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Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to remove outdated supplies from the Medical/Surgical Unit. Failure to remove outdated supplies could potentially result in staff using the expired items for patient care beyond the manufacturers' expiration dates, after which the manufacturer will no longer guarantee the safety and quality of the supplies. The CAH administrative staff identified an inpatient census of 5 patients upon entrance and 621 inpatient admissions for fiscal year 7/1/2021 to 6/30/2022.

Findings include:

1. Observations during a tour of the Medical Surgical area on 5/15/2023 at approximately 10:15 AM, with Charge Nurse A revealed the following expired supplies:

Medical Surgical Supply Closet
a. 4 of 4 Gastroccult pH Hb cards- Lot 203125 Expiration 2/2023
b. 1 of 1 Gastroccult Solution 5 mL bottle- Illegible Lot and Expiration
c. 1 of 1 Ecolab Quik-Care Aerosol Foam Hand Sanitizer refill Lot PZ050612 Expiration 04/2023
Medical Surgical Hallway
a. 8 of 15 Ecolab Quik-Care Aerosol Foam Hand Sanitizer refills Expiration 03/2023 and 04/2023

2. Review of a CAH policy titled, "Patient Care Services Department Outdate Policy," dated 1/2023, revealed in part, "... Each Department Director will ensure there is a check list that will be signed by staff members once they've inventoried all supplies to ensure there are no outdates. Supplies will be checked on a monthly basis with any outdates being discarded and replaced immediately. (This will include all supplies on the crash carts, patient rooms and the supply closets.)...".

3. During an interview at the time of the tour, Charge Nurse A confirmed the Gastroccult cards, Gastroccult bottle and hand sanitizer refills were outdated.

4. During an interview on 5/16/2023 at 10:00 AM, the Medical Surgical Clinical Manager confirmed staff check outdates monthly and sign a log that is posted at the end of the Medical Surgical hallway. The Medical Surgical Clinical Manager acknowledged staff failed to remove the expired supplies from the supply room.

5. During an interview on 5/16/2023 at 08:46 AM, the Director of Environmental Services reported hand sanitizer refills had been unavailable and he recently received a shipment but confirmed the staff failed to remove the expired hand sanitizer refills from the hallway dispensers.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure it maintained a clean and sanitary environment to avoid sources and transmission of infection when it failed to launder the patient privacy curtains based on Centers for Disease Control and Prevention (CDC) guidelines. Failure to remove sources of infection could result in the transmission of the infectious organism(s) to the next patient that handled the contaminated item, which could potentially result in the CAH patients developing a life-threatening infection or death. The CAH administrative staff identified an inpatient census of 5 patients upon entrance and 621 inpatient admissions for fiscal year 7/1/2021 to 6/30/2022.

Findings include:

1. During an observation of a terminal patient room clean, in Medical/Surgical room 111, on 5/15/23 at 2:55 PM, Housekeeper B reported the patient privacy curtains are laundered on a quarterly or as needed.

2. Review of the current Centers for Disease Control and Prevention guidelines, titled "Best Practices for Environmental Cleaning for Healthcare Facilities", recommended monthly scheduled cleaning of bed curtains.

3. Review of the CAH's policy, "Cleaning Discharged Patient Rooms," effective 1/2023, failed to specify the frequency for which the patient privacy curtains are cleaned.

4. During an interview on 5/16/2023 at approximately 8:46 AM, the Director of Environmental Services (EVS), reported EVS staff follow the "Cleaning of Dialysis Unit Curtains" policy for inpatient privacy room curtains and they are cleaned by laundry services quarterly or if visibly soiled.

5. During an interview on 5/16/23 at 2:30 PM, the Infection Preventionist and EVS Director acknowledged the curtains in the patient rooms were not being laundered after each patient is discharged. The EVS Director reported the patient privacy curtains would be removed and laundered quarterly or if they were visibly soiled. The Infection Preventionist acknowledged the CAH follows the CDC guidelines, but confirmed they lacked a policy to address the frequency of laundering the patient privacy curtains.

6. During an interview on 5/17/23 at 2:05 PM, the Process Improvement Director reported the Infection Preventionist confirmed the CDC guidelines identified cleaning patient privacy curtains monthly and did not know EVS laundered them quarterly, unless visibly soiled.