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Based on observation and interview, the CAH failed to ensure that all paper medical records were maintained and protected from water damage should the sprinklers engage.
Findings:

On 09/14/22 at 10:00 a.m., interview with S2MedRecords revealed that approximately 80% of the CAH's medical records are electronic. S2MedRecords stated the other 20% are paper medical records and are scanned into the patients electronic medical record after discharge.

Observations at that time of the medical records department revealed there were two large rooms that contained over one thousand medical records on rolling shelves with large openings at the top of the shelves. Sprinkler heads were observed above the open shelves Observation of some of the records on the shelves revealed a stack of surgery records from procedures dated 09/02/22 that were needing to be scanned into the medical record. Further observation of some of the other records revealed they dated back to 2016.

Interview with S2MedRecords at that time revealed these large shelves contained patient medical records that needed to be scanned into the electronic medical record system. When asked if these paper records were protected from water damage, should the overhead sprinklers engage, she stated no.

Based on policy/procedure review, CDC guidelines, observations and interviews, the CAH failed to maintain a clean and sanitary environment to avoid sources and transmission of infection as evidenced by 1) failing to ensure equipment was properly cleaned or sterilized after each use and 2) failing to ensure staff sanitized their hands after removing and changing gloves between the dirty and clean aspects of a dressing change.
Findings:

1) Review of the facility's policy titled, "Equipment and Cleaning and Decontamination" from the Cardiopulmonary Department revealed in part: Once equipment is no longer needed by the patient, it will be stripped of all disposable parts and surfaces will be cleaned. Adhesive residues (i.e., tape glue) must be removed prior to processing for reuse. Review of the facility's policy titled, "Department Cleaning" from the Radiology department revealed in part: Equipment with be properly cleaned and sterilized after each use.

Observations on 09/12/22 at 2:20 p.m. of the Radiology department revealed grime and debris on the CT-Computed Tomography exam table and grime and debris on the neck/head splint. Continued observation of the ultrasound room revealed grime and debris on the wire leads of the EKG-Electrocardiograph machine. S1DON accompanied surveyor during the observations.

In an interview following the observations, S1DON acknowledged them equipment was not cleaned according to policy after each patient use.

2) Review of the CDC-Centers for Disease Control and Prevention "Hand Hygiene in the Healthcare Setting" revealed in part: Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. Change gloves and perform hand hygiene during patient care, if gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, and moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs.

Observation of wound care for Patient #16 on 09/14/22 at 8:45 a.m. revealed S3RN did not sanitize or wash her hands between glove changes after removing the soiled dressings and applying the new dressings on the patient's legs.

In an interview on 09/14/22 at 10:00 a.m., S1DON acknowledged best practices dictate that staff should wash or sanitize their hands after removing soiled gloves between the dirty and clean aspects of a dressing change.