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Based on observation and interview, the provider failed to ensure medical supplies and sterilization test supplies were not outdated in three of seven areas (operating room, central sterilization room, and cardiac rehabilitation (rehab) crash cart) where those supplies were kept. Findings include:

1. Observation on 11/2/10 at 2:00 p.m. of the cardiac rehab crash cart revealed:
*Eight packages of 18 gauge intravenous catheter needles had an expiration date of June 2004.
*Eight packages of 20 gauge intravenous catheter needles had an expiration date of June 2004.
*Seven packages of tracheal suction tubes of assorted sizes had expiration dates in 2001 and 2002.

Interview with the pharmacy technician at the above time revealed she only reviewed medications in the cart for expiration dates. The above supplies were in different drawers from the medications. She expected someone from another department to review the supplies for expiration dates.

Interview on 11/2/10 at 2:40 p.m. with the central distribution technician revealed she did not stock the crash carts. The technician stated she placed supplies in the medication room at the nurses station. She stated the nurses would use those supplies to update the crash carts when needed.



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2. Observation on 11/3/10 from 8:20 a.m. to 10:00 a.m. revealed the following surgical and sterilization supplies were outdated and still remained in stock in the following areas:

Operating room:
*Twelve packages of intravenous catheters dated December 2000 through May 2009.
*One Vacutainer with a buffered 3.7% sodium solution dated August 2003.
*Eleven packages of spinal needles dated December 2006 through April 2010.
*Two boxes of black 3.5 and 4.0 sutures dated August 2010.

Central Sterilization room:
*Three boxes of Attest biological test indicators dated August 2010.

Interview with the certified registered nurse anesthetist (CRNA) at the time of the observation of the operating room supplies confirmed those findings. The CRNA stated he was responsible for checking and restocking the operating room supplies in his area. However since they were not using the operating room on a frequent basis, the supplies had not been checked for several years.

Interview with the operating room director (ORD) at the time of the observation of the operating room and central sterilization room supplies confirmed those findings. She stated she and the surgical technician had just checked the surgical supplies in their area of the operating room but had apparently missed those two boxes of sutures. The ORD also confirmed the biological test indicators were outdated. She stated she had recently ordered them from their parent company and had not noticed the supplies the parent company had sent were outdated.

Based on observation, testing, and interview, the provider failed to maintain cleanable and durable surfaces for:
*The handsink cabinet in the darkroom.
*The corner of the wall under the counter in the laboratory (lab).
*The home-style rug in used in the lab drawing room.
*The ceiling and walls in intensive care units (ICU) one and two.
*The walls and corners next to the housekeeping closet on the patient floor.
*The wall around the old Sitz Bath faucets.
*The doors and frames for patient rooms 204 and 207, and the hospice room.
*The wall next to the wheelchair scale on the patient floor.
*The wall of the staff restroom in the administration corridor.
*The walls in the pre/post operative area in the operating suite.
*The wall in the housekeeping closet in the operating suite.
*The wall and mopboard juncture in the operating room.
Findings include:

1. Observation at 9:05 a.m. on 11/2/10 revealed the edge of the cabinet for the handwashing sink in the dark room of the x-ray department had a piece of chipped laminate that exposed the unfinished wood.

Interview with the environmental services supervisor at the time of the observation confirmed that finding. She stated she was not aware that laminate was chipped. She stated if her staff had not submitted a work order to her then it was up to the x-ray department to submit a work order to maintenance for repairs.

2. Observation at 9:30 a.m. on 11/2/10 revealed the corner of the wall under the requisition counter in the lab had missing plaster in two places. Those two places were approximately one to two inches wide, and twelve inches and three inches long (photo 5).

Interview with the lab supervisor at the time of the observation revealed she was aware of the chipped plaster but had not submitted a work order.

3. Observation at 9:35 a.m. on 11/2/10 revealed a home-style rug approximately two foot by three foot in size on the floor in the lab drawing room storage area. Closer observation at that time revealed gray dust would puff out from under that rug when walked upon. That gray dust appeared to be the old dried rubber backing of the rug and covered the area under that rug (photo 4).

Interview with the environmental services supervisor at the time of the observation confirmed that finding. She stated she was not aware of the condition of that rug or why that rug was in that clean work area.

4. Observation from 9:45 a.m. to 10:00 a.m. on 11/2/10 revealed the following in the ICU patient rooms:
a. ICU 1 had chipped and cracked plaster around the base of the sprinkler head (photo 6) and on the wall approximately 8 by 10 inches (photo 7).
b. ICU 2 had raw plaster that was painted where an old sprinkler head had been removed (photo 9).
c. ICU 2 had an inside corner of the wall of the bathroom that was discolored from what appeared to be a leak at one time (photo 8).
Interview with the environmental services supervisor at the time of the above observations confirmed those findings. She stated she was not aware of the condition of the walls and ceilings in the ICU. She stated if her staff had not submitted a work order to her then it was up to the nursing department to submit a work order to maintenance for repairs.

5. Observation beginning at 10:30 a.m. on 11/2/10 revealed:
a. The patient floor corridor corner walls next to the housekeeping closet were chipped, void of plaster, or had holes in the wall (photos 14 and 15).
b. The old Sitz Bath room next to the housekeeping closet was now used for storage. The wall around the faucets for the old Sitz Bath had eroded plaster and gypsum board (photo 16).

Interview with the environmental services supervisor at the time of the above observations confirmed those findings. She stated she was aware of the condition of the walls. She stated if her staff had not submitted a work order to her then it was up to the nursing department to submit a work order to maintenance for repairs.

6. Observation from 10:30 a.m. to 11:00 a.m. on 11/2/10 revealed:
a. The doors and frames of patient rooms 204 and 207 and the hospice room had gouges in the veneer that left splinters and a rough surface (photos 12 and 17). One door had been repaired but not sealed or painted to create a smooth surface (photo 18).
b. The door frames of patient rooms 204 and 207 had areas of missing and chipped paint the size of quarters and half dollars (photo 13).
Interview with the environmental services supervisor at the time of the above observations confirmed those findings. She stated she was aware of the condition of the doors and frames. She stated if her staff had not submitted a work order to her then it was up to the nursing department to submit a work order to maintenance for repairs.

7. Observation at 11:15 a.m. on 11/2/10 revealed the corridor wall next to the wheelchair scale had gouges, pits, and scratches that covered the entire wall (photo 19). Interview with the environmental services supervisor at the time of the observation confirmed that finding. She stated she was aware of the condition of the walls. She stated if her staff had not submitted a work order to her then it was up to the nursing department to submit a work order to maintenance for repairs.

8. Observation at 1:00 p.m. on 11/2/10 revealed a staff restroom in the administration corridor. The wall in that bathroom had a large crack that had bubbled the plaster surface and ran from the wall beneath the sink to under the toilet approximately four feet long (photos 20 and 21).

Interview with the environmental services supervisor at the time of the above observations confirmed that finding. She stated she was aware of the condition of the wall. She stated if her staff had not submitted a work order to her then it was up to the administration department to submit a work order to maintenance for repairs.

9. Observation from 1:30 p.m. to 2:30 p.m. on 11/2/10 revealed:
a. Tears and gaps in the seams of the vinyl wall covering throughout the pre and post operative area of the operating suite (photos 23, 24, and 25).
b. The vinyl wall covering had receded from the mop floor sink base in the housekeeping closet of the operating suite (photo 26).
c. The above tears, gaps and recession in the vinyl wall covering created uncleanable surfaces.

Interview with the environmental services supervisor at the time of the above observations confirmed those findings. She stated she was aware of the condition of the walls. She stated they had started to remodel the operating suite but had not started in the above areas as of yet. She also revealed if her staff had not submitted a work order to her then it was up to the operating suite department to submit a work order to maintenance for repairs.

10. Observation at 9:30 a.m. on 11/3/10 revealed approximately 75 percent of the wall above the mop board in the operating room had peeled or chipped paint. Those unpainted areas were the size of dimes and quarters and connected to one another along the length of the walls.

Interview with the director of the operating suite at the time of the above observation confirmed that finding. She stated she was aware of the condition of the walls. She stated she thought she had submitted a work order, but checked and revealed she had neglected to let maintenance know of the condition of the walls.

Based on observation and interview, the provider failed to remove outdated drugs from one of one operating room. Findings include:

1. Observation from 9:15 a.m. to 9:30 a.m. on 11/3/10 revealed the following drugs used by the nurse anesthetist were beyond the manufacturers' expiration date:
- One vial of sodium chloride dated September 2004.
- Five 2 milliliter (ml) ampules of Marcaine dated October 2010.
- One Xopenex inhaler dated March 2009.
- Two bottles of 10 ml Neostigmine Methylsulfate dated September 2010.
- One bottle of 20 ml Amidate dated May 2010.
- Fourteen vials of 2 ml Metoclopramide dated October 2009.

Interview with the certified registered nurse anesthetist (CRNA) at the time of the observation of the operating room supplies confirmed those findings. The CRNA stated he was responsible for checking and restocking the operating room drugs and biologicals in his area. However since they were not using the operating room on a frequent basis, the drugs and biologicals had not been checked for several years.

Based on observation, interview, and policy review, the provider failed to ensure all infection prevention and control practices were implemented for the following:
*Storage of Cidex and containers used to sterilize patient use equipment in emergency room (ER) 1.
*Training and education regarding the transfer of information for standard precautions for patient room 207.
*Cleanable wood supports for toilet bases in three of three patient rooms (202, 204, and 206).
*Hand hygiene and wound care instruments during observation for one of one patient's (23) wound care.
*Maintenance of sterilization equipment.
Findings include:

1. Observation at 9:20 a.m. on 11/2/10 revealed a one gallon container of Cidex was stored under the drain line of the handwashing sink in ER 1. A plastic tub was also stored under that drain line.

Interview with the physician assistant at the time of the observation revealed that container of Cidex and plastic tub were used to disinfect the video laryngoscope for the emergency rooms. She stated she was not aware those items could become contaminated stored under that drain line.

2. Observation at 10:10 a.m. on 11/2/10 revealed a small portable cart with face masks and vinyl gloves was stored in the corridor outside of patient room 207.

Interview with the environmental services supervisor (ESS) at the time of the observation revealed she was not aware why that cart was stored in front of that room.

Interview with the head housekeeper at that same time revealed she was not aware why the cart had been stored in front of that room. The head housekeeper stated the cart was usually used for infection control and was used by the nursing staff to store items to be used by staff and visitors before entering the patient's room. She stated she was not clear on how to treat and clean the room as no instructions were posted regarding use of the items on the cart. The ESS told the head housekeeper to receive instructions from the charge nurse on precautions for that room.

Interview with the charge nurse revealed he had relayed information to the infection control nurse early that morning that the patient in room 207 had been admitted last night with upper respiratory symptoms related to possible pneumonia. He stated the infection control nurse had told him the lab reports had not returned with information to proceed with care of the patient and how to treat the room. The ESS told the head housekeeper to wear a face mask and gloves to enter and clean the room. The charge nurse stated he had not been told to post any type of precautionary signs for that room.

Interview with the infection control nurse at 3:00 p.m. on 11/2/10 confirmed she had talked to the charge nurse regarding the condition of the patient in room 207. She stated she had seen no reason to post precautionary signs as there had not been any lab reports to confirm an infection control sign was needed. She was asked why standard precautions had been placed into effect for the room by placing the isolation cart in the hall. She stated she did that for precautionary protection of the patient and the staff. She also stated all staff should be aware of standard precautions. She was asked again how a visitor would know to use the supplies on that table. She then stated she understood the confusion of placing an isolation cart without a precautionary sign.

Review of the provider's Standard Precautions policy dated February 2008 revealed under Guidelines: "Standard Precautions apply to all patients of the facility. No physician order is required. Transmission-based precautions information will be posted on the patient's door."

3. Random observation from 10:15 to 10:20 a.m. on 11/2/10 revealed patient rooms 202, 204, and 206 had four inch by four inch wooden support posts under the bases of the wall mounted toilets (photos 10 and 11). Interview with the ESS at the time of the observations confirmed those findings. She stated maintenance had added those wooden redwood supports for patients who were overweight. She confirmed those posts were not cleanable and could absorb liquid substances.




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4. Observation of a dressing change at 10:20 a.m. on 11/2/10 to patient 23's lower right leg wound revealed licensed practical nurse (LPN) A and a student nurse entered the room and donned gloves. LPN A was acting as a preceptor for the student nurse. Neither LPN A nor the student nurse had washed their hands prior to putting on gloves and beginning the dressing change. At the conclusion of the dressing change the student nurse pulled scissors from her pocket to cut the guaze that was wrapped around the wound. She did not disinfect those scissors prior to use. The LPN preceptor did not stop her from using those scissors. Once the student nurse had cut the guaze, she disinfected the scissors with alcohol, and placed those scissors back into her pocket.

Interview with LPN A following that dressing change revealed that was her usual practice. She confirmed washing her hands upon entering the patient's room would have been an appropriate practice. She also confirmed she should have had the student nurse disinfect her scissors prior to use.

Interview with the infection control coordinator at 11:15 a.m. on 11/2/10 revealed all staff had been instructed regarding the importance of handwashing prior to providing patient care. She stated education was provided upon orientation and at least annually via online learning through the provider's regional network. She stated handwashing observations were done twice annually to observe staff practices and make corrections as needed. She confirmed handwashing should have been done by both LPN A and the student nurse prior to putting on gloves. She also confirmed the scissors should have been disinfected upon being removed from the pocket and prior to use.

Review of the provider's reviewed/revised May 2010 handwashing policy revealed instructions were provided as to handwashing technique. Nothing in that policy reflected the need to wash hands prior to providing patient care or donning gloves.

5. Observation at 9:45 a.m. on 11/3/10 revealed the round handle used to open the autoclave had a yellow substance on the flat surface in the middle of the handle (photo 22). That substance was pliable to the touch and could be removed with a fingernail.

Interview with the director of the operating suite at the time of the above observation confirmed that finding. She stated there had been an information plate with the name of the machine attached to the handle at one time, and it had fallen off. She confirmed that surface was not cleanable and could contaminate clean hands when opening the sterilization unit.

Based on observation, testing, record review, policy review, staff training records review, and interview, the provider failed to comply with proper food handling practices and maintain food contact and non-food contact surfaces in durable cleanable condition. Findings include:

1. Observation on 11/1/10 from 3:15 p.m. to 5:15 p.m. revealed the following in the cafeteria and kitchen:

a. The cafeteria line had an assortment of the following fresh fruits and salads (photo 2). Temperature testing of certain foods revealed the following:
- The sliced egg on the two chef salads was 53-55 degrees Fahrenheit (F).
- The chicken salad was 43-47 degrees F.
- The two saucers of cut Honey Dew melon were 55-56 degrees F.
- The two saucers of cut watermelon were 56-57 degrees F.
Those above items had either been dated 11/1/10 or 11/3/10 but there was no time written on the cellophane wrap used to cover the food. The temperature inside the refrigeration unit was at 40 degrees F. and the temperature on top of the unit holding the fruit and salad dishes was 41 degrees F.

Interview with the kitchen manager at the time of the above observations and testing confirmed the above findings. She stated they kept a temperature log of the refrigeration unit itself but there was no log for the foods. She stated those fruit and salad dishes were placed on the top surface of the cold unit at approximately 11:30 a.m. that morning. The time was now 4:15 p.m.

Interview with the director of food and nutrition services (DFNS) at 4:30 p.m. on that same day revealed he was not aware those fruits and salads were not held at the correct cold holding temperature of 41 degrees F. He stated the unit was about 30 years old and could not be adjusted colder. He stated he would store certain new foods in the refrigerator until a new unit could be purchased. He removed the above foods at that time.

b. One of two light shields in the food storage room was missing. Neither of the two fluorescent light bulbs in that fixture were shatterproof bulbs. Interview at 10:45 a.m. on 11/3/10 with the DFNS revealed he was not aware that light shield was missing but would have maintenance order a new one.

c. The top of the tan plastic food transportation cart had holes the size of quarters and a cracked surface approximately six inches long (photo 3). Those holes and and that crack created an uncleanable surface.

Interview at 10:45 a.m. on 11/3/10 with the DFNS revealed he was aware of the cart and would remove it from the kitchen area.

d. A tray cart used for utensil storage was stored by the tray line and had been covered on two sides with cork bulletin boards (photos 27 and 28). That tray cart held dishes and utensils used by the kitchen staff. Those cork bulletin boards held memos and notes for the kitchen staff. That cork surface was not cleanable and durable for use in the kitchen. Interview at 10:45 a.m. on 11/3/10 with the DFNS revealed he was aware of the cart and stated it was in-use when he took over the position about one year ago.

e. The corner of the countertop for the handsink in the cafeteria had a chipped piece of laminate approximately two and three inches long and one inch wide (photo 1). That laminate was sharp to the touch and created an uncleanable surface. Interview at 10:45 a.m. on 11/3/10 with the DFNS revealed he was aware of the chipped countertop and would have it repaired or replaced.

Review of the Infection Control policy dated June 2008 revealed under paragraph "H. Food Production 1. All potentially hazardous food should be prepared so they will spend less than four hours total in the temperature danger zone of 41 degrees to 140 degrees Fahrenheit."

Review of the kitchen staff in-service conducted on 7/19/10 revealed the following topics were covered: Safe Temperature Zones, Keep food hot/Keep food cold, and Food Danger/Hazard Zone. Those topics included the correct holding temperatures for cold foods.

Based on policy review and interview, the provider failed to ensure all policies were reviewed and revised annually. Findings include:

1. Review of multiple policy sets with the administrator on 11/2/10 beginning at 8:15 a.m. revealed multiple policies had last revision/review dates back to 2005, 2006, and 2007.

Interview with the administrator at the above time revealed the process for reviewing and revising policies was:
*Accomplished electronically.
*The responsibility of department heads and policy authors.
*To have occurred annually.

Review of the provider's reviewed/revised September 2010 policy and procedure development, review, and revision policy revealed:
*The department or person whose job functions were most pertinent to the policy was designated as the author.
*Policies requiring review would be tracked by the policy author and "kicked off" by that designated author 90 days prior to the annual review date.
*Administrative policies and department polices would be reviewed annually.