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11683

Based on observation, interview and record review, the facility failed to ensure the dietary staff was competent in performing the manual pot and pan wash procedure using the three (3) compartment sink. This deficient practice had the potential for pots and pans no to be sanitized properly.

Findings:

On December 21, 2016, at 8 : 50 a.m., during the tour of the kitchen area, Dietary Staff was requested to explain the manual process of washing pots and pans using the three (3) compartment sink. The Dietary Staff when questioned about the required times for the immersing/soaking time of the items in a sanitizing solution stated he had the times in her head. However, there was no device that could assist the staff to be tell the time. The Dietary Staff kept re-dipping the Hydrion strip to test if the level of the sanitizer was between 200 to 400 parts per million. According to the QT-40 Hydrion strip it should be immersed for 10 seconds to compare colors indicated in the strip container.

Review of the procedure "Washing Pots and Pans" indicated sanitize properly by immersing all items for one minute in the sanitizing solution. Immerse for 30 seconds, if hot water is used for sanitizing.

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11683

Based on observation and interview, the facility failed to maintain a clean and sanitary environment. This deficient practice had the potential for not meeting the needs of the patient.

Findings:

On December 20 and 21, 2016, from 8:50 a.m., through 11: 35 a.m., during tour of the different units with Administrative Staff the following was observed:

1. There was a missing tile on the ceiling in the emergency department.
2. There was no hot water on the handwash sink by 2 East Nursing Station. During an interview with the maintenance staff at the time of observation, he stated the knob for hot water was shut off. Review of the work order indicated on December 17, 2016, there was leak in the said faucet, was fixed and the hot water knob was not turned on.
3. The water temperature reading on the handwash sink by Coronary Care Unit (CCU) 1 was 71 degrees Fahrenheit.
4. There were missing tiles in the kitchen by the paper goods store room and dishwashing area; leaking faucets by the three (3) compartment sink and preparation area; warped ceiling by the walk -in freezer and the pipes from the soda, coffee and juice machines were directly draining into the floor drain without an air gap.

Based on observation, interview and record review, the facility failed to:
1. Ensure operating table mattress did not have residual tapes and dried red/ white stains on the seams.
2. Ensure the Dialysis Nurse staff changed gloves and perform hand hygiene after touching soiled linen and trash bins.
3. Provide and maintain a sanitary environment for surgical services. A sink used to clean the dirty colonoscopies was observed next to surgical supplies for endoscopy procedures.
4. Ensure two chairs in two different patient rooms did not have cracks.

These deficient practices had the potential for cross contamination and the spread of infection which may or may not affect patient safety or health.

Findings:

1. On December 20, 2016, at 11 a.m., during the tour of the Operating Room 3 with registered nurse (RN) 1, a black mattress on top of the operating table had residual tapes underneath the mattress. On top of the mattress there were red stains along the seams and white dried stains on the other parts of the mattress. During a concurrent interview, RN 1 stated the stains are from betadine solution used during the procedure. RN 1 was requested if it can be cleaned. With gloved hands she used a Sani Cloth (wipe) and was able to remove the stains.
During an interview with RN 1 at the time of observation, she stated the mattress should have been cleaned thoroughly.
Review of the Daily OR Mattress Audit indicated the mattress in OR 3 was last audited on December 12, 2016 and it was in compliant.

2. During tour of the unit on December 21, 2016, at 2:30 p.m., a Dialysis Nurse was observed with gloved hands trying to bring out the portable reverse osmosis (RO) machine out of Room 329, however, the soiled linen bin and the trash bin were on the way. He moved the trash and soiled linen bins out of the way and without changing gloves or performing hand hygiene moved the RO unit out of the room. During an interview, the Dialysis Nurse stated the dialysis machine had been cleaned after the patient's use. During an interview, the Dialysis Supervisor stated the staff should change gloves after touching the dirty bins and moving the RO unit.



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3. On 12/20/16, at 11:00 a.m., during a tour of the endoscopy procedure room a sink used to clean the dirty colonoscopes was observed next to surgical supplies for endoscopy procedures. The endoscopy procedure supplies included : IV starter kits; Biopsy Snares; Ballon dialators; Trapezoid kits; dialationsyringes; Bronchoscopy Biopsy forceps; Cytology brushes. On another shelf contained: Patient gowns; towels; linen and pillows.

During an interview with the registered nurse (RN), on 12/20/16 at 11:10 a.m.,When asked what the sink next to the endoscopy procedure supplies was used for, she indicated the sink was used to clean dirty endoscopes after GI procedures.

During a tour of the Operating room, on 12/20/16 at 11:40 a.m., brown area of the floor was observed without any tile by the substerile entrance door to OR#2. During an interview, the RN indicated the floor was under repair.


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4. On 12/21/2016 at 2:08 p.m., during a tour of the facility ADM 1, ADM 2, and ADM 4, the randomly selected room 1 in the Coronary Care Unit (CCU) had a chair with multiple cracks on the seat.

During the concurrent tour at 2:25 p.m., the randomly selected room 329 on the third floor also has a chair with multiple cracks (the longest crack was approximately 4 inches in length) on the seat. ADM 1 acknowledged the cracks and indicated the chair should be replaced.

During an interview at 3 p.m., ADM 3 acknowledged that cracks on the chair seat made cleaning or disinfection difficult to rid of microbial.