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Based on observations, interviews and record review, the facility failed to meet life safety codes standards. These deficiencies affected 6 of 6 buildings utilized and under the hospital Centers for Medicare and Medicaid Services (CMS) Certification Number 270003.

Findings include:

A full life safety code survey was conducted of the acute care hospital and all satellite facilities offering patient customary access from 7/24/17 to 7/27/17. A full life safety code report was completed and contains standard level deficiencies. See the full life safety code report dated 7/27/17 for further details.

Based on observation, interview, and record review, the facility failed to implement infection control measures while accessing the rubber septum on medication vials for 1 (#33) of 34 patients. The facility failed to utilize a facemask upon entering a room with droplet precautions; this deficient practice had the potential to affect all patients whom received care on the medical floor. The facility failed to store clean linens in a manner that ensured protection from contamination of dirty linens; this deficient practice had the potential to effect all patients utilizing the laundry services. Findings include:

1. During an observation on 8/1/17 at 1:15 p.m., staff member F removed the orange lid to a 10 ml vial of Versed. The staff member entered the rubber septum of the vial with a filter needle and removed 5 ml of Versed. The staff member failed to wipe the rubber septum with alcohol prior to puncturing the vial of Versed. The staff member recapped the needle and set the syringe labeled as Versed aside. The staff member then opened a glass vial of Fentanyl, withdrew 2 ml of Fentanyl with a filter needle and recapped the needle, labeling the medication and setting it aside. The staff member failed to wipe the glass vial of Fentanyl prior to accessing the medication.

During an observation on 8/1/17 at 1:20 p.m., staff member J intervened during staff member F's process, and asked her to not use the Versed and the Fentanyl since she did not wipe the rubber septum of the vial of Versed and did not wipe the glass vial of Fentanyl with alcohol. Staff member F asked staff member G to observe her waste the medications as was requested by staff member J.

During an interview on 8/1/17 at 1:22 p.m., staff member F stated she was not aware she needed to clean the rubber septum of medication vials with alcohol prior to withdrawing the medication. Staff member F asked staff member G if she was aware of this process, and staff member G stated she was aware of the need to wipe the top of the medication vials with alcohol prior to administration.

During an interview on 8/1/17 at 2:30 p.m., staff member J stated it was the policy and procedure for staff to wipe the rubber septum with alcohol prior to administration.

During an interview on 8/1/17 at 2:37 p.m., staff member K stated it was not the facility policy and procedure to wipe the rubber septum on medications vials prior to medication administration and stated staff member J was wrong on what the facility's policy and procedure for infection control of medication administration stated. Staff member K stated staff member F did not need to clean the rubber septum on the medication vials with alcohol.

During an interview on 8/2/17 at 12:50 p.m., staff member H stated the facility followed nursing procedures on medication administration from Lippincott Nursing Procedures. She stated the cap, which covered the rubber septum, is not considered sterile and the cap is only a barrier; the penetration of the rubber stopper would be puncturing the sterile field. Staff member H stated it was the policy and procedure of the facility to clean the rubber septum with alcohol before penetrating the rubber stopper and wiping the glass vial with alcohol and let it dry before withdrawing the medication.

A review of the facility's policy and procedure, titled Medication Management, dated 2/1/17, showed, "L... Procedures for drug administration are outlined in Lippincott Procedures."

A review of the Lippincott Procedures utilized by the facility, titled IV solution preparation, Adding Medication to the Container, showed, "For Medication from a vial: Remove the medication vial's lid. Perform a vigorous mechanical scrub of the vial stopper using an alcohol pad. Allow it to dry completely. For Medication from an ampule: Disinfect the neck of the glass ampule thoroughly with an alcohol pad using friction. Allow it to dry completely. Break the ampule, insert the filter needle into the ampule, and withdraw the medication."

2. During an observation on 8/2/17 at 10:51 a.m., staff member B entered a patient room which had isolation droplet precautions. The staff member donned a gown and gloves and walked behind the privacy curtain to talk with the patient. The patient answered a couple of questions staff member B asked. The staff member came back to the door where staff member L was standing in the door way. Staff member L pointed to the PPE hanging on the door and staff member B reached in and pulled out a face mask from the kiosk. Staff member B placed the face mask on without removing her gloves or performing hand hygiene. Staff member B then returned behind the privacy curtain of the patient's room to assist the patient.

During an interview on 8/2/17 at 10:30 a.m., staff member L stated she had just finished assisting the patient who was on droplet precautions, and stated she had donned a mask, gown, and gloves, prior to entering the patient's room.

During an interview on 8/2/17 at 10:51 a.m., staff member B stated it was the facility policy to wear a mask as well as gown and gloves when entering a room with contact precautions. The staff member stated she was not familiar with the patient, and she was only answering the patient's call light. She stated the facility provided training on the donning and removal of PPE at the time of hire, and also yearly in their Health Stream competencies.

During an interview on 8/2/17 at 11:09 a.m., staff member A stated all new employees received education on proper donning of PPE for all types of precautions. She stated the training for donning of PPE was also updated yearly for all staff during annual competency training. She stated the facility also used Lippincott Nursing Procedures for proper donning of PPE.

A review of the facility's policy and procedure, titled Infection Control Isolation Precautions, dated 2/20/14, showed, "Droplet Precautions, to prevent the transmission of nasal or oral secretions over short distances (3 feet or less), may cohort patient if necessary, private room, patient wears mask outside room, strict attention to hand hygiene. Wear a gown, gloves and a surgical mask upon entry into room if within 6 feet of patient."

A review of the Lippincott Procedures utilized by the facility, titled Personal Protective Equipment (PPE) putting on, showed, "Implementation: Pick up the fluid-resistant gown, and allow it to unfold in front of you. Put on the gown, making sure that it covers your torso fully from your neck to your knees, covers your arms to the ends of your wrists, and wraps around your back. Fasten the gown at the back of your neck and at your waist. Place the face mask snugly over your nose and mouth and below your chin. Secure the ear loops around your ears, or tie the string sat the middle of the back of your head and neck so that the mask won't slip off." A special note titled, Putting on Face Mask, showed, "To avoid spreading airborne particles wear a face mask. Position the face mask to cover your nose and mouth, and secure it high enough to ensure stability."

3. During an observation on 8/1/17 at 7:59 a.m., there was a large linen bin which contained visibly soiled linens. The bin was filled with visibly soiled linen above the rim. The pile of soiled linen almost touched a wall mounted fan. The bin, which was filled with visibly soiled linen, was surrounded on all three sides by four separate large bins of clean, already washed linen, which were waiting to be dried. The four surrounding bins were not covered.

During an interview on 8/1/17 at 7:59 a.m., staff member C stated the bin, which had the visibly soiled linen, was linen which had already been washed once, but had either fallen on the floor or were not fully cleaned. She stated the bin was always located under the fan and was emptied one to two times a week. The staff member stated since the linen was piled so high in the re-washed bin, and the re-washed bin was surrounded by clean laundry, there would be a possibility the re-washed linen could contaminate the clean laundry.

During an interview on 8/1/17 at 8:30 a.m., staff member E stated the rewashed bin should not be piled above the rim and it would be better if it was not located in the middle of the clean bins which could potentially cross contaminate the clean laundry.