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Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff and visitors.

Findings:

Observation on 06/03/2024 at 1:45 p.m. - 2:22 p.m. of the 2nd floor medical unit with S1CNO, S2RM, and S3UM revealed the following:
Room "a": 2 ceiling tiles with brown stains

Observation on 06/05/2024 at 3:24 p.m. - 3:37 p.m. of the 2nd floor medical unit with S1CNO and S2RM revealed the following:
Room "c": 3 ceiling tiles with brown stains
Room "d" bathroom: 1 ceiling tile was missing and 1 ceiling tile had 2 cracks in the tile.
There were multiple ceiling tiles with brown stains in the hallways.

In interviews during the observations S1CNO and S2RM verified the above stated findings.

Based on observations and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by:

1.) failing to ensure proper storage of patient equipment; and

2.) failing to maintain a sanitary environment.

Findings:

1.) Failing to ensure proper storage of patient equipment.

Review of the hospital's Infection Prevention and Control Plan 2023 presented as current revealed in part, Limiting Transmission related to Devices, Supplies, and Medical Equipment: The process of cleaning/decontaminating multi-use patient care supplies and equipment, such as glucometers, vital sign monitors, IV poles, wheelchairs, bedside commodes, linens, etc., will be evaluated on a regular basis to ensure effectiveness and consistency according to the manufacturer's instructions for use. Staff will be educated on the process as needed. Expectations are that items should be easily distinguished as "clean" by tag, bag, or other signage and properly stored in a clean designated storage area. Equipment or supplies considered "dirty" should be processed before use by the next patient, or stored in a dirty area behind closed doors until processed. A biohazard label or sign should be affixed to the door designating that room as a "soiled utility" room.

Observation on 06/03/2024 at 1:45 p.m. - 2:22 p.m. of the 2nd floor medical unit with S1CNO, S2RM, and S3UM revealed the following:
Storage Room: multiple vital sign machines stored with no indication of being "clean" by tag or being covered with a bag.
Clean Equipment Room: 4 bedside commodes with no indication of being "clean" by tag or being covered with a bag.

In interviews during the observation S3UM verified the above stated findings.

2.) Failing to maintain a sanitary environment.

Observation on 06/03/2024 at 1:45 p.m. - 2:22 p.m. of the 2nd floor medical unit with S1CNO, S2RM, and S3UM revealed the following:
Room "b" bathroom: fire sprinkler had rust spots which could not be disinfected and gray, dust-like material hanging from the sprinkler. The return vent also had gray, dust-like material in between each opening.

In an interview during the observation S1CNO and S2RM verified the above stated findings.