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Based on observation, interview, and policy review, the provider failed to ensure only authorized personnel had access to medications including:
*One of one sampled medication storage area at the internal medicine clinic.
*One of one storage area for phamaceutical waste containers.
Findings include:

1. Observation on 8/2/16 at 2:39 p.m. revealed the environmental services and security manager had used a master key to unlock the door to the sample medication room. There was a coded entry lock that was also able to be accessed with a key.

Interview on 8/3/16 at 10:50 a.m. with the pharmacy supervisor revealed:*The coded entry lock for that sample medication room had been recoded approximately one year ago.
*She was not aware there was the ability to use a master key for entry.
*She agreed the environmental services and security manager was not authorized to access that sample medication storage room.
*She stated other personnel with a master key would have also had access to that room.

Review of the provider's undated Pharmacy Department Security policy revealed secured areas where medications were stored but not locked up could consist of rooms that were physically locked. Approved personnel were a licensed or registered professional in the health care field. Those personnel would have been doctors, pharmacists, nurses, and pharmacy technicians. Personnel that were not considered approved to be let into a secured area where medications were kept unlocked would have been housekeepers, maintenance staff, and the general public.



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2. Observation on 8/3/16 at 11:00 a.m. of a pharmaceutical waste container in operating room 2 revealed a large container beside the anesthesia cart. The container had a black top lid that remained open. It was partially filled with used intravenous (IV) medication bottles.

Interview at that time with the operating room supervisor regarding the procedure for disposition of the black pharmaceutical waste containers revealed:
*The housekeeping staff were responsible for removing and transporting the filled waste containers.
*He did not know where the housekeepers put them when they removed them from the surgical area.

Interview on 8/3/16 at 1:30 p.m. with the pharmacy supervisor regarding the protocol for the black pharmaceutical waste containers revealed:
*The housekeeping department had previously transported the filled containers. That job was now being done by the janitors.
*The janitors transferred the filled containers to a locked room containing all the black trash containers.
*"Plant Ops" (plant operations personnel) had keys to that room.
*The black trash contained pharmaceutical waste that had not been completely used.
*Bottles containing less than 3 percent (%) of medication were discarded with standard trash.
*Bottles containing more than 3% of medication were placed in the black waste container and secured in the black trash room until the medical waste collector removed it from the site.
*All controlled (narcotic) medications were discarded in the sewer system.
*No controlled medications were placed in black waste containers.
*She agreed the black waste containers had contained other medications including propofol used for starting anesthesia and for sedation.
*She agreed propofol had a potential for abuse and drug diversion.
*She stated non-licensed employees were used for transporting the black pharmaceutical waste containers, because it would have been more costly using licensed personnel.

Observation on 8/4/16 at 2:00 p.m. of the black trash storage room with the pharmacy supervisor and environmental services and security manager revealed:
*The black trash room was secured with a key.
*The room contained multiple black waste containers lined up against a wall.
*The waste in those containers remained unsecured. The lids opened easily and contents could have been removed.
*That room was approximately ten feet away from an outside exit door.
*That exit door was locked from the outside but could be opened from the inside.
*The exit opened onto a driveway.
*Vehicles could drive right beside the door for delivery and removal.

Interview at that time with the environmental services and security manager regarding transporting and storage of the black pharmaceutical waste containers revealed:
*The janitors transported the filled containers from the medical floors to the black trash room.
*Janitors were approved for removal of the black waste bags from the containers when the pharmaceutical waste disposal company came to remove it.
*All Plant Ops personnel had master keys that unlocked many secured areas in the hospital.
*That same master key unlocked the black trash room.
*The Plant Ops personnel consisted of maintenance supervisors, nursing supervisors, administration, housekeeping supervisors, and other supervisors.
*At the time of the survey he had just given out the fiftieth master key to personnel.
*There was no documentation as to what was in the pharmaceutical waste containers or how much pharmaceutical waste was removed when the pharmaceutical trash company came to remove the waste.
*He agreed the black pharmaceutical waste could have been removed from the room without knowing what had been removed or how many containers had been removed.

Review of the provider's December 2015 Waste Management Program: Pharmaceutical Waste policy revealed:
*The purpose was "to provide a systematic approach to identify, manage, properly dispose of and document all regulated hazardous and non-hazardous waste in conformance with local, state and federal regulations as applicable."
*The policy did not apply to controlled medications.
*Pharmaceutical waste was broken down to different containers depending on the hazard or compatibility of the waste.
*The pharmacy director would establish mechanisms for identifying how the different medications were disposed of.
*All departments would dispose of the waste in the appropriately coded containers.
*Pharmaceutical waste of more than 3% of the original weight left in it's container was placed in the black pharmaceutical waste containers.
*The policy had not included how the black waste awaiting destruction was to have been secured or who was to have access to the pharmaceutical waste awaiting destruction/removal.

A. Based on observation, testing, interview, policy review, and record review, the provider failed to ensure:
*All toys used at the therapy center were disinfected according to their policy and references.
*Three of five covers on the clean linen carts in one of one clean laundry room were kept clean and sanitary when in-use.
*All clean supplies in the west storage room were not transported through a soiled room.
*Three of seven roller board covers were not frayed and tattered in the equipment storage room of the operating suite.
*One of two head pads on two of two shoulder positioning devices did not have cracks in the equipment storage room of the operating suite.
*Two of two processing table shelves in the sterile processing department (SPD) were kept in a cleanable condition.
*All ceiling tiles in the processing side of the SPD had a smooth finish that would not expel lint or debris.
Findings include:

1. Observation on 8/2/16 at 9:00 a.m. revealed three large totes and four small baskets of toys in the dirty utility room at the therapy center.

Interview at the time of the observation with the director of physical therapy revealed:
*Toys were used in the center and for home visits.
*All toys were brought into the dirty utility room to be disinfected.
*Staff would wipe the toys off with a food grade sanitizer, and then let them air dry.
*He did not have a reference for how to disinfect the toys.
*He had written a policy for the toy cleaning.

Review of the provider's 11/25/13 Therapy Center Toy Cleaning policy and procedure revealed staff would use a quaternary food grade sanitizer on the toys. Then they would let the toys air dry.

Interview on 8/3/16 at 3:00 p.m. with the infection control manager revealed:
*All toys should have had a bleach water rinse and been allowed to air dry.
*She had updated the toy cleaning policy, but it had not been reviewed and approved.
-The new policy revealed all toys would be cleaned after each use with an approved disinfectant.

2. Observation and interview on 8/2/16 at 1:00 p.m. revealed several clean linen carts stored in the clean laundry room. Three of those cart covers were visibly soiled with unknown splatters and darkened spots from what appeared to be hand prints on the covers. Laundry aides K and L revealed they had not laundered the covers. They stated they were unaware if the covers were ever laundered.

Interview on 8/3/16 at 4:00 p.m. with the environmental services and security manager revealed he was not aware the clean linen covers should have been laundered.

3. Observation and interview on 8/2/16 at 4:00 p.m. revealed clean supplies in the west clean supply and materials storage room on the other side of the garbage/soiled linen/box breakdown (dirty) storage room. The director of materials management revealed:
*Clean supplies would be removed from the room and carried through the dirty storage room into the corridors to be placed into use in the appropriate departments.
*The clean supply room had boxes of intravenous bags, individual baby bottles, individual diapers, cans of formula, and individual maternity kits.
*Some materials had to be logged into the computer in the large clean supply room on the other side of the dirty storage room.
*Staff removed the clean supplies from the small storage room, carried them through the dirty storage room, and then entered the large clean supply room.

No policy was provided upon request from risk management for the traffic flow of clean supplies throughout the facility.

4. Observation and interview on 8/3/16 at 10:00 a.m. in the equipment storage room of the operating room suite revealed:
*Three vinyl roller board covers were tattered and frayed along the stitched edges of the covers.
*One black vinyl head pad on a shoulder positioner had cracks that made the entire surface appear to have a white spider web. It was also frayed along the stitched seams.
*The director of surgical services confirmed those findings. He stated he was not aware of the condition of the covers and relied on the nursing staff to let him know when a surface was no longer cleanable.

Review of the provider's May 2016 Infection Control in the Operating Room policy revealed "d. Mattresses and padded positioning device surfaces should be moisture resistant and intact."

5. Observation on 8/3/16 at 9:45 a.m. of the SPD revealed:
*Two processing tables with shelves in the packaging room. The clear finish on the shelves had worn off down to the bare wood.
*The entire drop down ceiling of the packaging room, approximately sixty feet by thirty feet, had perforated ceiling tiles. Those perforated ceiling tiles were not cleanable and could expel lint and debris from the perforations.

Interview with the director of surgical services, who also oversaw the SPD, confirmed those findings. Interview with an unidentified sterilization technician revealed she had worked for that program for over twenty years. She stated the ceiling tiles might be the original tiles.

Review of the provider's February 2016 SPD Department Cleaning policy revealed it had no direction on the cleanability or construction of the SPD including the ceiling.

Review of the 2008 Centers for Disease Control and Prevention guideline revealed "Ceilings and wall surfaces should be constructed of non-shedding materials."

B. Based on observation, testing, document review, policy review, and interview, the provider failed to:
*Maintain the cleanliness for two of two mixers and one of one slicer in the main kitchen and baking kitchen.
*Clean one of one exhaust hood in the baking kitchen and maintain a cleaning schedule for that hood.
*Protect food on display at one of one cafeteria self-service buffet.
*Maintain proper refrigerator temperatures for one of one breast milk refrigerator in the nursery.
Findings include:

1. Observation on 8/2/16 from 10:50 a.m. to 12:30 p.m. revealed:
*The slicer in the preparation area was noted to have dried on food particles that could be scraped or picked off with a fingernail. The crevices around the blade and guard also had dried on food debris in them.
*The splash area of the Kitchen Aide mixer and the Hobart floor mixer had splashes and particles of dried on food on them that had started to dry up and curl.
*The exhaust hood in the baking kitchen had a layer of brown and orange colored grease and dust around the pipes and at the air exhaust entry point for the hood.
*Several dishes of desserts and fruit sat on top of the buffet bar in the cafeteria. Containers of uncovered bacon bits and croutons also sat outside of the sneeze guard by the salad buffet.

Interview at the time of the above observations with the food service manager confirmed the above findings. She revealed:
*The slicer and mixers were to be cleaned after each use or as often as needed.
*She was not aware staff were not doing a thorough cleaning of the slicer and mixers.
*She had noticed the grease build-up outside the hood and on the pipe.
*Maintenance had a regular schedule for cleaning the hoods in the kitchen.
*Staff were aware all food must be covered that was not shielded under the sneeze guard.

Interview on 8/3/16 at 10:00 a.m. with the maintenance manager revealed he had:
*A commercial company that cleaned the hood in the kitchen.
*Thought they cleaned the hood in the bakery too.

At the time of the exit on 8/4/16 no paperwork had been provided to ensure the bakery hood had been cleaned or was on a cleaning schedule with a commercial company.

Review of the provider's March 2016 Handling and Preparation of Food policy revealed "5. All work surfaces, utensils and equipment are thoroughly cleaned and sanitized after each use."

Review of the provider's August 2005 Kitchen Safe Rules policy revealed "6. Keep all containers of foodstuffs covered."

2. Observation on 8/2/16 at 2:00 p.m. revealed a small apartment sized refrigerator in the nursery with a daily temperature chart on top of it. Review of the chart revealed:
*The small refrigerator was used to store breast milk.
*There were no parameters given for the temperature range of breast milk.
*Listed temperatures for April, May, June, and July 2016 ranged from 34.7 degrees Fahrenheit (F) to 44.1 degrees F.
*A work order had been placed on two consecutive days when the temperature had been 43.1 degrees F and 43.3 degrees F.
*Instructions on the calendar were "Plant Operations or Biomed must be notified immediately if two consecutive reading are outside the recommended range. Record any action taken on the back of this form."
-No notations had been written on the back of the form to ensure the refrigerator had been fixed.

Interview at the time of the observation with registered nurse (RN) B confirmed those findings. She stated it looked as if a patient technician had done the temperature recordings and had not reported the high temperatures.

Further interview at the time of the observation with the RN obstetrics manager confirmed the high temperature recordings. She:
*Was not aware the temperature had been out of range for the refrigerator.
*Was not aware what guidelines or policy should have been used for the temperature.

Review of the provider's undated Breast milk, Collection and Storage policy revealed no guidelines had been given for the temperature of refrigerated breast milk.

References used in the above policy were The Academy of Breastfeeding Medicine Clinical Protocol #8: Human Milk Storage Information for Home Use for Full Term Infants. Review of that reference revealed breast milk may be stored under refrigeration at 39 degrees F.



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C. Based on observation, interview, record review, and policy review, the provider failed to ensure:
*Appropriate cleaning procedures for one of one sampled patient (13) who had clostridium difficile (C. Diff) during one of one observed room cleaning with housekeeper (E).
*Appropriate hand hygiene practices were used during:
-One of one sampled patient's (9) dressing change with physical therapist (PT) (I).
-One of one sampled patient's (9) personal care performed by one of one patient care technician (PCT) (H).
-One of one block procedure prior to a total knee surgery for sampled patient (52) with one of one registered nurse (RN) (F).
*The manufacturer's suggested dry time (thirty seconds) for chlorhexidine prior to performing a left knee injection in surgery by one of one physician (G) for one of one sampled patient (52).
*Sanitary conditions were maintained by one of two RNs (C) while providing personal care for one of one patient (3) who required the collection of a urine specimen.
Findings include:

1. Observation and interview on 8/2/16 at 10:10 a.m. outside patient 13's room who had been diagnosed with C. Diff. with housekeeper E revealed:
*The patient was not in his room.
*On the patient's door there was a sign "White Contact Precautions" instructions:
-"Wear gloves, wear gown, perform hand hygiene using soap and water. Clean with 1:10 bleach solution or bleach cloth.
-A 1:10 bleach solution is used for daily and terminal cleaning. Disinfection of reusable patient care equipment."
*Housekeeper E stated she would:
-Put a gown and gloves on prior to entering the patient's room.
-Wipe down the patient's items in the room with wet task wipes.
-Only use a bleach solution when she was performing terminal cleaning after the patient had been discharged.
-Sanitize her hands with an alcohol based hand gel, and "maybe wash her hands" after she had completed the cleaning in the patient's room.
-Clean the floor with a generalized floor cleaner.
*During the observation from outside the patient's room housekeeper E:
-Returned to the housekeeping cart to retrieve items such as paper towels.
-Opened the full pack of paper towels with her dirty gloves.
-Took the packet of paper towels into the patient's bathroom.
-Returned the unused clean paper towels to her cart.
-Removed her dirty gloves.
-Sanitized her hands with an alcohol based gel.
-Applied new gloves.
-Took a toilet bowl brush from her cart and went into the patient's room.
-Cleaned the toilet.
-Brought the toilet bowl brush back to the housekeeping cart.
-Cleaned the toilet bowl brush with the wet task wipes and placed it back on her cart.

Surveyor: 20031
Interview on 8/2/16 at 2:20 p.m. with the housekeeping supervisor revealed:
*She trained her housekeepers to use quaternary disinfectant on the floors of patients with C. Diff.
*They had used bleach at one time, but it made the floors look bad.

2. Observation and interview on 8/2/16 from 10:55 a.m. through 11:25 a.m. in patient 9's room during a dressing change and personal care revealed:
*PT I changed patient 9's dressing to his infected left foot. She:
-Removed the patient's old dressings from his foot.
-Removed her gloves.
-Sanitized her hands.
-Put a new set of gloves on her hands.
-Placed a 4 by 4 gauze in her gloved hands.
-Saturated the gauze with Betadine.
-With her other gloved hand had the package of Kling gauze she had removed from the patient's cupboard of supplies.
-Touched the Betadine saturated 4 by 4s with the unopened package of Kling gauze prior to placing the 4 by 4 Betadine saturated gauze on the patient's infected left foot.
-Placed the saturated gauze on the patient's left foot and wrapped it with the Kling gauze.
-Removed her gloves.
-Took her pen that was on the sink.
-Without washing or sanitizing her hands marked the date on the patient's dressing.
-Returned the pen to the counter by the sink.
-Reached into her pockets.
*PCT H assisted PT I.
*The patient had an incontinent bowel movement and was placed on the bed pan.
*PCT H performed personal hygiene care on patient 9. She:
-Changed her gloves three times during the care.
-Never washed or sanitized her hands after handling the fecal soiled wash cloths and bedding.
-Placed the soiled garbage on the floor under the patient's sink.
-Stated there was no room in his closet for the soiled garbage. Housekeeping or maintenance had not collected the soiled linen and garbage at that time.

3. Observation on 8/3/16 at 8:00 a.m. in the post anesthesia care unit during a block procedure for patient 52 with RN F assisting the physician revealed RN F:
*Put on a pair of gloves to assist with the block procedure.
*Removed her gloves.
*Without sanitizing or washing her hands placed a new set of gloves on her hands.
*Then assisted the physician with administering the numbing medication into the patient's upper left thigh area.

4. Observation on 8/3/16 at 9:21 a.m. in the operating room with patient 52 during the injection of the left knee with surgeon G revealed:
*RN I took the patient's left leg and painted chlorhexidine on the leg. She placed the leg on the operating table.
*Surgeon G came in immediately following the application (under ten seconds) of the chlorhexidine and started to inject the patient's left knee.

Interview on 8/3/16 at 9:55 a.m. with circulating RN I regarding the above observation revealed she thought the appropriate dry time for chlorhexidine once it was placed on the patient's skin was two to three minutes.

Review of the chlorhexidine package insert given by the above circulating RN revealed on dry surgical sites the solution should air dry for approximately thirty seconds were the manufacturer's suggested dry time.

5. Interview on 8/4/16 with the infection control manager, the performance improvement specialist, and the performance improvement supervisor regarding the above observations and interviews involving infection control issues revealed:
*They all agreed there had been inappropriate hand hygiene issues during the dressing change and personal care for patient 9.
*The housekeeper had not performed the cleaning of patient 13's room according to the "White Contact Precautions" instructions.
*The surgeon had not waited the appropriate drying time for patient 52.
*There was hand hygiene training upon being hired for new staff and annually with all staff.

Review of the provider's August 2011 Hand Hygiene policy revealed:
*"[Provider's name] recognizes hand hygiene as one of the most important methods to prevent transfer of micro-organisms that cause disease. It is an expectation that appropriate hand hygiene will be used in all routine patient care practices, in combination with effective gloving techniques, as well as for personal hygiene. Routine hand hygiene includes a combination of lotion soap, alcohol-based hand rubs.
*Decontaminate hands with alcohol hand rubs:
-Any time hands are not visibly soiled.
-Before direct patient contact.
-After contact with mucous membranes or non-intact skin if hands are not visibly soiled.
-If moving from a contaminated body site to a clean body site during cares.
-After contact with objects (including equipment) located in the patient's environment."

Review of the provider's August 2015 Standard Precautions policy revealed:
*"Standard precautions at [provider's name] is a system of infection control and prevention which places responsibility on the health care worker to consider all body fluids as potentially infectious and to adhere rigorously to infection control practices to minimize the risk of exposure or the transmission of germs.
*Change gloves between patient contacts. Always wash hands or use alcohol hand rubs after removal of gloves."

Surveyor 20031
Review of the provider's April 2015 Transmission Based Precautions (Isolation) policy revealed:
*"O. Room Cleaning and Disinfection:
1. Per Housekeeping policies.
2. Leave isolation signage posted until room terminally cleaned (Housekeeping will remove isolation signs).
3. White contact Precautions: use bleach wipes for daily and terminal room clean."



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6. Observation on 8/2/16 at 11:00 a.m. with RNs C and D while they collected a urine specimen from patient 3 using a straight catheter revealed:
*RN D retrieved the necessary supplies required to collect a urine specimen.
*They both sanitized their hands and put gloves on.
*While RN C had her gloves on she:
-Helped RN D reposition the patient and adjusted the blankets.
-Retrieved two hand towels from the clean linen cupboard.
-Placed those clean towels inside the sink and wet them with water.
-Gave those wet towels to RN D. RN D used those towels to wash the perineal and rectal areas of the patient.
-Put the side rail down on the gurney and adjusted the patient's gown.
-Assisted the patient with proper positioning while RN D collected a urine specimen from her.
*They removed their gloves after collecting the urine specimen and washed their hands.
*RN C put on gloves.
*With those clean gloves on RN C:
-Assisted RN D to change the soiled linens from the patient. Those linens had several brown colored spots on them.
-Placed the soiled linens on the floor.
-Retrieved two clean sheets and a blanket from the clean linen cupboard.
-Assisted RN D with putting those clean linens on the patient.
-Picked up the soiled linens from the floor and placed them in a hamper.
-Removed her gloves and washed her hands.

Interview on 8/2/16 at the time of the observation with RN C and the emergency room director revealed:
*The above process had not been completed in a sanitary manner.
*They agreed the process had created a potential for cross-contamination of bacterial germs from one patient to another.
*RN C had not been aware she had not completed the above tasks in a sanitary manner.

Review of the provider's July 2015 Personal Hygiene Measures policy revealed no documentation to support a process for the staff to follow to ensure sanitary conditions were maintained.

Based on observation, interview, and policy review, the provider failed to ensure only authorized personnel had access to medications including:
*One of one sampled medication storage area at the internal medicine clinic.
*One of one storage area for phamaceutical waste containers.
Findings include:

1. Observation on 8/2/16 at 2:39 p.m. revealed the environmental services and security manager had used a master key to unlock the door to the sample medication room. There was a coded entry lock that was also able to be accessed with a key.

Interview on 8/3/16 at 10:50 a.m. with the pharmacy supervisor revealed:*The coded entry lock for that sample medication room had been recoded approximately one year ago.
*She was not aware there was the ability to use a master key for entry.
*She agreed the environmental services and security manager was not authorized to access that sample medication storage room.
*She stated other personnel with a master key would have also had access to that room.

Review of the provider's undated Pharmacy Department Security policy revealed secured areas where medications were stored but not locked up could consist of rooms that were physically locked. Approved personnel were a licensed or registered professional in the health care field. Those personnel would have been doctors, pharmacists, nurses, and pharmacy technicians. Personnel that were not considered approved to be let into a secured area where medications were kept unlocked would have been housekeepers, maintenance staff, and the general public.



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2. Observation on 8/3/16 at 11:00 a.m. of a pharmaceutical waste container in operating room 2 revealed a large container beside the anesthesia cart. The container had a black top lid that remained open. It was partially filled with used intravenous (IV) medication bottles.

Interview at that time with the operating room supervisor regarding the procedure for disposition of the black pharmaceutical waste containers revealed:
*The housekeeping staff were responsible for removing and transporting the filled waste containers.
*He did not know where the housekeepers put them when they removed them from the surgical area.

Interview on 8/3/16 at 1:30 p.m. with the pharmacy supervisor regarding the protocol for the black pharmaceutical waste containers revealed:
*The housekeeping department had previously transported the filled containers. That job was now being done by the janitors.
*The janitors transferred the filled containers to a locked room containing all the black trash containers.
*"Plant Ops" (plant operations personnel) had keys to that room.
*The black trash contained pharmaceutical waste that had not been completely used.
*Bottles containing less than 3 percent (%) of medication were discarded with standard trash.
*Bottles containing more than 3% of medication were placed in the black waste container and secured in the black trash room until the medical waste collector removed it from the site.
*All controlled (narcotic) medications were discarded in the sewer system.
*No controlled medications were placed in black waste containers.
*She agreed the black waste containers had contained other medications including propofol used for starting anesthesia and for sedation.
*She agreed propofol had a potential for abuse and drug diversion.
*She stated non-licensed employees were used for transporting the black pharmaceutical waste containers, because it would have been more costly using licensed personnel.

Observation on 8/4/16 at 2:00 p.m. of the black trash storage room with the pharmacy supervisor and environmental services and security manager revealed:
*The black trash room was secured with a key.
*The room contained multiple black waste containers lined up against a wall.
*The waste in those containers remained unsecured. The lids opened easily and contents could have been removed.
*That room was approximately ten feet away from an outside exit door.
*That exit door was locked from the outside but could be opened from the inside.
*The exit opened onto a driveway.
*Vehicles could drive right beside the door for delivery and removal.

Interview at that time with the environmental services and security manager regarding transporting and storage of the black pharmaceutical waste containers revealed:
*The janitors transported the filled containers from the medical floors to the black trash room.
*Janitors were approved for removal of the black waste bags from the containers when the pharmaceutical waste disposal company came to remove it.
*All Plant Ops personnel had master keys that unlocked many secured areas in the hospital.
*That same master key unlocked the black trash room.
*The Plant Ops personnel consisted of maintenance supervisors, nursing supervisors, administration, housekeeping supervisors, and other supervisors.
*At the time of the survey he had just given out the fiftieth master key to personnel.
*There was no documentation as to what was in the pharmaceutical waste containers or how much pharmaceutical waste was removed when the pharmaceutical trash company came to remove the waste.
*He agreed the black pharmaceutical waste could have been removed from the room without knowing what had been removed or how many containers had been removed.

Review of the provider's December 2015 Waste Management Program: Pharmaceutical Waste policy revealed:
*The purpose was "to provide a systematic approach to identify, manage, properly dispose of and document all regulated hazardous and non-hazardous waste in conformance with local, state and federal regulations as applicable."
*The policy did not apply to controlled medications.
*Pharmaceutical waste was broken down to different containers depending on the hazard or compatibility of the waste.
*The pharmacy director would establish mechanisms for identifying how the different medications were disposed of.
*All departments would dispose of the waste in the appropriately coded containers.
*Pharmaceutical waste of more than 3% of the original weight left in it's container was placed in the black pharmaceutical waste containers.
*The policy had not included how the black waste awaiting destruction was to have been secured or who was to have access to the pharmaceutical waste awaiting destruction/removal.

A. Based on observation, testing, interview, policy review, and record review, the provider failed to ensure:
*All toys used at the therapy center were disinfected according to their policy and references.
*Three of five covers on the clean linen carts in one of one clean laundry room were kept clean and sanitary when in-use.
*All clean supplies in the west storage room were not transported through a soiled room.
*Three of seven roller board covers were not frayed and tattered in the equipment storage room of the operating suite.
*One of two head pads on two of two shoulder positioning devices did not have cracks in the equipment storage room of the operating suite.
*Two of two processing table shelves in the sterile processing department (SPD) were kept in a cleanable condition.
*All ceiling tiles in the processing side of the SPD had a smooth finish that would not expel lint or debris.
Findings include:

1. Observation on 8/2/16 at 9:00 a.m. revealed three large totes and four small baskets of toys in the dirty utility room at the therapy center.

Interview at the time of the observation with the director of physical therapy revealed:
*Toys were used in the center and for home visits.
*All toys were brought into the dirty utility room to be disinfected.
*Staff would wipe the toys off with a food grade sanitizer, and then let them air dry.
*He did not have a reference for how to disinfect the toys.
*He had written a policy for the toy cleaning.

Review of the provider's 11/25/13 Therapy Center Toy Cleaning policy and procedure revealed staff would use a quaternary food grade sanitizer on the toys. Then they would let the toys air dry.

Interview on 8/3/16 at 3:00 p.m. with the infection control manager revealed:
*All toys should have had a bleach water rinse and been allowed to air dry.
*She had updated the toy cleaning policy, but it had not been reviewed and approved.
-The new policy revealed all toys would be cleaned after each use with an approved disinfectant.

2. Observation and interview on 8/2/16 at 1:00 p.m. revealed several clean linen carts stored in the clean laundry room. Three of those cart covers were visibly soiled with unknown splatters and darkened spots from what appeared to be hand prints on the covers. Laundry aides K and L revealed they had not laundered the covers. They stated they were unaware if the covers were ever laundered.

Interview on 8/3/16 at 4:00 p.m. with the environmental services and security manager revealed he was not aware the clean linen covers should have been laundered.

3. Observation and interview on 8/2/16 at 4:00 p.m. revealed clean supplies in the west clean supply and materials storage room on the other side of the garbage/soiled linen/box breakdown (dirty) storage room. The director of materials management revealed:
*Clean supplies would be removed from the room and carried through the dirty storage room into the corridors to be placed into use in the appropriate departments.
*The clean supply room had boxes of intravenous bags, individual baby bottles, individual diapers, cans of formula, and individual maternity kits.
*Some materials had to be logged into the computer in the large clean supply room on the other side of the dirty storage room.
*Staff removed the clean supplies from the small storage room, carried them through the dirty storage room, and then entered the large clean supply room.

No policy was provided upon request from risk management for the traffic flow of clean supplies throughout the facility.

4. Observation and interview on 8/3/16 at 10:00 a.m. in the equipment storage room of the operating room suite revealed:
*Three vinyl roller board covers were tattered and frayed along the stitched edges of the covers.
*One black vinyl head pad on a shoulder positioner had cracks that made the entire surface appear to have a white spider web. It was also frayed along the stitched seams.
*The director of surgical services confirmed those findings. He stated he was not aware of the condition of the covers and relied on the nursing staff to let him know when a surface was no longer cleanable.

Review of the provider's May 2016 Infection Control in the Operating Room policy revealed "d. Mattresses and padded positioning device surfaces should be moisture resistant and intact."

5. Observation on 8/3/16 at 9:45 a.m. of the SPD revealed:
*Two processing tables with shelves in the packaging room. The clear finish on the shelves had worn off down to the bare wood.
*The entire drop down ceiling of the packaging room, approximately sixty feet by thirty feet, had perforated ceiling tiles. Those perforated ceiling tiles were not cleanable and could expel lint and debris from the perforations.

Interview with the director of surgical services, who also oversaw the SPD, confirmed those findings. Interview with an unidentified sterilization technician revealed she had worked for that program for over twenty years. She stated the ceiling tiles might be the original tiles.

Review of the provider's February 2016 SPD Department Cleaning policy revealed it had no direction on the cleanability or construction of the SPD including the ceiling.

Review of the 2008 Centers for Disease Control and Prevention guideline revealed "Ceilings and wall surfaces should be constructed of non-shedding materials."

B. Based on observation, testing, document review, policy review, and interview, the provider failed to:
*Maintain the cleanliness for two of two mixers and one of one slicer in the main kitchen and baking kitchen.
*Clean one of one exhaust hood in the baking kitchen and maintain a cleaning schedule for that hood.
*Protect food on display at one of one cafeteria self-service buffet.
*Maintain proper refrigerator temperatures for one of one breast milk refrigerator in the nursery.
Findings include:

1. Observation on 8/2/16 from 10:50 a.m. to 12:30 p.m. revealed:
*The slicer in the preparation area was noted to have dried on food particles that could be scraped or picked off with a fingernail. The crevices around the blade and guard also had dried on food debris in them.
*The splash area of the Kitchen Aide mixer and the Hobart floor mixer had splashes and particles of dried on food on them that had started to dry up and curl.
*The exhaust hood in the baking kitchen had a layer of brown and orange colored grease and dust around the pipes and at the air exhaust entry point for the hood.
*Several dishes of desserts and fruit sat on top of the buffet bar in the cafeteria. Containers of uncovered bacon bits and croutons also sat outside of the sneeze guard by the salad buffet.

Interview at the time of the above observations with the food service manager confirmed the above findings. She revealed:
*The slicer and mixers were to be cleaned after each use or as often as needed.
*She was not aware staff were not doing a thorough cleaning of the slicer and mixers.
*She had noticed the grease build-up outside the hood and on the pipe.
*Maintenance had a regular schedule for cleaning the hoods in the kitchen.
*Staff were aware all food must be covered that was not shielded under the sneeze guard.

Interview on 8/3/16 at 10:00 a.m. with the maintenance manager revealed he had:
*A commercial company that cleaned the hood in the kitchen.
*Thought they cleaned the hood in the bakery too.

At the time of the exit on 8/4/16 no paperwork had been provided to ensure the bakery hood had been cleaned or was on a cleaning schedule with a commercial company.

Review of the provider's March 2016 Handling and Preparation of Food policy revealed "5. All work surfaces, utensils and equipment are thoroughly cleaned and sanitized after each use."

Review of the provider's August 2005 Kitchen Safe Rules policy revealed "6. Keep all containers of foodstuffs covered."

2. Observation on 8/2/16 at 2:00 p.m. revealed a small apartment sized refrigerator in the nursery with a daily temperature chart on top of it. Review of the chart revealed:
*The small refrigerator was used to store breast milk.
*There were no parameters given for the temperature range of breast milk.
*Listed temperatures for April,