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Based on document review and interview the facility failed to have a Governing Body that included oversight for the Medical Staff and Quality Assurance Performance Improvement Committee and failure to ensure the facility had an operational budget resulting in failure to have oversight of the facility operational functions. Findings include:

1. The facility failed to ensure the governing body consulted with the individual responsible for medical staff. See tag A-053

2. The facility failed to have an institutional plan and budget for the fiscal year of 2017 resulting in lack of awareness of the facility's anticipated income and expenses, the facility's capital expenditures for the next 3-year period, facility assets, sources for financing, facility improvements, and the replacement and modernization of buildings and equipment. See tag A-073.

Based on document review and interview the facility failed to show to ensure the governing body consulted with the individual assigned for leadership of the facility's medical staff resulting in the potential of less than optimal medical care. Findings include:

On 6/26/2017 at 1015 a request was made for the organization's governing body meeting minutes. On 6/27/2017 at 0900 a second request was made for the organization's governing body meeting minutes. On 6/28/2017 at 0830 a third request was made for the governing body meeting minutes. On 6/28/2017 at 0900 staff A was interviewed as to if there were governing body meeting minutes available for review. Staff A stated the documentation was being printed and the governing body meeting minutes were not available on site. Staff A further stated that the meeting minutes would be delivered for review.

On 6/28/2017 at 1000 a review of documentation titled Governing Body meeting minutes occurred. Upon review it was revealed the governing body meeting minutes failed to show consultation with the leadership of the Medical Staff. The documentation failed to include information from the Medical Staff committee.

On 6/28/2017 an interview with staff T occurred. Staff T was asked if the governing body included information from the Medical Staff Committee. Staff T responded "the governing body was not aware of the regulation to include Medical Staff Committee information in the governing body minutes."

Based on interview and document review the facility failed to have an institutional plan and budget for the fiscal year of 2017 resulting in lack of awareness of the facility's anticipated income and expenses, the facility's capital expenditures for the next 3-year period, facility assets, sources for financing, facility improvements, and the replacement and modernization of buildings and equipment. Findings include:

On 6/26/2017 at 1015 a request was made for the facility's institutional plan and budget for the fiscal year. On 6/28/2017 at 0900 a final request was made for the facility's institutional plan and budget for the fiscal year. Staff U stated that because the institution had been through bankruptcy that no plan was available for the fiscal year nor a plan for capital expenditures for a 3-year period.

Based on observation, document review, and interview the facility failed to protect the rights of all current (41) patient and all discharged patients at risk for loss of their rights. Findings include:

1. The facility failed to ensure the Important Message from Medicare information sheet for the appeal of discharge had current and correct information of the Quality Improvement Organization for patients to appeal discharge. See tag A-117.

2. The facility failed to keep a log of all complaints and grievances received by the facility and failed to respond to complaints. See tag A-118.

3. The facility failed to maintain a safe environment in the psychiatric unit by use of beds with exposed metal spring coils and beds with open side rails. See tag A-144.

Based on document review and interview the facility failed to ensure the Important Message from Medicare (IMM) was accurate with information in order for patients to call and appeal discharge from the hospital for three of three (#3, 13, 14) medical records reviewed for IMM, from a total sample of 22, resulting in all discharged and current Medicare patients their patient rights. Findings include:

On 6/26/2017 at 1130 during document review of patient #3 medical record it was revealed the IMM being used listed the Quality Improvement Organization (QIO) as MPRO, instead of the correct QIO which is KEPRO. KEPRO was designated the QIO for facilities in this geographic region in 2014. On 6/26/2017 at 1135 staff F was queried if the document was the current information given to all Medicare patients about their right to appeal discharge from the facility. Staff F confirmed the sheet was the current sheet used for all Medicare patients. It should be noted that a telephone call was placed to the number provided for MPRO and was connected to a retail company.

On 6/28/2017 at 0930 an interview occurred with staff T. Staff T was asked if she was aware the IMM sheet used for Medicare patients had incorrect information for Medicare patients to appeal discharge from the facility. Staff T replied "yes, it has been brought to our attention during this survey that the information is incorrect."





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On 6/27/2017 at 0937 during document review of Patient #13's medical record it was revealed the IMM being used had information for MPRO and not KEPRO.

On 6/27/2017 at 0946 during document review of patient #14's medical record it was revealed the IMM being used had information for MPRO and not KEPRO.

On 6/26/2017 at 1135, Staff F was queried as to if this form was used for all Medicare patients to which she replied "yes."

Based on observation, document review and interview the facility failed to maintain a log of complaints and grievances received by the facility for 12 out of 12 months reviewed (June 2016 through June 2017) and failed to keep a letter of resolution sent to complainants resulting in the potential to deny all 41 current patients and all discharged patients their rights. Findings include:

On 6/26/2017 at 1015 a request was made for the facility's complaint and grievance log for June 2016 through June 2017. On 6/27/2017 at 0930 a review of a document identified as the complaint log was conducted.

On 6/27/2017 at 1000 an interview was conducted with staff Z occurred. Staff Z was queried if the log was inclusive of all complaints and grievances received at the facility. Staff Z stated that the log was for recipient rights and complaints filed only by psychiatric patients. Staff Z was then further queried if additional complaints and grievances were received from patients on the medical/surgical floor and the urgent care area. Staff Z stated "yes but they are not in a log." Staff Z was then asked if there was documentation to show how each complaint and grievance was addressed. Staff Z stated copies of correspondence was not available.

Based on observation and interview, the facility failed to provide a safe setting for care for 30 of 30 patients on the psychiatric unit resulting in the potential for injury, up to and including death, for all patients served by the facility on this unit. Findings include:

On 6/26/2017 at 1205, the psychiatric unit was entered on 4 South during the initial facility tour. Room 465 was observed to have two regular hospital beds with a metal frame and exposed metal springs. The beds also were observed to have side rails present. Upon further inspection, all patient rooms were observed to have this type of bed present.

On 6/26/2017 at 1212, Staff H, a registered nurse, was queried as to if the patient population on the unit included suicidal patients and/or self mutilating patients to which she replied "yes." Staff H was further queried as to if it were safe to have regular hospital beds for suicidal and/or self-mutilating patients to which she replied "probably not."

Based on Quality Assessment Performance Improvement (QAPI) program review and interview, the facility failed to maintain an ongoing program for patient outcomes for 10 out of 10 months reviewed (August 2016 - June 2017) resulting in the potential failure to improve health outcomes of patients receiving care at the facility. See the following QAPI citations:

1. The facility failed to have a Quality Assessment Performance Improvement (QAPI) program that showed measurable improvement in indicators for improved health outcomes of patients resulting in the failure to improve health outcomes of patients receiving care at the facility. See tag A-273.

2. The facility failed to have a Quality Assessment Performance Improvement (QAPI) program that identified areas for performance improvement, failed to have priorities set for performance improvement, and failed to implement initiatives for performance improvement. See tag A-283.

3. The facility failed to report medical errors and adverse events as part of the Quality Assessment Performance Improvement (QAPI) program resulting in the potential for unidentified areas for improvement to prevent adverse patient events. See tag A-286.

Based on document review and interview the facility failed to have a Quality Assessment Performance Improvement (QAPI) program for 10 out of 10 months reviewed (August 2016-June 2017) that showed measurable improvement or analysis in indicators for improved health outcomes of all patients resulting in the failure to improve health outcomes of patients receiving care at the facility. Findings include:

On 6/27/2017 at 1330 a review of the documents titled "Quality Council Meeting Minutes" from August 2016 through June 2017 occurred. During document review the QAPI program failed to have any information of measurable improvement in indicators. The facility failed to track, trend or analyze its indicators. The minutes included patient falls as raw data but did not include evidence of analysis.

On 6/28/2017 at 0930 an interview with staff T occurred. Staff T was asked if any evidence could be shown that indicators were used within the QAPI program for use of improvement in patient care. Staff T stated that although data was collected there was no information that could be produced to show how indicators were used for improvement measures or quality of care.

Based on document review and interview the facility failed to have a Quality Assessment Performance Improvement program (QAPI) that identified areas for performance improvement, failed to have priorities set for performance improvement, and failed to implement initiatives for performance improvement for 10 out of 10 months reviewed (August 2016 through June 2017) resulting in failure to improve patient safety and quality of care. Findings include:

On 6/27/2017 at 1330 a review of the documents titled "Quality Council Meeting Minutes" from August 2016 through June 2017 occurred. During document review the QAPI program failed to have any information of priorities for facility improvement measures or priorities to address areas of needed improvement.

On 6/28/2017 at 0930 an interview with staff T occurred. Staff T was asked if any evidence could be shown that indicators were used within the QAPI program for use for prioritization of improvement in patient care. Staff T stated that although data was collected there was no information that could be produced to show how indicators were used for improvement measures or quality of care nor were there priorities set for the QAPI program.

Based on document review and interview the facility failed to report medical errors and adverse events as part of the Quality Assessment Performance Improvement (QAPI) program for 10 out of 10 months reviewed (August 2016 through June 2017) resulting in the potential for unidentified areas for improvement to prevent adverse patient events. Findings include:

On 6/27/2017 at 1330 a review of the documents titled "Quality Council Meeting Minutes" from August 2016 through June 2017 occurred. During the review of the documents it was revealed the committee failed to address adverse events and medical errors as part of the Quality Assessment Performance Improvement (QAPI) program. A log was reviewed for adverse events in the facility but the information was not present the the QAPI program. The minutes included patient falls as raw data but did not include any initiatives put in place for performance improvement. Missing from the information was also defined goals for reduction in falls.

On 6/28/2017 at 0925 an interview occurred with staff T. Staff T was asked if adverse events and medication errors were incorporated in the QAPI program. Staff T stated that data was collected but there was no documentation to support initiatives or measures put in place for improvement purposed. Staff T was then asked if the Governing Body was an active part of the QAPI program ensuring oversight of the function of the QAPI program's expectation for patient safety. Staff T stated the Governing Body functioned as a separate entity apart from the QAPI program.

Based on record review and interview, the facility failed to maintain current licensure for 3 (Staff DD, EE, FF) of 10 medical staff reviewed resulting in the potential for unqualified personnel, unrecognized and/or unaddressed patient needs for all patients served by the facility. Findings include:

On 6/27/17 at 1657, the medical staff file for Staff DD, a neurosurgeon, was reviewed with Staff D, a quality credentialing specialist. The DEA (Drug Enforcement Administration) card was found to be expired on 5/2017. No current copy of the DEA card was found within the file. This was confirmed by Staff D at the time of discovery.

On 6/27/2017 at 1723, the medical staff file for Staff EE, an anesthesiologist, was reviewed with Staff D. State licensure for Staff EE's physician license and state licensure for controlled substances were both found to be expired on 1/31/2017. No current copy of either license was found within the file. This was confirmed by Staff D at the time of discovery.

On 6/27/2017 at 1746, the medical staff file for Staff EE, a certified registered nurse anesthetist (CRNA), was reviewed with Staff D. State licensure for Staff EE was found to be expired on 3/31/2017. No current copy of the license was found within the file. This was confirmed by Staff D at the time of discovery.

Based on observation, record review and interview the facility failed to ensure the development of comprehensive nursing care plans, failed to ensure the competence of staff, and failed to ensure medications were administered in accordance with professional standards resulting in the potential for unrecognized needs and less than optimal outcomes for all patients served by the facility. Findings include:

See specific tags:

A-0396 Failure to develop a nursing care plan based on patient problems, measurable goals, interventions, and evaluation
A-0397 Failure to ensure the competence of the nursing staff
A-0405 Failure to administer medications according to professional standards of care

Based on observation, record review, and interview, the facility failed to ensure nursing staff maintained an updated plan of care for 3 (#1, 2, 3) of 5 charts reviewed for plans of care out of a total sample of 22 patients resulting in the potential for unidentified patient needs and ineffective patient care for all patients served by the facility. Findings include:

On 6/27/2017 at 0925, Staff G was observed giving Patient #1 a narcotic pain medication for a headache. Review of the electronic medical record on 6/28/2017 at 0927 with Staff C revealed Patient #1 was admitted for abdominal pain. Additionally, Patient #1 had a history of seizures, headaches and had schizoaffective disorder. Further review of the medical record revealed a nursing care plan had been established on admission on 6/20/2017 "Impaired mobility" as the only nursing diagnosis. Continuation of the care plan was indicated daily however no updates were made to the plan of care.

Staff C was queried on 6/28/2017 at 0929 as to how often the care plan should be updated to which she replied "I would think it should be updated at least daily. I'm not sure. We will ask (Staff F)." Staff C did show that a box indicating the plan was to continue with this nursing diagnosis. Staff C stated, "The staff marks this box and we know that they have looked at the care plan." Staff C was queried as to if the care plan could be expanded based on admitting diagnosis, past medical history, and the medication list to which she replied "yes."

On 6/28/2017 at 0931, Patient #2's medical record was reviewed and revealed that she was a 36 year old female admitted on 6/25/2017 with chest pain. Cardiac enzyme labs resulted negative. The medical diagnosis was determined to be anxiety. Review of the nursing care plan revealed the single diagnosis of "chest pain, angina" which was established upon admission. Continuation of the plan was indicated daily however no updates were made to the care plan.

On 6/28/2017 at 0921, Patient #3's medical record was reviewed and revealed that the Patient #3 was 30 years old and was admitted with chest pain on 6/25/2017 and had a history of myocardial infarction (heart attack) and sickle cell disease. Review of the care plan revealed one nursing diagnosis of "pain" with a goal that stated "pain will be decreased". This diagnosis and goal was established upon admission with daily indication that the plan should continue but had no updates to the plan of care or updated measurable goals. Staff C was queried as to if the goal that was established could be measured to which she stated it would be difficult to tell without looking at the nursing flow sheet.

On 6/28/2017 at 1013, Staff F was queried as to how often the nursing care plan should be updated to which she replied "every shift." Staff F was further queried regarding the lack of an individualized, comprehensive plan of care. Staff F stated, "We have identified that this was one of the things we need to work on...There are so many things we have to fix. We started with hourly rounding and vital signs..."

Facility policy #CL-T-38 titled "Care Plan Policy" last revised 1/23/2017 was reviewed on 6/28/2017 at 1015. Policy states, "Care is initiated as clinically indicated and documented accordingly...Nursing care plan which includes: Patient specific priority problems, Short term goals and measurable outcomes, Interventions to meet the goals, Nursing summary reflecting response to care interventions, Nursing plan priorities changes and recommendations..."

Based on document review and interview, the facility failed to ensure the competency of the nursing staff for 6 (Staff C, F, G, H, I, Y) of 6 nursing staff personnel files reviewed resulting in the potential for inadequate patient care and poor patient outcomes. Findings include:

On 6/27/2017 between 1630-1800, staff personnel files were reviewed and revealed no competencies were present for the four nurses and two medical assistants whose files had been selected.

Nurse Educator Staff AA was interviewed on 6/28/2017 at 1134 as to how long she had been in her role as educator and if the staff had completed yearly competencies. Staff AA stated she started her role as educator in November 2016 and realized shortly thereafter that yearly competencies for the staff had not yet been completed. She stated that she "scrambled to get everything done" by the end of December because "if competencies weren't done the staff wouldn't be allowed to work." Staff AA was requested to provide documentation that all nursing staff had completed their competencies to which she replied that she "hadn't thought to keep track of who had or had not done their competencies" but would definitely do that in the future. She further stated, "It's always a revolving door around here. People come and go and it's hard to keep track of."

The Director of Nursing was out of town and unavailable for interview. Hospital policy regarding staff competencies was requested but not provided prior to exit of survey.

Based on observation, interview, and record review, the facility failed to administer medications according to facility policy and acceptable standards of practice for 1 of 2 medication passes observed out of a total sample of 22 patients resulting in the potential for medication error and the potential for infection for all patients served by the facility. Findings include:

On 6/27/2017 at 0900, Staff O, a registered nurse (RN) was observed removing medications from the Pyxis machine in the medication room on 5 North for Patient #13 and putting them unopened in a small paper cup on the left lower corner of her computer desk. There was also observed to be a small paper cup on the upper right side of the computer desk with unopened medication in it. No patient label, time, initials or room number was seen on either cup. Staff O was queried as to the medications in the two cups to which she replied that the medication located in the upper right corner of the computer desk was for Patient #14. Staff O was then queried as to why she was pulling out medications for two different patients at the same time to which she replied "to make it a little faster." On 6/27/2017 at 0906, Clinical Coordinator RN Staff GG was queried as to if it were acceptable to remove medications for two patients at the same time to which she replied, "That is not supposed to happen."

On 6/27/2017 at 0940, Pharmacy Director Staff E was on the 5 North unit and asked if there were any issues observed with medication administration. Staff E was told of the above observation. Staff E grimaced and shook his head. He then stated, "We've gone through many changes and I think it is starting to turn around but we're not quite there yet."

Facility policy #CLI-M-2 titled "Medication Management" last revised 5/13/2013 was reviewed on 6/27/2017 at 1303. Policy states, "Any time or anywhere one or more medications are prepared but are not administered immediately, the medication container must be appropriately labeled..."

Based on observation and interview, the facility failed to ensure that the hospital's food and dietetic services were sanitary, organized, directed and sufficiently staffed to meet the patients' nutritional needs according to acceptable standards of practice resulting in the potential for less than optimal patient outcomes for all patients served at the facility. Findings include:

See specific tags:

A- 0620 - The facility failed to ensure the kitchen adhered to acceptable standards of practice and sanitation, failed to maintain the kitchen and kitchen equipment in good repair, failed to develop and adhere to written policies and procedures for employee illness, food safety and kitchen sanitation, failed to maintain compliance with state and federal food service standards and regulations, and failed to implement quality improvement initiatives resulting in the potential for transmission of food borne illness to all 41 patients served by the facility.

A-0629 - The facility failed to ensure high risk patients were assessed and monitored for nutritional risk for two of two patients reviewed for nutritional assessment (# 18 and #19).

Based on observation, interview, and record review the facility failed The Food Service manager failed to develop and adhere to policies and procedures for kitchen sanitation, safe storage of perishable foods, and employee exclusionary illnesses; failed to adhere to state and federal regulations for food safety and kitchen sanitation; failed to ensure that the kitchen and kitchen equipment were maintained in good repair and sanitary condition, free of pests and sources of pest attraction; and failed to remove sources of standing water and other potential microbial and fungal hazards; resulting in the potential for transmission of foodborne illness for all 41 patients in the facility. Findings include:

On 6/26/17 from 0920 to 1030, a tour of the facility kitchen was conducted with the Food Service Manager, Staff K, and the following was noted:

The staff handwashing sink was visibly soiled with layers of brown, yellow and grey material. The garbage can for the hand washing sink had a lid that was not hands free. There was a mouse bait station under the handwashing sink.

There was a 18 inch bug light by the wall. The bottom of the light was covered in dead flies. Staff K was unable to state when the bug light was last cleaned or the dead flies removed. The door from the kitchen to the loading dock area was observed to have an approximately 3/4 inch gap at the bottom. The door to the loading dock area was observed to be open and was in an unobstructed straight line from the kitchen door.

There were three uncovered laundry hampers full of soiled cloth material. There were large areas of dried brown liquid visible on the bottoms of each hamper. Visible swarms of small flying insects were seen flying around the hampers. When asked, Staff K stated, "Those are fruit flies. They come and collect the soiled linen from those hampers once a week."

There was a 55 gallon uncovered trash can (no cover or lid) 3/4 full with food waste by the three compartment sink, and another one in similar condition by the dishwashing machine. There were visible flying insects around the trash cans.

There were flying insects visible above the food preparation tables and the steam table.

The food storage cabinet's glass doors were smeared with yellow matter and shelves had visible food debris.

There was a small sink on the same counter beside the three compartment sink (dishwashing sink). The sink was full of food debris, the faucet was dripping water, and the sink was not connected to any waste drain plumbing. The sink waste pipe (from the sink drain) ended approximately 18 inches above the floor and several inches above a plastic bucket which was overflowing on to the floor with grey colored liquid. When asked, Staff K stated, "That sink used to have a garbage disposal, but it broke, so they took the garbage disposal out a couple of years ago." Staff K then emptied the bucket under the sink into a floor drain. The bottom and lower sides of the bucket were observed to be coated with thick grey green slime.

There was a long commercial grade hose coiled up on the wall beside the three compartment sink. The outside of the red colored hose was covered with areas of black material. When asked, Staff K reported that the hose hadn't been used ,"in several years", and when asked if the hose was regularly flushed to prevent fungal and bacterial growth of the standing water inside the hose length and the plumbing fixtures, Staff K reported that it had not been done.

The floor underneath the three compartment sink was visibly soiled with food debris and sticky brown/black material in the corners and along the edge with the wall. The wall in the area was soiled with spatters of debris. There was a visibly damp, crushed cardboard packing box on the floor under the three compartment sink. When asked, Staff K stated, "It's over the grease trap. It got plugged the other day and I had to snake it out." Staff K removed the crushed cardboard packing box, and the area underneath was observed to be a large drain coated with greasy grey material.

The faucet for the three compartment sink leaked water in a steady flow. When asked, Staff K was unable to state how staff ensured that the continuously leaking faucet did not dilute the sanitizer in the three compartment sink to ineffective levels.

The dishwashing machine drain trough was coated with a layer of dry brown material that obscured the metal in multiple areas. When asked, Staff K stated, "It needs cleaning. We just don't have the staff to do this kind of thing. I have to do the cooking today, and the cafeteria cashier has to do the prep (preparation) for the salad bar." The dishwashing machine drain screen was full of food debris. When asked. Staff K could not state when it had last been cleaned or who was responsible for cleaning it. When asked, Staff K stated that dishes from breakfast had not returned to the kitchen to be washed yet. The floor underneath the dishwashing machine was visibly soiled with food debris and sticky brown/black material in the corners and along the edge with the wall.

There were multiple broken floor and wall molding tiles underneath the dishwasher. The underflooring on the floor, and the drywall under the molding were exposed and the holes left by the broken tiles were filled with tile shards and debris. When asked, Staff K stated "We had a leak there."

A shelving unit was observed to contain a food serving platter that had visible food debris adhering to it. When asked, Staff K stated that it was a clean rack, and that the serving platter was clean. When asked to inspect the platter, Staff K removed it and said, "It's not clean, it has food on it."

Three of three implement/dish storage shelf units had visible dust and debris on the bottom shelf. All cabinets, refrigerators, and large pieces of kitchen equipment were noted to have dust on their tops. When asked, Staff K stated that there was no cleaning schedule determined, and no specific staff assigned to perform kitchen cleaning. Staff K stated, "We barely have enough staff to get the food out."

There was a large baking tray filled with water on the counter in front of the ice machine. When asked, Staff K stated, "Sometimes the ice machine overflows." A service sticker indicated that the ice machine had been serviced on 1/5/17. When asked, Staff K stated that he was not sure how often the ice machine should be serviced, or whether the service provider should be contacted to repair the overflow problem.

The three uncovered individual serving cereal storage bins all contained cereal debris. When asked, Staff K stated that a pest control company came regularly to check the mouse bait stations placed at various areas in the kitchen.

The serving scoop was stored inside flour storage bin with the flour.

The two refrigerators in the kitchen were inspected. One was noted to be empty and not running. The second refrigerator had two of four sections that were empty and not turned on. Staff K reported that the non running refrigerator and half of the second (running)refrigerator were "broken", but when asked how long they had been out of order, and whether a maintenance request for repairs was submitted, Staff K stated, "We don't really need them." The door gaskets on the two functional sections of the second refrigerator were damaged and were visibly hanging off outside of each door on the bottom corners when the doors were closed.

Both walk-in coolers had ventilation fans that were visibly dusty with fluffy grey strings of dust. Staff K was unable to state when they were last cleaned, or who was responsible for cleaning them. A lunch box was observed in the walk in cooler. When queried, Staff K stated, "That belongs to one of my staff. They're diabetic. It's their insulin. It has to be refrigerated and the staff refrigerator is broken. If they aren't allowed to keep it here, then what should I do?"

There were two opened, partially used gallon jugs of milk inside the refrigerator, which were not labeled with the date they were opened. When asked, Staff K stated, "They're not expired. We go by the manufacturer's expiration date." There were two opened, partially used 1 quart cartons of soy milk, that were not dated when opened. The manufacturer's instructions on the cartons noted, "Keep for 7 to 10 days after opening."

The walk-in cooler contained a pan of red sauce, and a pan of cooked pasta that were unlabeled and undated. There were three unlabeled patient serving trays with meat, mashed potatoes and beans in disposable take-out containers which were not labeled or dated. Two one gallon jugs of milk were opened, partially used, and were not dated when opened. There was a partial tray of desserts, custards and cheesecake partitioned into individual servings that was not dated or labeled.

There were three missing ceiling tiles in the area between the dishwashing machine and the food preparation tables. The walls beneath the missing ceiling tiles were soiled with brown material. There were broken floor tiles under the missing ceiling tiles, with debris in the holes in the floor tiles. Staff K stated, "There was a steam leak in one of the pipes above the ceiling." Damaged drywall that was discolored, moist and peeling long sheets from the surface were visible through the missing ceiling tile. Staff K stated that the leak had happened several months previously.

The outside of both steam jacket kettles was visibly soiled with multiple colors of dried material.

The back of the stove, and the area underneath the stove and convection oven had visible pieces of food debris and smears of matter.

The oven contained multiple areas of raised black crusted matter.

The white vinyl floor drain underneath the food prep sink was crusted with dried black matter and brown greasy residue. Staff K stated, "It's a large kitchen, there are too few of us, it's frustrating."

When asked, Staff K was unable to provide any schedule of kitchen cleaning assignments, or any policies and procedures related to kitchen sanitation, food storage, equipment repair, or staff illness. When asked, Staff K reported that staff were not required to tell him the reason for absences, and that he was not aware that the Infection Control Department needed to be contacted if staff were ill with communicable disease. When queried, Staff K was unable to provide any documentation of quality improvement projects or of any reporting to either the Infection Control Department or the Quality Improvement Department.

On 6/26/17 at 1500, the Chief Operating Officer, Staff A and the Quality consultant, Staff T were requested to provide facility policies regarding kitchen sanitation, kitchen cleaning, equipment repair and/ or maintenance, and food storage. On 6/27/17, a Policy on food storage dated 6/26/17 (the same date the policy was requested) was provided. Both Staff A and Staff T indicated that no other policies were available.

On 6/29/17 at 1530, review of the Michigan Modified 2009 Food Code (State food handling regulations) revealed the following state regulations were not followed:
1. " Refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL
FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. "

2. "Written procedures shall be prepared in advance, maintained in the FOOD ESTABLISHMENT and made available to the REGULATORY AUTHORITY upon request that specify: Pf (a) Methods of compliance with Subparagraphs (B)(1)-(3) or
C)(1)-(5) of this section; Pf and (b) Methods of compliance with § 3-501.14 for FOOD that is prepared, cooked, and refrigerated before time is used as a public health control. Pf Time - maximum up to 4 hours .(B) If time temperature control"

3. "NonFOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance."

4. "4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition
that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners,
and kick plates shall be kept intact, tight, and adjusted in accordancewith manufacturer's specifications."

5. "NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris."

6. "Soiled LINENS shall be kept in clean, nonabsorbent receptacles or clean, washable laundry bags and stored and transported to prevent contamination of FOOD, clean EQUIPMENT, clean UTENSILS, and SINGLESERVICE and SINGLE-USE ARTICLES."

7. "A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; P and (B) Maintained in good repair"

8. "5-501.13 Receptacles. (A) Except as specified in ¶ (B) of this section, receptacles and waste Index 153 handling units for REFUSE, recyclables, and returnables and for use with materials containing FOOD residue shall be durable, cleanable, insect- and rodent-resistant, leakproof, and nonabsorbent. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered"

9. "6-201.13 Floor and Wall Junctures, Coved, and Enclosed or Sealed. (A) In FOOD ESTABLISHMENTS in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be coved and closed to no larger than 1 mm (one thirty-second inch)."

10. "6-202.15 Outer Openings, Protected. (A) Except as specified in ¶¶ (B), (C), and (E) and under ¶ (D) of this
section, outer openings of a FOOD ESTABLISHMENT shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings; (2)Solid, self-closing, tight-fitting doors."

11. "6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair."

12. "6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean"

13. "6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: Eliminating harborage conditions."

14. "6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests. Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the PREMISES at a frequency that prevents their accumulation, decomposition, or the attraction of pests."

15. "6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; and (B) Litter.

The Registered Dietitian failed to assess and monitor high risk patients for nutritional risk, for two of two patients reviewed for nutritional assessment (# 18 and #19), out of a total sample of 23, resulting in the potential for unmet dietary neeeds and decline in nutritional status. Findings include:


On 6/26/17 during a tour of the facility kitchen, the facility Dietary Manual and Patient meal tickets for breakfast on 6/26/17 were reviewed with the dietary aide, Staff M. Staff M stated that she looked at the daily computer print-out of patient census in the kitchen manager's office, and selected the correct type of meal ticket for each patient based on the patient's ordered diet type, and listed allergies. Staff M stated, "We only have a Registered Dietitian occasionally, and I don't know when she comes." Staff M stated that a Renal diet is a purple meal ticket, green is a cardiac diet, and yellow is a controlled carbohydrate (diabetic) diet. Patient #18, who received a controlled carbohydrate diet (yellow meal ticket) and Patient #19, who received a renal diet (purple meal ticket) were selected for medical record review.

On 6/28/17 at 1500, Patient #18's clinical record was reviewed with the Assistant Director of Nursing, Staff C, and revealed the following:

Patient # 18 was a 42 year old female admitted to the facility on 6/22/17 at 1336, with diagnoses which included Diabetes II and Urinary tract infection. There was no nutritional risk assessment or any other documentation by the Registered Dietitian. When asked whether there was any documentation that the Registered Dietitian had assessed Patient #18, Staff C reported that she had looked through the clinical record and there was no documentation by the Registered Dietitian.

On 6/28/17 at approximately 1500, Patient #19's clinical record was reviewed with the Assistant Director of Nursing, Staff C, and revealed the following:

Patient #19 was a 55 year old male admitted to the facility on 5/16/17 at, 1911, with diagnoses which included Gastro-esophageal Reflux Disease (GERD), Hyperlipidemia (high blood level of fats), Gout (a metabolic disease affecting the joints, made worse by eating certain foods), and renal failure. There was no nutritional risk assessment or any other documentation by the Registered Dietitian for the patient's current hospitalization. When asked to provide any documentation that Patient #19 was assessed and monitored by the Registered Dietitian, Staff C provided a Registered Dietitian Progress note dated 4/24/17 at 1523 (previous admission) that documented Patient #19 had a 4% weight change since 3/14/17 (one month), and was at nutritional risk and the plan for follow up was documented as, "Every 7-10 days." Staff C stated, "that's all there is."

The Registered Dietitian was unavailable for interview.

A Policy for nutritional risk assessment and monitoring was requested, but not provided by survey exit.

Based on observation and interview the facility failed to ensure the physical environment was developed and maintained to ensure the safety of the patients, resulting in the potential for harm to all 41 patients served by the facility. Findings include:
See specific tags:

A-0701 - Failed to maintain the condition of the physical plant.

A-0703 Failed to maintain adequate emergency fuel supply for their boilers and emergency generator to meet their emergency management plans.

A-0710 Failure to meet the LSC.

A-0724 - Failed to maintain equipment and supplies to ensure safety.

A-0726 - Failed to provide proper ventilation, illumination, and temperature controls.

Based upon observation, document review, and interview the facility failed to maintain the condition of the physical plant to assure the safety and well-being of patients which could result in harm to all 41 patients within the facility. Findings include:

1. On 06/27/17 at approximately 1000 during document review with Staff B, observed that the emergency plans had not been updated since 09/13/2012. Also, there was no record of emergency drills in the past 12 months.

2. On 06/27/17 at approximately 1000 during document review with Staff B, observed that there was no record of any routine equipment preventive maintenance program actively in place. The facility had only a repair work order system in use.

3. On 06/27/17 at approximately 1640 during document review with Staff B, observed that the recent medical gas annual inspection report (service dates May 16 & 18, 2017) documented numerous medical gas outlets leaking and also documented that the medical air outlets in various locations such as Intensive Care Unit (ICU) rooms 135, 136, and Respiratory Care Room 204. At the time of survey these outlets could not be tested. The report documented numerous other problems with the medical gas system such as mislabeled gas shut off valves. Staff B explained that he had recently received the report and had not had a chance to address any of the medical gas issues identified.

4. On 06/26/17 at 1310, observed the small grab bar in the behavioral health patient toilet room in Room 468 was not maintained to prevent risk of ligature as the bottom plastic protective plate for the grab bar was missing.

5. On 06/26/17 at 1349, observed the grab bar on the back wall in the behavioral health patient toilet room in Room 446 was not maintained to prevent risk of ligature as the bottom plastic protective plate for the grab bar was missing.

6. On 06/27/17 at 1100 inspected the filters for Air Conditioning Unit (ACU) 3 in the North Mechanical Room. The filters looked clean but there was no record of preventive maintenance (PM) having been performed on the air handling unit. The PM cards attached to the equipment have not been used to document maintenance work in over a year. Staff LL explained that he had performed the PM on ACU 3 and recorded it in the boiler log. On 6/27/17 at 1205 the boiler log was reviewed with Staff LL. The log noted record of filter change for ACU 2 on (March 25, 2017) but the record of the filter change for ACU 2 did not mention whether the prefilter was changed or the final filter was changed or both.

7. On 06/27/17 at approximately 1120, observed two vacuum pumps in the North Mechanical Room (Mech Rm) that were out of service. On 6/27/2017 at approximately 1130 in Mech Room 222 (S Mechanical) observed an anesthesia vacuum pump in the room with a blinking red alarm light on. There was a note that instructs maintenance to push the red light button to clear the alarm in the powerhouse & security when the vacuum pump is turned on. On 06/27/17 at approximately 1300 observed in Room G 30, the Vacuum pump room (used solely for surgery), that there was one pump not working so that Surgery was operating on only one surgical vacuum pump. Staff B explained that the facility was getting quotes to replace the defective surgical vacuum pump. There were no records available regarding preventive maintenance on any portable suction pumps in Surgery.

8. On 06/27/17 at approximately 1130 in Mech Rm 222 observed that the roof top fan motor had for roof top unit #1 (RTU 1) had loose belts as confirmed by Staff LL. A set of older broken belts were lying on the floor next to RTU 1.

9. On 06/27/17 at approximately 1600, observed a stained ceiling tile in ICU Rm 139. All of the stained or missing ceiling tiles in ICU had been replaced after a May 2017 survey per Staff B, the new stain was evidence of active water intrusion. Inspection above the suspended ceiling revealed the source of the water was from a leak in the roof directly above ICU Rm 139.

The above findings were confirmed by accompanying Staff B, Staff MM, and Staff LL.



27713

On 6/26/17 at 0920, a tour of the facility kitchen was conducted with the Food Service Manager, Staff K, and the following was noted:

There was a small sink on the same counter beside the three compartment sink (dishwashing sink). The sink was full of food debris, the faucet was dripping water, and the sink was not connected to any waste drain plumbing. The sink waste pipe (from the sink drain) ended approximately 18 inches above the floor and several inches above a plastic bucket which was overflowing on to the floor with grey colored liquid. When asked, Staff K stated, "That sink used to have a garbage disposal, but it broke, so they took the garbage disposal out a couple of years ago."

The faucet for the three compartment sink leaked water in a steady flow. When asked, Staff K was unable to state how staff ensured that the continuously leaking faucet did not dilute the sanitizer in the three compartment sink to ineffective levels.

There were multiple broken floor and wall molding tiles underneath the dishwasher. The underflooring on the floor, and the drywall under the molding were exposed and the holes left by the broken tiles were filled with tile shards and debris. When asked, Staff K stated "We had a leak there."

There were three missing ceiling tiles in the area between the dishwashing machine and the food preparation tables. The walls beneath the missing ceiling tiles were soiled with brown material. there were broken floor tiles under the missing ceiling tiles, with debris in the holes in the floor tiles. Staff K stated, "There was a steam leak in one of the pipes above the ceiling." Damaged drywall that was discolored, moist and peeling long sheets from the surface were visible through the missing ceiling tile. Staff K stated that the leak had happened several months previously.

On 6/27/17 at 1430, the provided facility maintenance contract was reviewed and revealed that the contract was no longer valid, as it was contracted with a different entity previously located at the same location as the current facility. There was also no time frame specified for completing repairs.

On 6/28/17 at 1450, the facility comtroller, Staff U was interviewed, and stated, "We called our maintenance company about the broken floor tiles and the ceiling leak a two months ago. The work was supposed to be done by now." Staff U was requested to provide any documented work orders for the repairs, but was unable to do so by survey exit.

On 6/27/17 at 1630, the maintenance contractor's contact person, Staff B was interviewed by telephone. Staff B was asked about the damaged and missing floor tiles and molding, the broken refrigerators, the broken door seals on the functional refrigerator, the dusty ventilation fans in the walk in coolers, the sink with the drainage pipe cut off and not connected to a drain, and the missing ceiling tiles and moisture damaged drywall. Staff B stated that repairing the refrigerators, "would be subbed out (subcontracted)", and stated that he was aware of "some of the issues", but was unable to provide any documentation of repair requests made by the facility when requested, and was unable to state a time-frame for completing the repairs when asked.

A facility policy on maintenance and repair was requested but not provided by survey exit.

Based upon observation and interview the facility failed to provide adequate emergency fuel supply for their boilers and emergency generator to meet their emergency management plans resulting in the potential for harm to all 41 patients served by the facility. Findings include:

1. On June 27, 2017, at approximately 1150, the level of the fuel in the fuel tanks was 2027 gallons (5000 gal tank 1 ), 5170 gallons (30000 gal tank 2) and 6357 gallons (30000 gal tank 3) for a total of 13,554 gallons out of a total 65,000 gallon capacity which was 2,696 gallons short of the stated minimum in their emergency plan. During document review at approximately 1000 on June 27, 2017, Staff B explained that their emergency plan included a policy which was recently updated to stipulate that the facility will maintain their on-site fuel oil tanks at a minimum of 25 % full. This was also stated in the plan of correction submitted on the 2567 form for survey event Z7CKU. The plan of correction indicated a completion date of 06-16-17 for refilling the fuel to over 16, 250 gallons to meet their 25% minimum level. As of 6/27/2017, the additional fuel had not been delivered.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated June 27, 2017.
K-0100
K-0133
K-0211
K-0225
K-0281
K-0300
K-0321
K-0345
K-0355
K-0363
K-0372
K-0374
K-0712
K-0781
K-0791
K-0918
K-0919
K-0920
K-0923

Based on observation and interview the facility failed to ensure supplies and equipment in use met safety requirements and were maintained resulting in the potential for adverse staff and patient outcomes.

Findings include:

1. On June 26, 2017 at 1159, observed that wall mounted nurse charting station by Room 533 would not automatically retract when tested. The pneumatic return was not working well.

2. On 06/26/17 at 1338 observed that in the behavioral health dining room on 4 South, one outlet above the countertop at the far end of the room was tested and showed that it had an open neutral.

3. On June 27, 2017 at approximately 1330, observed that the hot water handle for the handwash sink in Nuclear Medicine Room 118 was very difficult to turn.

4. On June 27, 2017 at approximately 1530 observed that there was no Glutaraldehdye (or Formaldehyde) spill kit in the Decontamination area by the endoscope reprocessor on the day of the survey. The reprocessor was filled with Metricide with glutaraldehyde as the active high level disinfectant chemical.

The above findings were confirmed by accompanying Staff B, Staff MM, and Staff LL.





27713

On 6/26/17 at 0920 during a tour of the facility's kitchen a large baking tray filled with water was observed on the counter in front of the ice machine. When asked, Staff K stated, "Sometimes the ice machine overflows."

On 6/26/17 at 0920 during a tour of the facility's kitchen the two refrigerators in the kitchen were inspected. One was noted to be empty and not running. The second refrigerator had two of it's four sections that were empty and not turned on. Staff K reported that the non running refrigerator and half ( two of four sections) of the second ( running) refrigerator were "broken." The door gaskets on the two functional sections of the second refrigerator were damaged and were visibly hanging off outside of each door on the bottom corners when the doors were closed.

On 6/26/17 at 0920 during tour of the facility's kitchen both walk-in coolers had ventilation fans that were visibly dusty with fluffy grey strings of dust. A lunch box was observed in the walk in cooler. When queried, Staff K stated, "That belongs to one of my staff. They're diabetic. It's their insulin. It has to be refrigerated and the staff refrigerator is broken."

On 6/28/17 at 1430, the provided facility maintenance subcontractor contract was reviewed and revealed that the contract was no longer valid, as it was contracted with a different entity previously located at the same location as the current facility. There was also no time frame specified for completing repairs, or equipment excluded.

On 6/28/17 at 1450, the facility comtroller, Staff U was interviewed. Staff U was requested to provide any documented work orders for the repairs, but was unable to do so by survey exit. Staff U reported no knowledge of the broken refrigerators.

A facility policy on maintenance and repair was requested but not provided by survey exit.

Based upon observation, document review, and interview, the facility failed to provide proper ventilation, illumination, and temperature controls within the hospital resulting in the potential harm to all 41 patients. Findings include:
1. On June 27, 2017 at approximately 1040, during document review with Staff B, staff B explained that none of the thermostats in the hospital were working. This was also confirmed by Staff MM and Staff LL during discussions with them during the facility tour. On 6/27/17 at 1205 the boiler log was reviewed with Staff LL which revealed one example of the lack of thermostatic control is evidenced by documentation which indicated that the chiller was manually turned off at 0630 on 6/27/17 and turned back on at 0900 after staff from surgery called the powerhouse to mention they were getting warm. When queried which the air compressor was for the pneumatic controls, Staff LL mentioned that he did not know where it was. Staff LL stated that currently there is no thermostatic control for the heating cooling system in the building. The facility is in the process of looking into it, but not fix has been identified. Meanwhile the facility is manually turning on & off chillers or adjusting dampers to get the rooms within a comfortable temperature range.
2. On 06/26/17 at 1153 observed that the through the wall heating and air conditioning unit (PTAC) in Room 545 was disabled. Staff MM explained that there had been a water leak from the PTAC. Observed that the piping for the PTAC unit was cut and drained. The water from the PTAC leak out, covering much of the floor of Room 545 as evidenced by dried water stains on the floor which were still visible. Although not currently in use, Room 545 is a licensed hospital bedroom.
3. On 06/26/17 at approximately 1500, observed that 3 of the 12 overhead lights in OR 1 were burnt out.
4. On 06/26 & 27/17 observed various locations where the overhead light was burned out. These include:
a. Room 525 light out over the hand wash sink (06/26/17 at 1155)
b. Room 455 light out above the toilet (06/26/17 at 1340)
The above findings were confirmed by accompanying Staff B, Staff MM, and Staff LL.

Based on observation, interview and document review the facility failed to maintain an ongoing infection control program designed to prevent, control and investigate infections and communicable diseases for five of five months (February 2017-June 2017) reviewed and failed to ensure a sanitary environment resulting in the potential for transmission of infectious agents for all 41 patients served by the facility. See specific tags:

A-- 0749 - The facility failed to ensure a sanitary environment, failed to ensure that there was an active infection control program, failed to develop and implement policies for the prevention, control, reporting and investigation of infections and communicable diseases, and failed to ensure that infection control surveillance data was reviewed, evaluated and used to identify areas of improvement.

A--0756 The facility failed to ensure that the infection control program was integrated into the quality assessment and performance improvement program (QAPI) and used to identify areas of improvement.

This citation has multiple deficient practice statements:

Deficient Practice statement #1:

Based on observation, interview and record review, the facility failed to maintain an active Infection Control Program, based on nationally recognized guidelines, which conducted tracking, trending, reporting, investigation, and prevention of infections, and failed to have policies for the detection, identification, analysis, investigation and prevention, of infections and communicable diseases, and failed to ensure that infection control surveillance data was reviewed, evaluated and used to identify areas of improvement for five of five months (February 2017 through June 2017) reviewed, and failed to have an active Infection Control Committee with participation from critical departments, resulting in the potential failure to prevent the spread of communicable disease to all 41 patients in the facility. Findings include:

On 6/28/17 at 0900, the Infection control Coordinator, Staff BB, and the Consultant for Quality, Staff T were interviewed and all available documents and materials in the Infection Control Program were reviewed. The following was noted:

Staff BB reported that he was hired as the facility Infection control Coordinator (ICC) in February 2017, and prior to that, the facility was out of compliance for Infection control.

Review of Infection Control (IC) Committee Minutes and sign in sheets from February 2017 through June 2017 revealed only two IC meetings were held during that time, 3/15/17 and 5/31/17. There was no IC Policy or documentation from the governing body to determine how often meetings should be held, or who the committee should consist of. The ICC was unable to provide a sign- in (attendance) sheet for 3/15/17 to identify who was present. There was no one on the list of possible attendees to represent Environmental Services. The sign in sheet for the 5/31/17 meeting documented that no representative from Environmental Services attended, the Dietary Manager did not attend, and only the Nurse Educator signed in to represent Nursing. There was no documentation discussion of facility acquired infections, or of tracking or trending of infections or of facility acquired infection rates. There was no documentation of surveillance for environmental sanitation or identification of trends or clusters of infection.

On 6/18/17 at 1030 the Nurse Educator, Staff AA was interviewed and stated, "I went to the meeting, but I wasn't there as a participant. I didn't report to anyone about the meeting, or talk at all during the meeting. If I was there to represent Nursing, someone should have told me."

There was no documentation of tracking or trending of infections in the facility, or of facility acquired infection rates. When queried, the ICC was unable to provide any documentation that tracking, trending, investigation and analysis was done. The ICC stated, "I've asked someone to make a spread sheet for me, but it's not finished yet." When asked how surveillance for Surgical Site Infections (SSI) was done, the ICC was unable to provide any policy or procedure, was not sure how it was done, and reported that the Surgical Manager, Staff Y, who did not attend the IC meeting, conducted surveillance for SSI. When queried, the ICC was unable to provide documentation of facility acquired infection rates, could not verbalize definitions for facility acquired infections, could not provide a facility policy or resources for definitions for facility acquired infections, and was unable to state how to calculate (do math) facility infection rates by standardized nationally accepted methods. When queried, the Infection Control Coordinator was able to provide only two policies for the Infection Control program, a policy for Isolation Precautions, and another one for the job description of the ICC and the IC mission statement.

Review of Microbiology reports for March and April 2017 (the only months available for review) revealed no documentation to indicate that the ICC had reviewed or analyzed them. There was no additional documentation of any additional method for detecting infection, and the ICC reported that he did not utilize any other method. When queried about randomly selected microbiology results, including one for a multi-drug resistant microorganism (MDRO) in a urine sample on 3/7/17, the ICC was unable to provide any notes or documentation that these were reviewed or investigated to determine whether they were facility acquired, and stated he would have to look up the patient's medical record, as he had no notes and could not remember. The ICC was unable to state whether the patient with the MDRO in the urine had been placed on Contact Precautions (Isolation Precautions), and when asked to review the electronic clinical record,was unable to do so, and stated that he did not know how to see whether the patient had an order for Contact Precautions.

Review of microbiology reports for March and April 2017 revealed three laboratory results for communicable diseases that were required to be reported to the local Public Health Department. The ICC was unable to provide documentation that this was done for two of three.

When queried, the ICC was unable to provide documentation that employee absences were screened for communicable disease, or exclusionary illnesses, and stated that he was unaware he needed to do this. When queried, the ICC was unable to provide documentation of employee vaccinations for Hepatitis B (HBV) and Influenza (flu), or for screening of employees or patients for tuberculosis (TB).

On 6/17/17 at 1500, review of 10 personnel files revealed that no documentation of TB testing or annual screening was performed for 7 of 10 direct care staff reviewed. There was no documentation of HBV titer (test for current and past infection), HBV vaccination, HBV vaccination refusal, or for Influenza vaccination for 10 of 10 direct care staff reviewed. The facility was unable to provide any additional documentation by survey exit.

There was no documentation of surveillance or monitoring for environmental sanitation. When queried, the ICC was unable to state that this was done. When queried, the ICC verbalized no knowledge of sanitation or infection control concerns in the urgent care unit or kitchen.

When queried, the ICC was unable to provide or verbalize a facility emergency plan or policy/procedure for an outbreak or a bioterrorism event.


Deficient Practice Statement #2

Based on observation, and interview, the facility failed to ensure a sanitary environment resulting in the potential for transmission of infection to all 41 patients in the facility. Findings include:

On 6/26/17 at 1000, the Urgent Care Unit was toured with the Urgent Care Manager, Staff II. Two of two scales for weighing patients had cracked, broken and peeling foot rests. When queried, Staff II stated, "You're right, they're impossible to clean in that state."

The phlebotomy (blood draw) chair had cracks in the vinyl of the armrest, exposing the foam.

Three of three gurneys (stretchers) inspected had tape residue and smears on the intravenous (IV) pole, and debris, litter and dust on the shelf below the patient mattress.

Three of three cardiac monitors had brown material on the touch pad that came off with alcohol wipes.

On 6/27/17 at 1440, the contact person for the facility's contracted cleaning service was interviewed by telephone and stated that he did not know who was responsible for cleaning the gurneys, IV poles and cardiac monitors in the Urgent Care Unit, and that questions should be referred to the onsite Housekeeping Supervisor, Staff S.

On 6/27/16 at 1500, Staff S was interviewed and reported that Nursing was responsible for cleaning the gurneys, IV poles and cardiac monitors in the Urgent Care Unit.

On 6/27/17 at 1700, the Assistant Director of Nursing, Staff C stated that it was housekeeping's job to clean under gurneys, IV poles and the surfaces of the cardiac monitors in Urgent Care.

On 6/26/17 at 0920, a tour of the facility kitchen was conducted with the Food Service Manager, Staff K, and the following was noted inside the kitchen (see A0618 and A0620)

There was food debris, and grease buildup underneath the three compartment sink, food preparation tables, steam table and dishwasher.

Review of Pest control reports from the contracted pest control company from February through June 2017 revealed the kitchen had active infestations with mice and flies.

Two of three 55 gallon trash containers in the kitchen were uncovered, contained food waste, and had flying insects around them. A bug light was filled with many dead flies. There was a large gap under the kitchen door leading to a hallway that opened directly to the loading dock.

There were three uncovered laundry hampers filled with soiled linens that were surrounded by flying insects. The Kitchen Manager, Staff K reported that the laundry hampers were collected once per week.

There was standing dirty water in an overflowing plastic bucket near the three compartment sink (used for hand washing large items) with visible biofilm, under a sink with waste pipe that was cut off and draining into the bucket.

There was standing water in an unused hose connected to a water outlet beside the three compartment sink.

There were multiple broken and missing floor and baseboard tiles.

The walls were soiled with smears and spatters in multiple areas.

Upper surfaces of large equipment were visibly dusty.

Refrigerator door gaskets were not intact on the two functioning refrigerators.

Food preparation equipment was dirty with visible debris.

Food storage shelving and bins were dirty with food debris.

There were multiple undated and unlabeled perishable food items in the refrigerator and the walk in coolers.

There were three missing ceiling tiles exposing moist and deteriorated drywall.

There were no cleaning schedules or policies and procedures for kitchen sanitation and food storage.

On 6/28/17 at 0930, review of the Infection Control Program and Infection Control Committee Minutes and signatures of attendees with the Infection Control Coordinator, Staff BB revealed no documentation to indicate that the Kitchen was incorporated into or reported to the Infection Control Program, and no documentation that any representative from the kitchen attended the meetings.


19647

1. On June 26, 2017 at 1130 the toilet in the men's restroom by the elevator on 5 th floor was completely dry. There was a musty odor in the room. Staff MM explained that the facility had a policy for monthly running the water in the fixtures to flush stagnant water in all unused portions of the hospital, but did not confirm that this was being completed as per policy or provide documentation that was being completed. Other observations of dried up fixtures with stagnant water include:
a. 06/26/17 at 1138, observed the toilet in Room 568 did not have any water in the bowl.
b. 06/26/17 at 1140, observed the Soiled utility on fifth floor hopper was dry
c. 06/26/17 at 1140, observed Room 564 and 565 toilets were dry.
d. 06/26/16 at 1151, observed the toilet in Room 551 was dry.
e. 06/26/17 at 1152 observed the water in the handwashing sink for Room 549 was very rusty. the cold water was turned off.
f. 06/26/17 at 1154 observed the toilet in Room 524 was dry.
g. 06/26/17 at 1155 observed the water in Room 525 was dry.

2. On June 26, 2017 at approximately 1600 during an interview with Staff A and Staff B, they confirmed that the facility did not have any water management policies and procedures to reduce the risk of growth and spread of Legionella. Staff A was provided with a copy of the June 2, 2017 CMS S&C letter 17-13 entitled, "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires ' Disease (LD)," which was effective immediately.

3. On June 26, 2017 at 1159, observed the 5 North medication room had an intravenous (IV) fluid bag left on the counter next to the sink which could be contaminated by splashes whenever the sink is used.

4. On June 26, 2017 at 1327, observed the floor behind the 4 South nurse station had a 1 inch x 3 feet portion of the tile floor missing which created an area that was collecting dirt and debris because it was not easily cleanable.

5. On June 26, 2017 at approximately 1515, observed that there was had an accumulation of dust on top of the shelves in the Anesthesia workroom (Room 197).

6. On June 26, 2017 at 1635, observed the drain for the bathtub in Room 303 was not working and had standing water.

7. On June 26, 2017 at 1330, observed a large section of the toilet room floor in Room 464 that was ripped exposing bare concrete. It was approximately 1 ft x 2 ft in size.

The above findings were confirmed by accompanying Staff B, Staff MM, and Staff LL.


36887

On 6/26/2017 at 1129 on the 5 North unit, Room 504 was observed to have small bits of debris on the floor include bits of paper, a piece of a glove, a cap of off a medication vial as well as dust. There was also thick dust noted on the bedside televisions, light over the head of the bed as well as on the TV mounted to the wall.

On 6/26/2017 at 1133, Staff F was queried as to if Room 504 was ready to receive a new patient to which she replied"yes." Staff F was then queried as to it were acceptable to have the debris on the floor and the dust on high level surfaces to which she stated, "No. I will talk with housekeeping about this."

On 6/26/2017 at 1140, the clean supply room of 5 North multiple cardboard boxes which were stacked and sitting on the floor. Staff F stated, "It looks like they just made a delivery." Additionally, a bag containing 11 yellow top blood tubes was sitting on the supply shelf ready for use with a note on it stating "Expires 5-31-2017." Staff F was queried as to if this were where expired supplies were kept to which she replied, "No. I'll take care of them."

On 6/26/2017 at 1145, a damp washcloth was found sitting on the handrail in the hallway of 5 North on the corner just outside of the clean supply room. This was confirmed by Staff F at the time of discovery.

Polices regarding infection control practices, the responsibilities of housekeeping, or what do with expired supplies were requested but not made available.


29955



38269

On 06/26/17 approximately 1530 during initial tour of surgical services, upon entrance to the surgical services reception area, a large shipping box was observed on the floor next to a wall under a white grease board. Staff Y (director of surgical services) was queried as to why the box was located directly on the floor. Staff Y stated the box was "vender supplies, that arrived by a (commercial carrier) and it should not be there".

On 06/27/17 continued tour of surgical services was conducted. Upon entering Operating room #3, staff Y walked across the room to a shelf and picked up an open drinking bottle, wrapped with a paper towel and a straw sticking out of the top, she stated "they know they cannot have drinks in here". Staff Y was observed as she disposed of the bottle. Suction tubing and a younker taped in an open package, propped on the anesthesia cart was observed. Staff Y was queried as to why the younker was open, she stated "the anesthesiologist must have opened it while preparing for an earlier case that was canceled". Staff Y was observed throwing the open younker in the trash. Tour continued to the dirty supply/ utility room where three bristled brushes were propped on the back of the sink, no staff was able to speak to weather these brushes were used, and or if they were single use. The packaging of unopened brushes of the same character were marked single use. One long handled brush was found to have brown / rust colored markings on the metal portion of the handle. The tour proceeded to the clean equipment storage room. The clean equipment, storage room was found to be in a disheveled condition, without organization. Staff Y stated "the majority of equipment in this room is never used". Several large gel pads were observed to have open tears 3 to 4 inches in length, allowing gel to seep out, staff Y stated "the gel pads were no longer in use". When queried as to how other staff would be aware that the gel pads were not acceptable to be used, and why they were still in the equipment storage room. Staff Y picked up the pads stating "I see your point I will throw them away".

Based on observation, interview and record review, the facility failed to ensure the hospital wide Quality Assessment and Performance Improvement Program (QAPI) implemented Infection Control performance improvement projects, failed to develop Infection Control Policies, and failed to analyze Infection Control Data and recommend improvement projects, for five of five months reviewed, resulting in the potential for transmission of infection to all 41 patients in the facility. Findings include:

On 6/28/17 at 0900, the Infection control Coordinator, Staff BB, and the Consultant for Quality, Staff T were interviewed and all available documents and materials in the Infection Control Program were reviewed. The following was noted:

Staff BB reported that he was hired as the facility Infection control Coordinator (ICC) in February 2017, and prior to that, the facility was out of compliance for Infection control.

Review of Infection Control (IC) Committee Minutes and sign-in (attendance) sheets from February 2017 through June 2017 revealed only two IC meetings were held during that time, on 3/15/17 and 5/31/17. There was no IC Policy or documentation from the governing body to determine how often meetings should be held, or who the committee should consist of. There was no documented discussion of facility acquired infections, or of tracking or trending of infections or of facility acquired infection rates. There was no documentation of surveillance for environmental sanitation or identification of trends or clusters of infection. When requested, the ICC was unable to provide documentation of participation in the Quality Improvement Committee, and stated that he did not attend. When questioned, the ICC was unable to document any quality improvement projects other than one staff inservice (continuing education) but was unable to provide a course outline or documentation of which staff failed to attend. Handwashing audits for March 2017 identified three staff who failed to wash hands when required, but failed to document any corrective measures.

Review of Infection Control (IC) Committee sign in sheets from February 2017 through June 2017 revealed only two IC meetings were held during that time, 3/15/17 and 5/31/17. The ICC was unable to provide a sign in sheet for 3/15/17 to identify who was present. The Nurse Educator was the only one documented as present to represent Nursing. On 6/18/17 at 1030 the Nurse Educator, Staff AA was interviewed and stated, "I went to the meeting, but I wasn't there as a participant. I didn't report to anyone about the meeting, or talk at all during the meeting. If I was there to represent Nursing, someone should have told me." The ICC was unable to state how the agenda of the ICC was reported to the Director of Nursing.

The ICC was unable to provide any policies for identification of infections or for surveillance, investigation, reporting and corrective measures for facility acquired infections, or for employee illnesses. When queried, the Infection Control Coordinator was able to provide only two policies for the Infection Control program, a policy for Isolation Precautions, and a mission statement with the job qualifications for the ICC.

The ICC was asked whether he attended meetings of the Quality Improvement Committee and presented Infection control Data. The ICC did not answer, but left the room for 20 minutes. Staff T provided a spreadsheet document for review with facility "Quality Measures" for each month from April 2016 through May 2017. There was no documentation provided to indicate who had seen or reviewed this document. Facility acquired infection rates were documented each month as zero percent (0%), including for months when there had been no Infection Control Coordinator. When queried, neither Staff T nor Staff BB was able to provide any surveillance data or calculations (data analysis) of facility acquired infection rates to substantiate these 0% rates.

There was no other documentation provided to indicate that the Infection Control Program reported identified problems to the Quality Assurance committee, and that performance improvement projects were developed as a result.

Based on observation, interview and record review the facility failed to provide well organized surgical services in accordance with standards of practice, resulting in the potential for unrecognized needs of all surgical patients served by the facility. Findings include:

A-0941: Facility failed to provide organizational guidelines and delineation of authority and clear lines of relationships with all services of the facility.
A-0945: Facility failed to provide and maintain a roster of practitioners performing surgery and surgical procedures.
A-0951: Failure to provide resources to assure and maintain high standards of medical practice and safe patient care.
A-0952: Failure to provide presurgical complete and legible medical H&P (history and physical) prior to receiving surgical procedures requiring anesthesia.

Based on interview and record review the facility failed to provide organizational guidelines and delineation of authority and clear lines of relationships with all services of the facility, resulting in the potential for poor surgical patient outcomes. Findings include:

On 06/26/17 at approximately 1530 staff Y, director of surgical services, was queried as to who the chief of surgery was, she stated she was "not sure", staff Y later (within a fifteen minute time frame) stated "there was no chief of surgery at this time".

On 06/26/17 at approximately 1550 review of organizational chart revealed "heading; "Board" with a direct line to, "Medical Executive Committee" with a direct line to "Chief of Staff" with a direct line to "Department Chairs "(Various)". There were no departments or names listed under the "Department Chairs" heading. Surgery was also not noted as a department anywhere on the organizational chart provided by administration demonstrating a failure to delineate clear lines of authority for surgical services.

Based on interview and record review the facility failed to provide and maintain a roster of practitioners performing surgery and surgical procedures resulting in the potential for poor surgical patient outcomes. Findings include:

On 06/27/17 at approximately 1000, during tour of the surgical services department a roster of practitioners specifying the surgical privileges of each practitioner was requested but not provided. Registered Nurse (RN) Staff W was queried as to how to determine specific privileges of surgeons performing surgery and/or procedures in the surgical services unit. Staff W stated "not sure, we just know what our physicians do".

Based on observation, interview and record review the facility failed to provide resources to assure and maintain high standards of medical practice and safe patient care resulting in the potential for poor surgical patient outcomes. Findings include:

On 06/26/17 at approximately 1550 during initial tour of surgical services, PACU (post anesthesia care unit) inspection of "Heart Cart" (crash cart, emergency equipment supplies and medication), it was observed that the form titled 'Heart Cart Check Form' dated June 2017, was incomplete. There was no documentation of review/check for the following dates, June 3, 4, 10, 11, 17 and 18 (these dates had a line or an x over them), upon query of staff Y (surgical services director), staff Y stated "those are weekend dates and they were not in the hospital those dates, we don't usually get called in on the weekends". Upon further review dates June 22, 23, 24, 25, as well as June 26, (date of tour) were noted to be incomplete or blank. Staff Y was ask what the policy was for checking and documenting on the "Heart Cart Check Form", staff Y stated "staff did not follow the guidelines, nurses on shift should be completing the form and checking the cart supplies for outdates, to ensure emergency equipment/ supplies and medications were in functioning order, not expired and available in the event of an emergent situation". No policy was provided prior to exit on 06/28/17.

Upon further inspection, defibrillator pads in the cart available for use were found to have expired on 03/2017. Staff Y was unable to determine if the date, 03/2017 next to the picture of an hour glass, was a "lot number" or an expiration date. When staff Y was queried as to what the expiration date on the defibrillator pad package was, she stated "they only have a lot number, many of the OR (operating room) supplies do not have an expiration date". Staff Y, later stated the date 03/2017 on the defibrillator pads was confirmed to be an expiration date. The defibrillator pads were immediately removed and replaced with current pads. The facility failed to assure all patients that had surgical services provided between the date of defibrillator pad expiration 03/2017 and 06/26/2017, were at risk for defibrillator failure, secondary to expired defibrillator pads leading to the possibility of non-conductivity of the defibrillator, due to omission of safe checks and maintenance of emergency equipment. Policy was requested for review.

Policy with heading "former name of hospital", (no policy available with the current hospital name) Policies and Procedure, Number A-0724, Revision date: December 5, 2012 (current year 2017) was provided and reviewed. Under section 8 "Expired supplies are to be audited and tracked by the Manager of Materials Management and donated to charitable organizations". At the bottom of policy Number A-0724 the CEO& President is listed a XXX (not the current Chief Executive Officer) and there were blank lines for sign off of policy.

Based on record review and interview, the facility failed to provide a pre-surgical, complete, and legible medical history and physical for 1 of 4 (patient #12) surgical records reviewed prior to receiving a surgical procedure requiring anesthesia, resulting in the potential for poor surgical patient outcomes. Findings include:

On 06/27/17 at approximately 0915 review of patient #12's medical record revealed the patient was a 65 year old female admitted on 06/26/17 for a surgical procedure (re-exploration of lower spine and possible removal of previous instrumentation and reinsertion), with history of back pain and Chronic obstructive pulmonary disease. Review of the paper form titled "Pre-Surgical Admission Record History & Physical" was found illegible and incomplete. Dedicated spaces to record "Current Medications" and "Physical Examination/ Description of Surgical Problem" were blank. Documentation in the dedicated spaces to record general appearance and lung sounds was illegible. On 06/27/17 Staff Y (director of surgical services) was asked if patient #12's pre-surgical history and physical (H&P) was complete and legible to which she replied, "No, I cannot be certain what it says"

On 06/27/17 at approximately 0930 the facility's policy regarding pre-surgical H&P was requested but not provided prior to survey exit. On 06/27/17 at approximately 1300 review of medical staff bylaws dated January 2015, section 22.3, revealed " ...A complete history and physical shall be written or dictated within twenty-four hours of admission ...".