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Based on observation of the kitchen, medical surgical unit, radiology, and the Emergency Department (ED), and interview, it was determined that the facility failed to maintain the building physical structure in a state of repair. The failed practice promoted the spread of infection. The failed practice had the likelihood to affect all patients, staff and visitors. Finding follow:

A. Observation of the kitchen 3/26/2024 at 9:52 AM showed:
1) Molded ceiling tiles over food preparation area,
2) Wall tiles were not attached to the wall,
3) The wall behind ice machine had hole in the wall,
4) The paper attached to the sheet rock was removed from the ceiling,
5) The concrete floor was not sealed to prevent the absorption of fluids.
6) The ventilation vents were covered with dust and grime.

B. The findings of A were confirmed in an interview with the Director of Maintenance on 3/25/2024 at 9:52 AM.

C. Observation of the medical surgical unit on 3/25/2024 at 1:30 PM showed:
1) Room 26 had a hole in the wall behind the chair
2) Room 25 had an electrical socket that was missing a cover.
3) The medication room ice machine had a drain that had collected greenish black colored substance
4) The sink at the nurse's station had a buildup of white colored substances around the handles and drains
5) The sink in patients' room 6,9,25, and 26 had white colored substance around handles
6) Room 6 and 9 had black substance on the ceiling tile
7) The base board in Room 9 was peeling away from the wall

D. The findings of C were confirmed in an interview with the Director of Maintenance on 3/25/2024 at 2:00 PM.

E. Observation of the Radiology Department on 3/25/2024 at 2:20 PM showed the ceiling in the hallway had black substance.

F. The findings of E were confirmed in an interview with the Director of Maintenance on 3/25/2024 at 2:20 PM

G. Observation of the emergency department on 3/25/2024 at 2:22 PM showed:
1) The ambulance entrance hallway had a missing ceiling tile
2) The hallway had brown leaking substance in the light panel

H. The findings of G were confirmed in an interview with the Director of Maintenance on 3/25/2024 at 2:35 PM

Based on policy and procedure review, National Fire Protection Agency (NFPA) 101 2015 standards, observation and interview, it was determined the facility failed to formulate and implement policies and procedures regarding annual scheduled polarity and tension testing and labeling emergency receptacles. The failed practice did not ensure a steady supply of power to the receptacles was maintained. The failed practice had the likelihood to affect all patients in the facility. Findings follow:

A. Review of NFPA 99 standards, referred by NFPA 101 2015 edition, showed the receptacles in patient areas must be tested after initial installation, replacement or service at intervals determined by the facility based on documented performance data or grade tested at least annually.
B. Review of the facility's policies and procedures on 03/26/24 showed there was no evidence of a policy for annual scheduled polarity and tension testing or labeling emergency receptacles.
C. There was no evidence provided polarity and tension testing was conducted.
D. The findings in A, B, and C were confirmed in an interview with The Director of Maintenance on 03/26/24 at 11:00 AM.

Based on NFPA (National Fire Protection Association) Guidelines review and interview, it was determined the facility failed to conduct an infrared breaker check on an annual basis. The failed practice didn't ensure the breaker did not overheat or meet regulated temperature. The failed practice had the likelihood to affect all patients in the facility. The findings follow:

A. Review of NFPA 70E standards, referred to by NFPA 101 2015 edition, showed infrared inspections of the electrical distribution systems must be conducted on an annual basis.
B. A request was made on 3/25/2024 at 10:01 AM for evidence of electrical panel infrared testing. In an interview with the Director of Maintenance on 3/25/24 at 11:00 AM, the Director of Maintenance stated the facility had not conducted electrical panel infrared testing.




Based on NFPA (National Fire Protection Association (NFPA) Guidelines review, observation and interview, the facility failed to provide battery-powered emergency lighting as required by NFPA (National Fire Protection Agency) 101, 2012 edition in Operating Room #1. The failed practice had the likelihood to affect all patients and staff in that in the event of a power outage emergency there would be no lighting to illuminate the work area in procedure rooms and had the likelihood to affect all patients undergoing procedures. Findings follow:

A. Review of NFPA 99-2012, referred to by NFPA 101 section 6.3.2.2.11.1 requires one or more battery-powered lighting units within locations where deep sedation and general anesthesia administered.
B. Observation of Operating Room #1 on 3/25/2024 at 11:30 AM showed there was no evidence of emergency backup lighting.
C. The findings of B were confirmed in an interview with Director of Maintenance on 3/25/2024 at 11:30 AM

Based on review of the Bylaws of the Medical Staff, review of the Infection Prevention and Control Plan (2024), review of the Infection Control Committee meeting sign-in sheets and interview, it was determined the facility failed to assure a Physician Advisor attended and chaired the Infection Control Committee meetings (per plan). Without the Physician Advisor's involvement, the committee was lacking medical direction in:
- evaluating and analyzing medical management, patient outcomes and medical surveillance of staff as applicable to the control disease transmission;
- reviewing, analyzing and presenting infection risks and data to the medical staff and medical executive committee; and
- working with medical departments or individual physicians as appropriate to institute infection control policies or plans.
This failed practice had the likelihood to affect all patients who receive care in the hospital. Findings follow:

A. Record review of the Bylaws of the Medical Staff, revised August 2022, showed the composition of the Infection Prevention and Control Meeting Committee should have one member of the Active Medical Staff appointed by the Chief of Staff.
B. Record review of the Infection Prevention and Control Plan (2024) showed the Physician Advisor was to be chairing the committee and working in collaboration with the Program Director on topics to include: routine surveillance, clusters/outbreaks surveillance and control, emerging pathogens, public health issues, employee health issues, special studies or reports, antibiograms and policies and procedures related to the program.
C. Record review of the Infection Control Committee meeting sign-in sheets from 2021, 2022, 2023 and January 2024 showed there was not a Physician Advisor present for any of the meetings.
D. During an interview on 03/26/24 at 1:23 PM, the Chief Nursing Officer verified there was not a Physician Advisor on the Infection Prevention and Control Committee.

Based on review of policy, observation, and interview, it was determined the facility failed to check the integrity of the seal at the beginning of each shift (per policy) for one of one (Stroke) kit observed on tour. The potential exists for the emergency medication kit not to have medications present for patient emergencies. The failed practice had the likelihood to affect all patients who needed medications in an emergency. Findings follow:

A. Record review of the facility's policy titled "Emergency Carts Security," reviewed 08/2022, showed the integrity of the seal to the crash cart/ crash kit was to be checked at the beginning of each shift.
B. During a tour of the facility on 03/25/2024 1:13 PM to 2:37 PM, observation showed a Stroke emergency medication kit in the emergency department. There was not any evidence that the integrity of the seal was being checked at the beginning of each shift.
C. During an interview on 03/25/2024 at 2:30 PM, the Director of Quality/ Stroke Co-Ordinator verified the integrity of the seal to the Stroke emergency medication kit was not being checked each shift.

Based on clinical record review and interview, it was determined the facility failed to have individualized care plans for 3 (#6, #7, and #8) of 10 patients. By not individualizing the care plans the facility could not ensure that the patients received care for all their needs. This failed practice had the likelihood to affect all patients cared for in the facility. The findings follow:

A. Clinical record review of Patients #6 and #8 showed each patient was admitted with skin breakdown problems. There were no interventions for integumentary problems in the nursing care plan for either patient.
B. Clinical record review of Patient #7 showed Patient #7 was labeled a fall risk due to nursing admission assessment scoring. There was no evidence of fall risk interventions in the nursing care plan.
C. During an interview with the Director of Quality and Clinical Informatics, the findings of A and B were confirmed.

Based on review of policy, observation, and interview, it was determined the facility failed to keep hand washing sinks and sink areas clean, per policy, in two (Medical/Surgical and Emergency Department) of three (Medical/Surgical, Emergency Department and Emergency Room) Departments toured. By not keeping the hand washing sinks and sink areas clean, the facility could not assure employees hands were clean to perform tasks like medication preparation, medication administration and patient care, to prevent the spread of infection. This failed practice had the likelihood to affect all patients receiving medications and patient care in these two areas. Findings follow:

A. Record review of the facility's policy titled, "Infection control, Cleaning environment, Patient Equipment and Medical Devices," showed sinks and sink areas should be cleaned at least daily for infection prevention, infection control and patient wellbeing.
B. During a tour of the facility on 03/25/2024 from 1:13 PM to 2:37 PM, observation showed the following:
1) Medical / Surgical Floor:
a) Medication Room Sink #1: The hand-washing sink was visibly dirty, with a dark grimy substance accumulated around the entire sink's edges and the back splash where it attached to the counter. The faucet head had white and green substances around it.
b) Medication Room Sink #2: The hand-washing sink was visibly dirty, with a dark grimy substance accumulated around the entire sink's edges. Substances were dried out and not cleaned up from around the hot/cold handles. The faucet head had white, brown and green substances around it. There was yellow, brown and tan substances dried inside the sink. The ice machine was directly next to the handwashing sink and its fan was blowing directly into the handwashing sink and was only 6-8 inches from the sink.
c) Nurse's Station Handwashing Sink/ Eye Washing Station: The hand-washing sink was visibly dirty, with a dark grimy substance accumulated around the entire sink's edges and around the hot/cold handles. The sink was stopped up and 1-2 inches of stagnant water sat on the bottom of the sink. There was missing caulk at the back splash and a dark grimy substance accumulated where the caulk was missing.
2) Emergency Department's Medication Room: The hand-washing sink/ eye wash station was visibly dirty, with a dark grimy substance accumulated around the entire sink's edges and the back splash where it attached to the counter. Where the backsplash met the counter, a dark grimy substance accumulated where the caulk was missing and along the caulk. In the sink were wet brown chunks of a substance.
C. The findings were verified at the time of observation by the Infection Control Preventionist.


50014

Based on policy and procedure review, and interview, it was determined that the facility failed maintain a current nursing procedure guide to ensure urine catheterizations were being inserted per the established policy. The failed practice placed the patients receiving a urinary catheter at risk of infection and had the likelihood to affect all patients receiving a urinary catheter. Findings follow:

A. Review of policy and procedure "Urinary Catheter Insertion Protocol" on 03/27/24 at 1:45 PM, showed "See Lippincott Manual Of Nursing Care For Catheter Insertion Procedure."

B. Observation with the Quality Control Director on 03/27/24 at 1:50 PM, showed the Lippincott Nursing Care Manual was a 2014 edition. In an interview with the Quality Control Director, he stated he did not know if there was an updated version of the manual.

Based on observation and interview, it was determined the facility failed to assure the environment was maintained in a clean and sanitary manner in that in the crash cart located on the Med-Surg unit in the second drawer there are two of three Mac blades that are stained and discolored. By failing to maintain these items in a clean manner the facility could not ensure that these items were sanitary for use. This failed practice had the likelihood to affect all patients needing intubation in an emergency. The findings follow:

A. Observation during a tour of the Med-Surg Department on 3/25/2024 at 1:25 PM, showed two of the Mac Blades were discolored with brown stains.
B. The findings in A were confirmed with the Assistant Chief Nursing Officer on 3/25/2024 at 1:25 PM.



Based on observation and interview, it was determined the facility failed to assure the environment was maintained in a clean and sanitary manner in that on the Med-Surg Department Linen Closet there were two linen carts containing curtains and scrubs that were uncovered. The failed practice did not ensure that these items were clean and free from infectious material. The failed practice had the likelihood to affect all patients cared for by employees wearing these scrubs or needing the privacy curtains. The findings follow:

A. Observation during a tour of the Med-Surge Department on 3/25/2024 at 1:30 PM, showed that in the Linen Closet on the Med-Surg unit there were two of two carts containing linens (scrubs and privacy curtains) that were uncovered and not protected from dust and debris.
B. The findings in A were confirmed with the Assistant Chief Nursing Officer on 3/25/2024 at 1:35 PM.



Based on observation and interview, it was determined the facility failed to assure the environment was maintained in a clean and sanitary manner in that in the ultra-sound room there were four hole penetrations in wall behind door and a gouge in the drywall by the door. By failing to mainatain this area in a clean manner the facility could not ensure that patients in this area were not exposed to infectious material. The failed practice had the likelihood of affecting all patients treated in this area. The findings follow:

A. Observation during a tour of the Radiology Department in the Ultra-Sound room on 3/26/2024 at 1:10 PM, showed there were four wall penetrations near the door and a large gouge in the drywall behind a chair near the door.
B. The findings in A were confirmed by the Director of Radiology Department on 3/26/2024 at 1:15 PM.



Based on observation and interview, it was determined the facility failed to assure the environment was maintained in a clean and sanitary manner in that in the x-ray room there were seven wall penetrations behind the chest stand, one floor penetration on the floor under the chest stand and six floor penetrations on the floor under the radiology table. By failing to maintain this area in a clean manner the facility could not ensure that patients in this area were not exposed to infectious material. The failed practice had the likelihood to affect all patients treated in this area. The findings follow:

A. Observation during a tour of the Radiology Department in the x-ray room on 3/26/2024 at 1:20 PM, showed there were seven wall penetrations behind the chest stand, one floor penetration below the chest stand and six floor penetrations under the radiology table.
B. Findings in A were confirmed with the Director of Radiology on 3/26/2024 at 1:25 PM.



Based on observation and interview, it was determined the facility failed to assure the environment was maintained in a clean and sanitary manner in that in the radiology department hallway there were two ceiling tiles missing and nine tiles discolored with brown stains. By failing to maintain this area in a clean manner the facility could not ensure that patients in this area were not exposed to infectious material. The failed practice had the likelihood to affect all patients treated in this area. The findings follow:

A. Observation during a tour of the Radiology Department on 3/26/2024 at 1:30 PM, it was observed that there were two ceiling tiles missing in the entry way from the main patient entrance and seven ceiling tiles discolored with brown stains.
B. The findings in A were confirmed with the Director of Radiology on 3/26/2024 at 1:30 PM.


48468

Based on policy and procedure review and interview, it was determined the facility failed to formulate and implement policies regarding steps to minimize the growth and transmission of Legionella and other waterborne pathogens in the building water system. The failed practice placed the patients, visitors and staff at risk of infection from water borne pathogens. The failed practice had the likelihood to affect all patients, visitors and staff. Findings follow:

A. Review of the facility's policies and procedures on 03/26/24 showed there was no evidence of a policy for steps to minimize the growth and transmission of Legionella and other waterborne pathogens.
B. A request was made on 03/26/24 for Legionella water testing conducted at the facility. In an interview with The Director of Maintenance on 03/26/24 at 11:00 AM, The Director of Maintenance stated the facility had not conducted testing for Legionella or other waterborne pathogens in the building water system. The Director of Maintenance confirmed the findings of A.


50014

Based on observation, policy and procedure review, and interview, it was determined that the facility failed to maintain a clean and sanitary environment throughout the hospital in that:
1) Throughout the patient rooms, operating room and emergency room treatment room, there were multiple holes in the walls.
2) An exposed ice maker drain in the medication room on the Medical/Surgical Unit had a brown and white substance around the bottom of the drain.
3) Ceiling tiles were missing throughout the hospital.
The failed practice practice placed the patients at risk of infection and had the likelihood to affect all patients in the facility. The findings follow:

A. Observation during a tour of hospital on 03/25/24 from 1:15 PM to 2:30PM, showed:
1) On the Medical/Surgical Unit, Patient Room's #6, #9, #11, #25, and #26 had multiple holes in the sheetrock throughout the rooms.
2) Medication room on the Medical Surgical Unit had 14 holes in the walls.
3) The wall behind the nursing station on the Medical Surgical floor had 16 holes in the sheetrock.
4) In the Medication room on the Medical Surgical Unit there was an exposed ice maker drain with a thick black and white substance around the bottom of the drain.
4) Room #154 in the Operating Room (OR) had four holes in the walls.
5) Room #2 in the Emergency Room (ER) had several holes in the walls.
6) In OR Room #1 the ceiling tiles were stained.
7) In the hallway outside of the cafeteria, multiple ceiling tiles were missing.
8) The findings in A were verified with the Infection Control Preventionist and the Director of Engineering at the time of the observation.

B. Review of policy and procedure "Cleaning Environment, Patient Equipment and Medical Devices" on 03/26/25 at 9:45 AM, showed:
1) All staff were trained in cleaning techniques, task and infection prevention and control.
2) Environmental Services Supervisors responsible for carrying out cleaning of the general environment and where necessary environmental disinfection and housekeeping tasks to the highest possible standards in accordance with specifications.
3) All staff were responsible for ensuring high standards of cleanliness regarding patient care equipment, medical devices, and the environment of care.
4) The environment of care including, but not limited to, furniture, fixtures, floors, carpets, and window treatments should be visibly clean and no blood and body substances, dirt, debris, dust adhesive tape, stains, or spillages. Floors, carpets, ceilings, and window treatments should have a uniform appearance and an even color with no stains or watermarks.
5) Monitoring of compliance with environmental and equipment cleaning will be carried out, documented, and reported to the Infection Prevention and Control Committee.

Based on review of facility policy, personnel file review and interview, it was determined the facility failed to assure one (Speech Language Pathologist (SLP) #1) of two (SLP #1 and #2), one (Physical Therapist Assistant (PTA) #4) of four (PTA #1-4) and one of one (Occupational Therapist Assistant (OTA) #1) were screened to assure no individuals were hired who had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Failure to perform background checks did not assure each patient would be protected from abuse, neglect, exploitation, misappropriation of property, or mistreatment. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Record review of the facility's policy titled "Criminal History Record Policy," revised 03/12/2014, showed that a criminal history background check was required.
B. Review of personnel files showed the following:
1) SLP #1 was hired on 10/07/2020 and did not have a criminal history background check prior to working with patients.
2) PTA #4 was hired on 10/10/2018 and did not have a criminal history background check prior to working with patients.
3) OTA #1 was hired on 11/08/2022 and did not have a criminal history background check prior to working with patients.
C. During an interview on 03/27/2024 at 12:57 PM, the Director of Human Resources verified SLP #1, PTA #4, and OTA #1 have worked at the facility without a criminal history background check being completed to verify they had not been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.