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Based on observation, document review and interview the governing body failed to:
A. provide a sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to poor hand hygiene, unsanitary food handling, unsanitary cooking implement storage, unsanitary food service item (pots, pans, bowls and plates) storage, and poor general sanitation practices was found throughout the dietary department.

B. ensure surgical equipment was properly disinfected, surgical sterilizers were kept clean and patient supplies were stored in a manner to prevent cross contamination. The facility failed to maintain clean surgical floors.
C. ensure disinfectants used on equipment for invasive procedures was properly labeled. The facility failed to ensure floors, patient stretchers, supply closets, crash carts and equipment was kept up in a manner to prevent cross contamination.

D. properly clean patient care areas between the discharge of one patient and the admission of another patient. The facility also failed to provide adequate routine sanitation in the facility. These findings in the Behavioral Health Unit have the likelihood to cause the spread of infection due to lack of proper sanitization.
E. ensure surgical equipment was properly disinfected, surgical sterilizers were kept clean, temperature and humidity monitored, and patient supplies were stored in a manner to prevent cross contamination. The facility failed to maintain clean surgical floors.
F. ensure nursing assessed and developed a nursing plan of care in 1 of 2 patients reviewed for intravenous (IV) therapy (Patient #14).
Refer to tag A0396

G. ensure verbal orders/order sets were complete and signed off timely by the physician in 3 of 3 sampled patients (#s' 12, 33 and 34).
Refer to tag A0407

H. ensure blood transfusions were administered per their policy in 3 of 4 patients (#s' 12, 13, and 33) reviewed for blood administration and reactions.
Refer to tag A0409

I. complete history and physical on 1 (# 27) of 15 surgical inpatients.
Refer to tag 952

J. ensure the intraoperative anesthesia record documentation was complete on 9 (#22, 24, 25, 26, 27, 28, 29, 30, and 31) of 15 surgical inpatients.
Refer to Tag 1004

K. the post anesthesia evaluation was performed for the proper anesthesia recovery on 10 (#22, 23, 24, 25, 26, 27, 28, 29, 30, and 31) of 15 surgical inpatients.
Refer to Tag 1005

L. provide a safe and sanitary environment for patient care.

Refer to Tag A0144

Based upon observation and interview, the facility failed to provide a sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to poor hand hygiene, unsanitary food handling, unsanitary cooking implement storage, unsanitary food service item (pots, pans, bowls and plates) storage, and poor general sanitation practices was found throughout the dietary department. The facility failed to ensure surgical equipment was properly disinfected, surgical sterilizers were kept clean, and patient supplies were stored in a manner to prevent cross contamination. The facility failed to maintain clean surgical floors. The facility failed to ensure disinfectants used on equipment for invasive procedures were properly labeled. The facility failed to ensure floors, patient stretchers, supply closets, crash carts and equipment were kept up in a manner to prevent cross contamination. The facility failed to properly clean patient care areas between the discharge of one patient and the admission of another patient. The facility also failed to provide adequate routine sanitation in the facility.

Refer to Tag A0144

Based upon observation and interview, the facility failed to:

A. provide a sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to poor hand hygiene, unsanitary food handling, unsanitary cooking implement storage, unsanitary food service item (pots, pans, bowls and plates) storage, and poor general sanitation practices was found throughout the dietary department.

B. ensure surgical equipment was properly disinfected, surgical sterilizers were kept clean, and patient supplies were stored in a manner to prevent cross contamination. The facility failed to maintain clean surgical floors.
C. ensure disinfectants used on equipment for invasive procedures were properly labeled. The facility failed to ensure floors, patient stretchers, supply closets, crash carts and equipment were kept up in a manner to prevent cross contamination.

D. properly clean patient care areas between the discharge of one patient and the admission of another patient. The facility also failed to provide adequate routine sanitation in the facility. These findings in the Behavioral Health Unit have the likelihood to cause the spread of infection due to lack of proper sanitization.

Findings for
SECTION A

A tour was done of the Dietary Department on 12/18/2013, at approximately 09:00 am with staff #5, #26 and staff #32. Findings were as follows:
A storage rack was observed filled with pots, pans, metal bowls and baking sheets. Staff #32 identified the cooking equipment (pots, pans etc.) as being clean. The pots, pans, metal bowls and baking sheets were being stored upside down with like items stacked on top of each other. An inspection of the stacked pans revealed the first pan had water condensation on the inside of the pan. The second pan in the stack had water pooled on the bottom of the pan. The second pan was removed from the stack revealing water condensation on the inside. All of the pans in the stack revealed the same results. Approximately 10 pans, stored in the stack had water pooling on the bottom of the pan and water condensation on the inside of the pan.
An inspection of the stacked metal bowls revealed the first bowl had water condensation on the inside. The second bowl in the stack had water pooled on the outside of the bowl and water condensation on the inside. All of the bowls in the stack revealed the same results. Approximately 4 bowls, stored in the stack had water pooling on the outside of the bowl and water condensation on the inside of the bowl.
An inspection of approximately 20 stacked baking sheets revealed the first baking sheet had water condensation on the inside of the pan. The second baking sheet in the stack had water pooled on the bottom of the baking sheet. The second baking sheets removed from the stack revealed water condensation on the inside. All of the baking sheets in the stack revealed the same results. The baking sheets were approximately 16 inches by 24 inches. The baking sheets were about 1 inch deep with a rolled edge that surrounded the entire baking sheet. The rolled edge created a hollow void that captured and held water. Underneath the rolled edges of 19 of the 20 baking sheet, was a black, thick, greasy substance. When the baking sheet was picked up and held with a corner of the baking sheet pointing towards the floor a steady stream of water would flow from the hollow void that captured and held water. The pooling water and water condensation on the pans, metal bowls and baking sheets provided a medium for bacterial growth.
All of the pans, metal bowls and baking sheets observed and inspected were covered with a slick, greasy film.
Further observation revealed:
-5 wire storage units with no impermeable barrier on the bottom shelves in the kitchen;

-Items on the bottom racks included serving plates and bowls, flat cooking trays, and other food preparation and serving supplies;

-With no impermeable barrier on the bottom shelves, these supplies stored on the bottom shelves were not being protected from contamination by floor debris becoming airborne through mopping and foot traffic.


Staff #32 confirmed the plates and bowls, flat cooking trays, and other food preparation and serving supplies were being used by kitchen staff.

A 3 X 10 foot rug was observed on the floor between the kitchen and dry storage supply. The rug was pulled back, exposing the floor. The floor tiles were chipped and broken. Pieces of the tile flooring was missing, exposing the concrete underneath. The open areas exposed a porous surface that would prevent cleaning and disinfecting of the floors.
In a corner of the kitchen, near the food service line (a steam table where food is plated before being delivered to the facility's patients and to a contracted hospital), approximately 10 metal rolling food carts were being stored. The food carts were moved to expose the floor covered with dust, food particles along with bits and pieces of unidentifiable trash. A dried, crusty, brittle frog was observed lying on the floor, against the wall. A thick, black build up was observed on the floor that could be scraped away with the sole of a shoe. The thick black buildup became darker as it neared the wall and baseboard. The floor covered with dust, food particles along with bits and pieces of unidentifiable trash along with the thick, black build up provided a medium for bacterial growth and posed a slipping/fall hazard.
The tour continued to the beginning of the service line. A brown, plastic, rolling food cart was observed sitting against the wall approximately 4 foot from the food service line. The food cart was soiled and stained. The top of the food cart was covered with dust and what appeared to be food particles. The top of the food cart was soiled with sticky, circular areas. The lower part of the cart's door, was covered with a black buildup. What appeared to be the same substance that formed the circular areas top of the food cart was streaked down the front of the food cart's door. The food cart was pulled away from the wall exposing the sides and back of the cart. The exposed areas of the cart were consistently soiled as the door.
Behind the brown, plastic, rolling food cart, low on the wall near the base board was a dry, black substance. A discussion at the time of the finding raised concerns of mold. In the same area of the black substance a hole measuring approximately 2X6 inches was observed in the wall. Pink insulation was observed in the hole. The floor was covered with dust, food particles along with bits and pieces of unidentifiable trash. A damp, black sticky substance covered the area under the cart. Also observed in the area of the rolling food cart was a rolling food warmer. The food warmer was moved exposing a wet floor covered with a black, sticky substance. A floor drain located under the rolling food warmer was encircled with a white, cheese-like substance that had the likelihood to prevent proper drainage. The drain located under the rolling food warmer that was encircled with a white, cheese substance if blocked, would spread bacteria over the entire kitchen, if flooded.
Observation of the service line revealed a rolling plate warmer that was moved to expose the floor covered with dust, food particles along with bits and pieces of unidentifiable trash lying on top of a damp, black sticky substance. The steam table had plates, bowls, and other food preparation and serving supplies being stored wet on a bottom shelf of the steam table. The floor under the steam table was observed covered with dust, food particles along with bits and pieces of unidentifiable trash lying on top of a damp, black, sticky substance. Under the steam table, a drain pan for a food cooler could be visualized. The drain pan was full of water and the water was overflowing onto the floor. Near the overflowing water was a second floor drain. The over flowing water was following the path of a slimy, black trail, across the floor to the drain located approximately 10 inches away. Floating in the drain pan was what appeared to be a small, individual butter cups along with other unidentifiable trash. The wet floor covered with a, black sticky substance provided a medium for bacterial growth.
A third floor drain was observed and located between the foodservice line and a prep table where staff was preparing food. The drain and floor around the drain was covered with a black stick substance. The drain cover contained a buildup of the black sticky substance. The buildup caused a narrowing of the holes in the drain cover. What appeared to be a plastic bag lying on the floor near the drain was covered in a thick, creamy, yellow, opaque substance. The buildup of the black sticky substance covering the drain provided a medium for bacterial growth.

A kitchen staff employee was observed entering the kitchen from outside, pushing a large, grey, trash bin. The staff member pushed the trash bin through the kitchen, around the food service area, stopped and waited for other staff to move and then preceded to push trash bin between the foodservice line and a prep table where staff was preparing food. The large, grey, trash bin had a clearance of approximately 2 foot from the foodservice line and a clearance of approximately 2 foot from the prep table where staff was preparing food. The large, grey, trash bin was stored approximately 6 foot from the foodservice line and in a high traffic area where kitchen staff had the potential to brush against, contaminating clothing and apron. The trash bin was covered with a black, greasy film. The inside of the bin was covered with white sticky substance. Trash was stuck to the inside, bottom of the bin. The wheels on the trash bin were caked with a black, sticky substance. The paint on the wall where the trash bin was being stored, was chipped and flaking in multiple areas. The areas where the paint was missing exposed a porous surface that would prevent cleaning and disinfecting of the walls.

A detailed observation was done of a food cart, used to deliver food treys throughout the hospital to patients. Staff #10 was asked to disassemble the food cart, The process exposed a black sticky substance caked in the corners and crevices within the cart where the patients' food trays were placed. The disassembling of approximately 10 food carts was not done as a result of a discussion among staff #10 and staff #26. Staff #10 and staff #26 agreed the findings would be the same as the first cart and that appropriate cleaning of the carts was not being done.

During kitchen observations on 12/18/13 at 10:28 a.m., the following were found:
Staff member #37 was on the food prep line handling meat patties without gloves. Staff member #37 was observed pouring gravy over the meat patties from one pan to the other pan without using gloves or a utensil. The gravy was dripping down the side of the pan onto the soiled countertop and Staff #37 failed to stop and cleanse it. The now soiled pan was then used to pour gravy over another tray of meat patties and a pan of chicken. The gravy pan, which had gravy residue down the side, was then covered with plastic wrap and placed in a warming cart without being cleaned. Lack of proper cleaning had the likelihood to cause contamination of food prepared in this manner.
Staff member #33 was observed cooking without gloves. He placed his bare hands in the inside of his apron, against his clothes, and watched the activities in the kitchen. Without washing his hands, staff member #33 resumed cooking without gloves. Lack of hand hygiene had the likelihood to cause contamination of food prepared by this employee.
Two female kitchen staff members were preparing glasses of tea for the patients' meal trays. The staff members had tea and ice mixed together in a large stainless steel bowl. They used a plastic glass to dip the tea from the bowl into the patients' glasses. The tea was splashing and running down the side of the stainless steel bowl and the patients' glasses. This process had the likelihood to cross-contaminate all of the tea served to the patients.

Two plastic and one metal food cart was stored in the hallway outside the Dietary Department. The floor of the hallway was covered with leaves, which had blown in from the outside. The metal food cart had a build-up of grease, food particles, and hair. The hinges on the metal food cart were covered with a build-up of grease. One of the plastic food carts, which had just been cleaned, was found soiled with food particles and a brown stain. Lack of food cart cleansing had the likelihood to cause contamination to food transported on these carts.
Interviews were conducted with staff #10 and #26 though out the tour and the findings were witnessed and confirmed.

The tour continued to an off-site kitchen located in the behavioral health unit, with staff #10, #26, #1, and #34. During the tour, the following was observed:

Two (2) wire storage units with no impermeable barrier on the bottom shelves in the kitchen. Items on the bottom racks included serving plates and bowls, and other food preparation and serving supplies. With no impermeable barrier on the bottom shelves, these supplies stored on the bottom shelves were not being protected from contamination by floor debris becoming airborne through mopping and foot traffic.

A food warmer located next to the ice machine was moved exposing a wet floor. The floor under the food warmer was observed covered with dust, food particles along with bits and pieces of unidentifiable trash lying on top of a black sticky substance.

The ice bin was full of ice that was being served to patients, patients' families, staff and other patrons that visited the facility. In the corner of the ice bin was a half full bottle of Mountain Dew (soft drink) shoved down into the ice, creating a likelihood of contamination to the surrounding ice.

Interviews were conducted with staff #1, #10, #26 and staff #34 though out the tour and the findings in the behavioral health kitchen were witnessed and confirmed.


An interview was held on 12/19/13 at approximately 11:00am in the Administrative Conference Room with administrative personnel #19, #34 and #35. The question was asked of each, when was the last time you were in the kitchen:

- Administrative personnel #19's response was, back in the spring during an accreditation survey.

- Administrative personnel #34's response was, a visit was made to the front office portion of the kitchen last week. Administrative personnel #34 had not been in the actual service portion of the kitchen in approximately a month.

- Administrative personnel #35's response was, an infrequent pass is made through the kitchen because it joins a conference room. Administrative personnel #35 was unable to provide an answer as to when a visit was made for the purpose of a visual inspection.

Administrative personnel #19 stated during the interview, "The seriousness of the findings in the kitchen for the liklehood of harm from a food borne illness can't be disputed." Administrative personnel #34 and #35 verbalized agreement with this statement.


Findings for
SECTION B
During a tour of the Respiratory Department on 12/16/2013 at approximately 3:00PM the following was observed:
The Cidex-OPA (cold disinfectant sterilization strips) solution test strips had expired on 11/2013.
The Cidex-OPA test had two open dates documented on the bottle. The first date documented was 11/29/2013. The second date documented was 12/8/2013.
A review of the log titled, "Cidex- OPA Equipment Immersion and Removal Log," revealed thirty three pieces of equipment had been soaked in this solution. The solution was used to disinfect the equipment was not properly tested due to expired strips.
Review of Cidex OPA product insert revealed:

"CIDEX OPA Solution may be reused for up to a Maximum of 14 days provided the required conditions of ortho-phthalaldehyde concentration and temperature exist based upon monitoring described in the Direction for use. Do not rely solely on day in use. Concentration of this product during its reuse life must be verified by the CIDEX OPA Solution Test Strips prior to each use to determine that the concentration of ortho-phthalaidehyde is above the MEC of 3%. The Product must be discarded after 14 days." On the bottle of Cidex -OPA test strips the label reads, "Caution: Do not use after 90 days of opening the bottle."

A review of the policy titled, "Respiratory Care Services" revealed
"2. Check the expiration date on the bottle of Cidex-OPA test strips. Do not use test strips beyond their expiration date as these strips can provide false readings.
3. Record the date the canister of test strips have been opened and a "do not use after ....date" on the bottle in the spaces provided. Do not use any remaining strips 90 days after opening canister."
Staff #39 was questioned if she saw anything wrong with the Cidex-OPA test strip bottle. Staff #39 was unable to find any issues with the strips and had to be shown the expiration date.
An interview staff #38 and #39 confirmed the Cidex-OPA test strips were expired and thirty three pieces of equipment had been soaked in the Cidex without proper testing.
During a tour of the Second Floor Surgical Area on 12/18/2013 at approximately 3:00 PM the following was observed:
-There were 2 large sterilizers and 4 small sterilizers on the floor;

-All six sterilizers were soiled on the interior;

-Cob webs and dust particles were found in the door of the large sterilizer in the sterilization room.

-Exposed insulation material was found surrounding the opening of the large sterilizer in the sterilization room.

During the tour, staff #22 confirmed these findings.

Review of the sterilizer service provider's (Steris) contract/service agreement for 09/01/2010 through 08/31/2013 revealed no evidence cleaning the sterilizers was included.

Review of the sterilizer service provider's (Steris) contract/service agreement for 09/01/2013 through 08/31/2016 revealed cleaning the sterilizers was included.

During an interview on 12/18/13 at 2:50pm in the conference room, staff #23 confirmed the following:

-Cleaning the sterilizers was not included in the contract with the sterilizer service provider (Steris) for the period from 09/01/2010 to 08/31/2013;

-Steris did not clean the sterilizers from 09/01/2010 to 08/31/2013;

-The new contract with Steris, beginning 09/01/13, includes cleaning the sterilizers;

-As of today (12/18/13), Steris has not cleaned the sterilizers.

Patient nutrition refrigerator in the pre-op area had brown substance on the door and on the shelves.
In the Operating Rooms #3 and #6, there were a total of five rusty trash and linen hampers observed. The hampers could not be properly cleaned or sanitized due to the rust.
In the Operating Room #6 dust was found on the shelves of the sterile supply cabinet and there was a liquid spillage on a cardiac monitor cart.
The floors throughout the surgical areas were unclean, discolored, and covered in dust particles.
On the outside of the Cardiac Catherization Laboratory and in front of the entrance to the Operating Room were two pallets of cardboard shipping boxes. This is the main area behind the surgery closed doors, on the main hallway to the operating room suites. The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation stated that "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

During a tour of the 1st floor surgical area on 12/19/2013 at approximately 11:00AM the following was observed:
Operating Room #1 had two rusted trash and linen hampers. Hampers were unable to be properly cleaned or sanitized.
Instruments in the Sterile Instrument Room were stored on the bottom shelf of an open wire rack without a barrier.
Multiple card board shipping boxes were on an open wire rack by the entrance to the Sterile Instrument Room. This is the main area behind the surgery closed doors, on the main hallway to the operating room suites. The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation stated that "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

During a tour of the 1st floor Pre-Operative area on 12/19/2013 at approximately 11:00AM the following was observed:
A stretcher in the Pre-Operative Area had an approximate 2x3 inch tear in the mattress.
In the Pre-Operative storage room, patient care supplies were stored on the bottom shelf without a barrier. The floor below was unclean and had dust particles.
An interview with Staff #32 and #41on 12/19/2013, at approximately 12:30 confirmed the above findings. Staff #32 confirmed that the shipping boxes are bought into the surgical area. She also confirmed that the shipping boxes were brought into the hospital departments and stored with clean supplies. The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation stated that "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

A revisit was performed to the Second Floor Surgical Area on 12/19/2013, at approximately 12:30 PM the following was observed:
The patient nutrition refrigerator had not been cleaned. The brown substance spilled on the shelves was still present. There were two food containers for Cath lab (Catheterization Laboratory is where patient receives cardiac diagnostic procedures) patients dated 12/17/2013 were still in the refrigerator.
In the Cath Lab storage room, outside shipping boxes were found next to clean heart catheterization catheters. The catheters were on open wire racks with approximately a ¼ inch of dust and dirt accumulation on the above rack above the boxes of clean catheters. The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation stated that "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

During a tour of the Gastrointestinal (GI) Lab on 12/17/2013 at 9:00AM and on 12/18/2013 at 4:00PM observed the following:
In the decontamination room #1, the Endoscope Reprocessor .45-Micron Filter and 1-Micron Filter were dated 5/28/13 to show when the filters were last changed.
A review of the log titled, "DSD Filter Change Log" revealed the filters were to be changed every six months.
In the decontamination room #2, the Endoscope Reprocessor .45-Micron Filter and 1-Micron Filter were dated 5/13 to show when the filters were last changed.
The Endoscope Reprocessor Instruction and Service manual states, "The micron filters must be replaced, and the water lines disinfected, a minimum of once every six months."
A review of the of the log titled, "Disinfectant Efficacy Monitoring Log" in decontamination room #2 revealed the temperature, change, and the "pass/fail" were to be recorded daily. A review of the recordings for the month of October 2013, 20 of 31 days recorded, November 2013 16 of 30 days recorded, and in December 2013, 6 of 18 days were recorded.
An interview with staff #40 on 12/17/2013 at approximately 4:00PM, confirmed the log had not been recorded daily.
Staff #40 on 12/17/2013, at approximately 10:30AM, was observed taking the endoscopy cart to another department of the facility and being used for an endoscopy procedure.
Staff #40 was questioned on how the endoscopy cart would be cleaned after being taken and used in other departments of the facility. She answered, "I just wipe the top of the cart."
An interview with #32 and #41 on 12/19/2013, at approximately 12:30PM, confirmed the cart is not being cleaned properly after being bought back to the department.

Findings for
SECTION C

During observations the following was found:
*Radiology
On 12/16/2013, at 1:30 p.m., open containers of the disinfectant Cidex OPA used on intra-vaginal transducers were found in Ultrasound Room #'s 1, 2, 3, and 4. All the containers had no open date.
Review of the manufacturer label revealed once opened the unused portion of the solution may be used up to 75 days. There was also a place on the label for the open date to be recorded.
Review of a log in Ultrasound Room #3 named "Performance Improvement-Ultrasound" used for documenting quality control checks revealed a serial number recorded for a container of Cidex OPA. The documentation indicated staff were currently using this bottle of Cidex OPA.
The bottle of Cidex OPA which was logged could not be found. Two more open bottles of the solution were in the room, but they were not logged as being currently used.
Ultrasound Room #2 had a mattress on the stretcher which had a tear approximately one inch in size.
Staff #24 confirmed the observations and reported the staff should be dating the containers.

*Medical Surgical Unit
On 12/17/2013, at 12:00 p.m., the top of a crash cart had a hard plastic covering which was soiled with an accumulation of tape residue and old stickers.

*Intensive Care Unit
On 12/17/2013, at 2:55 p.m., the top of two crash carts had a build-up of tape residue and was soiled with brown substance.
Two isolation carts were found rusted and contained clean patient supplies. There was no way for the carts to be properly sanitized.
Staff #31 confirmed the conditions of the carts.

*Therapy Room
On 12/18/2013, at 2:10 p.m., three tread mills were found with broken and cracked panels and were noted to be secured with tape.
Staff #25 confirmed the observations.

*Emergency Room
On 12/18/2013, at 9:45 a.m., Patient Room #'s 7, 9, 10, 11, and 12 had patient stretchers which had a metal side strip that had separated from the frame. The panels were secured to the frame with clear tape.
Room #12 had an approximate 3 inch tear in the mattress which was taped up. Underneath the mattress was a build-up of white particles and there dried gum on the bed frame.
The floor in one of the triage rooms had a build-up of wax and there was a build-up of dirt and dust near the baseboards. One crash cart had a plastic white covering which was cracked and had a build-up of tape residue.
One suction cart had a piece of cardboard which was taped into drawer to make a panel to separate clean supplies.
The patient ice machine had a dried brown substance covering a metal panel near the spout where the ice came out.
The clean supply room was disorganized and supplies just thrown on a shelf. There was a build-up of dirt and dust on the floor.
Staff #29 confirmed the observations.


Findings for
SECTION D
A tour of the Behavioral Health Unit on Fannin Street was conducted on 12/17/2013.
The medication room on the Adult Acute Unit was found to have the following issues:
1.) A sharps container soiled with blood;
2.) Dirty and stained floor;
3.) The base boards were dirty with a dried substance and a dirty build up;
4.) The medication Pixys was soiled on top and on the front panels;
5.) The back splash on the sink was buckled and warped from water exposure, causing the underlying particle board to be exposed and unable to be properly cleaned;
6.) The medication refrigerator was dirty;
7.) Stains and dried spilled substances were on the walls.
Staff #1, #5, and #17 confirmed the issues found in the medication room.
The electrical closet in the nurses' station on the Adult Acute Unit had a large amount of dust and dirt on the floor. Staff #1 and #5 confirmed this finding.
The Adult Unit seclusion rooms had no base boards, resulting in a gap between the walls and tile floor. The floor could not be sanitized properly. Dirt and hair had accumulated in the resulting gap. The mattresses in two of the four seclusion rooms were dirty. Staff #1 and #5 confirmed the findings.
One of two mattresses were soiled in the Child and Adolescent Unit seclusion rooms. The bathroom floor of the seclusion room was dirty. Staff #1 and #5 confirmed the findings.
Clean medical supplies were found stored in a room with unclean supplies, a copier machine, paper sacks, and a paper shredder. Therefore, clean supplies were unable to be protected from becoming contaminated. Staff #1 and #5 confirmed the finding.
In room 304, the floor tiles were missing along the south wall. The floor could not be sanitized properly. Dirt and hair was found between the tiles and the wall. Staff #5, #1, and #17 confirmed the above findings.
Observation in the Child and Adolescent Unit medication preparation room revealed the following:
1.) Broken and dirty floor tiles;
2.) Broken wooden door under the sink exposing bare wood and that could not be properly cleaned;
3.) Ice machine was dirty;
4.) Bright red splatters around the sink and on back splash;
5.) Dusty equipment sitting on the medication refrigerator;
6.) The inside of the medication refrigerator was dirty and had ice buildup;
7.) The medication Pixys system was soiled on top, on the sides, and front with a dry, splattered substance.
Staff #1 and #5 confirmed the findings in the Child and Adolescent Unit medication preparation room.
The back board, suction machine, and lower shelf of the emergency cart was covered in dust and dirt. Staff #52, #1, and #46 confirmed the findings.
The Geriatric Unit seclusion room had tears in the mattress, allowing fluids to seep into the foam. This made the mattress impossible to be properly cleaned. Staff #1 and #46 confirmed the tears.
The shower room on the Geriatric Unit had soap scum build up on the shower and shower floor. The shower chair had stains from a previous mold removal. The metal shower handles had rust around the screw caps. Staff #1 confirmed these findings.
These findings in the Behavioral Health Unit have the likelihood to cause spread of infection due to lack of proper cleaning between patients and inadequate routine sanitation.

Based on document review and interview the governing body failed to ensure follow up by the quality department on 36 of 36 findings presented by the Infection Control Department. The 36 of 36 findings were discovered on routine environmental rounds on 07/24/2013 and submitted by e-mail to the Director of Quality Assessment Performance Improvement (QAPI) and to the Vice President (V.P.) of Business Development.

A review of the e-mail document dated 7/24/13, from staff #41, to QAPI Director staff #5, (V.P.) of Business Development staff #34, Director of Dietary staff #10 and Director of Infection Control staff #32 revealed, "Ladies and Gentleman, Attached are the findings of our environmental rounds from the kitchen. Please review and provide resolutions for the outstanding issues. Thank you."
A review of the environmental rounds document mentioned in the e-mail, titled "Infection Control Assessment of Beaumont Nutritional Services 7/24/13" revealed:
1 Refrigerator #8 personal creamer with patient food
2 Refrigerator #9 no dates on several items
3 Refrigerator #9 cardboard boxes in refrigerator
4 Food in CVAP not fully covered
5 Sink by CVAP needs to be cleaned
6 Gloves need replacing by CVAP
7 No label/date on gravy mix
8 Bread not dated
9 Employee water bottles in patient refrigerators and on countertops
10 Produce walk-in: vegetables not dated
11 Produce walk-in: Caesar dressing not dated
12 Produce walk-in: lower shelves dirty
13 Clean bins on dirty shelves
14 Spices not labels/dated
15 Open hamburger buns on counter not dated/labeled
16 Clean dishes stored on dirty trays
17 Standing water in rim of pans
18 Fruit and pie trays not labeled
19 Dirty meat slicer
20 Standing water in food processor
21 Bread rolls on below meat slicer not dated
22 Food transporters dirty
23 Refrigerator bottoms dirty
24 Utensils stored in refrigerator
25 Counter tops dirty
26 Shelves dirty
27 Ice machine front and top dirty, and surrounding floor area
28 Chicken in standing refrigerator not covered/labeled
29 Refrigerated batter not dated
30 Dirty range 31 Black rags & brushes by grill stacked on baskets
32 Cleaning supplies and products by dishwasher
33 Cans not dated in supply room
34 Rice and flour stored near sink
35 Tops of refrigerators need to be cleaned
36 Cardboard boxes on floor
A review of the document dated 7/29/13 and titled, "Corrective/ preventive Action Form" revealed:

"What is the Nonconformity/Potential Nonconformity?
Not dating/labeling of all foods in the kitchen and general sanitation.

What actions or steps led to the cause or potential cause of nonconformities:
Dating/labeling is inconsistent among staff, Employees are not being held accountable for general sanitation and being checked out by Supervisors before leaving each day.
Corrective/Preventive Action Plan: In-Service production staff and Hostesses on dating/labeling to include all foods. All food items are to be dated/labeled upon being opened. The Executive Chef and Director will do a weekly checklist through the kitchen to make sure all foods are dated/labeled. This will include dry storage areas, refrigeration and in the production areas themselves. The Executive chef and Kitchen Manager will check out production staff daily until this becomes hard wired."
An interview with staff #41 on 12/19/13 at approximately 9:00 am in the Infection Control Office revealed environmental rounds are scheduled and made every six months. Staff #41 revealed there had not been any environmental rounds or follow up to the Dietary Department since the findings on 7/24/13.

An interview was held on 12/19/13 at approximately 11:00am in the Administrative Conference Room with administrative personnel #19, #34 and #35. The question was asked of each, When was the last time you were in the kitchen? The responses were as follows:

- Administrative personnel #19's response was, back in the spring during an accreditation survey.

- Administrative personnel #34's response was, a visit was made to the front office portion of the kitchen last week. Administrative personnel #34 had not been in the actual service portion of the kitchen in approximately a month.

- Administrative personnel #35's response was, an infrequent pass is made through the kitchen because it joins a conference room. Administrative personnel #35 was unable to provide an answer as to when a visit was made for the purpose of a visual inspection.

Administrative personnel #19 stated during the interview, "The seriousness of the findings in the kitchen for the likelihood of harm from a food borne illness can't be disputed." Administrative personnel #34 and #35 verbalized agreement with this statement.

Based on observation, interview and record review the facility failed to:

A. ensure nursing assessed and developed a nursing plan of care in 1 of 2 patients reviewed for intravenous (IV) therapy (Patient #14).
Refer to tag A0396

B. ensure verbal orders/order sets were complete and signed off timely by the physician in 3 of 3 sampled patients (#s' 12, 33 and 34).
Refer to tag A0407

C. ensure blood transfusions were administered per their policy in 3 of 4 patients (#s' 12, 13, and 33) reviewed for blood administration and reactions.
Refer to tag A0409

Based on observation, interview and record review the facility failed to ensure nursing assessed and developed a nursing plan of care in 1 of 2 patients reviewed for intravenous (IV) therapy (Patient #14).
This deficient practice had the likelihood to cause harm to all patients receiving intravenous therapy.
Findings include:
Review of a "Nurse's Note" dated 12/15/2013, 6:23 a.m. revealed Patient #14 was a 42 year old female who presented to the emergency room as a walk-in. Patient #14 had a history of bipolar disorder and presented with a diagnosis of a "Septic Joint-Right knee: Cellulitis." According to the "Nurse's Note" Patient #14 received an 18 gauge (IV -intravenous needle) to the right forearm prior to arrival to the emergency room. There was documentation of Patient #14 being awake, alert, oriented and obeys commands. At 7:00 a.m., there was documentation to "maintain field IV. Dressing intact. Good blood return noted. Site clean and dry. Gauge and site: "18 gauge to right FA." There was no documentation of what time the IV was inserted in the field.
Review of the "Medication Administration Record" dated 12/15-17/2013 revealed Patient #14 was receiving the antibiotics Vancomycin and Rocephin IV every 12 hours.
During an observation on 12/17/2013 at 10:50 a.m., Patient #14 was in bed, lethargic and with an IV (heploc) site to the right lower arm which had no time or date of insertion. Coban dressing was wrapped around the right arm above and below the site and was so tight it caused indentions in the arm. The IV site was swollen, red and there was a bag of IV fluids infusing. During an interview Staff #21 confirmed the missing dates, times and the condition of the IV site.
Review of "Nurse's Note" revealed documentation of the IV site on 12/15/2013 at 5:30 p.m. and 12/16/2013 at 8:00 a.m. As of 12/17/2013 at 11:00 a.m. (27 hours later) there was no documentation of an assessment of the IV site.
Review of the policy dated 12/2012 named "Insertion, Discontinuation of and Management of Intravenous Therapy" revealed the following:
"Reassess the infusion rate, drip rate and patient condition frequently during the infusion. Observe for signs of infiltration, redness, swelling or no blood return. Needles should be discontinued upon evidence of edema, redness, phlebitis pain or subcutaneous infiltration.
Assess the venipuncture site for signs of infiltration. Record condition of site and/or surrounding area in the Nurses notes' every shift.
Document date, time, and amount and type of solution, additive, flow rate and insertion site. The Narrative Notes should reflect insertion site, size of needle inserted and site care, any problems encountered with the procedure.
IV catheters inserted under emergency conditions )I.e.: in the field by EMS), must be removed and a new catheter inserted at a different site within 48 hours. If the site cannot be rotated due to lack of another site being available, or some other reason, is to be documentation in the Nurses' Notes."
During an interview on 12/17/2013 at 11:00 a.m., Staff #21 confirmed the missing assessments and not knowing when the initial IV was inserted.

Based on interview and record review the facility failed to ensure verbal orders/order sets were complete and signed off timely by the physician in 3 of 3 sampled patients (#s' 12, 33 and 34).
This deficient practice had the likelihood to cause harm to all patients.
Findings include:

Review of "Admission Orders" revealed Patient #34 was a 64 year old male admitted on 12/08/2013 with diagnoses of dehydration and tachycardia.
Review of physician orders revealed the following verbal orders taken by nursing which had not been signed off by the physician as of 12/18/2013:
12/08/2013 - Two different verbal orders timed for 8:15 p.m.
12/08/2013 - Hypoglycemia order sets which were signed as verbal orders and timed 9:45 p.m.
12/09/2013 - Thromboembolic therapy order sets which were verbal orders and timed 9:45 p.m.
12/09/2013- Two different verbal orders timed 10:40 a.m. and 10:45 a.m..
12/09/2013- Adult Severe Sepsis and Sepsis Shock order sets which included had orders for labs, treatments and medications.
12/10/2013, 12/11/2013. 12/12/2013, 12/13/2013, 12/14/2013, 12/15/2013, 12/16/2013 - Daily Parenteral Nutrition Orders. Nursing continued to administer without getting the physician to sign off.
12/10/2013- Two verbal orders, one without a date and one timed 10:15 p.m.
12/11/2013 - Adult ICU Electrolyte Replacement order sets which included orders for medications.
12/11/2013 - one verbal order timed 9:50 a.m.
12/12/2013- One verbal order timed 5:30 p.m.
12/13/2013- One verbal order timed 12:35 p.m.
12/14/2013- One verbal order timed 10:00 a.m.
12/15/2013- One verbal order timed 4:32 p.m.

Review of a "Transfusion Order Set" dated 12/15/2013 timed 7:15 a.m., revealed Patient #12 was a 71 year old female admitted on 12/14/2013.
According to the "Transfusion Order Set" Patient #12 was to receive 2 units of packed red blood cells. According to instructions on the orders the physician was to indicate the type and amount on the first line and make "x" in one or more of the categories and corresponding justification (s). The only part of the orders completed was the type and amount of blood. There was no justification listed nor was the hemoglobin and hematocrit section completed.
The "Transfusion Order Set" was signed as a verbal order by nursing, but was not signed off by the physician. The orders were incomplete.
There was a thromboembolic therapy order set dated 12/15/2013, 8:10 a.m. which were verbal orders which had not been signed off by the physician.

Review of a "Transfusion Order Set" dated 12/15/2013 revealed Patient #33 was a 45 year old female admitted on 11/19/2013 and was ordered 3 units of packed red blood cells on 11/20/2013.
The "Transfusion Order Set" was signed as a verbal order by nursing, but was not signed off by the physician until 12 days later on 12/02/2013.
Review of the "Medical Staff Bylaws and Rules and Regulations" dated 12/17/2012 revealed the following about physician orders:
"Standing Orders may be formulated by a member of the Medical Staff for individual patients. These orders shall be signed by the attending physician and shall be reviewed annually by the attending physician.
All orders for inpatients and outpatients treatment shall be documented. All orders shall be in writing, dated, and timed. Orders shall be considered documented, if identified by the name of the person receiving the order and the name of the practitioner giving the order.
The hospital employee who takes the verbal order will flag the verbal order chart entry for the practitioner' s signature. The goal of the Medical Staff is to have all verbal orders signed within 48 hours or as soon as possible thereafter."
During an interview on 12/18/2013 at 4:55 p.m., Staff #36 confirmed the orders had not been signed off by the physician.

Based on interview and record review the facility failed to ensure blood transfusions were administered per their policy in 3 of 4 patients (#s' 12, 13 and 33) reviewed for blood administration and reactions.
This deficient practice had the likelihood to cause harm to all patients receiving blood transfusions.

Findings include:

Review of a "Transfusion Order Set" dated 12/15/2013 revealed Patient #33 was a 45 year old female admitted on 11/19/2013 and was ordered 3 units of packed red blood cells on 11/20/2013.
Unit #1
*The first set of vital sets was taken on 11/20/2013 at 6:50 p.m. and other set of vital signs were taken at 6:55 p.m., 7:05 p.m., 8:00 p.m. and then the blood was stopped at 8:30 p.m. According to the flow sheet the blood was stopped because of a reaction. Patient #33 had whelps on her neck which spread to the upper and lower extremities. There was no documented time of when the blood was initially hung.
*Unit #2
The first full set of vital signs was taken on 11/21/2013 at 3:05 p.m. Six more sets of vital signs were taken they did not include the temperature, respirations or times. The next full set of vital signs was not taken until over 2 hours later at 5:42 p.m.
*Unit #3
The first full set of vital signs was taken on 11/21/2013 at 7:23 p.m. 10 more sets of vital signs were taken and they did not include the temperature, respirations or times. The blood was stopped over 2.5 hours later at 10:00 p.m. and the temperature and respirations were not taken.


Review of a "Transfusion Order Set" revealed Patient #13 was a 71 year old male admitted on 12/10/2013.
Review of a "Blood and Blood Component Flow Sheet" on Patient #13 revealed the following:
Unit #1
*The first set of vital signs was taken on 12/10/2013 at 11:00 p.m. and two nurses signed the blood was verified on 12/10/2013 at 11:00 p.m. The next set of vital signs was taken on 11:45 p.m. There was no documented time of when the blood was initially hung.
Unit #2
* The first set of vital signs was taken on 12/11/2013 at 2:45 a.m. and two nurses signed the blood was verified on 12/10/2013 at 2:45 a.m. The next set of vital signs was taken at 3:25 a.m. There was no documented time of when the blood was initially hung.

Review of a "Transfusion Order Set" dated 12/15/2013 revealed Patient #12 was a 71 year old female admitted on 12/14/2013.
According to the "Transfusion Order Set" Patient #12 was to receive 2 units of packed red blood cells. According to instructions on the orders the physician was to indicate the type and amount on the first line and make "x" in one or more of the categories and corresponding justification (s). The only part of the orders completed was the type and amount of blood. There was no justification listed nor was the hemoglobin and hematocrit section completed.
Review of a "Blood and Blood Component Flow Sheet" on Patient #12 revealed the following:

Unit #1
*The first set of vital signs was taken on 12/15/2013 at 12:30 p.m.
*Two nurses signed the blood was verified on 12/15/2013 at 12:48 p.m. and 1:00 p.m.
*The next set of vital signs was taken at 1:00 p.m... There was no documented time of when the blood was initially hung.
* The next hourly vital sign was taken over an hour later at 2:30 p.m.

Unit #2
*The first set of vital signs was taken on 12/15/2013 at 3:20 p.m.
*Two nurses signed the blood was verified on 12/15/2013 at 3:25 p.m.
*The next set of vital was taken at 3:45 p.m. There was no documented time of when the blood was initially hung.

Review of the policy dated 11/2012 named "Blood or Blood Component Therapy/Management of Transfusion Reaction" revealed the following:
"Take an record the patient's vital signs, including temperature prior to administration of blood or components, and after the first 50 mls of blood has infused, and then hourly for the duration of the transfusion.
Baseline vital signs are used for later comparisons, to determine possible transfusion reaction.
The most common clinical events accompanying a severe transfusion reaction in order of frequency area:
a. fever, with or without chills
b. lumbar, extremity, or chest pain
c. change of pulse, temperature or blood pressure (hypotension)
d. nausea
e. nausea, flushing of the face
f. dyspnea
g. bleeding"
During an interview on 12/17/2013 at 11:40 a.m., Staff #21 confirmed there was no blood initiation dates on the forms. They were just realizing it was not there.

Based upon observation and interview, the facility failed to provide a sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to poor hand hygiene, unsanitary food handling, unsanitary cooking implement storage, unsanitary food service item (pots, pans, bowls and plates) storage, and poor general sanitation practices was found throughout the dietary department.


It was determined that these deficient practices created an Immediate Jeopardy situation, resulting in a likelihood of harm, serious injury, and subsequent death to all patients, staff, and visitors consuming food prepared in the dietary department.


A tour was done of the Dietary Department on 12/18/2013, at approximately 09:00 am with staff #5, #26 and staff #32. Findings were as follows:

A storage rack was observed filled with pots, pans, metal bowls and baking sheets. Staff #32 identified the cooking equipment (pots, pans etc.) as being clean. The pots, pans, metal bowls and baking sheets were being stored upside down with like items stacked on top of each other. An inspection of the stacked pans revealed the first pan had water condensation on the inside of the pan. The second pan in the stack had water pooled on the bottom of the pan. The second pan was removed from the stack revealing water condensation on the inside. All of the pans in the stack revealed the same results. Approximately 10 pans, stored in the stack had water pooling on the bottom of the pan and water condensation on the inside of the pan.

An inspection of the stacked metal bowls revealed the first bowl had water condensation on the inside. The second bowel in the stack had water pooled on the outside of the bowl and water condensation on the inside. All of the bowls in the stack revealed the same results. Approximately 4 bowls, stored in the stack had water pooling on the outside of the bowl and water condensation on the inside of the bowl.

An inspection of approximately 20 stacked baking sheets revealed the first baking sheet had water condensation on the inside of the pan. The second baking sheet in the stack had water pooled on the bottom of the baking sheet. The second baking sheets removed from the stack revealed water condensation on the inside. All of the baking sheets in the stack revealed the same results. The baking sheets were approximately 16 inches by 24 inches. The baking sheets were about 1 inch deep with a rolled edge that surrounded the entire baking sheet. The rolled edge created a hollow void that captured and held water. Underneath the rolled edges of 19 of the 20 baking sheet, was a black, thick, greasy substance. When the baking sheet was picked up and held with a corner of the baking sheet pointing towards the floor a steady stream of water would flow from the hollow void that captured and held water. The pooling water and water condensation on the pans, metal bowls and baking sheets provided a medium for bacterial growth.

All of the pans, metal bowls and baking sheets observed and inspected were covered with a slick, greasy film.

Further observation revealed:
-5 wire storage units with no impermeable barrier on the bottom shelves in the kitchen;

-Items on the bottom racks included serving plates and bowls, flat cooking trays, and other food preparation and serving supplies;

-With no impermeable barrier on the bottom shelves, these supplies stored on the bottom shelves were not being protected from contamination by floor debris becoming airborne through mopping and foot traffic.


Staff #32 confirmed the plates and bowls, flat cooking trays, and other food preparation and serving supplies were being used by kitchen staff.

A 3 X 10 foot rug was observed on the floor between the kitchen and dry storage supply. The rug was pulled back, exposing the floor. The floor tiles were chipped and broken. Pieces of the tile flooring was missing, exposing the concrete underneath. The open areas exposed a porous surface that would prevent cleaning and disinfecting of the floors.

In a corner of the kitchen, near the food service line (a steam table where food is plated before being delivered to the facility's patients and to a contracted hospital), approximately 10 metal rolling food carts were being stored. The food carts were moved to expose the floor covered with dust, food particles along with bits and pieces of unidentifiable trash. A dried, crusty, brittle frog was observed lying on the floor, against the wall. A thick, black build up was observed on the floor that could be scraped away with the sole of a shoe. The thick black buildup became darker as it neared the wall and baseboard. The floor covered with dust, food particles along with bits and pieces of unidentifiable trash along with the thick, black build up provided a medium for bacterial growth and posed a slipping/fall hazard.

The tour continued to the beginning of the service line. A brown, plastic, rolling food cart was observed sitting against the wall approximately 4 foot from the food service line. The food cart was soiled and stained. The top of the food cart was covered with dust and what appeared to be food particles. The top of the food cart was soiled with sticky, circular areas. The lower part of the cart's door, was covered with a black buildup. What appeared to be the same substance that formed the circular areas top of the food cart was streaked down the front of the food cart's door. The food cart was pulled away from the wall exposing the sides and back of the cart. The exposed areas of the cart were consistently soiled as the door.

Behind the brown, plastic, rolling food cart, low on the wall near the base board was a dry, black substance. A discussion at the time of the finding raised concerns of mold. In the same area of the black substance a hole measuring approximately 2X6 inches was observed in the wall. Pink insulation was observed in the hole. The floor was covered with dust, food particles along with bits and pieces of unidentifiable trash. A damp, black sticky substance covered the area under the cart. Also observed in the area of the rolling food cart was a rolling food warmer. The food warmer was moved exposing a wet floor covered with a black, sticky substance. A floor drain located under the rolling food warmer was encircled with a white, cheese-like substance that had the likelihood to prevent proper drainage. The drain located under the rolling food warmer that was encircled with a white, cheese substance if blocked, would spread bacteria over the entire kitchen, if flooded.

Observation of the service line revealed a rolling plate warmer that was moved to expose the floor covered with dust, food particles along with bits and pieces of unidentifiable trash lying on top of a damp, black sticky substance. The steam table had plates, bowls, and other food preparation and serving supplies being stored wet on a bottom shelf of the steam table. The floor under the steam table was observed covered with dust, food particles along with bits and pieces of unidentifiable trash lying on top of a damp, black, sticky substance. Under the steam table, a drain pan for a food cooler could be visualized. The drain pan was full of water and the water was overflowing onto the floor. Near the overflowing water was a second floor drain. The over flowing water was following the path of a slimy, black trail, across the floor to the drain located approximately 10 inches away. Floating in the drain pan was what appeared to be a small, individual butter cups along with other unidentifiable trash. The wet floor covered with a, black sticky substance provided a medium for bacterial growth.


A third floor drain was observed and located between the foodservice line and a prep table where staff was preparing food. The drain and floor around the drain was covered with a black stick substance. The drain cover contained a buildup of the black sticky substance. The buildup caused a narrowing of the holes in the drain cover. What appeared to be a plastic bag lying on the floor near the drain was covered in a thick, creamy, yellow, opaque substance. The buildup of the black sticky substance covering the drain provided a medium for bacterial growth.


A kitchen staff employee was observed entering the kitchen from outside, pushing a large, grey, trash bin. The staff member pushed the trash bin through the kitchen, around the food service area, stopped and waited for other staff to move and then preceded to push trash bin between the foodservice line and a prep table where staff was preparing food. The large, grey, trash bin had a clearance of approximately 2 foot from the foodservice line and a clearance of approximately 2 foot from the prep table where staff was preparing food. The large, grey, trash bin was stored approximately 6 foot from the foodservice line and in a high traffic area where kitchen staff had the potential to brush against, contaminating clothing and apron. The trash bin was covered with a black, greasy film. The inside of the bin was covered with white sticky substance. Trash was stuck to the inside, bottom of the bin. The wheels on the trash bin were caked with a black, sticky substance. The paint on the wall where the trash bin was being stored, was chipped and flaking in multiple areas. The areas where the paint was missing exposed a porous surface that would prevent cleaning and disinfecting of the walls.


A detailed observation was done of a food cart, used to deliver food treys throughout the hospital to patients. Staff #10 was asked to disassemble the food cart, The process exposed a black sticky substance caked in the corners and crevices within the cart where the patients' food trays were placed. The disassembling of approximately 10 food carts was not done as a result of a discussion among staff #10 and staff #26. Staff #10 and staff #26 agreed the findings would be the same as the first cart and that appropriate cleaning of the carts was not being done.


During kitchen observations on 12/18/13 at 10:28 a.m., the following were found:
Staff member #37 was on the food prep line handling meat patties without gloves. Staff member #37 was observed pouring gravy over the meat patties from one pan to the other pan without using gloves or a utensil. The gravy was dripping down the side of the pan onto the soiled countertop and Staff #37 failed to stop and cleanse it. The now soiled pan was then used to pour gravy over another tray of meat patties and a pan of chicken. The gravy pan, which had gravy residue down the side, was then covered with plastic wrap and placed in a warming cart without being cleaned. Lack of proper cleaning had the likelihood to cause contamination of food prepared in this manner.

Staff member #33 was observed cooking without gloves. He placed his bare hands in the inside of his apron, against his clothes, and watched the activities in the kitchen. Without washing his hands, staff member #33 resumed cooking without gloves. Lack of hand hygiene had the likelihood to cause contamination of food prepared by this employee.

Two female kitchen staff members were preparing glasses of tea for the patients' meal trays. The staff members had tea and ice mixed together in a large stainless steel bowl. They used a plastic glass to dip the tea from the bowl into the patients' glasses. The tea was splashing and running down the side of the stainless steel bowl and the patients' glasses. This process had the likelihood to cross-contaminate all of the tea served to the patients.

Two plastic and one metal food cart was stored in the hallway outside the Dietary Department. The floor of the hallway was covered with leaves, which had blown in from the outside. The metal food cart had a build-up of grease, food particles, and hair. The hinges on the metal food cart were covered with a build-up of grease. One of the plastic food carts, which had just been cleaned, was found soiled with food particles and a brown stain. Lack of food cart cleansing had the likelihood to cause contamination to food transported on these carts.

Interviews were conducted with staff #10 and #26 though out the tour and the findings were witnessed and confirmed.


The tour continued to an off-site kitchen located in the behavioral health unit, with staff #10, #26, #1, and #34. During the tour, the following was observed:

Two (2) wire storage units with no impermeable barrier on the bottom shelves in the kitchen. Items on the bottom racks included serving plates and bowls, and other food preparation and serving supplies. With no impermeable barrier on the bottom shelves, these supplies stored on the bottom shelves were not being protected from contamination by floor debris becoming airborne through mopping and foot traffic.


A food warmer located next to the ice machine was moved exposing a wet floor. The floor under the food warmer was observed covered with dust, food particles along with bits and pieces of unidentifiable trash lying on top of a black sticky substance.


The ice bin was full of ice that was being served to patients, patients' families, staff and other patrons that visited the facility. In the corner of the ice bin was a half full bottle of Mountain Dew (soft drink) shoved down into the ice, creating a likelihood of contamination to the surrounding ice.


Interviews were conducted with staff #1, #10, #26 and staff #34 though out the tour and the findings in the behavioral health kitchen were witnessed and confirmed.


An interview was held on 12/19/13 at approximately 11:00am in the Administrative Conference Room with administrative personnel #19, #34 and #35. The question was asked of each, when was the last time you were in the kitchen:

- Administrative personnel #19's response was, back in the spring during an accreditation survey.

- Administrative personnel #34's response was, a visit was made to the front office portion of the kitchen last week. Administrative personnel #34 had not been in the actual service portion of the kitchen in approximately a month.

- Administrative personnel #35's response was, an infrequent pass is made through the kitchen because it joins a conference room. Administrative personnel #35 was unable to provide an answer as to when a visit was made for the purpose of a visual inspection.

Administrative personnel #19 stated during the interview, "The seriousness of the findings in the kitchen for the liklehood of harm from a food borne illness can't be disputed." Administrative personnel #34 and #35 verbalized agreement with this statement.

Based on observation, record review, and interview, the facility failed to:

A. provide a sanitary environment in the dietary department (food storage and preparation areas). There was a likelihood for cross-contamination due to poor hand hygiene, unsanitary food handling, unsanitary cooking implement storage, unsanitary food service item (pots, pans, bowls and plates) storage, and poor general sanitation practices found throughout the dietary department.

A tour was done of the Dietary Department on 12/18/2013 at approximately 09:00 am with staff #5, #26 and staff #32.

Findings were as follows:

A storage rack was observed filled with pots, pans, metal bowls and baking sheets. Staff #32 identified the cooking equipment (pots, pans etc.) as being clean. The pots, pans, metal bowls and baking sheets were being stored upside down with like items stacked on top of each other. An inspection of the stacked pans revealed the first pan had water condensation on the inside of the pan. The second pan in the stack had water pooled on the bottom of the pan. The second pan was removed from the stack revealing water condensation on the inside. All of the pans in the stack revealed the same results. Approximately 10 pans, stored in the stack had water pooling on the bottom of the pan and water condensation on the inside of the pan.

An inspection of the stacked metal bowls revealed the first bowl had water condensation on the inside. The second bowel in the stack had water pooled on the outside of the bowl and water condensation on the inside. All of the bowls in the stack revealed the same results. Approximately 4 bowls, stored in the stack had water pooling on the outside of the bowl and water condensation on the inside of the bowl.

An inspection of approximately 20 stacked baking sheets revealed the first baking sheet had water condensation on the inside of the pan. The second baking sheet in the stack had water pooled on the bottom of the baking sheet. The second baking sheets removed from the stack revealed water condensation on the inside. All of the baking sheets in the stack revealed the same results. The baking sheets were approximately 16 inches by 24 inches. The baking sheets were about 1 inch deep with a rolled edge that surrounded the entire baking sheet. The rolled edge created a hollow void that captured and held water. Underneath the rolled edges of 19 of the 20 baking sheet, was a black, thick, greasy substance. When the baking sheet was picked up and held with a corner of the baking sheet pointing towards the floor a steady stream of water would flow from the hollow void that captured and held water. The pooling of water and water condensation on the pans, metal bowls and baking sheets provided a medium for bacterial growth.

All of the pans, metal bowls and baking sheets observed and inspected were covered with a slick, greasy film.

Further observation revealed:

-5 wire storage units with no impermeable barrier on the bottom shelves in the kitchen;


-Items on the bottom racks included serving plates and bowls, flat cooking trays, and other food preparation and serving supplies;


-With no impermeable barrier on the bottom shelves, these supplies stored on the bottom shelves were not being protected from contamination by floor debris becoming airborne through mopping and foot traffic.



Staff #32 confirmed the plates and bowls, flat cooking trays, and other food preparation and serving supplies were being used by kitchen staff.


A 3 X 10 foot rug was observed on the floor between the kitchen and dry storage supply. The rug was pulled back, exposing the floor. The floor tiles were chipped and broken. Pieces of the tile flooring was missing, exposing the concrete underneath. The open areas exposed a porous surface that would prevent cleaning and disinfecting of the floors.

In a corner of the kitchen near the food service line (a steam table where food is plated before being delivered to the facility's patients and to a contracted hospital), approximately 10 metal rolling food carts were being stored. The food carts were moved to expose the floor covered with dust, food particles along with bits and pieces of unidentifiable trash. A dried, crusty, brittle frog was observed lying on the floor, against the wall. A thick, black build up was observed on the floor that could be scraped away with the sole of a shoe. The thick black buildup became darker as it neared the wall and baseboard. The floor covered with dust, food particles along with bits and pieces of unidentifiable trash along with the thick, black build up provided a medium for bacterial growth and posed a fall hazard.

The tour continued to the beginning of the service line. A brown, plastic, rolling food cart was observed sitting against the wall approximately 4 foot from the food service line. The food cart was soiled and stained. The top of the food cart was covered with dust and what appeared to be food particles. The top of the food cart was soiled with sticky, circular areas. The lower part of the cart's door, was covered with a black buildup. What appeared to be the same substance that formed the circular areas top of the food cart was streaked down the front of the food cart's door. The food cart was pulled away from the wall exposing the sides and back of the cart. The exposed areas of the cart were consistently soiled as the door.

Behind the brown, plastic, rolling food cart, low on the wall near the base board was a dry, black substance. A discussion at the time of the finding raised concerns of mold. In the same area of the black substance a hole measuring approximately 2X6 inches was observed in the wall. Pink insulation material was observed in the hole. The floor was covered with dust, food particles along with bits and pieces of unidentifiable trash. A damp, black sticky substance covered the area under the cart. Also observed in the area of the rolling food cart was a rolling food warmer. The food warmer was moved exposing a wet floor covered with a black, sticky substance. A floor drain located under the rolling food warmer was encircled with a white, cheese-like substance that had the likelihood to prevent proper drainage. The drain located under the rolling food warmer was encircled with a white, cheese-like substance; it would spread bacteria over the entire kitchen if it is blocked, and the area is flooded.

Observation of the service line revealed a rolling plate warmer that was moved and exposed the floor covered with dust, food particles along with bits and pieces of unidentifiable trash lying on top of a damp, black sticky substance. The steam table had plates, bowls, and other food preparation and serving supplies being stored wet on a bottom shelf of the steam table. The floor under the steam table was covered with dust, food particles along with bits and pieces of unidentifiable trash lying on top of a damp, black, sticky substance. Under the steam table, a drain pan for a food cooler could be visualized. The drain pan was full of water and the water was overflowing onto the floor. Near the overflowing water was a second floor drain. The over flowing water was following the path of a slimy, black trail, across the floor to the drain located approximately 10 inches away. Floating in the drain pan was what appeared to be a small, individual butter cups along with other unidentifiable trash. The wet floor covered with a, black sticky substance provided a medium for bacterial growth.

A third floor drain was observed and located between the food service line and a foof preparation table where staff was preparing food. The drain and floor around the drain was covered with a black sticky substance. The drain cover contained a buildup of the black sticky substance. The buildup caused a narrowing of the holes in the drain cover. What appeared to be a plastic bag lying on the floor near the drain was covered in a thick, creamy, yellow, opaque substance. The buildup of the black sticky substance covering the drain provided a medium for bacterial growth.


A kitchen staff employee was observed entering the kitchen from outside, pushing a large, grey, trash bin. The staff member pushed the trash bin through the kitchen, around the food service area, stopped and waited for other staff to move and then preceded to push trash bin between the foodservice line and a food preparation table where staff was preparing food. The large, grey, trash bin had a clearance of approximately 2 foot from the foodservice line and a clearance of approximately 2 foot from the food preparation table where staff was preparing food. The large, grey, trash bin was stored approximately 6 foot from the food service line and in a high traffic area where kitchen staff had the potential to brush against, contaminating clothing and apron. The trash bin was covered with a black, greasy film. The inside of the bin was covered with white sticky substance. Trash was stuck to the inside, bottom of the bin. The wheels on the trash bin were caked with a black, sticky substance. The paint on the wall where the trash bin was being stored, was chipped and flaking in multiple areas. The areas where the paint was missing exposed a porous surface that would prevent cleaning and disinfecting of the walls.


A detailed observation was done of a food cart, used to deliver food trays throughout the hospital to patients. Staff #10 was asked to disassemble the food cart. The process exposed a black sticky substance caked in the corners and crevices within the cart where the patients' food trays were placed. The disassembling of approximately 10 food carts was not done as a result of a discussion among staff #10 and staff #26. Staff #10 and staff #26 agreed the findings would be the same as the first cart and that appropriate cleaning of the carts was not being done.


During kitchen observations on 12/18/13 at 10:28 a.m., the following were found:

Staff member #37 was on the food preparation line handling meat patties without gloves. Staff member #37 was observed pouring gravy over the meat patties from one pan to the other pan without using gloves or a utensil. The gravy was dripping down the side of the pan onto the soiled countertop and Staff #37 failed to stop and cleanse it. The now soiled pan was then used to pour gravy over another tray of meat patties and a pan of chicken. The gravy pan, which had gravy residue down the side, was then covered with plastic wrap and placed in a warming cart without being cleaned. Lack of proper cleaning had the likelihood to cause contamination of food prepared in this manner.

Staff member #33 was observed cooking without gloves. He placed his bare hands in the inside of his apron, against his clothes, and watched the activities in the kitchen. Without washing his hands, staff member #33 resumed cooking without gloves. Lack of hand hygiene had the likelihood to cause contamination of food prepared by this employee.

Two female kitchen staff members were preparing glasses of tea for the patients' meal trays. The staff members had tea and ice mixed together in a large stainless steel bowl. They used a plastic glass to dip the tea from the bowl into the patients' glasses. The tea was splashing and running down the side of the stainless steel bowl and the patients' glasses. This process had the likelihood to cross-contaminate all of the tea served to the patients.

Two plastic and one metal food cart was stored in the hallway outside the Dietary Department. The floor of the hallway was covered with leaves, which had blown in from the outside. The metal food cart had a build-up of grease, food particles, and hair. The hinges on the metal food cart were covered with a build-up of grease. One of the plastic food carts, which had just been cleaned, was found soiled with food particles and a brown stain. Lack of food cart cleansing had the likelihood to cause contamination to food transported on these carts.

Interviews were conducted with staff #10 and #26 though out the tour and the findings were witnessed and confirmed.


The tour continued to an off-site kitchen located in the behavioral health unit, with staff #10, #26, #1, and #34. During the tour, the following was observed:

Two (2) wire storage units with no impermeable barrier on the bottom shelves in the kitchen. Items on the bottom racks included serving plates and bowls, and other food preparation and serving supplies. With no impermeable barrier on the bottom shelves, these supplies stored on the bottom shelves were not being protected from contamination by floor debris becoming airborne through mopping and foot traffic.


A food warmer located next to the ice machine was moved exposing a wet floor. The floor under the food warmer was observed covered with dust, food particles along with bits and pieces of unidentifiable trash lying on top of a black sticky substance.


The ice bin was full of ice that was being served to patients, patients' families, staff and other patrons that visited the facility. In the corner of the ice bin was a half full bottle of Mountain Dew (soft drink) shoved down into the ice, creating a likelihood of contamination to the surrounding ice.


Interviews were conducted with staff #1, #10, #26 and staff #34 throughout the tour and the findings in the behavioral health kitchen were witnessed and confirmed.



An interview was held on 12/19/13 at approximately 11:00am in the Administrative Conference Room with administrative personnel #19, #34 and #35. The question was asked of each, when was the last time you were in the kitchen:


- Administrative personnel #19's response was, back in the spring during an accreditation survey.


- Administrative personnel #34's response was, a visit was made to the front office portion of the kitchen last week. Administrative personnel #34 had not been in the actual service portion of the kitchen in approximately a month.


- Administrative personnel #35's response was, an infrequent pass is made through the kitchen because it joins a conference room. Administrative personnel #35 was unable to provide an answer as to when a visit was made for the purpose of a visual inspection.


Administrative personnel #19 stated during the interview, "The seriousness of the findings in the kitchen for the liklehood of harm from a food borne illness can't be disputed." Administrative personnel #34 and #35 verbalized agreement with this statement.



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B. ensure surgical equipment was properly disinfected, surgical sterilizers were kept clean, and patient supplies were stored in a manner to prevent cross contamination. The facility failed to maintain clean surgical floors.
During a tour of the Respiratory Department on 12/16/2013 at approximately 3:00PM the following was observed:
The Cidex-OPA (cold disinfectant sterilization strips) solution test strips had expired on 11/2013.
The Cidex-OPA test had two open dates documented on the bottle. The first date documented was 11/29/2013. The second date documented was 12/8/2013.
A review of the log titled, "Cidex- OPA Equipment Immersion and Removal Log," revealed thirty three pieces of equipment had been soaked in this solution. The solution was used to disinfect the equipment was not properly tested due to expired strips.
Review of Cidex OPA product insert revealed:

"CIDEX OPA Solution may be reused for up to a Maximum of 14 days provided the required conditions of ortho-phthalaldehyde concentration and temperature exist based upon monitoring described in the Direction for use. Do not rely solely on day in use. Concentration of this product during its reuse life must be verified by the CIDEX OPA Solution Test Strips prior to each use to determine that the concentration of ortho-phthalaidehyde is above the MEC of 3%. The Product must be discarded after 14 days." On the bottle of Cidex -OPA test strips the label reads, "Caution: Do not use after 90 days of opening the bottle."

A review of the policy titled, "Respiratory Care Services" revealed
"2. Check the expiration date on the bottle of Cidex-OPA test strips. Do not use test strips beyond their expiration date as these strips can provide false readings.
3. Record the date the canister of test strips have been opened and a "do not use after ....date" on the bottle in the spaces provided. Do not use any remaining strips 90 days after opening canister."
Staff #39 was questioned if she saw anything wrong with the Cidex-OPA test strip bottle. Staff #39 was unable to find any issues with the strips and had to be shown the expiration date.
An interview staff #38 and #39 confirmed the Cidex-OPA test strips were expired and thirty three pieces of equipment had been soaked in the Cidex without proper testing.

During a tour of the Second Floor Surgical Area on 12/18/2013 at approximately 3:00 PM the following was observed:
-There were 2 large sterilizers and 4 small sterilizers on the floor;

-All six sterilizers were soiled on the interior;

-Cob webs and dust particles were found in the door of the large sterilizer in the sterilization room.

-Exposed insulation material was found surrounding the opening of the large sterilizer in the sterilization room.

During the tour, staff #22 confirmed these findings.

Review of the sterilizer service provider's (Steris) contract/service agreement for 09/01/2010 through 08/31/2013 revealed no evidence cleaning the sterilizers was included.

Review of the sterilizer service provider's (Steris) contract/service agreement for 09/01/2013 through 08/31/2016 revealed cleaning the sterilizers was included.

During an interview on 12/18/13 at 2:50pm in the conference room, staff #23 confirmed the following:

-Cleaning the sterilizers was not included in the contract with the sterilizer service provider (Steris) for the period from 09/01/2010 to 08/31/2013;

-Steris did not clean the sterilizers from 09/01/2010 to 08/31/2013;

-The new contract with Steris, beginning 09/01/13, includes cleaning the sterilizers;

-As of today (12/18/13), Steris has not cleaned the sterilizers.

Patient nutrition refrigerator in the pre-op area had brown substance on the door and on the shelves.
In the Operating Rooms #3 and #6, there were a total of five rusty trash and linen hampers observed. The hampers could not be properly cleaned or sanitized due to the rust.
In the Operating Room #6 dust was found on the shelves of the sterile supply cabinet and there was a liquid spillage on a cardiac monitor cart.
The floors throughout the surgical areas were unclean, discolored, and covered in dust particles.
On the outside of the Cardiac Catherization Laboratory and in front of the entrance to the Operating Room were two pallets of cardboard shipping boxes. This is the main area behind the surgery closed doors, on the main hallway to the operating room suites. The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation stated that "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

During a tour of the 1st floor surgical area on 12/19/2013 at approximately 11:00AM the following was observed:
Operating Room #1 had two rusted trash and linen hampers. Hampers were unable to be properly cleaned or sanitized.
Instruments in the Sterile Instrument Room were stored on the bottom shelf of an open wire rack without a barrier.
Multiple card board shipping boxes were on an open wire rack by the entrance to the Sterile Instrument Room. This is the main area behind the surgery closed doors, on the main hallway to the operating room suites. The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation stated that "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

During a tour of the 1st floor Pre-Operative area on 12/19/2013 at approximately 11:00AM the following was observed:
A stretcher in the Pre-Operative Area had an approximate 2x3 inch tear in the mattress.
In the Pre-Operative storage room, patient care supplies were stored on the bottom shelf without a barrier. The floor below was unclean and had dust particles.
An interview with Staff #32 and #41on 12/19/2013, at approximately 12:30 confirmed the above findings. Staff #32 confirmed that the shipping boxes are bought into the surgical area. She also confirmed that the shipping boxes were brought into the hospital departments and stored with clean supplies. The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation stated that "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

A revisit was performed to the Second Floor Surgical Area on 12/19/2013, at approximately 12:30 PM the following was observed:
The patient nutrition refrigerator had not been cleaned. The brown substance spilled on the shelves was still present. There were two food containers for Cath lab (Catheterization Laboratory is where patient receives cardiac diagnostic procedures) patients dated 12/17/2013 were still in the refrigerator.
In the Cath Lab storage room, outside shipping boxes were found next to clean heart catheterization catheters. The catheters were on open wire racks with approximately a ¼ inch of dust and dirt accumulation on the above rack above the boxes of clean catheters. The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation stated that "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

During a tour of the Gastrointestinal (GI) Lab on 12/17/2013 at 9:00AM and on 12/18/2013 at 4:00PM observed the following:
In the decontamination room #1, the Endoscope Reprocessor .45-Micron Filter and 1-Micron Filter were dated 5/28/13 to show when the filters were last changed.
A review of the log titled, "DSD Filter Change Log" revealed the filters were to be changed every six months.
In the decontamination room #2, the Endoscope Reprocessor .45-Micron Filter and 1-Micron Filter were dated 5/13 to show when the filters were last changed.
The Endoscope Reprocessor Instruction and Service manual states, "The micron filters must be replaced, and the water lines disinfected, a minimum of once every six months."
A review of the of the log titled, "Disinfectant Efficacy Monitoring Log" in decontamination room #2 revealed the temperature, change, and the "pass/fail" were to be recorded daily. A review of the recordings for the month of October 2013, 20 of 31 days recorded, November 2013 16 of 30 days recorded, and in December 2013, 6 of 18 days were recorded.
An interview with staff #40 on 12/17/2013 at approximately 4:00PM, confirmed the log had not been recorded daily.
Staff #40 on 12/17/2013, at approximately 10:30AM, was observed taking the endoscopy cart to another department of the facility and being used for an endoscopy procedure.
Staff #40 was questioned on how the endoscopy cart would be cleaned after being taken and used in other departments of the facility. She answered, "I just wipe the top of the cart."
An interview with #32 and #41 on 12/19/2013, at approximately 12:30PM, confirmed the cart is not being cleaned properly after being bought back to the department.



10135

C. ensure disinfectants used on equipment for invasive procedures was properly labeled. The facility failed to ensure floors, patient stretchers, supply closets, crash carts and equipment were kept up in a manner to prevent cross contamination.


During observations the following was found:

*Radiology
On 12/16/2013, at 1:30 p.m., open containers of the disinfectant Cidex OPA used on intra-vaginal transducers were found in Ultrasound Room #'s 1, 2, 3, and 4. All the containers had no open date.

Review of the manufacturer label revealed once opened the unused portion of the solution may be used up to 75 days. There was also a place on the label for the open date to be recorded.

Review of a log in Ultrasound Room #3 named "Performance Improvement-Ultrasound" used for documenting quality control checks revealed a serial number recorded for a container of Cidex OPA. The documentation indicated staff were currently using this bottle of Cidex OPA.

The bottle of Cidex OPA which was logged could not be found. Two more open bottles of the solution were in the room, but they were not logged as being currently used.

Ultrasound Room #2 had a mattress on the stretcher which had a tear approximately one inch in size.

Staff #24 confirmed the observations and reported the staff should be dating the containers.

*Medical Surgical Unit
On 12/17/2013, at 12:00 p.m., the top of a crash cart had a hard plastic covering which was soiled with an accumulation of tape residue and old stickers.

*Intensive Care Unit
On 12/17/2013, at 2:55 p.m., the top of two crash carts had a build-up of tape residue and was soiled with brown substance.
Two isolation carts were found rusted and contained clean patient supplies. There was no way for the carts to be properly sanitized.
Staff #31 confirmed the conditions of the carts.

*Therapy Room
On 12/18/2013, at 2:10 p.m., three tread mills were found with broken and cracked panels and were noted to be secured with tape.
Staff #25 confirmed the observations.

*Emergency Room
On 12/18/2013, at 9:45 a.m., Patient Room #'s 7, 9, 10, 11, and 12 had patient stretchers which had a metal side strip that had separated from the frame. The panels were secured to the frame with clear tape.

Room #12 had an approximate 3 inch tear in the mattress which was taped up. Underneath the mattress was a build-up of white particles and there dried gum on the bed frame.

The floor in one of the triage rooms had a build-up of wax and there was a build-up of dirt and dust near the baseboards. One crash cart had a plastic white covering which was cracked and had a build-up of tape residue.

One suction cart had a piece of cardboard which was taped into drawer to make a panel to separate clean supplies.

The patient ice machine had a dried brown substance covering a metal panel near the spout where the ice came out.

The clean supply room was disorganized and supplies just thrown on a shelf. There was a build-up of dirt and dust on the floor.

Staff #29 confirmed the observations.



32143


D. properly clean patient care areas between the discharge of one patient and the admission of another patient. The facility also failed to provide adequate routine sanitation in the facility. These findings in the Behavioral Health Unit have the likelihood to cause the spread of infection due to lack of proper sanitization.

A tour of the Behavioral Health Unit on Fannin Street was conducted on 12/17/2013.

The medication room on the Adult Acute Unit was found to have the following issues:
1.) A sharps container soiled with blood;
2.) Dirty and stained floor;
3.) The base boards were dirty with a dried substance and a dirty build up;
4.) The medication Pixys was soiled on top and on the front panels;
5.) The back splash on the sink was buckled and warped from water exposure, causing the underlying particle board to be exposed and unable to be properly cleaned;
6.) The medication refrigerator was dirty;
7.) Stains and dried spilled substances were on the walls.

Staff #1, #5, and #17 confirmed the issues found in the medication room.

The electrical closet in the nurses' station on the Adult Acute Unit had a large amount of dust and dirt on the floor. Staff #1 and #5 confirmed this finding.

The Adult Unit seclusion rooms had no base boards, resulting in a gap between the walls and tile floor. The floor could not be sanitized properly. Dirt and hair had accumulated in the resulting gap. The mattresses in two of the four seclusion rooms were dirty. Staff #1 and #5 confirmed the findings.

One of two mattresses were soiled in the Child and Adolescent Unit seclusion rooms. The bathroom floor of the seclusion room was dirty. Staff #1 and #5 confirmed the findings.

Clean medical supplies were found stored in a room with unclean supplies, a copier machine, paper sacks, and a paper shredder. Therefore, clean supplies were unable to be protected from becoming contaminated. Staff #1 and #5 confirmed the finding.

In room 304, the floor tiles were missing along the south wall. The floor could not be sanitized properly. Dirt and hair was found between the tiles and the wall. Staff #5, #1, and #17 confirmed the above findings.

Observation in the Child and Adolescent Unit medication preparation room revealed the following:
1.) Broken and dirty floor tiles;
2.) Broken wooden door under the sink exposing bare wood and that could not be properly cleaned;
3.) Ice machine was dirty;
4.) Bright red splatters around the sink and on back splash;
5.) Dusty equipment sitting on the medication refrigerator;
6.) The inside of the medication refrigerator was dirty and had ice buildup;
7.) The medication Pixys system was soiled on top, on the sides, and front with a dry, splattered substance.

Staff #1 and #5 confirmed the findings in the Child and Adolescent Unit medication preparation room.

The back board, suction machine, and lower shelf of the emergency cart was covered in dust and dirt. Staff #52, #1, and #46 confirmed the findings.

The Geriatric Unit seclusion room had tears in the mattress, allowing fluids to seep into the foam. This made the mattress impossible to be properly cleaned. Staff #1 and #46 confirmed the tears.

The shower room on the Geriatric Unit had soap scum build up on the shower and shower floor. The shower chair had stains from a previous mold removal. The metal shower handles had rust around the screw caps. Staff #1 confirmed these findings.

These findings in the Behavioral Health Unit have the likelihood to cause spread of infection due to lack of proper cleaning between patients and inadequate routine sanitation.

It was determined that these deficient practices created an Immediate Jeopardy situation, resulting in a likelihood of harm and serious injury to all patients, staff, and visitors.

Based on observation, record review, and interview the facility failed to
A. ensure surgical equipment was properly disinfected, surgical sterilizers were kept clean, temperature and humidity monitored, and patient supplies were stored in a manner to prevent cross contamination. The facility failed to maintain clean surgical floors.
During a tour of the Second Floor Surgical Area on 12/18/2013 at approximately 3:00 PM the following was observed:
-There were 2 large sterilizers and 4 small sterilizers on the floor;

-All six sterilizers were soiled on the interior;

-Cob webs and dust particles were found in the door of the large sterilizer in the sterilization room.

-Exposed insulation material was found surrounding the opening of the large sterilizer in the sterilization room.

During the tour, staff #22 confirmed these findings.

Review of the sterilizer service provider's (Steris) contract/service agreement for 09/01/2010 through 08/31/2013 revealed no evidence cleaning the sterilizers was included.

Review of the sterilizer service provider's (Steris) contract/service agreement for 09/01/2013 through 08/31/2016 revealed cleaning the sterilizers was included.

During an interview on 12/18/13 at 2:50 PM in the conference room, staff #23 confirmed the following:

-Cleaning the sterilizers was not included in the contract with the sterilizer service provider (Steris) for the period from 09/01/2010 to 08/31/2013;

-Steris did not clean the sterilizers from 09/01/2010 to 08/31/2013;

-The new contract with Steris, beginning 09/01/13, includes cleaning the sterilizers;

-As of today (12/18/13), Steris has not cleaned the sterilizers.

Patient nutrition refrigerator in the pre-op area had brown substance on the door and on the shelves.
In the Operating Rooms #3 and #6, there were a total of five rusty trash and linen hampers observed. The hampers could not be properly cleaned or sanitized due to the rust.
In the Operating Room #6 dust was found on the shelves of the sterile supply cabinet and there was a liquid spillage on a cardiac monitor cart.
The floors throughout the surgical areas were unclean, discolored, and covered in dust particles.
On the outside of the Cardiac Catherization Laboratory and in front of the entrance to the Operating Room were two pallets of cardboard shipping boxes. This is the main area behind the surgery closed doors, on the main hallway to the operating room suites. The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation stated that "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

During a tour of the 1st floor surgical area on 12/19/2013 at approximately 11:00 AM the following was observed:
Operating Room #1 had two rusted trash and linen hampers. Hampers were unable to be properly cleaned or sanitized.
Instruments in the Sterile Instrument Room were stored on the bottom shelf of an open wire rack without a barrier.
Multiple card board shipping boxes were on an open wire rack by the entrance to the Sterile Instrument Room. This is the main area behind the surgery closed doors, on the main hallway to the operating room suites. The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation stated that "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

During a tour of the 1st floor Pre-Operative area on 12/19/2013 at approximately 11:00 AM the following was observed:
A stretcher in the Pre-Operative Area had an approximate 2 x 3 inch tear in the mattress.
In the Pre-Operative storage room, patient care supplies were stored on the bottom shelf without a barrier. The floor below was unclean and had dust particles.
An interview with Staff #32 and #41 on 12/19/2013, at approximately 12:30 PM confirmed the above findings. Staff #32 confirmed that the shipping boxes are bought into the surgical area. She also confirmed that the shipping boxes were brought into the hospital departments and stored with clean supplies. The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation stated that "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

A revisit was performed to the Second Floor Surgical Area on 12/19/2013, at approximately 12:30 PM the following was observed:
The patient nutrition refrigerator had not been cleaned. The brown substance spilled on the shelves was still present. There were two food containers for Cath lab (Catheterization Laboratory is where patient receives cardiac diagnostic procedures) patients dated 12/17/2013 were still in the refrigerator.
In the Cath Lab storage room, outside shipping boxes were found next to clean heart catheterization catheters. The catheters were on open wire racks with approximately a ¼ inch of dust and dirt accumulation on the above rack above the boxes of clean catheters. The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation stated that "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

During a tour of the Gastrointestinal (GI) Lab on 12/17/2013 at 9:00 AM and on 12/18/2013 at 4:00 PM observed the following:
In the decontamination room #1, the Endoscope Reprocessor .45-Micron Filter and 1-Micron Filter were dated 5/28/13 to show when the filters were last changed.
A review of the log titled, "DSD Filter Change Log" revealed the filters were to be changed every six months.
In the decontamination room #2, the Endoscope Reprocessor .45-Micron Filter and 1-Micron Filter were dated 5/13 to show when the filters were last changed.
The Endoscope Reprocessor Instruction and Service manual states, "The micron filters must be replaced, and the water lines disinfected, a minimum of once every six months."
A review of the of the log titled, "Disinfectant Efficacy Monitoring Log" in decontamination room #2 revealed the temperature, change, and the "pass/fail" were to be recorded daily. A review of the recordings for the month of October 2013, 20 of 31 days recorded, November 2013 16 of 30 days recorded, and in December 2013, 6 of 18 days were recorded.
An interview with staff #40 on 12/17/2013 at approximately 4:00 PM, confirmed the log had not been recorded daily.
Staff #40 on 12/17/2013, at approximately 10:30 AM, was observed taking the endoscopy cart to another department of the facility and being used for an endoscopy procedure.
Staff #40 was questioned on how the endoscopy cart would be cleaned after being taken and used in other departments of the facility. She answered, "I just wipe the top of the cart."
An interview with #32 and #41 on 12/19/2013, at approximately 12:30 PM, confirmed the cart is not being cleaned properly after being bought back to the department.

A review of the temperature and humidity log for the endoscopy decontamination rooms 1 and 2 for the months of September, October, November, and December 1st thru 18th for the year 2013 revealed the following:
Room 1- Temperatures
*September -1 of 30 days were not recorded
*October - all days recorded
*November -3 of 30 days were not recorded
*December - 2 of 18 days were not recorded
Room 1 Humidity
*September - 1 of 30 days were not recorded
*October - all days recorded
*November -3 of 30 days were not recorded
*December - 2 of 18 days were not recorded
Room 2 Temperatures
*September -3 of 30 days were not recorded
*October -5 of 31 days were not recorded
*November -13 of 30 days were not recorded
*December- 11 of 18 days were not recorded
Room 2 Humidity
*September -3 of 30 days were not recorded
*October -5 of 31 days were not recorded
*November - 13 of 30 days were not recorded
*December - 11 of 18 days were not recorded
The guidelines per the AORN (Association of perioperative Registered Nurses) "Perioperative Standards and Recommended Practices 2012, Recommendation V" revealed the following:
"Potential hazards associated with HVAC (Heating, Ventilation, and Air Conditioning) systems in the practice setting should be identified, and safe practices should be established. Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an oxygen enriched environment or when flammable agents are in use and increases the potential dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed."
An interview with staff member # 40 on 12/17/2013 at approximately 10:00 AM confirmed the findings from above.

A review of the log titled, "Endoscopy Scope Leak Test" and the data log for scopes being washed (print out from the scope washer) for every scope washed per day the print out did not match the leak test performed.
A review of the log for scopes washed in from December 1 thru 16th of 2013 was a total of 159. The leak test log indicated only 98 leak test performed. This review revealed 61 scopes had not been leak tested prior to washing.
The guidelines per the AORN (Association of perioperative Registered Nurses) "Perioperative Standards and Recommended Practices 2012, Recommendation IV" revealed the following:
"In the decontamination area and before cleaning, pressure (i.e., leak) tests should be performed on flexible endoscopes with leak testing capabilities."
An interview with staff member # 40 on 12/17/2013 at approximately 10:00 AM confirmed the findings from above.

B. a complete history and physical on 1 (# 27) of 15 surgical inpatients.
Refer to tag 952

C. ensure the intraoperative anesthesia record documentation was complete on 9 (#22, 24, 25, 26, 27, 28, 29, 30, and 31) of 15 surgical inpatients.
Refer to Tag 1004

D. the post anesthesia evaluation was performed for the proper anesthesia recovery on 10 (#22, 23, 24, 25, 26, 27, 28, 29, 30, and 31) of 15 surgical inpatients.
Refer to Tag 1005

Based on record review and interview, the facility failed to ensure a complete history and physical on 1 (# 27) of 15 surgical inpatients' record.
A review of the medical records revealed the following:
Findings:

A review of patient #27's medical record revealed the history and physical was completed at the physician's office on 12/11/2013. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was left blank. On 12/17/2013 a Total Right Knee Replacement surgery was performed on this patient without an updated history and physical.

An interview with staff member #26 on 12/18/2013 at approximately 4:00 PM confirmed the findings from above.

Based on record review and interview, the facility failed to ensure the intraoperative anesthesia record documentation was complete on 9 (#22, 24, 25, 26, 27, 28, 29, 30, and 31) of 15 surgical inpatients.
A review of patient #22's medical record revealed the documentation on the anesthesia record for the surgery start time and stop time was left blank.

A review of patient #24's medical record revealed the documentation on the anesthesia record for the surgery start time and stop time was left blank.

A review of patient #25's medical record revealed the documentation on the anesthesia record for the surgery start time and stop time was left blank. The anesthesiologist signature was present, but the signature was not dated and timed.

A review of patient #26's medical record revealed the anesthesia end time for the surgery was left blank on the anesthesia record.

A review of patient #27's medical record revealed the documentation on the intraoperative anesthesia end time for the surgery was left blank and the surgery start time and stop time was left blank.

A review of patient #28's medical record revealed the documentation on the intraoperative anesthesia record for the surgery start time and stop time was left blank.

A review of patient #29's medical record revealed the documentation on the intraoperative anesthesia record for the surgery start time and stop time was left blank.

A review of patient #30's medical record revealed the documentation on the intraoperative anesthesia record for the surgery start time and stop time was left blank.

A review of patient #31's medical record revealed the documentation on the intraoperative anesthesia record for the surgery start time and stop time was left blank.

An interview with staff member #26 on 12/18/2013 at approximately 4:00 PM confirmed the findings from above.

Based on record review and interview, the facility failed to ensure the post anesthesia evaluation was performed for the proper anesthesia recovery on 10 (#22, 23, 24, 25, 26, 27, 28, 29, 30, and 31) of 15 surgical inpatients.
A review of the medical records revealed the following:
Findings:

A review of patient #22's medical record revealed the post anesthesia note on the condition of patient after surgery was completed on 12/17/2013 at 2027 (8:27 PM). According to the anesthesia record, the anesthesia for the surgery procedure did not end until 2031(8:31 PM).

A review of patient #23's medical record revealed the post anesthesia note on the condition of patient after surgery was blank. A signature was present without any time, date, or documentation.

A review of patient #24's medical record revealed the post anesthesia note on the condition of patient after surgery was completed on 12/14/2013 at 1745 (5:45 PM). According to the anesthesia record, the anesthesia for the surgery procedure ended at 1745 (5:45 PM).

A review of patient #25's medical record revealed the post anesthesia note on the condition of patient after surgery was completed on 12/16/2013 at 1300 (1:00 PM). According to the anesthesia record, the anesthesia for the surgery procedure ended at 1300 (1:00 PM).

A review of patient #26's medical record revealed the post anesthesia note on the condition of patient after surgery was completed on 12/17/2013 at 8:30 AM. The anesthesia end time for the surgery was left blank. According to the anesthesia record, the surgery start time was 8:00 AM and stop time was 8:10 AM on 12/17/2013.

A review of patient #27's medical record revealed the post anesthesia note on the condition of patient after surgery was completed on 12/17/2013 at 11:36 AM. The anesthesia end time for the surgery was left blank. The documentation on the anesthesia record for the surgery start time and stop time was left blank.

A review of patient #28's medical record revealed the post anesthesia note on the condition of patient after surgery was completed on 12/16/2013 at 1415 (2:15 PM). The anesthesia end time for the surgery was 1415 (2:15 PM). The documentation on the anesthesia record for the surgery start time and stop time was left blank.

A review of patient #29's medical record revealed the post anesthesia note on the condition of patient after surgery was completed on 12/16/2013 at 0935 (9:35 AM). The anesthesia end time for the surgery was at 0935 (9:35 AM). The documentation on the anesthesia record for the surgery start time and stop time was left blank.

A review of patient #30's medical record revealed the post anesthesia note on the condition of patient after surgery was completed on 12/16/2013 at 0926 (9:26 AM). The anesthesia end time for the surgery was at 0935 (9:35 AM). The documentation on the anesthesia record for the surgery start time and stop time was left blank.

A review of patient #31's medical record revealed the post anesthesia note on the condition of patient after surgery was completed on 12/16/2013 at 1400 (2:00 PM). The anesthesia end time for the surgery was at 1400 (2:00 PM). The documentation on the anesthesia record for the surgery start time and stop time was left blank.
An interview with staff member #26 on 12/18/2013 at approximately 4:00 PM confirmed the findings from above.

An interview with staff member #26 on 12/18/2013 at approximately 4:00 PM confirmed the findings from above.