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Based on observation, interview, and record review the facility failed to ensure that emergency supplies were stocked and available by failing to document crash cart and defibrillator monitoring checks daily in 1 of 7 crash carts (Medical/Surgical unit) in a total of 12 Departments observed and complete weekly eye wash station verifications in 2 of 6 (Laundry room and Environmental Services (EVS) storage room hallway) eye wash stations in a total of 12 departments observed and failed to follow the packaging and storage directions for electrodes in 4 of 6 ED (Emergency Department) rooms observed.

Findings include:

Review of the facility policy, titled "Emergency Equipment Checks, TCMNsg-9260", dated 8/2023, revealed: "Emergency Resuscitation Cart Daily Inspection and Documentation: 2. Emergency carts will be checked at least daily when the department is open."

Review of the facility policy, titled "Emergency Eye Wash and Shower Equipment", dated 1/2023, revealed: "1. Plumbed eye wash and shower equipment will be activated weekly by the user department for at least 3 minutes......Weekly verification will be documented on the 'Emergency Eyewash/Shower Weekly Verification of Proper Operation' log."

Medical/Surgical Unit (M/S unit):

On 8/30/2023 at 11:45 AM during a tour of the M/S unit accompanied by Nurse Manager M, observed a Crash cart in room 216 without a daily check list.

In an interview with Nurse Manager M on 8/30/2023 at 11:45 AM, Manager M confirmed the finding and stated, "The crash cart should be checked daily."

Environmental Services (EVS):

On 8/30/2023 at 11:50 AM during a tour of the laundry room outside of the M/S unit accompanied by Nurse Manager M, observed a plumbed eyewash station in the laundry room with a blank verification tag.

In an interview with Nurse manager M on 8/30/2023 at 11:50 AM, Manager M confirmed the finding and stated, "I think EVS oversees the laundry room."

In an interview with EVS supervisor Z on 8/30/2023 at 12:15 PM, EVS supervisor Z stated, "I was unaware of the eyewash station in the laundry room."

On 8/30/2023 at 8:45 AM during a tour of EVS services accompanied by EVS supervisor Z, observed a plumbed eye wash station in the hallway outside of the EVS storage room without a verification tag.

In an interview with EVS supervisor Z on 8/30/2023 at 8:45 AM, EVS supervisor Z confirmed the finding and stated, "I don't know what department is responsible for checking this eye wash station."


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Emergency Department:

Review of the Directions for Use of the 3M Health Care Red Dot electrodes revealed, "Electrode stay fresh for 30 days in an open bag, or tray, but up to sixty days if the bag is double folded."

On 8/29/2023 at 11:00 AM during a tour of the ED (Emergency Department) accompanied by ED Supervisor G, 3M Red Dot electrodes were observed to be undated and out of the original package, in the following rooms: Room 1 and 2 - 5 strips each of 5 electrodes, Room 3 - 8 strips of 5, Room 4 - 9 strips of 5.

On 8/29/2023 at 11:10 AM in an interview with ED Supervisor G, Supervisor G confirmed the findings and stated that it is just easier to get to them if they are not in the package. "Looks like we will need to keep them in the package."

Based on observation, record reviews and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0223 - Doors With Self-Closing Devices
K-0225 - Stairways and Smokeproof Enclosures
K-0346 - Fire Alarm System - Out of Service
K-0354 - Sprinkler System - Out of Service
K-0355 - Portable Fire Extinguishers
K-0363 - Corridor - Doors
K-0372 - Subdivision of Building Spaces - Smoke Barriers
K-0521 - HVAC
K-0711 - Evacuation and Relocation Plan
K-0919 - Electrical Equipment - Other
K-0923 - Gas Equipment - Cylinder and Container Storage

As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET.

Based on observation, record reviews and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0223 - Doors With Self-Closing Devices
K-0225 - Stairways and Smokeproof Enclosures
K-0346 - Fire Alarm System - Out of Service
K-0354 - Sprinkler System - Out of Service
K-0355 - Portable Fire Extinguishers
K-0363 - Corridor - Doors
K-0372 - Subdivision of Building Spaces - Smoke Barriers
K-0521 - HVAC
K-0711 - Evacuation and Relocation Plan
K-0919 - Electrical Equipment - Other
K-0923 - Gas Equipment - Cylinder and Container Storage


As a result of these deficiencies, 42 CFR 485.623(c) Life Safety from Fire was NOT MET.

Based on observation and interview staff failed to provide safe storage of intravenous catheters, with needles attached, away from patient access in 1 of 1 EDs (Emergency Department) observed in a total of 12 departments observed.

On 8/29/2023 at 11:00 AM during a tour of the ED accompanied by ED Supervisor G, each of the 5 ED rooms were observed to each have 5 BD (Name Brand) autoguard intravenous catheters in an unlocked drawer.

On 8/29/2023 at 11:10 AM in an interview with ED Supervisor G, Supervisor G stated, "We really should lock those up, we have them in each room just out of convenience."

Based on observation and interview the facility failed to maintain a clean and sanitary environment free from potential contamination to patients and staff in 4 of 12 departments (Emergency Department, Dietary, Medical-Surgical, Environmental Services) observed and failed to ensure appropriate infection precautions (hand hygiene) were taken in 1of 1 staff (RN V) observed providing wound care, in a total of 12 departments observed.

Findings:

Review of the facility policy titled, "Patient Care Supplies and Environment" #13940100 dated 8/2023 revealed, "...6. Linen handling a. Cover clean linen to prevent contamination..."

Review of the facility policy titled, "Hand Hygiene, TCMIP-0050 # 11006656 dated 1/2022 revealed, "Gunderson Tri-County uses the WHO (World Health Guidelines) for Hand Hygiene Model "Five Moments for Hand Hygiene". ...1. Cleanse hands with alcohol-based hand rub...a. before and after direct patient contact,..c. after removing sterile or non-sterile gloves ...e. after contact with objects and equipment in the patient's immediate vicinity...

In ED (Emergency Department):

On 8/29/2023 during a tour of the ED accompanied by ED Supervisor G the clean linen cart was observed to be uncovered in the clean supply room.

Supplies stored in cardboard boxes were observed on the bottom shelves of 2 metal carts in the clean supply room. The bottom shelves did not have any plastic liners that would protect the items from water when the area was mopped.

Numerous personal hygiene products, including deodorant, body spray, fragrance mist and hair spray were observed in the ED staff bathroom in the main ED hallway which is accessible to patients.

On 8/29/2023 in an interview with ED Supervisor G, Supervisor G stated, "We should cover that linen cart. I wasn't aware of the need for the plastic liners on the bottom shelves but it makes sense." Regarding the personal products in the staff bathroom Supervisor G stated that staff have been told more than once that they cannot have those items. "I will enforce that fact again."

Dietary Department:

On 8/29/2023 at 11:15 AM during a tour of the Dietary Department accompanied by Dietary Director I, 16 mental carts were observed in the dry storage room. The carts contained food items, some stored in cardboard boxes on the bottom shelves. None of the bottom shelves had plastic barrier liners to prevent items from water when the area was mopped.

In an interview with Dietary Director I on 8/29/2023 at 11:30 AM, Director I confirmed the finding and stated, "Yeah we need to order liners."

Medical Surgical Unit:

On 8/30/2023 at 11:00 AM during an observation of wound care by RN V and accompanied by Nurse Manager M, RN V was observed to change and don new gloves 4 times without proper hand hygiene prior to regloving.

On 8/30/2023 at 2:00 PM in an interview with Nurse Manager M, when asked about RN V's hand hygiene during the procedure "I agree, I also saw several missed opportunities for hand hygiene."





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Environmental Services (EVS):

On 8/30/2023 at 8:30 AM during a tour of the EVS Department accompanied by EVS Supervisor Z, observed clean linens in the clean EVS room on shelving and carts without coverings.

In an interview with EVS Supervisor Z on 8/30/2023 at 8:30 AM, Supervisor Z confirmed the finding and stated, "I wondered about that, we use to cover the clean linens at the old hospital."

Medical/Surgical Unit (M/S unit):

A review of the facility policy, titled "Refrigerator - Freezer Units, TCMDi-0500", dated 2/2022, revealed: "3. Refrigerator and freezer temperatures are to be recorded daily...5. Refrigerator temperature should be between 33 and 41 F; Freezer temperature should be at or below 0."

On 8/30/2023 at 11:45 AM during a tour of the M/S unit accompanied by Nurse Manager M, a nutrition refrigerator for patient items was observed to not have a thermometer in the refrigerator or freezer and there was no log for temperature monitoring.

In an interview with Nurse Manager M on 8/30/2023 at 11:45 AM, Manager M confirmed the finding and stated, "This refrigerator should have thermometers and a temperature log with daily checks."