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Based on observation, interview and record review the facility failed to ensure emergency supplies were readily available when expired supplies were available for use.

Findings included:

Review of Crash Cart Inspection states in part, "Purpose: To insure that the crash carts are maintained and fully stocked at all times for emergency situations.
Purpose: 1. Nursing at shift change (one per 24 hours)
a. Will do a 24 hour defibrilator check by turning on the defibrillator, turning the joules to 20-50, pressing the charge button, and discharging the unit. A tracing is to be run during the process and initialed by the RN. The striip is then placed in the crash cart log book that is on the cart.
b. Suction equiipment, oxygen, laryngoscope, and , if open, the cart istself, are to be checked. If eqiipment is not in proper working order, a repair reequest is to be make, or necessary batteries or bulbs replaced. After the caar is checked. A new lock is placed on the cart, and the number of the lock recorded in the log book.
c. If the crash cart is used after hours, the RN charge nurse is responsible for overseeing the restocking and locking of the cart, and initialing in the log book.
d. Nursing is responsible for restocking the crash carts with any missing items.

Observation during a tour of the facility on 02/18/2020 revealed the following:
ED Trauma Room
Plain Packing Strip (sterile container) was opened and available for use.
Naloxone HCL Injection 0.4 mg/ml, expired 2-1-19 X2
Pleur-Evac Tray Infant Sahara expired 11/18/19
Flexi-Set Uncuffed endo trach tubes expired. 9/2019
Sterile I&D Kit expired 11/30/19
Blue Sensor SP ECG electrodes expired 6/15/19

Pedi Emergency
Levin 10F (Stomach Tube) exp. 01/2019
Intubation Module expired 09/2018
IV Cannula 18 Ga expired 01/2019
IV Cannula 22 Ga expired 03/2019

Radiology Department (X-ray room)
X 23 Blunt Filled Needles expired 03/2011.
CT room
adult air way expired 8/2018
Pedi airway expired 8/2019
The findings were confirmed by the CNO during a tour of the facility on 02/18/20.

Tour of the Physical Therapy department on the morning of 2/19/20 revealed the following expired supplies:

X2 Plain Packing strips expired 4/2019
Plain Packing Strips expired 7/2018
X2-xeroform petrolatum dressing overlap expired 1/2012
Bateriostatic wound dressing expired 9/2016
X7-Adaptic non-adhering dressing expired 9/2018

The findings were confirmed by staff #19 on 2/19/20.

Based on observation, interviews, and record reviews, the facility failed to ensure kitchen microwave was maintained in safe operating condition, in that 1/3 of the inner surface of the base area was covered with rust and still used by kitchen staff.

Findings included:

In an observation of the kitchen service area on 2/18/20, at 11:32 a.m., the microwave was found to have rust at the inner surface of the base area. The rust covered approximately 1/3 of the base area.

In an interview on 2/18/20, at 11:46 a.m., Staff #17 stated she told the Dietary Manager about the rust in the microwave about 3 months ago. She stated, "this is the only microwave we have in the kitchen."

In an interview on 2/18/20, at 12:05 p.m., Staff #16 stated she knew the rust inside the microwave was progressively getting worse but just haven't gotten to it. She stated it was her responsibility to replace it as needed, "I suppose I could just go down to the store and get one."

In an interview on 2/19/20, at 1:10 p.m., Staff #25 stated he performed monthly kitchen inspections, but inspecting microwave was not on the list so he didn't inspect it. He stated no one from kitchen staff mentioned about any issues with the microwave. He stated when he does check for other equipment in the kitchen, he does check for rust. He does monthly checks using the Kitchen Inspections form. He further stated if there's rust in the microwave, "it's not something you can fix, but should be replaced. That responsibility would fall under the Dietary Director."

Review of facility policy titled Equipment Condition and Safety, Policy #2009, with reviewed date of 8/14/19, reflected, " ... The interior and exterior of the equipment must be free of rust ..."

Review of Kitchen Inspections form, dated 1/21/20, reflected detailed list of tasks and equipment to inspect. Inspection item #10 reflected, "work tables clean on top and under without rust ..." This inspection form did not include checking the microwave.

Review of facility policy titled Nutrition Services Department Safety, Policy #2001, with reviewed date of 8/14/19, reflected, " ... The Dietary Manager shall be responsible for notifying the Safety Officer in case of any safety hazard ... The Maintenance Department shall be responsible for routine inspections and care of fans, vents and equipment ..."

Based on observation and interview the facility failed to ensure unusable drugs were no available for patient use.

Findings included:

Review of Multiple Dose Vials policy states in part, "Obtain the order requesting the use of medication. The vial will be dated and initialed when it is originally opened. Using proper technique, draw out the desired dose for administration to the patient. Check the order again before administration.
The use of multiple dose vials is discouraged when possible. Multiple dose vials will be discarded 28 days after they are originally entered into. The medication should be returned to the pharmacy.
Medication labels will indicate whether the drug is a multiple dose vial or a single dose vial. Only multiple dose containers may be used for multiple doses. Medications intended for single use are either unstable, or do not contain a preservative. They should be discarded immediately after use."

Observation during a tour of the facility on 02/18/2020 revealed the following:
Trauma ED cart:
X2 Naloxone HCL injection 0.4 mg/ml (Trauma ED cart) expired 11/18/2019
Nurse Station Medication Room:
Influenza Vaccine 0.5 ml/ 5ml vial did not have a dated when opened.
Tuberculin Purified Derivative 1 ml opened 11/26/2019 and available for use.

The findings were confirmed by the CNO during the tour.

Based on review of facility documents, observation and staff interview, the facility failed to ensure radiology services were furnished appropriately.

Findings included:

In an article published by Spectrum Health in July, 2014 it was stated "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."

Tour of the Radiology department revealed:
*a layer of dust on top of the CT machine
*layer of dust and debris in the glass-covered cabinet
*external shipping corrugated boxes stored in the patient care area
*two floor oscillating fans with dust build-up on the blades
*dirt build-up on the walls by the clean sink, indicating the area was not cleaned
*many cleaning bottles and other equipment stored under the sink
*the contrast injector covered with dried on contrast, including the base and wheels

In an interview with staff #25 on the morning of 2/18/20, when asked about the contrast injector, they stated they had to wait to clean the machine until the substance had dried. The substance was dried and flaked off with a pen. When asked when it was last cleaned, staff #25 stated, "Yesterday." When asked why the substance was still there, they stated, "I really have to scrub that off." When asked if anyone tested the injector, they stated, "No."

The above was verified in an interview with administrative staff on the afternoon of 2/19/20.

Based on observations, interviews, and record reviews, the facility failed to maintain an effective infection control, prevention, and surveillance measures, including maintaining a clean and sanitary environment to avoid sources and transmission of infection when:

1) Expired food items were available for use, and food items were not properly labeled.
2) Improper storage of kitchen supplies/equipment.
3) Microwave was not properly maintained/replaced.
4) Physical Therapy department with dirty therapy areas, patient room, and equipment.
5) Facility failed to ensure biological indicators for the sterilizers were included with at least one run each week and preventive maintenance were performed according to manufacturer's service manual.
6) Facility failed to ensure employees involved in processing clean and soiled linen were given initial and follow-up in-service training to ensure a safe product for patients.

Findings included:

1) During a tour of the kitchen with Staff #16 on 2/18/20, at 10:57 a.m., the following observations were made:
- approximately 20 x 8 oz. bottles of Ensure Original, with expiration date of "1FEB2020"
- approximately 5 x 6 lb. 5 oz. cans of Allens Seasoned Turnip Greens, with sell by date of 12/29/19
- 3 x large containers of unknown food items without any label/date
- Various opened 1 gallon tub of condiments such as dill slices, mayonnaise, dressings without label (only received dates were written)

In an interview on 2/18/20, at 11:20 a.m., Staff #16 confirmed the above findings. She stated Ensure should have been returned to the Pharmacy department and other expired food items should have been removed. For the 3 large containers of food items, she confirmed they were sugar, flour, and oatmeal that were transferred from larger bins in the dry storage area for convenience. She stated, "we don't label them." When she was asked about food storage and labeling procedures she stated, "we use the received date only, and don't use the opened date on food items even if they are opened." She did not know when the expiration dates were for the various condiments.

In an interview on 2/19/20, at 12:30 p.m., Staff #17 was asked how she would know about the expiration dates on large condiment tubs. She admitted she didn't know but "we usually go through these [condiments] within 2 weeks."

In an interview on 2/19/20, at 12:35 p.m., Staff #16 stated, "I talked to our food vendor and was told food items such as large tub of mayonnaise, pickles, salad dressings, are good for 150 days from manufactured date, or 3 months after opening." When asked about how staff would know when opened date would be if only received date was used, Staff #16 stated, "we go through these items really fast."

Review of facility policy titled Food Supply, Policy #7107, with reviewed date of 8/14/19, reflected, "Food and non-food supplies shall be purchased and stored under sanitary, safe and secure conditions as required to meet federal, state and local laws."

Review of TFER (Texas Food Establishment Rules, October 2015) reflected the following under section §228.81:
"Contaminated Food, Disposition. Discarding or reconditioning unsafe, adulterated, contaminated food ... (1) A food that is unsafe, adulterated, or not honestly presented as specified under §228.61 of this title shall be reconditioned according to an approved procedure or discarded."

Review of facility policy titled Food Storage, Policy #7108, with reviewed date of 8/14/19, reflected, " ... all unlabeled, or damaged containers shall be removed, and destroyed ... if there is any question about a product's storage or expiration, the product shall be discarded."

2) In an observation of kitchen services area on 2/18/20, at 11:46 a.m., the storage rack shelf for pots, trays, and pans did not have a solid bottom shelf. The bottom shelf had large pans and trays on them, exposing them to splash, dust, or other contamination.

In an interview on 2/18/20, at 11:46 a.m., Staff #17 confirmed the above findings and stated pans and trays are normally stored on the bottom shelf.

In an interview on 2/18/20, at 12:03 p.m., Staff #16 stated there was no policy related to kitchen supply/equipment storage.

Review of TFER reflected the following under section §228.124, Storage:
"(a) Equipment, utensils, linens, and single-service and single-use articles ... (1) Except as specified in paragraph (4) of this subsection, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored ... (A) in a clean, dry location ... (B) where they are not exposed to splash, dust, or other contamination ..."

Review of facility policy titled Nutrition Services Department Safety, Policy #2001, with reviewed date of 8/14/19, reflected, " ... All equipment and supplies must be properly stored ..."

3) In an observation of the kitchen service area on 2/18/20, at 11:32 a.m., the microwave was found to have rust at the inner surface of the base area. The rust covered approximately 1/3 of the base area.

In an interview on 2/18/20, at 11:46 a.m., Staff #17 stated she told the Dietary Manager about the rust in the microwave about 3 months ago. She stated, "this is the only microwave we have in the kitchen."

In an interview on 2/18/20, at 12:05 p.m., Staff #16 stated she knew the rust inside the microwave was progressively getting worse but just haven't gotten to it. She stated it was her responsibility to replace it as needed, "I suppose I could just go down to the store and get one."

In an interview on 2/19/20, at 1:10 p.m., Staff #25 stated he performed monthly kitchen inspections, but inspecting microwave was not on the list so he didn't inspect it. He stated no one from kitchen staff mentioned about any issues with the microwave. He stated when he does check for other equipment in the kitchen, he does check for rust. He does monthly checks using the Kitchen Inspections form. He further stated if there's rust in the microwave, "it's not something you can fix, but should be replaced. That responsibility would fall under the Dietary Director."

Review of facility policy titled Equipment Condition and Safety, Policy #2009, with reviewed date of 8/14/19, reflected, " ... The interior and exterior of the equipment must be free of rust ..."

Review of Kitchen Inspections form, dated 1/21/20, reflected detailed list of tasks and equipment to inspect. Inspection item #10 reflected, "work tables clean on top and under without rust ..." This inspection form did not include checking the microwave.

Review of facility policy titled Nutrition Services Department Safety, Policy #2001, with reviewed date of 8/14/19, reflected, " ... The Dietary Manager shall be responsible for notifying the Safety Officer in case of any safety hazard ... The Maintenance Department shall be responsible for routine inspections and care of fans, vents and equipment ..."

4) During a tour of an offsite Physical Therapy (PT) department on 2/19/20, at 9:50 a.m., the following observations were made:
A) In treatment room #2:
-cloth covered therapy wedge with stains.
-two chairs with tears in the vinyl covering, making it impossible to clean
-the outer surface of a storage cabinet with visible dirt and stains
-the hydrocollator [a heating unit for hot packs] with visible dirt on the outer surface
-the carpet floor with dirt and stains in high traffic areas
-trash bin with visible dirt build-up on the foot pedal
B) In the main gym area:
-several weight machines with tears in the vinyl covering, making it impossible to clean
-a table used for storage with tears in the vinyl covering
-layers of dust on free-weights
-discoloration of dumbbells
C) In the patient bathroom:
-a hot water heater stored on the floor with a layer of dust and debris build-up
-a discolored cart with discolored tape
D) In the back room:
-Laundry washer and dryer with dirt build-up on the inside and out
-foam roller and positioner that were discolored; when asked how they were cleaned, Staff #19 stated towels were put over when in use and were not cleaned regularly. Porous surfaces are impossible to clean between patients.
-Storage room with housekeeping supplies such as mop, broom and vacuum mixed with old dirty equipment such as used walkers, used wheelchairs, holiday decorations and boxes

In an interview on 2/19/20, at 9:55 a.m., Staff #19 confirmed the above findings and stated PT staff usually maintains the cleaning of rooms and environment. She further stated the cloth cover of the therapy wedge is washed once every six months, but "we use a towel on top of it."

Review of facility policy titled General Cleaning and Sanitation- Housekeeping Services, Reference #5013, with unknown reviewed date, reflected, "All patient and nonpatient rooms shall be thoroughly cleaned and/or disinfected keeping in mind Standard Precautions and infection control ..."

Review of facility policy titled Housekeeping, Reference #5012, with unknown reviewed date, reflected, "To control the spread of infection within the hospital by maintaining a thoroughly clean and safe environment." It further reflected:
A) Under Responsibilities section:
-Director of Housekeeping to " ... review possible role of fomites in infection outbreaks ..."
-Infection Control Nurse to " ... assist ... in evaluation of sanitation practices, assist in infection control related programs for Environmental Services, periodically assess infection control practices in the department.
B) Under Infection Control Practices:
-Sanitation ... "There shall be procedures for cleaning walls, floors, windows, beds, furniture, draperies, carpets, waste containers, bathroom, equipment, stairs, special patient care departments ..."
-Patient Rooms ... "Carpeted floors shall be vacuumed and cleaned daily ... shall be shampooed on a regular basis ... all mattresses and pillows shall be covered with plasticized covers ..."

5) Facility policy titled "Central Sterile Policies and Procedures" stated in part, "Biological controls: 1. All gravity run loads shall include a [sic]
...j. Storage: 1. After Sterilization cycle is completed all gravity steamed items are placed on cooling rack and allowed to cool while the biological indicators incubate ...
Autoclave procedures:
...b. ...Documentation will include ... final results of bio-indicator.
...h. Cleaning of Autoclave: 1. The autoclave is to be cleaned before use with water."

Facility policy titled "Sterilization" stated in part, "Sterilization Controls: ...2. Biological cultures or indicators are the best means of confirming the sterility of a particular article or evaluating the effectiveness of a sterilizer. Biological indicators will be performed for every load sterilized and the results recorded as a permanent record.
...4. Sterile Processing personnel are responsible for the proper use, interpretation and documentation of sterilization controls.
...Attest Biological Indicator Use: ...Choose the proper Attest indicator for each load
...5. For standard Attest indicators the first reading is done in 24 hours. Compare the test capsule and control capsule...
6. If no color change occurs, the capsules are allowed to incubate for another 24 hours. The procedure described above is again followed.
7. Documentation of test results will be placed in the appropriate log book for furture reference. Read results as positive or negative..."

Midmark autoclave manual stated in part, "Daily: Clean external Surfaces & gaskets
...Weekly: Clean Internal Surfaces
A) Drain water ... B) Remove trays ... C) Refill reservoir with clean water ...
Monthly Maintenance: Flush System ... Clean Filter Screens ... Check Pressure Relief Valve, Remove/Clean/Inspect Gaskets ..."

Tour of the sterilizing area revealed a box of Attest, Biological indicators, that expired 1/2010. No other indicators were available for use. Staff #2 stated, "I will order some."

Biological indicators were missing for the following runs: 7/31/18, two loads on 8/23/18, and 8/15/19.

No documentation that cleaning was completed for the following runs: 7/31/18, 8/23/18 for two loads, 8/8/19, 8/15/19.

The above was confirmed in an interview with Staff #2 on the morning of 2/19/20.

6) Observation of the linen area of the physical therapy department on the morning of 2/19/20 revealed visible dirt noted on the inside and outside of the washer and dryer.

In an interview with Staff #19, when asked how often the machines were cleaned, they denied they were cleaned on a regular basis. When asked how the temperature was monitored on the washer, they stated they do not check the temperature. When asked about policies regarding the cleaning and handling of the machines and linen, they denied there were policies.

The above was verified with administrative staff on the afternoon of 2/19/20.