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Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on August 29 -30, 2022, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on document review and interview, it was determined that for 2 of 5 (Pt.#1 and Pt.#5) clinical records reviewed for wound care management the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient by failing to complete the physician's order for wound care.

Findings include:

1. On 08/29/22, the clinical record for Pt.#1 was reviewed. Pt. #1 was admitted on 08/17/22, due to Right below the knee amputation and left heel wound. Pt. #1's clinical record included a physician's order dated 8/17/22, for daily wound care to left medial heel ulcer, clean with betadine and cover with dry xeroform dressing. Pt. #1's clinical record lacked documentation that the daily wound care was completed on 08/24/22.

2. On 08/29/22, the clinical record for Pt.#5 was reviewed. Pt. #5 was admitted on 08/15/22, due to gun shot wound. Pt. #5's clinical record included a physician's order dated 08/16/22, for daily wound care to back, cover with dry dressing. Pt. #5's clinical record lacked documentation that the daily wound care to back was completed on 08/20/22.

3. On 08/29/22 the Hospital's Job Description for Registered Nurse (revised 3/2020) was reviewed and required, "The RN will assess... implement... total nursing care for designated group of patients... Performs treatments and procedures... as required..."
4. On 08/29/22 at approximately 11:30 AM, the findings were discussed with E #3 (Manager of 3SE & 3SW). E #3 stated that she could not provide documentation that the physician's orders were completed. E #3 stated that all care provided by the RN should be documented.

Based on observation, document review, and interview, it was determined that that the Hospital failed to ensure that outdated and/or mislabeled medications were not available for patient use.

Findings include:

1. A tour of the Radiology Department was conducted on 08/29/22 from 1:55 PM to 2:20 PM. At approximately 2:10 PM, on the medication room counter an opened bottle of E-Z Disk (Barium Sulfate Tablets-contrast agent used in radiography of the esophagus) 700 mg (milligrams) with an expiration date of 04/2022 was observed. The bottle of E-Z Disk was not labeled with an open and used by date, therefore it could not be determined how long the bottle had been opened.

2. The Hospital's policy, titled "Security of Drugs in Patient Care Areas" (revised 10/2020) was reviewed on 8/30/2022, and required, "... i. All expired ... medications are removed, and stored separately from medications, available for administration. Segregate all expired ... medications from usable medications ... "

3. On 08/29/22 at approximately 2:25 PM, an interview was conducted with the System Resource Coordinator (E#4). E#4 stated that when medications are opened they should be labeled with an open or used by date. All expired medications should be removed to prevent accidental use. E #4 stated that the bottle of Barium tablets was the only available at the time of the tour.

A. Based on document review, observation, and interview, it was determined that for 25 of 32 days reviewed for food temperature monitoring, the Hospital failed to manage dietary services by ensuring the temperature of prepared foods were taken upon arrival and again within 2 hours as required. This had the potential to affect the average daily census of 48 patients receiving meal service.

Findings include:

1. The Hospital's policy titled, "Food Delivery to [Hospital]" (revised February 2020), was reviewed on 8/30/2022 and required, "Food is delivered to [Hospital] three times a day... Once cart arrives at [Hospital] kitchen, manager checks temperature/time upon arrival..."

2. The Hospital's Contracted Dietary Service policy titled "Food Safety Management System" (revised 4/1/2022), was reviewed on 8/30/2022 and required, "...HACCP [Hazard analysis and critical control points] records must be reviewed for accuracy and completion... holding food temperature logs during meal service: Temperature must be checked at 2-hour intervals..."

3. An observational tour of Dietary Services was conducted on 8/30/2022, at approximately 10:30 AM. At approximately 10:43 AM, hot foods (prepared outside the Hospital) arrived in the kitchen. The Operations Manager (E#7) and a Food Service Staff (E#8) were observed unloading the food pans from the delivered cart. Some food items (burgers, chicken breasts, baked fish, meatballs, and enchiladas) were placed in a warmer (set at 200 degrees Fahrenheit and above) without temperatures being taken prior. These items were then later plated for service to patients without being measured for temperature.

4. Daily Food Temperature Logs from 7/1/2022-7/15/2022 and 8/14/2022-8/30/2022 were reviewed on 8/30/2022 and included the following:
- No arrival and/or holding times/temperatures were documented for one or more food items served on the following dates: 7/3/2022, 7/5/2022, 7/6/2022, 7/8/2022, 7/9/2022, 7/10/2022, 7/14/2022, 8/14/2022, 8/16/2022, 8/17/2022, 8/18/2022, 8/19/2022, 8/20/2022, 8/21/2022, 8/22/2022, 8/23/2022, 8/24/2022, 8/26/2022, 8/28/2022, and 8/29/2022.
- Breakfast meal holding temperatures were taken greater than 2 hours after arrival time on the following dates: 7/5/2022, 7/6/2022, 7/7/2022, 7/8/2022, 7/9/2022, 7/10/2022, 7/11/2022, 7/12/2022, 7/13/2022, 8/16/2022, 8/17/2022, 8/18/2022, 8/19/2022, 8/20/2022, 8/21/2022, 8/22/2022, 8/23/2022, 8/24/2022, and 8/30/2022.

5. An interview was conducted with Dietary Service Operations Manager (E#7) on 8/30/2022, at approximately 12:55 PM. E#7 stated that food temperatures should be measured upon arrival to the kitchen and again within 2 hours. E#7 stated that if the food was not served or there is none left at the 2-hour holding temperature check, it should be noted on the logs, not just left blank. E#7 stated that they typically measure the temperature of the food once they set up the trayline. E #7 stated that another delivery of food came after that first batch. E#7 stated that she did not measure the temperatures of the burger patties (and other items) that were placed in the warmer first before going to the trayline (or were delivered at a later time).


B. Based on document review, observation, and interview, it was determined that for 32 of 32 days reviewed of food temperature logs, the Hospital failed to manage dietary services by ensuring the food temperature logs were completed in real-time as required by policy. This had the potential to affect the average daily census of 48 patients receiving meal service.

1. The Hospital's Contracted Dietary Service policy titled "Food Safety Management System Record Keeping" (revised 4/1/2022), was reviewed on 8/30/2022 and required, "All manual HACCP [Hazard analysis and critical control points] record keeping must be done in real time and in pen... HACCP records must be reviewed for accuracy and completion..."

2. During an observational tour of Dietary Services on 8/30/2022, at approximately 10:30 AM. The Daily Temperature Logs for Lunch and Dinner were observed in the kitchen area before the food had arrived. The logs were pre-printed (not in written in real-time and in pen) with times for "Reheating" (indicating the time of arrival) and Holding check times. The food had arrived at approximately 10:43 AM and the lunch log had a time of 11:00 AM pre-printed. The dinner logs were pre-printed with an arrival time of 4:35 PM and a holding time check of 6:35 PM.

3. Daily Food Temperature Logs from 7/1/2022-7/15/2022 and 8/14/2022-8/30/2022 were reviewed on 8/30/2022. All times documented under "Reheating" and "Holding" were pre-printed on the forms (not written in pen as required).

4. An interview was conducted with Dietary Service Operations Manager (E#7) on 8/30/2022, at approximately 12:55 PM. E#7 stated that the logs are printed with the times already populated. E#7 stated that it's possible the food doesn't arrive at the exact the time printed on the log but it's usually fairly close. During another interview with E#7 on 8/31/2022, at approximately 10:00 AM, E#7 stated that they would remove the pre-printed times from the logs.


C. Based on document review, observation, and interview, it was determined that for 40 of 40 prepared salads and 2 of 4 bread loafs, the Hospital failed to manage dietary services by ensuring that food items were labeled with a use- by-date and that outdated items were discarded. This had the potential to affect the average daily census of 48 patients receiving meal service.

Findings include:

1. The Hospital's Contracted Dietary Service policy titled "Food Safety Product Labeling & Dating Guide" (revised 7/29/2020) was reviewed on 8/30/2022 and required, "Labels required [for] food prepared [includes] date of preparation and/or use-by date... Food may not exceed... 'use by' date..."

2. During an observational tour of Dietary Services on 8/30/2022, at approximately 10:35 AM, 40 of 40 prepared side salads were observed in a refrigerator without a label indicating the date prepared or a use by date. At approximately 11:30 AM, 2 of 2 loafs of bread were available for use for the lunch tray line with a use-by-date of 8/26/2022.

3. An interview was conducted with the System Director of Dietary Services (E#6) on 8/30/2022, at approximately 10:35 AM and 11:35 AM. E#6 stated that the salads were just prepared today. E#6 stated that every item should be labeled with date/time of prep or a use-by-date. E#6 stated that outdated items should be discarded.


D. Based on document review, observation, and interview, it was determined that for 2 of 2 Food/Dietary Service Staff (E#7 and E#11), the Hospital failed to manage dietary services by ensuring that verification testing of sanitizing solution was conducted according to the manufacturer's instruction for use. This had the potential to affect the average daily census of 48 patients receiving meal service.

Findings include:

1. The Hospital's Contracted Dietary Service policy titled "Sanitizing Solution, Testing Devices" (revised 4/1/2022), was reviewed on 8/30/2022 and required, "The food establishment must have a test kit that accurately measures the concentration of each type of sanitizer available... The employee must test the sanitizer solution according to the chemical company's manufacturer's instructions..."

2. The sanitizing solution testing strip manufacturer's instructions for use (undated) included, "Withdraw a test strip from the canister. Dip test strip for 5 seconds to test solution. Shake off excess solution. Compare colors after 10 seconds with colors on the test strip canister to determine concentration... Testing solution should be between 272-702 ppm [parts per million]..."

3. During an observational tour of Dietary Services on 8/30/2022, at approximately 11:55 AM, the Operations Manager (E#7) demonstrated the procedure to test the sanitizing solution used in the 3 compartment sink for pots and pans. E#7 dipped the test strip in the solution and then took it out and compared it to the color chart immediately (not allowing the strip to develop for 10 seconds as required). The test strip color did not meet the acceptable range on the canister scale so E#7 dipped it in the solution again. E#7 did not use a clock, timer, or watch during the test.

4. An interview was conducted with E#7 on 8/30/2022, at approximately 12:00 PM. E#7 stated that the strip is dipped in the solution for 5 seconds then after it's taken out, compare it to the bottle. E#7 verbalized the correct acceptable range; however, was not aware that the instructions required the user to wait 10 seconds after removing the strip before comparing to the chart. When asked how E#7 ensures the strip is submerged for 5 seconds, E#7 stated that she counts to 5 using the one-one-thousand method.

5. A telephone interview was conducted on 8/30/2022, at approximately 12:17 PM, with the Dietary Services Staff (E#11) who conducted the sanitizing test in the morning. E#11 was not present on-site to demonstrate the test; however, E#11 stated that the solution did pass this morning when she did the test. E#11 verbalized that she dips the strip in the solution for 5 seconds then compares it to the color scale right away. E#11 could not verbalize what the acceptable numerical range for the testing solution; however, stated that she knows what color shade the strip should be between on the bottle.


E. Based on document review and interview, it was determined that for 2 of 3 dietary equipment logs reviewed, the Hospital failed to manage dietary services by ensuring that equipment was operating at the correction temperatures and if acceptable range was not met, corrective action was taken. This had the potential to affect the average daily census of 48 patients receiving meal service.

Findings include:

1. The Hospital's Contracted Dietary Service policy titled "Cleaning and Sanitizing Food Contact Surfaces" (revised 4/1/2022), was reviewed on 8/30/2022 and required, "A high temperature dish machine must have a minimum final rinse temperature of 180 degrees Fahrenheit [F]...The final rinse temperature must be verified once per meal... If the final rinse is not being met contact your service representative immediately. The food establishment may have to temporarily go to disposable service utensils until the machine is adjusted to specifications... Dish machine temperatures must be checked and recorded on the dish machine temperature log once per meal period..."

2. "Weekly High Temperature Mechanical Ware Washing Machine Logs" for August 2022 were reviewed on 8/30/2022 and indicated that the minimum Final Rinse Temperature of 180 degrees Fahrenheit was not met on the following dates/meal periods [B = Breakfast, L = Lunch, D = Dinner, A = All 3 meal periods]: 8/1/2022 (B); 8/2/2022 (A); 8/3/2022 (B & L); 8/4/2022 (B & L); 8/12/2022 (D); 8/13/2022 (A); 8/14/2022 (B & L); 8/15/2022 (B); 8/16/2022 (B & L); 8/17/2022 (B & L); 8/18/2022 (B & L); 8/19/2022 (B & L); 8/20/2022 (B); 8/23/2022 (B & L); 8/24/2022 (A); 8/25/2022 (B & L); 8/26/2022 (A); 8/27/2022 (A); 8/28/2022 (A); and 8/30/2022 (B). The logs lacked documentation of corrective actions taken on those dates/times when the results were outside proper operating ranges.

3. The Hospital's Contracted Dietary Service policies titled, "Hot and Cold Holding" (revised 4/1/2022); "Weekly Refrigerator Temperature Log" (revised 4/1/2022); and "Weekly Freezer Log" (revised 6/1/2022), were reviewed on 8/31/2022 and required, "Temperatures of cold and hot food storage units (refrigerators, freezers, and warming cabinets) must be taken and recorded at least once a day, preferably in the morning when temperatures are stable... Corrective Actions: Highlight any results outside proper operating ranges and comment on reason. Inform head chef/manager. Record corrective actions... Maintain refrigerator temperature at 40 degrees Fahrenheit or below during stable times... freezer temperatures should be maintained at 0 degrees Fahrenheit or below..."

4. "Refrigeration/Freezer Temperature Logs" for August 2022 were reviewed on 8/30/2022 and indicated that Fridge #1 had a temperature of 42 degrees F on 8/16/2022. Freezer #2 had the following out of range temperatures: 8/2/2022 10 degrees F; 8/23/2022 2 degrees F; and 8/25/2022 2 degrees F. The logs lacked documentation of any corrective action taken to address the out of range temperatures.

5. Interviews were conducted with the Operations Manager (E#7) on 8/30/2022, at approximately 12:00 PM, and again on 8/31/2022, at approximately 10:00 AM. E#7 stated that the final rinse temperature should be 180 degrees F or higher. E#7 stated that staff may be writing the temperature down when the machine is idle instead of when it's actively washing a load. E#7 stated that the refrigerators should be 40 degrees F or below and the freezers should be 0 degrees F or below. E#7 stated that if the temperature is above than range, we temp the food and if the food is also above range, then they are tossed. E#7 stated that any steps taken to address the out of range temperatures should be documented on the log.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on August 29 - 30, 2022, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on document review, observation, and interview, it was determined that for 2 of 4 staff observed for hand hygiene, the Hospital failed to ensure that staff performed hand hygiene before and after patient care, when moving from dirty to clean tasks, and after removing gloves as required by the infection prevention and control program.

Findings include:

1. The Hospital's policy titled, "Standard Precautions" (revised February 2020), was reviewed on 8/31/2022 and required, "Hand Hygiene... b. After touching instruments, equipment, materials, and other objects likely to be contaminated. c. Before and after treating each patient. d. Before putting on gloves and again immediately after removing gloves..."

2. During a tour of the 2 South Inpatient Unit on 8/29/2022, the following was observed:
- At approximately 11:00 AM, an EVS/Environmental Services Staff (E#14) was cleaning patient rooms with gloved hands. E#14 went in and out of a clean storage room at the end of the hall and also touched a patient's belongings who was being prepared for discharge without removing the gloves and performing hand hygiene.
- At approximately 11:44 AM, a Registered Nurse (E#12) went in to Pt. #15's room to administer medications and provide care. E#12 changed gloves two times while in the room and did not perform hand hygiene immediately after glove removal. After completing care, E#12 exited Pt. #15's room and went to the medication room to pull medications for the next patient without performing hand hygiene. At approximately 12:27 PM, E#12 went to administer intravenous (IV) medication to Pt. #16. E#12 touched the patients arm to assess the IV site and then went to change gloves without performing hand hygiene. E#12 then flushed the patients IV line and then went to change gloves again without performing hand hygiene.

3. During a tour of Dietary Services on 8/30/2022, at approximately 12:30 PM, a Dietary Services Staff (E#9) was scraping off dirty/soiled plates. Another staff member arrived and took over loading the dirty dishware into the dishwasher. E#9 went over to retrieve the cleaned dishes out of the dishwasher without changing gloves and performing hand hygiene. At approximately 1:00 PM, E#9 brought in a cart of dirty dishes from the inpatient units. E#9 then went to retrieve and unload clean dishware from the washer without changing gloves and performing hand hygiene.

3. An interview with the Assistant Chief Nursing Officer (E#15) was conducted on 8/31/2022, at approximately 11:37 AM. E#15 stated that hands should be washed/disinfected before and after patient care/treatment, when moving from a dirty task to clean task, and after removing gloves.


B. Based on document review, observation, and interview, it was determined that for 2 of 2 staff (E#12 and E#13) observed using workstations on wheels, the Hospital failed to ensure that equipment brought into patient rooms were cleaned in between patients and/or before being returned to a clean storage area as required by the infection prevention and control program.

Findings include:

1. The Hospital's policy titled, "Low Level Disinfection" (revised 6/2020), was reviewed on 8/31/2022 and required, "Workstations on Wheels (WOWs) must be disinfected each shift and between each patient use if enters patient rooms, diagnostic rooms, or procedure/treatment areas.

2. During an observational tour of the 2 South Unit on 8/29/2022, between approximately 11:20 AM and 1:00 PM, two Registered Nurses (E#12 and E#13) were observed bringing WOWs in and out of different patient rooms (5 different times/patients during the tour) for medication administration/treatments/assessments. Neither E#12 or E#13 disinfected the workstations before bringing them to another patient's room or before returning them to the clean medication room.

3. An interview was conducted with the Registered Nurse (E#12) on 8/29/2022, at approximately 1:10 PM. E#12 stated that they usually clean the WOWs in the morning, end of shift, and during lunch/breaks. E#12 stated that disinfecting wipes are available at the nurses station.


C. Based on document review, observation, and interview, it was determined that for 1 of 4 Inpatient Units (2 South) observed, the Hospital failed to ensure that dirty linens were not stored with clean equipment/supplies as required by the infection prevention and control program.

Findings include:

1. The Hospital's policy titled, "Low Level Disinfection" (revised 6/2020), was reviewed on 8/31/2022 and required, "Clean equipment shall be stored in a clean, designated storage area."

2. During an observational tour of the 2 South Unit on 8/29/2022, at approximately 1:21 PM. A hamper with soiled linens was located inside a designated "clean storage" for linens and equipment.

3. An interview was conducted with a Certified Nursing Aide (E#16) on 8/31/2022, at approximately 11:09 AM. E#16 stated that the room at the end of the hall (where the hamper was located) is used to store the clean linen cart and cleaned vital sign equipment. E#16 stated that hampers with soiled linen are not to be left in the room.

4. An interview with the Interim Nursing Manager of 2 South and 3 South (E#17) was conducted on 8/31/2022, at approximately 11:11 AM. E#17 stated that generally staff are to take soiled linens directly to the chute that leads to the soiled linen room in the basement. E#17 stated that it should not be stored with clean supplies/equipment.


D. Based on document review, observation, and interview, it was determined that for 1 of 1 Nurse (E#13) observed drawing up medication from a vial, the Hospital failed to ensure that the rubber septum was disinfected prior to puncturing the vial as required by the infection prevention and control program.

Findings include:

1. . The Hospital's policy titled, "Standard Precautions" (revised February 2020), was reviewed on 8/31/2022 and required, "Disinfect the rubber septum on a medication vial with alcohol before piercing."

2. During an observational tour of the 2 South Unit on 8/29/2022, at approximately 1:10 PM, a Registered Nurse (E#13) removed the dust cap off of a vial of heparin (a blood thinner). E#13 then pierced the rubber septum of the vial with the needle of a syringe to withdraw the medication without first disinfecting the rubber septum with alcohol.

3. An interview was conducted with E#13 on 8/29/2022, at approximately 1:15 PM. E#13 stated that if the vial is new you don't have to wipe the septum.

Based on observation, document review and interview it was determined that for 1 of 1 (Pt. #40) patient observed for breathing treatment, the Hospital failed to maintain a clean and sanitary environment ensuring the oxygen cannula and humidifier was discarded prior to date of expiration. This has the potential for hospital acquired infection for thirteen (13) patients on oxygen as of census dated 08/31/2022.

Findings include:

1. On 08/31/2022 at 9:30 AM, the breathing treatment for Pt. #40 was observed. Prior to initiating the breathing treatment, the following was found:

- Pt. #40 on two (2) liters humidified oxygen via nasal cannula with label on the nasal cannula dated 07/12/2022 with no staff initials.
- The humidifier did not have date of open or staff initials on it.

2. On 08/31/2022 at 10:00 AM, Pt. #40's clinical record was reviewed. Pt. #40 was admitted to the hospital on 06/01/2018 at 1:48 PM, with a diagnosis of traumatic brain injury. Pt. #40's physician order dated 03/27/2022, included, "Oxygen 2 liters per nasal cannula daily, respiratory equipment change Q5D [every five days] ...Resp [respiratory] nebulizer treatment daily prn [as needed] ..."

3. On 08/31/2022 the Hospital's policy titled, "Oxygen Therapy" dated 10/2022 was reviewed and included, "...Infection Control: Nasal Cannulas ... (or any respiratory equipment that has humidified air) should be changed every five days ..."

4. On 08/31/2022 at 9:50 AM, the Registered Nurse (E #1) was interviewed. E #1 stated that she was not sure who put the nasal cannula for the patient and why it was not changed it since 07/12/2022. E #1 stated that the nasal cannula should have been changed every seventy-two (72) hours. E #1 stated that if the nasal cannula and the humidifier is not changed it could cause infection for the patient.

5. On 08/31/2022 at 11:00 AM, the findings were discussed with the Clinical Manager of Respiratory Therapist (E #2). E #2 stated that it is definitely not acceptable to have patient's nasal cannula and humidifier for more than a week. E #2 stated that it would cause infection for the patient.