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Based on observation, staff interviews, and review of maintenance records between November 30 through December 1, 2021, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies:
K161 Building Construction Type and Height
K211 Means of Egress - General
K222 Egress Doors
K223 Doors with Self-Closing Devices
K321 Hazardous Areas - Enclosure
K343 Fire Alarm System - Notification
K345 Fire Alarm System - Testing and Maintenance
K351 Sprinkler System - Installation
K354 Sprinkler System - Out of Service
K363 Corridor - Doors
K372 Subdivision of Building Spaces - Smoke Barriers
K511 Utilities - Gas and Electric
K521 HVAC
K541 Rubbish Chutes, Incinerators, and Laundry Chutes
K753 Combustible Decorations
K754 Soiled Linen and Trash Containers
K902 Gas and Vacuum Piped Systems - Other
K914 Electrical Systems - Maintenance and Testing
K918 Electrical Systems - Essential Electrical Systems Maintenance and Testing
K919 Electrical Equipment - Other

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.
Refer to the full description at the cited K tags.

Based on record review, observation and interview the facility failed to ensure that patient equipment Easy Stand (devise designed to assist patients to a standing position), The Vest Airway Clearance System (devise designed to help patients mobilize secretions in the lungs) & crash carts (emergency equipment and medications) were maintained according to facility and manufacturer's recommendation in 2 of 2 areas observed (medical surgical inpatient floor and emergency department) in a total universe of 11 areas observed.

Findings include:

The facility policy, titled "Equipment Safety Checks, GB-11006" last revised 11/2021, revealed: "This policy is to provide a standard by which all equipment, brought into this facility, is in a safe operating condition prior to its use. Implementation: All equipment that is purchased, rented, leased or to be used in the facility for patient care will have a copy of its most recent PM (preventative maintenance) checklist and will be kept in their own department. Facilities manager will be informed when equipment is brought into the facility. Facilities Manager will then inform the contracted Biomed team of the added piece of equipment and it will be put on a PM if it is not already under a contracted service. A PM report will be sent out to all directors as the Facilities Maintenance Manager receives them."

The facility policy, titled "Annual Service Review, FAC-018" last approved 11/2021, revealed: "Facilities Maintenance provides the following services that also include the Clinic locations... Among the other duties that include: 5. Preventative maintenance on required equipment."

During observation on 11/30/2021 at 10:00 AM in the Clean Supply/Linen room on the Medical Surgical Unit with Director of Inpatient Operations B observed the Easy Stand PM tag was dated 2/2020 and the Vest Airway Clearance system PM tag was dated 8/2019.

During an interview on 11/30/2021 at 10:00 AM, Director B, stated, [name] Biomed is responsible for doing PM checks on most of our equipment.

During an interview on 12/2/2021 at 9:20 AM, Director B, stated, I did not find a current PM record for the Easy Stand or the Vest. Per manufacturer recommendations the Easy Stand should have yearly checks on the castors and lubricated. The Vest should have annual safety tests.

An observation was made on 11/30/2021 at 1:30 PM of facility document "Crash Cart Check List" from November 2021 had no documented AM daily checks completed on 11/4, 11/6, 11/7, 11/9, 11/11, 11/15, 11/16, 11/19, 11/23, 11/24, and 11/25 and no documented PM daily checks completed on 11/4, 11/19, 11/20, 11/21, 11/25, 11/27, 11/29 and 11/30. Confirmed the missing checks at time of observation with Acute Care Manager M.

During an interview on 12/1/2021 at 2:30 PM, Manager M stated "I don't have a policy regarding crash cart checks but the expectation is that crash carts are checked twice a day (AM and PM)."



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During observation on 11/30/2021 at 11:15 AM, observed Emergency Room (ED) daily 'Crash Cart Check List' for November 2021 that revealed, a total of 4 days (11/4, 11/8, 11/9 and 11/30) of no documented ED Crash Cart checks done; review of 6 months of previous ED Crash Cart Checks in 2021 revealed, a total of 15 days (5/6, 6/6, 6/22, 6/30, 7/18, 7/27, 8/9, 8/10, 8/11, 8/12, 8/13, 9/7, 9/21, 9/26 and 10/14) of no documented ED Crash Cart Checks done.

During an interview on 11/30/2021 at 11:18 AM with Manager of Acute Care Nursing M, when asked who does the daily Crash Cart checks, Manager of Acute Care Nursing M stated "The Nurses do the checks." When asked if there should be daily Crash Cart checks done, Manager of Acute Care Nursing M stated "Yes, I'm sure staff were busy or forgot on the days it wasn't marked as done."

Based on observation, record review and interview, facility staff failed to monitor daily temperatures and expiration dates of the warming unit holding contrast medication used in CT (Computerized Tomography-specialized x-ray using computers and rotating X-ray machines) procedures on 11 days from 01/25/2021 through 11/30/2021 in a total universe of 1 of 1 Radiology Departments observed.

Findings include:

Record review of facility policy titled, "Iodinated Contrast Medication Management, Image-500", last reviewed 01/13/2020 revealed, "Warming of contrast will follow manufacturers guidelines including: temperature will not exceed 37 degrees C (Celsius).....temperature and expiration dates will be monitored and documented daily."

Record review of the daily contrast warmer log from 01/25/2021 through 11/30/2021 revealed no temperature or expiration dates recorded on 03/22/2021, 05/09/2021, 5/30/2021, 6/7/2021, 6/28/2021, 8/1/2021, 9/26/2021, 09/27/2021, 11/01/2021, 11/26/2021 and 11/29/2021. Confirmed in interview on 11/30/2021 at 10:45 AM with Radiology Technician H. When asked what the expectation was regarding monitoring temperatures of the warmer unit, Radiology Technician H stated, "The warmer is to be at 37 degrees Celsius we're supposed to check it everyday, if it's blank then it is not being checked..."

During an interview on 12/01/2021 at 3:30 PM with Lead Radiology Technician Z, when asked what happens when the warmer log isn't checked, Lead Radiology Technician Z stated, "We wouldn't know if the warmer was in parameters, it's supposed to be checked everyday, the weekend person is supposed to do it, but we have new employees."

Based on observation, staff interviews, and review of maintenance records between November 30 through December 1, 2021, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
K161 Building Construction Type and Height
K211 Means of Egress - General
K222 Egress Doors
K223 Doors with Self-Closing Devices
K321 Hazardous Areas - Enclosure
K343 Fire Alarm System - Notification
K345 Fire Alarm System - Testing and Maintenance
K351 Sprinkler System - Installation
K354 Sprinkler System - Out of Service
K363 Corridor - Doors
K372 Subdivision of Building Spaces - Smoke Barriers
K511 Utilities - Gas and Electric
K521 HVAC
K541 Rubbish Chutes, Incinerators, and Laundry Chutes
K753 Combustible Decorations
K754 Soiled Linen and Trash Containers
K902 Gas and Vacuum Piped Systems - Other
K914 Electrical Systems - Maintenance and Testing
K918 Electrical Systems - Essential Electrical Systems Maintenance and Testing
K919 Electrical Equipment - Other


The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.
Refer to the full description at the cited K tags.

Based on record review and interview and observation, the facility failed to follow their policies and procedures to ensure inpatient nutritional needs are met by failing to complete a registered dietitian assessment of 1 of 20 inpatients (Patient #18) in a total of 21 medical records reviewed and failed to ensure patients receive safe quality food by failing to properly monitor refrigerator temperatures and ensure food was not expired in 1 of 1 kitchens observed.

Findings include:

Record review of the "Standard Operating Procedure" Subject "Dietary Consults" #GB-12148 last revised 6/26/2018 under Implementation revealed "All patients admitted... are screened on admission, using the Malnutrition Screening Tool (MST)... Patients with risk for malnutrition (MST score of 2 or greater) will be assessed by the Registered Dietitian within 3 days."

Review of Patient #18's medical record with Coder/Privacy Officer W revealed Patient #18 was a 60-year-old admitted to the medical-surgical unit on 10/23/2021 at 10:15 AM. Malnutrition screening tool completed on 10/23/2021 at 5:08 PM indicated a MST score of 2. Patient #18 was discharged 10/27/2021 at 4:41 PM (4 days after admission). There was no registered dietitian assessment documented.

On 12/01/2021 at 8:48 AM during interview with Coder/Privacy Officer W, when asked if there was a dietary consult, Privacy Officer W confirmed, "I can't find one."


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The facility policy, titled "Food Labeling/Dating Policy" last reviewed 6/3/2021, revealed: "Procedure: 2. All foods that are prepared in the kitchen are to be dated using the today-plus-seven day method...."

The facility policy, titled "Food Expiration Policy" last reviewed 6/3/2021, revealed: "Policy: the dietary department will never use a product that has passed manufacturer expiration or expiration points beyond that of manufacturer expiration. Procedure: Canned or Sealed products: Follow manufacture expirations for all unopened cans, containers, and vacuum-sealed products."

Per review of the Air Curtain Refrigerator Temperature Logs from 11/1/2021-11/30/2021, there was no logged temperature for the following dates:
-November 1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 19 and 21.
Per review of the Juice Refrigerator Temperature Logs from 11/1/2021 - 11/30/2021, there was no logged temperature for the following dates:
-November 7, 8, 9, and 21.

Observations of the kitchen on 12/1/2021 between 10:30 AM and 12:00 PM revealed the following:

1. Dry Goods items expired
*9 Chocolate Ensure containers expired 10/21/2021
*12 1-gallon cans of Lemon pudding expired 4/2021
2. Food was expired
*12 Hotdog buns expired 11/30/2021

Per interview with Dietary Manager BB on 12/1/2021 at 12:00 PM, Manager BB confirmed that staff should be logging the refrigerator's temperature on a daily basis. Per manager BB it was confirmed that expired items should be removed from the kitchen.

Based on record review and interview, the facility did not maintain and adhere to policies and procedures to reduce the risk of growth and spread of legionella and other opportunistic pathogens in building water systems - in accordance with CMS Memo QSO-17-30 - Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease.

Findings include:

On 12/01/2021 at 9:12 AM, record review revealed the facility did have a policy with requirements to prevent Legionella infections; however, the facility did not follow the policy requirements. Interview of Staff revealed the policy requirements not implemented comprised of maintaining circulating water at a temperature above 122 degrees F, removing dead end hotwater piping, cutting down the length of dead end hotwater piping, and including mixing valves at patient sinks and showers.

This deficient practice was confirmed by Staff GG at the time of discovery.

Based on observation, record review, and interview, the facility failed to maintain a sanitary environment free of potential contamination to patients and staff by not adhering to infection prevention and control practices of the facility and nationally recognized standards of practice for 1 of 10 patient care observations (Patient # 21), and in 5 of 5 areas observed (Emergency Department, Kitchen, Surgery, Central Supply and Radiology ) in a total universe of 11 areas observed.

Findings include:

The facility policy titled, "Expiration Dating of Multidose Medication Vials" last revised 11/2019, revealed "...Opened multidose medication vials must be labeled with the date they are opened."

The facility policy titled, "Contaminated Waste and Sharps" last revised 08/2017, revealed "...Policy 1. Infectious sharps [medical instruments that are sharp or may puncture that are contaminated with blood and other bodily fluids] shall be contained for disposal in leakproof, rigid, and puncture resistant containers, such as plastic or metal."

The CDC (Centers for Disease Control) Safe Practice for Medical Injections (https://www.cdc.gov/injectionsafety/ip07_standardprecaution.html) revealed, under "Recommendations: IV.H.7. Do not keep multidose vials in the immediate patient treatment area...Medications should be drawn up in a designated clean medication preparation area that is not adjacent to potential sources of contamination."

Examples in the Multidisciplinary Room of the ED (Emergency Department):

During observation on 11/30/2021 at 10:05 AM, observed RN (Registered Nurse) Q access a COVID-19 multidose vial in the same room as the patient and administer the COVID-19 (Coronavirus) vaccine via injection to Patient #21. The multidose vial did not have an 'open date' written on it.

During an interview on 11/30/2021 at 10:10 AM with Registered Nurse Q, when asked about an 'open date' on the COVID-19 vaccine vial used for Patient #21, Registered Nurse Q stated "No open date is needed, the vial expires after 12 hours of opening; we get a new vial from the pharmacy in the morning, and then we take the vial back to the pharmacy at the end of the day."

During an interview on 12/01/2021 at 11:05 AM with Manager of Acute Care Nursing M, when asked about facility staff writing the 'open date' on multidose medication vials, Manager of Acute Care Nursing M stated "There is a yellow sticker that staff should be placing on the vial when it's opened, this is where they can write the date opened."

During an interview on 12/01/2021 at 2:21 PM with Business Operations Manager AA, when asked if she is the direct Manager for the Registered Nurses administering COVID-19 vaccinations in Multidisciplinary Room, Business Operations Manager AA stated "Yes, I have been in this role since May of this year." When asked if she was aware of the facility Multidose Medication vial dating policy, Business Operations Manager AA stated "No, I was not aware." When asked if she was aware that the current COVID-19 vaccination vials being used are multidose vials, Business Operations Manager AA stated "Yes, they get a vial from the pharmacy in the morning and use that vial for that day; vaccination clinics are held once per/week on Tuesdays right now."

Examples in the ED (Emergency Department):

During observation on 11/30/2021 at 11:00 AM, observed 7 ED exam rooms and 2 ED Trauma Bay rooms that did not have 'leakproof, rigid, and puncture resistant containers' to transport 'Infectious Sharps' to the ED Dirty Utility room for disinfection prior to sterilization.

During an interview on 11/30/2021 at 11:25 AM with ED Registered Nurse T, when asked if there are containers in any of the ED exam rooms or ED Trauma Bay rooms to transport instruments/sharps contaminated with blood and/or bodily fluids per the 'Contaminated Waste and Sharps' policy, ED Registered Nurse T stated "No rooms have containers to carry dirty utensils to the dirty utility room, we have gloves on when we carry instruments to the dirty utility room, this is where we place them into a hard covered container to be taken to Central Sterilizing."

During observation on 11/30/2021 at 11:30 AM, observed 'Monthly Check' log for 'Oxivir (cleanser) Dispensers' for 2021 that revealed, no documented checks were done for the 2021 year; the Oxivir bottle observed in the ED dirty utility room was dated '09/2021' as the open date. There was one bottle of 'Indicator Strips' observed next to the Oxivir bottle that expired '02/2021.'

During an interview on 11/30/2021 at 11:32 AM with EVS (Environmental Services) staff U, when asked what the Oxivir cleanser is used for, Environmental Services staff U stated "It is used as a floor cleanser." When asked about the Oxivir 'Monthly Check' log for 2021, Environmental Services staff U stated, "It hasn't been checked for 2021, when a new bottle is opened it should be checked with the Indicator Strips." When asked how long the Indicator Strip is suppose to sit before a 'pass/fail' reading is documented on the log, Environmental Services staff U stated "I think it sits for about 30 seconds." Indicator Strip bottle directions revealed, "...at exactly 120 seconds, compare the strip color with the color block."


38763


Examples in the Kitchen:

During the tray line observation on 12/1/2021 at 11:30 AM, Cook CC was observed handling baked potatoes with a gloved hand and placing it on a plate. The gloved hand was also touching the non food items.

During an interview on 12/1/2021 at 2:30 PM, Dietary Manager BB stated "I expect staff to handle baked potatoes with a tong, not a gloved hand."


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Examples in Radiology:

Record review of facility policy titled, "Hand Hygiene", GB-35026, last reviewed 04/2021 under policy, revealed "All staff will use hand-hygiene techniques as set forth in the following procedure. The CDC has recommended guidelines on when to use non-antimicrobial soap and water, an antimicrobial soap and water or an alcohol-based hand rub......before each patient encounter....after contact with medical equipment/supplies in patient care areas."

During observation on 11/30/2021 at 10:25 AM-10:45 AM, Radiology Technician H while wearing gloves, touched equipment in the CT (Computerized Tomography a specialized x-ray using computers and rotating X-ray machines) room, removed a saline flush from the cupboard, flushed the intravenous line on patient's right arm, touched the machine to start the intravenous infusion, removed their gloves and began working on the computer to begin the CT scan. No hand hygiene was observed to be performed during this time.

During an interview on 11/30/2021 at 10:45 AM with Radiology Technician H, when asked what was the expectation around hand hygiene, stated, " I took my gloves off and didn't wash my hands, with any type of patient contact I should be washing my hands."



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Examples in Surgery Department and Central Supply:

On 11/28/2021 at 2:14 PM observed Central Supply Technician EE carry an approximately 9" X 13 " wire basket containing soiled surgical instruments, with two surgical light covers on top, down the surgical hall into the dirty utility area, and place it on the stainless steel counter by the sink, and empty the instruments into the sink.

On 11/28/2021 at 2:14 PM during interview with Central Supply Technician EE, when asked if that was the usual method of transportation of instruments, Tech EE stated "yes, after the procedure."

On 11/29/2021 at 10:19 AM during tour with Supervisor of Environmental Services FF, Supervisor FF described the testing process of their Oxivir sanitizer to ensure the correct concentration of their product. Supervisor FF stated when each bottle was opened, a test was competed with a test strip. Supervisor FF stated the date the bottle was opened is written on the bottle, and a log for each bottle is kept with the date the bottle was opened and the staff's initials to ensure the bottle was tested prior to use. The bottle of Oxivir sanitizer in the surgical dirty utility room was 2/3 full with no date written on the Oxivir bottle. The last date on the Oxivir log was 11/26/2021 with no initials.

On 11/29/2021 at 10:20 AM observed dirty utility room in the surgical area with multiple black scuffs, gray dirty floor which stuck to the bottom of the surgical booties when walking through.

On 11/29/2021 at 10:19 AM interview with Supervisor of Environmental Services FF, Supervisor FF stated there was no written policy or procedure on testing of the Oxivir sanitizer. Supervisor FF stated the bottle must have just been opened. Supervisor FF confirmed "the bottle should have been dated" when it was opened to ensure it was tested. Supervisor FF also confirmed the floors in the dirty utility area were sticky stating they are "scrubbed daily," but "need to be waxed."

On 11/30/2021 at 1:50 PM during observation of the surgical area, observed Operating Room #2 with pink tiled walls with multiple screw holes (>19) on the back wall and the wall on the right and a large, approximately 2-1/2 foot, cracked tile on the back wall. Observed endoscope cabinet with the door closed, vented on the bottom, on front wall to the left, with 6 endoscopes hanging inside of cabinet.

On 11/30/2021 at 1:50 PM during interview with Director of Surgery Y, Director Y stated the surgical area needed updating and confirmed the findings of the holes and crack in Operating Room 2. Director Y stated they were planning to move the endoscope cabinet with their remodel stating, "it's on my wish list."