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Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its patients and staff.

Findings were:

" OSHA/Bloodborne Pathogen Regulations Policy #138-030-060 " stated in part " The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. "

Tour of the facility on 6/30/15 revealed the following infection control issues:

· 3 live beetles were observed in Patient Room # 5 (where the surveyors were set to work)
· A lanyard was tied to the pull cord of a light fixture in Patient Room # 5 to extend the length of the cord which indicated improper maintenance of the area.
· The linen room housed a large torn box full of pillows. This box was torn on the bottom and sat on the floor. This practice could lead to cross contamination.
· The Isolation room had 2 boxes of trashcan liners stacked on a small shelf above a hand washing sink. These boxes were stained and water damaged.
· Also in the Isolation Room, dead bugs were observed in the overhead lighting fixture and high horizontal dust was noted on the light fixtures. Debris was noted on the "clean" bed. There were deep gouges surrounding the air conditioning unit in the room.
· A ceiling tile outside of the communal shower room was stained with a black substance which may have been mold. This stain indicated a water leak.
· The patient nutrition/supply room had dead bugs in the overhead light fixture.
· The restroom in the X-ray area had a gouged sheetrock wall above the hand washing sink.
· Multiple dead bugs were noted in the two light fixtures in the laboratory.
· Overhead light fixtures were dusty/dirty in rooms # 12 and #5.
· Medical supply room had boxes stacked on the floor and shipping boxes on shelves next to clean supplies. This practice to could lead to cross contamination.
· In the pharmacy a stained ceiling tile was observed which indicated a leak.

In an interview with the Maintenance Supervisor on 6/30/15, the above issues were confirmed.

Based on review of staff records, it was determined that the Governing Body failed to ensure facility policy was followed relating to tuberculin skin testing for all direct patient care staff.

Findings were:

The Centers for Disease Control and Prevention (CDC) article, Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, stated in part:" Every health-care setting should conduct initial and ongoing evaluations of the risk for transmission of M. tuberculosis, regardless of whether or not patients with suspected or confirmed TB disease are expected to be encountered in the setting. "
· Staff # 13, staff # 14, staff # 9, and staff # 11, did not have current TB Skin Tests
According to the Director of Nursing, employee TB Skin Tests are done annually.
These deficits were confirmed by the Director of Nursing on 07/01/15 and she acknowledged that TB Skin Test was done annually as per hospital policy.

Based on observation and interview, it was determined that the facility failed to ensure that outdated medications and supplies were not available for patient use.

Findings were:

United States Pharmacopeia General Chapter 797 recommends the following for multi dose vials of sterile pharmaceuticals: "If a multi dose has been opened or accessed (e.g. needle punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. If a multi dose vial has not been opened or accessed, it should be discarded according to the manufacturer ' s expiration date. The manufacturer ' s expiration date refers to the date after which an unopened multi dose vial should not be used. The beyond use date refers to the date after which an opened multi dose vial should not be used. The beyond use date should never exceed the manufacturer ' s original expiration date."

Facility policy entitled "Multi-dose Vials" stated in part "All multi-dose vials will be dated the day they are opened, by the person that opens it ...All multi-dose vials will be destroyed 28 days from the first date of usage."

Tour of the facility on 6/30/15 revealed the following open, multi-use vials that were unlabeled as to date opened and the staff member who opened the vial.

· Lidocaine 2 % 20 ml
· Sensorcaine 5 ml
· 4 Xylocaine 1 % 5 ml
· Nebulizer mask and tubing in patient room # 1 was open, and did not have a date opened

The above unlabeled medications and tubing were confirmed by the Director of Nursing on 6/30/15.