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Based on observation, record review, and staff interviews, the hospital's Governing Body failed to ensure:

A. the 5th floor and Emergency Department had a working emergency call system for patients and staff to utilize in the event of an emergency.

B. the hospital staff had a standardized process for calling a "code blue" in the event a patient becomes unresponsive from a cardiopulmonary arrest.

Cross Refer to tag: A0144

C. the hospital has the available funds to purchase nutrition for the patients.

An interview with Administrator, Chief Nursing officer (CNO), and Quality Director on 02/07/2024 at 9:30 AM revealed that the leadership group had taken their personal credit cards and purchased milk and bread for the dietary department for patient nutritional needs. The hospital had to close the cafeteria for a week due to lack of dietary staff to work in the dietary department in January 2024. Leadership cross trained Patient Care Technicians to run the food tray line.

D. the hospital's infection prevention program provided a clean and sanitary environment in the following 10 of 10 departments: dietary, dialysis, emergency department, Labor and delivery, second floor, fourth floor, fifth floor, seventh floor, eight floor, and surgical department.

E. Identify and correct the presence of systemic infection control issues such as dried blood in the operating room, "clean" equipment covered in dust and dirt, broken exterior windows on floors three through eight (3-8) with insulation exposed to weather elements, interior windows and ventilation ducts covered with cobwebs, dirt, dust, and a thick black substance.

F. the Dietary Department had sanitary conditions, and safe food practices that prevent foodborne illness and healthcare-associated illness that can compromise patients. There were expired foods available for preparation and consumption. There was no consistent process for the labeling of food items' with expiration dates.

Cross refer to Tag: A0750


The deficient practices were identified under the following Condition of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Based on observation, record review, and staff interview, the hospital failed to ensure:

A. a critical patient was being monitored by a registered nurse while undergoing hemodialysis treatment.

B. the 5th floor and Emergency Department had a working emergency call system for patients and staff to utilize in the event of an emergency.

C. the hospital staff had a standardized process for calling a "code blue" in the event a patient became unresponsive from a cardiopulmonary arrest.

D. follow hospital policies titled, "Code Blue, Response to" and "Patient's Rights and Responsibilities".

Cross Refer to Tag: A 0144


The deficient practices were identified under the following Condition of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Based on observation, record review, and staff interview, the hospital failed to:

A. ensure a critical patient was being monitored by a registered nurse while undergoing hemodialysis treatment.

B. ensure the 5th floor and Emergency Department had a working emergency call system for patients and staff to utilize in the event of an emergency.

C. ensure the hospital staff had a standardized process for calling a "code blue" in the event a patient became unresponsive from a cardiopulmonary arrest.

D. follow hospital policies titled, "Code Blue, Response to" and "Patient's Rights and Responsibilities".

This deficient practice had the likelihood to cause harm by not having a system to identify a patient in need of assistance which could result in patient harm, injury, and/or death due to a delay in care.


HEMODIALYSIS TREATMENT ROOM

A tour of the hospital's Hemodialysis Treatment Room was conducted on 02/07/2024 at 10:10 AM with Staff # 1.

The surveyor observed Patient # 4 was receiving hemodialysis treatment. At the time of the observation, there was no Registered Nurse with the patient. The patient's curtains were pulled shut and the patient's dialysis access was covered so that the patient and their access could not be visualized. Staff # 1 called out to the patient's Nurse (Staff # 16) and there was no response. The patient's Registered Nurse could not be found for 2 minutes.

This deficient practice had the likelihood of resulting in harm to all dialysis patients receiving hemodialysis at the hospital due to the increased risk of bleeding dialysis patients have during treatment. Ensuring visibility of the patient's dialysis access is imperative in the early recognition of bleeding in dialysis patients.

During an interview with Staff # 16 on 02/07/2024 at 10:15 AM, Staff # 16 was questioned about the status of Patient # 4. Staff # 16 stated, "The patient is critical. She came in with a very high potassium, she was sweating and very hot. She had to be dialyzed emergently."


EMERGENCY DEPARMENT

A tour of the hospital's Emergency Department was conducted on 02/07/2024 at 10:30 AM with Staff # 1 and # 10.

The surveyor observed Room # 9 was out of service due to a broken call light.

In an interview with Staff # 1 on 02/07/2024 at 10:40 AM Staff # 1 stated, "Room # 9 is out of service, the call light does not work so we have not admitted patients to that room since the issue was identified."

The surveyor then entered Room # 4 and tested the call cord. The call cord did not work and there was no response from the hospital's staff. Staff # 1 also attempted to pull the call cord and a red light appeared on the wall but there was still no response from hospital staff. Staff # 20 (ED Clerk) was responsible for answering call lights.
Staff # 1 called the unit clerk (Staff # 20) and it was confirmed Staff # 20 was not alerted to the call from room # 4.


The surveyor observed there were no "code blue" buttons in any of the Emergency Department rooms. A code blue is an event in which a patient becomes unresponsive due to cardiopulmonary arrest. A code blue button is used to alert other staff members of the patient's unresponsiveness so that additional help can be obtained quickly. The surveyor interviewed the Emergency Department RN (Staff # 11) on 02/07/2024 at 10:45 AM. Staff # 11 stated, "If I find a patient unresponsive, I yell for help very loudly and pull the call cord completely out of the wall. When the call cord is unplugged from the wall it will continue to alarm until it is plugged back into the wall."



MEDICAL-SURGICAL 5th FLOOR

A tour of the hospital's Medical Surgical Unit located on the 5th floor was conducted on 02/07/2024 at 11:05 AM with Staff # 1 and # 8.

The surveyor observed there were no working call lights or code blue buttons in any of the rooms on the 5th floor.

An interview with Staff # 1 and # 8 confirmed the call system on the 5th floor had been broken since January 3rd, 2024, and patients had been using desk bells to alert the hospital staff when assistance was needed. Staff # 1 confirmed the average daily patient census on the 5th floor had been 25-30 patients since January 3rd. At the time the tour was conducted there were 8 patients admitted to the 5th floor.


A review of the hospital's policy, "Code Blue, Response to" with an approval date of 08/03/2023 revealed the following:

"POLICY: In the event of a cardiac and/or respiratory arrest (Code Blue), hospital staff will initiate lifesaving interventions based on their training and competency level, unless the patient has a documented Do Not Resuscitate order (DNR) by the physician.
The intent and purpose of this policy is to ensure prompt response and delegation of healthcare providers during a Code Blue. This policy is to be broadly applied and is intended for use throughout the facility.

SCOPE: This policy applies organizational-wide.

PROCEDURE:

RESPONSE:
1. Upon recognition of a Code Blue situation in the hospital, the first person on the scene will establish unresponsiveness and immediately call for help by dialing 7777 and reporting "Code Blue", followed by the location of the Code Blue. The hospital PBX operator will then use the hospital's overhead system to announce, "Code Blue and location"."


A review of the hospital's policy titled, "Patient's Rights and Responsibilities" with a revision date of February 2023 revealed the following:

"POLICY:

In compliance with applicable state laws, and in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services issued pursuant of these statues at Title 45 Code of Federal Regulations Parts 80, 84, and 91 every patient of a Steward Health Care System hospital has access to information about his/her rights and responsibilities as a patient.
The complete and up-to-date patient rights and responsibilities document is provided to patients on admission, or upon request. Copies are available for distribution throughout the hospital.
Excerpts of Patient Rights and Responsibilities is visibly posted and available in the main lobby, all registration areas, and in other key waiting areas around the hospital and/or other locations under the Hospital license as well as on the Hospital intranet webpage when available. Welcome guides, when available, will also have information specific to Patient Rights and Responsibilities.
Hospital staff members are committed to ensuring that patients are aware of their rights and responsibilities while providing patients with care that is of the highest quality.
Under this policy, the rights and responsibilities of minor patients and/or incapacitated patients shall apply to their parents, guardians, and/or surrogate decision-makers.
The hospital does not discriminate against any person on the basis of age, gender, race, national origin, religion, sexual orientation, gender identity, or disabilities in admission, treatment, or participation in its programs, services, and activities.
All hospital staff, medical staff members, and contracted agency staff performing patient care activities will observe all patient rights.
All patients/representatives will follow the patient's responsibilities as noted.

PROCEDURE ...

2. Patient Rights:
*Be informed of his/her rights as a patient in advance of, or when discontinuing care. The patient may appoint a representative to receive this information should he/she so desire ...
*Receive considerate and respectful care provided in a safe environment, free from all forms of abuse, neglect, harassment, or exploitation ...."

Based on observations, record review, and staff interviews, the facility failed to ensure the infection prevention and control program maintained a clean and sanitary environment to avoid sources and transmission of infection in the Hemodialysis Unit, Emergency Department, Medical/Surgical Second Floor, Medical/Surgical Fifth floor, Fourth floor, Dietary Department, Seventh/Eighth-floor Employee Offices, Labor and Delivery, Surgical Department, Cafeteria and Outdoor Loading Dock.
Also, the hospital staff failed to follow the hospital policy, "Infection Control Program Policy".

Cross refer to Tag: A0750

The deficient practices were identified under the following Condition of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Based on observations, record review, and staff interviews, the facility failed to ensure the infection prevention and control program maintained a clean and sanitary environment to avoid sources and transmission of infection in the 11 of 11 areas for Hemodialysis Unit, Emergency Department, Medical/Surgical Second Floor, Medical/Surgical Fifth floor, Fourth floor, Dietary Department, Seventh/Eighth-floor Employee Offices, Labor and Delivery, Surgical Department, Cafeteria and Outdoor Loading Dock. Also, the hospital staff failed to follow the hospital policy, "Infection Control Program Policy".

Findings included:

Upon entrance to the hospital on 02/07/2024 at 8:49 AM, surveyors observed that glass was missing from the exterior windows on floors three through eight, leaving insulation exposed to the weather elements.

An interview with Staff #3 on 02/07/2024 at 10:00 AM reported the windows had been broken with missing glass since a winter storm on December 24, 2022. Staff #3 reported that a large antenna was blown off the roof and was hanging by its cables. The antenna fell and broke the glass out of the windows. The windows remain open to weather elements such as rain, snow, and wind. According to Staff #3 when it rains depending on which way the wind is blowing the rain will come into the interior wall and leak down the walls of the interior wall surface. The insulation that is exposed becomes wet. During the tour on floors 3 through 8 the interior windows were covered with plywood 6 X 8 in size X 2 on each window. Some of the plywood was painted, but some floors had raw plywood which could not be disinfected. The glass windows that were beside the plywood coverage had large cracks in the exterior windows and were covered with tape. Cracked windows were on the third floor through 5th floor.


A document was given to the surveyors including proof that the facility obtained an estimate from a glass company on February 3, 2023. The estimate does not include water intrusion and continued cleanup. The estimate was $124,222.50 to $199,222.50. Also, this document contained emails that were sent to the corporate team for funding to complete the repairs on the broken glass windows. However, there was no documented response from the corporation.


A tour of the facility and observation of patient care areas by the surveyor staff and leadership was conducted on 02/07/2024. The following safety and infection control issues were observed.

Hemodialysis Unit:

A tour was conducted on 02/07/2024 at 10:11 AM with the hospital's leadership.

* Observed 5 of 5 expired Intravenous Fluids (Normal Saline) with an expiration date of 01/2024 located in the medication room inside the dialysis treatment area. Intravenous fluids were available for staff use.

* AVF (Arteriovenous fistula) needles were stored on top of a trashcan in the hemodialysis treatment area.

* Dialysis pick-up wands were unsecured in acid and bicarb jugs which were used in the hemodialysis unit. Calcium additives had been added to the solution jugs without proper labeling to indicate the additive type and amount.

* A staff member's water bottle was left open and stored on the window seal in the hallway of the hemodialysis treatment area. No food or drinks are allowed in the hemodialysis area due to possible blood splatter.


Emergency Department:

A tour was conducted on 02/07/2024 at 10:32 AM with the hospital's leadership.

* Observed a Pill crusher in the ER with dust and debris on the handle.

* Observed a large hole in the wall of the clean supply room in the Emergency department. The hole was approximately 8 inches long and 3 inces wide.

* Oximeter probe, trash, dust, and dirt located on the floor between the glass window and desk inside the triage room of the Emergency room.

* Observed black dust and dirt particles on the edges of the glass door that lead into the triage room.

* The patient's nutrition refrigerator located in the emergency room had dust particles and an unknown red sticky substance on the bottom shelf. The red substance had spilled onto the counter below the refrigerator.

* The cabinet door above the discolored sink had a broken hinge and the door hinge was severely rusted.

* The sink in the ER medication room was stained brown and had a discolored appearance. The sink had an unclean appearance. There was a zip tie in the bottom of the sink.

* Observed wall damage inside a patient's room. The wall had a small hole in it and was covered with plaster. The wall had not been painted or repaired so that adequate cleaning and disinfecting could be accomplished. Also, the wall damage could allow for insects and rodents to enter the patient room through the hole in the wall.

* A large area of plaster approximately 12 inches by 8 inches was missing from the wall located in the hallway of the Emergency room outside patient room # 2. The area was not properly repaired and painted to allow for adequate cleaning and disinfecting. Also, the wall damage could allow for insects and rodents to enter the patient room through the hole in the wall.

* Observed a cleanly wrapped suction canister holder in the emergency room. When the surveyor unwrapped the suction canister holder observed an unknown brown substance on the suction holder which had been designated as "clean."

* Observed the ceiling tiles in the Emergency room had an unknown brown substance and stain appearance. The ceiling tile metal frames had rust spots.

* Observed an unknown brown substance leaking from the light fixture and around the ceiling vent in a patient room.

* A stretcher in the ER with tape and other sticky residue affixed to the mattress. The stretcher was designated as "clean."

* Observed furniture in a patient's room with damaged and exposed wood. Exposed raw wood cannot be adequatley disinfected.

Medical/Surgical Second floor:

A tour was conducted on 02/07/2024 at 11:24 AM with the hospital's leadership.

Surveyors observed that some of the rooms on the second floor do not have showers in the room the patients have to share a shower located in the main hallway.

* The shared patient's shower on the second floor had a chipped, broken, and cracked tile in the bench seat. The chipped and cracked tile would make it difficult to disinfect the tile bench seat between patient usage. There was a strong musty foul odor coming from the shower room when the door was opened. The actual shower area had orange-colored build-up stains around all the corners of the shower floor.

* A patient room #245 on the second floor designated as "clean" was found to have dirt, dust, and an unknown sticky, red substance on the patient's bedside table.

* The cart used to transport patient nutrition was observed in the hallway of the second floor with a build-up of brown spillage, dust, and debris. The cart had an unclean appearance with spillage running down the side of the food cart.

* The patient's nutrition refrigerator on the second floor when opened had a large amount of dried brown spillage in both drawers of the refrigerator. Also, the shelf containing the patient's nutrients had brown spillage.

* The wooden cabinet in the nutrition room that held sodas and cereals had large chips of particle board missing. There was no way to disinfect the exposed particle board on the shelves. The shelves had an unclean discolored appearance with spillage. The 3 drawers in the nutrition room had spillage, hair, and trash particles mixed with the coffee filters and plastic silverware.

* Observed in the equipment storage room were 2 "waffle" mattresses in open plastic bags cleaned by environmental services. "Waffle" mattresses are single-use only items.

* Observed equipment designated as "clean" with dirt, dust and debris located inside the "clean equipment storage" room on the second floor.

The surveyors observed interior windows in the hallway of the second floor (near the elevators) that had cobwebs and dead bugs hanging around the window seals. There was a build-up of a thick black substance on the interior windows. There were several ceiling tiles with large brown water stains in the main hallway. Also, there was a large brown stain by the sprinkler system head.

Medical/Surgical Fifth Floor:

A tour was conducted on 02/07/2024 at 11:44 AM with the hospital's leadership.

* The call system on the fifth floor was not working and patients were using desk call bells for assistance. When the surveyor entered the floor the lights over the shower room and hall bathroom were flashing. Surveyor feared that a patient could be in the shower room or bathroom. There was no alarm just flashing lights. A plant operation staff member knocked on the door and then tried to turn the lights off but had no success. When the doors were opened to enter the shower room and bathroom it had a foul musty odor.

An interview with Staff #3 on 02/07/2024 at 11:50 AM confirmed that the call system had not been working since January 3, 2024.

An interview with Staff #1 at 11:55 AM confirmed the daily census on this floor has been 25-30 patients, but today's (02/07/24) census was 8 patients.

* The cart used to transport patient nutrition trays was observed in the hallway of the fifth floor with brown spillage, dust, and debris. The cart had an unclean appearance with spillage running down the side of the food cart (X 2 carts).

* The first room that the surveyor entered on the fifth floor had rusted shower handles and large orange-colored stains running from the handles down to the floor of the shower. Also, there was a large gray stain around the shower handles.

* The air conditioner vents in the patient rooms had a large amount of black-colored substance observed on the vents. Observed in one of the empty rooms that was designated as a "clean" room had dead bugs on the floor.

Fourth floor:

A tour was conducted on 02/07/2024 at 12:01 PM with the hospital's leadership.

* Observed a rusted drain 3 X 3 in size in the floor and the air condition vent was covered with a large amount of black substance in the same room.

* Observed in the main hallway of the fourth-floor an unknown brown and black substance on the air return vents.

The fourth floor was where the patients were going to be moved to from the fifth floor. The fourth floor had been closed for over 2 years. The rooms had an unclean appearance with dust, dirt, and trash particles.


Dietary Department:

During a tour of the dietary department on 02/07/2024 at 2:12 PM with staff #1, #3, and #14 the following safety and infection control issues were observed:

* The intake air vent had dust and dirt particles with brown and black substance build-up located inside the kitchen prep area.

* Food art used to transport clean food trays with dust, dirt, and other unknown substances inside the kitchen prep area.

* Observed in the kitchen hallway an unknown black and brown substance, as well as dirt and dust, build up inside the wall molding. The wall molding was ripped and falling off the wall. There were several areas in the hallway where the molding was falling off. Wall damage was in the hallway outside the washroom for the kitchen. The wood where the wall molding was falling off was rotten with a black substance. Also, the brick on the wall was noted to be dirty and had a build-up of black and brown substances.

* A dead bug was found hanging on the wall of the hallway located just outside the kitchen prep area above where the wall molding was falling off the wall.

* Dirt and a thick build-up of a black substance were found inside the kitchen prep area on the floor.

* A cart used to store clean kitchen equipment was covered in a black and brown substance.

* Patient food trays designated as "clean" were found to have old food debris on them and this was on the side where the trays had been processed through the washer.

* Kitchen equipment and cooking trays were observed with a build-up of brown and black substance on them. The cooking trays were not adequately dried and had moisture on them. These trays had been run through the washer but had not had time to dry before being stacked together.

* A large build-up of dirt, dust, dead bugs, and other unknown black substances was found on the floor of the kitchen freezer.

* Expired mayonnaise with an unknown green, brown, and black substance on the lid and side of the container. Dated use by December 14, 2023, and another mayonnaise container with use by December 26, 2023.

* Food container with unknown brown sauce inside. The expiration label was illegible, and it is unknown what was stored inside.

* The surveyor found another container of mayonnaise-expired inside the kitchen prep area refrigerator dated October 3, 2023.

* Roast beef deli meat found in the kitchen prep fridge with inconsistent expiration date labeling. Original package with an expiration date of "02/18" and kitchen staff labeled with a use-by date of "02/20".

* Return air vent inside the kitchen, on the ceiling above a food prep table was brown in color.

* Nine muffin pans had a thick build-up of old dried food on the outside bottom of the pans and a brown-colored substance. The muffin pans were stored on the rack and designated as "clean". There was moisture found on the muffin pans.

* Wheels of carts used to store clean kitchen pans and utensils found inside the kitchen prep area were covered in a black substance. The drain in the floor located under the carts was covered in a black, brown, and red substance.

* The floor of the kitchen had a large build-up of dirt, dust, and other unknown substances. The grout in between the tiles was black and had a thick build-up of unknown black and brown substance.

* Observed a dirty drain located in the kitchen food prep area. The grout in between the tiles was black and had a thick build-up of unknown black and brown substance. The wall was covered in a dark brown substance with dirt and trash particles.

* Kitchen equipment and supplies designated as "clean" were found with old food and other unknown debris stuck to equipment.

* Observed a valve leak coming from the piping in the kitchen. The leak was located next to the ovens and large pot where meat was cooked.

* A light bulb above the kitchen stove was covered in dust and cobwebs.

* Observed the ovens with a large amount of build-up of black substance on the doors and inside of the ovens.

* Observed dust and other unknown debris located on the back of the oven.

* The ceiling in the kitchen above the stove had a large amount of build-up of sticky-looking brown substance.

* The surveyor asked the staff to remove the meat slicer blade to see if the blade had been cleaned. A couple of hard black substances fell out of the meat slicer when the blade guard was removed. The blade holder of the meat slicer had a build-up of thick brown and white substance on the inside of it.

* The carts used to transport nutrition to the patient rooms were dirty and covered in dust and dirt on the bottom. These carts were located inside the kitchen prep area.

* A black plastic cart located inside the kitchen prep area was covered in food particles with unclean appearance. This cart was used to transport "single nutrition trays" to patients.

* The grease pump was covered in a thick build-up of sticky yellow and brown substance located in front of the food tray line.

*The floor located behind the grease pump in the kitchen food tray line prep area was dark brown and black.

* Wall and floor damage in the hallway outside of the kitchen. The floor had a large bump in it and the wall was protruding out. This crack was located under an exterior window. A ceiling tile in the hallway was noted with moisture damage. This ceiling tile was in front of a large exterior window outside the kitchen.

7th and 8th Floor Employee Offices:

A tour was conducted on 02/07/2024 at 3:09 PM with the hospital's leadership.

The ledge below the exterior windows on the 7th and 8th floors had large cracks in the foundation with a black substance in the cracks. There were large pieces of the cement foundation ledge missing. There was a large blue draft protector plugged into a hole in the cement foundation. Plaster was missing from the walls and the floor was covered in dust and dirt. Observed a large amount of black substance along the wall of the cracked foundation ledge. Employees who work on floor 7 are PBX phone operators. The employees that work in the IT department work on the 8th floor.

* On the 7th floor inside where the PBX phone operators work on the window ledge were several wet soiled stained towels lying along the window ledge.

An interview with Staff #3 on 02/07/2024 at 3:16 PM reported that the towels catch the water when it rains due to window leaks.

Labor and Delivery Department:

A tour was conducted on 02/07/2024 at 3:24 PM with the hospital's leadership.

* Ceiling tiles were observed to have large water-stained circles in the main hallway of the labor and delivery area.

* Observed in the cesarean section room #1 cabinet was a glove labeled with sterile Dermabond (Advanced skin adhesive). The glove was tied with a rubber band and labeled with white tape as sterile Dermabond. Also, found in the cabinet were 2 staple guns out of their sterile package. These items are single-use items for surgery patients.

An interview with Staff #22 (Director of Labor and Delivery) on 02/07/2024 at 3:39 PM stated, "I have no idea why those items were stored in the cabinet or why staff had wrapped the Dermabond in a glove. Staff members know that this is not an acceptable practice."

* A brown and red substance was found on the table in cesarean section room #2.

* Observed in the cesarean section room #2 on the wall was a red substance and the room had been designated as "clean".

* Observed unidentifiable fabrics and debris attached to the Velcro located under the cushion that covers the surgical table.


Surgical Department:

During a tour of the surgical department on 02/07/2024 at 4:14 PM with Staff #1 the following safety and infection control issues were observed:

* Observed in Cystoscopy Room #2 a cushion stirrup was found ripped with the cushion exposed to water moisture from a procedure being performed.

* The wall located next to the door in the Cystoscopy Room had cracked plaster and there were chips in the paint of the door frame.

* The anesthesia cart was unlocked, and medications were accessible to unauthorized personnel.

*There were large black floor mats located in front of the operating room scrub sinks in the main surgery area.
Observed a large amount of build-up dust and dirt in the holes of the mats. When the mats were pulled back by the surveyor the floor had dried brown, orange, and black substance on it.

* Observed a surgical step stool used in the operating room was covered with a brown and orange unknown substance.

* An electro-surgical unit (Bovie) cart used in the operating room had exposed metal edges. The edges were sharp, and the paint was chipping off of the cart. There was an unknown brown substance on the cart.

* Observed on the entrance to one of the main operating rooms were brown stains on the floor. The surveyor took a white wipe and wiped the floor, and the wipe was brown. The room was designated as "clean".

* In the vascular room the operating room table was covered in a white substance with dust and debris. The operating room was designated as "clean". The surveyor was able to wipe away the dust and debris and the white wipe was black. There was a red substance splatter on the floor.


Cafeteria:

During a tour of the public cafeteria on 02/08/2024 at 9:30 AM with Staff # 1, the surveyors observed the following:

* An expired hand sanitizer solution at the entrance of the cafeteria. The expiration date was "09/2023".

* A green chair with a large rip in the seat portion. There was no way for the environmental service staff to adequately clean the seat due to the damage.

* There were two vents in the ceiling located above the tables and chairs that visitors and staff members eat at that were covered in an unknown black and brown substance.

Outdoor Loading Dock:

During a tour of the outdoor loading dock on 02/08/2024 at 9:15 AM the surveyors observed two large dumpster pods overflowing with trash. Also, there was a pick-up truck hauling a large trailer that was overflowing with trash bags. The trash was not covered or secured and was exposed to outdoor elements such as rodents and insects. The trash was accessible to the public and could be easily pilfered through.

During an interview with Staff # 14 on 02/08/2024 at 9:45 AM, Staff # 14 stated, "The trash is overflowing because it has not been picked up. The bill had not been paid until yesterday."


A review of the hospital policy titled, "Infection Control Program" with a revision date of August 2023 revealed the following,

"POLICY: Infection Control Programs are affected by professional and nonprofit organizations; government, regulatory, and accrediting agencies; and scientific research and publications. Organizations including the Food and Drug Administration (FDA) and the Occupational Safety and Health Administration (OSHA) issue regulatory standards that must be implemented. Also, organizations such as the Centers for Disease Control (CDC) and the Society for Healthcare Epidemiology of America (SHEA) provide recommendations based on research to guide practice. The Hospital Infection Control Program is supported by the mission of Steward Health Care System and is guided by the demographics and needs of the individuals served. The infection control committee provides input into specific infection control issues to prevent and control the risk of hospital-acquired infections.

SCOPE: This policy provides guidance to infection control practitioners for the structure and function of hospital infection control programs ...

A. OVERALL STRUCTURE and FUNCTION:

1. Infrastructure documents outline the three principle goals for infection prevention and control programs:
a. Protect the patient.
b. Protect HCW (healthcare workers), visitors, and others in the healthcare environment.
c. Cost-effectively accomplish the previous two goals whenever possible.
2. Each facility is unique, and its specific needs must be considered when developing or reorganizing an Infection Control (IC) Program. Factors include size, case mix, and types of care provided. The principal functions are generally similar, however, and include the following:
a. To obtain and manage critical data and information, including surveillance for infections.
b. To develop and recommend policies and procedures.
c. To intervene directly to prevent infections and interrupt the transmission of infectious diseases.
d. To educate and train HCWs, patients, and nonmedical caregivers.
3. The ability of the IPC program to influence practices that affect safe patient care depends on certain characteristics of the patient population, the patient's risk of infection, and the characteristics of the organization and personnel.
4. These characteristics include the number of beds, professional school affiliation, geography, the volume of patient encounters, patient population serviced, clinical focus, number of employees, and administrative philosophy ...

E. HOSPITAL INFECTION CONTROL COMMITTEE (HICC)

1.The Hospital Infection Control Committee (HICC) is the multidisciplinary committee that is
responsible for the oversight of the infection control program.
2. The HICC has been delegated the authority, by the Hospital Board of Directors, to institute
improvement strategies, policies, and procedures, and to make recommendations to all departments that will reduce the incidence of infections. In the event of an outbreak or infectious disease emergency, the Infection Control Committee has the authority to conduct investigations, institute control measures, and collaborate with state and local departments of health or public health authorities as appropriate. Such authority is vested in the Hospital Epidemiologist and/or Chairperson of the Infection Control Committee, the Infection Control Practitioner(s), and each physician-member of the Infection Control Committee.
3. The responsibilities of the committee are as follows:
a. To oversee infection control and prevention in all settings of the facility including outpatient areas, inpatient areas, ambulatory areas, procedure rooms, operating rooms, delivery rooms (where applicable), recovery rooms, and special care units.
b. To oversee and support activities directly related to infection prevention practices:
cleaning, disinfection, and sterilization; hand hygiene; transmission-based precautions, antimicrobial stewardship; prevention of device-associated infections; other situations by the Medical Staff Executive Committee.
c. At least annually, to evaluate, revise as necessary, and approve the type and scope of surveillance activities by reviewing the following: data trend analysis generated by surveillance activities during the past year, the effectiveness of prevention and control intervention strategies in reducing the healthcare-associated infection risks, services instituted, and procedures, priorities, or problems identified in the past year.
d. To approve the plan used in the annual evaluation of the program for infection surveillance, prevention, and control.
4. The core of the HICC should include the ICP, the chair of the infection prevention committee and the Employee Health Practitioner.
5. The HICC is a multidisciplinary team composed of representatives from appropriate departments throughout the healthcare facility including, but not limited to the following: Physicians from applicable departments, Surgeons, Laboratory/Microbiology, Nursing, Pharmacy, SLT, representatives from the following areas: High-Level Disinfection/Endoscopy/Sterilization, Perioperative Services, Food Services, Facilities, and Environmental Services.
6. Reporting structures will be established at each facility. (Refer to Attachment B: Sample Infection Control Meeting Agenda Template). The meeting schedule should be outlined in the annual infection control plan."

An interview with Staff #1, #2, and #6 on 02/08/2024 at 9:30 AM acknowledged that the hospital had safety and infection control issues found in 11 of 11 departments which included Hemodialysis Unit, Emergency Department, Medical/Surgical Second Floor, Medical/Surgical Fifth floor, Fourth floor, Dietary Department, Seventh/Eighth-floor Employee Offices, Labor and Delivery, Surgical Department, Cafeteria and Outdoor Loading Dock.