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Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on 09/12/2023 through 09/13/2023 the surveyor finds the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code therefore the requirements of 42 CFR Subpart 485.623, Physical Plant and Environment are NOT MET.

See the life safety code deficiencies on the associated K-tags.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on 09/12/2023 through 09/13/2023 the surveyor finds the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies on the associated K-tags.

Based on document review, observation, and interview, it was determined that for 1 of 1 Medical Records Department (H.I.M), the Hospital failed to ensure that confidentiality of the patient's clinical records was maintained, by limiting access to designated individuals.

Findings include:

1. The Hospital's policy titled, "Badge Access System" dated 8/15/2023, was reviewed, and required, "Badges ...protect patient privacy ...Badges limit unauthorized individuals from occupying restricted areas of the hospital ..."

2. The "Cardholder Access to Readers" list (staff that have access to the Medical Records Department and/or all doors), was reviewed on 9/12/2023. The list indicated that 105 employees have access to the department (including housekeepers, certified nursing assistants, security, nurses, physicians, and administration). The H.I.M. department is staffed with 4 employees.

3. On 9/12/2023 at 12:30 PM, an observational tour of the Medical Records Department (H.I.M.) was conducted with the Director of Nursing (E #1). During the tour, E #1 badged into the department with her ID. E #3, a Medical Records Clerk, was present and stated that there are staff other than those assigned to H.I.M, that have access to the department for "after-hour" use. The department contained open shelves of paper medical records.

4. On 9/12/2023 at 12:40 PM, an interview was conducted with (E #3). E #3 stated that employees, other than the staff from the Medical Records department, do have access since the H.I.M staff are not here "after-hours", and the doctor may need to access a previous record.

Based on document review and interview, it was determined that the Hospital failed to comply with the Condition of Participation, 42, CFR 485.640, Infection Prevention & Control & Antibiotic Stewardship.

Findings include:

1. The Hospital failed to measure and record food temperatures to ensure food was being served at safe temperatures. See deficiency at C-1206 (A).

2. The Hospital failed to ensure that the dishwasher temperatures that were not at the required final rinse temperature, were addressed.. See deficiency at C-1206 (B).

A. Based on document review, observation, and interview, it was determined that for 1 of 1 Dietary Department, the Hospital failed to ensure that food temperatures were taken and/or monitored, to prevent potential foodborne illness or infection. This has the potential to affect the average 8 patients on census per day.

Findings include:

1. The Hospital's policy titled, "Food Temperatures" (undated), was reviewed, and required, "The temperatures of the food items will be taken and properly recorded for each meal ...Cooking temperatures must be reached and maintained according to regulations ...A recording Form is also needed to document temperatures ...Resource: Critical Temperatures for Safe Food Handling: Hot Food Handling (less than 140 degrees Fahrenheit: temperature danger zone, rapid bacteria growth, foodborne illness zone)."

2. The Dietary Department's food temperature logs from 6/2023-9/2023, were reviewed on 9/11/2023. The logs lacked the required documentation of food temperature for the 3 daily meals (breakfast, lunch, supper) as follows::

- 6/1, 6/2, 6/5, 6/6, 6/7, 6/8, 6/9, 6/12, 6/13, 6/14, 6/15, 6/16, 6/19, 6/20, 6/21, 6/22, 6/23, 6/26, 6/27, 6/28, 6/29, and 6/30/2023, lacked recorded breakfast and supper food temperatures.
- 6/3, 6/4, 6/10, 6/11, 6/17, 6/18, 6/24, 6/25/2023, lacked recorded food temperatures throughout the day for any meals.
- 7/3, 7/4, 7/5, 7/6, 7/7, 7/10, 7/11, 7/12, 7/13, 7/14, 7/17, 7/18, 7/19, 7/20, 7/21, 7/24, 7/25, 7/26, 7/27, 7/28,7/31/2023, lacked recorded breakfast and supper food temperatures.
- 7/1, 7/2, 7/8, 7/9, 7/15, 7/16, 7/22, 7/23, 7/29, 7/30/2023, lacked recorded food temperatures throughout the day for any meals.
- 8/1, 8/2, 8/3, 8/7, 8/8, 8/9, 8/10, 8/11, 8/14, 8/15, 8/16, 8/17, 8/18, 8/21, 8/22, 8/23, 8/24, 8/25, 8/28, 8/29, 8/30, and 8/31/2023, lacked recorded breakfast and supper food temperatures.
-8/5, 8/6, 8/12, 8/13, 8/19, 8/20, 8/26, and 8/27/2023, lacked recorded food temperatures throughout the day for any meals.
- 9/1, 9/4, 9/5, 9/6, 9/7, and 9/8/2023, lacked recorded breakfast and supper food temperatures.
- 9/2, 9/3, 9/9, and 9/10/2023, lacked recorded food temperatures throughout the day for any meals.

The logs did not include a pre-printed section to record breakfast temperatures.

3. On 9/11/2023 at 2:30 PM, an interview was conducted with the Dietary Manager (E #2). E #2 acknowledged that the logs lacked the required food temperatures and was unable to state the reasoning for the missing recordings. E #2 stated that E#2 does review the logs each month. E # 2 stated that the logs should have recorded food temperatures for each meal.

4. On 9/12/2023 at 10:55 AM, an interview was conducted with a Cook (E # 4). E #4 stated that E#4 does take the food temperatures before they are served. E # 4 stated that, however, E#4 was not trained to record the breakfast temperatures.

B. Based on document review, observation, and interview, it was determined that for 1 of 1 Dietary Department, the Hospital failed to ensure that the dishwasher temperatures were at the required range during the rinse cycle, to prevent potential infection. This has the potential to affect the average 8 patients on census per day.

Findings include:

1. The Hospital's policy titled, "Maintenance of Dishwasher", (9/12/2023) was reviewed, and required, "Dietary will take temperature of dishwasher twice daily once in AM and once in PM. Document temperature on dishwasher log. Hot water sanitizing Dishwasher wash temperature 180*(Fahrenheit). If dishwasher is out of range. Contact Manager and Manager will follow up with call to [Manufacturing company]."

2. The Dietary Department's dishwasher logs from 7/2023-9/2023, were reviewed on 9/13/2023. The logs included dishwasher temperatures for the final rinse that were not at the required temperature of 180 degrees Fahrenheit in:

- 7/2023: 7/4/2023 and 7/6/2023 - 7/31/2023: No final rinse reached 180 degrees.

-8/2023-8/29/2023: No final rinse temperature reached 180 degrees. The log lacked recordings on 8/30 and 8/31/2023.

-9/1/2023-9/12/2023: No final rinse temperature reached 180 degrees.

The log included a section that the staff could document action taken if the temperature was not within range. The logs lacked this documentation and no documentation of action taken.

3. On 9/13/2023 at 9:00 AM, an interview was conducted with the Dietary Manager (E #2). E #2 stated that the final rinse temperature for the dishwasher should be 180 degrees according to policy and manufacturer's instructions. E #2 stated that E#2 is responsible for the oversight of the logs and the staff should let E#2 know if the temperatures are not within range.

C. Based on document review, observation, and interview, it was determined that for 1 of 1 Inpatient Nursing Unit, the Hospital failed to ensure that the patient's nourishment refrigerator temperatures were recorded daily, as required per policy.

Findings include:

1. The Hospital's policy titled, "Refrigerator Food Safety and Temperature Control", (9/12/2023), was reviewed, and required, "Check and record the temperature of refrigerators daily ..."

2. On 9/11/2023 at 12:45 PM, an observational tour of the one Inpatient Unit was conducted. During the tour, there was a refrigerator in the storage room that contained patient's nourishments. The log for the refrigerator (dated 7/1/2023-9/11/2023), that was attached to the front of the refrigerator, was reviewed. The log lacked recorded temperatures for 10 days (7/4, 7/5, 7/11, 7/16, 7/27, 8/20, 8/21, 8/22, 8/30, and 8/31/2023).

3. During the tour on 9/11/2023 at 12:50 PM, an interview was conducted with the Case Manager Registered Nurse (E #5). E #5 stated that the refrigerator temperatures should be recorded daily.

D. Based on document review, observation, and interview, it was determined that for 1 of 1 Certified Nurse Anesthetist (CRNA/E #6), the Hospital failed to ensure that jewelry was removed or contained while in the Operating Room and providing patient care, in accordance with policy.

Findings include:

1. The Hospital's policy titled, "Dress Code for the Surgical Department" (12/19/2022), was reviewed, and required, " ...8. Jewelry (e.g., earrings, necklaces, bracelets, and watches) that cannot be contained or confined within the scrub attire shall not be worn in the semi-restricted areas ..."

2. On 9/12/2023, between 8:10 AM and 10:45 AM, an observational tour of Surgical Services, was conducted. During the tour, in OR #2, the CRNA (E #6), entered to provide care to Pt #7. The CRNA had on a necklace, ring, and a watch that were visible and not confined under the scrubs.

3. On 9/13/2023 at 10:45 AM, an interview was conducted with the Surgical Director (E #7). E #7 stated that jewelry should be either removed or confined while in the OR.


E. Based on document review, observation, and interview, it was determined that for 1 of 1 Scrub Tech (E #8,) the Hospital failed to follow infection control practices in the Operating Room (OR), by ensuring that back was not positioned to the opened sterile field.

Findings include:

1. The Hospital's policy titled, "Principles of Aseptic Technique" (undated), was reviewed, and required, "To assure an aseptic environment in the department ...The sterile field shall be continually maintained/monitored ..."

2. The 2022 AORN Guidelines for Perioperative Practice (provided from the Surgical Director/E #7), was reviewed, and included, "Scrubbed team members should ...not turn their backs on the sterile field ..."

3. On 9/12/2023, between 8:10 AM and 10:45 AM, an observational tour of Surgical Services, was conducted. During the tour, the following was observed:

- At 8:17 AM, the Scrub Tech (E #8), opened the sterile field and then walked out of the OR, leaving the table unattended for approximately 1 minute.

-At 8:59 AM, E #8 (who was scrubbed in at this time), turned her back to the sterile field that contained instruments ready for the procedure. E #8 turned her back for approximately 1 minute and was less than a foot away from the sterile field/table.
-At 9:04 AM, E #8 turned her back to the sterile field for approximately 30 seconds.
-From 9:08 AM-9:10 AM, E #8 turned her back to the sterile field, with her arms folded onto the sterile gown.

4. On 9/13/2023 at 10:45 AM, an interview was conducted with the Surgical Director (E #7). E #7 stated that once the sterile field is opened, the scrubbed in-person should not turn their back on the field. E #7 stated that the AORN guidelines does not particularly state how far they should be standing from the field; however, E #7 stated that E #8 was observed, within proximity (less than 1 foot away from the table).