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Based on document review, observation and staff interview it was determined the facility failed to ensure Respiratory Care Services and the Radiology Department followed policies and procedures for patient supplies by failing to ensure the supplies were not expired. This failure has the potential to adversely affect all patients receiving care at the facility.

Findings include:

A review of the policy titled "Recall of Outdated & Potentially Contaminated Supplies," approved 11/2021, stated in part: "lll. RESPONSIBILITY: A. All hospital personnel must check the expiration dates on sterile items that they are using for patient care. Outdated items should not be used."

A review of the policy titled "Medical Asepsis with Supplies and Storage," last revised 06/2020, stated in part: "Follow manufacturer shelf life dates for supplies."

A tour of the Respiratory Care Services' supply room conducted on 2/22/22 at 1:36 p.m. with the Director of the Operating Room and the Manager of Respiratory Services revealed eight (8) arterial blood gas (ABG) syringes, expired 12/2021, and two (2) heat and moisture exchangers (HME), expired 11/2018, were located with the supplies for patient use.

A tour of the Radiology Department's supply room conducted on 2/22/22 at 3:00 p.m. with the Director of the Operating Room and the Office Manager revealed seven (7) intravenous (IV) starter kits for patient use expired on 1/30/20.

During the tour of Respiratory Care Services on 2/22/22 at 1:36 p.m., an interview was conducted with the Manager of Respiratory Services. The Manager concurred the ABGs and HMEs were expired and located with the supplies for patient use.

During the tour of the Radiology Department on 2/22/22 at 3:00 p.m., an interview was conducted with the Office Manager, who concurred seven (7) IV starter kits located in the supply room for patient use were expired.

Based on document review, observation and staff interview it was determined dietary staff failed to follow procedures to ensure the nutritional needs of patients are met in accordance with recognized dietary practices. This failure was identified in two (2) of two (2) tours of the Dietetic Services. This failure has the potential to adversely affect all patients at the facility.

Findings include:

A review of the policy titled "Department Safety," approved 04/2021, stated in part: "l. POLICY: ... AC. Observe cleanliness rules carefully. Wash hands thoroughly before handling any food or dishes."

A tour of the Dietetic Services conducted on 2/22/22 at 2:12 p.m. with the Director of the Operating Room and dietary staff revealed no sample of potentially hazardous foods was retained for the a.m. meal on 2/22/22.

An observation of dietary services meal tray preparation for patients was conducted on 2/22/22 at 4:15 p.m. Dietary staff was observed preparing the samples for potentially hazardous foods for the p.m. meal. The dietary staff took a piece of paper to the garbage can, lifted the garbage can lid and threw away the paper then continued with the preparing of the samples of potentially hazardous foods for the p.m. meal. After completion of the food samples, the dietary staff went to the garbage can, lifted the lid of the garbage can and threw away some type of material then proceeded to get a pair of gloves, don the gloves, and prepare the trays for the patients. The dietary staff failed to wash their hands after touching the garbage can lid twice before donning gloves and preparing the patient's trays.

During the tour on 2/22/22 at 2:12 p.m., the dietary staff was asked about the sample of potentially hazardous foods retained from each meal and they concurred no sample of potentially hazardous food was retained from the breakfast meal for 2/22/22.

An interview was conducted with the Manager of Dietetic Services on 2/23/22 at approximately 9:30 a.m. The Manager concurred the dietary staff did not follow procedures in accordance with recognized dietary practices.

A. Based on observation and staff interview it was determined the facility failed to provide a sanitary environment to avoid sources and transmission of infectious and communicable diseases. This failure was identified during a tour of the Rehabilitation Services Department and has the potential to adversely affect all patients by potential transmission of infectious and communicable diseases.

Findings include:

A tour of the Rehabilitation Services Department conducted on 2/22/22 at 1:55 p.m. with the Director of the Operating Room revealed four (4) resistance bands lying on the floor attached to the weight machine for patient use and four (4) gait belts hanging on the entrance door touching the floor, which were soiled at the point of touching the floor.

During the above noted tour, the Occupational Therapist (OT) was observed working with a patient who dropped a small peg on the floor. The OT retrieved the peg and placed it back on the peg board for patient use but failed to clean the peg after retrieving it off the floor.

During the above noted tour, the Physical Therapist (PT) was observed taking a gait belt off the entrance door, that was touching the floor, to a patient for use; the gait belt was not cleaned prior to taking it to the patient for use.

During the above noted tour on 2/22/22 at 1:55 p.m., the PT was asked how the resistance bands were cleaned and the PT stated they were cleaned with the wipes provided by the hospital. When asked if the wipes were approved by the manufacturer for cleaning of the resistance bands, the PT stated, "I don't know." The PT stated the bands are not cleaned between patients and are used for more than one (1) patient. When the PT was asked if the gait belts were cleaned between patients, the PT stated, "I don't know. You don't want me to lie."

B. Based on document review, observation and staff interview it was determined the facility failed to provide a sanitary environment to avoid sources and transmission of infectious and communicable diseases. This deficient practice was identified during a tour of the Dietetic Services Department and has the potential to adversely affect all patients by potential transmission of infectious and communicable diseases.

Findings include:

A review of the policy titled "Department Safety," approved 04/2021, stated in part: "l. POLICY: ... AC. Observe cleanliness rules carefully. Wash hands thoroughly before handling any food or dishes."

An observation of dietary services meal tray preparation for patients was conducted on 2/22/22 at 4:15 p.m. Dietary staff was observed preparing the samples for potentially hazardous foods for the p.m. meal. The dietary staff took a piece of paper to the garbage can, lifted the garbage can lid and threw away the paper then continued with the preparing of the samples of potentially hazardous foods for the p.m. meal. After completion of the food samples, the dietary staff went to the garbage can, lifted the lid of the garbage can and threw away some type of material then proceeded to get a pair of gloves, don the gloves, and prepare the trays for the patients. The dietary staff failed to wash their hands after touching the garbage can lid twice before donning gloves and preparing the patient's trays.

During the tour on 2/22/22 at 2:12 p.m., the dietary staff was asked about the sample of potentially hazardous foods retained from each meal and they concurred no sample of potentially hazardous food was retained from the breakfast meal for 2/22/22.

An interview was conducted with the Manager of Dietetic Services on 2/23/22 at approximately 9:30 a.m. The Manager concurred the dietary staff did not follow infection control precautions.