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Based on review of Medical Executive Committee Minutes, Rules and Regulations, Physician Order sets and interview, it was determined the Governing Body failed to assure the Medical Staff fulfilled its responsibility to review all practitioner-specific pre-printed order sets semi-annually as required by Medical Staff Rules and Regulations. Failure to review practitioner-specific pre-printed order sets did not assure order sets were current and applicable. The failed practice affected the behavioral health census on 04/05/19 of 20 patients on the 1300 hall and 29 patients on the 1400 hall and was likely to affect all new Behavioral Health Unit admissions. Findings included:

A. Review of item 3.6, page 28 of the September 2018 Rules and Regulations, as provided by the Chief Quality Officer 04/11/19 at 2:31 PM, showed that in order to ensure continued appropriateness, practitioner-specific pre-printed orders shall be reviewed semi-annually by the physician and the Utilization Management Committee.

B. Review on 04/11/19 at 3:15 PM of the Medical Executive Committee minutes for 03/22/18 showed Topic 3, 3.8 Pharmacy and Therapeutics were reported and "all P & P's (Policies and Procedures) were reviewed, discussed and approved." The Chief Quality Officer stated on 04/11/19 at 3:23 PM that there had been no review of the pre-printed order sets since 03/22/18 and included the Behavioral Health Unit.

Based on Board of Trustee (BOT) Bylaws, clinical record review and interview, it was determined the governing body failed to ensure quality care was provided to patients placed in "Virtual Bed" status. The BOT failed to ensure the Medical Staff established a procedure for accepting, housing, and treating Behavioral Health Unit (BHU) patients when the Units (1300 and 1400) were at maximum capacity. The failed practice did not assure each patient admitted to the BHU had an actual bed and bathroom and failed to ensure the privacy, comfort, dignity, and safety of those patients on "Virtual Bed" status. The failed practice had the likelihood to affect all patients who were placed in "Virtual Bed" status. Findings follow:

A. Review of the document titled "Board of Trustee Bylaws," received from the Chief Quality Officer at 1:45 PM on 04/01/19, showed the following under Article VIII, Medical Care Evaluations, 8.3(h), Professional Accountability to the Board; Establishing a process to support the efficient flow of patients, such as a plan concerning the care of admitted patients who are in temporary bed locations, and ...

B. The Assistant Chief Nursing Officer (ACNO) stated during an interview at 3:45 PM on 04/03/19 the Virtual Bed was not an actual physical room. The ACNO stated when there were no beds available on the Behavioral Health Unit (BHU) and patients were waiting in the Emergency Room (ER), or other ERs, the BHU Medical Director reviewed anticipated discharge numbers. The BHU Medical Director then reviewed those patients waiting for BHU bed placement, and decided who was to be admitted. The patients who were to be discharged were moved to a Virtual Bed status. The patient in the Virtual Bed status was moved to the dining room or day room along with their belongings. The ACNO stated the patients waiting in the facility's ER were admitted to Virtual Bed status and moved to the dining room or day room in the BHU. The ACNO stated the Virtual Bed patients waited in the dining room or dayroom until the patient's assigned physical bed/room was cleaned and ready for occupancy or the patient's transportation arrived. The ACNO stated the seclusion room bathroom was opened and available for use by Virtual Bed patients. The ACNO stated the patients received their medications, ate their meals, and went into the community meeting while in the Virtual Bed status. The ACNO stated the facility had designated four Virtual Beds for the 1400 Unit and three Virtual Beds for the 1300 Unit.

C. The Chief Quality Officer stated during an interview at 11:15 AM on 04/05/19 there was not a policy and procedure for the Virtual Bed process.

D. Registered Nurse (RN) #1 stated during an interview at 4:58 PM on 04/10/19 that BHU patients were only discharged to a Virtual Bed at the physician's order. RN #1 stated Virtual Bed patients waiting for a bed "hang out in the dining room or day room" until their bed/room is cleaned. RN #1 stated Virtual Bed patients waiting for transportation to leave the facility also hang out in the dining room or day room until "their ride comes." RN #1 stated patients have waited up to seven hours for their physical bed to be ready for their occupancy, but generally it is only a 1-2 hour wait. RN #1 was asked how staffing was handled for the Virtual Bed patients. RN #1 stated the staffing was increased. RN #1 was asked what the patient did for medications and meals and she stated the Virtual Bed admissions and discharges got their medications and meals from the nursing staff as they normally would. RN #1 stated the seclusion room bathroom was opened up for access by the Virtual Bed patients.

E. Examples of patients in Virtual Bed status and their wait times in the dining room/day room included the following:
1) Review of Patient #4's clinical record showed an order to discharge Patient #4 to a Virtual Bed at 10:55 AM on 04/03/19. Review of the clinical record showed Patient #4 left the unit at 11:49 AM on 04/03/19. The Chief Quality Officer verified the above findings during an interview at 2:53 PM on 04/05/19.
2) Review of Patient #5's clinical record showed an order to discharge Patient #5 to Virtual Bed B at 7:13 AM on 04/02/19. Review of the clinical record showed Patient #5 left the unit at 11:30 AM on 04/02/19. The Chief Quality Officer verified the above findings during an interview at 1:15 PM on 04/05/19.
3) Review of Patient #12's clinical record showed an order to discharge Patient #12 to Virtual Bed A at 10:50 AM on 01/22/19. Review of the clinical record showed Patient #12 left the unit at 11:03 AM on 01/22/19. The Chief Quality Officer verified the above findings during an interview at 11:31 AM on 04/05/19.
4) Review of Patient #14's clinical record showed an order to discharge Patient #14 to a Virtual Bed at 7:53 AM on 12/11/18. Review of the clinical record showed Patient #14 left the unit at 12:14 PM on 12/11/18. The Chief Quality Officer verified the above findings during an interview at 12:46 PM on 04/05/19.

Based on Board of Trustee (BOT) Bylaws, clinical record review and interview, it was determined the governing body failed to ensure quality care was provided to patients placed in "Virtual Bed" status. The BOT failed to ensure the Medical Staff established a procedure for accepting, housing, and treating Behavioral Health Unit (BHU) patients when the Units (1300 and 1400) were at maximum capacity. The failed practice did not assure each patient admitted to the BHU had an actual bed and bathroom and failed to ensure the privacy, comfort, dignity, and safety of those patients on "Virtual Bed" status. The failed practice had the likelihood to affect all patients who were placed in "Virtual Bed" status. Findings follow:

A. Review of the document titled "Board of Trustee Bylaws," received from the Chief Quality Officer at 1:45 PM on 04/01/19, showed the following under Article VIII, Medical Care Evaluations, 8.3(h), Professional Accountability to the Board; Establishing a process to support the efficient flow of patients, such as a plan concerning the care of admitted patients who are in temporary bed locations, and ...

B. The Assistant Chief Nursing Officer (ACNO) stated during an interview at 3:45 PM on 04/03/19 the Virtual Bed was not an actual physical room. The ACNO stated when there were no beds available on the Behavioral Health Unit (BHU) and patients were waiting in the Emergency Room (ER), or other ERs, the BHU Medical Director reviewed anticipated discharge numbers. The BHU Medical Director then reviewed those patients waiting for BHU bed placement, and decided who was to be admitted. The patients who were to be discharged were moved to a Virtual Bed status. The patient in the Virtual Bed status was moved to the dining room or day room along with their belongings. The ACNO stated the patients waiting in the facility's ER were admitted to Virtual Bed status and moved to the dining room or day room in the BHU. The ACNO stated the Virtual Bed patients waited in the dining room or dayroom until the patient's assigned physical bed/room was cleaned and ready for occupancy or the patient's transportation arrived. The ACNO stated the seclusion room bathroom was opened and available for use by Virtual Bed patients. The ACNO stated the patients received their medications, ate their meals, and went into the community meeting while in the Virtual Bed status. The ACNO stated the facility had designated four Virtual Beds for the 1400 Unit and three Virtual Beds for the 1300 Unit.

C. The Chief Quality Officer stated during an interview at 11:15 AM on 04/05/19 there was not a policy and procedure for the Virtual Bed process.

D. Registered Nurse (RN) #1 stated during an interview at 4:58 PM on 04/10/19 that BHU patients were only discharged to a Virtual Bed at the physician's order. RN #1 stated Virtual Bed patients waiting for a bed "hang out in the dining room or day room" until their bed/room is cleaned. RN #1 stated Virtual Bed patients waiting for transportation to leave the facility also hang out in the dining room or day room until "their ride comes." RN #1 stated patients have waited up to seven hours for their physical bed to be ready for their occupancy, but generally it is only a 1-2 hour wait. RN #1 was asked how staffing was handled for the Virtual Bed patients. RN #1 stated the staffing was increased. RN #1 was asked what the patient did for medications and meals and she stated the Virtual Bed admissions and discharges got their medications and meals from the nursing staff as they normally would. RN #1 stated the seclusion room bathroom was opened up for access by the Virtual Bed patients.

E. Examples of patients in Virtual Bed status and their wait times in the dining room/day room included the following:
1) Review of Patient #4's clinical record showed an order to discharge Patient #4 to a Virtual Bed at 10:55 AM on 04/03/19. Review of the clinical record showed Patient #4 left the unit at 11:49 AM on 04/03/19. The Chief Quality Officer verified the above findings during an interview at 2:53 PM on 04/05/19.
2) Review of Patient #5's clinical record showed an order to discharge Patient #5 to Virtual Bed B at 7:13 AM on 04/02/19. Review of the clinical record showed Patient #5 left the unit at 11:30 AM on 04/02/19. The Chief Quality Officer verified the above findings during an interview at 1:15 PM on 04/05/19.
3) Review of Patient #12's clinical record showed an order to discharge Patient #12 to Virtual Bed A at 10:50 AM on 01/22/19. Review of the clinical record showed Patient #12 left the unit at 11:03 AM on 01/22/19. The Chief Quality Officer verified the above findings during an interview at 11:31 AM on 04/05/19.
4) Review of Patient #14's clinical record showed an order to discharge Patient #14 to a Virtual Bed at 7:53 AM on 12/11/18. Review of the clinical record showed Patient #14 left the unit at 12:14 PM on 12/11/18. The Chief Quality Officer verified the above findings during an interview at 12:46 PM on 04/05/19.

Based on review of Medical Executive Committee Minutes, Rules and Regulations, Physician Order sets and interview, it was determined the Medical Staff failed to fulfill its responsibility to review all practitioner-specific pre-printed order sets semi-annually as required by Medical Staff Rules and Regulations. Failure to review practitioner-specific pre-printed order sets did not assure behavioral health order sets remained applicable. The failed practice affected the behavioral health census on 04/05/19 of 20 patients on the 1300 hall and 29 patients on the 1400 hall and was likely to affect all new Behavioral Health Unit admissions. Findings included:

A. Review of item 3.6, page 28 of the September 2018 Rules and Regulations, as provided by the Chief Quality Officer 04/11/19 at 2:31 PM, showed that in order to ensure continued appropriateness, practitioner-specific pre-printed orders shall be reviewed semi-annually by the physician and the Utilization Management Committee.

B. Record review on 04/11/19 at 3:15 PM of the Medical Executive Committee minutes for 03/22/18 showed Topic 3, 3.8 Pharmacy and Therapeutics were reported and "all P & P's (Policies and Procedures) were reviewed, discussed and approved." The Chief Quality Officer stated on 04/11/19 at 3:23 PM that there had been no review of the pre-printed order sets since 03/22/18 and included the Behavioral Health Unit.

Based on clinical record review and interview, it was determined the facility failed to document: intake and output per physician order, meal percentages, baths offered or refused and Registered Nurse (RN) documentation on each shift for four (#3, #7, #8 and #10) of eight (#1, #2, #3, #7, #8, #9, #10 and #11) patients who were on the Medical Surgical Units 2400 and 2500. Failure to document the care provided did not assure patients health status and response to care would be accurately evaluated. The failed practice was likely to affect all patients on the medical surgical unit. Findings included:

A. Patient #3 was admitted to the 2400 Unit on 03/25/19 and was discharged on 04/03/19. Clinical record review showed a physician order for Intake and Output to be documented per unit routine, which was one time per shift as verified by the Quality Coordinator on 04/11/19 at 2:25 PM. The clinical record showed no evidence Patient #3's intake was documented on 5 of 19 opportunities and no output documented 5 of 18 opportunities. Meal percent consumed was not documented 03/27/19 or 04/01/19.The findings were confirmed by the Quality Coordinator on 01/11/19 at 2:25 PM.

B. Patient #7 was admitted to the 2400 Unit on 02/26/18 and discharged on 03/03/18. Clinical record review showed no Registered Nurse Documentation for 02/27/18, 02/28/18 and 03/02/18 for the 7:00 PM to 7:00 AM shift. The findings was confirmed by the Quality Coordinator on 04/11/19 at 2:25 PM. There were no baths offered, refused or documented for four (02/26/19 -02/28/19, 03/02/19) of six days. This was confirmed by interview and record review by the Quality Coordinator at 2:15 PM on 04/11/19.

C. Patient #8 was admitted to the 2500 Unit on 11/12/18 and discharged on 11/14/18. Clinical record review showed no evidence baths were offered or refused on 11/13/18 and 11/14/18. This was confirmed by interview and record review by the Quality Coordinator at 8:56 AM on 04/11/19.

D. Patient #10 was admitted to the 2500 Unit on 08/18/17 and discharged on 08/21/17. Clinical record review showed no evidence baths were offered or refused on 08/20/17 and 08/21/17. This was confirmed by interview and record review by the Quality Coordinator at 9:29 AM on 04/11/19.


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Based on clinical record review and interview, it was determined a registered nurse (RN) failed to supervise and evaluate the nursing care in that five (#8, #10, #11, #12 and #13) of sixteen (#1-16) clinical records did not contain evidence patient care was rendered as directed by physician's orders. Review of the clinical records showed no evidence ambulation occurred, dressing changes were performed, supplements were given, daily weights were obtained and meal percentages were performed and documented. Failure of an RN to evaluate, supervise, and manage patient care to ensure physician's orders were followed had the potential for adverse events to occur leading to prolonged hospitalization. The failed practice did not ensure vital information was available for the provider to make informed decisions regarding patient care. The failed practice had the likelihood to affect Patients #8, #10, #11, #12 and #13. Findings follow:

A. Review of Patient #8's clinical record showed orders authored by Physician #1 at 7:49 PM on 11/12/18 for Patient #8 to be ambulated every four hours and daily dressing changes to operative site performed. Review of the clinical record showed Patient #8 was ambulated at 2:00 PM on 11/13/18 and at 8:00 AM on 11/14/18 only and there was no evidence the dressing change was performed on 11/13/19. The Quality Coordinator verified the above findings during an interview at 8:56 AM on 04/11/19.

B. Review of Patient #10's clinical record showed orders authored by Physician #2 at 3:08 PM on 08/20/17 for daily dressing changes to operative sites. Review of the clinical record showed no evidence the dressing changes were performed on 08/19/18 and 08/20/18. The Quality Coordinator verified the above findings during an interview at 9:29 AM on 04/11/19.

C. Review of Patient #11's clinical record showed orders authored by Physician #3 at 10:01 AM on 05/16/18 for dressing changes to right leg and back Monday, Wednesday and Fridays and as necessary. Review of the clinical record showed no evidence the dressing changes were performed on Friday, 05/18/19 or on 05/19/18, the day of discharge. The Director of Quality verified the above findings during an interview at 12:00 PM on 04/11/19.

D. Review of Patient #12's clinical record showed orders authored by the Director of Behavioral Health at 2:15 PM on 01/22/19 for Ensure daily. Review of the Master Treatment Plan also showed orders for daily weights and monitor food and fluid intake each shift and report changes in percentages to the physician. Review of the clinical record showed no evidence Patient #12 received the Ensure for twelve of twelve (01/11/19 - 01/22/19) days. Review of the clinical record showed no evidence Patient #12 was weighed 10 (01/11/19 - 01/16/19, 01/19/19 0 91/22/19) of twelve days (01/11/19-01/22/19) and no evidence meal percentages were recorded for three (01/11/19, 01/16/19 and 01/18/19) of twelve days (01/11/19 - 01/22/19).

Based on Refrigerator and Freezer Temperature Log review for 01/01/19 through 04/03/19 and interview, it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that the facility failed to implement the Arkansas Rules and Regulations for Hospitals and Related Institutions for the frequency of temperature monitoring of kitchen refrigerators and freezers. Failure to document the temperature opening, mid-operation and closing of the department for six of six (1-#6) coolers (refrigerators) and one of one freezer created the potential for refrigerator or freezer malfunction to go unnoticed and compromise the integrity of the food. The failed practice affected all patients who receive food from the kitchen. Findings included:

A. Review on 04/04/19 at 2:36 PM of the facility's policy titled, "Cold Storage Temperatures," revised 01/2018, showed a new temperature log was to be placed on the clipboard at the beginning of the month. Each morning at opening and each evening at closing, temperatures were to be recorded for each refrigerator storage unit. The Dietary Director verified this was the current policy on 04/04/19 at 3:34 PM.

B. Review of 2016 Arkansas Rules and Regulations for Hospitals and Related Institutions, Section 17.B.12, required temperatures of all refrigerators and freezers in the kitchen to be recorded a minimum of three times per day at opening, mid-operation and closing of the department.

C. Observation of the Dietary Department on 04/04/19 showed six refrigerators: #1 (Tray line);
#2 (Tray line); #3 (Milk); #4 (Meat/Dairy); #5 (Vegetable) and #6 (Production) and one of one freezer.

D. Review of Refrigerator and Freezer Temperature Log documentation for 01/01/19 through 04/03/19 showed required refrigerator and freezer temperature checks were not documented at opening 25 of 651 opportunities; mid-operation 651 of 651 opportunities and closing of the department 4 of 651 opportunities. The Dietary Director verified the temperature was not documented as required on 04/04/19 at 3:34 PM.


Based on observation, review of policy, and interview, it was determined the facility failed to follow the standard of practice in that a Test Tray Evaluation was not performed one time per week on two of two Behavioral Health Unit (1300 and 1400 Hall) as required by Facility Policy and failed to ensure food temperatures were as required by Arkansas Rules and Regulations for Hospitals and Related Institutions. The failed practice did not ensure the facility would identify practices that compromised the temperature and quality of the food served to patients. The failed practice affected the census of 20 patients on 1300 Hall and 29 patients on 1400 hall of the Behavioral Health Unit. Findings included:

A. Review on 04/04/19 at 3:33 PM of Patient Food Services policy titled, "Test Tray Evaluation," revised 01/2018, showed a test tray was to be sent to a patient area and evaluated by each management team member on their unit at least once a week. The Test Tray Evaluation process was to provide food service management with a tool to measure the quality level of the meal service and to identify areas of substandard service that required corrective action. Other Test Trays could be performed to check quality of products/service within the department as long as each manager had completed the Test Tray on the assigned unit each week.
1) The Test Tray procedure included:
a. Recording the temperature of the foods on the steam table
b. Following the tray from the tray line to the nursing unit
c. Wait the normal amount of time from preparation of tray to when tray is recognized to be delivered in order to mimic the time of regular delivery practices. The time should be between 30 - 45 minutes of preparation.
d. Takes the point-of -service temperatures. Satisfactory point-of-service temperature is based on state requirements or account's standards.
e. Develops an action plan for assessments that are below 90% or have significant opportunity for improvement.

B. Review of the Arkansas Rules and Regulations for Hospitals and Related Institutions in Arkansas, 2016 Table 9, showed the temperature of hot foods at the bedside should be 140 degrees Fahrenheit (F) or greater and cold foods should be 40 degrees F or less.

C. Review of the "Contact list and Meal Service Schedule for Nursing Unit:1400" posted in the nutrition/supply room on the 1400 hall of the Behavioral Health Unit showed breakfast delivery time was 7:45 AM and tray pick-up was 8:45 AM. "Contact list and Meal Service Schedule for Nursing Unit:1300" posted in the nutrition/supply room on the 1300 hall of the Behavioral Health Unit showed breakfast delivery time was 7:50 AM and tray pick-up was 8:50 AM.

D. An interview was conducted on 04/04/19 at 9:40 AM with Patient #18 on the 1400 Hall of the Behavioral Health Unit who stated her breakfast was cold on 04/03/19 and 04/04/19. Patient #18 stated she stopped to take her medication so she "knew it would be cold today".

E. Observation of the dining/activity area of the 1300 hall in the Behavioral Health Unit on 04/04/19 at 10:00 AM, showed that nursing students were distributing breakfast trays from an open dietary cart. The nursing students stated the trays came to the unit 30 minutes prior.
1) Mental Health Technician (MHT) #1 stated on 04/04/19 at 10:00 AM that the trays were on the hall at 8:30 AM.
2) Interviews were conducted with 11 random patients on 1300 hall who had just been served their tray on 04/04/19 at 10:05 AM. By interview, 10 of 11 patients stated their food was cold or cool when asked by Surveyor #1: three female and one male patients at one table stated the breakfast meal was cold; two male patients at a different table stated the breakfast was cold; one female patient at a different table stated the food was cold; one male patient at a separate table stated the food was cold. One male at a separate table stated the food was always cold, one stated it was fine and one stated it was cool. All patients interviewed wished to remain anonymous and did not provide their names. The Quality Coordinator was present and witnessed the interviews at the time they were conducted.
3) Surveyor #1 requested a thermometer be brought to test extra tray temperatures. The Dietary Director arrived at 10:10 AM on 04/04/19 with a thermometer. There were extra trays on the cart and extra tray #1 was observed in the dietary cart with the main entrees covered and the doors to the cart were open. The temperature of tray #1 as tested by the Dietary Director showed (all measured as degrees in Fahrenheit): Fruit temperature was 68.9 F and the egg omelet was 90.8 F. The Dietary Director stated at the time the temperatures were taken that the fruit should be less than 40 F and the omelet should be greater than 135 F at time of serving. Extra tray #2, also in the dietary cart with main entrees covered, was temperature tested by the Dietary Director and showed the omelet temperature was 83.3 F; hash browns 79.1 F; and bacon 79.5 F. The Dietary Director stated at the time the temperatures were taken that the omelet, hash browns and bacon temperature should be greater than 135 F when served.

F. Continuous observation on 04/04/19 from 11:28 AM - 12:03 PM showed food temp for Lunch trays for the 1300 hall were obtained and documented by dietary staff prior to start of tray preparation and after the last tray was prepared. The prepared trays for the Behavioral Health Unit left the dietary department at 11:37 AM and were delivered to the 1300 hall of the Behavioral Health Unit. The temperature of the test tray at 12:19 PM once delivered to the unit was: carrots 131.3 F; meat 134 F and potatoes 160.5 F. The first tray was delivered to patients at 12:26 PM. The last patient was served at 12:31 PM. Test tray temperatures were: carrots 127 F, meat 124.3 F and potato 144.8 F.

G. On 04/05/19 at 7:31 AM by interview with Dietary Employee #2, she stated "I dropped the 1400 trays off less than 10 minutes ago." Observation on 04/05/19 showed the first tray was removed from the food cart on 1400 Hall at 8:08 AM. At 8:13 AM the last tray was removed from the cart by MHT #2. On 04/05/19 at 8:14 AM the Patient Services Manager for the Dietary Department removed an extra tray from the dietary cart and measured the temperature of food as: egg, sausage and cheese sandwich 109.4 F; breakfast potatoes 93.9 F and fruit 53.6 F. At 8:18 AM MHT #2 retrieved and delivered a tray from the cart and served it to a patient.

H. The Dietary Director was interviewed on 04/04/19 at 3:20 PM and stated the patient care services Manager was responsible for conducting Test Tray Evaluations. The Dietary Director called the Patient Services Manager for the Dietary Department. The Dietary Director stated Test Tray Evaluations had not been performed on the Behavioral Health Unit 1300 and 1400 Hall because they did not want to disturb the patients.

Based on policy and procedure review, observation, and interview, it was determined the Infection Control Officer failed to control the spread of infections in that two of two (2508 and 2207) discharged room bathrooms were not cleaned from clean to dirty. Failure to clean the bathrooms from the cleanest item/area to the dirtiest item/area had the potential for surface and hand contamination for the next patient placed in the room as well as visitors and staff. The failed practice had the potential to affect any patient, visitor, or staff utilizing the bathroom equipment. Findings follow:

A. Review of the policy and procedure titled "Patient Room Cleaning - Discharges and Transfers," received from the Director of Environmental Services (EVS) on 04/02/19, showed the policy and procedure outlined five different Zones each room was divided into. The sink and shower area were defined as Zone 4 and the toilet as Zone 5. The policy and procedure did not address patient equipment such as intravenous pumps and poles, bedside commodes or wheelchairs.

B. Observation of Room 2508 at 1:05 PM on 04/02/19 showed when Housekeeper #1 reached the bathroom, the red Biohazard bin was cleaned top and sides, then the same cloth used to clean the top of the bedside commode and arms. Housekeeper #1 verified the above findings during an interview at 1:34 PM on 04/02/19.

C. Observation of Room 2207 at 4:00 PM on 04/02/19 showed when Housekeeper #2 reached the bathroom, the shower handles, head, seat and walls were cleaned, then the bedside commode lid, seat, underneath the seat, sides of the bedside commode bucket, then the inside of the bedside commode bucket were all cleaned using rag #4. Housekeeper #2 then cleaned the bedside commode frame, legs, arms, the commode seat, underneath the seat, bowl rim, back of toilet and base of bowl all with Rag #4. The Director of Quality verified the above findings during an interview at 4:43 PM on 04/02/19.

D. During an interview with the Director of EVS at 1:15 PM on 04/02/19 he stated the policy and procedure was not specific to cleaning from clean to dirty areas/items; only specific items in the Zones.