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Based on observation and interview, the facility failed to ensure that emergency medical equipment, available for use was not expired, resulting in the potential to use expired medical equipment during an emergent event and poor patient outcomes for all pediatric patients presenting to the emergency department with a medical emergency. Findings include:

On 06/17/2019 at 1120 during the initial tour of the facility, the Emergency Department (ED) Broselow Pediatric Emergency equipment was found to have expired medical equipment in the organizer Bag compartments. 5 of the 8 compartments had expired Intravenous Module packs: outdates 1/31/2019, 2/28/2019, 3/30/2019, 3/31/2019, and 4/30/2019. 1 compartment had an expired oxygen delivery module: outdate 1/31/2019.

On 06/17/2019 at 1130 staff I the Manager of the ED was asked if someone was responsible to monitor the readiness of the emergency equipment. Staff I stated "A staff member is assigned to check the Broselow Bag monthly, but there is not a check sheet for accountability and there is not a policy that documents our practice."

Based on observation, interview and document review the facility failed to maintain the physical plant and patient equipment and failed to comply with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 485.623(d), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care resulting in the potential for less than optimal outcomes and harm in the event of a fire to all patients. Findings include:

See specific tags:

C-221: Failure to maintain a safe and functional environment
C-222: Failure to maintain patient equipment
C-224: Failure to secure medications
C-226: Failure to maintain proper ventilation in central sterile processing
C-231: Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

Based on observation, interview, and document review, the facility failed to maintain a safe and functional environment resulting in the potential for transmission of infectious agents to the 2 in-patients and 4 emergency room patients that were currently being served in the facility. Findings include:

On 6/17/2019 at 1121, emergency department (ED) room #5 was entered and found to have 2 holes present in the upper cupboard door exposing the wood underlayment. A piece of laminate was also found to be missing from the lower right corner of the lower cupboard. This finding was confirmed by Staff B at the time of discovery.

On 6/17/2019 at 1130, ED room #1 was entered and found to have laminate missing from the right lower corner of the upper cupboard exposing the wood underlayment. Additionally there was a piece of laminate missing from the corner of the sink area and a corner of the counter near the sink. On the wall behind the sink near the soap dispenser, damage was present to the wall exposing the brown paper underlayment of the drywall. These findings were confirmed by Staff B at the time of discovery.

On 6/17/2019 at 1141, ED room #3 was entered and found to have a wooden cabinet at the head of the bed with sliding doors that had large metal cups in which to place the fingers to open the cabinet. The middle cabinet had one of the finger cups missing exposing the bare wood underneath. Additionally, the splash guard to the right of the sink had the laminate separating from the wood. The wood underneath appeared swollen from getting wet. Further observation revealed there were areas surrounding the sink that had been repaired with spackle but had not been sealed. These findings were confirmed by Staff A at the time of discovery.

On 6/17/2019 at 1144, the ED medication room was entered and found to have heavy damage to the wall next to the computer exposing the plaster. This finding was confirmed by Staff A at the time of discovery.

Staff I was queried on 6/17/2019 at 1150 as to who was responsible for repairing the cupboards, counters, and walls to which she stated, "Maintenance."

Facility job description for the "Maintenance Mechanic" last revised 2/25/2008 states, "Performs a variety of carpentry tasks such as framing and finishing drywall...Repairs carpet, tiles and other floor coverings. Grouts and seals tiles and installs floor molding...Performs interior and exterior painting, includes repairing and preparing walls for painting and applying various types of paint..."




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On 06/17/2019 at 1100 during the initial tour of the facility, the kitchen was observed to have damage to the tiles at the entrance to the food area where the food carts are parked. There was 4 missing pieces of tile from the corners and the open areas had heavy collections of a black substance. This finding was confirmed by staff B at the time of discovery.

Based on observation, interview, and document review the facility failed to ensure that all patient-care equipment was maintained in safe operating condition, resulting in the potential for less than optimal outcomes for all patients treated by the facility.
Findings include:

On 06/17/2019 at 1150 During the initial tour of the facility, the Emergency Department "Pyxis" (medication dispensing machine) was found to have dirt, debris, and dead bugs on the bottom shelf under the medication dividers. The medication refrigerator was observed to have heavy ice buildup in the freezer. The thermometer in the trauma bay was covered with white/brown sticky residue. The findings were confirmed at the time of discovery by staff A.

On 06/17/2019 at 1455 during the tour of the rehab area the Occupational therapy cupboards were found to have heavy dirt, dust, debris and missing paint on the shelving inside the equipment storage cupboards. The finding was confirmed at the time of discovery by staff A.






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On 6/17/2019 at 1355 on the acute care unit, Room 223 was entered and found to have a vinyl chair in the corner by the foot of the bed. Both arms of the chair had multiple tears in them exposing the fabric, foam and wood of the chair frame underneath the vinyl. These findings were confirmed by Staff A at the time of discovery.

On 6/17/2019 at 1409 on the acute care unit, the clean supply room was entered and found to have oxygen extension tubing hanging down from the storage shelf and sitting on the floor. Additionally, the metal cupboard under the sink was found to have heavy rust present to all surfaces. These findings were confirmed by Staff A at the time of discovery.

On 6/17/2019 at 1451 in the physical therapy area, the ball trampoline was observed to have a seam separating in the lower left hand corner exposing the foam.

On 6/18/2019 at 1029, the refrigerator in the recovery room was opened and found to have thick frost in the freezer compartment. Staff K confirmed this finding at the time of discovery and stated she thought defrosting was done quarterly.

Policy regarding defrosting of refrigerators was requested but not found. A blank maintenance "Recurring Job List" undated, was provided and indicated refrigerators/freezers had monthly inspections to be done. No documentation was present regarding when the last check was done.

Based on observation, interview, and policy review, the facility failed to secure medications in a locked area which was only accessible by appropriate personnel resulting in the potential for medication to be removed and used by unauthorized patients, family members, or employees. Findings include:

On 6/18/2019 at 1000 after talking with Patient #22 about the procedure sedation, Certified Registered Nurse Anesthetist (CRNA) Staff T was queried as to what medications were used for sedation to which he stated he used "propofol and some lidocaine."

On 6/18/2019 at 1105, it was observed that the procedure room and endoscopy scope reprocessing room were at the end of the pre-/post-procedure hallway and there were no doors present separating the two areas. Upon entering the procedure room with Staff K, it was noted that there were no other staff in the room. There were 2 syringes containing medication sitting on top of an airway cart in the corner and a lock-box on the wall next to the cart was standing open with various types of unused medications present. While waiting for the patient to be brought into the room, registered nurse (RN) Staff Z, Endoscopy Technician Staff Y, and Scope Reprocessing Technician Staff X all entered and exited the room. Staff T also came in to the room for a short time before leaving to get the patient.

On 6/8/2019 at 1112, Patient #22 was brought into the procedure room, a time-out was conducted, and Staff T was observed administering the medication from the syringes that were sitting on top of the cart.

Review of facility policy titled "Anesthetic Responsibilities" last approved 5/17/2018 states, "The anesthesia cart shall be locked at all times except when directly monitored by an anesthesia provider or the sedating nurse."

On 6/19/2019 at 0852, Staff A was made aware that the procedure room did not have an anesthesia cart with medications but an airway cart and a wall lock-box for medications. Staff A was queried as to if the policy applied to the procedure room set up to which she stated, "Yes. It's the same concept."

Based on observation and interview the facility failed to maintain proper ventilation in the central sterile processing area with the potential for increased infections for all surgery patients as evidenced by:

1. On 6/17/19 at approximately 1345, during an onsite inspection of the surgical suite, observed that the central sterile processing room was under a net negative pressure to the surgical corridor as noted by air flowing into the room indicated by a flutter strip held at the undercut of the central sterile processing corridor door. This was confirmed by staff C, the maintenance director, at the time of the finding.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 485.623(d), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the K-tags on the CMS-2567 dated 6/19/2019, for Life Safety Code.

K-0211
K-0291
K-0321
K-0324
K-0331
K-0341
K-0353
K-0363
K-0761
K-0918
K-0919
K-0920
K-0921
K-0923

Based on observation, interview, and document review, the facility failed to maintain a clean and sanitary environment and failed to ensure policies were in place to address the presence of stagnant/contaminated water in the building potable water supply system which could result in the in the potential to spread infectious agents and increased patient infection and illness from opportunistic pathogenic oragnisms growing in the water supply and drains to the 2 in-patients and 4 emergency room patients that were currently being served by the facility. Findings include:

On 6/17/2019 at 1100, the cafeteria was entered and found to have heavy dust on the top of 2 refrigerated beverage coolers sitting on the counter. These findings were confirmed by Staff B at the time of discovery.

On 6/17/2019 at 1118, the secondary ultrasound room was entered and found to have heavy dust on top of the upper cabinets. This finding was confirmed by Staff H at the time of discovery.

On 6/17/2019 at 1121, emergency room (ED) #5 was entered and found to have heavy dust on top of the light fixture at the head of the bed. This finding was confirmed by Staff B at the time of discovery.

On 6/17/2019 at 1144, the ED medication room was entered and found to have a storage shelf/drawer mounted to the wall above the medication dispensing machine. The drawer was found to have brownish colored stains and dirt present as well as tape residue and residual. This finding was confirmed by Staff I at the time of discovery.

On 6/17/2019 at 1355, acute care unit room #223 was entered and found to have heavy dust on the monitor support. This finding was confirmed by Staff B at the time of discovery.

On 6/17/2019 at 1424, the acute care medication room was entered and found to have heavy dust top of the medication refrigerator, the medication dispensing machine bulk storage locker, and paper towel dispenser. Additionally, there was age-yellowed foam tape on the wall by the paper towel dispenser and dust along the outside edge of the instrument used to crush medications. These findings were confirmed by Staff K at the time of discovery.

On 6/17/2019 at 1428, the lab was entered and found to have a plush, green, stuffed toy present in the handle of the blood culture machine. Staff L confirmed this finding at the time of discovery and stated the company that the machine was purchased from provided the toy to indicate which side of the machine was available for use. Additionally in the lab, heavy dust was found on top of the table-top storage cabinet and on the cabinet directly across from the blood bank refrigerator. These findings were also confirmed by Staff L at the time of discovery.

On 6/18/2019 at 1010, Staff S was observed inserting an IV (an intravenous (in the vein) catheter to administer medications and/or fluids) into Patient #22. Upon completion, he picked up the bottle containing the blood glucose monitoring strips, opened it, obtained a strip, closed the bottle and proceeded to completing the test. When finished, he removed his gloves and discarded them but failed to wash his hands or perform hand hygiene.

At 1020 on 6/18/2019, Staff S was observed removing the used blood glucose monitoring strip from the machine with ungloved hands and discarded it. Staff S failed to wash his hands or perform hand hygiene. Staff S then picked up the blood glucose monitoring machine and test strips and walked down the hall to the nursing station, entered the medication room and proceeded to put away the monitor and test strips without first cleaning them.

Staff K was queried on 6/18/2019 at 1026 as to if she had noticed Staff S failing to wear gloves, perform hand hygiene and failing to clean the blood glucose monitor and test strip bottle to which she stated, "I did notice the failure to wear gloves and wash his hands. I couldn't see into the med room, but I believe that he didn't clean the (glucose monitoring machine)."

On 6/18/2019 at 1029, the post anesthesia recovery unit (PACU) was entered and found to have dust on top of the papertowel dispenser. This finding was confirmed by Staff K at the time of discovery.

Review of facility policy titled "10 Step Acute Care Room Cleaning Process" last revised 2/19/2019 states, "High dust (G [gloved]) the TV, lights, vents, windows, walls, and baseboards...Sanitize (G) the room using VW (type of sanitary wipe)...wiping all high touch items and horizontal surfaces..."

Review of facility policy titled "Hand Hygiene" last revised 8/16/2018 states, "Handwashing should be done...Before and after you treat a patient in any way...After touching objects or surfaces that may have been contaminated...After handling or touching blood or any other bodily fluid...As soon as you remove your gloves or other personal protective equipment..."

Review of facility policy titled "(Company Name) Glucose Meter Program" effective 3/2013 states, "Procedure For Cleaning: A. Meter cleaning is required between each patient test. Use a dampened or pre-moistened cloth...Gently wipe exposed surfaces of the meter...Ensure the meter is dry before putting back into use."



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Additional findings:

On June 17, 2019 at approximately 10:00 AM, observed that the hand wash sink in patient room 211 had rust colored water flowing from it when it was turned on. At the time of discovery, Staff C the facility director explained that housekeeping is instructed to flush all the fixtures in the room when they clean. Since many of these patient rooms are left unused due to low census, the rooms require only infrequent housekeeping.

On June 17, 2019 at approximately 10:24 AM, observed rusty water coming from a hand wash sink in the old Intensive Care Unit (ICU) corridor when the faucet was turned on.

On June 17, 2019 at approximately 2:00 PM, a review of the facility's water management plan identified that the plan did not address flushing of the water piping in vacant or infrequently used rooms.