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Based on observation, interview and policy review, the facility failed to maintain compliance with applicable Federal laws related to Occupational Safety and Health Administration (OSHA), by ensuring safe practices in the use of chemicals.

Findings included:

OSHA requires that employers implement Medical Service and First Aid: Where the eyes or body of any person may be exposed to injurious corrosive materials, provide suitable facilities for quick drenching or flushing of the eyes and body within the work area for immediate emergency use [29 Code of Federal Regulations (CFR) 1910.151(c)]
American National Standard for Emergency Eyewash and Shower Equipment standard guidelines.

A tour was conducted in the laboratory department at the hospital beginning 6/26/23 at 1:30 PM. It was observed that the eye flushing equipment provided for staff was not conducive to providing quick drenching or flushing of the laboratory staff eyes if exposed to corrosive materials. There was no evidence provided to show that this equipment was being inspected on at least a weekly basis to ensure it works in an emergency. There was no evidence provided showing staff knew how to use current eye wash device that was available during the tour.

Further observations revealed the emergency shower located in the laboratory was not being inspected on a routine basis. The location of the shower was a lab safety hazard if activated. It was surrounded by laboratory analyzers which would have caused an electrical hazard if activated. There were no drain in place under the emergency shower for drainage if the emergency shower had to be tested or placed in use.

On June 26, 2023 at 3:15pm reviewed Laboratory Safety Policy provided by the facility and last reviewed 04/22 that stated:" Laboratories often use hazardous chemicals. The Laboratory has an eye wash and emergency shower in the event." The policy did not have any other guidelines of use and maintenance of eye wash and emergency shower within the policy.

During the tour the Assistant Administrator, Maintenance Director and Director of Laboratory services were present and confirmed findings at 2:45pm on June 26, 2023 through interviews.

Based on observations and interviews, the facility failed to ensure that patients received care in a safe setting.

Specifically, the facility's GI Lab and Emergency Department failed to have emergency pull chords for patient safety in the patient's bathroom in the event of a medical event and/or emergency.

The findings were:

Observation on 6/27/2023 at 091:37 PM in the Facility ' s GI Lab revealed that the patient bathrooms did not have emergency pull cords in the event a patient had a medical event and/or emergency.

Further observations at 2:00 PM in the Facility ' s Emergency Department revealed that the patient bathrooms did not have emergency pull chords in the event a patient had a medical event and/or emergency.

Interview on 6/27/2023 at time of the observations with staff #2 confirmed the above findings.

Based on observation, interview, and record review the facility failed to provide a clean, sanitary, and safe environment to avoid sources and transmission of infections and communicable diseases.

Specifically, observations of the facility revealed the following:

1.) The Medical Surgical area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.
2.) The Newborn Nursery was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.
3.) The Labor and Delivery area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.
4.) The 1 patient room in the facility, Room 119, was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.
5.) The surgical services area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.
6.) The Main Linen Room had bags of linen with linen bags opened and exposed to the environment.
7.) Central Supply room was unorganized with boxes stored on shelves within 18 inches of ceiling.
8.) Outside Facility Waste Bin was missing the lid of the main waste bin.

These deficient practices placed the patients' health and safety at risk for the transmission of infections and/or communicable diseases.

Findings included:

Observations on 6/27/23 at 10:30 AM of the facility with staff #2 revealed the following:

1.) Med/Surg

A) Observations on the medical surgical floor revealed a small cove which housed a vital signs machine. The base of the vital signs machine was dirty.

B) A room with a sign "Waiting room", inside was stored supplies and equipment. IV poles which were identified as clean had dusty bases. Shipping boxes were stored in that room close to the ceiling.

C) Patient room 119. The patient bed, when lifting up the mattress, the bedframe was dusty. The support base which holds the mattress had rust spots. Opening up the recliner, the metal frame was dusty.

2.) Newborn Nursery

A) the sink nozzle in the newborn nursery was covered in calcium/lime deposits. The base where the handles were was discolored in a green/blue colors

B) A back splash that runs the length of the nursery, was painted. There are chips in the paint, making the surface uneven. The back splash is no longer a wipeable surface.

3.) Labor and Delivery Room 201

A) in labor and delivery room 201, the bedside table had a dusty base.

B) The window frame in the room had a dusty base.

C) Opening the cabinet doors under the handwashing sink revealed water damage. Clean supplies were stored under the sink near the water damage.

D) a ceiling tile had a water stain.

4.) Surgical area.

The door frames around Room A and Room B had chipped paint. Making it no longer a wipeable surface.
The Dirty Room, the sink had hard water stains. The painted wall above the sink had paint flaking off.
The scrub sinks between Room A and Room B had a blue/green discoloration on the nozzle.

5.) GI

The door frames around the pre procedure and post procedure doors had chipped paint. Making it no longer a wipeable surface.

Interview on 6/27/23 at the time of the above observations with Staff #2 confirmed all the above findings.

6.) Main Linen Room.

A) Observed bags of linen with linen bags opened and exposed to the environment. No outer cover to protect clean linen hampers from dust and other contaminants.

B) Interviews with Maintenance staff and Assistant Administrator on June 26, 2023 at 2:05pm in the facility who were present confirmed this finding.

7.) Central Supply Room.

A) Located in a building in back of the main facility. Observed supply room as being unorganized with boxes stored on shelves within 18 inches of ceiling.

B) Interviews with Maintenance staff , Assistant Administrator and Central Supply staff on June 26, 2023 at 1:45pm in the central supply room who were present to confirm finding. Central Supply staff explained supplies were just delivered and he was still in process of sorting supplies.

8.) Outside Facility Waste Bin

A) Located in back of facility. Observed lid of main waste bin was missing. This could allow rodents and birds to pull facility waste out of bins and spread on the facility grounds.

B) Interview with Maintenance staff, Assistance Administrator at 1:50pm on June 26, 2023 who were present during observation and confirmed observation. It was explained that lid blew off during a recent storm. The facility was in process of ordering a replacement.

Record review of the facility policy, titled Infection Control, Patient Care Unit, undated, states in part ...All non-disposable patient care unit equipment shall be wiped daily by nursing staff with a clean cloth soaked in hospital approved disinfectant. .....Floors and horizontal surfaces shall be cleaned daily with an approved antimicrobial cleaning agent. ....There should be separate areas for clean and dirty storage.