HospitalInspections.org

Based on observation and interview, the hospital failed to:
- Recognize the lack of services and provide effective training to ensure facilities for emergency backup gas supply were in place per hospital policy (A-0703).
- Recognize that three electric wall heater units were actively on, inside unoccupied patient bathrooms (#215, #221 and exam room #6 in convenient care) with visible scorch marks on the back of each of the bathroom doors that were very hot when touched (A-0709).
- Perform routine environmental rounding, maintain hospital facilities, and perform biomedical safety inspections to equipment used by staff and patients (A-0724).
- Ensure staff performed daily checks on the crash cart (mobile unit which contains emergency medical supplies and medication) for one of two crash carts observed, per hospital policy (0724).

These failures created an unsafe environment and had the potential to place all patients, staff and visitors at risk for their safety; including the risk of fire identified with the electric wall heaters. The hospital census was seven.

The severity and cumulative effect of these systemic practices resulted in the overall noncompliance with 42 CFR 482.41 Condition of Participation: Physical Environment that resulted in a condition of Immediate Jeopardy (IJ).

As of 04/14/22, at the time of the survey exit, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented the following actions:
- All bathroom electric heaters were disconnected from electrical service with completion on 04/12/22.
- Staff D, Registered Nurse (RN), House Supervisor (HS), performed a continuous fire watch that was implemented on 04/12/22 at 6:50 PM and continued throughout the hospital until all electric heaters were disconnected from electrical service.
- A fire watch log was completed by Staff D, RN, HS, that showed continuous rounds were made on 04/12/22 from 6:50 PM until 7:35 PM when the last heater was disconnected.
- A heater disconnection log was completed by Staff B, Chief Operating Officer (COO) that showed hospital patient room numbers (40 total rooms) with time of observation that ensured heater disconnection.

Based on interview and policy review, the hospital failed to provide operable equipment and effective training to ensure transition to a backup gas supply per hospital policy. This failure had the potential to affect all patients receiving care, and staff providing care, during an emergency situation where access to the natural gas supply was interrupted. The failure had the potential to cause inability to regulate temperatures within the heating, ventilation and air conditioning (HVAC) system to patient care areas and to utilize gas powered kitchen equipment for cooking. The hospital census was seven.

Findings included:

1. Review of the hospital's procedure titled "Alternate Fuel Source," reviewed 01/2021, showed that when the hospital required conversion from primary to alternate fuel, the process was implemented by the Maintenance Department. The hospital's procedure outlined the required steps in conversion from natural gas to liquefied petroleum from a propane storage tank via a vaporizer.

During an interview on 04/12/22 at 9:42 AM, Staff L, Maintenance Director, stated that the hospital utilized natural gas chillers and boilers to cool and heat water for their HVAC system. He stated that one of the boilers and none of the chilling units were operable by the emergency generator. Staff L also stated that the hospital had a propane tank purposed for back-up gas and there was propane stored in it. He stated that he did not know the procedure for conversion to the propane tank as a fuel source in an event the source of the hospital's natural gas was interrupted. Staff L stated that when he began as the hospital's maintenance director three years ago, he was told by his predecessor that the conversion process with the propane tank "does not work."

Based on observation and interview, the hospital failed to ensure the safety of patients, staff, and visitors, when electric wall heater units located in patient bathrooms, posed a fire risk when the heaters were in close proximity to the bathroom doors. The bathroom doors had visible scorch marks on the back of the doors from the high temperature emitted from the heaters. There were 40 electric wall heater units in multiple areas of the hospital. This failure placed all patients, staff and visitors at risk for their safety from fire. The hospital census was seven.

Findings included:

1. Observation, with concurrent interview, on 04/12/22 at 3:10 PM, of the electric wall heater units in patient rooms #215 and #221, showed the electric wall heater units on, with the heating coils noted to be red in color, and emitted heat at a high temperature. The metal grate that covered the heater unit and the back of the bathroom door were very hot when touched. The heating unit in room #215 was able to be turned off by a switch but the heating unit in room #221 was not able to be turned off manually. Staff A, Chief Financial Officer, (CFO), stated that environmental rounds had not been completed since early 2020. Staff A, CFO, and Staff B, Chief Operating Officer (COO), both stated that they were unaware of any current fire risk in the building and had not seen the electric wall heater units before.

Observation on 04/12/22 at 5:22 PM, of an unoccupied room identified as "Exam Room #6," located in the Convenient Care wing within the hospital, showed an inset electric wall heater in the bathroom. The heating coils within the wall unit were observed to be red in color and emitted heat at a high temperature. The bathroom door was within four inches of the heater, and the back of the bathroom door was hot to the touch. The heating unit could not be turned off manually.

Observation on 04/12/22 at 3:05 PM, of rooms #214 and #228, showed that although the electric wall heaters were not actively on, scorch marks were present on the back of the bathroom doors.

During an interview on 04/12/22 at 3:35 PM, Staff L, Maintenance Director, stated that two years ago he remembered that he was called down to the outpatient area when a patient had caught her dress on fire after she had gotten too close to an electric wall heater unit.

During an interview on 04/12/22 at 7:15 PM, Staff DD, Chief Executive Officer, (CEO), stated that the bathroom doors had metal plates installed on the back of the door to prevent a fire.

During an interview on 04/13/22 at 4:15 PM, Staff O, Certified Nursing Aide (CNA), stated that the wall heaters had been in use for several years. She stated that when the bathroom doors would become scorched from excessive heat, the bathroom door would be painted over to hide the scorch marks. She also stated that after the doors were painted, as the heat on the doors increased, the staff and patients could smell the burning paint. During the interview, Staff O escorted the surveyor to room #226 to observe a bathroom room door that had recently been painted over to cover a previous scorch mark.

During an interview on 04/13/22 at 11:30 AM, Staff L, Maintenance Director, stated that some of the backs of bathroom doors had been equipped with a metal plate and some had been equipped with a material of which the exact composition was unknown to him. He stated he understood these had been installed to provide fire protection to the back of the bathroom doors from the inset wall heating units. He stated that this had been done prior to his employment in 2019.

The hospital was aware of the fire risk when they had a previous incident of a patient whom caught her dress on fire from the electric wall heater unit, and that they had installed metal plates on the back of the doors, in the area where the door was in close proximity to the heater, to prevent the door from catching on fire. There were 40 electric wall heating units throughout the hospital.




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32280

Based on observation, interview, record review and policy review, the hospital failed to maintain the hospital environment and equipment to ensure an acceptable level of safety and quality when they failed to:
- Perform preventative maintenance (PM, [referred to as "Planned Maintenance" by the hospital] maintenance that is regularly performed on a piece of equipment to lessen the likelihood of it failing) inspections on floor fans, prior to use in two patient rooms (#217 and #227), one floor fan located in nursing station, and three floor fans located in the supply room.
- Monitor and maintain the hospital environment to ensure safety and quality.
- Ensure staff performed daily checks on the crash cart (mobile unit which contains emergency medical supplies and medication) for one of two crash carts observed, per hospital policy.
These failures had the potential to adversely affect the health and safety of all the patients within the hospital. The hospital census was seven.

Findings included:

1. Review of hospital policy titled, "Planned Maintenance," reviewed 01/2021, showed that all equipment was to be inventoried, given a control number, and properly recorded. Every piece of machinery, office furniture, patient furniture, heating and cooling, etc. were listed on separate cards.

During interview on 04/12/22 at 1:35 PM, Staff L, Maintenance Director, stated that biomedical engineering inspection services were contracted with an outside company and all equipment was supposed to be inspected prior to use within the hospital.

Review of hospital provided document titled, "Preventive Maintenance Agreement," dated 03/21/22, showed that the hospital had an agreement with an outside entity to perform PM. The agreement was limited to the PM of five pieces of medical equipment specific to patient heart monitors/testing equipment, and patient ventilators (a machine that supports breathing.

Observation on 04/11/22 at 4:15 PM, of the supply room located on 2A Medical/Surgical inpatient care unit, showed a body warmer (a convective temperature management system used in a hospital or a surgery center, to maintain a patient's core body temperature) system with a PM sticker, without a date or initials, and two box type floor fans and one oscillating, upright fan, with no PM stickers.

Observation on 04/12/22 at 10:00 AM, in patient room #227, showed an oscillating, upright fan in the room. The fan had no PM sticker.

Observation on 04/12/22 at 8:35 AM, in patient room #217, showed an oscillating, upright fan in use. The fan had no PM sticker.

During interviews on 04/13/22 at 11:10 AM, and 04/14/22 at 10:05 AM, Staff L, Maintenance Director, stated that he was not currently following any PM policy, and was unsure if the hospital had a policy. When shown the PM policy, he stated that he was unaware that the policy existed and had never seen it before.

During an interview on 04/14/22 at 8:45 AM, Staff B, Chief Operation Officer (COO), stated maintenance used to perform safety checks on electrical equipment, but with their new contract, those type of checks must have "fallen through the cracks."

2. Observation on 04/11/22 at 4:45 PM, in patient room #211, showed a shower head with a constant steady drip of water, and was unable to be turned off.

Observation on 04/12/22 at 2:57 PM, in patient room #222, showed a shower head with a constant steady drip of water, and was unable to be turned off. There was a black substance around the entire base of the shower and up the tiled wall on the faucet side. There was a black substance around the window sill. There was peeling paint between the window and the bathroom door.

Observation on 04/12/22 at 3:07 PM, in room #215, showed growth of an unknown black substance on the return air vent.

Observation on 04/12/22 at 9:50 AM, in room #211, showed what appeared to be rust on the return air vent with large amounts of black lint/dust on the filter.

Observation on 04/11/22 at 3:50 PM, in the conference room, showed a watermark on a drop ceiling tile, approximately six inches long by six inches wide with a black substance within the watermark.

Observation on 04/12/22 at 9:10 AM, in the hallway, on 2A Medical/Surgical inpatient unit, showed a watermark on a drop ceiling tile that was approximately 10 inches long by 10 inches wide with a black substance within the watermark.

Observation on 04/12/22 at 2:53 PM, in room #226, showed the bathroom had peeling paint around the base of the toilet and a piece of baseboard that had come off the wall and was lying on the floor. The patient area of the room had a drop ceiling tile that was missing with electrical cords hanging down.

Observation on 04/12/22 at 9:45 AM, in room #211, showed cracked ceiling plaster approximately one foot by one half foot above the window.

Observation on 04/12/22 at 2:50 PM, above the 2A nurse's station, showed a watermark on a drop ceiling tile that was approximately eight inches long by eight inches wide.

During an interview on 04/12/22 at 9:20 AM, Patient #8 stated that he was admitted on 04/11/22 to room #222. On the morning of 04/12/22 a staff member came and moved him to room #224 and told him it was due to his leaking shower head.

During an interview on 04/12/22 at 3:00 PM, Staff O, Certified Nurses' Aide (CNA), stated that Patient #8 was in room #222, which was supposed to be closed due to mold in the shower, so he was moved to room #224.

During an interview on 04/13/22 at 11:10 AM, Staff L, Maintenance Director, stated that:
- The black substance in room #222's bathroom, and around the window, was mildew. He did not believe it was black mold, but never had it tested.
- The maintenance staff replaced the filters in the air vents, but had never been asked to clean the vents.
- He did not have a schedule for replacing broken ceiling tiles.

During an interview on 04/14/22 at 12:45 PM, Staff N, Director of Housekeeping, stated that:
- Room #222 had not been used since 02/2022, so it had not been cleaned as housekeeping staff were under the impression it was out of order. After Patient #8 was accidentally placed in that room and they were made aware of the condition of the shower, housekeeping thoroughly cleaned the room.
- If the housekeeping staff saw dust, they were expected to clean it. She stated "high dusting" was on the list of daily rounds, but explained that some of the vents were old, and even after they were cleaned, they still looked dirty.
- Rusted vents that could not be cleaned were reported to maintenance for repair or replacement.

During interviews on 04/13/22 at 11:10 AM, and 04/14/22 at 10:05 AM, Staff L, Maintenance Director, stated that he did not have a dedicated schedule to make rounds, but that in his "free time," he would check on items that were in need of repair.

During an interview on 04/12/22 at 3:15 PM, Staff A, Chief Financial Officer, (CFO), stated that environmental rounds had ceased in early 2020.

3. Review of the hospital's policy titled, "Crash Cart Management," revised 11/2013, showed that the crash cart was checked to include medical supplies and medications at the beginning of each shift by nursing personnel, and that all equipment on the crash cart was checked daily.

During an interview on 04/11/22 at 3:55 PM, Staff E, Registered Nurse (RN), Emergency Department (ED) Manager, stated that the crash cart was checked twice daily by nursing personnel at the beginning of each shift at 7:00 AM and 7:00 PM.

Review on 04/11/22, of the ED document titled "Crash Cart Check Off List," dated April 2022, showed that the crash cart was not documented as checked during the 7:00 PM shifts on 04/01/22, 04/02/22, 04/03/22 and 04/07/22. The document also showed that the crash cart was not documented as checked during any shift on 04/08/22, 04/09/22 and 04/10/22.

The hospital failed to ensure that the crash cart suction machine was properly checked to ensure that it was operational.







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41865

Based on observation, interview, and policy review, the hospital failed to have systemic practices in place to ensure that:
- Biohazard (waste contaminated with potentially infectious agents or other materials that are deemed a threat to public health or the environment) waste and sharps (any object that can penetrate the skin) was managed and stored in a manner to prevent potential risk to patients, staff, visitors and the community (A-0749).
- Staff followed hospital policy for hand hygiene and glove use when they provided patient care (A-0749).
- Areas and equipment in and around surgical areas were maintained to ensure safety and quality, and minimized the risk of cross-contamination and infection (A-0749).
- Dietary department staff protected food and food preparation areas from potential cross-contamination and the potential for food-bourne illness (A-0749).
- There was a process for ensuring the implementation of additional precautions for all staff who were not fully vaccinated for COVID-19 (highly contagious and sometimes fatal, virus), intended to mitigate the transmission and spread of COVID-19, and that staff followed the policy regarding masks use to minimize the the transmission of COVID-19 (A-0792).
These failures placed patients, staff and visitors at risk for their health and safety.

The severity and cumulative effects of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and resulted in the hospital's failure to ensure quality health care and safety.

The hospital census was seven.

Based on observation, interview, and policy review, the hospital failed to have systemic practices in place to ensure that:
- Biohazard and infectious waste (waste contaminated with potentially infectious agents or other materials that are deemed a threat to public health or the environment) and sharps (any object that can penetrate the skin) was managed and stored in a manner to prevent potential risk to patients, staff, visitors and the community.
- Staff followed hospital policy for hand hygiene and glove use when they provided care for three patients (#2, #4 and #12) of eight patients (included two Emergency Department patients) observed during care.
- Areas and equipment in and around surgical areas were maintained to ensure safety and quality, and minimized the risk of cross-contamination and infection.
- Dietary department staff protected food and food preparation areas from potential cross-contamination or deterioration of food.
These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The facility census was seven.

Findings included:

1. Review of the hospital's policy titled "Hazardous Waste, Management," revised 06/2014, showed that Environmental Services collected, stored, processed, transported and discarded of all hazardous waste in a way that enabled the prevention of infection and injury. Hazardous waste included contaminated gloves, wound dressings, blood products, scalpels and hypodermic needles. Non-sharp hazardous waste was placed in red bags and taken to an infectious waste holding area. Sharps were placed in a puncture-resistant container and when containers were full, hospital staff labeled as hazardous waste and notified housekeeping for disposal.

Review of the hospital's policy titled "Biological Waste, Disposal," revised 08/2021, showed that infectious waste could cause infections and was kept separate from non-infectious waste. Infectious waste included materials soiled with blood, body fluid, scalpels, needles and syringes. Housekeeping collected and properly disposed of infectious waste. Infectious waste was to be handled according to the policy and procedure regarding infectious waste.

Review of the hospital's policy titled, "Bloodborne Pathogen Exposure Control Plan," reviewed 01/2021, showed that biohazardous waste was to be placed in red biohazard bags, and placed in the biohazardous waste collecting barrels.

Observation on 04/11/22 at 4:20 PM, on 2A Medical/Surgical inpatient unit nursing station, showed a trash can located in the nursing station, just outside of the medication room door. The trash can contained a red biohazard bag, and the trash can was left uncovered.

Observation on 04/12/22 at 2:53 PM, on 2A showed Staff K, Registered Nurse (RN), disconnected intravenous (IV, in the vein) tubing from the blood administration set for Patient #4. Staff K exited the room with the tubing, and disposed of the tubing in the open trash can located outside of a medication room. The trash can's red biohazard liner was observed to have two nickel size holes.

During an interview on 04/12/22 at 3:00 PM, Staff K, RN, stated that she should have obtained a red biohazard bag (and placed it in the patients room) to dispose of the blood tubing after disconnection.

Biohazardous receptacles that are left open, or have breaks in the surface of the liner, increase the risk of exposure to patients and staff.

Observation on 04/12/22 at 9:25 AM, showed Staff J, RN, prepared to cleanse and apply a dressing to a wound on Patient #7's right lower leg. Staff J, cleansed the wound with gauze pads, wiped the wound bed to remove exudate (fluid), and placed the soiled gauze pad on the patient's bed linens. After completion Staff J gathered the soiled gauze pads and placed them into the patient's trash can, which did not contain a red biohazard bag.

Interview on 04/12/22 at 10:13 AM, Staff J, RN stated that she placed the soiled gauze pads onto Patient #12's bed because she knew her bed linens would be changed that day. Staff J stated that it was okay to put the dirty dressing supplies in the regular trash can liner.

During an interview on 04/12/22 at 10:10 AM, Staff N, Director of Housekeeping, stated that the contracted company for the biohazard supplies only supplied a certain number of biohazard bags each month, and they sometimes ran out of bags prior to the next delivery.

Observation on 04/11/22 at 3:53 PM, of Emergency Department (ED) Rooms 102 and 106, showed wall-mounted containers for the disposal of sharps which were overfilled, obstructing the opening on the top of the containers.

During an interview on 04/11/22 at 3:55 PM, Staff H, RN, stated that the ED staff were responsible for removing full sharps' disposal containers from the ED rooms and for restocking the patient rooms with empty sharps' disposal containers.

Observation on 04/12/22 at 10:52 AM, outside of the hospital, showed an unattended trailer parked behind the hospital, accessible by a wooden ramp with a door propped open approximately four feet. The trailer contained red biohazard containers visible from the walkway.

During an interview on 04/12/22 at 10:53 AM, Staff N, Director of Housekeeping, stated that the trailer stored biohazard waste removed from the hospital's patient care areas, by housekeeping personnel. The trailer was to be kept locked and secured.

2. Review of the Association of periOperative Registered Nurses (AORN) "Guideline for Environmental Cleaning, Guideline for Perioperative Practice and Guideline for Perioperative Practice: Flexible Endoscopes (lighted tube with a camera, used to visualize the inside of organs)," dated 2021, showed that non-intact and non-waterproof surfaces were difficult to clean and promote cross contamination. The guidelines also showed that flexible endoscopes should be stored in a manner that minimized exposure to potential contamination in a storage cabinet with a door and should be identified with a distinct visual cue to indicate they have been processed and are safe for use. The AORN guidelines also recommended that hospitals maintained records of the processing and procedures of flexible endoscopes. Records included at a minimum the date and time, unique identity of the endoscope, method of cleaning and disinfection, lot number of disinfectant solution, identity of person who performed the processing and disposition of an endoscope if identified as defective.

Observation on 04/12/22 at 3:20 PM in the perioperative area showed the following:
- Endoscopes used for gastrointestinal and urologic procedures were processed utilizing a high-level disinfectant solution. No log was utilized which identified dates, processing times or control tests for each endoscope by serial number. There was no documentation to verify what date each of the endoscopes was last processed and that all manufacturer recommendations were monitored to ensure effective disinfection and reprocessing within recommended timeframes.
- Disinfected endoscopes were stored in a cabinet with a broken door which allowed exposure to dust or other contaminants.
- An area of rust covered a portion of a file cabinet in the presurgical staging area. The file cabinet contained sterile wrapped supplies and anesthesia (a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes) respiratory supplies.
- An oxygen shut-off valve in the hallway outside of Operating Room (OR) Room #1, without a plastic cover (presented a high potential for a contaminated and non-cleanable surface).
- Large gouges and cracked molding were seen in the hallway of the preoperative area (potentially contaminated and non-cleanable surfaces).
- Two surgical step stools in OR Room #1 with the underside completely covered with rust.
- A cabinet for surgical laparoscopic (surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis without having to make large incisions in the skin) and video equipment in OR Room 1 with rust on the side and back of the cabinet.
- Floor transitions from the operative suites to the "dirty" instrument processing room located between OR #1 and OR #2 with rust.
- A surgical trash can with rust located in OR Room #2.
- An opened aerosol spray can of silicone lubricant (combustible and flammable) without a lid stored in a plastic tub on a shelf under the operative table in OR Room #2.

Dirt, debris, and surfaces that are not smooth, intact and cleanable, in and around the surgical and procedural areas, have the potential to lead to cross-contamination of sugical equipment, surgical instruments, and lead to the potential for post-operative infections.

During an interview on 04/12/22 at 3:40 PM, Staff W, RN, Director of Operating Room Services, stated she was not aware of why the aerosol can of lubricant was being stored in the operating room. Staff W stated that no log was maintained to identify each endoscope by its serial number or when it was processed in the high-level disinfectant solution. She stated that the endoscopes were not labeled or tracked when each scope was last processed with high-level disinfectant.

During interviews on 04/13/22 at 11:10 AM, and 04/14/22 at 10:05 AM, Staff L, Maintenance Director, stated that he did not have a dedicated schedule to make environmental rounds, but that in his "free time," he would check on items that were in need of repair.

During an interview on 04/12/22 at 3:15 PM, Staff A, Chief Financial Officer, (CFO), stated that environmental rounds had ceased in early 2020.

3. Review of the hospital's policy, "Handwashing," revised 05/2014, showed that hand hygiene was done to prevent the spread of infection and that personnel were to perform hand hygiene:
- Before and after direct patient contact;
- Before and after use of gloves;
- After likely contact with blood or body fluids; and
- After contact with inanimate objects in the immediate vicinity of the patient.

Review of the hospital's policy titled "Instructions for cleaning patient equipment," revised 10/2014, showed that equipment utilized for patient care was cleaned after each use and as needed.

Observation on 04/12/22 at 4:30 PM, on 2A Medical/Surgical inpatient unit, showed Staff J, RN, perform a blood sugar testing on Patient #4. Staff J obtained the blood sample then exited the patient room and returned the glucometer (an instrument for measuring the concentration of glucose [sugar] in the blood) to the nursing station without wiping or cleaning it.

Observation on 04/11/22 at 4:35 PM, showed Staff G, Licensed Practical Nurse (LPN), did not remove gloves, perform hand hygiene, or clean the glucometer after checking Patient #2's blood sugar.

During an interview on 04/11/22 at 4:40 PM, Staff G, LPN, stated that the hospital's policy on hand hygiene was that gloves were removed and hand hygiene performed after patient care procedures and when leaving a patient room. She also stated that the hospital's policy was that the glucometer was cleaned with a disinfectant wipe before and after each use.

Observation on 04/12/22 at 9:15 AM, showed Staff J, RN, administer medications to Patient #12 with gloved hands, removed the gloves, and donned a new pair of gloves without performing hand hygiene.

Observation on 04/12/22 at 9:25 AM, showed Staff J, RN, perform wound care on Patient #12. Staff J prepared her supplies with gloved hands, removed and donned new gloves, cleansed the wound, and removed and donned new gloves, and failed to perform hand hygiene in between glove changes.

During an interview on 04/12/22 at 10:13 AM, Staff J, RN stated that was unsure of when the handwashing policy directed staff to wash their hands in relation to glove changes.

4. Review of the hospital's undated policy titled, "Dietary Department Infection Control," showed that:
- Windows would be closed at all times.
- All food would be stored in covered, dated containers, under proper temperatures.
- All food placed in coolers and freezers would be labeled and dated properly. All opened products would be labeled with date in and date out when it was placed in the cooler/freezer.
- All unused products would be marked with the received date.
- All waste materials would be discarded into a lined, covered container.
- Expiration dates would be checked closely.

Observation on 04/12/22 at 10:23 AM, in the Dietary Department, showed large amounts of black lint/dust on the return air vent filter, near the food preparation area. There were two windows open, with a strong air flow coming in from the outside. One of the window screens had two dime sized holes in the left corner of the screen. The second window screen had a live wasp on the interior of the screen. Approximately ten feet from the open windows were trays of uncovered lettuce, tomatoes and cheese. Staff Q, Dietary Manager was observed to be cutting pies in the close proximity.

Areas of the hospital that contain potential contaminants, where food is stored or prepared, can lead to cross-contamination of food through air movement, and cause food-bourne illnesses in both patients and staff.

Observation on 04/12/22 at 10:45 AM, inside the Dietary Department's cooler #2, showed the cooling fan cover with what appeared to be rust on the metal cover, with visible dust on the inside of the grate.

Observation on 04/12/22 at 10:25 AM, in the Dietary Department, showed two large, round trash containers with no lids.

Uncovered trash receptacles can lead to cross-contamination of food, in food storage and preparation areas.

Observation on 04/12/22 at 10:23 AM, of the Dietary Department's walk-in cooler, showed an opened container of macaroni salad and an opened bag of cooked bacon, that was not marked with a date in or date out.

Observation on 04/12/22 at 10:30 AM, of the Dietary Department's dry storage area, showed six containers of salad dressing with no expiration dates.

Observation on 04/12/22 at 8:30 AM, on 2A Medical/Surgical inpatient unit, showed dietary staff picking up patient breakfast trays. Inside the dietary cart there were two empty milk cartons on two separate trays. One milk carton had an expiration date of 04/11/22.

During an interview on 04/12/22 at 10:30 AM, Staff Q, Dietary Manager, stated that:
- All food was to be labeled with the date that it was received.
- When a food container was opened it was to be labeled with the date it was opened, and with the date it was to be discarded.
- Canned or dry goods were to be marked with the date received and should have a clearly identified expiration date on the package.

Observation on 04/12/22 at 10:52 AM, in the staff serving line area, showed an upright cooler with no door, which contained multiple plastic containers of fruit, cottage cheese, and salads. The containers with the fruit had visible condensation droplets on the inside of the containers and the cottage cheese appeared to be liquefied with visible moisture droplets on the outside of the containers (indicating the food had warmed). The wall mounted thermostat showed a temperature of 78 degrees.

During an interview on 04/12/22 at 10:58 AM, Staff R, Cook, stated that the upright cooler was filled 30 minutes before opened with cold food items, and that she had just put the cold food into the cooler (which read 78 degrees). Staff R stated that the dietary department was air conditioned, but the staff preferred to have the windows open.

Review of the hospital's policy titled, "Receiving and Storage of Food," dated 06/2017, showed that:
- The storage of food items outside of the Nutrition Services Department would be monitored by both the Nutrition Service Manager and the Nurse Manager.
- A temperature record for refrigerator and freezers on all units was maintained daily and was made easily accessible.
- "Leftovers" were discarded after three calendar days
- Resident/patient food items were stored separately from employee food items.

Observation on 04/11/22 at 4:22 PM, showed a residential-type side-by-side refrigerator/freezer in the ED with a label of "Patient Refrigerator." The refrigerator had no handle. The refrigerator contained an unsealed/unlabeled/undated pizza box, three opened/unlabeled/undated liquid coffee creamers, and four opened/unlabeled/undated salad dressing bottles. The freezer contained a large amount of ice crystallization and several prepackaged, unlabeled meals. A log of recorded refrigerator or freezer temperatures was not displayed.

During an interview on 04/11/22 at 4:28 PM, Staff F, RN, stated that the dietary department performed daily temperature checks on the refrigerator and freezer in the ED, but did not know the location of the log with temperature recordings. Staff F stated that after the ED was relocated, there was not a refrigerator dedicated for staff food. She stated ED staff kept their personal food in the refrigerator with the patient nutritional supplies. Staff F stated she did not know who placed the opened salad dressing, coffee creamers and pizza in the patient refrigerator or how long they had been stored there.

Observation on 04/11/22 at 4:00 PM, showed a residential-type one door refrigerator/freezer in the 2A patient dietary room with a label of "Patient Refrigerator." The refrigerator had no handle, did not have a thermometer inside of the refrigerator compartment, and no temperature log displayed. Directly beside the patient refrigerator was a second refrigerator labeled "Staff Refrigerator," with a temperature log displayed on the outside of the refrigerator with missing documentation. There were no temperatures documented for 04/01/22, 04/05/22, 04/09/22 and 04/10/22.






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44536

Based on observation, interview, and policy review, the hospital failed to ensure the implementation of additional precautions for all staff who were not fully vaccinated for COVID-19 (highly contagious and sometimes fatal, virus), intended to mitigate the transmission and spread of COVID-19. The hospital also failed to ensure all staff wore face masks inside the hospital per hospital policy. These failures placed all patients, staff and visitors at increased risk for infection. The hospital census was seven.

Findings included:

1. Review of the undated hospital document titled, "COVID-19 Health Care Staff Vaccination," showed that employees were required to wear a mask and use the COVID SCREENING kiosk before each shift.

Review of the hospital's policy titled, "Covid Vaccination Policy: Mandatory," dated 11/08/21, showed there was no process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for staff who were not fully vaccinated for COVID-19.

Observation on 04/11/22 at 4:08 PM, showed Staff G, Licensed Practical Nurse (LPN), and Staff H, Registered Nurse (RN), talking at the nursing station in the Emergency Department (ED) without masks on their faces.

Observation on 04/12/22 at 10:23 AM, showed Staff Q, Dietary Manager, cutting a pie without a mask on her face, in the dietary department.

Observation and concurrent interview on 04/12/22 at 10:52 AM, in the dietary department, showed Staff R, Cook, without a mask on her face. Staff R stated that she didn't need to wear one inside the department.

Review of the untitled hospital document showed a vaccination log of all employed staff. Staff R was listed as a cook with a vaccine exemption.

During an interview on 04/14/22 at 10:48 AM, Staff C, Chief Nursing Officer (CNO), stated that all staff were expected to wear masks on their faces at all times (unless eating or drinking) while inside the hospital.

During an interview on 04/14/22 at 11:20 AM, Staff Y, Interim Infection Control Coordinator, stated that the staff had plenty of masks and were expected to wear them while inside the hospital. She stated that she was unaware of any issues with staff not wearing masks.

During an interview on 04/13/22 at 10:13 AM, Staff BB, Human Resources (HR) Director, stated that she was responsible for overseeing the vaccine mandate, and that all staff were required to wear a face mask, regardless of their vaccination or exemption status, while inside the hospital. Staff BB added that there were no additional precautions that were necessary for unvaccinated staff.

The hospital failed to ensure all staff wore face masks while inside the hospital, and failed to implement additional precautions to mitigate the risk of transmission for those staff that were not fully vaccinated.


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