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Based on observation tour, facility policy and interview with staff (EMP), it was determined that the facility failed to ensure accountability of staff designated to perform the "7 Step Cleaning Process" was sustained and maintained according to facility policy in patient rooms designated as "ready for patient use" (admission of a new patient ).

Findings include:

Review of facility policy" Patient Rights and Responsiblities" last reviewed February 20, 2023, revealed " Care Delivery-The right to-...2. Receive care in a safe setting free...8. Receive efficient and quality care with high professional standards that are continually maintained and reviewed."

Findings include:

Review of facility policy "Shine-7 Step Cleaning Process" revealed "...This is the standard method for cleaning all areas, unless otherwise specified. The 7 Step Cleaning Process is designed to maintain the highest standards of Shine cleanliness. Summary of the 7 Step Cleaning Process: Step 1-Pull trash and linen. Step 2-Complete the High Dust process. Step 3-Damp wipe all contact surfaces. Step 4-Thoroughly clean the restroom. Step 5-Dust mop properly. Step 6-Damp mop all appropriate areas. Step 7-Inspect the work according to the Shine Standards."

An observation tour conducted on April 28, 2023, at 12:45 PM with EMP1, EMP2, EMP3, and EMP4 on the Medical Surgical Patient Care Unit-3rd floor revealed:

Observation tour conducted in Room 3314 designated as "ready for patient use" for newly admitted patients revealed:
1. Accumulated dirt in four corners of the medical surgical patient room.
2. Patient room door panels layered with dirt, grime and a reddish brown corrosive substance resembling rust.
3. Patient Room Sink with a thick dried brownish residue covering areas of the sink.
4. Light panel over the patient room sink with layered thick dust covering the light panel.
5. Bathroom towel dispenser with a brown residue covering the surface area of the towel dispenser.

Observation tour conducted in Room 3324 designated as "ready for patient use" for newly admitted patients revealed:
1. Accumulated dirt in four corners of the medical surgical patient room.
2. Patient room door panels layered with dirt, grime and a reddish brown corrosive substance resembling rust.
4. Patient Room Sink with a thick dried brownish residue covering areas of the sink.
5. Light panel over the patient room sink with layered thick dust covering the light panel.
6. Bathroom towel dispenser with a brown residue covering the surface area of the towel dispenser.

An interview conducted on April 28, 2023, at 1:00 EMP1, EMP2, EMP3, and EMP4 confirmed the findings in rooms 3314 and 3324. EMP4 stated " I completed a quality inspection earlier this morning of these rooms and I knew these issues existed in these rooms."

Based on observation, facility policy and interview with staff (EMP), it was determined that the facility failed to ensure a safe environment was provided for the delivery of patient care services by failing to ensure that standards for the "7 Step Cleaning Process" was maintained in rooms designated as "ready for patient use" for newly admitted patients.

Findings include:

Review of facility policy "Shine-7 Step Cleaning Process" revealed "...This is the standard method for cleaning all areas, unless otherwise specified. The 7 Step Cleaning Process is designed to maintain the highest standards of Shine cleanliness. Summary of the 7 Step Cleaning Process: Step 1-Pull trash and linen. Step 2-Complete the High Dust process. Step 3-Damp wipe all contact surfaces. Step 4-Thoroughly clean the restroom. Step 5-Dust mop properly. Step 6-Damp mop all appropriate areas. Step 7-Inspect the work according to the Shine Standards."

An observation tour conducted on April 28, 2023, at 12:45 PM with EMP1, EMP2, EMP3, and EMP4 on the Medical Surgical Patient Care Unit 3rd floor revealed:

Observation tour conducted in Room 3314 designated as patient room "ready for use" for newly admitted patient revealed:
1. Accumulated dirt in four corners of the patient room.
2. Patient room door panels layered with dirt, grime and a reddish brown corrosive substance resembling rust.
3. Patient Room Sink with a thick dried brownish residue covering areas of the sink.
4. Light panel over the patient room sink with layered thick dust covering the light panel.
5. Bathroom towel dispenser with a brown residue covering the surface area of the towel dispenser.

Observation tour conducted in Room 3324 designated as a room "ready for patient use" for a newly admitted patient revealed:
1. Accumulated dirt in four corners of the patient room.
2. Patient room door panels layered with dirt, grime and a reddish brown corrosive substance resembling rust.
4. Patient Room Sink with a thick dried brownish residue covering areas of the sink.
5. Light panel over the patient room sink with layered thick dust covering the light panel.
6. Bathroom towel dispenser with a brown residue covering the surface area of the towel dispenser.

An interview conducted on April 28, 2023, at 1:00 EMP1, EMP2, EMP3, and EMP4 confirmed the findings in rooms 3314 and 3324. EMP4 stated " I completed a quality inspection earlier this morning of these rooms and I knew these issues existed in these rooms."
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Based on observation, review of facility policy, documents and interview with staff (EMP), it was determined the facility failed to ensure the hospital's Dietary Department was maintained in an orderly manner to sustain safe and sanitary characteristics to minimize health hazards for the protection of both patients and employees.

Findings include:

An observation tour conducted on April 28, 2023, at approximately 1:40 PM to 2:00 PM with EMP1, EMP10 and EMP11 of the Dietary Department (Kitchen) revealed the following:

1. Observation of Refrigerator #12 located in the area of the Late Completed Trays and the Prep Sandwich Table revealed an electrical box covered with a dark gray thick substance resembling dirt, dust and grime covered on on all four sides and the front of the electrical box.

2. Observation of a large Storage Cabinet containing dietary supplies revealed thick layered substance resembling dust, dirt and grime on the top and sides of the storage cabinet.

3. Observation of the staff handwashing sink revealed a thick layered greenish substance covering the faucet and the base of the handwashing sink.

4. Observation of the exhaust fans (in operation during the observational tour) revealed the blades covered with a dark grayish caked substance resembling dirt and grime.

5. Observation of various food preparation areas and food packaging areas within the Dietary Department (Kitchen) revealed exposed pipes with a layered brown corrosive substance resembling rust.

An interview conducted on April 28, 2023, at 2:05 PM with EMP1, EMP10, and EMP11 confirmed the above findings in the Dietary Department (Kitchen). A request was made by the surveyor to the facility for the cleaning records for the Dietary Department (Kitchen), none was provided at the time of survey.
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Based on observation and interview with staff (EMP), it was determined the facility failed to ensure the hospital's Operating Rooms were maintained and sustained in a safe and sanitary manner for the delivery of surgical services.

Findings include:

Observation tour conducted on May 10, 2023, at 3:38 PM through 4:40 PM with EMP1, EMP7 and EMP8 of Operating Room Six and Operating Room Four:

An observation tour of OR6 revealed:
1. OR6: various sizes of floor penetrations consisting of gouges and deep crevices of various sizes.
2. Bowie Cart (Electrical Cautery Unit) positioned on a shelving unit with various areas of a brown substance on the shelves resembling rust.
3. OR6 with accumulated dirt in the corners of the floor.
4. Hamper in OR6 with a reddish brown substance resembling rust covering the lower frame area of the hamper.

An observation tour of OR4 revealed:
1. OR4: various sizes of floor penetrations consisting of gouges and deep crevices of various sizes.
2. Hamper in OR4 with a reddish brown substance resembling rust covering the lower frame area of the hamper.
3. Two Shelf Back Surgical Supply Table with a brown-reddish substance covering the four wheels and four wheel covers.

An interview conducted on May 10, 2023, at 4:00 PM with EMP1, EMP7, EMP8 and EMP9 confirmed the above findings in OR6 and OR4. EMP9 also confirmed that OR6 was listed as "ready for patient use" for a surgical procedure.

Based on review of facility policy, observation of patient care areas, and interview with staff (EMP), it was determined that the facility failed to ensure disposable syringes and needles were maintained in secured areas with access available only to authorized personnel.

Findings include:

Review of facility policy "Medications, Administration of (925-1068)" revealed "Equipment Safety... . 4. Sharps should be kept in secure, locked areas or locked drawers when not in use by authorized individuals to protect from tampering or theft."

Observation on April 28, 2023, with EMP1, EMP2, EMP3 and EMP4 at 2:05 PM of Medical Surgical Patient Care Unit-3rd floor, patient care room 3324 revealed unlocked patient care supply drawers containing various sizes of disposable syringes and needles.

An interview conducted on April 28, 2023, at 2:20 PM with EMP2 and EMP3 confirmed the unlocked drawers in patient care room 3324 contained various sizes of needles and syringes that had not been secured. EMP2 confirmed unlicensed personnel and patients had access to the unlocked drawers that contained the needles and syringes.