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Based on observation, interview, and record review the hospital failed to ensure medications were properly secured when:

1. Two crash carts in the Emergency Department (ED) had secure tags that did not match the daily crash cart logs;

2. Medications used for emergency resuscitation was left on top of the crash cart unsecured; and

3. Anesthesia medications (medicines to prevent pain during surgery and other procedures) were found in an unlocked anesthesia cart in one of the operating rooms.

These failures had the potential for unauthorized access and diversion or misuse to controlled anesthesia medications.

Findings:

1. During a tour of the ED on February 29, 2024, at 1:30 p.m., crash carts two and three had contradicting lock numbers with the crash cart and defibrillator monitoring logs.

An interview was conducted on February 29, 2024, at 1:39 p.m., with the Emergency Department Director (EDD). The EDD stated the expectation would be that the locks for the crash cart supplies and emergency medications should match the daily crash carts logs when checked and signed off. The EDD further stated the locks for crash carts two and three did not match the log.

An interview was conducted on February 29, 2024, at 1:44 p.m., with the ED Charge Nurse (EDCN). The EDCN stated the lock numbers did not match for both carts (two and three). The EDCN further stated the nurse checking the crash carts must check the actual number on the locks for the supplies and the emergency medications and make sure the numbers match the log, then sign off.

A review of facility document titled, "[Name of facility] Crash Cart and Defibrillator Monitor Log," Dated February 2024, for crash carts two and three were reviewed. The document indicated for crash cart two, "...Cart Lock # 85010186...Drug Lock # 0490962 ...DATE February 29, 2024, SHIFT NOC [7 p.m. to 7 a.m.]..." The actual Cart Lock Number (blue) 0492757 and the Drug Lock number (red) was 8484015.

A review of the facility's Policy and Procedure (P&P) titled, "[Name of the facility] RX 394 Crash Cart Monitoring Exchange," dated February 22, 2024, indicated, "...Once daily all patient care areas with crash carts will complete and document the crash cart integrity check. A registered nurse, Emergency Department technician, or by a designated person in the ancillary departments shall complete the check. The cart will be checked for the following...1. The front of the cart is locked with a blue numbered lock. This lock number is to be recorded on the monitoring form. 2. The top of the crash cart containing pharmaceuticals is locked with a red numbered lock. This lock number is to be recorded on the monitoring form...If a crash cart is replaced, document the new red and blue lock numbers on the Crash Cart Log to the right of previous number AND document the new crash cart number in the appropriate daily box..."

2. A tour of Unit A was conducted on February 29, 2024, at 3:05 p.m., with the Director of Unit A (DUA). During the tour, crash cart one was observed in the hallway with unsecured medications on top: One vial of Etomidate (a short- acting anesthetic) 20 mg iv (intravenous), and two Rocuronium 50 mg iv (intermediate-acting nondepolarizing neuromuscular blocker). The emergency medication drawer was observed unsecured after the cart was used for a rapid response.

An interview was conducted on February 29, 2024, at 3:15 p.m., with the DUA. The DUA stated the medications should have been secured, brought back to the nurse's station, and not left unattended in the hallway. The DUA stated the used medications should have been placed in a bag and placed in the locked refrigerator for the pharmacy to collect. The DUA further stated the nurse should have secured the emergency medication drawer of the crash cart with orange locks, however, the nurse did not do it.

An interview was conducted on February 29, 2024, at 3:29 p.m., with the Rapid Response Nurse (RRN). The RRN stated the medications taken out should have been secured in a bag and place in the unit refrigerator. The emergency medication drawer of the crash cart should have been secured with an orange lock, and then notify the central supply to replace the cart. The RRN further stated, "I did not do this, I assumed the other nurse would secure the cart and medications."

A review of the facility's Policy and Procedure (P&P) titled, "[Name of the facility] RX 394 Crash Cart Monitoring Exchange," dated February 22, 2024, was reviewed. The P&P indicated, "...Unused/partially used medications for Rapid Sequence Intubation should be placed in the sleeve/container that it came in and placed back into the unit's locked medication refrigerator in the "Used" medication bin by a Registered Nurse from the unit where the kit was opened. The unit clinical manager is responsible to ensure all medications are returned timely and properly...Pharmacy will pick up the used medication kit when they round...In the event the crash cart is opened for any reason...A. First, re-secure the crash cart's medication section of the crash cart with an orange lock, thus notifying subsequent health-care providers, that this cart has been accessed and requires replenishment...Then notify Central Supply for a secured replacement cart."

A review of the facility's P&P titled, "[Name of facility] RX Storage and Security of Pharmaceuticals," dated March 24, 2024, indicated, "...Medications shall remain in control of a licensed health care practitioner (HCP) at all times; unless otherwise stored in a secured medication room, cabinet, nursing cart, ADC, locked kit, or a similar secure location..."

3. A tour of the Post Anesthesia Care Unit (PACU) was conducted on March 4, 2024, at 10:45 am, with the Post Anesthesia Care Unit Manager (PACUM). During the tour, two bottles of anesthesia medications: Forane (a general anesthetic) 100 ml (milliliters- unit of measurement) and Sevoflurane (a volatile anesthetic that provides hypnosis, amnesia, analgesia, akinesia, and autonomic blockade during surgical and procedural interventions) 250 ml's, were found in an unlocked anesthesia cart in operating room A.

A concurrent interview was conducted with the PACUM on March 4, 2024, at 10:45 a.m. The PACUM stated the medications should not be left in the cart unsecured. The PACUM further stated there is a dedicated room in the pre-op area for anesthesia supplies including medications.

An interview was conducted on March 4, 2024, at 11:25 a.m. with the Anesthesia Tech (AT). The AT stated he oversees the anesthesia carts and the two anesthesia medications found in the bottom drawer of the anesthesia cart should not be there and should be locked.

A review of the facility's P&P titled, "[Name of the facility] RX Storage and Security of Pharmaceuticals," dated March 24, 2024, indicated, "...Medications shall remain in control of a licensed health care practitioner (HCP) at all times; unless otherwise stored in a secured medication room, cabinet, nursing cart, ADC, locked kit, or a similar secure location..."

Based on observation, interview, and record review the hospital failed to ensure that all available supplies and equipment are ready for use when:

1. Door handle of heated food cabinet in Kitchen A was loose;

2. Hinge for Refrigerator #2 in Kitchen A was broken;

3. Dishwasher in Kitchen A was not meeting appropriate temperature of 180 F;

4. Patient blanket warmer in the Emergency Department (ED), door was not closing properly;

5. Expired vacutainers and venous blood tubes were found in a supply cabinet on Unit B;

6. Patient blanket warmer in the Post Anesthesia Care Unit (PACU) was broken; and

7. Expired supplies were found in a Malignant Hyperthermia (MH) cart in the Operating Room (O.R.).

These failures had the potential to delay patient care and services or cause patient harm.

Findings:

1. A tour of Kitchen A was conducted on February 29, 2024, at 9:50 a.m., with the Dietary Supervisor (DS). During the tour the door handle for the heated food cabinet was observed to be loose, making it difficult to open the cabinet. The DS stated he submitted a work order for it to be repaired, but it has not been done yet.

There was no documented evidence a work order was submitted for this equipment.

A review of the FDA (Food and Drug Administration) Federal Food Code 2022, 4-501.11 titled, "Good Repair and Proper Adjustment", indicated, "...Proper maintenance of equipment to manufacturer's specification helps ensure that it will continue to operate as designed...Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk..."

2. A tour of Kitchen A was conducted on February 29, 2024, at 9:50 a.m., with the Dietary Supervisor (DS). During the tour the door hinge of refrigerator #2 was observed to be broken. The DS stated the hinge was broken and he will submit a work order to repair it.

A review of the facility's policy and procedure (P&P) titled, "Policy #G005: Safety and Equipment Maintenance" dated January 2023, was conducted. It indicated, "...Proper maintenance of the physical plan and all equipment in the Department is the responsibility of the Director in cooperation with the Maintenance Department..."

A review of the FDA (Food and Drug Administration) Federal Food Code 2022, 4-501.11 titled, "Good Repair and Proper Adjustment", indicated, "Proper maintenance of equipment to manufacturer's specification helps ensure that it will continue to operate as designed...Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk..."

3. During a tour of Kitchen A, on February 29, 2024, at 10:09 a.m., the DS performed a wash cycle on the dishwasher. The DS used a thermometer to test the hot water sanitation temperature. The thermometer result indicated the temperature was 174F (degrees Fahrenheit). The DS ran another wash cycle and used a red testing strip attached to a colored container. The test strip indicated the hot sanitation temperature of 180F was not achieved, similarly the thermometer indicated a temperature of 169F. The DS stated that the dishwasher did not reach the required hot sanitation temperature.

A review of the facility document titled, "Test Strip Log", dated February 2024, was conducted with the DS. The log indicated, the dishwasher temperature did not meet the required temperature for February 2024 except on February 8, 19 and 20, 2024.

A review of the Food Code of 2022, indicated, "...4-5 Maintenance and Operation 4-501 Equipment...4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures...in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90C (194F) ... For all other machines, 82C (180F) ..."

A review of the FDA (Food and Drug Administration) Federal Food Code 2022, 4-501.11 titled, "Good Repair and Proper Adjustment", indicated, "...Proper maintenance of equipment to manufacturer's specification helps ensure that it will continue to operate as designed...Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk..."

4. A tour of the Emergency Department (ED) was conducted on February 29, 2024, at 1:44 p.m., with the Emergency Department Director (EDD). The blanket warmer door was observed to not close appropriately. The EDD stated it was broken and he will request a repair work order.

A review of the facility's document titled, "[Name of Facility] Corrective Maintenance/ Repairs Work Order", dated March 1, 2024, was conducted. The work order indicated, "WO History...WO#287519...Problem: ED...by Trauma Room...Blanket warmer door hinge gets stuck causing door to stay slightly open, needs new door handle too...date 11/2/2023 [November 2, 2023]...Action...Called vendor for parts & [and] part number, vendor told me the blanket warmer is obsolete..."

There was no documented evidence that a follow up for this work order occurred since November 2, 2023, or a manufacturer instruction for use manual was available for review.

5. A tour of Unit B was conducted on February 29, 2024, at 2:24 p.m., with the Director of Unit B (DUB). In a supply cabinet there were 37 expired green tube vacutainers (venous blood tubes) with an expiration date of September 30, 2023. The DUB verified the vacutainers were expired and stated, "This should have been found in the Leader EOC [Environmental of Care] weekly rounding. There is a check list for checking for expired care supplies and discarding are included." The DUB further stated the expectation would be for the Night Clinical Manager (NCM) to carefully check the supplies and discard any expired patient care supplies.

A review of the facility's document titled, "The Leader EOC [Environment of Care] Rounds" dated February 18, 2024, through February 25, 2024, was conducted. It indicated, "...Expired patient care supplies discarded, Unit B...100% compliance..."

A review of the facility's P&P titled, "Procurement and Supply Chain Management ," dated June 21, 2023, was conducted. It indicated, " ...All supply items are to be stored so as to ensure that the oldest items are used first...2. All supply items should be reviewed weekly and upon issuance in respect to expiration dates.3. All expired items will be immediately removed from the storage location and placed in a holding area until proper disposition can be made..."

6. A tour of the Post Anesthesia Care Unit (PACU) was conducted on March 4, 2024, at 9:31 a.m., with the Post Anesthesia Care Unit Manager (PACUM). The patient's blanket warmer cabinet was observed to have silk tape attached to the side and holding a white hard plastic band attached to the blanket warmer door. The PACUM stated the "contraption" was used to hold the door because it does not close correctly. The PACUM stated that, currently this blanket warmer is not being used because it is broken as, it is not heating the blankets, and he had requested the blanket warmer be fixed eight months ago, however it is still broken.

A review of the facility's document titled, "Warmers Upper & Lower Temperature Record Log", for the PACU, was conducted. It indicated the blanket warmer was "broken" on the following dates:

a. July 20, 21, 22, 27 and 28, 2023;

b. August 21 and 25, 2023; and

c. January 2, 2023

A review of the facility's document titled, "[Name of Facility] Corrective Maintenance/ Repairs Work Order", dated March 4, 2024, was conducted. It indicated the last work order completed was July 7, 2023, and no documented evidence that a work order for the blanket warmer was submitted after that date.

An interview was conducted on March 6, 2024, at 1:30 p.m., with the PACUM. The PACUM stated he is unable to find the Manufacturer Instruction for Use (MIFU) for the blanket warmer as it is old. He further stated that he is not sure if the temperature indicated in the logs are still accurate or outdated.

7. A tour of the Operating Room (OR) was conducted on March 4, 2024, at 10:15 a.m., with the Operating Room Charge Nurse (ORCN). During the tour the following expired supplies in the Malignant Hyperthermia (MH) cart were found:

a. One Anesthesia Breathing Circuit - Expired April 27, 2022;

b. One Anesthesia Breathing Circuit - Expired November 20, 2022;

c. Four 20G [gauge] X 1" [one inch] Hypothermic Needle - Expired March 12, 2023;

d. Three [Brand] dressing - Expired October 31, 2023;

e. Two 22G X 1" Intravenous [IV] Catheter - Expired June 1, 2023;

f. One 24G X ¾" IV Catheter - Expired May 1, 2023;

g. One 18G X 1 ¼ "IV Catheter - Expired March 1, 2023;

h. One 18G X 1 ¼ "IV Catheter - Expired January 1, 2023;

i. One Non-Conductive Connecting Tubing- 10" length, 3/16" Diameter, Tubing with two Female Connector - Expired February 1, 2024;

j. One [Brand] 14 F [French] Intermittent Catheter - Expired January 31, 2024;

Two [Brand] 16 F Intermittent Catheter - Expired April 30, 2023;

l. One [ Brand] 24 F Intermittent Catheter Expired June 30, 2023;

m. Three 18G" Spinal Needle - Expired September 30, 2021;

n. Four 3ml [milliliters] Blood Sample Syringe - Expired October 2, 2022;

o. Two Gravity Infusion set -Expired May 5, 2023; and

p. One Gravity Infusion set -Expired March 20, 2023.

A concurrent interview with the ORCN was conducted on March 4, 2024, at 10:15 AM. The ORCN stated the nurses are responsible for the integrity of the lock but do not stock or check for supply expirations.

An interview was conducted on March 4, 2024, at 10:18 a.m., with the Pharmacy Technician (PT). The PT stated, the Pharmacy is only in charge of the medications in the MH cart, not the supplies.

An interview was conducted on March 4, 2024, at 10:25 a.m., with the Material Management Director (MMD). The MMD stated they provide supplies for the OR's but do not supply or oversee the MH cart.

A review of the facility's policy and procedure (P&P) titled, "Malignant Hyperthermia (MH)," dated October 4, 2020, was conducted. It indicated, "...Pharmacy will restock the Malignant Hyperthermia kit and Crash Cart supplies..."

Based on observation, interview and record review, the facility failed to ensure the facility's infection control program was maintained and methods to prevent the transmission of infections were implemented, and failed to ensure a clean and sanitary environment when:

a. Regular trash was found in biohazard bins and sharp containers in multiple patient care areas.

b. Corrugated boxes were found stored in a cabinet in the recovery area Unit E.

c. The ultrasound probe was not appropriately stored after performing a high - level disinfection.

d. Patients were not provided a Chlorhexidine Gluconate bath (CHG, bathing product that kills germs and reduces the spread of infection in hospitals), in accordance with the facility's policy and procedure (P&P), for seven of 32 sampled patients (Patient 2, 14, 17, 20, 22, 24, and 31).

This failure had the potential to result in the transmission and spreads of pathogens (bacteria, virus, or other microorganisms) which could cause disease/s to the patients receiving care in this facility. (Refer to A - 0749) ; and

e. Professional standards for food service safety were not followed in Kitchen A.

f. Food and personal items were found in the nurse's station in Unit G.

g. Food service safety were not followed in the nutrition areas in Units C and D.

h. Patient rooms in Unit C (rooms #1 and 2) and D (rooms #3, #4 and#5) had grime and accumulated debris on the floors and dirt on the base boards.

These failures had the potential to expose immunocompromised patients to foodborne illnesses (illness caused by ingestion of contaminated food or beverages) due to cross contamination (the transfer of harmful substances or disease- causing microorganisms to food), creating harborage conditions attracting pests, transmit and spread pathogens (bacteria, virus, or microorganism) which could cause disease. (Refer to A - 0750)

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care, in compliance with the Condition of Participation for Infection Prevention/Control/Abx Stewardship Program.

Based on observation, interview and record review, the facility failed to ensure the facility's infection control program was maintained and methods to prevent the transmission of infections were implemented within the facility when:

1. Regular trash was found in biohazard bins and sharp containers in multiple patient care areas.

2. Corrugated boxes were found stored in a cabinet in the recovery area Unit E.

3. The ultrasound probe was not appropriately stored after performing a high - level disinfection.

4. Patients were not provided a Chlorhexidine Gluconate bath (CHG, bathing product that kills germs and reduces the spread of infection in hospitals), in accordance with the facility's policy and procedure (P&P), for seven of 32 sampled patients (Patient 2, 14, 17, 20, 22, 24, and 31).

This failure had the potential to result in the transmission and spread of pathogens (bacteria, virus, or other microorganisms) which could cause disease/s to the patients receiving care in the facility.

Findings:

1. A tour of the Emergency Department (ED) was conducted on February 29, 2024, at 1:50 p.m., with the Emergency Department Director (EDD). Regular tape and gloves were observed inside the sharps container. The EDD stated, "It should not be there." The EDD further stated there are no regular trash bins in the ED.

During a concurrent observation and interview on March 1, 2024, at 9:15 a.m., with the Public Safety Officer (PSO), in Unit C, room 1, the sharps container and biohazard bin contained gloves, used gauze, and silver dressing package. The PSO stated the items found in the sharps container and biohazard bin should not be there.

During a concurrent observation and interview on March 1, 2024, at 9:35 a.m., with the PSO, in Unit D, room 1, the biohazard bin contained gloves and paper packaging. The PSO stated the items found in the sharps container should not be there.

During a concurrent observation and interview on March 1, 2024, at 9:37 a.m., with the PSO, in Unit D, room 2, the biohazard bin was observed to contain gloves and an irrigation syringe. The PSO stated the items found in the sharp container should not be there.

During a concurrent observation and interview on March 1, 2024, at 9:46 a.m., with the PSO, in Unit D, room 3, the biohazard bin contained unsoiled gloves, IV tubing, syringe cover, and a paper cup. The PSO stated the items found should not be there.

During an observation on March 1, 2024, at 1:32 p.m., in Unit H room 1, unsoiled gloves, and tape was observed inside the sharp container.

During an observation on March 1, 2024, at 1:50 p.m., in Unit I room 1, unsoiled gloves, were in the biohazard bin.

During an observation on March 1, 2024, at 2:05 p.m., in Unit I room 2, unsoiled gloves, were in the biohazard bin.

During an observation on March 1, 2024, at 2:11 p.m., in Unit J room 1, unsoiled gloves were observed inside the sharp container.

During an observation on March 1, 2024, at 2:13 p.m., in Unit J room 2, unsoiled gloves, and paper medicine cups were observed in the biohazard bin.

During an observation on March 1, 2024, at 2:25 p.m., in Unit K room 1, unsoiled gloves, paper, and tissue were observed in the biohazard bin.

During an observation on March 1, 2024, at 3:02 p.m., in Unit L room 1, unsoiled gloves and tissue were observed in the biohazard bin.

During an observation on March 1, 2024, at 3:05 p.m., in Unit L nurse's station, unsoiled gloves and tissue were observed in the biohazard bin.

During an observation on March 1, 2024, at 3:10 p.m., in Unit M room 1, unsoiled gloves, paper, needle covers, including an unused nasogastric (NG) tubing were observed in the biohazard bin.

An interview was conducted on March 1, 2024, at 11:00 a.m., with the Chief Administration Officer (CAO). The CAO stated trash should be in the trash bin and items soaked heavily with bodily fluids should be in the biohazard bin.

During a concurrent observation and interview on March 4, 2024, at 9:32 a.m., with RN 7, in Unit N, gloves, a styrofoam tray and plates, paper, and plastic spoons were observed in the biohazard bin. RN 7 stated the items should not be in the biohazard bin but in regular trash.

During a review of the facility's P & P titled, "Hazardous Waste management Plan", dated December 21, 2023, indicated, "...Type of Waste Generated...Regular Nonregulated waste is nonhazardous that is disposed of through traditional trash cans with clear bags...this includes food, cups styrofoam, disposable personal protective equipment (PPE) such as...gloves...Medical waste is categorized either BIOHAZARDOUS, (including sharps)...Biohazardous waste consists of the flowing waste that is red bagged or in red tubs/bins or sharp containers...Red Bag waste: includes anything contaminated with blood or other potentially infectious materials (OPIM) such as: Suction canister liners, blood collection devices, dressings with blood, blood tubing's with visible blood or OPIM, PPE soiled in blood...Sharps Waste: includes syringes(with or without needles), needles, broken glass...staples, scissors, lancets..."

2. A tour of Unit E was conducted on March 5, 2024, at 3:30 p.m., with the Patient Risk Officer (PSO), Unit E Manager (UEM), and Unit E Director (UED).

During a concurrent observation and interview on March 5, 2024, at 3:46 p.m., corrugated boxes in the supply cabinet located across the recovery bays were observed. The UED stated the boxes are stored as found after being delivered by materials management.

An interview was conducted on March 5, 2024, at 4:00 p.m., with the Accreditation and Regulatory Manager (ARM). The ARM stated, the facility does not have a policy regarding corrugated boxes.

A review of ANSI/AAMI ST79, dated 2017 (American National Standards/Association for the Advancement of Medical Instrument, standards development organizations) Comprehensive Guide to Steam Sterilization and Sterility Assurance in Healthcare Facilities, indicated, "...3.3.6.5...web-edged (corrugated) boxes can collect dust, debris, and insects during shipment and can carry contaminants into the area."

3. A tour of Unit F was conducted on March 5, 2024, at 10: 39 a.m., with the Patient Risk Officer (PSO) and the Unit F Manager (UFM).

During an observation on March 5, 2024, at 10:40 a.m., in Unit F, a [Brand Name] probe was stored without a cover in an open cylindrical container mounted on the wall.

An interview was conducted on March 5, 2024, at 10:45 a.m., with the Ultrasound Manager (USM). The USM stated the probe is stored uncovered in the cylindrical container after the high-level disinfection was performed.

During a concurrent interview and record review, was conducted on March 7, 2024, at 8:35 a.m., with the UFM, USM, and the Radiology Director (RD). The [Brand Name] User Manual, undated was reviewed. The [Brand Name] User Manual indicated, "The [Brand Name] is designed to provide high level disinfection (HLD) of validated ultrasound probes...Removing the probe...After completion of a successful HLD cycle...do not compromise the probe's high level disinfected surface...The probe is now ready for use or storage in a [Brand Name] Clean Ultrasound Probe Cover." The USM and RD stated they do not use the cover as stated in the user manual.

During a review of the facility's policy and procedure (P&P) titled, "[Facility Name] 360 High Level Disinfection", dated December 21, 2023, indicated, "...Definition: High-Level Disinfection (HLD): High-Level Disinfection is the complete elimination of all microorganisms in or on an instrument, except for small number of bacterial spores... Procedure...The HLD process follows manufacturers and regulatory standards and recommendation for use."

4. The following records were reviewed with the Accreditation Regulatory Manager (ARM) on March 6, 2024, at 9:30 a.m.

a. Patient 2's face sheet and History and Physical (H&P), indicated Patient 2 was admitted to the facility on February 8, 2024 for a pelvic fracture and is currently inpatient. There was no documented evidence Patient 2 was allergic to Chlorhexidine Gluconate (CHG, bathing product that kills germs and reduces the spread of infection in hospitals).

A review of Patient 2's Activity of daily living (ADL) flow sheet, dated February 28, 2024, to March 6, 2024, indicated no documented evidence that Patient 2 was provided a CHG bath on March 3, 2024.

b. Patient 14's face sheet and H&P indicated Patient 14 was admitted to the facility on February 28, 2024, currently inpatient, and was admitted for right knee infection. There was no documented evidence Patient 14 was allergic to CHG.

A review of Patient 14's ADL flow sheet, dated February 28, 2024, to March 6, 2024, indicated no documented evidence Patient 14 was provided a CHG bath on February 29, 2024.

c. Patient 17's face sheet and H&P indicated Patient 17 was admitted to the facility on February 10, 2024, currently inpatient, and was admitted for a left femur fracture. There was no documented evidence Patient 17 was allergic to CHG.

A review of Patient 17's ADL flow sheet, dated February 11, 2024, to March 6, 2024, indicated no documented evidence Patient 17 was provided a CHG bath on February 23, 2024, February 25, 2024, and February 29, 2024.

d. Patient 20's face sheet and H&P indicated Patient 20 was admitted to the facility on February 25, 2024, for shortness of breath for four days however, patient expired on February 29, 2024. There was no documented evidence Patient 20 was allergic to CHG.

A review of Patient 20's ADL flow sheet, dated February 26, 2024, to February 29, 2024, indicated no documented evidence Patient 20 was provided a CHG bath on February 25, 2024, and February 28, 2024.

e. Patient 22's face sheet and H&P indicates Patient 22 was admitted to the facility on March 4, 2024, currently inpatient, and was admitted for elective surgery right ovary removal. There was no documented evidence Patient 22 was allergic to CHG.

A review of Patient 22's ADL flow sheet, dated March 4, 2024, and March 5, 2024, indicated no documented evidence Patient 22 was provided a CHG bath.

f. Patient 24's face sheet and H&P indicates Patient 24 was admitted to the facility on February 19, 2024, currently inpatient, was admitted for a subarachnoid hemorrhage (bleeding between the brain and tissue). There was no documented evidence Patient 24 was allergic to CHG.

A review of Patient 24's ADL flow sheet, dated February 20, 2024, to March 6, 2024, indicated no documented evidence Patient 24 was provided a CHG bath on February 20, 2024, February 21, 2024, February 25, 2024, February 26, 2024, and February 27, 2024.

g. Patient 31's face sheet and H&P indicates Patient 31 was admitted to the facility on February 26, 2024, currently inpatient, was admitted due to multiple falls at home. There was no documented evidence Patient 31 was allergic to CHG.

A review of Patient 31's ADL flow sheet, dated February 27, 2024, to March 6, 2024, indicated no documented evidence Patient 31 was provided a CHG bath on March 3, 2024, and March 4, 2024.

During an interview with the ARM on March 6, 2024, at 1:30 p.m., the ARM stated there was no documentation that CHG baths were provided to Patients 2, 14, 17, 20, 22, 24, and 31 on the dates mentioned above. The ARM further stated the facility's policy was not implemented.

A review of the facility's policy and procedure (P&P) titled, "DES IP 914 Patient Daily Bathing with 4% Chlorhexidine Gluconate Solution", dated September 10, 2021, indicated, "...This policy applies to all inpatient areas of [Name of facility], excluding the Neonatal Intensive Care (NICU)...All patients are bathed daily with 4% CHG solution..."

Based on observations, interviews, and record reviews, the facility failed to ensure a clean and sanitary environment when:

1. Professional standards for food service safety were not followed in Kitchen A.

2. Food and personal items were found in the nurse's station in Unit G.

3. Food service safety were not followed in the nutrition areas in Units C and D.

4. Patient rooms in Unit C (rooms #1 and #2) and D (rooms #3, #4 and #5) had grime and accumulated debris on the floors and dirt on the base boards.

These failures had the potential to expose immunocompromised patients to foodborne illnesses (illness caused by ingestion of contaminated food or beverages) due to cross contamination (the transfer of harmful substances or disease- causing microorganisms to food), creating harborage conditions attracting pests, transmit and spread pathogens (bacteria, virus, or microorganism) which could cause disease.

Findings:

1. A tour of Kitchen A was conducted on February 29, 2024, at 9:29 a.m., with the Dietary Supervisor (DS).

During a concurrent observation and interview on February 29, 2024, at 9:29 a.m., with the DS, in Kitchen A, Refrigerator # 1, containing prepared food, had dried food residue on the bottom compartment, and dust particles in between the grooves of the refrigerator door seal. The DS stated the expectation is for this equipment to be cleaned every day after meal preparation.

During a concurrent observation and interview on February 29, 2024, at 9:39 a.m., with the DS, in Kitchen A, there were food crumbs, black grime build-up and trash observed under the sink. The DS stated this area is cleaned daily and should include the area under the sink.

During a concurrent observation and interview on February 29, 2024, at 9:50 a.m., with the DS, in Kitchen A, a male staff was observed not wearing a beard cover. The DS stated the expectation is a beard cover should be worn while in the kitchen.

During a concurrent observation and interview on February 29, 2024, at 9:53 a.m., with the DS, in Kitchen A, the inside of the [Brand Name] heated food cabinet, were food crumbs on the side walls, and dust on the bottom compartment with food crumbs, grime build up, and dust at the back and side of the cabinet. The DS stated the area should be cleaned thoroughly daily.

During a concurrent observation and interview on February 29, 2024, at 9:57 a.m., with the DS, in Kitchen A, the floor under the Refrigerator # 5, was observed to have grime build up, food crumbs, dust, and dirt. The DS stated this area should be included in the daily cleaning.

During a concurrent observation and interview on February 29, 2024, at 9:59 a.m., with the DS, in Kitchen A, the bottom corners of Refrigerator # 2, located behind the food preparation table had dirt and grime buildup. The DS stated this area should be cleaned thoroughly daily.

During a concurrent observation and interview on February 29, 2024, at 10:00 a.m., with the DS, in Kitchen A, under the metal supply shelf small dead bugs and dust was observed. The DS stated it needs to be cleaned.

During a concurrent observation and interview on February 29, 2024, at 10:01 a.m., with the DS, in Kitchen A, the floor drain by the supply shelf was observed to have a hole approximately three inches by three inches, where pests can enter. The DS stated the hole needs to be repaired.

During a concurrent observation and interview on February 29, 2024, at 10:02 a.m., with the DS, in Kitchen A, Refrigerator #3 was observed to have food debris and grime build up on the left side of the refrigerator. The DS stated it needs to be cleaned.

During a concurrent observation and interview on February 29, 2024, at 10:04 a.m., with the DS, in Kitchen A, the top of the dishwasher had thick dust and grime build up, which has the potential to contaminate sanitized utensils. The DS stated dusting and wiping the equipment should be done daily.

During a concurrent observation and interview on February 29, 2024, at 10:09 a.m., with the DS, in Kitchen A, there was a large size brown stain on the ceiling above the sink by the dishwasher. The DS stated it needs to be repaired.

During an observation on February 29, 2024, at 10:16 a.m., the metal wall covering inside the cleaning material closet was unhinged. This had the potential to harbor pests.

During an observation on February 29, 2024, at 10:17 a.m., there were dirt and trash under the vending machines, that can provide an environment for attraction of pests.

During a concurrent observation and interview on February 29, 2024, at 10:20 a.m., with the DS, in Kitchen A, there were food crumbs, black grime, and trash build-up under the stove range and deep fryer. The DS stated it needs to be cleaned.

During a review of the facility's policy and procedure (P&P) titled, "Policy#E006...Uniform Dress Code", dated January 2023, indicated, "... Procedures... Associates Working with Food...Restrain facial hair with net/restraints."

During a review of the facility's P&P titled, "Policy#F014...Area and Equipment Cleaning", dated January 2024, indicated, "Policies...Written procedures are available, detailing daily and weekly (as needed) cleaning for all areas and equipment in the department."

There was no documented evidence that daily, and weekly cleaning of all areas and equipment for Kitchen A was available for review.

A review of the FDA (Food and Drug Administration) Federal Food Code 2022, 4-601.11 titled "Equipment, Food-Contact Surfaces, Nonfood- Contact Surfaces and Utensils," indicated, "...(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris." In addition, 4-602.13, indicates "The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests."

A review of the FDA (Food and Drug Administration) Federal Food Code 2022, 4-402.12 titled, "Fixed Equipment, Elevation or Sealing," indicated, "The inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic microorganisms that are transmissible through food."

2. A tour of the Emergency Department was conducted on February 29, 2024, at 1:30 p.m., with the Patient Safety Officer (PSO), Emergency Department Director (EDD) and Charge Nurse Emergency Department (CNED).

During a concurrent observation and interview on February 29, 2024, at 1:35 p.m., with the EDD and CNED, in the ED Nurse's station, personal food items were observed on top of a computer, which consisted of water bottles, a bottled water with no cover, and a [brand name] coffee cup. There were opened and half eaten biscuits observed by the computer below a wide screen monitor, drinking canisters and a boiled egg in a small plastic storage bag by the radio room. The CNED stated personal food and beverages are not allowed in the nurse's station. The EDD stated personal food and beverages are not allowed in the nurse's station however, the items found are from the physicians.

During a review of the facility's P & P titled, "[Name of Facility] IP 126 Bloodborne Pathogen Exposure Control Plan", dated January 18, 2024, indicated, "...IV...Plan...Personal Miscellaneous...A...Eating and drinking...are not allowed in work areas where there is a reasonable likelihood of occupational hazard...B...Staff food and drink will not be kept in...countertops, workstations on wheels (WOW)..."

3. A tour of Unit C and D was conducted on March 1, 2024, at 9:08 a.m., with the Clinical Manager Intensive Care Unit (CMICU), the Accreditation Regulatory Manager (ARM), and the Director covering for ICU (DCICU).

During an observation on March 2, 2024, at 9:32 a.m., in Unit C's nutrition area, the microwave had food crumbs at the oven cavity, a clear sticky substance on the rotating glass, and a large brown dried sticky substance on the inside door. The outside surface of the microwave was dusty and had accumulated dust, debris, and rust on its base.

During an observation on March 1, 2024, at 9:35 a.m., in Unit C's nutrition area, the coffee maker's brewing heads were crusted with white, light brown, greenish residue buildup, while the surrounding area contained scattered brown to black dried liquid residue. The drip tray had dried crusted residue discoloration throughout. When the coffee maker was moved, a large brown dried sticky substance was observed.

During an observation on March 1, 2024, at 9:40 a.m., in Unit C's nutrition area, rust, debris, and dust behind the ice machine was observed. There was also white patchy discoloration found on the countertop.

During an observation on March 1, 2024, at 9:45 a.m., in Unit C's nutrition area, the drawer that holds the plastic utensils had yellow and orange discoloration and warping at the base. The succeeding drawers had debris, food crumbs, and dust inside.

During an observation on March 1, 2024, at 9:50 a.m., in Unit D's nutrition area, a large dried sticky liquid was observed under the refrigerator, behind was a large brown dried liquid stain, debris, and dust and on the wall to the left was a dried brown stain.

During an observation on March 1, 2024, at 9:53 a.m., in Unit D's nutrition area, the counter behind the microwave had debris, food crumbs, and dust.

An interview was conducted on March 1, 2024, at 9: 55 a.m., with the CMICU. The CMICU acknowledged the findings and stated, "The nurses will wipe things down daily as we come in and out of this nutrition room, but we do not wipe behind appliances." The CMICU further stated EVS (Environmental Services) oversees the terminal cleaning.

An interview was conducted on March 1, 2024, at 9:56 a.m., with the ARM. The ARM acknowledged the findings and stated, "It looks like this room needs to be cleaned".

An interview was conducted on March 1, 2024, at 9:57 a.m., with the Director of EVS (DEVS)/ Food and Nutrition Services Director (FANSD). The DEVS/ FANSD stated, "All staff who uses the nutrition rooms are responsible to ensure that the rooms remain clean, if there is an issue with debris or a large spill, they can call EVS, and we will take care of it." The DEVS/FANSD further stated under and behind the refrigerator will be cleaned monthly or as needed.

An interview was conducted on March 13, 2024, at 2:54 p.m., with the Chief Quality Officer (CQO). The CQO stated there was no prior policy for Patient Nutrition Rooms. The CQO further stated the policy was created on site on March 4, 2024.

4. A tour of Unit C was conducted on March 1, 2024, at 9:08 a.m., with the Patient Risk Officer (PSO).

During a concurrent observation and interview on March 1, 2024, at 9:08 a.m., with the PSO, in Unit C room 1, the floor had grime and accumulated dust under the wall mounted cabinet, and the floorboards had grime build up. The PSO stated the floor and floorboards are not clean.

During a concurrent observation and interview on March 1, 2024, at 9:08 a.m., with the PSO and Environmental Services Operations Manager (EVSOM) in Unit C room 2, there was black dirt buildup on the floor, floorboards, and under the mounted shelf. The EVSOM stated, Unit C and D has two dedicated EVS staff. The EVSOM stated the room is deep cleaned after a patient is discharge and as needed. Cleaning includes the floor, floorboards and under the mounted shelf. The EVSOM further stated the floor and floorboards in this room needs to be cleaned.

A tour of Unit D was conducted on March 1, 2024, at 9:33 a.m., with the Patient Risk Officer (PSO).

During a concurrent observation and interview on March 1, 2024, at 9:35 a.m., with the PSO, in Unit D room 3, the floor had black, sticky grime on the floor and dust build up under the wall mounted shelf. The PSO stated the floors needed to be cleaned.

During a concurrent observation and interview on March 1, 2024, at 9:36 a.m., with the PSO and EVSOM, in Unit D room 4, the floor had dust and black dirt build up, dust under the wall mounted shelf, and the floorboards had dust and white residue. The EVSOM stated the floor including under the mounted shelf needs to be cleaned.

During a concurrent observation and interview on March 1, 2024, at 9:46 a.m., with the PSO in Unit D room 5, the floor had trash, black stain, and dirt build up including under the mounted shelf, and the floorboards had dust and dirt build up. The PSO stated the floors needed to be cleaned.

An interview was conducted on March 1, 2024, at 10:59 a.m., with the DEVS/ FANSD. The DEVS/ FANSD stated, the rooms in Unit C and D should be terminally cleaned daily, including the floor and the floorboards. The DEVS/FANSD stated nursing should contact EVS when rooms need to be cleaned.

There was no documented evidence a terminal clean had been conducted on rooms 1, 2, 3, 4 and 5.

A review of the facility's policy and procedure titled, "High Profile Room Cleaning" dated October 1, 2023, was conducted. It indicated, "Purpose: to ensure the complete and systematic daily cleaning and disinfection of each patient/resident room...Procedure...High dust horizontal surfaces...Disinfect vertical surfaces including stains and spots from walls, light switches, door knob and other vertical surfaces...Dust mop the room beginning with corners and edges, moving from side of the room towards door...Dust under the bed furniture and behind the door...Damp mop hard surface floors beginning with corners and edges moving from the far side of the room towards the door..."