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Based on review of facility based policy, observation and interview, it was determined that the facility failed to ensure the premises are clean and orderly.

Findings included:

"OSHA/Blood Borne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

On a tour of the facility on 7/23/19, the following were observed:
*Throughout the facility, several cracked ceiling tiles
*Throughout the facility, several cracked floor and wall tiles
*Throughout the facility, several areas on the walls and doors with chipped paint (including patient rooms 116, 101, 102 and OR and procedure rooms)
*Dead bugs in overhead lighting in the hallway leading to the OR
*Table used to fold clean laundry was chipped in a couple of spots, making it impossible to clean
*Room where mops were hang-drying clean had several areas with chipped walls and cracked ceiling

The above was verified during the tour with the Infection Control Officer.

Based on interview and record review the facility failed to provide surgical services in a safe manner when,

- (3) patient's history and physicals (H&P) were not updated on the day of procedure to indicate there were not changes and;
- the facility did not implement a policy and procedure to ensure an industry safety practice was followed when it did not conduct safety time-outs; the "time out" represents the final recapitulation and reassurance of accurate patient identity, surgical site, and planned procedure.

Findings include:

Review of the facility's surgical patient's records revealed there were no updates to indicated it had been review on the day of the procedure and if there were any changes.
Patient # 5's H&P was completed on 7/3/19, the date of the procedure was 7/23/19.
Patient #12's H&P was completed on 7/11/19, the date of the procedure was 7/18/19.
Patient #13's H&P was completed on 7/13/19, the date of the procedure was 7/17/19.

Staff #2 confirmed the physicians were not updating the H&P on the day of the procedure and confirmed the facility did not have a policy for the updating of the H&P on the day of the procedure.

During an interview on the morning of 7/23/19, in the administrative conference room, Staff #2, DON stated, "We don't do time outs .... We've discussed it .... but it's their own patients ...." Staff #2 stated the facility used the AORN (Association of periOperative Registered Nurses) guidelines and that there was no policy and procedure for the time outs. The AORN guidelines advocates the use of time outs.

Based on observation, interview and record review the facility failed to meet a patient's psychosocial needs when Patient #6's requested activities were not being honored during her stay in the facility's swing bed.

Findings include:

During an interview on the afternoon of 7/27/19, Patient #6 when asked about her preferred activities, stated, " ...I like to do work puzzles and sudoku. I found a bible in the room, I read that sometimes .... I had a crochet project that I worked on last time I was here. I've been going a little stir crazy this time .... I mostly watch HGTV." Patient #6 confirmed she was not given any materials.

During an interview and Patient #6's record review, on the afternoon of 7/27/19, Staff #5, Social Worker confirmed Patient #6's activities assessment had been completed and included the sudoku and puzzle requests as well as one on one visits and various religious activities. Staff #6 confirmed the staffs were not documenting what or when they were providing activities to Patient #6 and stated, "We don't have the kind of program you are looking for ...."