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Based upon observation, and interview, the facility failed to maintain the hospital kitchen environment in a safe and sanitary condition. Food packages and items that have fallen and been left on the floor, present both a hazard for slips and falls, as well as create unsanitary conditions with potential for attracting pests and spread of harmful diseases to all staff and patients.

Findings include:

1. On March 26, 2024 between 12:45 - 1:45 PM, during a tour of the main hospital kitchen, observation revealed food packages and food debris that had fallen onto the floor in the walk-in coolers # 1, 3, 4, 5, and 7, including butter packets, yogurt containers, pasta, French fries, and food crumbs. These conditions were confirmed by staff EE, and staff FF at the time of the sighting. At approximately 1:00 PM, Staff FF was asked how often they clean the kitchen floors. He responded that the kitchen staff sweep and mop the floors at least daily and often twice daily.

Based on observation, interview and record review, the facility failed to maintain a clean and sanitary environment as part of Infection Prevention and Control program, and failed to ensure Infection Prevention and Control standards of practice and facility's policies were followed for Transmission Based Precautions and Standard Precautions, resulting in the potential for the spread of infection to all patients. Findings include:

Initial facility tour was conducted on 03/26/24 at 0930 with Staff B, Staff G and Staff H. Tour began in facility's Emergency Department (ED). During observation, staff nurse, Staff I, was noted handling patient's blood specimen in a vacutainer tube at the computer station, while wearing blue gloves. Staff I hand specimen at the computer station, used computer keyboard, printed label, placed it on the tube and proceeded to a different room with a specimen tube in hand (no biohazard plastic bag was observed in use at this moment or prior). Staff I returned to the computer station without a specimen. When asked about the process of specimen collection, Staff I stated that she always puts clean gloves on after collecting specimen from the patient. When asked if the tube came from a patient bedside area, she stated yes. She explained that she collected a specimen, and came to the nurses' station to print a label for it. When asked if she was planning to clean computer station, Staff I stated "absolutely, I have my sanitary wipes ready right here". Further, a roll of white tape was observed taped to a glass edge of the nurses' station about 7 feet high from the floor. Staff could not speak to why the roll was placed there. Patient triage examination room was observed and had a brown shipping box with supplies placed on a floor in a corner, with shipping label visible and hand-written instructions not to remove the box. Patients' public bathroom was observed next. There were two metal shelves with clean supplies stored in plastic bins about 2-3 feet away from the toilet. Supplies were not secured/locked and could be accessed/touched by anyone who used the bathroom. Patient bay #12 was observed next. It had a floor sideboard of approximately 3 feet in length missing. Side chair in a bay was noted to have tears with white material visible and exposed. Bay #14 was observed to have a hole through the drywall atop of the mounting board (headboard area) approximately 1- 1 1/2 inch in diameter. Multiple areas with paint missing and drywall exposed were observed throughout the tour of the ED. Staff B stated that all areas that need attention (patching and repainting) will be addressed with workorders immediately. Also, multiple areas with tape or tape residue were observed in ED on work surfaces, walls, and equipment. This was acknowledged by Staff G and Staff H at the time of observation.
Pediatric ED area was toured at 1025 on 3/26/24. Room #109 was empty and available for observation. White debris and dust collection was observed on the floor next to patient headboard area. Blue rubber tourniquet (from intravenous access start kit) was observed on the ceiling light holding two light arms together. Staff G could not explain the reason for its use on the light. Further, a sink was observed across nurses' station that had a step stool placed on top of it. After inquiring with nurses, Staff G said that it was used for pediatric patients to help step up and wash their hands at the sink. Next, patients' public bathroom located across from room #102 was observed. There were metal shelves with clean supplies stored in plastic bins about 2-3 feet away from the toilet. Supplies were not secured/locked and could be accessed/touched by anyone who used the bathroom. Further observation of ED confirmed that majority of the bathrooms had similar set up. Staff G and Staff H acknowledged it. Family area was observed at the end of the hall with two white privacy screens stored in it. Screens were connected together at 3 points of contact with Coban (self-adherent elastic wrap that is used for strain and sprain support and secure dressing or devices without the need to for adhesives, pins, clips, or tape).
Ambulance nurses' station was toured next. There was a copious amount of dark gray dust found on the top of the blanket warmer. This was acknowledged by Staff G and Staff H at the time of observation. Clinical staff member was observed in the same area with a face mask worn below her chin. Staff G was asked if this was appropriate wear of the PPE. She responded "no".
On 3/26/24 at 1140 Staff Z, facility's Infection prevention specialist joined the team on the facility tour. Staff Z was asked if he was aware of the scope and prevalence of tape use on surfaces, equipment and tape residue identified in ED areas. Staff Z shared that facility Infection control department was aware of "tape issue" and was working on implementing strategies to minimize it's use on surfaces in patient care areas.
On 3/26/24 at 1450 tour of 4 West Unit was conducted with Staff B, Staff L, and Staff J. Room #4925 was observed to have a contact isolation precaution sign on with PPE supplies bin placed outside of the room. Staff was observed exiting the isolation room wearing mask and blue gloves, holding clipboard and a pen. Staff was not noted to have a gown while in a room with a patient. Staff proceeded to walk the hall. Staff B stepped in with immediate correction and education. Next patient room had a bedside commode placed in a corner with 2 blue positioning assistive devices placed on it. Staff L was asked what those blue devices were used for. He stated that staff use them for keeping patient's feet off the bed (pressure injury prevention). When asked if storing these devices on a bedside commode was appropriate, Staff L stated that it was not. Family area was observed to have chair and a love seat with tears and underlayment material visible and exposed. Tape and tape residue was observed on surfaces and patient equipment (bedside commode). This was acknowledged by Staff B and Staff L.

On 03/27/24 at 1430 interview was conducted with Staff B, Staff Y, Manager of Infection Prevention department and Infection Control specialists, Staff Z, Staff AA, Staff BB, Staff CC and Staff DD. Facility's infection Prevention and Control Program was discussed in detail with pertinent documentation reviewed. Process of auditing and observing staff for compliance with Infection Prevention policies and procedures was identified. Staff was asked if issues identified during the tour of the ED department was known to the Infection Prevention department. Staff Y shared that the clean supplies storage in public/patients' bathrooms was not a prior identified issue. Prevalence of tape use was known to all staff present in the meeting.

On 3/27/24 at 1600 interview with CNO, Staff B, was conducted. Staff B stated that facility identified opportunities for improvement in ED and had already interventions in place to address the issues.
Facility's policies for Infection Prevention and Control, as well as policy for Infection Prevention and Control program were requested and reviewed on 3/27/24.

Standard Precautions Policy, effective and revised 4/18/23, indicated:
Purpose and Objective. Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions which are to be used as a minimum in the care of all patients.
Policy statement:
A. All patients are considered to be potentially infected with pathogenic microorganism. Standard precautions are a concept that emphasizes protection against direct or indirect contact with infectious agents that maybe found in blood, body fluids, other potentially infectious material (OPIM) or contaminated surfaces.
D. Standard precautions should be used consistently in the care of all patients in all patient care settings. These measures are to be used when providing care to all individuals, whether or not they appear infectious or symptomatic.
Handling of Specimens, linen, and equipment:
A. Laboratory Specimens
1. Each specimen should be placed in a container with a secure lid to prevent leakage during transport. Care should be taken when collecting specimens to avoid contamination of the outside of the container. The container must be labeled prior to placing a specimen in it.
2. It is unacceptable to send non intact or leak in specimen containers to the laboratory. All laboratory specimens are considered to be contaminated and should be placed in the leak-proof, labeled biohazard bags at point of use.
3. Vacutainer specimens that are transported in a specimen rack need not be placed in a leak-proof bag. Those vacutainer specimens that are transported by hand should be placed in the leak-proof biohazard bags at a site of use.
D. Storage of clean and sterile equipment and supplies
3. Medical and surgical items must not be stored under sinks, under exposed water or sewer pipes, or in any location where they could become wet.
a. Medications should not be prepared, and clean/sterile patient supplies should not be stored near areas of splashing water (i.e., within 3 feet/36 inches of a sink).
6. Outside shipping containers should be examined for obvious signs of damage and if damage is found it is advisable to unpack contents in the loading dock area.
a. Whenever possible shipping boxes should be unpacked and broken down in an area designated for this purpose; this should not be done in any area designated as "sterile", "semi-sterile" or clean.

Isolation Practices Policy, effective and revised 4/25/24, revealed:
II. Policy Statement:
3. Healthcare personnel (HCP) should always follow Standard Precautions in addition to transmission-based precautions to reduce the risk of cross contamination and microbial transmission. HCP includes all clinical and support staff, doctors, licensed mid-level providers, volunteers, students, etc.
7. Ensure isolation signs are posted clearly so that anyone entering the patient room is alerted to the precaution requirements to reduce transmission.
8. Educate all guests for the need to adhere to precautions prior to entering patient room.
III. Responsibilities for Isolation Management:
A. All healthcare workers are responsible for complying with all posted isolation precautions.
Proper Use of Personal Protective Equipment (PPE)
3. Removing (Doffing) PPE:
a. When removing PPE, care must be taken to avoid self-contamination and potential exposure to infectious materials.
b. PPE should be removed in the room or other patient environment in this order:
i. Slowly and carefully remove gloves; most contaminated piece of PPE.
ii. Remove googles or face shield.
iii. Remove gown.
iv. Remove mask or N-95 respirator or PAPR
v. Perform hand hygiene immediately after removing all PPE.

Facility's Infection Control Plan effective 2023 indicated:
EP 3: The hospital assigns responsibility for the daily management of infection prevention and control activities.
a. The daily management of infection prevention activities is given to the department of Infection Prevention & Epidemiology.
c. The Infection Prevention & Epidemiology staff and Committee will focus resources and attention on specific goals, e.g., respiratory education, (COVID-19, influenza), patient isolation, removing patient isolations, staff safety, patient and visitor safety, proper use of PPE, etc.
e. Continue to focus on hospital cleanliness via rounding and audits to ensure
appropriate cleanliness is being done.

Low Level Cleaning and Disinfection of Surfaces and Patient Care Equipment Policy, effective and revised 3/1/24, indicated:
I. Purpose and Objective: to provide information about best practice recommendations for the selection and use of cleaning and disinfecting products.
II. Policy Statement: Proper cleaning and disinfection of environmental services and patient care equipment is vital to protect patients and staff from infection.
IV. Procedure for cleaning and disinfection:
Non-critical care items: Patient care equipment or environmental surfaces which only come in contact with intact skin. Low level disinfection.