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A. Based on document review, observation, and interview, it was determined that the Hospital failed to manage daily dietary services by not ensuring that foods were labeled with an opened or use-by date. This had the potential to affect the 75 patients receiving oral diets on 7/13/2021.

Findings included:

1. The Hospital's policy titled, "Safe Food Handling (reviewed 8/21/2019)" was reviewed on 7/13/2021 and required, "All opened containers are labeled to indicate the date opened/date prepared..."

2. A tour of Dietary Services was conducted on 7/13/2021 at 11:15 AM. The following was observed:
- The dry storage room contained 3 opened, large bags of pasta that were not labeled with an opened or use-by date.
- The walk-in freezer contained an opened bag of meatballs, an opened package of prepared hamburgers, an opened bag of frozen carrots and an opened bag frozen spinach that were not labeled with the date opened or a use-by date.
- The walk-in refrigerator contained an opened bag of fresh carrots that was not labeled with an opened or use-by date.

3. During the tour, the Director of Dietary (E#4) stated that all items that have been opened, must be labeled with an opened date or use-by date.

B. Based on document review, observation, and interview, it was determined that the Hospital failed to manage daily dietary services by not ensuring that foods which had expired were discarded. This had the potential to affect the 75 patients receiving oral diets on 7/13/2021.

Findings included:

1. The Hospital's policy titled, "Safe Food Handling (reviewed 8/21/2019)" was reviewed on 7/13/2021 and required, "All opened containers are labeled to indicate the ... expiration/discard date.".

2. A tour of Dietary Services was conducted on 7/13/2021 at 11:15 AM. The following was observed:
- The dry storage room contained a large plastic bin of dry barley and a large plastic bin of corn meal, both with expiration dates of 6/30/21.

3. During the tour, the Dietary Inventory/Ordering Lead (E#3) stated that the contents of both containers should have been discarded on 7/1/2021.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on July 12 & 13, 2021, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on July 12 & 13, 2021, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on document review, observation and interview, it was determined that for 1 of 1 Sterile Processing Technician (E #9), observed for endoscope (long flexible tube used to visual the gastrointestinal tract) cleaning, disinfection, and sterilization, the Hospital failed to employ methods for preventing and controlling the transmission of infections within the Hospital by not ensuring that the protective gown was removed and hand hygiene was performed when moving from the decontamination area to the clean reprocessing/high-level disinfection equipment area. This has the potential to affect an average of 78 endoscopy patients per month.

Findings include:

1. On 7/13/2021, the Hospital's policy titled, "Hand Hygiene" revised by the Hospital 9/2019, was reviewed. The policy included, "...1. All personnel will use the hand hygiene techniques, as set forth in the following procedure...10. Always after removing gloves..."

2. On 7/13/2021 between 10:30 AM and 10:50 AM, with the Chief Nursing Officer (E #2) and the Sterile Processing Technician (E #9), an observational tour of the endoscopy area was conducted. E #9 cleaned and disinfected a contaminated endoscope in the designated decontamination sink. E #9 moved from the decontamination sink to the endoscope high-level disinfection machine and removed a clean/reprocessed endoscope and placed it in the clean area without changing the protective gown or performing hand hygiene between doffing and donning of gloves.

3. On 7/13/2021 at 10:50 AM, an interview was conducted with E #9. E #9 stated that he has to change his gloves, but can keep the same gown on when moving from the decontamination sink to the high-level disinfection machine.

4. On 7/13/2021 at 10:51 AM, an interview was conducted with E #2. E #2 stated that hand hygiene should be performed after removing gloves, and PPE (personal protective equipment - i.e. gowns) should be changed when moving from a decontamination area to a clean area.


B. Based on document review, observation, and interview, it was determined that for 1 of 1 decontamination sinks in the endoscope (long flexible tube used to visual the gastrointestinal tract) cleaning room, the Hospital failed to employ methods for preventing and controlling the transmission of infections within the Hospital by failing to ensure that the sink in the endoscope cleaning room was maintained to remain filled with the required water/detergent mixture during the cleaning and disinfection process. This has the potential to affect an average of 78 endoscopy patients per month.

Findings include:

1. On 7/13/2021, the Manufacturer's guidelines titled, "Prolystica 2X Concentrate Enzymatic Presoak and Cleanser Technical Data" (cleaning solution for endoscopes) dated 8/1/2015 was reviewed. The guidelines required, "...Manual/Ultrasonic Applications: Dilute 1/8 to 1/2 fl. /oz. per gallon (1- 4 ml/L) in warm water."

2. On 7/13/2021 between 10:30 AM and 10:50 AM, with the Chief Nursing Officer (E #2) and the Sterile Processing Technician (E #9), an observational tour of the endoscopy area was conducted. In the endoscope cleaning room, E #9 filled the decontamination sink with water and the pre-measured Prolystica enzymatic detergent. While E #9 was preparing the mixture, water was draining out of the sink, thus changing the amount of water/detergent mixture recommended for cleaning and disinfecting endoscopes.

3. On 7/13/2021 at 10:45 AM, an interview was conducted with E #9. E #9 stated that the manufacturer's recommended amount of enzymatic detergent is preset to mix with water at the fill line marked in the sink. E #9 stated that the water/detergent mixture is used to clean the endoscopes before placing them in the reprocessor for high-level disinfection. E #9 stated that the rubber drain stopper does not prevent the water/detergent mixture from draining out of the sink. E #9 stated that he requested a replacement stopper but it has not been replaced.

Based on observation, document review, and interview, it was determined that for 1 of 1 OR (Operating Room) Technician (E #8) and 1 of 1 Surgeon (MD #1) observed in OR #2, the Hospital failed to ensure adherence to the policies governing surgical care dress code while in the operating room.

Findings include:

1. On 7/14/2021 between 9:00 AM and 10:00 AM, an observational tour of OR #2 was conducted. At approximately 9:05 AM, when a sterile field was opened, E #8's hair was exposed on the sides of his face, and the surgeon (MD #1) was observed wearing a silver chain necklace.

2. On 7/14/2021 at approximately 10:15 AM, the Hospital's policy titled, "Surgical Attire" (revised 4/2019) was reviewed and required, "... All persons entering restricted areas of the surgery department will wear head covers/surgical hats. Head covers/surgical hats must cover all exposed head and facial hair...jewelry, other than watches, is not allowed in the restricted areas of the OR."

3. On 7/14/2021 at 10:20 AM, an interview was conducted with the OR Coordinator (E #7). E #7 stated that all facial hair should be covered, and necklaces should not be worn in the OR.