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Based on observation, interview, and policy review, the CAH (Critical Access Hospital) failed to maintain a clean and orderly kitchen environment; and failed to consistently label and date foods in accordance with safe food handling practices and the hospital's dietary policies. Findings include:

During a tour of the kitchen on 2/5/18 at 10:53 AM, the air filter on the ice machine had visible dust and dirt. The dish machine had a white film on the outside and around the perimeter of the machine; the top of the dish machine had visible dust. A bucket of food scraps used for compost was observed uncovered on the floor in the food preparation area. A second bucket of food waste used for compost was observed uncovered in a corner, approximately 3 feet from a shelf of clean salad bar containers. A hard plastic knife holder attached to the wall contained visible crumbs and dust on the top of the holder. The stacked convection ovens had visible grease covering the top, front, and sides. The stove top burners and griddle had a build up of grease and dried food/crumbs. The walk-in freezer contained a bag of open pizza crust without a date opened. The walk-in refrigerator had a container of yellow cake dated 1/19/18 and an opened bag of shredded cheese without a date opened. A reach-in refrigerator contained a plate of cottage cheese and pineapple and a plate of deli-meat, neither plate was labeled and dated. These observations, which were not in accordance with the dietary food handling polices, were confirmed at the time of the tour by the Director of Dietary Services.

Per review of the policy, FOOD SAFETY PRODUCT LABELING & DATING GUIDE-revised 7/29/14, stated: "Storing Prepared Food; Labels required ....name of product, date of preparation and/or "use-by" date."

Based on staff interview and record reviews, the CAH (Critical Access Hospital) failed to assure that all policies were reviewed at least annually by members of the group of professional personnel as required, and reviewed by the CAH as necessary. Findings include:

1. Per review of policies from the CAH health services/departments during the survey, multiple policies had not been reviewed at least annually; department policies reviewed included the following health service areas:

Staffing and Staff Responsibilities - NURSE PRACTITIONER/PA'S RESPONSIBILITIES, date reviewed: 3/16
Infection Prevention - STANDARD PRECAUTIONS, date reviewed: 5/14
- BLOODBORNE PATHOGEN EXPOSURE CONTROL PLAN, date reviewed: 3/13
Emergency Department - EMERGENCY SERVICES, date reviewed: 8/14.
Nutrition Services- ICE MACHINES-FACILITY WIDE, date reviewed: 8/15,
- INFECTION CONTROL-NUTRITION SERVICES, date reviewed: 9/10
Respiratory- WEANING FROM MECHANICAL VENTILATION, date reviewed: 6/16
Pharmacy- MEDICATION ORDERS, date reviewed: 5/16
Radiology - RADIOLOGY AFTER HOUR CT PATIENT WAITING PROCEDURE, date reviewed 1/3/17
- RADIOLOGY/ED DISCREPANCIES, date reviewed 8/9/16.
Laboratory - STAGO SATELLITE OPERATIONS AND START UP PROCEDURE, date reviewed 7/22/15

Surgical Services - Per review of Surgical Services policy and procedures the following policies were last reviewed 8/2015. - TRAFFIC PATTERNS IN CSR
- PACKAGING, STOCK ROTATION & OUTDATING OF STERILE SUPPLIES
- PRACTICES FOR STERILIZATION - DISINFECTION; AND CLEANING RECOVERY ROOM AND PRE-OP HOLDING AREA.

Per interview with representatives of the CAH's Quality Assurance Committee on 2/6/18 at 3:30 PM , the Director of Quality confirmed that not all of the CAH's departmental policies had been reviewed at least annually.

Based on observation, interview and record review, the hospital failed to ensure that staff maintained standards of practice for infection prevention in the delivery of care for 1 applicable Patient (Patient #1), and failed to ensure that policies and procedures were in place to mitigate the risks contributing to healthcare-associated infections. Findings include:

1. Per observation on 2/6/18 at 10:20 AM, a staff nurse failed to maintain standards of practice or follow the hospital policy for hand hygiene (cleaning hands with soap and water or using a alcohol-based hand rub) during the provision of wound care. Patient #1 required a daily wound dressing change. After removing the dressing and packing from Patient #1's wound, the nurse removed the soiled gloves but failed to sanitize hands before donning a clean pair of gloves. During the course of the wound care and application of a new dressing, the staff nurse was observed 5 additional times changing gloves and failing to sanitize and/or wash hands.

Per Hospital Hand Hygiene Policy (no date noted when last developed/updated) page 2 stated "Hand Hygiene is to be performed at other times including but not limited to: Before putting on gloves; after removing gloves...." The nurse confirmed on the afternoon of 2/6/18 s/he failed to follow hospital policy and maintaining standards of practice for infection control.

Per CDC (Centers for Disease Control) Hand Hygiene in Health Care Setting last revised 3/24/17 states " When to wear gloves: Put on gloves before touching a patient ' s non-intact skin, open wounds or mucous membranes, such as the mouth, nose, and eyes and change gloves during patient care if the hands will move from a contaminated body-site... to a clean body-site. When to perform hand hygiene: After glove removal".

2. Per review of the hospital's policy and procedures at the time of the survey, the Infection Control policies failed to include interventions to address respiratory hygiene and cough etiquette among staff, patients and visitors. While the hospital maintained an Infection Control Plan and policies addressing transmission-based precautions, there was no incorporation of techniques to address the potential spread of illness and disease through respiratory secretions for individuals presenting with signs and symptoms of a respiratory infection. The absence of a policy or procedure addressing respiratory hygiene was confirmed with the Infection Control RN at 0930 on 2/7/2017.

Based on observation and interview the Condition of Participation for Surgical Services was not met as evidenced by the failure of the CAH to limit access to restricted areas of perioperative services to include: Central Sterile, Decontamination room, operating rooms and PACU (Post Anesthesia Care Unit) to only authorized personnel and a failure to assure a designated space was delineated in the Decontamination room for individuals who enter this restricted area without proper protective attire. Findings include:

1. Throughout the days of survey, observations were made of the accessibility of unauthorized individuals to potentially enter the perioperative area which included the operating rooms (ORs), Post Anesthesia Recovery Unit (PACU), Central Sterile Supply and Decontamination room. During a tour on 2/5/18 at 3:20 PM with the Clinical Leader for perioperative services, the entrance into the perioperative area was observed located adjacent to the Medical/Surgical nurses' station. The double door entrance to this restricted location is accessed from a public hallway and is readily accessible by unauthorized individuals. The doors lacked signage stating "Do not enter" or "restricted to authorized personnel". There were no visual cues nor line of demarcation alerting a separation from unrestricted to restricted areas. Unauthorized access can be easily accomplished which would then facilitate further access to semirestricted and restricted areas. Once within the semi-restricted hallway, an unauthorized individual would have immediate access to Central Sterile (where surgical instruments are prepared, packed and sterilized for patient use) and the Decontamination Room (a receiving area for cleaning soiled, contaminated instruments/equipment) and where blood borne pathogen precautions must be maintained. The PACU could also be accessed where a patient would be recovering from surgery; an unauthorized access would also facilitate further entrance into the restricted operating suites.

In addition, within the Decontamination area there was a failure to have a red line inside the door entrance which marks where staff can not cross any further without PPE (Personal Protection Equipment: head covering, face shield, gown, gloves and shoe covers). This was confirmed during the morning of 2/6/18 with the lead Central Sterile technician.

Per 2016 AORN (Association of periOperative Registered Nurses): Patient and Workers Safety "Environment of Care" Part 2, page 267 states: "The designated areas should be separated by Signage indicating the attire required for entering the area and who may access... the doors separating the restricted area from the semi-restricted area;" and "Doors, signage or a line of demarcation to identify the separation between the unrestricted and semi-restricted areas. Signs provide a visual cue that alerts persons to the restrictions required for entry into each area. The doors must provide a physical barrier...." .