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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 October 23-24, 2018, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

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

Based on observation, document review, and interview, it was determined the Hospital failed to ensure the preventive maintenance policy for patient care equipment was followed. This has the potential to affect all patients serviced by the Hospital with an average census of 80.

Findings include:

1. An observational tour of the Emergency Department was conducted on 10/23/18 at approximately 10:00 AM, with the Director of the Emergency Department/Medical Imaging (E #9). The department contained an electronic stand-on scale with the last documented preventative maintenance on 7/27/15 and an electronic infant scale with a last documented preventative maintenance on 9/27/13.

2. The Hospital policy titled "Medical Equipment Management Plan (revised 3/2018) was reviewed on 10/25/18 at approximately 10:00 AM. The policy stated "VII. ELEMENTS OF THE ENVIRONMENTAL SAFETY MANAGEMENT PROGRAM... EC.02.04.01.06 - Inspection, Testing and Maintenance Intervals - Alternative Equipment Maintenance Program... All equipment on the medical equipment inventory,... will be considered and evaluated for an Alternative Equipment Maintenance (AEM) strategy... Maintenance requirements of the equipment"

3. The Alternative Equipment Program log was reviewed on 10/25/18 at approximately 10:30 AM. The log documented an electronic infant scale that requires maintenance every 2 years and an electronic stand-on scale with a maintenance requirement of every 2 years.

4. An interview was conducted with the Supervisor of Biomedical Equipment Services (E#11) on 10/25/18 at approximately 10:30 AM. E#11 stated "the scales should have been on the Alternative Equipment Maintenance program and they were overlooked. They should have maintenance performed every 2 years and it has not been."

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 October 23-24, 2018, 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.

Based on observation, document review and interview, it was determined the Hospital failed to ensure infection control measures were followed to prevent the potential of cross contamination. This has the potential to affect all staff, visitors, and inpatients serviced by the Hospital with an average census of 80.

Findings include:

1. An observational tour of the Comprehensive Care Unit was conducted on 10/24/18 at approximately 10:45 AM with the Nursing Operations Manager (E #10). A staff member walked down the hallway carrying a stack of linens against the staff member's body. The staff member then entered room 1024 without performing hand hygiene. The staff member then walked out of room 1024 with gloves, removed the gloves, and did not perform hand hygiene.

2. During the tour E #10 confirmed the observation and stated that the staff member should not have carried the linen against the body and did not perform hand hygiene and should have.

3. During an observation of a lumbar puncture on Pt #27 on 10/24/18 at approximately 2:00 PM with the Manager of Medical Imaging (E #12), the Radiologist (E#8) put on a pair of gloves, took the gloves off, and then put on another pair of gloves without the benefit of performing hand hygiene between changing gloves.

4. An interview was conducted with E#12 on 10/24/18 at approximately 2:30 PM. E#12 stated that E #8 should have performed hand hygiene between glove changes and did not.

5. During an observation on 10/25/18 at approximately 10:00 AM, an Emergency Room Registered Nurse (RN) performed an accucheck (blood glucose monitoring test) finger stick on a patient while wearing gloves. After the accucheck, the RN placed a piece of gauze on the patient's finger. The RN then opened a cabinet door with the contaminated gloved hand. The RN did not remove gloves and perform hand hygiene or disinfecting the cabinet door after touching the door with the contaminated glove.

6. An interview was conducted with the Director of the Emergency Department and Medical Imaging (E#9). E #9 confirmed the observation and stated "The nurse should have cleaned the door handle after touching it and did not. I will address the situation."

7. The Hospital policy titled "Hand Hygiene (revised 1/8/2018) was reviewed on 10/24/18 at approximately 10:00 AM. The policy stated "PROCESS: 1. Hand Hygiene and Use of Antiseptics a. Before and after patient contact.... f. Before and after wearing sterile or non sterile gloves."