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Based on observation and interview, the facility's policies, training, and quality oversite failed to ensure the condition of the hospital's physical plant was maintained in such a manner that the safety and well-being of patients are assured.

The facility's policies, training, and quality oversite failed to identify and mitigate breaks in the overall physical plant.

Findings included

During a tour of the surgical area on 12/17/19 ending at 10:49 AM with Personnel #5 and #20, the following items were identified and confirmed:

1) The storage area had a compromised ceiling tile.

During a tour on 12/17/19 ending at 3:32 PM with Personnel #2, the following items were identified and confirmed:

1) The hospital's outpatient sleep lab office had a compromised ceiling tile.

2) The hospital's outpatient laboratory blood draw station bathroom had a box stored on top of a storage cabinet (above 18 inches) below the fire sprinkler head.

Based on observation and interview the facility failed to ensure the equipment had an acceptable level of safety and quality in that the 3 compartment sink in the facility's kitchen did not ensure the concentration level of the sanitizer in the 3rd compartment was maintained according to the manufactures recommendations.

Findings included

During a tour of the facilities kitchen on 12/17/19 with Personnel #6 ending at 1005 the 3 compartment sink used to wash equipment had an automatic soap and sanitizer dispensing mechanism. The 3rd compartment had no visible means to measure the amount of water added to the sink.

During an interview on 12/17/19 ending at 1005 Personnel #6 was asked how the staff knew they had the correct concentration of water to sanitizer in the 3rd compartment of the sink. Personnel #6 stated that the staff knew about where to fill the sink and the sanitizer was automatically measured when it was dispensed.

Based on observation, record review, and interview, the facility's infection control policies, training, and quality oversite failed to ensure safe infection control practices throughout the hospital to provide care in a sanitary environment, and to prevent the spread of infectious diseases.

The facility's policies, training, and quality oversite failed to identify and mitigate breaks in infection control practices and cleanliness.

Findings included

During a tour of the hospital on 12/16/17 ending at 2:55 PM with Personnel #2, the following items were identified and confirmed:

1) The hospital's laundry worker allowed Personnel #2 and the surveyor to enter the clean laundry room without advice to wear a hair bouffant.

2) The hospital's laundry worker could not articulate the laundry process to communicate how items were disinfected at 160 degrees/hot water for 25 minutes and/or use of low temperature water requirements per the policy.

3) Room SCU #8 was labeled as ready for patient use. The toilet had a black ring in the bowl. The linoleum floor was dingy with a large percentage of the floor with grayish areas.

During a tour of the surgical area on 12/17/19 ending at 10:49 AM with Personnel #5 and #20, the following items were identified and confirmed:

1) There were 5 sterilized items/clamps ready for patient use found with their tips closed in the sterile supply room.

2) There was dried clear to tan evidence of previous leaks and a few moth looking insects in the light fixture in the hallway leading to Surgical Suite #9.

3) Multiple surgical supply cart covers were tattered and worn.

During a tour on 12/17/19 ending at 3:32 PM with Personnel #2, the following items were identified and confirmed:

1) The hospital's outpatient sleep lab storage closet had multiple crickets in the light fixture.

2) The hospital's outpatient laboratory blood draw station had multiple tear/rips in the seat of the blue lab draw chair.

Under the handwashing sink cabinet there was dried clear to green dinged evidence of previous leaks. There was a bottle of hand sanitizer and a bottle of bleach being stored under the sink.

The blood draw station had a bathroom attached. The linoleum had dried dark brown/rust colored evidence of previous leaks under the toilet.

During a tour on 12/18/19 ending at 10:30 AM with Personnel #1, two administrative bathrooms had broken/separated tiles behind and below the toilets. Both had black, organic material growth. Personnel #1 confirmed the findings.




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Based on interview and record review the infection control officer did not develop a system for controlling infections and communicable disease of patients in that 5 of 7 (Patient #16, #17, #18, #19, #20) patients were assigned to a nurse that had both infectious and post-operative patients.

Findings included:

The nursing assignment sheet dated 11/28/19 reflected Personnel #15 was assigned the care of Patient #19 that underwent a right total knee arthroplasty on 11/26/19. Personnel #15 was also assigned the care of Patient #20 that was diagnosed with left buttock cellulitis on 11/26/19.

The nursing assignment sheet dated 12/17/19 reflected Personnel #14 was assigned the care of Patient #18 that underwent a left total reverse shoulder arthroplasty on 12/16/19, Patient #17 that underwent a left total knee arthroplasty on 12/12/19, and Patient #16 that was diagnosed with Left hand cellulitis on 12/16/19.

During an interview on 12/17/19 at 0920 on the One West Patient Care area Personnel #13 stated the nursing assignments are made based on patient diagnosis. A nurse would not take care of a surgical patient if they had "dirty" patient. Personnel #13 was shown the assignment sheet for 12/17/19 and Personnel #13 stated the nurse should not have been caring for post-operative patients and a patient that was diagnosed with cellulitis.

During an interview on 12/17/19 ending at 1415 Personnel #1 was shown the assignment sheet for One West Patient Care area and Personnel #1 verified that Personnel #15 was taking care of post-operative patients and a patient with a diagnosed infection.

The policy titled Bed Assignment Effective 01/01/17 reflected..." Bed assignment in the patient care unit shall be determined addressing the isolation, infection prevention and control...nursing care needs of the patient..."