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Based on observation, staff interview and policy and procedure review, the facility:
1) failed to ensure there was adequate space for provision of services and that drugs were appropriately stored on one (1) of two (2) days of survey; and
2) failed to ensure that biohazard medical waste was stored according to State licensure law and the patient care environment was clean, orderly and safe during two (2) of two (2) days of survey.

Findings Include:

1) Observation of the acute and/or swing bed medical nursing floor environment on 06/21/16 from 2:30 p.m. to 4:00 p.m. revealed:
a) Room #101 had two (2) quarter-inch sized holes in the wall on the left of the call light system.
Room #102 had brown colored stain on the ceiling tile over the sink.
Room #105 had paint peeling from the entrance door facing and frame, a broken light in the patient bathroom, no handle on the closet door and a leaking/loose sink faucet.
Room #108 had paint peeling from the entrance door facing and frame.
Room #114 had a bedside table with a non-intact surface.
Room #116 had paint peeling off the entrance door facing and frame.
Room #119 had a loose sink faucet.
Room #123 had paint peeling off the entrance door facing and frame.
Room #124 had paint peeling off the entrance door facing and frame.
Room #125 had broken ceiling tile in the patient bathroom and paint was peeling off the entrance door facing and frame.

b) The Patient Supply Room had five (5) cardboard boxes stored on the floor.

c) The hallway on the east side of the nursing station had a missing five (5) to six (6) foot handrail section and a metal air-conditioning vent that was rusted and covered in dust.

d) Observation in the Storage Room on the west side of the nursing station revealed four (4) wheelchairs, three (3) walkers, one (1) lift chair, an open storage shelf with blood pressure cuffs, slings, blue pads and Styrofoam cups. An opened intravenous bag of fluid had been placed on the shelf which contained the oral diabetic supplies. There were multiple dead insects observed lying on the floor of the storage room. The back wall had a non-intact wall surface and green colored growth on the wall. The storage room entrance door had no security mechanism and was not locked. An ice machine was located to the right of the open shelving unit in the Storage Room. A sign on the front of the machine stated "Ice For Patients Only". Two (2) containers were observed on top of the ice machine: one container held a blue liquid and an ice scoop; and the other container held clear fluid and an ice scoop. Neither container had a lid. The ceiling above the ice machine had a two (2) foot by two (2) foot hole.

e) Observation in the Soiled Linen/Biohazard Room revealed a gray container holding biohazard waste which had no biohazard symbol on the outside of the container. Three (3) bags of soiled linen were lying on the floor and one (1) bag of soiled linen had been placed on top of the biohazardous waste container. Another gray container in the Soiled Linen/Biohazard Room contained soiled linen.
During an interview on 06/21/16 at 3:40 p.m. the Director of Nursing (DON) confirmed that the soiled linen and the biohazard waste were stored in the same room. When asked if the facility had any red biohazardous storage containers the DON stated, "We do not have a red container inside the building."

2) Observation of the outside Biohazard Waste Storage building revealed five (5) wood pallets lined up on the ground that led to the building entrance door. During an interview on 06/21/16 at 3:55 p.m. the Compliance Officer confirmed the wood pallets were used as a walkway to the biohazard waste storage building.

During an interview on 06/21/16 at 4:00 p.m., the Compliance Officer confirmed all acute and/or swing bed observations which had been made on the medical nursing floor.

Observation of the Soiled Linen/Biohazard Storage room made with the DON on 06/22/16 at 9:35 a.m. revealed a soiled linen bag was stored on top of the biohazard waste storage container and there continued to be no biohazard symbol on the outside of the gray container.

Observation made with Respiratory Therapist (RT) #1 in the Respiratory Department on 06/22/16 from 9:40 a.m. to 10:25 a.m. revealed:
Two (2) stacks of black crates containing respiratory supplies were stored on the floor in the Respiratory Office; Two (2) cardboard boxes of electrocardiogram reports were stored on the floor under a table; Pulmonary Function Testing (PFT) equipment was located in the Respiratory Office with the staff's microwave and food supplies stored on a open shelf to the left of the PFT equipment.
Observation in the Respiratory cleaning area revealed that a light over the sink was not working; and the equipment warmer had a maintenance sticker dated July 2012 to July 2013. A box of respiratory supplies was stored on top of the warmer. The front door of the warmer had a nine (9) inch break on the lower left corner and two (2) filters, one on each side of the warmer, were covered in dust.
Two (2) doors were observed in the Respiratory cleaning area. The sign on one (1) door stated "Storage Room". A sign on the other door stated "Janitor Room". The room labeled "Storage Room" contained three (3) unsecured oxygen tanks, one (1) mop head, an office table and there was a one (1) foot by one (1) foot hole in the ceiling above the filing cabinet. The room labeled "Janitor Room" had multiple cardboard boxes stored on the floor.
In the hallway outside the Respiratory Department four (4) croup tents draped in plastic were observed being stored against the wall. The floor under the croup tents had a broken floor tile.
During these observation in the Respiratory Department RT #1 stated that Pulmonary Function Tests were performed on patients in the Respiratory Office. She also stated that she had never cleaned the equipment warmer filters and that they used the storage room to store patient care supplies.
RT #1 confirmed all observations made in the Respiratroy Department.

During an interview on 06/22/16 at 10:25 a.m. all Respiratroy Department findings were discussed with the Compliance Officer and the Respiratory Department Director.

Observations made in the Radiology Department on 06/22/16 from 10:30 a.m. to 10:55 a.m. revealed:
Brown stains on the ceiling tile at the department entrance door.
The reading room had a five (5) inch by five (5) inch hole in the wall.
The general x-ray room patient bathroom had paint peeling off the wall behind the toilet.
An open shelf cabinet was located between the general x-ray room and computed tomography (CT) room that contained multiple bottles of contrast, an emergency medicine box, clean linen and equipment cleaning supplies. The CT room had intravenous supplies stored in an unlocked cabinet and broken sheetrock around the door frame leading into the main hallway. The doors to the general x-ray room and to the CT room were both unlocked.

During an interview on 06/22/16 at 10:40 a.m. the Radiology Director confirmed that any visitor or patient could enter during a procedure or after hours if the staff forgot to lock the door in the general x-ray or CT procedure rooms. The Director confirmed all Radiology Department observations.

Observation of the Dietary Department with Dietary Staff Employee #1 and the Compliance Officer on 06/22/16 from 11:00 a.m. to 11:35 a.m. revealed:
The dining room had paint peeling off the entrance door frame;
The dining room ceiling tile had brown colored stains and the air vent was rusted and covered in dust.
The freezer that stored desserts had a broken door latch.
The back door leading to the loading dock was not locked and had no security mechanism on the outside entrance.
The walk-in freezer located outside the loading dock had a leak on the inside and an ice build-up on the floor which was approximately one (1) half foot to one (1) and a half feet.
During these observations Dietary Staff Employee #1 stated that the back kitchen door exit was left unlocked during the daytime hours. She and the Compliance Officer confirmed all observations made in the Dietary Department.

Observation made in the Laboratory Department on 06/22/16 at 11:45 a.m. revealed multiple cardboard boxes of patient supplies being stored on the floor.

Review of the facility's "Environmental Services Discharge/Transfer Cleaning" policy (reviewed 08/04/15) revealed: "...Inspection Criteria For Housekeeping ...1. Floors: ...Baseboards ...The baseboards are in good condition ...2. Walls: ...There is no plaster, paint, or wall covering damage. The room does not need painting. Doors, Sills: The doors and sills appear to be clean and in good repair ...Vents: The vents appear to be clean and free of dust ...The paint or finish is in good condition ...".

Review of the facility's "Infection Control/Environmental Services" policy (reference number #5018) revealed: "Purpose: To control the spread of infection with the hospital by maintained a thoroughly clean and safe environment ...Infection Control Practices: Sanitation within the hospital environment depends upon cleaning thoroughness and frequency. There shall be procedures for cleaning ...floors ...Patient Rooms: ...Hard floor surfaces shall be wet-cleaned daily ...Environmental Services personnel shall report any equipment failure to Environmental Services Director ...".

Review of the facility's "Engineering Policy & Procedure Manual" policy revealed: "Section I: Introduction: ...It is to be used as a guide by Plant Operations and Engineering Department personnel for defining department policies and procedures. The purpose of this manual is to outline the safety procedures and methods used by the Plant Operations ...in fulfilling its responsibilities for maintaining the proper hospital environmental conditions while complying with all applicable local, state, federal codes, and regulations ...Preventive maintenance of equipment is foremost with the Department ...Description of the Plant Operations Department- Function: Regularly inspects and services all ...heating ...and air conditioning systems ...Specific Duties: 1. Frequent inspection, cleaning and replacement of the filters of all air-handling equipment ...3. Check food serving units using refrigeration ...4. Constant inspection and immediate repair of any opening or breaks in walls, foundations ...in order to preserve a clean environment ...Miscellaneous Duties: Responsible for checking regularly the proper function of ...faucets ...".

Review of the facility's "Medical Waste Management Plan" policy (reference #4034) revealed: "Purpose: The purpose of this plan is to describe the procedures for ...storage ...of medical waste ...Definitions: ...Biohazardous Waste: ...Biohazardous waste is contained in red plastic bags labeled as "Biohazardous" with the universal symbol of biohazard and stored in impervious leak-proof barrels with lids and labels on all four (4) sides and top with a "Biohazard" universal symbol ....Medical Waste Handling, Containment, Storage ...Handling: The department managers and supervisors are responsible for ensuring appropriate separation of medical waste and placing in properly constructed and labeled biohazardous containers. All medical waste will be segregated and contained separately ...Containment: Biohazardous Waste Receptacles - Rigid and leak resistant containers with a tightly fitted lid labeled with the biohazardous sign and symbol on the top, front and side of the container ...".

No further documentation was submitted for review by facility staff during the Exit Conference on 06/22/16 at 5:15 p.m.

Based on observation, staff interview and policy and procedure review, the facility failed to ensure there was adequate space for provision of services in the Respiratory Department and that the environment was safe for patients during two (2) of two (2) days of survey.

Findings Include:

Cross Refer to C-0220 for the facility's failure to ensure there is adequate space for Pulmonary Function Testing in the Respiratory Department.

Based on observation, staff interview and policy and procedure review, the facility failed to ensure biohazard medical waste is stored according to State licensure law during two (2) of two (2) days of survey.

Findings Include:

Cross Refer to C-0220 for the facility's failure to store biohazard medical waste according to State licensure law.

Based on observation and staff interview, the facility failed to ensure that drugs were appropriately stored in all departments during one (1) of two (2) days of survey.

Findings Include:

Cross Refer to C-0220 for the facility's failure to ensure drugs are properly locked and stored in the Radiology Department.

Based on observation, staff interview and policy and procedure review, the facility failed to ensure the patient care environment was clean and orderly during two (2) of two (2) days of survey.

Findings Include:

Cross Refer to C-0220 for the facility's failure to ensure the environment was clean and orderly.

Based on observation, staff interview and review of manufacturer guidelines, the facility failed to ensure respiratory and/or clinical staff followed manufacturer guidelines for patient care when using oxygen connectors, inflatable face mask, and when cleaning the croup tent during one (1) of two (2) days of survey.

Findings Include:

Observations were made in the Respiratory Department with Respiratory Therapist (RT) #1 on 06/22/16 from 9:40 a.m. to 10:25 a.m. These observations revealed the equipment warmer contained three (3) inflatable face masks. When RT #1 was asked what the manufacturer recommended on reuse of the inflatable face mask she stated, "We clean them (inflatable face mask) and reuse them." She stated that the inflatable face mask were cleaned with a germicide wipe, then rinsed in the sink and placed in the equipment warmer to dry. "The warmer was used yesterday." When asked if she recorded the equipment warmer temperature she stated, "I have not." During an interview on 06/22/16 at 10:25 a.m. all findings were discussed with the Compliance Officer and the Respiratory Department Director.

Observation of the equipment warmer in the Respiratory Department on 06/22/16 at 3:30 p.m. revealed two (2) adult inflatable face masks and one (1) pediatric inflatable face mask. The Respiratory Director confirmed the observation and disposed of all three (3) inflatable face masks.

During an interview with RT #1 on 06/22/16 at 9:48 a.m. she was asked if the oxygen connectors were recommended for single patient use or multiple patients use. She replied, "We clean them (oxygen connectors) between patients with germicide wipes and reuse them."

During an interview on 06/22/16 at 3:10 p.m. the Respiratory Director confirmed that the oxygen connectors the facility was using were disposable and single-use. At 3:25 p.m. the Respiratory Director stated, "We have been using this wrong. It (inflatable face mask) is disposable." At 3:40 p.m. the Respiratory Director confirmed they (respiratory staff) had been using an aerosol germicide to clean the croup tent equipment parts. He stated, "Purchasing was unable to get the Cidex (cold sterilization agent) for the past two (2) months." When the Cidex log for the croup tent equipment was requested, he stated, "There are no logs." No documentation was submitted for review.

Review of the "...Oxygen Tube Connector ..." manufacturer guidelines revealed: "...Disposable, Single-Use ...".


Review of the "Inflatable Face Mask" manufacturer guidelines revealed: "...Directions for Use: ...4. Discard after single use according to hospital protocol ...".


Review of the "Pediatric Aerosol Tent (Croup Tent)" cleaning and sterilization guidelines revealed: "...The non-removable cold plate may be cleaned with soap and water followed by drying and treatment with a commercially available cold sterilizing agent such as Cidex ...The entire nebulizer ...can be gas sterilized, cold sterilized, or autoclaved ...Clean the supply tubes with soap and water followed by a cold sterilization agent or gas sterilization ...".


Review of the facility's "Single Use Oxygen Connector" policy (reviewed and revised 06/22/16) revealed: "Purpose: To provide safe use of disposable oxygen connector on all patients. Policy: The Respiratory Department must provide a disposable oxygen connector for each patient. The green oxygen connector is a per patient stay single use only. Upon discharge the connector will be disposed of properly."


Review of the facility's "Inflatable Face Mask" policy (reviewed and revised 06/22/16) revealed: "Purpose: To provide safe use of disposable inflatable face mask on all patients. Policy: The Respiratory Department must provide a disposable inflatable face mask for each patient that needs to be resuscitated. The inflatable face mask is for single one time use only. After face mask is used it will be disposed of in a biohazard bag and disposed of properly."


Review of the facility's "Infection Control Plan" policy (reference #1017) revealed: "Infection Control (IC) Policy Statement - Commitment: ...The goal of the IC Program is to reduce the risk of acquisition and transmission of healthcare associated infections (HAIs) ...Statement: ...All healthcare providers ...are responsible for the safety, health and well being of all patients ...This responsibility may be met by ...observing all rules, regulations, procedural guidelines ...Each department ...will be responsible and held accountable for its role in the IC Program ...Program Description: ...Patient care services include Medical, Outpatient Services ...Departmental policies and procedures for IC will be reviewed and/or revised as an ongoing practice ...Because factors that may present potential IC problems may be present in any component of the hospital, the IC designees must maintain open communication with all departments ...Activities: IC activities include the following: Monitoring ...aspects of IC ...prevention and management ...Device-related infections ..".


Review of the facility's "Exposure Control Plan" policy (reference #4019) revealed: "Statement of Purpose: ...personnel face a significant health risk, as the result of occupational exposure ...The purpose of the plan is to: Establish individual responsibilities to minimize the risk for healthcare workers ...Methods of Compliance: ...Engineering and Work Practice Controls - used to eliminate or minimize staff member exposure ...The following engineering/work practice controls are used throughout the facility ...Eating, drinking ...is prohibited in work areas where there is potential for exposure to bloodborne pathogens ...".


No further documentation was submitted for review during the Exit Conference held on 06/22/16 at 5:15 p.m.

Based on observation, staff interview and review of manufacturer guidelines, the facility failed to ensure respiratory and/or clinical staff followed manufacturer guidelines for patient care when using oxygen connectors, inflatable face mask and when cleaning the croup tent during one (1) of two (2) days of survey.

Findings Include:

Cross Refer to C-0270 for the facility's failure to ensure staff followed manufacturer guidelines for patient care when using oxygen connectors, inflatable face mask and when cleaning the croup tents.

Based on observation, staff interview and patient's rights document review, the facility failed to provide safeguards to protect confidentially of medical record information during one (1) of two (2) days of survey.

Findings Include:

Observation on 06/22/16 at 2:35 p.m. revealed an office door open in the main hallway with patient's medical records in view of the open door. A desk located in the office had in plain site several patient medical records with information containing infections with the patients name, personal information, type of infections and treatment mode. Also noted was several records for precertification which contained patient personal information.

Interview with the Infection Control nurse on 06/22/16 at 3:15 p.m. confirmed these findings. When asked about why the records were left in view from when observed at 2:35 p.m. until she returned to her office at 3:15 p.m., she replied that she had only been in the position of Infection Control nurse for two (2) weeks and that prior to taking the position she was a PRN LPN (as needed Licensed Practical Nurse) at the facility.

Review of the facility document "Know your Rights" revealed, "...patient has the right for personal privacy and privacy of your health information..."