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Based on observation, interview and record review the facility failed to monitor and record blanket warmer temperatures in the Medical/Surgical unit and the Emergency Department for 2 of 6 blanket warmers in the facility.

Findings Include:

Review of Facility Policy, #416-112, current revision date of June 2018, titled, "Blanket Warmer," revealed, "This policy outlines the appropriate use of blanket warming cabinets and safe monitoring of warming cabinet temperatures to ensure their safe use in patient-care areas.....Temperature Regulation: .....4. Temperature monitoring of blanket warmers will be performed by staff by visual observation the warmer cabinet temperature display and of the posted sign with the acceptable ranges. This is to be recorded on the Warmer Cabinet Log daily."

On 09/13/2022 at 09:15 AM during a tour of the Medical/Surgical Nursing Unit with Director of Inpatient Services AC, observed the blanket warmer to have missing temperatures on the temperature log.

Review of the Blanket Warmer Log for 2022 for the Medical Surgical unit blanket warmer revealed missing temperatures for the following:

January 2022 missing 10 of 31 days (1/4, 1/5, 1/6, 1/9, 1/10, 1/11, 1/12, 1/13, 1/28, 1/31)

March 2022 missing 2 of 31 days ( 3/5, 3/6)

June 2022 missing 2 of 30 days (6/13, 6/15)

August 2022 missing 4 of 31 days (8/2, 8/8, 8/16, 8/17)

September 2022 missing 3 of 30 days (9/3, 9/4, 9/7). These findings were confirmed by Staff C.

In an interview on 09/13/2022 at 09:15 AM with Director of Inpatient Services C, when asked if the blanket warmer temperatures checks should be monitored and recorded every day, Staff C, stated, "Yes, daily."

Examples in the Emergency Department:

Record review of Cabinet Warmer Log for 6 months revealed:

April 2022 with 10 of 30 days not initialed that temperature checks were completed (4/01/2022, 4/03/2022, 4/04/2022, 4/05/2022, 4/06/2022, 4/11/2022, 4/12/2022, 4/13/2022, 4/17/2022 and 4/19/2022).

May 2022 with 5 of 31 days not initialed that temperature checks were completed (5/11/2022, 5/12/2022, 5/13/2022, 5/21/2022 and 5/22/2022).

June 2022 with 3 of 30 days not initialed that temperature checks were completed (6/04/2022, 6/05/2022 and 6/10/2022).

July 2022 with 3 of 31 days not initialed that temperature checks were completed (7/06/2022, 7/23/2022 and 7/24/2022).

August 2022 with 6 of 31 days not initialed that temperature checks were completed (8/12/2022, 8/13/2022, 8/15/2022, 8/20/2022, 8/21/2022 and 8/28/2022.

September 2022 with 2 of 13 days not initialed that temperature checks were completed (9/06/2022 and 9/07/2022).

On 9/13/2022 at 9:15 AM during interview with Registered Nurse (RN) GG, RN GG stated that they should be logging the temperatures of the blanket warmer "daily." RN GG confirmed "sometimes they forget."

Based on observation, interview, and record review the facility failed to ensure that emergency supplies were stocked and available by failing to document crash cart and defibrillator monitoring checks daily in 3 of 4 crash carts (Emergency Department, Medical- Surgical unit and Surgery) in a total of 10 Departments observed.

Findings include:

Examples in Emergency Department:

On 9/13/2022 at 9:15 AM during tour of the Emergency Department with Registered Nurse (RN) GG, observed crash cart logs missing documentation of the daily checks.

Record review of policy "Emergency Equipment" #100-080, last reviewed 11/20/2017, under Procedure revealed "Emergency equipment checks will be done... and documented on the flow sheets. Under defibrillators revealed "defibrillators shall be checked each shift... A test Defib (defibrillator) will be performed once every 24 hours." Under Crash carts revealed "Contents and medications should be checked each shift." Under Suction revealed "Check the portable suction units... for functionality."
Record review of 6 months of Crash Cart Logs in the Emergency Department revealed the log consisted of one row for each day of the month with one column titled [defibrillator] Daily Visual Check, one column titled [defibrillator] Weekly Check every Monday, and one column titled Outdates and Suction Machine tested the 1st of every month. The Crash Cart Logs revealed:

April 2022 with 2 of 30 days left blank under daily visual check (4/11/2022 and 4/13/2022) and 1 of 4 weekly Monday checks missing (4/11/2022).

May 2022 with 3 of 31 days left blank (5/12/2022, 5/21/2022, and 5/22/2022) and 2 of 4 weekly Monday checks missing (5/02/2022 and 5/30/2022).

June 2022 with 2 of 30 days left blank (6/05/2022 and 6/20/2022) and 1 of 4 weekly Monday checks missing (6/20/2022). There was no suction machine test documented 6/01/2022.

July 2022 with 9 of 31 days blank (7/04/2022, 7/09/2022, 7/11/2022, 7/14/2022, 7/19/2022, 7/23/2022, 7/24/2022, 7/28/2022 and 7/31/2022) and 1 of 4 weekly Monday checks missing (7/11/2022). There was no suction machine test documented 7/01/2022.

August 2022 with 6 of 31 days left blank (8/03/2022, 8/12/2022, 8/13/2022, 8/14/2022, 8/22/2022, and 8/29/2022) and 2 of 5 weekly Monday checks missing (8/22/2022 and 8/29/2022).

September 2022 with 4 of 13 days left blank (9/02/2022, 9/03/2022, 9/04/2022 and 9/05/2022) and 1 of 2 weekly Monday checks missing (9/05/2022). There was no suction machine test documented 9/01/2022.

On 9/13/2022 at 9:15 AM during interview with RN GG, when asked what the weekly Monday defibrillator checks consist of , RN GG stated they test the defibrillator, otherwise there is a daily visual check completed, documenting that the defibrillator was present. RN GG stated the suction machine was tested on the first of the month. RN GG confirmed, not all of the crash cart checks were completed.

Examples in the Surgery Department:

Record review of 6 months of Crash Cart Logs in Surgery revealed the same Crash Cart Log template. The Crash Cart Logs revealed:

March 2022 with 19 of 31 days left blank (3/01/2022, 3/05/2022, 3/06/2022, 3/07/2022, 3/08/2022, 3/09/2022, 3/10/2022, 3/11/2022, 3/12/2022, 3/13/2022, 3/14/2022, 3/15/2022, 3/18/2022, 3/19/2022, 3/20/2022, 3/23/2022, 3/25/2022, 3/26/2022, and 3/27/2022) and 2 of 4 Monday checks missing (3/07/2022 and 3/14/2022). There was no suction machine test documented on 3/01/2022.

April 2022 with 19 of 30 days left blank (4/02/2022, 4/03/2022, 4/05/2022, 4/05/2022, 4/06/2022, 4/09/2022, 4/10/2022, 4/11/2022, 4/12/2022, 4/13/2022, 4/14/2022, 4/15/2022, 4/16/2022, 4/16/2022, 4/17/2022, 4/18/2022, 4/20/2022, 4/22/2022, 4/23/2022, 4/24/2022, and 4/30/2022) and 2 of 4 Monday tests missing (4/11/2022 and 4/18/2022).

May 2022 with 20 of 31 days left blank (5/01/2022, 5/02/2022, 5/03/2022, 5/04/2022, 5/05/2022, 5/06/2022, 5/07/2022, 5/08/2022, 5/10/2022, 5/22/2022, 5/14/2022, 5/15/2022, 5/21/2022, 5/22/2022, 5/26/2022, 5/27/2022, 5/28/2022, 5/29/2022, 5/30/2022 and 5/31/2022) and 2 of 3 Monday tests missing (5/02/2022 and 5/30/2022). There was no suction machine test documented on 5/01/2022.

June 2022 with 9 of 30 visual checks blank (6/04/2022, 6/05/2022, 6/11/2022, 6/12/2022, 6/18/2022, 6/19/2022, 6/25/2022, 6/26/2022 and 6/28/2022) and 2 of 2 Monday tests missing (6/06/2022 and 6/13/2022). There was no suction machine test documented on 6/01/2022.

July 2022 with 12 or 31 visual checks blank (7/02/2022, 7/03/2022, 7/04/2022, 7/09/2022, 7/10/2022, 7/16/2022, 7/17/2022, 7/23/2022, 7/24/2022, 7/29/2022, 7/30/2022 and 7/31/2022) and 1 of 4 Monday tests missing (7/04/2022). There was no suction machine test documented on 7/01/2022.

August 2022 with 10 of 31 visual checks left blank (8/06/2022, 8/07/2022, 8/08/2022, 8/13/2022, 8/14/2022, 8/15/2022, 8/20/2022, 8/21/2022, 8/27/2022, 8/28/2022) and 3 of 5 Monday tests mission (8/08/2022, 8/15/2022 and 8/22/2022).

On 9/14/2022 at 7:47 AM during interview with Surgical Service Director S, Director S stated Post Anesthesia Care Unit does the checks for the crash cart "when they are here." Director S confirmed not all of the crash cart checks were completed.

Examples in the Medical-Surgical Department:

Review of the Crash Cart checklist for 2022 for the Medical Surgical Crash Cart revealed safety checks were not recorded:
January 2022 missing 10 of 31 days (1/1, 1/2, 1/3, 1/6, 1/10, 1/22, 1/23, 1/29, 1/30)
February 2022 missing 2 of 28 days (2/27, 2/28)
June 2022 missing 3 of 30 days (6/7, 6/9, 6/14)
July 2022 missing 1 of 31 days (7/14)
September 2022 missing 1 of 14 days (9/7). These findings were confirmed by Staff C.

In an interview on 09/13/2022 at 09:15 AM with Director of Inpatient Services C, when asked if the crash cart checks should be monitored and recorded every day, Director C, stated, "Yes, daily."

Based on observation, record reviews 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-0225 - Stairways and Smokeproof Enclosures
K-0233 - Clear Width of Exit and Exit Access Doors
K-0342 - Fire alarm System - Initiation
K-0521 - HVAC
K-0923 - Gas Equipment - Cylinder and Container Storage

As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET.

Based on interview and observation the facility failed to ensure the equipment used in the Cardiac Rehab department was on a preventative maintenance schedule to assure it is maintained in a safe operating condition in 1 of 1 cardiac rehab departments observed in a total universe of 10 patient care departments.

Findings:

On 9/14/2022 at 10:00 AM during a tour of the Cardiac Rehab outpatient department, a treadmill, recumbent bike and a Nustep (exercise equipment) machine were observed without Biomed or maintenance stickers on indicating that the equipment had been checked for proper maintenance and functioning. The lack of stickers was confirmed on the tour by Cardiac Rehab RN Y.

On 9/14/2022 at 10:45 AM in an interview with CNO (Chief Nursing Officer) B, CNO B stated, "The Cardiac Rehab Department is a joint venture with Essentia Health but is considered a department of the hospital. We haven't developed a formal process to check that equipment. We need to get it on a PM (preventative maintenance) schedule."

Based on observation, record reviews 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-0225 - Stairways and Smokeproof Enclosures
K-0233 - Clear Width of Exit and Exit Access Doors
K-0342 - Fire alarm System - Initiation
K-0521 - HVAC
K-0923 - Gas Equipment - Cylinder and Container Storage

As a result of these deficiencies, 42 CFR 485.623(c) Life Safety from Fire was NOT MET.

Based on record review and interview the Governing Body failed to assure monitoring and updating of the facility's Medical Staff Rules and Regulations and By-Laws per facility policy in 1 of 1 Rules and Regulations and By-Laws document reviewed.

Findings include:

Record review of the document titled, "Appendix VI of By-Laws of Medical Staff of Spooner Community Memorial Hospital and Nursing Home, Inc. Rules and Regulations" undated, revealed the following..."#4. All order for treatment shall be in writing... #8. All original records are the property of the hospital and nursing home...#10...all tissues removed during the operation shall be sent to the pathologist...#11...consultation with another qualified physician shall be required in all first Cesarean sections...#14...All autopsies shall be performed by the staff member...#16...a list (of approved abbreviations) is maintained by the medical records committee and is reviewed and approved by the Medical Staff annually...#18. Each staff member must indicate by signature, dated, that he agrees to be governed by the foregoing By-Laws, Rules and Regulations of the Medical Staff.... #27...The Medical Staff By-Laws shall be reviewed annually by the Chief of Staff and Administration..."

Record review of the Medical Staff By-Laws revealed a review date of 2018.

On 9/15/2022 at 7:50 AM in an interview with CEO (Chief Executive Officer) A, and CNO (Chief Nursing Officer) B when asked about review of the Rules and Regulations of the Medical Staff stated, "I have no idea when they were last reviewed. We knew that we had to update them them Covid hit." When asked about specific services listed in the Rules and Regulations CEO A stated, "We haven't had a nursing home since we moved in 2016, haven't done deliveries since 2015, can't remember when we last did an autopsy here and obviously the By-Laws aren't looked at every year, we typically make changes as needed."

When asked if the Rules and Regulations and By-Laws are given to new providers at their orientation CNO B stated, "Probably not. We expect providers to follow current practice." When asked how they would know what current practice and governing rules apply to them CNO B stated, "Good question."

Based on record review and interview the facility failed to conduct a review of policies per their facility's policy by failing to review 896 of 1,672 policies annually in 1 of 1 of their policy review procedures.

Findings include:

Record review of policy "Policy & Procedure Requirements" #415-101, last reviewed 4/25/2022 under B. Responsibilities revealed "The department director is responsible for all revisions and annual review."

Record review of list titled "Active Documents - Complete Listing" provided by Quality Director D on 9/15/2022 with columns titled Published Date, Next Review Date, and Last Review Date. 379 of 430 policies listed with Published Date prior to 9/15/2021, Next Review Date listed prior to 9/15/2022 and Last Review Date listed prior to 9/15/2021. 517 of 527 policies listed with Published Date listed prior to 9/15/2021, Next Review Date listed prior to 9/15/2022, and Last Review Date listed as blank. Out of 1,672 policies, 896 were not reviewed annually per facility policy.

On 9/15/2022 at 2:30 PM during interview with Quality Director D, while reviewing the list of their active documents, Director D stated they were in the process of getting new software to help track their policy review process. Director D confirmed there were "many" policies that had not been reviewed annually as listed in the "Active Documents - Complete Listing" provided.

Based on observation, record review and interview the facility failed to dispose of outdated supplies in 3 patient care areas (Medical-Surgical Nursing Unit, Housekeeping and Outpatient Surgery department) out of a total of 10 patient care departments.

Findings Include:

Review of facility policy, #027-033, titled, "Supplies Expiration Process," current revision 6/10/2022, revealed, "Manufacturer sterilized and non-sterilized items must not be used after the marked expiration date. Procedure: All expiration-dated items throughout the hospital must be checked for expiration dates on a routine basis. This is the responsibility of each department....Items that have reached the marked expiration date will be immediately removed from patient care areas and returned to the Materials Management Department....Responsibility: All hospital personnel must check the expiration dates on sterile and non-sterile items that they are using prior to implementing patient care. Outdated items should not be used."

Examples on Medical-Surgical unit:

On 09/13/2022 at 09:15 AM during a tour of the Medical-Surgical nursing unit with Inpatient Director C, observed the bladder procedure kit to contain 15 Provodine Iodine (skin antiseptic) (disinfectant) swab sticks with an expiration date of 08/2022. Inpatient Director C stated, "These are expired."

On 09/14/2022 at 9:15 AM during an observation of a terminal room clean for room 107, observed the housekeeping cart to contain a bottle of hand sanitizer, currently in use, with an expiration date of 03/2021.

On 09/14/2022 at 9:45 AM in an interview with Environmental Services Staff T, when asked if the hand sanitizer expired in 03/2021, Staff T stated, "That's a good lesson, it should be thrown out, it's expired."

Examples in the Emergency Department:

On 09/14/2022 at 10:00 AM during an observation in the Emergency Department, observed the housekeeping cart to contain a bottle of hand sanitizer, currently in use, with the expiration date unreadable.

On 09/14/2022 at 10:00 AM in an interview with Environmental Services Staff V, when asked when the hand sanitizer expired, Staff V stated, "You can't even see the expiration date, I'll get a new one."

Examples in the Outpatient Surgery Department:

On 9/14/2022 at 7:45 AM during a tour of the Outpatient Surgical Department with CNO (Chief Nursing Officer) B, observed 2 individually packaged purple nitrate gloves in the top drawer of exam room 1 with an expiration date of 7/22/2022. In interview with CNO B on 9/14/2022 at 7:50 AM, CNO B confirmed that the gloves were expired and should not be available for use.

Based on observation, record review and interview the facility failed to ensure the facility dietary manual was approved and authorized by the medical staff in 1 of 1 dietary manuals reviewed.

Findings include:

Review of Medical Staff meeting minutes for 2021 and 2022 revealed no documented evidence of approval of the facility dietary manual.

On 09/14/2022 at 3:55 PM in an interview with Chief Nursing Officer B, Officer B stated, "The diet manual did not go to medical staff for approval, it has been greater than 7 years since it has. In the transition from the old hospital to the new hospital we lost that piece."

Based on observation, record review and interview, the facility failed to protect the security of medical records in 1 (Infusion Department) out of a total universe of 3 areas where medical records are stored.

Findings Include:

Review of facility policy titled, "Retention and Destruction of Medical Records," #390-003, current revision: January 2017, revealed, "Medical Records will be maintained in a secure, locked file room."

On 09/13/2022 at 12:45 PM during a tour of the Infusion Department, observed a 2 drawer file cabinet housing 87 patient records. Files contained, consent forms, medications and patient identifying information.

In an interview on 09/13/2022 at 12:45 PM with Infusion Services Director IP, when asked how these records are secured, Director P stated, "Currently the cabinet isn't locked when we are present. There are short periods of time when we go on break and staff aren't present in the department. EVS (Environmental Services) cleans the department after hours and has access to the department." When asked how are the records secured after hours, Director P stated, "I have to be honest with you, we aren't locking the cabinet. At that time anyone can get in."

Based on record review and interview the facility failed to assure prompt completion of the medical record within 15 days of discharge per facility policy in 23 of 53 medical records on the Delinquent/Incomplete medical record log.

Findings:

Record review of the facility policy titled, "Completion of Medical Record" #390-025 dated 2021 revealed, "Policy:...#6. The medical record shall be considered delinquent if reports and signatures are not completed within 15 days following the allocation date. (Allocation Date: the date when dictation is assigned for completion or a report is ready for signature...) 10. "Health Information Services staff will close out medical records which are left incomplete when the responsible physician is no longer practicing at Spooner Health System...Procedure: ...#3. Physician records that are incomplete at least 15 days following the allocation date HIS (Health Information Systems) staff will notify the SH (Spooner Hospital) Department Director responsible for the services provided. #4 If delinquent medical records are not completed by noon on Tuesday of the following week, Health Information Services will email the SH Administrator and the SH Medical Director."

On 9/13/2022 at 12:45 PM in an interview with HIM (Health Information Management) Director H when asked about incomplete medical records Director H stated, "Staff check the incomplete list every day and provide it to me for follow-up. Many of the signatures that are missing are from the ED (Emergency Department) physicians because they work here so infrequently it's hard to get them to complete them. We have one incomplete medical record from May. When a record is not complete it means that it can't be coded or the bill dropped so it is an issue. When asked what the process is for follow up Director H stated that she just keeps trying to get ahold of the physicians by email or phone."

On 9/13/2022 at 4:50 PM in an interview with CEO A when asked about HIM notifying him of delinquent medical records as stated in facility policy, CEO A stated , "It seems like the system broke down, I have not been notified of this or I would have taken action."

Based on observation, interview and record review staff at this facility failed to maintain a sanitary environment free of potential contamination to patients and staff by not adhering to infection prevention (handwashing, cracks in upholstery on chairs, lack of proper masking, storage of clean equipment in soiled utility room and lack of policy for transporting dirty instruments) in 6 of 10 patient care areas (Medical-Surgical, Radiology, Emergency Department, Dietary, Registration, Infusion Department), in a total sample of 10 Patient Care areas observed.

Findings include:

Review of facility policy # 340-053, current revision date: 12/2019, titled, "Hand Hygiene," revealed, " 2.Hands will be washed before having direct contact with patients. 3. Hands will be washed after direct contact with patient's skin (e.g. lifting a patient, taking a pulse). 4. Hands will be washed with alcohol based waterless hand cleaners or soap and water between every patient/client contact or contact with environmental surfaces in the vicinity of a patient/client.....8. Gloves must be changed between patient/client contact or between "dirty" and "clean" body-site care on the same patient/client."

Review of facility policy #340-066, current revision dated: 03/24/2022, titled, "Standard Precautions," revealed, "Procedure: 1. Hand Hygiene is essential. Hand Hygiene requires the use of either plain or antimicrobial soap or alcohol-based (ABHS). Hand Hygiene must be performed: a. when entering a room and upon leaving, b. after touching blood, body fluids, secretions and excretions, c. after touching contaminated items, d. immediately after removing gloves, e. between patients.

Hand Hygiene examples in the Infusion Department and In the Medical Surgical Unit:

On 09/13/2022 from 12:45 PM-1:30 PM during an observation in the Infusion Department, observed Registered Nurse O during a chemotherapy (medication used to fight cancer) infusion, wash hands at the beginning and at the end of the infusion. During the infusion Registered Nurse O touched multiple objects in the patient area, removed the second pair of gloves and then replaced them, gathered equipment and the second medication and touched the intravenous line and cleansed the rubber hub with an alcohol wipe prior to inserting the medication to be administered, and then touched the patient without completing hand hygiene.

On 09/14/2022 from 08:10 AM-08:30 AM during an observation on the Medical Surgical unit, observed Respiratory Therapist W apply gloves, touch the computer, then touch equipment in the room, then prep equipment and apply hand sanitizer to gloved hands, scan in the medication, move patient's cane, then prepared the medication, touched the blood pressure monitor and the cords, handed the patient their phone ear piece, then applied hand sanitizer to gloved hands, charted on the computer, cleaned equipment after the medication was given, picked up garbage on the floor and then took wipes to clean the computer and removed the equalizer (appliance to give inhaled medication), removed their gloves, touched the patient and upon leaving the room performed hand hygiene.

In an interview on 09/14/2022 at 8:35 AM with Respiratory Therapist W, when asked when hand hygiene should be performed, Staff W stated, "Before and after patient contact," when asked why did they apply hand sanitizer to their gloved hand, W stated, "Just a habit from another facility." When asked what does your facility policy say when hand hygiene should be completed, W stated, "No policy about hand sanitizer being used on gloves." When Respiratory Therapist W was asked if there were some missed opportunities to perform hand hygiene during the patient treatment from 08:10 AM-08:30 AM, Staff W stated, "Probably."

On 09/14/2022 at 11:00 AM in an interview with Infection Prevention Registered Nurse Z, when asked when should hand hygiene be performed when giving chemotherapy, Staff Z stated, "Once they are done giving the chemo (chemotherapy) therapy and remove their gloves, they should hand sanitize and for sure before touching the patient. They should get everything ready before touching the medication. There is definitely room for improvement."

On 09/14/2022 at 11:00 AM in an interview with Infection Prevention Registered Nurse Z, when asked if hand sanitizer was okay to be used on gloved hands, Staff Z said, "No, in fact I think it can break down the gloves, depending on what they are using."




37419

Record review of facility policy titled "Cleaning of the Emergency Department between Patients--General Cleaning" policy #160-087, dated July 2020, under Policy revealed Emergency Department rooms and equipment ... shall be cleaned and disinfected between patients to prevent cross contamination and improve infection control." Under #2 revealed "reusable equipment to be washed with soap and water and transported to Surgical Services for disinfection and sterilization."

Record review of policy "Department-Specific Infection Control: Instrumentation" #180-093, last reviewed date 7/09/2021 under Cleaning revealed "All instruments from Surgery, Emergency Room, Acute... are brought to the Dirty Utility Room for cleaning. All instruments are washed with warm water, instrument soap, rinsed, and drained." Under "Instrument wash to Water Ratio" revealed "The correct instrument wash to water ratio is crucial for proper care and cleaning of surgical instruments. The manufactures instructions should be followed to obtain correct ratio."

Record review of policy "Flexible Endoscopes: Re-processing Steps", #1800335, last reviewed date 6/14/2019, under "Manual Cleaning" revealed "Perform manual cleaning using a freshly prepared cleaning solution. Change the cleaning solution for each endoscope cleaned."

Record review of policy "Aseptic Standards" #180-279, last review date 12/17/2021, under "XII. Cleaning Instruments" revealed "Wash all gross contaminates off of instruments in an instrument soap and water."

Record review of instructions for [Enzymatic Detergent] under "Directions for Presoak and Manual Cleaning" revealed "Add 1 fl. oz (30 ml) [Enzymatic Detergent] per gallon (3.78 L)... For heavy organic load, 2 fl. oz. (60 ml) may be required."

Record review of instructions for [Pre-cleanse soak], product number 2D66, revision date 06/01/2021, under Directions revealed "At point of use, Dispense gel over surgical tray of instruments to ensure soils are evenly covered. Transport instruments for further processing. There is no need to rinse."

Record review of sign above sink in Emergency Department dirty utility room revealed "BLACK LINE IN SINK EQUALS 2 GALLONS OF WATER. USE 1 PUMP OF THE [Enzymatic Detergent] PER GALLON OF WATER. *FILL SINK TO BLACK LINE AND ADD 2 PUMPS OF THE DETERGENT*

Examples in the Emergency Department:

On 9/13/2022 at 9:15 AM during tour of the Emergency Department dirty utility room with Registered Nurse (RN) GG, observed there was no biohazardous sign on the door to the dirty utility room from the Emergency Department and it was not locked, and there was no black line in the sink. Observed 2 bedside commodes in dirty utility room.

On 9/13/2022 at 9:15 AM during interview while touring the Emergency Department with Registered Nurse (RN) GG when asked what the cleaning process was for their dirty instruments, RN GG stated they are sprayed with the [Pre-cleanse soak], rinsed, dried, and taken down to the Operating Room decontamination area for reprocessing. When asked about the process if they use the enzymatic detergent per the sign above the sink, RN GG stated they put water in the sink with "one pump" of the enzymatic cleaner. RN GG confirmed there was no black line in the sink. When asked how they knew if the bedside commodes were clean or dirty, RN GG stated they were clean, "housekeeping or the nurses" clean them. When asked why they were kept in the dirty utility room, RN GG stated "I'm not sure."

Example in Radiology Department:

On 9/13/2022 at 12:37 PM observation during tour of the Radiology Department with the Director of Diagnostic Imaging II, in the Radiology Department dressing room, one chair with cracked material on the seat which is unable to be wiped clean between patients, confirmed by Director II during the tour.

Examples in the Surgical Area:

On 9/14/2022 at 3:35 PM during tour of the Operating Room decontamination area, with Registered Nurse (RN) HH, observed sitting on the counter to the right of a double sink, an approximately 18" x 12" plastic bin with dry, clean instruments inside. There was no black line in either sink noted.

On 9/14/2022 at 3:35 PM during interview with Operating Room Nurse (ORN) HH, when asked where the instruments came from that were on the counter, ORN HH stated that they must have been brought down by the floor or the Emergency Department for sterilizing. When asked how the detergent for the re-processing of the flexible endoscopes was mixed, ORN HH pointed to the sink and stated that the sink is filled and 2 pumps of detergent were added. When asked how much water was added, ORN HH stated that she could not confirm that the exact amount of water to detergent was mixed.

Transport of surgical instruments from Medical-Surgical unit:

On 09/15/2022 at 07:15 AM during a tour of the soiled utility room with Inpatient Manager D and Registered Nurse JJ observed a plastic box labeled biohazard. When Registered Nurse JJ was asked what that is used for, Staff JJ stated, "We put instruments in there, we spray them if we don't take them to surgery right away, typically they are walked to surgery at the end of the day. I don't put them in a solution and I don't always spray them when I am taking them right to the surgery soiled utility in surgery."



44431


Review of facility policy #696 EP 24, current revision date: May 2022, titled, "Employee, Patient and Visitor Facemask Policy," revealed, "It is required that all employees, patients, and visitors wear a facemask upon entering the facility.....(Facility Health Employee: Include (Contract Name), contracted employees, board members, venders, students, and volunteers while on premises."

Examples in the dietary department:

On 09/14/2022 at 11:20 AM during a tour of the dietary department, observed a dietary aide wearing a home made face mask, made of thin material that was worn like a scarf and hung down over the chin and covered the front of the neck and shirt.

Examples in the Emergency Department:

On 09/15/1022 at 08:30 AM during a tour of the Emergency Department, observed 2 registration staff sitting at the registration desk, not wearing masks and less than 6 feet apart. When asked, why they weren't wearing a face mask, they stated, "It isn't our policy and we are with (outside facility), we don't have to wear facemasks."

On 09/15/2022 at 07:45 AM with Infection Prevention Staff AZ, when asked if home made scarves are okay to be used for a facemask, Staff Z stated," No they should be wearing a surgical mask per our facility policy. All contracted staff , everyone needs to be wearing a mask."