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Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure intravenous (IV) sites and tubing were labeled; (A-0749)
- Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) and glove changes when providing patient care; (A-0749)
- Prepare a sterile field for the removal of sutures or staples; (A-0749)
- Prepare a clean work surface or barrier prior to patient care; (A-0749)
- Date opened sterile water for patient care; (A-0749)
- Date infusing medication; (A-749)
- Label supplies with an open date and remove expired supplies; (A-0749)
- Remove personal food items and discharged patients' food from the patient nutrition rooms; (A-0749)
- Ensure expired food was not available for patient use; (A-0749)
- Ensure food was dated in patient nutrition rooms and in the kitchen; (A-0749)
- Clean the kitchen dishes thoroughly prior to placement in the clean dish rack; (A-0750)
- Clean all surfaces and equipment in the patient rooms during terminal cleaning; (A-0750)
- Clean the microwave, refrigerators, ice machines in the patient nutrition rooms; (A-0750)
- Clean floors, sinks, hoppers and supply bins in supply rooms, clean utility rooms and dirty utility rooms; (A-0750) and
- Maintain a clean and sanitary environment. (A-0750)

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The hospital census was 356.


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Based on observation, interview and policy review, the hospital failed to:
- Label the intravenous (IV, in the vein) site for 10 patients (#6, #12, #13, #36, #37, #41, #44, #45, #46 and #60), observed and label the IV tubing for five patients (#5, #25, #26, #38 and #44) of 22 patients observed.
- Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) and glove changes when providing care for three patients (#17, #26 and #39) of 19 patients observed.
- Prepare a sterile field for the removal of sutures or staples for one patient (#39) of one patient observed.
- Prepare a clean work surface or barrier prior to performing patient care of 12 patients (#6, #24, #25, #26, #27, #35, #36, #37, #39, #40, #45 and #60) of 15 patients observed.
- Date an opened sterile water bottle in one patient (#29) of one patient room observed.
- Date an infusing medication for one patient (#5) of one patient room observed.
- Label supplies with an open date and remove expired supplies from storage areas.
- Remove expired food, label food when opened or with the expiration date in patient nutrition rooms and the kitchen.

These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection.

Findings included:

Review of the hospital's policy titled, "Vascular Access (IV) - Clinical Guidelines," dated 08/20/24, showed all IV dressings and lines should be labeled with the date and time they were changed.

Observation on 08/04/25 at 3:10 PM, showed no label on the IV dressing for Patient #6.

Observation on 08/04/25 at 2:50 PM, showed no label on the IV dressing for Patient #12.

Observation on 08/05/25 at 8:35 PM, showed no label on the IV dressing for Patient #13.

Observation on 08/05/25 at 8:55 AM, showed no label on the IV dressing for Patient #36.

Observation on 08/05/25 at 9:19 AM, showed no label on the IV dressing for Patient #37.

Observation on 08/05/25 at 10:50 AM, showed no label on the IV dressing for Patient #41.

Observation on 08/05/25 at 10:50 AM, showed no label on the IV dressing for Patient #44.

Observation on 08/05/25 at 9:05 AM, showed no label on the IV dressing for Patient #45.

Observation on 08/05/25 at 9:20 AM, showed no label on the IV dressing for Patient #46.

Observation on 08/06/25 at 9:50 AM, showed no label on the IV dressing for Patient #60.

Observation on 08/04/25 at 2:55 PM, showed Patient #5 had unlabeled IV tubing.

Observation on 08/05/25 at 9:30 AM, showed Patient #25 had unlabeled IV tubing.

Observation on 08/05/25 at 9:30 AM, showed Patient #26 had unlabeled IV tubing.

Observation on 08/05/25 at 9:31 AM, showed Patient #38 had unlabeled IV tubing.

Observation on 08/05/25 at 10:50 AM, showed Patient #44 had unlabeled IV tubing.

During an interview on 08/06/25 at 9:55 AM, Staff HHH, Registered Nurse (RN), stated that IV sites were to be dated and timed when started.

Review of the hospital's policy titled, "Infection Control Manual," dated 10/24/24, showed:
- Gloves should be worn as an additional measure, not as a substitute for hand hygiene.
- Hand Hygiene should be performed before and after any patient contact.
- Hand Hygiene should be performed prior to applying gloves and immediately after glove use.

Observation on 08/05/25 at 9:40 AM, showed Staff LL, RN, performed hand hygiene and donned gloves prior to providing care for Patient #39. She logged into the computer and confirmed the patient's identification. She then removed her right glove, held it in her left, used her right hand to scan the patient's armband and then placed the glove back on her right hand. She proceeded to prepare the patient's medications. She spiked the IV bag, primed the IV tubing, then removed her right glove, held the glove in her left hand, with the IV bag and tubing in her left hand, and scanned all the medications with her right hand. She then placed the glove back on her right hand. She used a saline flush to check the patency of the patient's IV catheter, then removed her right glove, held it in her left hand and used her right hand to hang the IV bag on the IV pole. She placed the glove back her right hand and started the IV pump. She then proceeded to place all the patient's medication in a cup. After placing the medications in the cup, she removed her right glove to pour water into the patient's cup. At that time, she dropped the glove she had removed from her right hand and stated, "oh I guess I will have to get a new glove now." She did not perform hand hygiene prior to donning the new glove.

Observation on 08/05/25 at 9:00 AM, showed Staff GG, RN, placed her hand in her pocket, answered the phone and failed to perform hand hygiene prior to donning gloves. She then prepared medications and handed Patient #17 his inhaler. Staff GG removed the dirty gloves and failed to perform hand hygiene prior to donning a second pair of gloves. She proceeded to prepare and administered additional medication by mouth. Staff GG then placed her hand in her pocket and answered the phone, placed the phone back in her pocket with gloved hands. She continued to prepare and scan medications with the same gloves. Staff GG then reached into her pocket and removed alcohol swabs. She removed the dirty gloves, failed to perform hand hygiene and donned a third pair of gloves. She proceeded to administer a subcutaneous (under the skin) medication. Staff GG then removed her gloves and threw away dirty trash with bare hands. Staff GG missed three opportunities for hand hygiene between glove changes during medication administration.

Observation on 08/05/25 at 9:40 AM, showed Staff V, RN, picked up a dropped transdermal patch (a medical device, typically an adhesive patch, that delivers medication through the skin and into the bloodstream) off the floor and did not perform hand hygiene and glove change before applying it to Patient #26's arm.

During an interview on 08/05/25 at 9:20 AM, Staff GG, RN, stated that she changed her gloves when dirty things were touched, but would have performed hand hygiene between glove changes only if she left the room and returned. She stated that it was not a problem to place gloved hands in pockets. Staff GG stated she should have possibly performed hand hygiene after she touched objects in the room.

Review of the hospital's undated, untitled, procedure for removing sutures or staples showed that a sterile field would be set up for both staple extractor and sterile suture removal kits.

Observation on 08/05/25 at 9:31 AM, showed Staff KK, RN, removed staples and sutures from Patient #39's surgical site. Neither the staple extractor kit, nor the sterile suture removal kit, were set up on a sterile field. Both items were placed directly on the patient's bedside table with his food, cell phone and spit cup.

Review of the hospital's policy titled, "Infection Control Manual," dated 10/24/24, showed:
- Physical separation between clean and contaminated supplies;
- Prepare medications in areas physically separated from those with potential blood/body fluid contamination; and
- Barriers were to be used to protect surfaces from blood contamination during blood sampling.

Observation on 08/04/25 at 3:10 PM, showed Staff O, RN, failed to create a clean work surface or use a barrier for medication administration for Patient #6.

Observation on 08/05/25 at 9:05 AM, showed Staff U, RN, failed to create a clean work surface or use a barrier for medication administration for Patient #24.

Observation on 08/05/25 at 9:30 AM, showed Staff W, RN, failed to create a clean work surface or use a barrier for medication administration for Patient #25.

Observation on 08/05/25 at 9:40 AM, showed Staff V, RN, failed to create a clean work surface or use a barrier for medication administration for Patient #26.

Observation on 08/05/25 at 11:10 AM, showed Staff Z, Patient Care Technician (PCT) entered the isolation room of Patient #27 with a supply kit for performing a blood glucose test. The PCT placed the kit on a bedside table without a barrier, touched the patient with gloved hands, used the soiled gloves to take supplies out of the kit, and then removed all the supplies from the patient room. The supplies were then taken out of the room to be used for all other blood glucose tests on the unit.

Observation on 08/05/25 at 10:10 AM, showed Staff EE, RN, placed IV start supplies directly on Patient #35's lap and bed.

Observation on 08/05/25 at 8:55 AM, showed Staff KK, RN, placed all supplies and medication in Patient #36's windowsill.

Observation on 08/05/25 at 9:19 AM, showed Staff OO, RN, placed Patient #37's medication on top of the dirty linen cart lid.

Observation on 08/05/25 at 9:40 AM, showed Staff LL, RN, placed Patient #39's medications on a stack of papers she brought into the room and placed IV supplies on the patient's counter.

Observation on 08/05/25 at 10:08 AM, showed Staff NN, RN, placed drain care supplies directly on Patient #40's lap and bed.

Observation on 08/05/25 at 9:05 AM, showed Staff SS, RN, failed to create a clean work surface or use a barrier for medication administration for Patient #45.

Observation on 08/06/25 at 9:50 AM, showed Staff HHH, RN, placed blood draw supplies directly on Patient #60's bed.

During an interview on 08/06/25 at 9:55 AM, Staff HHH, RN, stated that the bed was considered dirty and a clean work surface should have been used.

Observation with concurrent interview on 08/05/25 at 9:35 AM, showed in Patient #29's room, a bottle of sterile water opened and undated. Staff S, Nurse Manager, stated that bottles of sterile water were to be dated when opened.

Observation on 08/04/25 at 2:30 PM, showed no start date recorded on a bag of normal saline for Patient #5.

Review of the hospital's policy titled, "Patient Transport-Restocking of Supplies-Guidelines," dated 07/22/25, showed the Care Team Associates-Support will supplement clinical staff with restocking of supplies within an assigned work area and are to inspect all items for expiration dates and remove any expired products.

Observation on 08/04/25 at 2:05 PM, on the medical unit, at the nurse's station, showed two blood glucose strip vials with no opened date.

Observation with concurrent interview on 08/04/25 at 2:50 PM, in the Integrated Medical Unit storage room, showed a rectal tube that expired on 06/30/25. Staff I, Charge RN, stated that Distribution was responsible for the removal of outdated supplies.

Observation with concurrent interview on 08/04/25 at 3:40 PM, in the Medical Intensive Care Unit (ICU, a unit where critically ill patients are cared for) storage room, showed 24 lubricated gauze packages that expired on 08/2022, one tubing connector that expired on 03/31/25, one wound vacuum assisted closure (wound VAC, a device that decreases air pressure on a wound to help it heal more quickly) connectors that expired on 06/30/23, four that expired on 07/31/23 and one that expired on 03/31/25. Staff L, Acute Care Nurse Educator, stated that Distribution was responsible for the removal of outdated supplies.

Review of the hospital's policy titled, "Dietary Services-Dining & Nutrition-Floor Stock-Guideline," dated 06/12/23, showed patient refrigerators were for patient food items only. Staff were responsible for discarding expired food and beverages.

Observation on 08/05/25 at 9:20 AM, on the medical/surgical unit, showed the patient nutrition refrigerator contained two food items labeled with discharged patient's names and an expired milk.

Observation on 08/05/25 at 9:35 AM, on the medical/surgical unit, a patient refrigerator and freezer contained personal food items.

Observation with concurrent interview on 08/05/25 at 9:35 AM, on the medical/surgical unit, a patient refrigerator contained expired yogurt and the freezer contained a personal food item. Staff SSS, Infection Prevention, stated that removing expired food was everyone's responsibility and personal food should not be in patient refrigerators.

Observation on 08/05/25 at 12:45 AM, in the kitchen, showed three bags of pasta and a milk container with no opened date.

Observation on 08/05/25 at 10:20 AM, in the kitchen, showed approximately 20 small cup containers of granola filled from a bulk supply bin with no label or date showing expiration.

Observation with concurrent interview on 08/05/25 at 12:45 AM, in the kitchen, showed expired cornmeal stuffing. Staff XX, Nutrition Director, stated that expired food should be discarded and open food should have a date label.

During an interview on 08/06/25 at 2:00 PM, Staff NNN, Infection Control Manager, stated that IV sites and tubing were to be dated. Hand hygiene was expected before any care was given to a patient and between glove changes. Gloves were to be changed, and hand hygiene performed, after touching contaminated inanimate objects (areas or equipment that was not clean) in the room or placing a hand in a pocket. A patient's room was considered contaminated. She expected that a clean work surface or barrier was used when medications were prepped or a procedure was performed. Sterile water bottles were to be dated when opened. Oldest supplies were placed in the front, so they were used first, and she expected that a designated person check for outdates one time a month. Staff food should not be stored in patient refrigerators. She expected no expired food or beverages in the patient nutrition areas.

During an interview on 08/06/25 at 3:30 PM, Staff RRR, Chief Nursing Officer Executive (CNE), stated that IV sites and tubing were to be dated. She expected hand hygiene was performed between glove changes and before patient care was given. When inanimate objects were touched, staff were to remove gloves and perform hand hygiene. A clean work surface or barrier was to be used when a procedure or dressing change was performed. Sterile water bottles were to be dated when opened. It was everyone's responsibility to check for outdated food and supplies.


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Based on observation, interview and policy review, the hospital failed to:
- Clean the kitchen dishes thoroughly prior to placement in the clean dish rack;
- Clean all surfaces and patient equipment in a terminal cleaned (a thorough, deep-cleaning of a room to include the ceiling, walls and floors) patient room;
- Clean the microwave, refrigerators, drawers, shelving, coffee/tea machines and ice machines in the kitchen and patient nutrition areas;
- Clean floors, sinks, hoppers and supply bins in supply rooms, clean utility rooms and dirty utility rooms; and
- Maintain a clean and sanitary environment.

Findings included:

Review of the hospital manual titled "Infection Control" dated 10/21/24, states that standard precautions are used for all patient care areas to provide a consistent approach in protecting healthcare providers and patients from infection, which includes the cleaning and disinfecting of patient care equipment and environmental surfaces.

Observation on 08/04/25 at 3:00 PM, on the medical unit, showed a terminally cleaned patient room had a dirty floor with blood drops and sticky areas, trash on the floor, and visible dirt on a vital signs machine.

Observation on 08/05/25 at 9:30 AM, on the cardiology unit, showed a patient nutrition area with visible dirt on the floor, a refrigerator with rust halfway up the right side and ice machine with hard water build up around the dispenser.

Observation on 08/05/25 at 10:20 AM, showed a large tea canister with black crusty rings around the inside of the container being used to make tea in the patient kitchen.

Observation on 08/05/25 at 10:20 AM, showed dirty pans with food residue present on the clean rack of the patient kitchen.

During an interview on 08/05/25 at 10:30 AM, with Staff AA, Kitchen Manager, stated that the tea cannister should be cleaned daily and it didn't look like it had been cleaned prior to use. He further added he did not expect the granola cups to be undated, nor for dirty dishes to be placed on the clean rack.

Observation on 08/04/25 at 3:10 PM, showed a medication room on a medical unit had a dirty utility sink with unidentified brown and white crust accumulated around the top surface. The floor had several areas of accumulated dust and pieces of trash.

Observation on 08/04/25 at 3:10 PM, showed a medication room on a medical unit had a dirty floor with accumulated dust, sticky areas and trash.

Observation on 08/04/25 at 3:12 PM, showed a patient nutrition room on a medical unit with an overflowed trash can, an ice machine with hard water build up, a coffee machine with coffee splatters and accumulated dirt and the entire floor was sticky.

Observation on 08/04/25 At 3:15 PM, showed the supply room floor of a medical unit was dirty and had pieces of trash present.

Observation on 08/04/25 at 3:20 PM, showed a supply room on the medical unit with trash cans overflowed and the floor had spills, dust and pieces of trash.

Observation on 08/05/25 at 9:25 AM, showed a medication room on the medical/surgical unit that had accumulated dust and sticky residue on the floor.

Observation on 08/05/25 at 9:45 AM, showed a soiled utility room on the medical/surgical unit with a dirty hopper (a sink or receptacle for discarding clinical liquid waste) that held dark brown water.

Observation on 08/05/25 at 3:10 PM, showed overflowing trash cans in Patient #6's room on the Surgical Services unit.

Observation on 08/05/25 at 9:50 AM, on the Oncology unit nutrition area showed dirty drawers with sticky residue on edges and inside drawers. The floor of the nutrition area had dirt present and was sticky to the touch.

Observation on 08/05/25 at 0900 AM, showed the soiled utility room of the Bone Marrow Transplant unit with dirty linens not confined inside a bag, lying on the floor. The nutrition room on the same unit, had spills on and inside drawers. The freezer area of the refrigerator had a collection of brown dust and debris from opening boxes inside the freezer.

Observation on 08/04/25 at 3:25 PM, showed a patient nutrition room on the medical unit with two overflowed trash cans, a microwave with multiple food splatters/chunks of food and an ice machine with accumulated hard water.

Observation on 08/05/25 at 11:30 AM, in the Emergency Department (ED) showed spills on the outside and inside of the drawers in the nutrition area of unknown substance.

Observation on 08/04/25 at 3:37 PM, in Patient #7's room on a medical unit, showed a floor with dust accumulations and sticky residue. Patient #7 stated the room was very soiled when she arrived, her bedside table was sticky, and the bathroom toilet and sink had hair in it. She was concerned about wearing her socks while walking around the room, as she would track dirt into her bed. She further stated the room had not been mopped since she arrived seven days ago.

During an interview on 08/04/25 at 3:20 PM, Staff N, Acute Care Educator, stated that the sink should be clean and the floor free of debris.

During an interview on 08/06/25 at 2:55 PM, with Staff QQQ, EVS Manager, stated that the patient rooms should be mopped daily, trash removed daily and sinks to be cleaned as needed, in patient care areas.

During an interview on 08/06/25 at 3:30 PM with Staff RRR, CNE, stated she expected nutrition areas and patient rooms to be cleaned daily and as needed.


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