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Based on observation, interview and record review, the facility failed to ensure that adequately trained and credentialed facility staff performed venipuncture (blood draws) for one #38) of one patients reviewed for phlebotomy (venipuncture), resulting in the potential for adverse outcomes for the patient involved. Findings include:

On 11/27/18 at approximately 1430, the 5R critical care unit (ICU) was toured with the Administrator of Critical Care Staff G. At approximately 1445, Patient #38 was observed. Patient #3 was connected to mechanical ventillation (artificial respiration), had an indwelling urinary catheter and a rectal fecal tube, and had an arterial line (catheter inserted into an artery) and a central venous line with total parental nutrition running. Patient #38 was lethargic and did not respond or make eye contact. At approximately 1450 Patient #38's daughter entered the room escorted by a security guard who remained during her visit.

On 11/27/18 at approximately 1500, Staff G reported that Patient #38's daughter was only allowed in the hospital with a security escort as she had, "tried to choke one of her father's nurses." A security incident report for this incident was provided and reviewed.

On 11/28/18 at approximately 0930, Patient #38's clinical record was reviewed with Staff G and revealed the following information:

Patient #38 was a 48 year old male who was admitted to the facility on 10/25/18 with diagnoses which included abdominal pain, vomiting, and shortness of breath. Patient #38 did not receive a central venous catheter (CVC) until 5/29/18, and all blood samples for laboratory tests before 10/29 were collected by the nurse from a peripheral vein. It was documented that the facility Intravenous access team (IV team) were called to draw some of the blood samples needed for testing on 10/26/18. Staff Nurse ZZ was recorded on the clinical record as collecting Patient #38's blood for lab tests on 10/25/18 at 2150 and on 10/26/18 at 0147.

On 11/28/18 at approximately 0950 Staff Nurse ZZ was interviewed. Staff Nurse ZZ reported that Patient #38's daughter and ex-wife were intimidating and had physical and verbal altercations with the current wife and her daughter, and with staff who had tried to diffuse the altercations. Staff ZZ stated that Patient #38 was "very sick at the time" and his blood pressure and heart rate became elevated (high) during these incidents, which "was not good for him." Staff ZZ stated that the daughter tried to choke one of Patient #38's staff nurses over a care issue and now was only allowed to visit with a security guard escort. Staff ZZ stated that Patient # 38's arms were extremely swollen with tight skin from the swelling and it was very hard to find a vein to get a blood sample. Staff ZZ stated that he knew that Patient #38's daughter was a medical assistant, but did not know where she worked, but knew it was not at this facility. Staff ZZ stated that he had to collect blood one time while the daughter was in the room and she stood over him rolling her eyes and making faces. Staff ZZ stated that he missed the vein and when he took the needle out to try again, the daughter took the blood collection device out of his hand and collected the blood sample herself. Staff ZZ stated that he knew he should not have allowed her to do that, and that he should have called the IV team instead, but he was intimidated by the daughter and didn't want to have her make a scene in the room and have Patient #38 have a blood pressure cisis as a result.

On 11/28/18 at approximately 1000, Staff G stated, "It goes without saying that we can't have family members who aren't healthcare workers employed by the facility do blood draws."

On 11/28/18 at approximately 1600, review of the facility policy entitled, "Phlebotomy", dated 11/19/18 revealed the following statements, "Scope: REgistered Nurse (RN), Licensed Practical Nurse (LPN), Patient Care Associate (PCA) and other patient care providers with documented competency to perform venipuncture", "Blood specimens: RN or PCA make 2 attempts. If unable to start IV or obtain blood specimen: RN will contact unit super user, IV team member, Rapid Response Team, Phlebotomy Team and/or CRNA as appropriate to patient's condition and order request."

Based on observation and interview the facility failed to ensure the physical environment was developed and maintained to ensure the safety of the patient resulting in the potential for harm to all patients served by the facility. Findings include:
See specific tags:

A-0701 - Failure to ensure the physical environment of the hospital was developed and maintained to assure the safety and well-being of patients

A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

A-0726 - Failure to ensure exhaust ventilation in the kitchen

This citation has two Deficient Practice Statements

Deficient Practice Statement #1
Based on observation and interview during the facility tour the facility failed to provide a patient environment that protects the well-being of the patient and ensures risks are minimized for patients and employees in the emergency department resulting in the potential for less than optimal outcomes for all patients seeking emergency services.

Findings include;

On 11/28/2018 at 1:30 p.m. the patient holding bays in the emergency department for modules 2, 3, and 4 were observe to be sized at 4 feet x 10 feet. This measurement does not meet the 2007 minimum design standard for health care facilities to allow for adequate access for staff to deliver care to the patients. Allowing for a standard gurney (stretcher) size of 30 inches the circulation space around the patient is reduced to 9 inches on each side of the gurney.

On 11/28/2018 at 1:45 p.m. Staff XX facilities director was queried regarding the size of the patient holding bays in modules 2, 3, and 4. Staff XX stated that this is the way the cubicles have always been and suggested speaking to the facility architect to confirm.

On 11/28/2018 at 2:15 p.m. Staff NNN (facility architect) was queried regarding the size of the patient holding bays. Staff NNN stated, "This configuration is not correct. The cubicles should be a minimum of 8 feet x 10 feet to meet the minimum design standards for health care facilities.

Review of the 2007 Minimum Design Standards for Health Care Facilities in Michigan states in section 2.3.A2 a cubicle with a minimum of 80 square feet of clean floor area shall be provided with a minimum head wall dimension of 8 feet per bed or stretcher that is located in a multiple bed room. Section 2.3.A4 states a minimum of 4 feet shall be provided between the beds or stretcher and between an adjacent wall and the side of a bed or stretcher.


39083

Deficient Practice Statement #2
Based on observation, interview, and record review, the facility failed to maintain plumbing lines and provide backflow protection in the kitchen, resulting in potential contaminaiton of the physical facility and domestic water supply. The deficient practices have the potential to affect all 182 patients in the facility.

Findings include:

On 11/27/18 at 10:33 AM, the water supply line to the dish machine was observed to be leaking a significant amount of water, near the regulator, onto the floor. The floor was observed to have reddish/brownish mineral staining from the leak, indicating that the leak has been present for an extended period.

On 11/27/18 at 10:52 AM, a hose connection, underneath the loading end of the dish machine, was observed to not be provided with a backflow protection device to prevent backflow of contaminants and dangerous chemicals into the domestic water supply. The connected hose was observed to be submerged in a large tub of pre-soak chemical. At the time of the observation, Sous Chef "J" stated that he was unaware of the hose needing a backflow prevention device.

According to the 2012 Michigan Plumbing Code, incorporating the 2012 edition of the International Plumbing Code, Section 608 Protection of Potable Water Supply, "608.2 Plumbing fixtures. The supply lines and fittings for plumbing fixtures shall be installed so as to prevent backflow. Plumbing fixture fittings shall provide backflow protection in accordance with ASME A112.18.1/CSA B125.1."

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated November 28, 2018.
K-0293
K-0311
K-0321
K-0324
K-0341
K-0347
K-0353
K-0362
K-0363
K-0711
K-0920

Based on observation and interview, the facility failed to provide proper exhaust ventilation in the kitchen. This deficient practice has the potential to affect all patients, staff and visitors that consume food from the kitchen.

On 11/27/18 at 10:07 AM, condensation was observed to be collecting on the exhaust hood surfaces, above the steam kettles at the cookline. The condensation was observed to be dripping back down onto the steam kettles and the stove that is under the exhaust hood. An open stock pot was observed to be on the stove with water dripping around it. Sous Chef "J" was present at the time of observation and stated that the hood vent was currently on and working.

This citation has multiple Deficient Practice Statements.

Deficient Practice Statement #1:
Based on observation, interview and record review, the facility failed to ensure that surveillance methods for Surgical Site Infections were comprehensive enough to detect targeted postoperative infections and detect clusters of infections and unacceptable rates of infections in non-targeted surgeries, and failed to follow nationally recognized standards of practice to calculate and report surgical site infections as a ratio of the number of surgeries performed for five of five months reviewed, resulting in missed opportunities to detect and prevent the spread of infection.
Findings include:

On 11/28/18 at approximately 1000 the Infection Control Program for the months of July, August, September, October, and November of 2018 was reviewed with the Infection Control Lead, Staff AAA. Staff AAA reported at this time that she was not able to obtain the numbers of each surgery performed by the facility as she had no clerical support and the Surgical Department staff did not provide her with the numbers. Review of the facility"Surgical Site Infections (SSI)" report dated 11/26/18 for the period from October 2017 through October 2018 revealed no surgical site infection rates (per 100 surgeries) were reported since May 2018. A note at the bottom of the line listing of included SSI cases the following statement , "Note: No denominator data available 2018." When asked how the facility could detect increases in infection rates that were actual and not just due to a higher volume of surgeries, Staff AAA stated, "We look at each postoperative infection and review each one (for corrective measures)."

On 11/28/18 at approximately 1010, Staff AAA was interviewed and stated that the Infection control (IC) department reviewed every post operative infection, not just the ones that were required by the Center for Disease Control (CDC) National Healthcare Safety Network. Staff AAA stated, "We've prioritized all SSIs." Staff AAA stated that their method of surveillance for SSI (detecting them) was to look at the daily list of patient admissions and diagnoses and to look at all positive laboratory culture results (test results that were positive for infection). Staff AAA stated that her surveillance Infection Control Practitioner (ICP) Staff CCC covered surveillance at three other sister facilities, and each day he reviewed all patients who had an admission diagnoses of infection on the daily admission list to make sure that they were not readmitted due to a Health Care Acquired Infection (HAI) from a previous admission or surgery at the facility.

Staff AAA stated that there were only two SSI in November 2018. Both were colorectal surgeries. A list labeled, "Open Reduction of Fracture (ORIF) SSI (90 day surveillance)" in the IC report dated 11/26/18 noted there were three ORIF of the ankle or foot in October 2018 and one ORIF of the foot in November 2018.

On 11/28/18 at approximately 1030, review of four patients randomly selected for a diagnosis suspicious for infection from a list of patients discharged in August and September 2018 revealed two of the four patients (#40 and #43) reviewed had infections which were not noted or reviewed by the IC program. The following was noted:

Patient #40's diagnosis for discharge (death) from the facility on 8/11/18 was "local infection due to (d/t) a central venous catheter (CVC)." Patient #40 expired of a bloodstream infection (sepsis) on 8/24/18. Patient #40 was not on the IC program's list of patients flagged for review for infections. When asked about this, Staff AAA reported that the Surveillance ICP Staff CCC, "didn't have time to look at everything, so we've prioritized SSI." Staff AAA stated that IC surveillance relied on positive microbial laboratory culture results to create an electronic message that would trigger the ICP to review the patient to see if the infection was facility acquired (HAI). This contradicted Staff AAA's statement at 1010 that IC staff reviewed the daily admissions list each day. Patient #40's Hickman Catheter (a port inserted for longterm intravenous therapy) was cultured on 8/3/18 (a previous admission) and no microorganisms were detected. Patient #40 also had an internal jugular CVC during admission. Review of Patient #40's clinical record at this time revealed that Patient #40 received two different intravenous (IV) antibiotics every six hours at the time the culture was taken. Staff AAA stated, "That's probably why the culture was negative. We weren't aware that she had a CVC infection because the cultures were negative so we didn't get an electronic notification from a positive laboratory result.

Patient #43 was admitted on 8/9/18 with a diagnosis of "Post-Surgical Wound Infection". Patient #43 was not on the ICP's list of patients reviewed or on the IC list of SSI. Patient #43 was not on the IC electronic notification list from positive laboratory culture results. Patient #43 had an ORIF (Open Reduction Internal Fixation) repair of his left elbow in the facility on 7/16/18. On 8/11/18 the surgeon documented that Patient #43 had an infected abcess at the surgical site and purulent drainage from the wound. The patient received IV antibiotics and had surgery to drain and clean the wound (Irrigation and drainage) on 8/11/18. Patient #43 was not on the list of infections through the electronic laboratory result notification system (Theradoc). Patient #43 was not listed for July, August or September on the 11/26/18 report of "Open Reduction of Fracture SSI 2018 year to date." When asked about this, Staff AAA stated, "We didn't know about this because we didn't have a notification of a positive culture result. The Operating Room (OR) staff never told us about this."

On 11/28/18 at approximately 1400, Staff CCC and Staff AAA were interviewed. Staff AAA stated that the Surgical Department did not tell them when patients were scheduled for Irrigation and Drainage (I & D) of infected surgical sites or removal of infected surgically implanted devices. When asked, Staff CCC and Staff AAA reported that they relied on Surgery Department staff to tell them about surgeries for infected surgical sites and both stated that they did not do any surveillance of their own to screen for these types of surgeries.

On 11/28/18 at approximately 1420, the daily surgical schedule (list of patients whe received surgery) for 10/4/18 through 10/23/18 was reviewed. Three patients who were scheduled for surgery to clean out an infected wounds were randomly reviewed. None of the three patients were on the list of patients noted or reviewed by the IC department for SSI. Two patients ( #47 and #48) had SSI that occurred beyond the CDC timeframes for mandatory surveillance for SSI. The following SSI which met timeframes for inclusion was noted during review:

Patient #45 had surgery on 10/4/18 for an I & D of the left forearm for a postoperative infection. Patient #45 originally had surgery of the wrist for a carpel tunnel release on 8/23/18. A positive laboratory culture result dated 10/4/18 indicated that Patient #45's left wrist was infected with Staphyloccus aureus (a bacteria). Pataient #45 was not on the list of patients with infections reviewed by the IC program for possible HAI and was not documented in their list of patients with SSI for November. Review revealed that there was no indication that IC staff reviewed Patient #45's positive laboratory culture result to see if it was an HAI or SSI. Staff AAA stated, "I'm kind of shocked that it's not on our line list of infections, but we aren't following (targeting) carpel tunnel surgery infections." This statement contradicted the statements made earlier during the IC program review when Staff AAA state that the IC department looked at all SSI.

On 11/28/18 at approximately 1500 Staff AAA was asked how the IC program would notice an unusual cluster of infections in surgeries that were not "targeted" for surveillance if there was no line listing ( a list) or screening of infections. Staff AAA was asked how the IC program could accurately determine which surgeries should be targeted for future surveillance if the IC program did not conduct surveillance for clusters or an unusually high incidence of SSI in non targeted types of surgeries. Staff AAA stated, "I see what you mean."


Deficient Practice Statement #2:
Based on interview and record review, the facility failed to ensure that two Sterile Processing instrument auditors (#KKK and #LLL) out of two reviewed out of a total of six contracted instrument auditors (expeditors) were adequately trained, evaluated and monitored for their roles in auditing and checking cleanliness of surgical instruments, resulting in the potential for surgical site infections for all patients receiving surgery at the facility due to potential failure to detect inadequately cleaned surgical instruments.
Findings include:

On 11/27/18 at approximately 1000 the Sterile Processing Department Director Staff T was interviewed during a tour of the Central Sterile Processing Department (CSPD). Staff T stated that due to reports of continued incidents ("Midas Reports") of inadequately cleaned instruments reaching the operating rooms (OR) , a new process was recently put in place to check that surgical instruments were adequately cleaned before they were put into the sterilizer. Staff T stated that cleanliness audits were now done on all instrument trays with cannulated (hollow) instruments. When asked about the reported CSPD audit results of instrument cleanliness from 01/18 through 9/18, Staff T reported that the instrument auditing was increased to include 100% of trays containing cannulated instruments in October because while the CSPD audits reported 97% to 100% of the trays checked were adequately cleaned and contained no broken or missing instruments, Midas Reports (adverse event reports), incidents reported during surgery and Survey results contradicted this finding of 97% to 100% , and revealed there was a problem with inadequately cleaned or sterilized instruments reaching the OR.

Staff T was asked at this time which of her staff performed the CSPD Quality audits and checked the trays containing cannulated instruments. Staff T stated that the new process required two CSPD staff to initial the instrument tray label to document that they had made sure that the instruments inside the tray were adequately cleaned and contained no bioburden (residue of blood, tissue or bone). Staff T was unable to identify names of staff qualified to do this.

On 11/27/18 at approximatly 1100 Sterile Processing Tray checker (Auditor/"Expediter") Staff V was interviewed. Staff V stated, "The OR has been filling out plenty of Midas Reports on us lately."

On 11/27/18 at approximately 1102 Staff T was asked to provide Midas Reports for all inadequately processed (contaminated with bioburden or inadequately sterilized) instrument trays reported by the OR in November. Staff T reported, "I have a huge pile of them
that I haven't had time to get to yet. Most of them are just reports of missing non-critical instruments and had no effect on the patient because another pack containing the missing instrument was available right away in the OR. I can't sort through all of these to see if any are about bioburden or other sterilization problems."

On 11/27/18 at approximately 1110 a wrapped and sterilized (ready for surgery) Neurosurgery tray was inspected with Staff T and Staff V, who were also interviewed at this time. Staff T stated that she did not know who the cleanliness auditors were, but stated that there were two staff each shift who did the audits. Staff T stated that there was no special training for the instrument auditors. Staff T stated that six contracted sterile instrument processors were hired to do the audits and process instruments. At this time, the auditor initials on the inspected Neurosurgery tray label were reviewed. Staff T stated that she did not know the names of the staff who did the audit of this tray and said, "I don't know who that is." Staff T was asked at this time to provide a list of CSPD staff and contracted staff who performed audits of instrument cleanliness. This list was not provided until 1100 on 11/29/18. The signature of the Contracted Staff who performed the quality audit on the Neurosurgery surgical instrument tray was identified by Staff V at this time as Staff LLL.

On 11/29/18 at approximately 1100, a list of CSPD staff and "Instrument Expeditors" was provided for review. Six CSPD staff Instrument Expeditors" were listed. Two of the six (#LLL and #MMM) were selected for personnel file review. The Perioperative Administrative Director was interviewed at this time and reported that the staff who audited/checked the trays were "Instrument Expeditors". The Chief Human Resources Officer, Staff HHH was asked at this time to provide documentation of Staff LLL and Staff
MMM's credentials, documentation of education and training in instrument processing and competency evaluations.

On 11/29/18 at approximately 1300, Staff HHH stated that he had no documentation that Staff LLL and Staff MMM had education, training or certification in sterile instrument processing. Staff HHH stated that these staff were contracted employees and the contract with the contracted provider stated that the provider ensured that staff were trained, competent and met state licensing requirements. The contract was provided for review and was noted to be a terminated contract dated 2016 for a contracted provider to provide the entire management and staff for CSPD. There was no documentation to indicate that Staff LLL had any certification, training, education, experience or competency evaluation in cleaning or processing of sterile instruments. There was no documentation to indicate that Staff MMM had any education, training or certification in cleaning or processing of sterile instruments. There was no documentation of any training or evaluation for auditing surgical instrument cleanliness and sterility. The job titles of both Staff LLL and Staff MMM were requested at this time but not provided by the end of survey. A job description for Instrument Expeditors was requested at this time, and by survey end, only an undated, unsigned document labeled, "Confidential Document Draft: IMS Instrument Expediter Job Tasks" without a facility letterhead was received.

On 11/30/18 at approximately 0730 review of the undated, unsigned facility document entitled, "IMS Instrument Expediter Job Tasks" noted they had the following job duties, "perform quality checks in assembly after the Instrument Associates (IA) perform assembly of a tray", "Perform quality checks as loads are being made ready for the sterilization process."

On 11/30/18 at approximately 0740 review of the document entitled, "Job Posting Summary: Title: Instrument Associate", dated 8/17/15 noted the requirements for the positions to include:

1. High school Diploma or equivalent
2. Completion of an accredited program in Central Services Processing or six months of equivalent experience performing same duties in a Central Processing Department.
3. Certification through CBSPD or IAHCSMM required within 12 months of hire.






38269

Deficiency statement #3

Based on observation, interview and policy review, the facility failed to maintain a clean and sanitary environment in three of three endoscope closets and for the storage of patient medical supplies, resulting in the potential to spread infectious disease to all patients including but not limited to those requiring the use of endoscopes stored in any/all three closets. Findings include:

On 11/28/18 at 1020 in the operating room (OR) suite 2T30 deemed the "endoscopy suite" three endoscope (an instrument that can be introduced into the body to give a view of its internal parts) cabinets (storage for cleaned endoscopes) were observed to be used to store clean endoscopes. Three of three cabinet's mechanical ventilation systems were observed to have lint and dust accumulated in and on the grill of the system. At the time of observation (Registered Nurse, Director of OR) Staff Z was queried regarding who was responsible for maintaining and keeping the storage closets clean and if there was documentation as to the last time the closets were cleaned. Staff Z stated, "I'm not sure who cleans the fan part of these closets, I know it's not environmental services and no there is not documentation. I will call maintenance, they all need to be cleaned."

A Policy for cleaning and maintaining the clean endoscope closets, was requested at the time of observation and not received prior to exit.


21092


On 11/28/2018 at 11:30 a.m. dirt, debris, and patient supplies were observed under the storage shelving units in clean supply room 5R.24.

On 11/28/2019 at 11:45 a.m. dirt, debris, and patient supplies were observed under the storage shelving units in clean supply room 5N.24.

On 11/28/2019 at 12:00 p.m. dirt, debris, and patient supplies were observed under the storage shelving units in clean supply room 4l.19.

On 11/28/2018 at 12:15 p.m. dirt, debris, and patient supplies were observed under the storage shelving units in clean supply room 4U.15.

These findings were confirmed wth Staff XX facilities director at the time of observation.


39083

Deficient Practice #4:
Based upon observation, interview and record review the facility failed to provide a sanitary environment in the kitchen to prevent the transmission of foodborne and vectorborne communicable diseases. This deficient practice could potentially affect all inpatients, staff or visitors that consume food prepared from the kitchen.
Findings include:

On 11/27/18 at 10:15 AM, approximately 8 dead cockroach carcasses were observed in the drawer slides of a missing drawer at the prep table across from the cookline. At the time of observation, Cook "I" stated that they have had some roach issues in wet areas, but the roach issue has been recently resolved.

On 11/27/18 at 10:21 AM, Sous Chef "J" confirmed that they have had issues with cockroaches and stated that the pest control company services the dietary department twice a month.

On 11/27/18 at 10:26 AM, a partially decomposed mouse was observed in a glue trap under the sink across from the cookline. At the time of observation, Sous Chef "J" stated that the dietary staff do not have any part of removing or replacing traps, and that the pest control company is responsible for removing traps.

On 11/27/18 at 10:33 AM, a dead cockroach was observed in a trap on top of the dish machine.

On 11/27/18 at 10:40 AM, a dead cockroach was observed in the doorway between the corridor and kitchen, near the eyewash station.

On 11/27/18 at 10:47 AM, approximately 4 dead cockroaches were observed in a glue trap under the table next to the locked chemical locker.

On 11/27/18 at 11:34 AM, dead cockroach carcasses were observed in the drawer slides of the drawer underneath the coffee maker.

On 11/27/18 at 10:16 AM, a thick brown sludge mixed with food debris was observed behind the large reach-in cooler across from the cookline. At the time of observation, Sous Chef "J" was queried on the frequency of cleaning behind the large reach-in cooler and stated that he was unsure and that the cooler was scheduled to be removed from the kitchen.

On 11/27/18 at 10:33 AM, food debris, dishware (3 cups, and silverware), water, and dried spills were observed accumulating under the dish machine. At the time of observation, Sous Chef "J" was queried on the frequency of floor cleaning under the dish machine and stated, "It should be push broomed daily."

Record review of pest control summary reports, dated 11/17/18 noted that cockroaches had been treated for in the kitchen and cafeteria areas on 11/16/18, 11/6/18, 11/1/18, 10/23/18, 10/12/18. Roaches had been treated for in other areas of the facility besides the kitchen on: 11/13/18, 10/26/18, 10/19/18.
Record review of the "Pest Sighting Log" noted that staff had observed and reported cockroaches on: 11/16/18 (3 locations), 11/2/18, 10/29/18, 10/25/18, 10/15/18, 10/12/18.


26222

On 11/27/18 at 10:18 AM, during a tour of the kitchen, the food slicer was observed with dried on food debris on the guard surrounding the blade. During interview with Sous Chef "J" at this time, when asked how often the slicer is cleaned, Staff "J" stated that the slicer is cleaned after each use. When shown the debris on the slicer, Sous Chef "J" confirmed that was not considered cleaned.

On 11/27/18 at 10:30 AM, an opened and undated package of capicola and an opened and undated package of roast beef were observed in refrigerator 6 in the kitchen. Sous Chef "J" stated these products are used for sandwiches and should be marked with a discard date once opened. Sous Chef "J" was then observed to collect the food items and discard them into the trash container.

On 11/27/18 at approximately 11:45 AM, record review of the facility policy "Labeling and Dating Prepared Food Items", dated 05/18, noted "5 days" with "lunch meat once opened" listed below. This policy was observed posted in the kitchen outside of several walk in coolers.

Based on observation, interview and policy review the facility failed to follow policy and appropriate protocols, for care of surgical specimens and labeling, resulting in the potential of misdiagnosis or harm to one (#27) of one patient's specimens observed. Findings include;

On 11/28/18 at 1105 in operating room (OR) suite four, scrub technician Staff KK was observed placing used surgical instruments into a surgical casket and spraying the instruments with a clear spray. While Staff KK was collecting and spraying the instrument staff KK stated, "do you want to label this specimen?" The Circulating Nurse Staff LL responded, "yes, I have the labels here." In addition to the unlabeled tissue specimen on the back table, two culturette tubes with no patient identifier were observed lying on the computer work space tray.

On 11/28/18 at 1050 during an interview Staff LL was queried as to whom the specimens belonged to and what the policy on labeling specimens was. Staff LL stated, the specimens are abdominal wound bed tissue and abdominal wound cultures, from patient (#27) who was already taken to PACU (post anesthesia care unit). I usually label specimens before the patient is taken out of the room, but this was a big case."

On 11/28/18 at 1100 during an interview, OR Manager Staff AA stated, "the surgical specimens should be labeled at the point of care while the patient is still there."

Review of the facility policy "Title: Patient Identification, Policy No: 1CLN 044, effective date: 8/31/17" ...Page 3 of 4 "Safe Specimen Labeling, W. Identification of the patient and labeling of specimens must occur at the point of collection (at the bedside). X. For any specimen there are necessary items that need to be present on the label and they must all be correct."