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Based on observation, record review and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-363 Corridors - Doors
K-914 Electrical Systems - Maintenance and Testing

Based on observation, record review and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-363 Corridors - Doors
K-914 Electrical Systems - Maintenance and Testing

Based on observation and interview staff failed to remove expired biologicals from inventory for patient and staff use in 1 of 8 areas observed (Laboratory).

Findings include:

Per observations during tour of the Laboratory on 09/21/2021 at 11:45 am, observed 10 vials of "Dade Innovin Reagent" with the expiration date of 12/10/2020, 12 vials of "FSL Activated PTT Reagent" with the expiration date of 12/10/2020, and 2 containers of "Formalin Spill Material" with expiration dates of 12/31/2020.

Per interview with Lab Manager X on 09/21/2021 at 2:40 pm, X stated that the expired Reagents were used for "troubleshooting", but should have been labeled, "Do not use for patient testing." Lab Manager X stated that the Formalin Spill Material containers were expired and should have been discarded.

Based on record review and interview, the facility failed to follow Food Services policy to ensure the quality and temperature of food served to patients in 1 of 1 Dietary kitchen observed. Facility failed to complete a test tray per facility policy in 18 of 18 weekly test tray audits reviewed.


Findings include:

Record review of the Patient Food Services Policy titled, "Test Tray Evaluation" #C020 dated 2/21 under Policy revealed, "A minimum of three test trays to be completed per week. The Test Tray Evaluation process provides food service management with a tool that measures the quality level of the meal service and identifies areas of substandard service requiring corrective action."

Record review of the form "Food and Nutrition Services Test Tray Evaluation," that were kept in a binder in the kitchen, revealed completed forms for 2021; there were not test tray audits 3 times per/week per policy in the following weeks: 2/17-2 test trays done; 3/2-1 test tray done; 3/16-1 test trays done; 3/25-2 test trays done; 4/8-2 test trays done; 4/22-2 test trays done; 5/6-2 test trays done; 5/20-2 test trays done; 5/31-2 test trays done; 6/12-2 test trays done; 6/28-1 test tray done; 7/6-2 test trays done; 7/21-1 test tray done; 8/3-1 test tray done; 8/12-1 test tray done; 9/3-2 test trays done; 9/12-1 test tray done; 9/20-1 test tray done. All other weeks in this period had zero test trays documented.

On 2/21/2021 at 11:10 AM during interview with Dietary Supervisor Q when asked how often test trays are to be performed Dietary Supervisor Q stated, "I think twice a week, I try to do that but it's only me and it's hard to get them done."

On 2/21/2021 at 11:45 AM during an interview with Food Services Manager P, Food Services Manager confirmed the findings for 2021 completed "Food and Nutrition Services Test Tray Evaluation" forms; Food Services Manager P confirmed that of the 8 months reviewed there were no weeks where the evaluations were performed the minimum of three per week per policy.

Based on observation, record review and interview the facility failed to use aseptic technique to clean and disinfect equipment as per policy in 1 of 4 staff observations (Physician Z). Facility staff failed to place signage for transmission based precautions on the door of 1 of 1 COVID positive patients (Patient #18) out of 5 ED patient doors observed. Facility failed to follow CDC (Centers for Disease Control) guidelines and facility policy for transmission-based precautions for COVID positive patients for proper use of PPE (Personal Protective Equipment) in 1 of 3 staff (Lab Personnel CC) observations. Facility failed to identify COVID positive patients requiring isolation in the ED (Emergency Department) in 3 of 10 medical records (Patient #18, #22 and #23) reviewed.

Findings Include:

Review of policy and procedure titled, "Cleaning, Disinfection, and Sterilization, 1.9071" last reviewed 05/12/2020 revealed that the stethoscope should be cleaned with Alcohol 70-90%, Bleach 5.2%, Iodophor detergent, or Quaternary Ammonium.

Per observations on 09/21/2021 at 10:46 AM, observed Emergency Physician Z apply sanitizer to hands and then proceeded to use hands to rub hand sanitizer onto Z's stethoscope.

Director A observed Emergency Physician Z use hands to apply sanitizer to his/her stethoscope. Per interview with Director A on 09/21/2021 at 10:48 AM, when asked if staff should use hands to apply hand sanitizer to stethoscopes, A responded, "No, he should have used a disinfectant wipe."



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The Facility Policy, titled "Infection Prevention and Control Plan-[facility]", dated 2/19/2021, revealed: "The goals of the infection prevention and control program include...developing a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel...The organization has developed specific policies, procedures or work processes that address the following: Measures for the early identification of patients who require isolation in accordance with CDC....use and techniques for isolation precautions as recommended by the CDC."

The Facility Policy, titled "Isolation Precautions, AW", dated 11/2/2020, revealed: "It is the practice of all hospitals associated with [system] to follow the most current, "The Guidelines for Isolation Precautions" which was developed by the CDC and the HIPAC (Hospital Infection Control Practices Advisory Committee)."

The Facility Policy, titled "Isolation Procedures-Standard and Transmission based Precautions [system], dated 07/2021 revealed: "Isolation precautions are derived from CDC guidelines for isolation precautions in Hospitals 2007 and shall be based on the patient's diagnosis or clinical condition....clinical staff has the responsibility for initiating appropriate transmission based precautions when an infection or communicable disease is suspected or diagnosed...place the appropriate sign on the patient's door...the type of isolation precautions will be designated in the EMR (Electronic Medical Record)."

The Facility Policy, titled "[Facility] Emergency System Wide policy-COVID-19, Influenza and Emerging Respiratory Pathogens, dated 5/4/21, under the section for PPE revealed: "An N95 respirator is intended to be worn when a patient is symptomatic, suspected COVID-19, COVID-19 positive or in the testing pathway."

Observations of the ED on 9/21/21 from 9:30 AM until 12:30 PM revealed:
Staff C entered Patient #18 room at 10:40 AM, no isolation signage on door.
Lab personnel entered Patient #18 room at 10:50 AM wearing a surgical mask and not an N95 mask, no isolation signage present on door.
Staff D entered Patient #18 room at 11:00 AM, no isolation signage present on door.

Observed isolation signage placed on Patient #18 door at 12:30 PM, 2 hours and 10 minutes after admission to the ED.

A review of Patient #18 medical record revealed an admission on 9/21/21 at 10:20 AM with a diagnosis of COVID-19, no isolation precautions were documented.

A review of Patient #22 medical record revealed an admission on 9/14/21 at 11:00 AM with a COVID exposure and symptoms, tested COVID positive, no isolation precautions documented.

A review of Patient #23 medical record revealed an admission on 8/19/21 at 5:21 AM with COVID exposure and symptoms, no isolation precautions documented.

During an interview on 9/21/21 at 11:10 AM, Staff C, when asked why no isolation signage on Patient #18 door, stated, "We usually just communicate with each other if COVID positive." When asked how do you ensure all staff know isolation status when no one is present, stated, "There should be a sign on the door."

During an interview on 9/21/21 at 12:35 PM with Staff F, Infection Prevention Director, stated, "We follow the CDC guidelines for isolation, RN's can implement isolation precautions and place signs on patient rooms."

During an interview on 9/21/21 at 1:55 PM with Staff F, Infection Prevention Director, asked When would isolation signs be placed on patient doors, stated, "I would expect isolation signs be placed immediately at point of admission to the ED, anyone with suspicion of symptoms or PUI (Person Under Investigation) should be in isolation."

During an interview on 9/22/21 at 10:30 AM with Staff AA, Infection Prevention RN (Registered Nurse) when asked about isolation orders said, our isolation protocols are standard work and we don't need a provider order, our protocols are based on CDC guidelines and RNs can place the order. "It is an expectation that isolation signs be placed on patient room doors when a patient is put in isolation, this should have been done right away."

During an interview on 9/22/21 at 12:10 PM with Staff AA during record review stated, "Staff are not documenting when they are putting patients in isolation, PUI (Person Under Investigation) would be to put patients in isolation per policy."

During an interview on 9/22/21 at 12:25 PM with Staff A during record review stated, "Isolation precautions weren't documented and should have been...not sure why this wasn't present."