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Based on an unannounced Re-approval survey, the observations at the Transplant Center located at the sixth floor on 09/08/2021 from 9:30 AM to 11:00 AM for the COVID-19 Focused Infection Control Survey Tool: Acute and Continuing Care and physical environment with the facility Transplant Center Administrator (employee #3) and Transplant Manager Sixth Floor (employee #5) , it was determined that the facility failed to ensure that the Alcohol Based Hand Rub (ABHR) dispensers is installed in a manner that minimizes of risk of cross contamination.

Findings include:

On 09/08/2021 at 9:30 AM to 11:00 AM the Transplant Ward located in the six floor was visited with the facility Transplant Center Administrator (employee #3) and Transplant Manager Sixth Floor (employee #5) and provided evidence that the transplant ward has nine (9) alcohol based hand rub (ABHR) dispensers around the corridor of the ward. ABHRs are located above safety handrail approximately two to three inches between the safetyhandrail and the ABHR dispenser, the hands has contact with the handrail when introduce to sanitize it, which increasing risk of cross contamination.

The facility's policy and procedure was reviwed on 09/08/2021 at 2:00 PM related to dry cleaning with gel 60-95 % alcohol based, page #2 section # II.

Based on a unannounced Re-approval observational tour, COVID-19 Focused Infection Control Survey Tool: Acute and Continuing Care at the Transplant Center at the sixth Floor on 09/08/2021 from 9:30 AM to 11:00 AM and interview with the Transplant Unit Manager (employee #5), review of policies/procedures, it was determined that the facility failed to ensure and maintain a sanitary environment to prevent and control communicable diseases within the hospital which can affect 9 out of 9 patients admitted at the transplan center,60 out of 60 patients at the transplant clinic, staff and visitors.

Findings include:

During the observational tour with the Transplant Unit Manager (employee #5) on 09/08/2021 from 9:30 AM to 11:00 AM the following was found:

1. On 09/08/2021 at 9:30 AM to 11:00 AM the Transplant Ward located in the six floor was visited with the facility Transplant Center Administrator (employee #3) and Transplant Manager at the sixth floor (employee #5) and provided evidence that the transplant ward has nine (9) alcohol based hand rub (ABHR) dispensers around the corridor of the ward. ABHRs are located on the safety handrail approximately two to three inches between the handrail and the dispenser. A dry-cleaning procedure was performed, and it was observed than when placing the hands to apply the hand sanitizer, the hands has contact with the handrail, which increasing risk of cross contamination.

2. On 09/08/2021 at 10:00 AM the Medication room and an isolation room #625 with negative pressure was visit and provide evidence that the temperature of the medication's refrigerator is not within the established parameters. According with the temperature record of the medication refrigerator must be at a minimum temperature of 36-degree (º) Farenheights (F) and maximum of 46º F.

A. The temperature of the medication refrigerator was reviewed from July, August and September of the present year 2021 and the following was found:

1. July 2021: The temperature was between 29º F and 40º F not according with the establish parameters 36º F to 46º F.

a. On July 1, 2, 9 and 29 the temperature was kept at 29º F.
b. On July 12, 14, 15, 17, 22, 24 and 31 the temperature was kept at 30º F.
c. On July 10, 11 and 21 the temperature was kept at 31º F.
d. On July 3, 4, 5, 7, 13, 23, 27 and 28 the temperature was kept at 32º F.
e. On July 6, the temperature was kept at 33º F.
f. On July 8 and 25 the temperature was kept at 34º F.
g. On July 30 the temperature was kept at 35º F.
h. On July 16 and 18 the temperature was kept at 38º F.
i. On July 19 and 20 the temperature was kept at 39º F.
j. On July 26 the temperature was kept at 40º F.

2. August 2021: The temperature stayed between 29º F and 40º F not according with the establish parameters 36º F to 46º F.

a. On August 1, 14 and 15 the temperature was kept at 29º F.
b. On August 3, 4, 5, 10, 20, 21, 22, 26 and 30 the temperature was kept at 30º F.
c. On August 12, 23, 24, 25 and 29 the temperature was kept at 32º.
d. On August 2, 17 and 18 the temperature was kept at 34º F.
e. On August 6, 13 and 27 the temperature was kept at 36º F.
f. On August 16 the temperature was kept at 37º F.
g. On August 28 and 31 the temperature was kept at 38º F.
h. On August 9, 11 and 19 the temperature was kept at 39º F.
i. On August 7 and 8 the temperature was kept at 40º F.

3. September 2021: The temperature stayed between 29º F and 40º F not according with the establish parameters 36º F to 46º F.

a. On September 1 and 2 the temperature was kept at 30º F.
b. On September 8 and 9 the temperature was kept at 32º F.
c. On September 3 the temperature was kept at 34º F.
d. On September 4 the temperature was kept at 36º F.
f. On September 5 and 6 the temperature was kept at 40º F.

B. The temperature of the isolation Room Refrigerator was reviewed from July, August and September of the present year 2021 and the following was found:

1. July 2021: The temperature stayed between 29º F and 40º F not according with the establish parameters 36º F to 46º F.

a. On July 6, 7, 9, 10 and 11 the temperature was kept at 20º F.
b. On July 8, 12, 13, 14, 15, 16, 17, 18 and 19 the temperature was kept at 30º F.
c. On July 23 and 24 the temperature was kept at 34º F.
d. On July 25 and 26 the temperature was kept at 36º F.
e. On July 27, 28 and 31 the temperature was kept at 38º F.
f. On July 1, 2, 3, 4, 5, 20, 21, 22, 29 and 30 the temperature was kept at 34º F.

2. August 2021: The temperature stayed between 29º F and 40º F not according with the establish parameters 36º F to 46º F.

a. On August 4 the temperature was kept at 20º F.
b. On August 1, 3 and 31 the temperature was kept at 22º F).
c. On August 5 the temperature was kept at 24º F).
d. On August 9, 10, 11, 12, 13, 24, 25 and 28 the temperature was kept at 26º F).
e. On August 27 the temperature was kept at 28º F).
f. On August 6, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 26, 29 and 30 the temperature was kept at 30º F
g. On August 7 and 8 the temperature was kept at 36º F).
h. On August 2 the temperature was kept at 40º F).

3. September 2021: The temperature stayed between 29º F and 40º F not according with the establish parameters 36º F to 46º F.

a. On September 1, 2, 3, 4, 5, 6, 7, 8 and 9 the temperature was kept at 40º F.

4. The facility failed to establish procedures and responsibilities to ensure that went the record of temperature parameters of the refrigerators are below or above the established parameters, it is notified engineering department.

5. The facility failed to ensure that the medications in the medication refrigeration and isolation room refrigeration are kept in a safe place maintaining temperature within the established parameters.

6. During performing the infection control observational tour on 09/08/2021 from 9:30 AM through 11:00 AM with the Transplant Manager (employee #5) the following was observed:

a. During the initial tour the register nurse (employee #11) was observed on 09/08/2021 at 9:45 AM entering the medication room she goes to the washbasin open the faucet and applied soap then rubbed her hands, rinse and then shook both hands to drip the water off and did not dried her hands with paper towel.

b. On 09/08/2021 at 9:45 AM on the interior of the medication room three medications carts were observed on back of the room, at left side stuck to the sink one of the medication cart was observed, near the medication cart a second medication cart was observed, near the second cart a large dump, near the dump at right side a large cardboard case open cardboard box inside exposed 50 milliliter of dextrose sachets were observed.

c. Two large sharp containers were observed opened and without a security base under the sink directly on the floor during the observational tour of the medication room on 09/08/2021 at 9:45 AM. The sharp container was observed with used needles. The facility failed to maintain the sharps containers in security rag this puts the staff safety at risk.

d. On 09/08/2021 at 10:05 AM the housekeeping room found with open lock the housekeeping personnel failed to keep lock closed after being used putting patients and families at risk of safety as high-risk cleaning materials.

e. On 09/08/2021 at 10:10 AM the dirty linen room found with open lock. The nurse personnel failed to keep lock closed after being used.

f. Transplant Manager Nurse (employee #5) stated during an interview on 09/08/2021 at 9:45 AM will work immediately with the deficiencies identified during the observational tour of the department.


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7. While performing the observational tour through transplant center ambulatory clinics on 09/07/2021 at 11:05 AM; 1 patient and 1 patient relative interviewed stated that they were concern in relation with the organization performed by the outpatient clinic personnel before beginning the clinic early in the morning at 5:30 AM.

Accordingly, with information provided by this patient and her relative, they stated that very early in the morning before opening the doors to begin the outpatient clinics at 5:30 AM, patients' and their relatives crowded in the entrance without any social distancing or precautions. They were very concern in relation with precautions that must be taken and maintained to prevent contagious due to COVID-19 virus.

8. The facility faild to evaluate complaince with social distancing or preacutions need during the COVID-19 pademic.(Cross refer Tag X0100 of the transplant program ).