large accumulation of dust and debris. The above indicated a lack of cleaning, and also created a fire hazard by the potential for grease and dust ignition.
? On observation, the metal mesh bottom of the pan used in the small grilling unit was dirty, torn and deteriorating; approximately one third of the mesh where food was placed while in the grill unit was missing. This item was in need of replacement as it could not be cleaned properly, and pieces of the deteriorating metal mesh could contaminate patient food.
? There were 3 clear plastic containers observed filled with "clean" patient food preparation utensils, however, the clear containers were observed to have debris adhering both inside and outside which indicated a lack of cleaning and potential for contamination of clean patient food preparation utensils.
? There were multiple boxes of food observed which were stored on the floor, not protecting the items from insect or rodent contamination or protection from water which could contaminate the food.
? The bread box had a one inch area of black substance (resembling mold) across the complete length of the lid which indicated a lack of cleaning and potential for contamination of patient food.
? The outside of the sugar and flour bins were observed to have an accumulation of dirt on the outside of the bins, which indicated a lack of cleaning and a potential for contamination of patient food.
? On observation, the dirty linen cart was stored in the dry food storage area. This presents a risk for cross contamination between used linens and patient food.

The facility failed to follow the above policies for the dietary departments of both campuses as evidenced by the above descriptions of the condition of the departments.

The above items were confirmed in multiple interviews during observation with the Dietary Director and dietary staff during tours of both of the hospitals kitchen areas on 2/7/12 and 2/8/12.

Based on observations, review of facility documents and interviews with staff, it was determined that the facility failed to ensure that their hospitals were constructed, arranged and maintained at an acceptable level of safety for patients and staff.

The facility failed to effectively implement facility policies to maintain the physical environment of their hospitals, and maintain supplies and equipment to ensure an acceptable level of safety and quality.

Findings were:

1. During a tour conducted on 2/6/12, 2/7/12 and 2/8/12 of the facility ' s hospitals, the survey team found that the facility failed to maintain an environment that assured the safety and well-being of patients and staff. Cross Refer: Tag A0701

2. During a tour conducted on 2/8/12 of the Main Campus, the survey team found two oxygen cylinders unsecured in the oxygen storage room, expired sterile supplies were found in patient care areas available for patient use and crash cart checks were not performed daily. Cross Refer: Tag A0724

Based on observation, review of documentation, and interview, the facility failed to maintain facilities to ensure an acceptable level of safety in violation of facility policy, as the facility failed to maintain an environment that assured the safety and well-being of patients and staff.

Findings were:

Facility policy entitled " Management of the Environment of Care ...Policy #EC.8.0 " , reviewed on 2/9/12 stated the following under the heading " Statement of Purpose " : " The Management of Environment of Care planning document is designed to provide a safe, supportive, and effective environment of care for patients, staff members, and other individuals. The process is designed to eliminate or reduce to the extent possible in the physical environment and to manage staff activities to reduce the risk of injuries to individuals and loss to properties. " Additionally the policy stated the following under the heading " Program Elements " : " The Management of the Environment of Care addresses at least the following: ...Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided ...Areas used by patients are clean and fee of offensive odors ...Keep furnishings and equipment safe and in good repair ...Environmental tours will be conducted every six months in patient care areas to evaluate the effectiveness of previous implemented activities intended to minimize or eliminate environment of care risks. Environmental tours will be conducted annually in nonpatient care areas to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate risks in the environment. "

The following items were observed during a tour of the Main Campus on 2/6/12, 2/7/12, and 2/8/12:
? A directional sign in 2 Central was torn and appeared swollen from possible moisture exposure.
? Floor molding was swollen and separated from the wall in 2 Central.
? Floor molding was also swollen and separated from the wall in a room located in the Emergency Department between pods B and C.
? The corner of wall in 2 Central had cracked and gouged sheetrock.
? Floor in 2 Central had missing and cracked tiles in various areas.
? A ceiling tile was missing in the main entrance.
? The ceiling in 2 West Wound Care was stained and dirty.
? Wall gouges were present in patient rooms on 7 South.
? There was tape and gouges on the ceiling in the Nourishment room on 5 East.
? The ceiling in the patient restroom on 5 East was scratched and gouged.
? The door frame in the shower room on 4 West Rehab was covered in rust.
? In the cleaning room of the Endoscopy Department, the edges of the cabinet underneath the sink were falling off, the linoleum underneath the sink was damaged exposing the wood underneath, and there was a hole in the wall that had a washcloth inside the plastic covering.
? In the scope storage room of the Endoscopy Department, the ceiling tile was scratched in multiple areas and the ceiling tiles appeared to have water damage.
? In the pre-op area of the Surgery Department -main campus, there was one missing blue tile at the nurse ' s station.
? Outside operating room #4 of the Surgery Department-main campus, there were cracks in the floor.
? In operating room #9 of the Surgery Department-main campus, there was there was hole in the ceiling and the ceiling was also torn in places, there was paint on the supply cabinet, and there was a hole in the wall.
? In operating room #20 of the Surgery Department-main campus, the paint was peeling off the wall.
? The mat that divides the old and new sections of the operating rooms was torn in multiple areas.
? In operating room #220 of the Surgery Department -main campus, there was a hole in the wall.
? In operation room #214 of the Surgery Department- main campus, there was a hole in the wall and the ceiling was chipped.
? In operation room #215 of the Surgery Department- main campus, there was a hole in the wall.
? In the hallway of the operating room under the sink, the paneling was falling off.
The following items were observed during a tour of the Lakeside campus on 2/6/12 and 2/7/12:
? Flooring in the basement near the pharmacy had numerous pocked, broken and swollen tiles.
? Ceiling tile in the basement near the pharmacy was stained and broken.
? Floor molding in the basement near the pharmacy was swollen and separated from the wall.
? The walls in the Lakeside campus laboratory were gouged in numerous locations.
? Flooring in the Lakeside campus laboratory was stained and cracked.
? Ceiling tile was missing (but replaced by a square of cardboard) in the Lakeside campus laboratory.
? The ceiling in the Lakeside campus pharmacy was stained and dusty.
? Hand railing was broken on the wall on 4 South.
? The floor was gouged on 4 South.
? Ceiling tile was broken on 4 South.
? On 4 North in the restroom, the tile was damaged from what appeared to be a water leak.
? On 4 North in L&D #1, there was rust in the shower, the sink need to be re-caulked, there were black marks all over the floor, the wood floor had a piece broken from one of the tiles.
? On 4 North in the nourishment room, there was a drain uncovered with unknown buildup.
? On 4 North in L&D operating room #2, there was a hole in the wall.
? On 4 Central in the circumcision room, the handle was broken on one of the cabinets.
? Floor tiles were torn in the hallway on 2 South.
? Emergency cords in patient restrooms were wrapped around the railing in PACU, 4 North, and 4 South.
? In operating room K of the Surgery Department, there was a crack on the floor underneath the operating table and the vent was damaged.
The above findings were confirmed during an interview with the Chief Nursing Officer on 2/6/12, 2/7/12, and 2/8/12.

The following items were observed during a tour of the kitchen at the Main campus on 2/8/12:
? The ceiling of the kitchen had numerous large cracks.
? 2 holes approximately one inch in diameter were in the tile wall behind a grill.
? Floor tile was missing behind the same grill.
? 2 holes greater than one inch in diameter were in a column near the stove.
? Foam covering a pipe in the walk-in refrigerator for room serve prep was torn and missing several large pieces exposing the pipe beneath.
? Foam covering a pipe in the walk-in dairy refrigerator was also torn and missing several large pieces exposing the pipe beneath.
? A column in the walk-in dairy cooler had broken/crumbling areas near the ceiling on all four sides.
? An operable electrical outlet in the bakery walk-in freezer was covered in ice and an electric cord, covered in ice, was plugged into this outlet.
? A light bulb cover in the walk-in vegetable refrigerator was broken exposing the light bulb.
? The ceiling in dry storage had a hole around a fire sprinkler.
? The ceiling outside of dry storage had a hole around electrical conduits.
? 3 ceiling tiles were missing above the clean side of the dish washing machine.
The above findings were confirmed during the tour in an interview with the Director of Dietary.

The following items were observed during a tour of the kitchen at Lakeside campus on 2/7/12:
? The following areas had water leaks:
- There were tray line pans under two freestanding cooling units and according to staff interview they were collecting dripping water.
- There were two sinks in this area that were observed to have leaking pipes.
- There was an open drain observed not preventing items being dropped into the drain.
? The seal was broken in refrigerator #14 and the inside insulated area was broken and pieces missing.
? The condenser unit in #4 freezer was observed to have paint peeling, a possible food contaminant.
? The tile at the entrance on the floor to freezer #3 was missing and the area in need of repair.
? The ceiling in the kitchen and food storage areas were in need of repair/cleaning
? There were four ceiling tiled observed to be stained from leaks and there was an open area around the sprinkler unit that was also open
? There was a ceiling vent near the grill that was observed to have black dusty areas hanging from the vent
The above findings were confirmed during the tour in an interview with the Director of Dietary.

Based on observation, review of documentation, and interview, the facility failed to maintain supplies and equipment to ensure an acceptable level of safety and quality in violation of facility policy.

Findings were:

The facility policy entitled " Stored Gas Policy #EC.3.7 with a review date of 6/11 reflected " Compressed Gas 1. All cylinders must be secured at all times so they can not fall. Oxygen Use 1. Store oxygen cylinders upright and anchored to prevent tipping or falling at all times empty, full or in use. "

On a tour of the facility on 2/7/12, an "H" cylinder of oxygen and an "H" cylinder of helium 80% and oxygen 20% were observed in the oxygen storage room to be standing unsecured, without a chain, cylinder cart, or other device to prevent the cylinders from tipping or falling. In an interview with the Respiratory Manager on 2/7/12 at 3:15 pm, she stated that the two cylinders should be secured with a chain or in a cylinder cart.

On a tour of the facility on 2/8/12, the following expired sterile supplies were found in the emergency department pod A supply room: Thal-Quick Chest Tube Tray expired 1/12; Vicryl 5-0 suture, partial box of 12, expired 1/12; and Vicryl 3-0 suture, partial box of 36, expired 1/12. In an interview with the Emergency Department Assistant Manager on 2/8/12 at 11:20 am, he confirmed that the above listed supplies were expired and removed them. The facility policy entitled "Stocking and Cleaning Emergency Department " #270.0 with a revised date 2/08 reflected that " Integrity of all sterile instrument packs, equipment, and medication and fluids should be checked. "

On a tour of the facility on 2/7/12, the facility provided no documented evidence the crash carts in the following areas had been checked on a daily basis to ensure unexpired patient emergency supplies were available in an emergency: 4 West SICU, not checked on 1/30/12 and 2/6/12; 8 South CICU, not checked on 2/4/12; Radiology Holding Area, adult cart, not checked on 1/30/12, 1/31/12, 2/3/12, 2/4/12, 2/5/12; Radiology Holding Area, pediatric cart, not checked 2/2/12, 2/3/12, 2/4/12, 2/5/12. In an interview with the facility Director of Medical-Surgical Nursing, and Quality Manager on 2/7/12 at 2:00 pm, they acknowledged that the above crash cart checks were not done on a daily basis and stated that they should be done daily.
The facility policy entitled " Code Blue " #PC 08 with a revised date of 2/10 reflected that " Crash carts should be checked at least daily by assigned personnel for supplies located on the top of the crash cart, the oxygen content of the oxygen tank located on the side of the crash cart, that the seals are intact, and then complete the crash cart list.

On a tour of the facility on 2/8/12, in the in the basement of the main campus in the central supply and main sterile area the following was observed:

-Boxes of new supplies for patient use were observed to be stored on the floor in all areas, which did not protect the patient supplies from dust, insect or rodent contamination, or protection from fluids during mopping.
-There was a hole in the wall which was covered loosely with a wooden board that was easily removed; this covered an area which included a set of no longer used hot and cold water faucets. The opened area provided an opening for dust, insects or rodent contamination.
-A sharps container was closed and the " full " indicator was displayed; however there were 3 long silver thin cylindrical items sticking out of the container for approximately 6 inches, which prevented the sharps container lid from closing completely.
-A light fixture was observed to have a black substance on the interior of the cover.
-A 10 x 10 inch ceiling vent was not intact against the ceiling tiles, was hanging down into the room and two paper towels were wedged in between the ceiling and the vent to prevent the vent from rattling and/or dripping.
-There were multiple areas in the walls in the humid central supply area that had chipped and missing plaster, providing an opening for dust, debris, or insect penetration.
-In clean equipment room, six intravenous fluid equipment stands available for patient use had not been cleaned of multiple drips on the bases; three of the stands had approximately 12 inches red and white tape wrapped around the pole; tape cannot be disinfected.
-There were three vent covers missing in the clean equipment room, providing an entrance for dust or insect penetration.
-There were pipes extending into the ceiling and the area around the pipes had not been sealed so the ceiling areas was not intact, which could allow the entry of insects and dust.
-There was a " washing " room that has not been used for this purpose and the base of the door to this room was rusted out and was crumbling; a second door in this room was also rusted, areas with disintegrating materials and rust cannot be effectively cleaned.
-In the cabinet where cast padding supplies for patient use were stored a line of drips rust-like in appearance was observed to go across the entire shelf area with some drips to the bottom shelf.
-There were ceiling tiles throughout the area that were stained a dark brown and were warped and sagging into the room; there was one tile in front of one of the large sterilizers that was bowed and sagging approximately 3 inches and this tile had a poked hole in it to allow the leaking water to drain.

The ethylene oxide (EO) sterilizer #6 had a handwritten sign taped to the front which stated, "Jake fixed #6, but do not put anything "critical" in the first load." The staff stated that the sign was placed to remind staff not to place any critical items in the first load per the advice of the Steris representative, "Jake". Staff indicated that "there is something not working with the EO sterilizers, as something is wrong with the venting. Also the Steris repairman is here almost every day; all of our equipment is refurbished, so it's touch and go". The above indicates that the sterilizer is unreliable and presents a potential for ineffective sterilizing of patient instruments.

In the Central Supply area, 20 out of 20 hemostats sealed and ready for patient use were in the closed position and the clamps were locked and closed, therefore not all surfaces were exposed to the sterilizing agent preventing effective sterilization. In an interview with the sterilization supervisor, she stated after being asked about sterilizing hemostats, " They ' re to be open. "

The CDC (The Centers for Disease Control and Prevention) article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf, states on page 74 that hinged instruments and instruments that are closed should be opened during the process of sterilization.

The above findings were confirmed in interview with the Chief Nursing Officer during the tour on 2/8/12.

On a tour of the facility on 2/8/12, in the kitchen at the main campus the following was observed:
? The ceiling had multiple 2 to 3 foot cracks and peeling and cracking paint above the food preparation areas.
? There were two holes in the tile wall and eight floor tiles missing behind the grill, which provided a potential for contamination of patient food from dust, insects, rodents.
? There were two 2-inch holes in the column near the stove, which provided potential for contamination of patient food from dust, dirt, or insect.
? There were leaking pipes under two sinks in the kitchen. The floor under the sinks was wet and provided a safety hazard.
? There was an open drain in the kitchen floor, which contained dirt and debris. Facility policy entitled "Infection Control - Food Service" stated in part "Floor drains that might permit contamination by sewage backflow should be prohibited. "
? The ceiling in the dry storage room had a 2 inch hole around a fire sprinkler and the ceiling just outside of the dry storage room had holes around multiple electrical conduits from which insulation could contaminate patient food.
? In the dish wash room, 3 large ceiling tiles approximately 4 by 12 feet were missing above and adjacent to the clean side of the dish machine. There was a blue substance observed in drips off the pipes in the exposed ceiling area. An interview with the Dietary Director revealed that the exposed pipes had been leaking and that maintenance had not replaced the tiles as they were soaked each morning. The clean dishes used for patients were not protected from contamination from the debris from the open ceiling area.
? Four ceiling vents in the dry storage area were visibly dusty and in need of cleaning.
? The soda mixing devices and connected tubing were observed to be covered in dust, potentially contaminating the soda when the syrup or air lines required routine changing.
? In the dry food store room there were three large windows that had windowsills that were observed to have an accumulation of dust and debris, as well as large cracks from the sides of the window sills, creating a potential for contamination of the dry food by dust, insects and rodents.

The above findings were confirmed in interview with the Dietary Director during the tour on 2/8/12.

Based on review of available documentation, observation in the facility, and staff interviews, the facility failed to actively follow hospital policy and the identified program to avoid sources of infection and communicable diseases.

Findings were:

The facility failed to follow their own infection control program policies to provide a safe and sanitary environment for its staff and patients. Cross refer to A0749

The facility failed to maintain supplies and equipment to ensure an acceptable level of safety and quality in violation of facility policy. Cross refer to A0724

In an interview with the Chief Nursing Officer, the Dietary Director, the Chief Medical Officer and the Assistant Vice President of Patient Experience on 2/6/12 and 2/7/12, the above deficits were acknowledged.

Based on observation and interview, it was determined that the facility failed to follow their own infection control program policies to provide a safe and sanitary environment for its staff and patients.

Findings were:

Facility policy entitled "Glutaraldehyde, Use and Monitoring" stated its procedure pre sterilization in part " Clamp type instruments and valves are opened and instruments with lumens or closed spaces are filled with glutaraldehyde solution. "

The Centers for Disease Control and Prevention (CDC) article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: , states on page 74 that hinged instruments and instruments that are closed should be opened during the process of sterilization.

During a tour of the nursing floors on 2/6/12, the following was revealed:

In the Gynecological exam room on 7E, 12 pairs of "sterile " scissors and hemostats were discovered in the Gynecological exam kits that were in the closed position. Any item with lock boxes sterilized in the closed position is not sterile, as the sterilizing medium cannot reach all areas of the instrument.

During a tour of the Central Supply and sterilizing area in the basement on 2/8/12, the following was revealed:

In the Central Supply area, 20 out of 20 hemostats sealed and ready for patient use were in the closed position and the clamps were locked and closed, therefore not all surfaces were exposed to the sterilizing agent preventing effective sterilization. In an interview with the sterilization supervisor, she stated after being asked about sterilizing hemostats, "They ' re to be open."

Facility policy entitled " Standard Precautions " stated in part " Standard Precautions includes infection control practices and use of Personal Protective Equipment (PPE) recommended for healthcare personnel when having contact with all patients, whenever healthcare is delivered, regardless of patient diagnosis or presumed infection status. PPE selection is based on the nature of the patient interaction and/or the likely mode of transmission, and is worn whenever there is potential for exposure to:
? Blood
? All body fluids, secretions and excretions, except sweat, regardless of whether or not they contain visible blood
? Non-intact skin
? Mucus membranes"

Tour of the acute dialysis unit on 2/6/12 revealed:
? Staff members were observed working directly with patients undergoing dialysis treatment. None of these staff members were wearing Personal Protective Equipment, putting them in danger of blood splatter. When the Charge Nurse was asked about the lack of PPE, she stated "We only wear PPE when we are taking the patients on and off dialysis. "

Facility policy entitled "Prevention Guidelines for Transmission of Blood Borne Pathogens" stated in part "Standard Precautions will be utilized during all procedures in which contact with blood and body fluids may occur."

Tour of the nursing floors on 2/6/12 revealed:
? 5 "Barton " chairs on the orthopedic and neurology floors that had torn vinyl foot rests. The vinyl support on a patient lift in the same area was also noted to be torn. 3 other " Barton " chairs were found with torn footrests on 3E (SICU), 4E (SICU), and the 4th floor (MICU) of the Heart Center. A positioning device in the Nuclear Medicine area of the main campus had torn vinyl. These tears made cleaning impossible and cross contamination likely. 2 of the " Barton " chairs appeared dirty and stained, indicating ineffective cleaning.
? The vinyl covering on a wedge mat discovered in the rehab gym was torn in several spots, making cleaning impossible and cross contamination likely.

" Environmental Service Policy and Procedure Manual " stated the following housekeeping procedures:
? Patient Room Cleaning Steps-Weekly: " High/low dust: Work in a counter-clockwise direction around the room using a microfiber high duster. High dust surfaces above shoulder height, including the tops of lights, doors, curtain tops, partitions, ventilation covers, etc. Low dust surfaces below waist height, including radiators and air conditioning units, etc. "
? Dismissal Cleaning: Walls should be spot cleaned with general purpose cleaner. Windows and glass should be cleaned with general purpose cleaner or glass cleaner
? Cleaning of Elevators: "High dust ledges. Check for debris in high ledges and ceiling panels. "

Tour of nursing floors on 2/6/12 revealed the following:

? In a medication area on the Cardiothoracic floor, a vent that had dried, splattered medication was noted. This splatter indicated ineffective cleaning. On that same floor in the patient nutrition room, ceiling tiles were not joined, allowing entry of dust/dirt particles, insects, or rodents into the room.
? On the Coronary Care unit (4th floor), stained and splattered wall surfaces behind the sink in patient room 463 were noted, indicating ineffective cleaning. On 4S, in the patient nutrition area, a dirty vent was positioned over a countertop, sending dust onto food preparation areas.
? On the Orthopedic floor, the nutrition room had a dirty sink and ice machine, with apparent water damage in back of the sink. This water damage created a swollen surface, which would not allow for effective cleaning.
? The Nourishment room (available for patients, staff and families to access) on the 5th floor, Heart Center/Neurology, had a refrigerator with a dried yellow substance that had spilled/dripped in the door from the top to bottom shelves. The ice machine and the sink in the Nourishment room on 5E were stained and dirty and the vent above the counter tops was covered in dust. The Nourishment room refrigerator on 4SICU was also dirty inside. All of these items demonstrated ineffective cleaning of the area.
? In the hallway near the elevators, a chair was noted to have a " blood drip " stain which would make cross contamination possible and demonstrated the failure to effectively clean these areas
? In the Gynecological exam room on 7E, a stained and torn " sterile " package of equipment was discovered in the Gynecological exam kit. The stained and torn package rendered the equipment non-sterile. Dust was visible between the exam bed frame and the headboard.
? The shelving in the Pharmacy in main campus had chipped and pitted paint which prevented effective cleaning. The ceiling tiles in this same area had water stains and appeared dirty, which demonstrated ineffective cleaning.
? 4 elevators were noted to have foreign objects (Jello cups, gloves, and bird feathers) pushed atop the plexi glass that protected the fluorescent lights above. This demonstrated ineffective cleaning of the area.
? Copious amounts of dust were observed on all high horizontal surfaces throughout the tour of the facility which demonstrated ineffective cleaning.
? In the main supply room, multiple bins were dirty inside and one had an unknown brown spill on the outside, demonstrating ineffective cleaning of the bins.

On 2 South (mother/baby floor) in room 222, the following was observed:
? The mattress was torn making disinfection impossible and cross contamination likely
? there was a reddish/brown substance (blood like in appearance) on the outside of the light fixture above the bed
? the couch in the room had multiple stains
These items demonstrated ineffective cleaning of the area.

On 3 South (mother/baby floor) in room 326, the couch in the room had multiple stains which demonstrated ineffective cleaning of the furniture in the room.

On 4 North in L&D #1, there was a reddish/brown stain (blood like in appearance) on the mattress. This demonstrated ineffective cleaning of the labor and delivery bed.

On 4 North in L&D #11, there was a reddish/brown stain (blood like in appearance) on the mattress. The foam tape on the bed was torn. This demonstrated ineffective cleaning of the labor and delivery bed.
On 4 North in L&D Operating Room #1, there was a layer of dust on the high horizontal surfaces which demonstrated ineffective cleaning of the area.

On 4 North in L&D Operating Room #2, the following was observed:
? The roller board (used to transfer patients) was on the floor
? An unknown spill was observed on the wheel of the anesthesia cart
? there was tape on the anesthesia cart
These items demonstrated ineffective cleaning of the area.

On 4 Central, the following was observed:
? The Isolette (Incubator) drawers were dusty
? there was a reddish/brown substance (blood like in appearance) on the lid of the sharps container
? Open and partially eaten food and drinks were found in a procedure room (Circumcision room) which created the potential of cross contamination
These items demonstrated ineffective cleaning of the area.

In the Wound Care and Hyperbaric Department, there were 2 boxes on the floor that had Human Tissue in them (putting a clean item atop a dirty item creates the potential for cross contamination.)

In Exam Room 7, there was an exam chair with a tear. The tear made thorough cleaning impossible and cross contamination likely.

During a tour of the Endoscopy Department of the Main campus on 2/8/12, the following was revealed:
? In Procedure Room 7, there was double sided tape on the blue cart and the ceiling tile was cracked
? Behind the door of the Scope Storage Room, the floor was dirty (toothpick, hair and other miscellaneous small debris)
? In the Step-down Area, the safety railing held unknown brown stains
? In the Holding Area (where patients wait for their procedures) there was a bed with a yellowish stain underneath the mattress. This room contained a light fixture with unknown black spots inside (bug like in appearance)
These items demonstrated ineffective cleaning of the area.

In an interview with the Chief Nursing Officer and Assistant Vice President of Patient Experience during the tours of these areas, the above infection control issues were confirmed. It was also acknowledged that cleaning of the facility was not performed according to the hospital's policies and procedures.

Facility policy entitled "General Cleaning of Operating Rooms" stated in part: Cleaning between surgical cases:
? All equipment in a room should be thoroughly cleaned with a germicidal spray.
? Cleaning begins at the OR Bed moving outward to the periphery.
? All linen and trash bags should be changed.
? All other equipment, such as electrocautery units, should be cleaned and wiped down using electrical safety precautions.
? Used or contaminated suction equipment should be discarded and replaced with new suction tubing, tip and liner.
? The lights and bed should be cleaned thoroughly, being sure to clean all areas of the bed.
? After everything is wiped down and dirty instruments, trash and used linens removed from the room, the floor should be mopped.
? The cloth used to clean the room should be discarded with the dirty linen. "

Aramark (contracted cleaning service) policy entitled " Surgical Area Cleaning Procedures " stated in part, " End of day or terminal cleaning is a detailed, intensive cleaning process intended to prepare the operating room for the next day ' s cases. The process is designed to sanitize all contact surfaces, and to remove any dust accumulation that may have occurred during the day ....Follow the procedures below to perform an end of day cleaning:
? Contaminated instruments, basins, trays, and other items, soiled/contaminated linen and waste should be removed as described for concurrent cleaning. Any obvious fluid or waste spills should be cleaned up at this time as well.
? The operating room should be cleaned in a " top down " manner, beginning with high dusting. ...High dusting will include all horizontal surfaces or ledges higher than 5 feet off the floor, such as the tops of clocks, wall display panels, control consoles etc. Also dust wall and ceiling ventilation covers, power cord tracks and light fixtures.
? Continuing the " top down " process, the following equipment or areas should be cleaned by housekeeping and/or surgical personnel using SaniMaster 4 to perform this step. Use a microfiber cloth or disposable wipes.
1. Surgical lights and tracks. Begin with the highest portion of the light assemblies and work down towards the lights themselves. Pay special attention to the face and hand rails for possible blood or fluid stains. As each light is completed, move it back into its starting position.
2. Laminar flow shields. Be sure to clean both sides of each panel, and pay special attention to corners and braces.
3. Fixed and ceiling mounted equipment. Use caution around the wires, cables and hoses attached to medical equipment.
4. All furniture including instrument stands, tables, chairs, trash and linen holders and kick buckets, including wheels and casters. Again, each item should be cleaned in a " top down " manner.
5. Handles of cabinets, latches and push plates. In general, sanitize any surface or object that might be handled or touched by medical personnel during a procedure.
6. Sanitize all wall vents and panels. Use caution around switches or controls.
7. Horizontal surfaces e.g. tops of counters, fixed shelving, tops of autoclaves, etc.
? Using a microfiber cloth or disposable wipes, clean the operating table as follows:
1. Sanitize the entire top of the table. Remove each cushion and sanitize all surfaces of each one. As each cushion is sanitized, they should be stacked atop one another on an already sanitized surface, such as a table or a stand. This includes the main cushions and cushions for all extensions and limb support. Sanitize the attachment area for each cushion before reattaching them to the table. Also remove and sanitize the support plates for each cushion, sanitizing all surfaces and edges of each plate as well as the posts or legs.
2. Sanitize the frame and base of the table. Pay special attention to pivot points and the underside of the frame to insure that all fluid or blood spills are removed.
3. Sanitize all hand controls, control pads or pedals. Arrange the cords and controls as requested by the medical staff.
? Walls and ceilings should be spot cleaned if they are visibly soiled.
? Damp mop the entire floor. Begin by moving all moveable items away from the walls. Mop the entire perimeter of the room using the 18 inch microfiber mop. Maintain the same leading edge so that debris is not left behind. When the perimeter has been mopped, move all equipment and furniture back into place, and mop inwards towards the center of the room. "

During a tour of the Surgery Department of the main campus on 2/6/12, the following was revealed:

In Operating Room #3, the following was observed:
? A reddish/brown substance, (blood like in appearance) on the base of the IV pole
? A black unknown substance (mold like in appearance) was observed inside the tubing of the perfusion equipment
? Unknown black areas inside the light fixture
? Tape on warmer door
? A layer of dust on multiple pieces of equipment, the floor was dirty (unknown stains, miscellaneous small debris)
? An unknown white substance was on top of a steel table.
These issues demonstrated ineffective cleaning of the area.

In Operating Room #4, the following was observed:
? The floor was dirty (unknown stains, miscellaneous small debris)
? underneath the operating room table revealed what appeared to be human tissue with a string attached
? A piece of tape was attached underneath the operating table
? A cart used for sterile supplies had rust around the wheels (which made cleaning impossible)
? Plastic pad on the anesthesia machine had multiple stains
? There was a box on the floor
? Layer of dust was observed on high horizontal surfaces
? A steel table with unknown white substance on top
? A reddish/brown substance (blood like in appearance) on the yellow tubing of cardiac machine
? A reddish/brown substance (blood like in appearance) was found on the operating room table
These items demonstrated ineffective cleaning of the area.

In Operating Room #9, the following was observed:
? High horizontal surfaces were dusty
? The keyboard used by staff was dusty
? The floor was dirty (unknown stains, miscellaneous small debris)
? A reddish/brown substance (blood like in appearance) was found on the blue cart,
? A piece of tape on the side of the operating room table
These items demonstrated ineffective cleaning of the area.

In Operating Room #11, the following was observed:
? An unknown black substance (mold like in appearance) was found in the tubing of the perfusion equipment
? Boxes and supplies were on the floor
These items demonstrated ineffective cleaning of the area

In Operating Room #14 (a supply room), the following was observed:
? The floor was dirty (unknown stains, miscellaneous small debris).
This demonstrated ineffective cleaning of the area.

In Operating Room #19 (a supply room), the following was observed:
? Multiple bins were observed on the floor preventing effective cleaning of the area

In Operating Room #20, the following was observed:
? A blue stool was torn, making disinfection impossible and cross contamination likely
? A dirty electrode pad was found underneath the operating room mattress
? A green gel pad was torn and found with a reddish/brown substance (blood like in appearance)
? The white pad underneath the operating room mattress and the operating room mattress was torn in multiple places making cleaning impossible and cross contamination likely
? Multiple pieces of tape were found on the stereo
The above items demonstrated ineffective cleaning of the area.

In the Supply Room, the following was observed:
? One can of Red Bull Energy Drink was on a clean supply shelf
? Supplies and boxes were on the floor (making cleaning of the area impossible)
? A reddish/brown substance (blood like in appearance) was found on the Cautery unit and the Atri-Cure equipment
These items demonstrated ineffective cleaning of the area.

In Operating Room #211, the following was observed:
? The operating room mattress was torn making disinfection impossible and cross contamination likely
? An unknown white substance was on top of a steel table
? Multiple pieces of tape on drawers
These items demonstrated ineffective cleaning of the area.

In Operating Room #212, the following was observed:
? A reddish/ brown substance (blood like in appearance) was found on the operating room mattress
? The mattress was torn making disinfection impossible and cross contamination likely
? The base of the supply table was corroded and rusty making thorough cleaning impossible
? Tape was found on multiple drawers
? The anesthesia cart was dirty with an unknown brown/black substance
? Tape was observed on the anesthesia cart
These items demonstrated ineffective cleaning of the area.

In Operating Room #214, the following was observed:
? A roll of tape was found on the floor
? Tape was noted on the operating room table
? The operating room table was also chipped making thorough cleaning impossible
These items demonstrated ineffective cleaning of the area.

In Operating Room #215, the following was observed:
? The operating room mattress was torn in multiple areas making disinfection impossible and cross contamination likely
? Tape was observed on the operating room table
? An unknown substance was noted on the floor underneath the operating room table
? Tape was observed on stereo speakers that were taped to a table
? An unknown white substance was found on top of a steel table
? The floor was dirty (unknown stains, miscellaneous small debris)
These items demonstrated ineffective cleaning of the area.

In Operating Room #217, the following was observed:
? The keyboard used by staff was dusty and the wrist guard was torn making disinfection impossible and cross contamination likely
? Supplies were on the floor
? The plastic mat on the anesthesia cart was dirty
These items demonstrated ineffective cleaning of the area.

In Operating Room #219, the following was observed:
? A reddish/ brown substance (blood like in appearance) was found on the side of the operating room table and one sandbag
? The operating room mattress was torn making disinfection impossible and cross contamination likely
? Electrodes were observed on the floor
These items demonstrated ineffective cleaning of the area.

In Operating Room #222, the following was observed:
? A reddish/ brown substance (blood like in appearance) was found on the operating room table and mattress
? The floor was dirty (black shoe print, unknown stains, miscellaneous small debris)
These items demonstrated ineffective cleaning of the area.

During a tour of the Surgery Department of the Lakeside campus on 2/7/12, the following was revealed:
? In the pre-op area #1, there was a layer of dust on the high horizontal surfaces
? In the pre-op area #6, there was a reddish/brown substance (blood like in appearance) in the top drawer of the nurse ' s supply cart.
These items demonstrated ineffective cleaning of the area.

In Operating Room A, the following was observed:
? The operating room mattress was torn in multiple areas making thorough cleaning impossible and cross contamination likely
? The same mattress was taped completely across from top to bottom
? Tape was observed on an electrical cord on a large piece of patient care equipment
? Supply table has rust on the base making cleaning impossible
These items demonstrated ineffective cleaning of the area.

In a supply room there was dirty equipment stored with clean supplies creating the risk for cross contamination.

In a hallway of the Surgery Department, an "Andrews ' s table" was stored. This table was torn and taped making disinfection impossible and cross contamination likely.

In Operating Room H, the following was observed:
? The suction canister tubing was taped
? There was a layer of dust on the high horizontal surfaces
? There was tape on the operating room table
? A physician chair was torn and the handle was taped
? The floor was dirty (unknown stains, miscellaneous small)
These items demonstrated ineffective cleaning of the area.

In Operating room K, the operating room mattress was torn making disinfection impossible and cross contamination likely.

In an interview with the Chief Nursing Officer and Assistant Vice President of Patient Experience during the tours of these areas, the above infection control issues were confirmed. It was also acknowledged that cleaning of the operating rooms and storage areas were not cleaned according to the hospital ' s policies and procedures.

Facility policy entitled " Infection Control - Food Service " stated in part " It is the policy of the Food and Nutrition Department at Covenant Health System to contribute to the health maintenance of patients and employees alike, by preventing infection and disease transmission ...Food Products and Storage:
? Upon arrival, all food should be inspected for damage, rodent or insect infestation, and spoilage.
? Floor drains that might permit contamination by sewage backflow should be prohibited. Food must be stored sufficiently above floor level and away from walls in accordance with local health and safety standards. This facilitates cleaning of floors and corners, and protects against contamination by the cleaning process itself and accidental flooding from any source.
Food Preparation and Service
? Food should be served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements so as to avoid manual contact of un-packaged foods.
? Separate cutting boards for meat, poultry, fish and vegetables. They are washed and sanitized daily.
Equipment:
? All food grinders, choppers, mixers, all working surfaces, utensils, etc., should be cleaned, sanitized, dried and reassembled after each use.
Housekeeping:
? Ranges and grills should be cleaned daily
? All work surfaces, utensils, and equipment should be cleaned and sanitized after each use. All counters should be cleaned daily and as needed.
? All floor surfaces must be wet-mopped daily and as needed
? Storage facilities for raw and cooked food must be cleaned and sanitized on a fixed schedule
Controls on the System:
? Periodic prevalence walks should be conducted by the nurse epidemiologist and the food service director. "

Facility policy entitled " sanitation " stated in part " The food service department maintains a sanitation program which meets all applicable health regulations.
? All equipment and furnishings and interior walls and windows are cleaned by an acceptable method.
? Trash is removed
? The department is clean and tidy
? Cleaning schedules are posted
? In-service training is given to employees about sanitation and cleaning. "

Facility policy entitled " Cleaning Schedule for Dry Storage and Cold Vaults " stated " Proper sanitation procedure must be followed to keep clean and sanitary food and non food items from becoming contaminated before use.
? Dry storage area must be swept and scrubbed regularly. Walls, ceiling, floor shelves, light fixtures and racks require cleaning on a daily basis. Garbage must never be kept in the same room as food.
? Refrigerator (vaults) Interior parts should be cleaned and sanitized on a regular basis, depending on use. Shelves should be removed as part of this cleaning process. (the presence of debris, mold or objectionable odors is a sign of poor cleaning and demands immediate remedy.) Walls, ceiling, floor, shelves, light fixtures and racks all must be cleaned to ensure proper storage procedures. "

During a tour of the kitchen area of the Lakeside campus on 2/7/12, the following items were observed to be covered in dust and grease:

? Top shelf where the condiments were stored
? The soda mixing devices and connected tubing
? The tops of ALL freestanding coolers and freezers
? The top of the Vulcan
? The wall areas behind the stoves
? The floor under and behind all equipment was observed to have a large accumulation of grease and debris. Rust was observed on the legs and base of warmer in the prep area making effective cleaning impossible
? there was rust observed on the legs and base of warmer in the prep area
? The exposed motor in back of one of the units was observed to have a large accumulation of dust and debris. The filter under the grill was dusty which indicated ineffective cleaning.

The following equipment in the Lakeside kitchen was stored in the following unsanitary/unusable condition:
? The pan used in the small grilling unit was observed to have the mesh torn and missing from about one third of the pan rendering it unusable.
? 3 clear plastic containers filled with "clean " utensils, however, the clear containers were observed to have areas with food and debris attached which indicated ineffective cleaning.
? There were multiple boxes stored on the floor, containing food and non food items which violated company policy
? The bread box had a one inch area of black substance across the length of the lid which indicated ineffective cleaning
? Sheet pans in the warming unit had visible food spills which indicated ineffective cleaning
? The outside of the sugar and flour units were dusty and covered with flour and sugar, indicating ineffective cleaning.
? The dirty linen cart was stored in the dry food storage area which could cause cross contamination
? The large can holding rack was observed to have dirt and debris on the rack indicating ineffective cleaning

The ceiling in the kitchen and food storage areas at the Lakeside campus were in need of repair/cleaning:
? Four ceiling tiles were observed to be stained from leaks. There was an open area around the sprinkler unit that allowed for entry of vermin into the facility
? There was a ceiling vent near the grill that had black dusty areas hanging from the vent indicating ineffective cleaning

The following issues were observed during a tour of the kitchen at the main campus on 2/8/12:
? In the dish wash room 3 large ceiling tiles were missing above and adjacent to the clean side of the dish machine. There was a blue substance dripping off the pipes in the exposed ceiling area. An interview with the Dietary director revealed that the exposed pipes had been leaking and that maintenance had not replaced the tiles as they were soaked each morning. The clean dishes could be contaminated by debris from the open ceiling area.
? The ceiling above a food preparation had splatter marks indicating ineffective cleaning
? Four ceiling vents in the dry storage area were visibly dusty which indicated ineffective cleaning
? The large can rack in the dry storage area was contaminated with dust and dried food which indicated ineffective cleaning
? There was an accumulation of dust and debris on the soda mixing devices and connected tubing which indicated ineffective cleaning
? In the dry food store room there were three large windows that had windowsills that were observed to have an accumulation of dust and debris, as well as large cracks from the sides of the sills which indicated ineffective cleaning

The above items were confirmed in interviews with the Dietary Director during tours of both of the campus ' kitchen areas on 2/712 and 2/8/12. It was also acknowledged that cleaning of the kitchens were not performed according to the hospital's policies and procedures.

? Boxes of new supplies for patient use were observed to be stored on the floor in all areas.
? There was a hole in the wall which was covered loosely with a wooden board that was easily removed; this covered an area which included a set of no longer used hot and cold water faucets.
? A sharps container was closed and the "full" indicator was displayed; however there were 3 long silver thin cylindrical items sticking out of the container for approximately 6 inches, which prevented the sharps container lid from closing completely.
? A light fixture was observed to have a black substance on the interior of the cover.
? A 10 x 10 inch ceiling vent was wedged into place with a paper towel.
? There were multiple areas in the walls throughout the area that had chipped and missing plaster in all areas of central sterile supply which cannot be effectively cleaned
? In the room where the clean equipment was stored, there were multiple intravenous fluid equipment stands that were cleaned ready for patient use that were observed to have multiple drips on the bases; three of the stands had approximately 12 inches red and white tape wrapped around the pole. Taped areas cannot be effectively cleaned or disinfected in preparation for patient use.
? There were three vent covers missing from this area.
? There were pipes extending into the ceiling and the area around the pipes had not been sealed so the ceiling areas was not intact, which could allow the entry of insects and dust.
? There was a "washing " room that was being used to store patient equipment such as walkers; the base of the door to this room was rusted out and was crumbling; a second door in this room was also rusted, areas with disintegrating materials and rust cannot be effectively cleaned.
? In the cabinet where cast padding supplies for patient use were stored a line of drips rust-like in appearance was observed to go across the entire shelf area with some drips to the bottom shelf.
? There were ceiling tiles throughout the area that were stained as they had been wet and dried; there was one tile in front of one of the large sterilizers that was bowed approximately 3 inches and this tile had a hole in it to allow the leaking water to drain.

The ethylene oxide (EO) sterilizer #6 had a sign on the front which stated, "Jake fixed #6, but do not put anything "critical" in the first load" indicating not to place any critical items in the first load per the advice of the sterilizing equipment repairman, "Jake". Staff indicated that "there is something not working with the EO sterilizers, and something is wrong with the venting...Also the Steris repairman is here almost every day; all of our equipment is refurbished, so it's touch and go."

The above findings were confirmed in interview with the Chief Nursing Officer during the tour on 2/8/12.

In an interview with the Chief Medical Officer, Chief Nursing Officer, Director of Nursing and Nurse Managers during the tours of these areas on 2/612, 2/7/12 and 2/8/12, the above infection control issues were confirmed. It was