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Based on interview and record review the facility failed to make sure the Chief Nursing Officer met the required educational requirements to be in compliance with the required State or local laws.


Personnel file reviewed on 04/18/2018 at 1:00 p.m. for CNO ID #51 revealed no evidence of a required master's degree in nursing, health care, administration or business administration, or in a health-related field obtained through a curriculum that included courses in administration and management. Education was documented in employees file as Bachelor Degree in Nursing.

There was no evidence of the CNO progressing under a written plan to obtain the nursing administration qualifications associated with a master's degree in nursing.

Interview with CNO #51 on 04/17/2018 at 11:00 a.m. confirmed he had a Bachelor of Science Degree in Nursing. CNO stated he was looking into enrolling into a master's program, but had not done so as of yet, but stated he would enroll in a master's program.

Based on observation of the facility, record review and interview the facility failed to maintain patient equipment and the facility environment which could potentially result in the spread of infection and communicable diseases among patients and staff. These infection control issues were observed in 6 of 6 operating rooms (OR#'s 1,2,3,4,5 and 6), operating rooms hallway and post anesthesia area (PACU).

Findings include:

Observation on 04-17-15 at 11:50 a.m. the surveyors along with Chief Nursing Officer employee ID #51 and Director of the Operation Room employee ID #61 toured the facility. Areas toured included the preoperative holding area, OR's (operating room), transport hallway in OR area, operating rooms and PACU (post anesthesia care unit). Surveyors observed for damaged/stained ceiling tiles, damaged wall surfaces, visible rust, temperature/humidity of the OR's, storage of equipment/supplies areas and the emergency room area.

Based on interview on 04/17/2018 at 11:50 a.m. with Director of the OR ID #61 revealed the preoperative area to have six patient station areas, with privacy curtains separating each area. employee ID # 61 stated the operating area had 8 operating rooms, but only 6 were used, the other 2 were used for storage.

Operating Room #1
Observation on /4/17/2018 at 11:50 a.m. along with Chief Nursing Officer ID #51 and Director of Operating Room ID #61 toured OR # 1. The following was observed: Bovie machine cart with multiple paint chips and visible surface rust on bottom shelf, 2- storage carts with visible rust on all wheels, Jackson operation room table with visible rust on the head and foot bases of the OR table, OR table mattress pad had visable worn and craked areas at base of pad. Four walls in the OR were observe to have exposed sheetrock due to multiple paint chips and gouges in the sheetrock which left sheetrock exposed and unable to be cleaned. The doorway of OR had multiple visible paint chips on the inside and outside of doorway.

Operating Room #2
Observation on /4/17/2018 at 12:10 p.m. along with Chief Nursing Officer ID #51 and Director of Operating Room ID #61 toured OR # 1. The following was observed: Jackson operating room table with visible rust on the front base and surface rust on all 4 wheel of the OR table. Surgical table mattress was observed with tears and worn areas at bottom area of mattress. The doorway of OR had multiple visible paint chips on the inside and outside of doorway.

Operation Room #3
Observation on 04/17/2018 at 12:05 p.m. along with Chief Nursing Officer ID #51 and Director of Operating Room ID #61 toured OR #3. The following was observed: 2- stainless steel hampers with with plastic liners were observed with visible rust on all 4 of the legs of each hamper and the bottom shelf support and wheels of the hampers. OR surgical table mattress pad for the head section observed to have worn and cracked area. Bovie cart was observed with visible rust on the bottom shelf and surface rust on all 4 wheels. IV pole with surface rust on wheel brackets. The doorway of OR had multiple visible paint chips on the inside and outside of doorway.

Operating Room #4
Observation on 04/17/2018 at 12:00 p.m. along with Chief Nursing Officer ID #51 and Director of Operating Room ID #61 toured OR #4. The following was observed: Jackson OR bed with visible rust on the base of bed and 4 of the OR table wheels had visible surface rust. Rust was observed on the bottom panel of the IV pole and also an accumulation of visible rust on each wheel bracket of IV pole. Silver surgical instrument stand had visible rust on all four wheel brackets. Left wall was observed to have multiple areas of exposed sheetrock due to paint chips and gouges to the surface and could not be properly cleaned. The doorway of OR had multiple visible paint chips on the inside and outside of doorway.

Operating Room #5
Operating Room Observation on 04/17/2018 at 12:20 p.m. along with Chief Nursing Officer ID #51 and Director of Operating Room ID #61 toured OR #5. The following was observed: silver colored supply cart had visible rust on all 4 wheel brackets. Rust was observed on the bottom panel of the IV pole and also an accumulation of visible rust on each wheel bracket of IV pole.

Operating Room #6
Operating Room Observation on 04/17/2018 at 12:30 p.m. along with Chief Nursing Officer ID #51 and Director of Operating Room ID #61 toured OR #6. The following was observed: rolling black stool with 4 wheel and brackets with visible rust, Bovie cart with visible rust on all four wheels and bottom shelf with visible surface rust, stainless steel cart observed with surface rust on all four wheel brackets and wheels, left wall and front wall with gouges and exposed sheetrock.

Operation Rooms Transportation Hallway
Operating Room Observation on 04/17/2018 at 12:30 p.m. along with Chief Nursing Officer ID #51 and Director of Operating Room ID #61 toured the transportation hallway of the OR. The following was observed: 10 tiles were observed to have discoloration and stains. One tile had multiple dark blackish colored round spots on the outer surface of the tile, while the other 9 tiles had various stains that appeared to be brownish in color. A tile joint segment was observed bowing downward in the hallway approximately 5 feet x 10 feet long area near the scrub sinks. 16 vents in the operation room area were observed and 11 vents appeared to be dark stained and dirty. Operating room - no visible damaged ceiling tiles or leaks were seen in the operating rooms.

Post Anesthesia Care Unit (PACU)

Observation of the post anesthesia care waiting area on 04/17/2018 at 12:50 p.m. along with Chief Nursing Officer ID #51 and Director of Operating Room ID #61 revealed the following: Seven cloth chairs were seen in a waiting area, that were available for use by visitors, family members or patients. The cloth chairs could not be properly disinfected. Further observation revealed 10 floor tiles that appeared broken, chipped or missing with visible cement flooring exposed underneith. Also identified were 3 ceiling vents out of 14 observed to be dark color and dirty.

Interview on 04/17/2018 at 12:55 p.m. with Director of Operating Room ID #61 stated that she uses the waiting area with the cloth chairs for post surgery teaching for visitors, family members and sometimes patients prior to discharge home. Employee ID #61 stated that she did not know the chairs could not be cloth.

Interview at on 04/17/2018 at 13:00 with CNO ID #51 confirmed the chairs in the setting area of post anesthesia care area were cloth cover and could not be wiped down or sanitized and would need to be replaced with chairs that could be properly disinfected. CNO #51 was asked if it was acceptable to have the broken and chipped tiles in the hospital, CNO stated, "No, the floor tiles need to be replaced and the vents need to be cleaned".

Record review of Facility's Infection Control Plan revised 01/2018 revealed the policy states the Purpose: "The Infection Control Program assists in providing a high level of patient care by reducing the risk of Nosocomial infections to patient's (both inpatient and outpatients) healthcare providers and visitors. This is accomplished through surveillance, prevention, control of potential infections and continuous review and evaluation of Infection Control practices. Responsibilities: The assurance of safe hospital environment, which provides quality care and necessary resources to prevent and control infections, is the responsibility of the governing Board through the hospital administration team.

Review of the facility's Environment of Care policy/procedure manual, last revision date 10/2017, Titled: "Building Maintenance Program" reads in part......Statement of purpose: The purpose of the Building Maintenance program (BMP) is to insure, enhance and maintain the safety of patient, visitors, and staff of facility by identifying and quickly resolving to Life Safety Code (LSC) deficiencies through a formal program of inspection and corrective action program. The BMP is coordinated with regular inspections of the facility to assure all LSC systems are maintained at the highest level".

Review of the facility's manual titled Patient Care Manual revealed a policy titled "Patient Safety, Policy No: 602-21, last reviewed 01/2018 read in part........ Statement of Policy: The safety plan supports and promotes the mission, vision and values of the facility through practice of developing and implementing a culture of safety among its consumers, which implies but limited to patients, staff and visitor. The patient safety plan provides a systematic, coordinated and continuous approach to the maintenance and improvement of safety through the organization that support effective response to actual occurrences".

Review of facility's "Environment of Care/Safety Rounds" dated 02/27/2017 completed by Director of Maintenance Employee ID #62 address the following environmental cleanliness items documented as "no" Are air vents clean? Are walls/doors without chips? Are ceiling tiles in good shape?

During tour of the OR area CNO employee ID #51 on 04/17/2018/ at 12:20 p.m. CNO was asked if that was acceptable to have the damaged tiles in the OR area. He stated "No, they need to be changed". When the CNO employee ID #51 was asked about the tiles that were bowing downward in the hallway. CNO stated, "It needed to be repaired, the support structure need to be replaced". CNO was asked if routine environmental rounds were done by the facility. CNO replied that the Environment of Care Committee just meet, the committee does not do rounds or observation. CNO stated that maintenance does the observation rounds and gives written reports the Environment of Care Committee. Employee ID #51 further stated the facility had lost staff and were in the process of replacing staff and had planned on doing the repairs. No additional statement was received.

During an interview on 04/18/2018 at 9:55 a.m. the Infection Control Nurse employee ID #63 stated that maintenance does the environmental rounds and their concerns are shared with infection control and shared in the committee meetings.

During an interview and document review on 04/18/2018 at 2:00 p.m. Director of Maintenance employee ID #62 was asked if he does the environment surveillance round of the facility. Employee ID #62 stated "yes" and presented one document titled "Environment of Care/Safety Rounds" which was dated 02/27/2018. Employee ID # 62 stated that he does the environment rounds and does not have a set time frame for the rounds. When asked who the environment surveillance round results were given to employee ID #62 replied the CNO, Infection Control and they are reviewed in the Safety Committee and Environment of Care Committee. When asked about the identified repair items on the Environment Rounds sheet for February 27, 2018 employee ID # 62 stated they have not got to them yet.