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Based on observation and interview, it was determined that the facility was not always maintained in a manner to ensure staff and patient safety.

Findings were:

* Tour of the facility on 5/7/19 revealed broken crash cart handles in the ED and X-ray areas.
* Floors throughout the patient care areas had raised and water damaged tiles. The floors in the nursing stations in the OB and ED areas were gouged and pitted, revealing improper maintenance of the area.
* The automatic door opened leading from the ED to the ambulance bay was inoperable.

These findings were confirmed by the Director of Quality during the tour of the facility on 5/7/19.

Based on observation and interview, it was determined that the facility did not always practice effective infection control.

Findings were:

In an article published by Spectrum Health in July, 2014 it was stated "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."

The Centers for Disease Control and Prevention (CDC) article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf, states on page 74 that hinged instruments and instruments that are closed should be opened during the process of sterilization.

Tour of the facility on 5/7/19 and 5/8/19 revealed the following:

* Tour of the Radiology area revealed the Scan Slicker (plastic covering on the CT bed) was torn and yellowed with age. A wedge pillow in the room was torn and open alcohol pads were found on the floor. Room 2 housed a wooden chair with a cloth cushion. These items could not be cleaned properly.
* Room 19 in the Obstetrics area was inspected. The fold out couch bed had a tear in its vinyl covering. The nursery cabinetry had tape on many of its drawers and doors and the laminate was chipped. The chipped laminate, taped surfaces and torn vinyl made the areas impossible to clean.
* Throughout the hospital corrugated shipping boxes were found that were stored with clean supplies. These boxes are considered dirty as they have been found to house vectors. Storing a clean item with a dirty item could lead to cross contamination.
* Also throughout the hospital, including the radiology area, the ER triage room and the nursery, clean items were found stored under the sinks.
* The surgical supply room had water damage to the ceiling. This large water mark was directly over a clean supply cart. These clean supplies were in danger of contamination.
* The ED Trauma Room had 4 sets of sterile hemostats that were closed. The closed hinged instruments made complete sterilization uncertain.
* The tile floor in the ED and the OB areas were gouged and pitted. This made the floor impossible to clean.

In an interview with the Infection Control Nurse on 5/7/19, the above concerns were confirmed.

Based on review of documentation, tour of the facility and interview, it was determined that the sister facilities failed to control the temperature and humidity in all areas of the hospital.

Findings were:

According to an article entitled "Relative Humidity Levels in the Operating Room Joint Communication to Healthcare Delivery Organizations 2015" it was stated in part:

"Relative humidity may affect the operation of some electro-medical equipment used in the OR, particularly with older model electro-medical equipment. This equipment may malfunction unexpectedly. Too low humidity levels may also impact calibration. Larger electrostatic discharge (ESD) pulses may create a risk of destruction of parts, premature failure, and erratic behavior of software that is "confusion" from ESD pulses. And, in an environment where humidity is low, a person can more easily become "charged" and receive an electrostatic shock when coming in contact with medical equipment."

Temperature and Humidity Log "Scope Room" stated "The room temperature should range between 64 F and 72 F and the room humidity should range between 20% to 60%.

Review of 6 months of Temperature and Humidity Logs in the "Scope Room/Sterile Supply Room" found the following discrepancies:

* In October 2018, humidity and temperature were out of range for 16 out of 23 recorded days.
* In November 2018, humidity and temperature were out of range for 8 out of 21 recorded days.
* In December 2018, humidity and temperature were out of range 5 out of 18 recorded days.
* In March 2019, humidity and temperature were out of range 4 out of 21 recorded days.
* In April 2019, humidity and temperature were out of range 9 out of 21 recorded days.

Each of the above days that the temperature was out of range, staff wrote that maintenance was contacted. There was no notation of what maintenance did to correct the problem.

In an interview with the Surgery Director on 5/7/19, the above out of range humidity and temperatures for the sterile supply room were confirmed. She stated, "When the humidity is out of range in this room, we usually move the sterile supplies into one of the ORs. Since only one OR is operating now, we haven't moved the supplies.

Based on observation and interview, it was determined that the facility did not always adhere to applicable standards of practice when disposing of emergency medical supplies.

Findings were:

Tour of the facility on 5/7/19 revealed the following expired supplies:

The Medication Room in the ER:

* Gastroccult Test Slides with expiration date 8/18
* Blue top lab tubes with expiration date 4/30/19

ED Room 3's crash cart held the following expired supplies:

* Tegaderm film X 6, expired 07/2018
* Multi-lumen Central Venous Catheterization Kit X 2 expired 04/2019
* Volumart Line (dual spike transfusion set) expired 01/2019

X-ray Area crash cart:

* Multi-lumen Central Venous Catheter Kit expired 5/31/18
* Lo-pro Oral Nasal Trachael Tube cuffed 9.5 mm expired 03/2018

The above expired medical supplies were confirmed by the Infection Control Nurse/Director of Quality on 5/7/19.

Based on review of documentation and interview, it was determined that the facility did not employ a qualified Activities Director for its swing bed patients.

Findings were:

In an interview with staff member # 23 (LVN/Activities Director) on 5/8/19, it was determined that she was not qualified for the position according to federal regulations. According to staff member # 8 (ER Director), who until recently was Swing Bed Director, the Activities Director had only had that position for 2 months and had not received the required training for the position.

The above information was confirmed after reviewing the employee file of staff member # 23 on 5/8/19.

Based on review of documentation and interview, it was determined that the facility did not perform activity assessments for its swing bed patients.

Findings were:

The medical records of 6 swing bed patients were reviewed. 6 of 6 did not have activity assessments.

The above findings were confirmed by staff member # 23 (Activities Director) on 5/8/19.