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Based on document review and staff interview, it was determined in 2 of 25 (Pt #22, Pt #24) medical records reviewed, the Hospital failed to ensure appropriate wound care was provided. This has the potential to affect all patients receiving wound care, with an inpatient census of 10.

Findings include:

1. The Hospital policy revised 11/2012, titled,"Wound Risk Assessment, Prevention and Management" was reviewed on 5/2/19 at 11:00 AM. The policy indicated under "TREATMENT: All wounds that are a Stage II or greater should be assessed and documented. Physician should be contacted and Wound care order set initiated." The policy indicated under, " DOCUMENTATION...Documentation of dressing change and wound assessment should occur on the Wound Assessment in HMS."

2. Pt #22 - Admission date 2/5/19 - Diagnosis: Anemia, Fatigue, and Generalized Pain. A review of Pt #22's medical record was conducted on 5/1/19 at approximately 9:00 AM. Pt #22's record indicated Pt #22 had a coccyx wound/ulcer. A Physician order dated 2/4/19 stated "Sensicare to wound every shift and PRN until wound is healed." Pt #22's clinical record lacked documentation that sensicare was applied by nursing staff during hospitalization or documentation that wound was healed.

3. Pt #24 - Admission date 11/16/18 - Diagnosis: Sepsis. Date of Death: 11/20/18. A review of Pt #24's medical record was conducted on 5/2/19 at approximately 9:30 AM. A wound assessment completed by Medical/Surgical Nursing Director (E #11) indicated, "has a stage II decub (pressure ulcer) to coccyx." Pt #24's clinical record lacked documentation a Physician was notified of the Stage II pressure ulcer or that wound orders were received.

4. An interview with E #11 was conducted on 5/2/19 at approximately 11:00 AM. E#11 reviewed the medical records of Pt #22 and Pt #24 and stated, "Wound care should be charted as ordered. Wound care done for patients with no specific order, I would expect staff to use the 'Staging Wound Guide' which is posted on the unit." E#11 confirmed the above findings for Pt #22 and Pt #24, and stated that the hospital policy for wound assessment, treatment and documentation was not followed.

Based on observation, document review, and staff interview, it was determined that the Hospital failed to ensure outdated drugs and/or biologicals were not available for patient use. This has the potential to affect all inpatients and outpatients receiving Hospital services.

Findings include:

1. The hospital policy titled "Beyond Use Date (Expiration Date) Drug Policy" [last approved by the Hospital 11/2018] was reviewed 4/30/19 at approximately 2:00 PM. The policy required "Expired drugs and devices shall not be made available for patient use...expiration dates shall be checked...and expiration dates scheduled to expire next month shall be removed from stock..."

2. On 4/30/19 at approximately 11:30 AM, a tour of the Surgical Services Department with the Manager of Surgical Services (E#10) and the Infection Control Coordinator (E#9) was conducted. Inside the anesthesia cart located within the urology procedure room was one [1] unopened glass vial of Isoflurane 25 milliliter (ml) (a general anesthetic used to start or maintain anesthesia) with an expiration date of 8/31/18.

3. During the tour with E #9 and E #10, both confirmed that the medication was expired and should not be in the cart.

A. Based on observation, document review, and staff interview, it was determined the Director of Dietary Services (E#2) failed to ensure all foods were labeled and expired foods discarded per Hospital policy. This failure has the potential to affect all patients receiving dietary services.

Findings include:

1. On 4/29/19 at 10:30 AM, a tour of the Dietary Department was conducted with the Quality Director (E#1) and Director of Dietary Services (E#2). The kitchen area contained the following: one (1) opened, unlabeled box of corn muffin mix; one (1) unlabeled clear, plastic container of a white substance (Identified as yogurt); and approximately four (4) apple juice containers, with an expiration date of 4/26/19.

2. The Hospital policy, last revised by Hospital 8/2016, titled, "Food and Supply Storage" was reviewed on 4/30/19 at 10:00 AM. The policy indicated under "Procedure:...The "use by" date is the last date that a food can be consumed...Foods past the "use by" date should be discarded. Cover, label and date unused portions and open packages."

3. An interview was conducted with E#1 and E#2 on 4/29/19 at 10:45 AM. E#1 and E#2 reviewed the corn muffin, yogurt and apple juice containers, and stated that the food items should have been labeled per policy and the apple juice had expired and should have been thrown away.


B. Based on observation, document review, and staff interview, it was determined the Director of Dietary Services (E#2) failed to ensure all food areas were clean and sanitary. This failure has the potential to affect all patients and visitors receiving dietary services.

Findings include:

1. On 4/29/19 at 10:30 AM, a tour of the Dietary Department was conducted with the Quality Director (E#1) and Director of Dietary Services (E#2). The Department contained the following: a dirty mop head on the floor in the dishwashing room; yellow pepper and onion peels on the floor of the walk-in refrigerator; and a roll of paper towels on the floor in the storage room.

2. The Hospital policy, revised by Hospital 8/2016, titled, "Sanitation Program" was reviewed on 4/30/19 at 10:15 AM. Under "Policy: All food, non-food items and supplies used in food preparation shall be stored in such a manner to prevent contamination to maintain the safety and wholesomeness of the food for human consumption." The policy indicated under "Procedure: b. Specific areas are used for storing cleaning equipment. c. Cleaning supplies are stored separate from food items and paper supplies."

3. An interview was conducted with E#1 and E#2 on 4/29/19 at 10:45 AM. Both visualized the dirty mop head, the yellow pepper and onion peels on the floor, and the roll of paper towels on the floor; and stated that the items should have been removed from the floor and stored appropriately.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of a Sample Validation Survey conducted April 29, 2019, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were cited. Also see A710.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of a Sample Validation Survey conducted April 29, 2019, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were cited. See the Life Safety Code deficiencies identified with the K-Tags.

A. Based on observation, document review, and staff interview, it was determined for 1 of 1 hepatobiliary scanners (used in nuclear medicine), the Hospital failed to ensure patient equipment was maintained in a manner to prevent cross-contamination. This has the potential to effect all patients receiving services via the the hepatobiliary scan.

Findings include:

1. A tour of the Nuclear Medicine Department with E #5 (Risk Manager) and Nuclear Medicine Technician (E #6) was conducted on 4/30/19 at approximately 2:15 PM. The hepatobilary scan (HIDA Scan) had two pads (for patient comfort) placed on the scan. The smaller pad available for the patient's head had two pieces of tape attached to the pad.

2. A review of Facility policy on 5/1/19 at 3:15 PM "Guidelines for Cleaning, Disinfection and Sterilization" (last revised by Hospital on 9/15) indicated "To determine the appropriate category under which a patient item is to be cleaned, disinfected or sterilized depends on the use of the item...non-critical, class three". " Cleaning...Failure to remove foreign matter from an object before disinfection...is likely to render ... the process ineffective".

3. An interview with Quality Administrator (E #4) on 5/1/19 at 3:30 PM was conducted. E #4 agreed that there was potential for cross contamination from the equipment pad because the tape prevented complete disinfection during cleaning.


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B. Based on observation and interview, it was determined for 2 of 2 (Pt #13, Pt #15) surgical patients observed, the hospital failed to ensure infection control measures were followed to prevent the potential for cross contamination. This has the potential to affect all staff, visitors, and inpatients and outpatients serviced by the Hospital, with a current inpatient census of 10 and an average monthly same day surgery census of 300.

Findings include:

1. In Operating Room (OR) #2 on 4/30/19 at approximately 12:15 PM, it was observed during Pt #13's Hysteroscopy, Myosure with biopsy of endometrium procedure the Certified Registered Nurse Anesthetist (CRNA) (E # 3) whom was caring for Pt #13; put gloves on without performing hand hygiene, opened a vial of medication without cleaning the septum, administered medication to Pt #13 through the Intravenous (IV) injection port without cleaning the port, and changed gloves without utilizing hand sanitizer or washing hands.

2. In OR #2 on 05/01/19 at approximately 10:00 PM, it was observed during Pt #15's, Endoscopic Sinus Surgery the CRNA (E # 8) whom was caring for Pt #15; put gloves on without performing hand hygiene, opened a vial of medication without cleaning the septum, administered medication to Pt #15 through the IV injection port without cleaning the port, and changed gloves without utilizing hand sanitizer or washing hands.

3. The Hospital policy titled, "Hand Hygiene" (last approved by the Hospital on 09/2016) was reviewed on 5/2/19 at approximately 11:00 AM. The policy stated, "B. Indications for hand hygiene... 2. Before and after patient contact... 5. After contact with all patients and equipment. 6. After removing gloves..."

4. The Hospital policy titled "Sterile Products-Aseptic Technique" (last approved by the Hospital on 03/2019) was reviewed on 5/2/19 at approximately 11:15 AM. The policy stated "Aseptic Technique... Clean diaphragms, injection ports and ampoule necks with sterile 70% alcohol."

4. An interview was conducted with the Infection Control Coordinator (E#9) on 05/01/19 at approximately 8:35 AM. E #9 agreed that E #3 and E #8 should have performed hand hygiene before donning gloves and after removing gloves, as well as, cleaning the septum and medication port with alcohol prior to administration of medication.