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Based on observation, staff interview, and policy review, the facility failed to ensure supplies in the pediatric cart were not outdated. This deficient practice has the potential to expose patients to ineffective supplies in an emergency situation.

Findings Include:

-Observation on 2/5/2018 at 1:45 PM, Emergency Room #2 revealed the following outdated IV insertion catheters in the pediatric crash cart:

3 Autoguard Insyte size 22 expired 1/ 2018
2 Autoguard Insyte size 20 expired 1/2018

Interview on 2/5/2018 at 2:00 PM, Nursing staff (B) stated, "Those shouldn't be in there." She removed the outdated supplies from the working area.

- Review on 2/7/2018 at 4:00 PM of Policy titled, "Infection Prevention and Control" directed, Central service staff shall follow all infection prevention and control policies and procedures by checking and returning of outdated items to Central Services.

Based on observation, interview and document review, the facility failed to ensure physical therapy equipment, the hydrocollator (a machine with hot water inside holding hot packs for patient use), was in safe working condition. The facility failed to check and document hydrocollator water temperatures for the hydrocollator in the physical therapy treatment room. This deficient practice has the potential to expose patients to harm in the form of injury or burns.

Findings include:

- Observation on 2/5/2018 at 1:04 PM, Physical Therapy Treatment room revealed a hydrocollator without a corresponding temperature log.

Interview on 2/5/2018 at 1:04 PM, Physical Therapy Staff C explained that they do not measure water temperatures or keep a log of temperatures for the hydrocollator.

- Review on 2/7/2018 of Document titled "Instructions of Operation of the Hydrocollator" directed, water temperature in the hydrocollator is approximately 160 degrees F, and the water scalding temperature is about 120 degrees F.

Based on observation, staff interview, and policy review the facility failed to ensure medications in the Physical Therapy (PT) department were useable and ensure one of two medication refrigerators (in the swing bed medication room) only stored medications. These deficient practices have the potential to expose patients to ineffective or contaminated medications.

Findings Include:

-Observation on 2/5/2018 at 1:00 PM in the Physical Therapy (PT) department, treatment room revealed 1 - 32 ounce container of 91% Isopropyl alcohol open and ¾ used with expiration date of 6/2014.

- Observation on 2/7/2018 at 2:55 PM in the Swing Bed Unit Medication Room Refrigerator revealed 12 packages of hearing aid batteries stored in a basket with various insulin pens.

Interview on 2/7/2018 at 2:55 PM, LPN Staff P acknowledged the batteries should not be stored with medications in the refrigerator and explains that the facility no longer uses the batteries anyway.

- As of 2/7/2018, the facility failed to provide a policy regarding medication refrigerator storage.

Based on observation, staff interview, and policy review the facility failed to: 1. Ensure the decontamination showers had a splash shield; 2. Ensure a hopper (a flushable basin) had a splash shield and or personal protective equipment (PPE) (mask, gown, and gloves) available for use; 3. Failed to document water changes and maintain a cleaning schedule for the hydrocollator; 4. Ensure proper cleaning of gait belts in the physical therapy treatment room; 5. Ensure proper bleach to water ratio for the sanitation of dishes for the three basin sinks in the facility's kitchen; 6. Ensure the kitchen grill was in sanitary condition; and 7. Ensure the facility's washing machine reached adequate temperature. These deficient practices have the potential to expose patients and staff to harmful bacterial and infectious diseases.

Findings Include:

- Observation on 2/6/2018 at 12:30 PM, Decontamination shower located in the laboratory revealed the shower lacked a splash containment device to prevent cross contamination of the surrounding area while using the shower.

Interview on 2/6/2018 at 12:30 PM, Maintenance Staff D indicated they had not thought about the shower requiring a curtain or splash shield because it was located in a separate area in the old hospital, but agreed one should be put in place.

Review on 2/7/2018 at 9:36 AM of Policy titled "Standard Precautions" directs, Standard precautions recommend wearing gloves for any known or anticipated contact with blood, body fluids, tissue, mucous membrane, and non-intact skin. If the task or procedure being performed may result in splashing or splattering of blood or body fluids to the face, a mask and goggles or face shield should be worn.

- Observation on 2/6/2018 at 12:35 PM, the hopper located in the soiled utility room lacked a splash shield and the room failed to contain personal protective equipment PPE. Failure to have either a splash shield or PPE has the potential to cause staff to be exposed to contaminated materials.

Interview on 2/6/2018 at 12:35 PM, Registered Nurse Staff B indicated the room should contain PPE and acknowledged there was not any PPE located inside the soiled utility room.

- Review on 2/7/2018 at 9:36 AM of Policy titled "Standard Precautions" directed, Standard precautions recommend wearing gloves for any known or anticipated contact with blood, body fluids, tissue, mucous membrane, and non-intact skin. If the task or procedure being performed may result in splashing or splattering of blood or body fluids to the face, a mask and goggles or face shield should be worn.


- Observation on 2/8/2018 at 11:30 AM, Hydrocollator located in the physical therapy room revealed no cleaning log or water changing schedule.

Interview on 2/8/2018 at 11:30 AM, Physical Therapy Assistant Staff C confirmed they do not have a cleaning schedule or water changing schedule for the hydrocollator.

- The facility failed to provide a policy directing staff to maintain a cleaning schedule with a record of water changes.

- Review on 2/7/2018 at 11:50 AM of the Hydrocollator Models D-3, E-1, E-2 Master Heating Unit's operating manual directed, the tank should be drained and cleaned periodically, usually every two (2) weeks.


- Observation on 2/5/2018 at 1:04 PM, Physical Therapy Gym Treatment Room revealed three fabric gait belts on the side table.

- Interview on 2/7/2018 at 4:17 PM, Physical Therapist Staff N explained the fabric gait belts are wiped down occasionally by the physical therapy technician, but they are never laundered.

- As of 2/7/2018, the facility failed to develop and implement a policy regarding the cleaning of fabric gait belts.


- Observation on 2/7/2018 at 8:54 AM of the kitchen revealed a three-basin sink with dishes soaking in soapy water in the first basin and water filling approximately one-third of the other two sinks. Kitchen Supervisor Staff O explained the second sink was plain water for rinsing dishes and the third sink was bleach-water for sanitizing the dishes before they are set out to dry.

Interview on 2/5/2018 at 8:54 AM, Kitchen Supervisor Staff O explained they did not know how many gallons were in the third sink, but they fill it about half-way and add a capful of bleach to it.

- Review on 2/7/2018 at 8:54 AM of Bleach Container Label directed, glass, dishware, utensils: 1 Tablespoon to 1 gallon. After washing, soak for at least 5 minutes in bleach solution. Drain and let air dry.


- Observation on 2/7/2018 at 9:12 AM of the kitchen revealed a large kitchen grill with a white residue and black charred pieces of food between the grill channels.

Interview on 2/7/2018 at 9:12 AM, Kitchen Supervisor Staff O explained it was from the night before and staff are supposed to clean it after use. Supervisor Staff O shared the status of the grill was not up to their standards.


- Observation on 2/7/2018 at 9:12 AM of the kitchen revealed 21 various containers of spices near the stove covered in a sticky, gritty residue.

Interview on 2/7/2018 at 9:12 AM, Kitchen Supervisor Staff O acknowledged the spice containers were dirty, and explains they should have checked these items.

- Review on 2/7/2018 of Policy titled, "Infection Prevention and Control: Nutritional Services" directed, Nutritional Services Director shall: Ensure clean, sanitary work areas, storage areas and equipment for the equipment and storage of supplies, and all equipment will be thoroughly cleaned after use.

- Observation on 2/7/2018 at 9:00 AM in the laundry department revealed there is no personal protection equipment (PPE) supplies available for staff to sort soiled linens or linens from isolation. The current water temperature for washer #1 is 158 F and washer #2, in the rinse cycle, is 118 F. Laundry department staff have not recorded water temperatures for their washing machines since 9/20/2017.
Interview on 2/7/2018 at 9:30 AM, Laundry staff (M) stated, "we have been having trouble with regulating the cold water and that they have not recorded water temperatures since they moved in the new building."

- Review on 2/7/2018 at 9:30 AM of Document titled, "Laundry-Quality Assurance" water temperatures for their washing machines have not been recorded since 9/20/2017.

- Review on 2/7/2018 of Policy titled, "Laundry Policy and Procedures" directed, laundry personnel wash all linens with Clorox and hot water no less than 165 degrees.

- Review of Policy titled "Infection Prevention and Control" policy for housekeeping stated, staff will wear gloves and other appropriate protective equipment (PPE) when handling soiled linen.

Based on observation, staff interview, and policy review, the facility failed to ensure food was labeled and dated properly in the patient's food refrigerator, and failed to store food products away from harmful cleaning products in the nutrition room. This deficient practice has the potential to expose patients to foodborne illness and/or harmful chemicals.

Findings include:

- Observation on 2/5/2018 at 1:45 PM, Patient food refrigerator revealed a plastic container containing cooked food items without a name or date on the package.

Interview on 2/5/2018 at 1:45 PM, Registered Nurse Staff B confirmed the food was brought in by a patient's family and the leftovers were placed in the refrigerator without a name or date on the items.

The facility failed to provide a policy directing staff to ensure all foods are dated to ensure food is safe for consumption.

- Observation on 2/5/2018 at 1:50 PM, Nutrition Room lower cabinet revealed cleaning supplies stored with un-popped popcorn and a popcorn maker.

Interview on 2/5/2018 at 1:50 PM, Registered Nurse Staff B confirmed there should not ever be food items stored with cleaning supplies.

Review on 2/7/2018 at 9:25 AM of Policy titled "Infection Prevention and Control" directed, all toxic cleaning products shall be properly labeled and stored in a locked separate area from food products.

Based on document review and staff interview, the facility failed to include in their Swing Bed Rights that the facility will provide orientation for discharge and transfer to Patient Rights documents given to all swing bed patients. Failure to provide notification puts all swing bed patients at risk of inappropriate transfer.

Findings Include:

- Review on 2/6/2018 of Document titled, "Swing bed Patient Rights" lacked the right to the orientation for discharge and transfer provision.

Interview on 2/7/2018 at 10:30 AM, Chief Nursing Officer (CNO) Staff B explained the facility has never had to transfer a patient to another facility other than in an emergency to a hospital.