HospitalInspections.org

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one AirTime dryer used on all endoscopic procedures passed an initial biomedical inspection prior to being placed in operation. Findings include:

1. Observation on 8/27/19 at 1:30 p.m. revealed an AirTime dryer was installed on an intravenous pole. Interview at that time with surgical technician (tech) H at that time revealed she had:
*Used that dryer on all scopes for over two months.
-Two scopes could be done at one time with the one dryer.
*Not contacted bio-medical inspection to get an initial inspection prior to use.
*"Pushed to buy the dryer, because the scopes would drip after placed in the clean scope cabinet. Now that she had the air dryer that flushed the inside of the scopes with air the scopes no longer dripped in the clean cabinet."
*No idea what the date of 10/2018 meant on the two filters for the tubing that exited the machine.
-She stated she changed the tubing and the couplers according to the directions off the internet. But had not noticed the date of 10/2018 on the filters.

Surgical tech H further revealed:
*The provider had purchased the AirTime dryer from E-Bay internet site.
-It did not come with any directions or a manufacture's booklet.
-She had gotten the directions for use off the internet.

Review of the current bio-medical inspections asset list revealed the AirTime dryer had not been inspected by the bio-medical division. The latest inspections had been 7/1/19 and did not include the dryer.

Review of the provider's 1/1/19 Equipment policy revealed:
*"EC.02.02.01 EP5 The hospital's activities and frequencies for inspecting, testing and maintaining the following item must be in accordance with manufacturer's recommendations:
-Equipment subject to federal or state laws of Medicare Conditions of Participation in which inspecting, testing, and maintaining must be in accordance with the manufacturer's recommendations, or otherwise establishes more stringent maintenance requirements.
-New medical equipment with insufficient maintenance history to support the use of alternative maintenance strategies."

Based on record review, interview, testing, record review, and policy review, the provider's governing board failed to ensure:
*A comprehensive surgical, sterilization, high level disinfection, outpatient services, and compounding pharmacy infection control program under the direction of a trained infection control officer was established.
*A comprehensive monitoring and training program was established for medical equipment, sterilization, high level disinfection, outpatient, pharmacy, and compounding pharmacy departments.
Findings include:

1. Review of the infection control program revealed a lack of proper supervision, implementation, and integration of the infection control program into surgical services, sterilization, high level disinfection, outpatient services, and compounding pharmacy.
Refer to: C222, C270, C276, C278, and C320.

B. Based on employee record review and interview, the provider failed to ensure a written job description was in place for one of one registered nurse (RN) (F) who was in charge of the infection control program for the facility. Findings include:

1. Interview on 8/29/19 at 2:30 p.m. with RN F revealed she:
*Was the director of nursing for the medical unit and nursing department.
*Was the coordinator for the IC program to ensure sanitary conditions were maintained in all areas and departments of the facility.

Interview on 8/29/19 at 3:55 p.m. with the administrative assistant revealed:
*There was no job description available for the surveyor to review for the IC coordinator to ensure her duties and responsibilities had been established.
*She stated:
-"We have no job description for the IC nurse."
-"It is up to the nurses to define those duties."

C. Based on observation and review of medical equipment, sterilization, high level disinfection, outpatient services, pharmacy, and the compounding of hazardous medications, revealed no specific training or monitoring had been completed to ensure sanitary conditions were maintained. Findings include:

1. Through observations and interviews the facility failed to identify areas of concern with sanitation processes and procedures identified in the above areas.
Refer to C222, C276, C278, C279, and C320.

Based on observation, interview, testing, document review, record review, and policy review, the provider failed to ensure appropriate services were provided for eight of eight reviewed services offered:
*Pharmacy.
*Compounding Pharmacy for chemotherapy.
*Nursing services.
*Food and Dietetic.
*Surgical and anesthesia.
*Outpatient procedures.
*Swing bed services.
Findings include:

A. Based on observation, testing, interview, and policy review, the provider failed to ensure medications (med) had been properly monitored and secured to prevent unauthorized access in the following areas:
*One of one operating room (OR) by one of one certified registered nurse anesthetist (CRNA) G.
*One of two (main) emergency room's (ER) medical supply cupboards and closet.
*One of one med room and one of one labor and delivery supply cart.
Findings include:

1. Refer to C276.

B. Based on observation, interview, and policy review, the provider failed to ensure a bacteria-controlled environment for the aseptic processing of hazardous chemotherapy (chemo) medications had occurred in one of one compounding and mixing room. Findings include:

1. Refer to C276.

C. Based on observation, interview, and policy review, the provider failed to ensure:
*One of two (main) emergency rooms (ER) did not have:
-A rusted patient commode.
-A taped temporal thermometer.
-Tape on the gurney.
-Rust colored dried spots and drips on the bed of the gurney.
-An outdated Trocar Catheter Kit in the chest tube tote.
*Clean linen for the hospital was not stored in one of one procedure rooms.
*Two of two trash cans (at the scrub sinks and in the scope processing area) with flip lids were hands free for disposing paper towels.
*Rusty paper towel dispensers were replaced in two of two areas (at the scrub sinks and in the scope processing area).
*Two of two contracted doctor's pharyngeal scopes were processed at the facility prior to use.
*One of two shower floors were free from what appeared to be mold.
*Two of two baskets of sterilized packages of instruments were stored in a clean area.
Findings include:

1. Refer to C278.

D. Based on observation, testing, interview, and policy review, the provider failed to maintain:
*The cleanliness and cleanability for:
-Two of two microwaves (main kitchen and satellite kitchen).
-Two of two doors for the walk-in cooler and walk-in freezer.
*Separation of staff food from residents food in one of one satellite kitchen refrigerator.
*Separation of raw uncooked food according to cooking temperature in one of one walk-in cooler.
*The door closer for the walk-in freezer.
Findings include:

1. Refer to C279.

E. Based on observation, interview, record review, document review, and policy review, the provider fail to ensure:
*Reusable instruments from two of two emergency rooms (ER) were properly transported to the dirty processing room after an initial cleansing in the soiled utility room.
*One of one procedure room was constructed with cleanable walls and ceilings.
*One of one surgical room was constructed with cleanable ceilings.
*A terminal clean was completed after each surgery.
*Proper guidelines were followed for a terminal clean.
*An initial bio-medical inspection was completed for one of one AirTime dryer used on all scopes.
*A disinfection process was completed for two of two pharyngeal scopes brought into the facility from an outside physician.
*There was complete separation from packaging clean instruments, central supply, and the surg tech's office in one of one central sterilization (CS) area.
*One of one gallon of enzymatic cleaner was not outdated in the soiled instrument room of CS.
Findings include:

1. Refer to C320.

F. Based on policy reviews and interview, the provider failed to ensure policies and procedures were evaluated, reviewed, and revised periodically for one of five policy and procedure manuals selected for review (swing bed department). Findings include:

1. Refer to C334.

A. Based on observation, testing, and interview, the provider failed to ensure medications (med) had been properly monitored and secured to prevent unauthorized access in the following areas:
*One of one operating room (OR) by one of one certified registered nurse anesthetist (CRNA) (G).
*One of two emergency room's (ER) (main) medical supply cupboards and closet.
*One of one med room and one of one labor and delivery supply cart.
Findings include:

1a. Observation on 8/27/19 at 11:10 a.m. in the OR revealed:
*An unsecured Sharps container sitting on top of the anesthesia cart with a 30 millimeter (ml) sedating med vial inside.
-That vial had approximately 5 ml of liquid Propofol left inside of it.
--That medication had been used for sedation.
*There was a large Sharps container sitting unsecured on the floor in a corner of the room. That container:
-Was approximately five gallons in size.
-Had a large white lid with a large opening on one end.
--Testing revealed a hand would slide through that opening.
-Had a 100 ml vial of liquid Profolol inside of it.
--That vial contained approximately 30 ml left inside of it.

Interview on 8/27/19 at 12:00 noon with CRNA G regarding the above observation revealed:
*He confirmed:
-There was med left in those containers that had been used for anesthesia and sedating purposes.
-That had been his usual process for drug disposal of that med.
*Within the last two weeks they had established a new process for drug disposal.
-That drug disposal process had not been put into effect yet.
*Once the containers were full the maintenance or housekeeping staff were responsible to remove and replace them.
*All the surgical, maintenance, and housekeeping staff had access to that room.
*He agreed:
-If meds were disposed of in the Sharps containers only authorized staff should have had access to them.
-Maintenance and housekeeping staff were not considered authorized staff.

b. Observation and interview on 8/28/19 at 4:20 p.m. of the main ER revealed:
*The room had been locked and required an access code to enter.
*Registered nurse (RN) E had opened the door for the surveyor and assisted with observations of the room.
*There was a two door, glass cabinet in the back of the room with a keyed locking device.
-The right side of the cabinet door could be pulled open, was unlocked, and allowed for easy access to individual plastic containers with the following meds:
-Two intravenous (IV) bags of Dopamine.
-Four boxes of Amiodarone.
-Three vials of Levophed.
-Two IV bags of Dobutamine.
-One IV bag of Nitroglycerine.
-Silervernitrate.
*RN E stated:
-"That should not be like that."
-"Those cabinets should be locked."
-"The charge nurse is the only one who has the key for this cabinet."
-"The meds in there are for crisis and critical situations."
-"I'm gonna go get the charge nurse."
*RN E left the room unsecured with the surveyors in there, and neither her nor another staff member returned.
*Another surveyor had noted the room had been unlocked on that same day from 9:00 a.m. to 11:00 a.m.

Continued observation at 4:25 p.m. of the main ER room revealed:
*There was a storage area in the back of the room enclosed with curtains.
*Behind the curtains were multiple supplies that included a large cloth covered pack labeled Kangaroo.
-That pack contained supplies and meds that could have been used for infants during a critical situation.
-Those meds were been epinephrine, sodium bicarbinate, and naloxone.
*RN E never returned to the room to check on the surveyors.
*There had also been two unidentified visitors sitting in the waiting area outside of the ER.

c. Interview on 8/29/19 at 8:00 a.m. with director of nursing (DON) F regarding the above observations revealed she confirmed:
*The provider's current medication destruction policy required the staff to waste their meds in the sharps containers.
-"It has always been that way."
-"If they drop a pill or need to waste a med it's placed in the Sharps containers."
-"Yes, that also includes Fentanyl patches."
-"We are in the middle of doing a different process where everything will be destroyed in the Cactus [medication destruction device]."
-"We have them and one is up in the OR, but the batteries have been on back order."
-"But yes, until we get them in place [Cactus and batteries] the staff are still using the Sharps containers."
*The interview with CRNA G regarding the involvement of maintenance and housekeeping departments for removal and replacement of those containers.
-She had not considered them as unauthorized staff until further review with the surveyor.
*She would have expected RN E or the charge nurse to have returned to the main ER to have secured the unlocked medications by locking the cabinet.
-She had not considered the Kangaroo pack and the meds inside it as unsecured.
*She agreed all of the above meds:
-Had the potential for creating a negative outcome should they have been used inappropriately.
-Should have been secured and not easily accessible to unauthorized staff, visitors, and patients.

d. Observation and interview on 8/29/19 at 8:25 a.m. of the labor and delivery cart with the DON revealed:
*The cart required a numerical code to unlock it.
*Inside of the cart were the following meds:
-Pitocin for the induction of labor.
-Cytotec for the induction of labor.
-TXA [tranexamic acid] to prevent or reduce excessive bleeding.
-Magnesium sulfate to prevent seizure activity.
*The labor and delivery cart was new and had required set-up of the code to unlock it.
-The maintenance technician assisted her to set-up the code.

e. Observation and interview on 8/29/19 at 8:50 a.m. of the med room on the medical unit with the DON revealed:
*The entrance door required a numerical code to unlock it.
*The maintenance technician could change that code if needed.

B. Based on observation, interview, record review, and policy review, the provider failed to ensure a bacteria controlled environment for the aseptic processing of hazardous chemotherapy (chemo) medications had occurred in one of one compounding and mixing room. Findings include:

1. Observation and interview on 8/28/19 at 9:35 a.m. of the second emergency room (ER) in the back of the hospital with the director of nursing (DON) revealed:
*The entrance door required a numerical code to enter the ER.
*Beyond the entrance to the room there was another closed door to the left.
-On that door was a sign with instructions for the door to remain closed and booties (shoe covers) to be worn inside.
*The door to that room was unlocked and easily accessible to anyone in the ER.
*That room had a compounding and mixing hood for hazardous medications.
*The ceiling had perforated ceiling tiles.
*There was a red taped area on the floor by two electrical panels.
*The DON revealed the room was:
-Used for mixing chemotherapy medications for those patients who required them.
-Always unlocked and allowed access by anyone, even those who required care from the ER department.
-She was not aware of the policies and procedures required for the staff who used that room to mix those meds.
*She agreed as the infection control (IC) coordinator she should have known an aseptic technique and a sanitary environment was required in the pharmacy compounding area.

Interview on 8/28/19 at 2:40 p.m. with the pharmacist regarding the chemotherapy mixing room revealed:
*He had been aware of the room and its location.
*He was not aware the door was unlocked and allowed for by anyone.
*Neither he nor his staff had oversight of the room and did not assist with the mixing of those meds.
*Two of the nurses who worked in the outpatient area had been trained to use the hood and mix those meds.
*He did not do competencies or evaluations of the room and the nurses to ensure:
-Appropriate attire was worn for and during:
--Mixing of the hazardous meds.
--Cleaning and maintenance of the hood.
--Cleaning of the room by the housekeeping department.
*He stated:
-"That room is not ideal and recently failed an inspection."
-"I believe the air quality test had grown a bacteria from garden soil."
-"They recently had to have it re-inspected and they passed."
-"There is a concern with the ceiling tile, and they had changed the type of gloves they were using."
-"They are questioning the technique that is used for testing the air quality."
*He confirmed:
-There had been failed air inspections in the past.
-Attended the pharmacy and therapeutics meetings but was not responsible for the compounding room.
--Two of the nurses who worked in the facility had taken the certification to mix those meds and were in charge of that room.
-Was not aware of the process for med destruction and the use of the Sharps containers for that purpose.
*He offered no comment when the surveyor inquired about his involvement:
-As the pharmacist of the facility and the oversight of all the meds.
-For the preparation, administering, security, and destruction processes for the meds.
*He did agree those areas would fall under the pharmacy department.

Review of the 3/11/19 Diagnostic Final Report Form for the chemotherapy mixing hood revealed:
*A total of three air samples had been taken for testing purposes.
*Location number 1, that was the static area of the chamber, failed due to a high colony count of that area.
*The microbial analysis of that area had grown bacteria:
-That were commonly found in soil, air, dust, debris, and surfaces.
-That were commonly detected as normal flora of the skin, mucosa, and oropharynx of humans and mammals.

The air sample for location number 1 had been rechecked on 6/5/19 and passed the air quality test.

Review of the provider's 4/10/19 Pharmacy and Therapeutics Medication Safety meeting minutes revealed:
*"All US health care facilities that store, transport, prepare, or administer HDs [hazardous drugs] must attain full compliance with USP 800 by 12/1/19."
*"The pharmacy team at [hospital name] continues to work on this and policies along with education are evolving."
*"We failed our most recent air viable testing on 3/12/19 with ATA [At Analytical, Inc.]. We need to retest location in 3 months. [Hospital name] has said they are working on doing this testing internally as we are not confident in their testing techniques."
*"The [hospital name] architects have a plan to make this a non-porous and USP 800 compliant room."
*"Discussed the Rural Chemotherapy requirements. By November 1st we have to be compliant with their checklist in order to continue receiving chemo orders from Avera oncologist's."

Observation and interview on 8/29/19 at 10:30 a.m. with RN C regarding the chemotherapy med mixing hood revealed:
*The entrance door to the chemotherapy mixing room remained unsecured.
*The light was on in that room.
*She stated: "Housekeeping would have been in here to clean."
*She confirmed:
-The failed inspection on 3/11/19.
-They had replaced the gloves and type of gloves on the chemo hood used for mixing meds.
-There was no identification of what the room was used for.
-The door had a locking device on the handle and could have been secured shut.
-Currently there was nothing in place to ensure the ER patients and their visitors had not or could not enter that room.
-The red tape on the floor was for the electrical panels in the room, and the maintenance department would have access to the room.
-The perforated ceiling tiles had created the potential for cleaning concerns.
-Her certification for the mixing of hazardous meds.
-The pharmacist and IC coordinator had not been involved with the process and oversight of that room.
--She agreed they should have been due to the complex process required to ensure those meds were mixed and administered under a safe and aseptic environment.
*She confirmed the housekeeping department had been trained on the proper process for cleaning that room.
*She was:
-Not sure what the maintenance technician had been trained on for entering and exiting that room.
-Aware of the future changes required for that room to meet code and inspection requirements.

Interview on 8/29/19 at 10:45 a.m. with the maintenance technician and housekeeping supervisor confirmed:
*The process for handling the Sharps containers as observed and interviewed above.
*They were responsible for removing the containers once they were full.
*They placed the full containers in a room next to ER until biohazard waste management picked them up.
*They were not aware the staff had been putting meds in the Sharps containers for destruction.
*They had been aware of the failed inspection of the chemotherapy mixing hood on 3/11/19.
*The housekeeping department had been trained on the proper process for cleaning that room.
-That education had been requested from the supervisor and was never received prior to exit on 8/29/19.
*"After the failed inspection it was decided we needed to start wearing booties over our shoes."
*The electrical panels in the room required the maintenance technician to enter that room at various times.
-He stated: "Especially on outages as those boxes service other areas of the facility."
*He had not been trained on the proper attire to wear into that room.
*He stated: "After the failed inspection I just started wearing booties into that room, because I heard about it and the sign said to."
*Neither the housekeeping supervisor nor the maintenance technician were aware of any competencies or observations of them to ensure proper attire had been worn into that area.

Interview on 8/29/19 at 10:55 a.m. with the administrator regarding the above observations, record reviews, and interviews revealed:
*He had not been aware of all the above identified concerns.
*He agreed:
-The current med destruction process needed to be started as soon as possible.
-There should not have been any meds placed in the Sharps containers for destruction purposes.
-The maintenance and housekeeping departments were not considered authorized staff to be handling meds under any circumstances.
*He:
-Was aware of the failed inspections on the chemotherapy mixing hood.
-Confirmed that corporate office was to have been assisting them with updating that room to meet code criteria.
-Was not aware when those changes and renovations were to be initiated.
-Agreed:
--The IC coordinator should have been involved with the process and procedures of that room to ensure aseptic technique was maintained for safety purposes during mixing, cleaning, and maintenance repair.
--The pharmacy department should have been involved due to the complexity and education required for mixing and administering of those meds.

Review of the provider's 3/13/14 Sharp Container Inserts Disposal policy revealed:
*"Housekeeping personnel checks sharp container inserts daily. When container is full of disposed needles housekeeping personnel unlocks wall mount cabinet containing sharp container insert, takes out container snapping the flap on the lid so it's securely closed shut."
*"The full container is put in a red garbage bag so it can be disposed of to the biohazardous waste receptacle."
*"The key is kept with the housekeeping cart. NS [nursing] also has a key kept in a secure place."

Review of the provider's July 2019 Daily Cleaning of Chemo Room policy revealed:
*Purpose: "To ensure a bacteria-controlled environment for the mixing of chemo."
*Information and procedure: Equipment and supplies:
-"Proper PPE [personal protective equipment]"
-"Cleaning cloth and broom."
-"Cleaners."
*Off to the side of the equipment and supplies needed was a handwritten note stating: "booties, gloves, mask."

Review of the provider's November 2018 CSP [compounded sterile preparation] BSC [biological safety cabinet] Cleaning policy revealed:
*"Purpose: To ensure that the pharmacy is maintaining an environment suitable for the aseptic processing of hazardous compounded sterile preparations in accordance to requirements of USP 797 and USP 800.
a. Quality of cleaning components.
b. Performance of personnel.
*Documentation of cleaning process and environmental testing will be maintained in accordance to Federal, State, and regulatory agencies."

Review of the provider's May 2017 Acute Care Pharmacy Contract revealed:
*"We have the contracted services of one or more pharmacists for the appropriate methods and procedures for obtaining, dispensing, and administering drugs and biologicals."
*"Drugs and medications utilized in special care areas (OR, ER) will be kept in a storage area this is readily available to the professional staff but inaccessible to patients and visitors."
*"Medications shall be destroyed by the following methods:
a. Outdated or discontinued medication should be returned to the pharmacy for proper disposal or return.
b. Legend drugs not controlled may be destroyed by 2 licensed professional nurses.
c. Medications controlled should be destroyed in the facility by a pharmacist and registered nurse.
d. Medications, excluding controlled substances in unit dose packaging, should be returned to the pharmacy for proper disposal."

Based on observation, interview, and policy review, the provider failed to ensure:
*One of two emergency rooms (ER) (main) did not have:
-A rusted patient commode.
-A taped temporal thermometer.
-Tape on the gurney.
-Rust colored dried spots and dried drips on the bed of the gurney.
-An outdated trocar catheter kit in the chest tube tote dated 7/31/19.
*Clean linen for the hospital was not stored in one of one procedure room.
*Two of two trash cans (at the scrub sinks and in the scope processing area) with flip lids were hands free for disposing of paper towels.
*Rusty paper towel dispensers were replaced in two of two areas (at the scrub sinks and in the scope processing area).
*Two of two contracted doctor's pharyngeal scopes were processed at the facility prior to use.
*One of two shower floors was free from what appeared to be mold.
*Two of two baskets of sterilized packages of instruments were stored in a clean area.
Findings include:

1. Observation on 8/27/19 at 11:00 a.m. of the main ER revealed:
*The patient commode had rusted legs.
*The in-use temporal thermometer had Tegaderm tape wrapped around and around the outside of the thermometer.
*Several pieces of Tegaderm tape were stuck to the arms of the gurney.
*A rust colored dried spot and a dried drip were found on the gurney.
*A trocar catheter kit with an expiration date of 7/31/19 was inside the chest tube tote.
-A handwritten note on a checklist inside the tub stated "nearest outdate 8/2020."

Interview at the time of the above observations with registered nurse (RN) F confirmed those findings. She stated the surgical technician/central supply person was in charge of checking for any outdates.

2. Observation on 8/27/19 from 1:30 p.m. to 2:30 p.m. revealed:
*Patient care technician (PCT) D entered the procedure room and obtained clean linen that was stored inside the cabinets in the procedure room.
*She then left the area and went back to the hospital corridor to make up patient beds.
*A trash can by the scrub sinks and in the scope processing area had domed lids with flip doors on the side that needed to be pushed open with a hand to dispose of used paper towels after handwashing.
*Interview with RN I at the time of the above observation confirmed that finding. She stated she had not considered those flip lids were an infection control issue after handwashing.
*White paper towel dispensers in the scrub sink area and in the scope processing had missing paint and were rusted. The rust covered approximately one third of the dispensers.
*Interview with RN I at the time of the above observation confirmed that finding. She stated she had not considered the rusted paper towel dispensers an infection control issue.

3. Interview on 8/27/19 at 2:00 p.m. with surgical technician (tech) H revealed there was one contracted physician that would bring his own pharyngeal scopes. She stated she did process them before he used them but had no documentation to prove that.

Interview with RN I at the above time revealed they had no policy on the processing of outside items before use in the facility.

4. Observation and interview on 8/28/19 at 9:00 a.m. revealed a black substance on the grout of the west shower tiled floor. That black substance could be scraped off with a fingernail. Interview with the environmental services manager confirmed that finding. She stated she was the housekeeping supervisor but had not done any quality assurance on her housekeeping people for some time.

Review of the provider's 2/28/15 Cleaning of Shower policy revealed housekeeping would clean the shower at the end of day and use a disinfectant cleaner, soft brush, and cleaning cloths. They would also mop the floor.

5. Observation and interview on 8/29/19 at 10:30 a.m. revealed two wicker baskets full of packages of sterilized instruments were stored in the cabinet of the scope processing room. Interview with surgical tech H confirmed that finding. She stated those sterilized instruments were used for the operating room. She had not considered the storage of sterilized instruments in a dirty scope processing room as being a problem.

Review of the provider's 12/12/09 and a reviewed on February 2019 Event Related Sterility policy revealed: "8. items will be stored in an environment free of moisture, excessive heat or contamination. The area must be clean, dry, dust free and lint free."

Based on observation, testing, interview, and policy review, the provider failed to maintain:
*The cleanliness and durability:
-Two of two microwaves (main kitchen and satellite kitchen) with chipped paint.
-Two of two doors for the walk-in cooler and walk-in freezer with chipped paint.
*Separation of staff food from patients' food in one of one satellite kitchen refrigerator to maintain sanitary conditions.
*Separation of raw uncooked food according to cooking temperature requirements in one of one walk-in cooler.
*The door for the walk-in freezer was in working condition.
Findings include:

1. Observation on 8/27/19 at 8:45 a.m. of the patients' satellite kitchen by the nurses station revealed:
*The inside top of the microwave had bubbled and peeling paint and was no longer cleanable or safe for use. The paint would flake at the touch of a finger.
*In the refrigerator was:
-Unlabeled and undated:
--Garden produce in bags.
--One half of sandwich.
--Plastic containers of ready-to-eat salads.
--Cheese slices.
--Cooked sausage links.
--Bottles of Ensure.
--Pudding and Jello.
Interview with registered (RN) C at the time of the observations confirmed that refrigerator was used for patients' food and snacks.

Continued observation on that same day at 10:15 of the main kitchen revealed:
*The inside top of the microwave had bubbled and peeling paint and was no longer cleanable or safe for use. The paint would fall off with a touch of the finger.
*The doors to the walk-in cooler and walk-in freezer had peeled and bubbled paint.
-There were also several areas by the door handles that had missing paint exposing the bare metal.
*A large cardboard box of two raw, uncooked turkey roasts were stored with pre-cooked pork roasts in the walk-in freezer.
*The door closer for the walk-in freezer was broken and a bungee cord had been attached to the door.

Interview at the time of the above observations with the certified dietary manager (CDM) confirmed those findings. She stated she:
*Did not monitor the patients' refrigerator or the microwave at the the nurses station.
-But she did confirm staff food should not be stored with patient food. And all food must be labeled and dated.
*Was not aware of the condition of the microwaves at the satellite kitchen or the main kitchen.
*Was aware of the condition of the peeling and missing paint on the walk-in cooler and walk-in freezer doors.
-She had sent in a work request some time ago, but the doors had not been repainted yet.
*Was aware raw and pre-cooked foods could not be stored together. Nor could meats with different cooking temperatures be stored together. She also confirmed a cardboard box was not a cleanable or durable container for food storage.
*Was aware the door closer was broken for the walk-in freezer.
-She stated it had broken some time ago, and maintenance had used a bungee cord until it could be repaired. She confirmed:
-She had sent a work order for the repair some time ago.
-Frost had built-up around the door from the improper closer.

Review of the provider's March 2015 and 2018 Kitchen polices revealed there were no policies
in place for the above listed items.

A. Based on observation, interview, record review, and policy review, the provider fail to ensure:
*Reusable instruments from two of two emergency rooms (ER) were properly transported to the dirty processing room after an initial cleaning in the soiled utility room.
*One of one procedure room was constructed with cleanable walls and ceilings.
*One of one surgical room was constructed with a cleanable ceiling.
*A terminal cleaning process was completed after each surgery.
*Proper guidelines were followed for a terminal cleaning process.
*An initial bio-medical inspection was completed for one of one AirTime dryer used on all scopes.
*A disinfection process was completed for two of two pharyngeal scopes brought into the facility from an outside physician.
Findings include:

1. Observation on 8/27/19 at 8:15 a.m. revealed the west soiled utility room had dry surgical instruments laid on a towel on the countertop by the sink.

Interview on that same day at 1:45 p.m. with surgical technician H revealed that soiled utility room was used to remove the gross contaminants from the instruments that were used in the operating rooms. The staff were to clean the gross contaminants off the surgical instruments, then bring them to the soiled area of central sterilization area.

Review of the provider's April 2019 Preparing Instruments for Sterilization policy revealed:
*"Any sterile, reusable instruments that were used during any patient procedure would be cleaned and stored appropriately until sterilization at the [hospital name].
*7. Clean instruments, rinse thoroughly, and dry.
8. Put into plastic container and spray pre-cleanse on instrument.
9. Transport back in the plastic container to dirty room in CSR (central sterilization room)."

2. Observation and interview on 8/27/19 at 1:30 p.m. with patient care technician D regarding the surgical suite area revealed:
*Two made-up beds were stored in the clean corridor of the surgical suite.
*In the Recovery room as labeled on the map was:
-A made-up bed with a separation curtain, an over-the-bed table, an overhead surgical light, a home-style wooden rocker with a worn finish and raw wood, and a home-style light wall fixture with an unshielded bulb.
-A long large table and other unknown equipment.
-Perforated ceiling tiles and textured walls.
--Those walls had several scrapes, holes, and gouges.
*Interview with the patient care technician D at the time of the above observation confirmed those findings.
-She stated that room was used as an extra procedure room, overflow for emergency rooms, recovery room, labor and delivery room, and an overnight room for physicians on call.

3. Continued observation and interview on that same day at 1:40 p.m. with surgical tech H regarding the surgical room revealed:
*They had surgical procedures and/or endoscopic procedures every Tuesday in that room.
*Some of those surgical procedures had been:
-Gallbladder removals.
-Mastectomy.
*Metal perforated ceiling tiles on the ceiling directly above the gurney. They were three, three by four foot, two - two by four foot; and two; two by two foot in size. Interview with surgical tech H revealed those tiles had been installed years ago so air conditioning could be provided to that room. Testing of the air conditioning unit at that time revealed cold air would blow out from those vents. She was not aware if the air conditioned air was filtered before it entered the room.
*There were rust colored drips along the edges of the perforated tiles where they met the flat white ceiling. Interview with surgical tech H at the time of the observation confirmed that finding. She was unaware what those drips were from.
*The two wall vent grates were layered and had mounds of lint and debris inside the grate.
Interview with surgical tech H at the time of the observation confirmed that finding. She stated she "wasn't aware there was so much lint inside those grates." She confirmed those air grates were for the fresh air flow into the room.

4. Interview on that same day at 1:50 p.m. with surgical tech H and RN I revealed they completed a terminal cleaning once a month in the surgical room using Virex Plus as a disinfectant. Surgical tech H stated they would coordinate it with the housekeeping services for when they would scrub and polish the floor. RN I stated they only did a horizontal or surface cleaning after each procedure and at the end of the day. They did not do a terminal clean at the end of a surgery day. They would wipe off all visible surfaces but did not wipe underneath any equipment such as rolling stools and tables. RN I revealed they used the Association of periOperative Registered Nurses or Association for the Advancement of Medical Instrumentation for guidelines.
-Those guidelines were not provided by RN I for the surveyor to review upon request and prior to exit on 8/29/19.

The surgical tech H revealed she would use a home-style sprayer to disinfect all areas for a terminal cleaning. She would mix up a disinfectant solution and spray all the ceilings, walls, and floors and any unmovable equipment. The prior RN for surgery told her she could spray the Virex to disinfect the area. All moveable equipment would be taken out of the room into the operating suite office and endoscope disinfection area. That equipment would then get completely disinfected then returned to the room. She did not test the solution to ensure it met the proper parts per million for disinfection per manufacturer's instructions for use. The sprayer held one and one half gallons. She stated she would use one half ounce of Virex to the one and one half gallon container. She kept the home-style sprayer in the housekeeping closet on the patient floor, as they shared the sprayer.

Review of the manufacture's guidelines for the Virex disinfectant revealed:
*Virex was a broad spectrum disinfectant.
*One ounce per one gallon of water was to used to kill Norovirus. One half ounce per gallon of water was used to kill bacteria, viruses, and fungus, HIV-1, and Influenza A.
*To use as a cleaner and deodorizer apply solution using a sprayer.

Review of the provider's November 2018 Decontamination and Terminal Cleaning policy revealed:
*Purpose: "To provide a clean environment for surgical patients and minimize the exposure risk of health care personnel and patients to potentially infectious microorganisms."
*Information and Procedure:
-"All horizontal surfaces in the OR including lights and equipment will be wiped off with a disinfecting wipe."
-"Equipment from areas outside the restricted area of the OR will be cleaned before being brought into the OR."
-"Damaged or worn covering will be replaced."
-"The OR and scrub utility areas shall be terminally cleaned when the scheduled procedures are completed for the day. That had included:
--All horizontal surfaces, hallways and floors, scrub/utility areas, scrub sinks, and sterile storage areas, surgical lights, and external tracks, fixed and ceiling mounted equipment, all furniture including wheels and casters, handles of cabinets, ventilation faceplates, and fixed shelving will be cleaned.
--Cleaning equipment shall be disassembled, cleaned, and disinfected with Virex solution and dried before reuse and storage."

B. Based on observation, interview, record review, and policy review, the provider failed to ensure:
*There was complete separation from packaging clean instruments, central supply, and the surgical technician's (tech) office in one of one area.
*One of one gallon of enzymatic cleaner was not outdated in the soiled instrument room.
Findings include:

1. Observation and interview on 8/29/19 at 1:20 p.m. of the central sterilization (CS) area revealed:
a. The packaging of surgical instruments and surgical packs was in the same room as the hospital's main central supply.
-Any staff could enter the room and retrieve supplies when needed.
b. The surgical tech's office was also located directly next to the packaging area. Her desk held a laptop computer, printer, and several piles of papers and books.
-On the shelves were:
--Two Blow Off compressed air containers. She stated she used those for her printer and laptop. She had not considered it would blow dust around the area.
--Several manufacture's manuals and ordering catalogues.
--Boxes, supplies, and other miscellaneous office items.
--Packages of clean instruments.
--Surgical packs.
c. There was a soiled room just outside of the CS area.
-The enzymatic cleaner for the cleaning of all surgical instruments had expired 2/1/19. The surgical tech revealed she was in charge of checking for outdates "But apparently had forgotten to check her own."
d. The surgical tech stated: "A few years ago, the CS area was located where the clinic was now. As the clinic grew, the CS area was relocated within central supply, and this was the solution the hospital had come up with."

Review of the provider's February 2019 Event Related Sterility policy revealed: "8) Items will be store in an environment free of moisture, excessive heat or contamination. The area must be clean, dry, dust free, and lint free."

Review of the provider's June 2009 Surgical Technician job description revealed:
*Summary:
-"Prepares for surgical procedures, directly assists the surgeon during procedures, oversees aseptic techniques of all personnel involved directly in the technical aspects of the surgical procedures and assists with clean up following surgical procedures."
-"Acts as a resource to the patient care areas for the placement and location of all equipment and supplies for nursing and surgery departments."
*Essential functions:
-"Performs all operative duties in accordance with established policies and procedures. They include but are not limited to preparing OR, monitoring aseptic technique of all team members, keeping sterile surgical field."
-"Assists with all Endoscopy procedures and maintains a working knowledge of cleaning, disinfecting/sterilizing endoscopy equipment as well as transporting equipment/instruments to CSR for sterilization process."
-"Maintains working knowledge of appropriate sterilization methods and keeps precise documentation regarding the sterilization process according to department policies and procedures."

C. Based on observation, interview, job description review, and policy review, the provider fail to ensure infection control, equipment maintenance, medication security, and housekeeping policies and procedures were specific to the surgical and procedure care areas.

Surveyor: 32355
1. Interview on 8/29/19 at 2:30 p.m. with the director of nursing (DON) revealed she:
*Was:
-The infection control (IC) coordinator for the facility.
-Not aware of all the concerns identified above in the surgical and sterilization areas.
*Would have followed procedures post-surgery to ensure no infectious problems for those patients had occurred.
*Stated:
-"The surgical nurse does her own audits and competencies back there."
-"I have never been involved with any of the education and sanitation concerns in that area."
-"She [surgical nurse] follows-up on her own issues and concerns back there.
*Agreed as the IC coordinator she should have been more involved to ensure policies and procedures were followed.
*Completed various monthly IC training but had not completed an actual infection control course to become an IC preventionist.

Interview on 8/29/19 at 3:55 p.m. with the administrative assistant revealed:
*There was no job description available for review for the IC coordinator.
*She stated: "Its up to the nurses to define those duties."

Based on policy review and interview, the provider failed to ensure policies and procedures were evaluated, reviewed, and revised periodically for one of five policy and procedure manuals selected for review (swing bed department). Findings include:

1. Review of the provider's swing bed policy and procedure manual revealed:
*Most of the Swing Bed policies had been reviewed and updated on 1/31/18 by the clinical nurse manager.
*A document in front of the swing bed policies stated:
-"The policies are developed with the advice of members of the CAH's [critical access hospital] professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff."
-"These policies are reviewed at least annually by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH."
-"[Hospital name] also chooses to have the Director of Patient Care Services, Clinical Nurse Manager, and the CEO [chief executive officer] join this group."
*There was no documentation to support the above staff had signed and dated their review and approval of the swing bed policies for three years.
-Their signatures to support a review and approval of those policies had not been done since 3/18/16.

Interview on 8/29/19 at 2:00 p.m. with registered nurse (RN) A regarding the Swing Bed policy and procedures revealed:
*They had not been updated for over a year.
*She was responsible to complete an initial review and update of the swing bed policies.
*She confirmed:
-The above staff were to have completed a final review of those policies to support the changes yearly.
-The last time those changes had been through a final review and acceptance process by those individuals was over three years ago.