HospitalInspections.org

Based on observation, staff interview, facility document review and encounters during the course of a complaint investigation, the facility staff failed to ensure the Quality Program was effective, hospital-wide and included monitoring of all aspects of patient safety processes. Observations made during a tour of the facility's patient care units on 8/16/21 beginning at 10:15 a.m., evidenced serious concerns related to the sanitary condition and maintenance of five (5) of ten (10) sampled ice/water dispensers used to provide ice and water for patients. The observations resulted in the finding of IMMEDIATE JEOPARDY. This demonstrated a systemic hospital wide failure of several processes to ensure the safety of patients.

On 8/16/21 during a tour of the patient care areas the surveyor visually inspected 10 ice/water dispensers and discovered that 50% of inspected ice/water units had visible slime/mold present on the outside and 20% of the units inspected included slime/mold in the dispenser part of the unit despite being cleaned on a quaterly basis.

On 8/17/21 at 10:41 a.m., the surveyor discussed with Staff Member #1, and #2, the integration of Quality in the monitoring of patient care areas. Through interviews and document reviews, it was determined the facility Quality Program did not routinely monitor any of the ice machines for cleanliness. Interviews with Infection Control staff evidenced that there was no routine or random culturing of ice machines, nor water testing done at the facility, as it was "not an standard of practice".

Further interviews and document review revealed the Quality Program sub-committee designated as "Environment of Care" (EOC) would randomly choose an area of the hospital once per month to make the rounds. The facility recently developed new "check-list" documents for the EOC staff to use and the surveyor's review found that this "Environment of Care" rounds documents did not include checking the ice/water dispensers for cleanliness anywhere. Previous "Environment of Care" rounds documents examined by the surveyor revealed that patient care areas were not being reviewed either. Areas documented as being "checked" by the EOC team were lounge areas and information technology areas. The last documented "rounds" on a patient care area was May 2021.

Please refer to 0286, 0700, 0724, 0747, and 0750 for further information.

Based on observation, staff interview, facility document review and encounters during the course of a complaint investigation, the facility Quality program failed to identify, track and monitor all areas directly affecting patients. Observations of ice/water dispensers on patient care units used to provide ice and water to patients, staff and visitors evidenced a greenish-black slimy substance in the overflow grate and black and reddish/pink substance adhering to two (2) of two ice machine dispenser nozzles. This affected 5 (five) of 10 (ten) ice/water dispensers observed. The affected ice/water dispensers observed during the tour were located in: CICU (Cardiac Intensive Care Unit - housing COVID19 positive patients), 3West- PCU, Emergency Department, 4East (Rehab), and 3East (Surgical Progressive Care).

The findings included:

On 8/16/21 at 10:15 a.m. the surveyor toured the patient care areas accompanied by Staff Member #1 (Quality), Staff Member #2 (Risk Manager), Staff Member #5 (Nurse Manager CICU), Staff Member #6 (Environmental Services and Facilities Maintenance), Staff Member #7 (Infection Control) Staff Member #9 (PCU Manager), Staff Member #10 (ED Manager), Staff Member #13 (Pulmonary and Renal Manager), and Staff Member #15 (Assistant Chief Nursing Officer).

On the CICU (Cardiac Intensive Care Unit): 8/16/21 at 10:29 a.m.,the ice/water dispenser located in the nourishment room had a black material adhering to the dispenser nozzle. The surveyor retrieved a tissue and wiped the nozzle outside and inside which demonstrated a black slick substance adhering to it. There was a greenish black slimy material in the bottom overflow grate and adhering to the bottom of the pan and drain. Staff Member #7 (Infection Prevention) stated, "We do not do environmental cultures. It is not a standard of practice. The observation of the machines are a part of the environment of care rounds, to check the cleanliness..." The surveyor asked to examine the environment of care rounding documents.

At 11:00 a.m., the surveyor observed a black slimy material in the bottom overflow grate of the ice/water dispenser on 3West. At 11:15 a.m., the surveyor observed a black-greenish slick material in the bottom grate and drain of the ice/water dispenser for the Emergency Department. At 12:17 p.m., there was observed a greenish-brown slimy substance in the bottom grate and drain of the ice/water dispenser located on 4East. At 12:21 p.m., the surveyor observed a red-pink slick substance adhered to the dispenser nozzle of the ice/water dispenser on 3East and a black slimy substance underneath the overflow grate as well as drain. All the above noted observations were witnessed and confirmed by the facility staff who accompanied the surveyor on the tour.

The surveyor requested and received the EOC (Environment of Care) rounding sheets and the Ice Machine cleaning logs on 8/16/21 at approximately 12:45 p.m. The EOC rounding sheets demonstrated "rounds" made in areas that were not patient care areas except for the MICU (Medical Intensive Care Unit) which was completed in May 2021. The rounding sheets included an area for checking the ice/water dispenser for cleanliness, with the MICU being clean at that time. The surveyor asked Staff Member #1 for EOC rounding sheets that were completed for other patient care units. Staff Member #1 stated that the EOC rounding sheets were "turned into" Quality for review and compilation of the information as well as notification of the appropriate department if there were any areas that needed attention.

On 8/16/21 at 11:30 a.m. a discussion was held with the surveyor and State Agency regarding the identified concerns of Immediate Jeopardy for Conditions of Participation of Physical Environment and Infection Control, and a request to open the Condition of Participation for Quality for investigation due to the concerns of the failure of the Quality Program to monitor all hospital areas that would affect patient care.

On 8/17/21 at 10:41 a.m., the surveyor discussed, in more detail, with Staff Member #1, and #2 the EOC (Environment of Care) Rounds and its integration into the Quality Program. Staff Member #1 stated EOC has "it's own committee" and the group consists of: Facilities Management, Contracted Vendor GE, Security Director, Emergency Management Coordinator, Information Technologies Director, Radiology Director, a Member of the Infection Prevention Team and Quality. They do the EOC rounding and document on the sheets. Infection Prevention is a member of the team. Everyone has a checklist and they "go through and check the items." The surveyor inquired as to why there were no patient care areas, other than the MICU, contained in the documents completed recently. Staff Member #1 stated, "I am not sure but they divide the areas up and go in pairs. They do one unit per month...we just redid the check off documents...they all report their findings and audits to the Quality Council..." The surveyor examined the "new" check off document for the EOC rounds and noted that it did not contain an area to check/monitor the cleanliness of the ice/water dispensers, as had been on the previous documents. This was brought to the attention of Staff #1 who stated, "That was an oversight. We need to add that..." The surveyor inquired again as to who was responsible for cleaning the dispensers between maintenance scheduled cleanings. At 11:17 a.m. Staff Member #4 (CNO) and #15 (Asst CNO) stated, "The expectation would be that the charge nurse and Nursing Leadership on the units would check the ice machines, since they are primarily the users. The Unit Nursing Leadership should be making daily rounds...if they see a problem they can call maintenance, or clean the machine if it is just a matter of wiping it down. They should be looking at it at least weekly and cleaning it as necessary...Infection Control do rounds on the units but I do not think this specifically is an area they check..." The surveyor also inquired again to have an opportunity to examine documents related to the EOC group rounding on patient care areas. The surveyor was not provided any documents that related to patient care areas, only documents of rounds made in the PBX, IT, VP lounge, and other areas that were not patient units. Staff Member #1 stated that when the "EOC rounds are done, they turn in their checklists and if there are areas identified as needing attention, I submit a work order, or send a message to whomever needs to take care of the concern. If it is nursing then it would go to the Nursing Leader on the unit identified. This is a new program and we are learning as we are going. We obviously see some areas of opportunities for improvement..." The surveyor discussed with Staff Member #1 and #2 the concern regarding ineffective machine maintenance, staff not observing and reporting maintenance issues and Quality program systematically failing to actively identifying problems in patient care areas, implementing solutions and monitoring effectiveness on quality of patient care. Staff Member #1 stated, "There was a breakdown in communication or understanding of responsibility at the lowest level right through the chain..." Staff Member #2 stated, "We are working on a revision of the policy and procedure for the cleaning processes to include the manufacturer's directions and cleaning instructions as well as including competencies and training. We will also review what needs to be done on a unit level..." Staff #1 stated, "We realize we have some areas we need to fully examine and that we have opportunities to improve..."

At 2:00 p.m. on 8/17/21, the surveyor discussed the concerns related to the complaint allegations and notified the facility that they would have to respond with a plan of correction for the Conditions of Participation identified with an acceptable plan of correction which would demonstrate robust and sustainable corrections and monitoring for the deficient practice and inclusion into the hospital-wide Quality Monitoring Program. Facility members present were: Staff Members #1 (Quality Manager), #2 (Risk Manager), #3 (Chief Medical Officer), #4 (Chief Nursing Officer), #15 (Assistant Chief Nursing Officer, #17 (President-Chief Executive Officer), #18 (Chief Operating Officer), and #19 (Chief Financial Officer).

The concerns were again discussed at an exit conference on 8/20/21 at approximately 3:00 p.m. with the facility Administrative Staff (Staff Members #1, 2, 3, 4, 15, 17, 18, and 19).

Based on observation, staff interview, facility document review and encounters during the course of a complaint investigation, the facility staff failed to ensure the physical environment was maintained to ensure the safety of patients. Observations made during a tour of the facility patient care units on 8/16/21 beginning at 10:15 a.m., identified concerns related to the unsanitary condition and lack of maintenance in five (5) of ten (10) ice/water units providing ice and water to patients, visitors and staff.

During the tour of the facility patient care units on 08/16/21, the surveyor examined ten (10) ice/water dispensers that provided ice/water to patients, staff and visitors. 50% of inspected ice/water units had visible slime/mold present on the outside and 20% of the units inspected included slime/mold in the dispenser part of the unit. The two most adversely effected ice/water machines were located in patient care units with patients that were already acutely compromised (Cardiac Intensive Care Unit, all nine patients were Covid 19 positive) and consuming water/ice from these affected machines presented a serious potential health risk to these patients and could have caused serious negative health outcomes.

This finding resulted in IMMEDIATE JEOPARDY and demonstrated the systemic failure of processes related to inspection and maintenance/cleaning of equipment which was determined on 8/16/21 at 2:45 p.m. after consultation with the State Agency and the Centers for Medicare and Medicaid Services (CMS).

On 8/16/21 at 3:06 p.m., the facility Staff #1 (Director of Quality and Accreditation) and #2 (Risk Manager) were notified of the Immediate Jeopardy situation and a Plan of Removal was requested.

On 8/17/21 at 9:14 a.m., the surveyor received the facility Plan of Removal. After review/revision of the Plan of Removal, validation of implementation, and consultation with the State Agency and CMS, the Immediate Jeopardy was abated on 8/20/21 at 3:31 p.m. but non-compliance with Condition of Participation remained for 482.41 Physical Environment.

Please refer to A0724 for further information.

Based on observation, staff interview, facility document review and encounters during the course of a complaint investigation, the facility staff failed to ensure equipment was maintained to ensure an acceptable level of safety. Observations of ice/water dispensers on patient care units used to provide ice and water to patients, staff and visitors evidenced a greenish-black slimy substance in the overflow grate and black and reddish/pink substance adhering to two (2) of two ice machine dispenser nozzles.

This substance affected various parts of 5 (five) of 10 (ten) ice/water dispensers incorporated in the sample, including two (2) of the observed units with the affected dispenser nozzles. The observations involved ice/water dispensers on : CICU (Cardiac Intensive Care Unit - housing COVID19 positive patients), 3East (Surgical Progressive Care), 3West- PCU, Emergency Department and 4East (Rehab), with the first two units housing the most unsanitary ice/water machines.

The findings included:

On 8/16/21 at 10:15 a.m. the surveyor toured the patient care areas accompanied by Staff Member #1 (Quality), Staff Member #2 (Risk Manager), Staff Member #5 (Nurse Manager CICU), Staff Member 6 (Environmental Services and Facilities Maintenance), Staff Member #7 (Infection Control) Staff Member #9 (PCU Manager), Staff Member #10 (ED Manager), Staff Member #13 (Pulmonary and Renal Manager), and Staff Member #15 (Assistant Chief Nursing Officer). The following was observed:

On the CICU (Cardiac Intensive Care Unit): 8/16/21 at 10:29 a.m.,the ice/water dispenser located in the nourishment room had a black material adhering to the dispenser nozzle. The surveyor retrieved a tissue and wiped the nozzle outside and inside which demonstrated a black slick substance adhering to it. There was a greenish black slimy material in the bottom overflow grate and adhering to the bottom of the pan and drain. The surveyor inquired as to the cleaning process for the machine. The facility staff stated that the cleaning was done by plant operations. The surveyor inquired as to when the machine was last cleaned and what was the schedule for cleaning and how was cleanliness assessed. Staff Member #6 stated, "We have them on a list to clean quarterly. I believe this was cleaned about a month ago by us, but I will get the schedule..." Staff Member #7 (Infection Preventionist) stated, "We do not do environmental cultures. It is not a standard of practice. The observation of the machines are a part of the environment of care rounds, to check the cleanliness..." The surveyor asked to examine the environment of care rounding documents.

At 11:00 a.m., the surveyor observed a black slimy material in the bottom overflow grate of the ice/water dispenser on 3West. At 11:15 a.m., the surveyor observed a black-greenish slick material in the bottom grate and drain of the ice/water dispenser for the Emergency Department. Staff Member #2 stated the ice/water dispensers are "primarily" used for patients, although staff could obtain ice and water and that visitors could also be provided ice and water from the machines by staff. At 12:17 p.m., there was observed a greenish-brown slimy substance in the bottom grate and drain of the ice/water dispenser located on 4East. At 12:21 p.m., the surveyor observed a red-pink slick substance adhered to the dispenser nozzle of the ice/water dispenser on 3East and a black slimy substance underneath the overflow grate as well as drain. All the above noted observations were witnessed and confirmed by the facility staff who accompanied the surveyor on the tour.

The surveyor requested and received the EOC (Environment of Care) rounding sheets and the Ice Machine cleaning logs on 8/16/21 at approximately 12:45 p.m. The EOC rounding sheets demonstrated "rounds" made in areas that were not patient care areas except for the MICU (Medical Intensive Care Unit) which was completed in May 2021. The rounding sheets included an area for checking the ice/water dispenser for cleanliness, with the MICU being clean at that time. The surveyor asked Staff Member #1 for EOC rounding sheets that were completed for other patient care units. The Maintenance log for the cleaning of the ice machines was presented and evidenced (16) sixteen ice/water machines. The dates for the cleaning/maintenance of the machines ranged from 4/30/21 to 7/6/21 with "Work Completed: Ice machine clean and sanitize. The CICU was last documented as completed on 7/2/21, 3West- 5/10/21, 4East- 5/11/21, ED- 6/16/21 and 3East- Surgical Progressive care was not identified on the list.

According to the provided facility policy and cleaning requirements the following was evidenced (in part): "Quarterly Cleaning and Sanitizing of the Icemaker and Dispenser Hopper:...2. Empty, disassemble and clean bin. 3. Wipe Storage bin cover, agitator, drip ring and spouts with cleaning solution. 4. Chemically clean evaporator and water side components...15. Fully sanitize, flush and rinse with water. 16. Discard ice, wipe down bin. 17. Wipe stainless steel exterior....Additional Operating Inspections: 1. Remove all debris from drain pan. 2. Wash drain pan and grille. 3. Flush drain lines with bleach mix...5. Wipe all surfaces."

The surveyor inquired as to who was responsible for cleaning and ensuring the ice/water dispensers were cleaned between the maintenance quarterly cleaning, and if there was a routine schedule, or who was responsible for ensuring this was done and if Infection Control participated in this process. Staff Member #1 stated, "I will have to check on that. It could be EVS." The surveyor reviewed the EVS (Environmental Services) Cleaning schedule for patient care units. The nourishment room and Ice/water dispensers were not on the EVS cleaning schedule. According to Staff Member #6, the facility has ended a contract with a vendor providing cleaning service for the ice/water machines and that the new facilities director would be implementing monthly cleaning and another vendor would be contracted.

On 8/16/21 at 11:30 a.m. a discussion was held with the surveyor and State Agency regarding the identified concerns of Immediate Jeopardy. After conferring with the State Agency and CMS, the surveyor notified the facility of the finding of Immediate Jeopardy at 3:06 p.m. and a immediate plan of removal was requested. The facility Staff Members #1 and 2 were notified of the Immediate Jeopardy finding and stated they would meet with the Executive Administration to also notify them of the concern.

At 2:00 p.m. on 8/17/21, the facility was notified they would have to respond with a plan of correction for the Conditions of Participation identified with an acceptable plan of correction demonstrating robust and sustainable corrections and monitoring for the deficient practice. Facility present were: Staff Members #1 (Quality Manager), #2 (Risk Manager), #3 (Chief Medical Officer), #4 (Chief Nursing Officer), #15 (Assistant Chief Nursing Officer, #17 (President-Chief Executive Officer), #18 (Chief Operating Officer), and #19 (Chief Financial Officer).

On 8/20/21 beginning at approximately 12:15 p.m., the surveyor toured the same patient care areas to validate the implementation of the Plan of Removal.

During the tour on the patient care units the surveyor interviewed random staff regarding the ice/water dispensers. At 1:33 p.m., on 8/20/21 a Patient Care Technician (Staff Member #21- who was on duty on one of the units the surveyor toured) stated "We have been provided and refrigerate the bottled water for the patients. If any patients request or require ice, we can get ice from the dietary department or have someone bring ice from another unit that has a working machine." A Registered Nurse (Staff Member #22) who worked on the 5th floor, stated at 1:45 p.m., "We have refrigerated bottled water for the patients. If we need ice, we can get it from the cafeteria or the (other unit) ice machine because that one is in service now." Two Registered Nurses on the Cardiac Unit stated, "We have bottled water for the patients. Frankly, they (the patients) are all very pleased with the bottled water. They really like it. If we need ice we can get it from dietary at any time..."

After observations, interviews, documents review and consultation with the State Agency and CMS, the Plan of Removal was validated and the Immediate Jeopardy removed on 08/20/21 at 3:31 p.m. but non-compliance with Condition of Participation remained for 482.41 Physical Environment.

The concerns were again discussed at an exit conference on 8/20/21 at approximately 3:00 p.m. with the facility Administrative Staff (Staff Members #1, 2, 3, 4, 15, 17, 18, and 19).

Based on observation, staff interview, facility document review and encounters during the course of a complaint investigation, the facility staff failed to ensure a clean and sanitary environment. Observations made during a tour of the facility patient care units on 8/16/21 beginning at 10:15 a.m., raised concerns related to the unsanitary condition of five (5) in ten (10) ice/water dispensers providing ice and water for patients that were already acutely compromised individuals/patients.

On 8/16/21 at 10:15 a.m. the surveyor toured the patient care areas and visually inspected ten (10) ice/water units. Observations were witnessed and confirmed by the facility staff who accompanied the surveyor on the tour. 50% of inspected ice/water units had visible slime/mold present on the outside and 20% of the units inspected included slime/mold in the dispenser part of the unit. These machines provided water/ice to patients, staff and visitors and presented a serious potential health risk to these individuals.

The findings of unsanitary ice/water machines, insufficient maintenance of equipment and only sporadic monitoring of sanitary conditions in the patient care areas resulted in consultation with the State Agency and the Centers for Medicare and Medicaid Services (CMS) and determination of IMMEDIATE JEOPARDY on 8/16/21 at 2:45 p.m. The findings demonstrated the systemic failure of having an active hospital-wide infection surveillance program to prevent infectious diseases and the maintenance of a sanitary environment. processes related to inspection and maintenance/cleaning of equipment. On 8/16/21 at 3:06 p.m., the facility Staff #1 (Director of Quality and Accreditation) and #2 (Risk Manager) were notified of the Immediate Jeopardy situation and a Plan of Removal was requested.

On 8/17/21 at 9:14 a.m., the surveyor received the facility Plan of Removal. After consultation with the State Agency and CMS and on-site validation of Removal Plan's implementation through observations, staff interviews and documentation review, the facility was notified of the abatement of the Immediate Jeopardy at 3:31 p.m. on 8/20/21 but non-compliance with Condition of Participation remained for 482.42 Infection Control.

Please refer to A0750 for further information.

Based on observation, staff interview, facility document review and encounters during the course of a complaint investigation, the facility staff failed to provide a clean and sanitary environment including equipment which would directly affect patients, particularly already medically compromised individuals. Observations of ice/water dispensers in patient care units providing ice and water to patients, staff and visitors evidenced a greenish-black slimy substance in the overflow grate in five (5) ice machines and black and reddish/pink substance adhering to two (2) of five (5) affected ice machine dispenser nozzles.

The sample include ten (10) ice/water machines and the five (5) affected ice/water dispensers were located in: CICU (Cardiac Intensive Care Unit - housing COVID19 positive patients), 3East (Surgical Progressive Care), 3West- PCU, Emergency Department and 4East (Rehab), with the first two units housing the most unsanitary ice/water machines.

The findings included:

On 8/16/21 at 10:15 a.m. the surveyor toured the patient care areas accompanied by Staff Member #1 (Quality), Staff Member #2 (Risk Manager), Staff Member #5 (Nurse Manager CICU), Staff Member 6 (Environmental Services and Facilities Maintenance), Staff Member #7 (Infection Control) Staff Member #9 (PCU Manager), Staff Member #10 (ED Manager), Staff Member #13 (Pulmonary and Renal Manager), and Staff Member #15 (Assistant Chief Nursing Officer). The following was observed:

On the CICU Unit: at 10:29 a.m.,the ice/water dispenser located in the nourishment room had a black material adhering to the dispenser nozzle. The surveyor retrieved a tissue and wiped the nozzle outside and inside which demonstrated a back slick substance adhering to it. There was a greenish black slimy material in the bottom overflow grate and adhering to the bottom of the pan and drain. The surveyor inquired as to the cleaning process for the machine. The facility staff stated that the cleaning was done by plant operations. The surveyor inquired as to when the machine was last cleaned and the schedule for cleaning. Staff Member #6 stated, "We have them on a list to clean quarterly. I believe this was cleaned about a month ago by us, but I will get the schedule..." Staff Member #7 Infection Preventionist) stated, "We do not do environmental cultures. It is not a standard of practice. The observation of the machines are a part of the environment of care rounds, to check the cleanliness..." The surveyor asked to examine the environment of care rounding documents.

At 11:00 a.m., the surveyor observed a black slimy material in the bottom overflow grate of the ice/water dispenser on 3West. At 11:15 a.m., the surveyor observed a black-greenish slick material in the bottom grate and drain of the ice/water dispenser for the Emergency Department. Staff Member #2 stated the ice/water dispensers are "primarily" used for patients, although staff could obtain ice and water and that visitors could also be provided ice and water from the machines by staff. At 12:17 p.m., there was observed a greenish-brown slimy substance in the bottom grate and drain of the ice/water dispenser located on 4East, At 12:21 p.m., the surveyor observed a red-pink slick substance adhered to the dispenser nozzle of the ice/water dispenser on 3East and a black slimy substance underneath the overflow grate and drain. Observations were witnessed and confirmed by the facility staff who accompanied the surveyor on the tour.

The surveyor requested and received the EOC (Environment of Care) rounding sheets and the Ice Machine cleaning logs on 8/16/21 at approximately 12:45 p.m. The EOC rounding sheets demonstrated "rounds" made in areas that were not patient care areas except for the MICU (Medical Intensive Care Unit) which was completed in May 2021. The rounding sheets identified a space for checking the ice/water dispenser for cleanliness with the MICU being clean at that time. The surveyor asked Staff Member #1 for EOC rounding sheets that were completed for patient care units.

On 8/16/21 at 11:30 a.m. a discussion was held with the surveyor and State Agency regarding the identified concerns of Immediate Jeopardy. After conferring with the State Agency and CMS, the surveyor notified the facility of the finding of Immediate Jeopardy at 3:06 p.m. and a immediate plan of removal was requested. The facility Staff Members #1 and 2 were notified of the Immediate Jeopardy finding and stated they would meet with the Executive Administration to also notify them of the concern.

On 8/17/21 at 9:17 a.m., the facility presented the surveyor with a Plan of Removal for the Immediate Jeopardy.

On 8/17/21 at 10:41 a.m., the surveyor discussed with Staff Member #1, and 2 the EOC (Environment of Care) Rounds. Staff Member #1 stated EOC has "it's own committee" and the group consists of: Facilities Management, Contracted Vendor GE, Security Director, Emergency Management Coordinator, Information Technologies Director, Radiology Director, a Member of the Infection Prevention Team and Quality. They do the EOC rounding and document of the sheets. Infection Prevention is a member of the team. Everyone has a checklist and they go through and check the items." The surveyor inquired as to why there were no patient care areas, other than the MICU, contained in the documents completed recently. Staff Member #1 stated, "I am not sure but they divide the areas up and go in pairs. They do one unit per month...we just redid the check off documents..." The surveyor examined the "new" check off document for the EOC rounds and noted that it did not contain an area to check/monitor the cleanliness of the ice/water dispensers, as had been on the previous documents. This was brought to the attention of Staff #1 who stated, That was an oversight. We need to add that..." The surveyor inquired again as to who was responsible for cleaning the dispensers between maintenance scheduled cleanings. At 11:17 a.m. Staff Member #4 (CNO) and #15 (Asst CNO) stated, "The expectation would be that the charge nurse and Nursing Leadership on the units would check the ice machines, since they are primarily the users. The Unit Nursing Leadership should be making daily rounds...if they see a problem they can call maintenance, or clean the machine if it is just a matter of wiping it down. They should be looking at it at least weekly and cleaning it as necessary...Infection Control do rounds on the units but I do not think this specifically is an area they check..."

At 2:00 p.m. on 8/17/21, the facility was notified they would have to respond with a plan of correction for the Conditions of Participation identified with an acceptable plan of correction demonstrating robust and sustainable corrections and monitoring for the deficient practice. Facility present were: Staff Members #1 (Quality Manager), #2 (Risk Manager), #3 (Chief Medical Officer), #4 (Chief Nursing Officer), #15 (Assistant Chief Nursing Officer, #17 (President-Chief Executive Officer), #18 (Chief Operating Officer), and #19 (Chief Financial Officer).

On 8/20/21 beginning at approximately 12:15 p.m., the surveyor toured the same patient care areas to validate the implementation of the Plan of Removal.

During the tour on the patient care units the surveyor interviewed random staff regarding the ice/water dispensers. At 1:33 p.m., on 8/20/21 a Patient Care Technician (Staff Member #21- who was on duty on one of the units the surveyor toured) stated "We have been provided and refrigerate the bottled water for the patients. If any patients request or require ice, we can get ice from the dietary department or have someone bring ice from another unit that has a working machine." A Registered Nurse (Staff Member #22) who worked on the 5th floor, stated at 1:45 p.m., "We have refrigerated bottled water for the patients. If we need ice, we can get it from the cafeteria or the (other unit) ice machine because that one is in service now." Two Registered Nurses on the Cardiac Unit stated, "We have bottled water for the patients. Frankly, they (the patients) are all very pleased with the bottled water. They really like it. If we need ice we can get it from dietary at any time..."

At 2:10 p.m. on 8/20/21 Staff Members #23 and #24 (Infection Control) were interviewed regarding their role in the inspection of the ice/water dispensers. The Staff Members stated, "We have just started a visual inspection of the machines after the terminal cleaning. We were not doing any visual checks before.... "

After inspecting the sanitary conditions of actively used ice/water machines in patient care areas, staff interviews, documents review and consultation with the State Agency and CMS, the Plan of Removal was validated and the Immediate Jeopardy removed on 08/20/21 at 3:31 p.m. but non-compliance with Condition of Participation remained for 482.42 Infection Control.

The concerns were again discussed at an exit conference on 8/20/21 at approximately 3:00 p.m. with the facility Administrative Staff (Staff Members #1, 2, 3, 4, 15, 17, 18, and 19).