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Based on observation, record review and interview, the facility failed to remove expired foods intended for patient consumptionon in 1 of 1 department (Emergency Department) in a total of 2 departments observed.

Findings include:

Review of policy "Floor Stock Distribution", policy #4130, revision date 9/01/2019 revealed "The Food and Nutrition Department is responsible for providing food supplies to inpatient units... all food is rotated on a first in/first out basis... ensuring
stock is labeled with the appropriate expiration.

On 8/22/2023 at 11:20 AM observed patient nutrition refrigerator in the Emergency Department with 10 creamers with expiration date 7/18/2023, 8 small packaged margarine with expired date 12/03/2022.

On 8/22/2023 at 11:22 am observed in the cupboard above patient refrigerator in the Emergency Department, one box of 24 apple juice with expiration date 8/12/2023, 27 tea packets with expiration date of 1/28/2022 .

During an interview with ED Manager B, at 11:20 AM when asked who is responsible for removing out dated food supplies, Manager B stated "dietary."

Based on observation, record review, and interview, staff at this facility failed to ensure that all surfaces are intact and in good repair in 8 of 27 rooms (Emergency Department Radiology Procedure Room, Emergency Department (ED) Room #6, #13, #18, #7, #10, #15, and #20) observed in the Emergency Department in a total of 2 departments observed.

Findings include:

Review of Facility Policy #6842, last reviewed 09/11/2020, titled, "(System) Cleaning Inpatient Rooms and Adjoining Public Areas," revealed, "8. Notification of appropriate department problems... should be documented on a daily duty sheet, reported to an EVS [Environmental Services] Supervisor or Manager, and/or a work ticket is to be submitted."

During observations on 8/22/2023 from 11:04 AM through 12:45 PM in the Emergency Department (ED) the following findings of breaches in facility integrity were verified with ED Manager B and Environmental Services (EVS) Supervisor:

ED Radiology procedure room with paint chips behind the door, right side wall with 6 divots in the wall and wallpaper above biohazard container, and behind trash bins underneath technician window were peeled through to drywall.

ED Room 6 with peeled wallpaper through to drywall behind the bed.

ED Room 13 with exposed nail holes in the walls.

ED Room 18 with peeled wallpaper through to the drywall, on back wall at chair level.

During observations on 8/22/2023 at 3:00 PM in the Emergency Department (ED) the following findings were verified with ED Manager B:

ED Room 7 with paint peeled off the lights and electrical panel behind the bed.

ED Room 10 with missing pieces of ceiling,

ED Room 15 with multiple gouges and chipped paint on the exterior of wooden door.

ED Room 20 with multiple areas of missing paint around the sink and gouges in the wall exposing sheet rock.



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On 8/22/2023 at 12:08 PM during interview with ED Manager B, when questioned on the process for ensuring a safe environment and getting repairs completed in the ED rooms, Manager B stated "anyone can put in a work order." Manager B stated equipment repairs and follow-up of outstanding findings are discussed in the weekly huddles. ED Manager B stated environmental rounds are done every 3 months and work orders can also be put in at that time.

On 8/22/2023 at 12:25 PM during interview with Facilities Manager G, when questioned on the process of getting repairs completed in the ED rooms, Manager G stated we "wait for work orders to go in" or "we can put them in during environmental rounds."Manager G stated they make the repairs when the work orders go in and stated they have no current work orders for repairing any walls in the Emergency Department.

On 8/23/2023 at 12:15 PM during interview with System Director of Facilities Q, during review of safety rounding summaries, when asked who is responsible for getting repairs completed in the ED rooms, Director Q stated the department leaders involved with environmental rounding are essentially responsible and stated it's "something we certainly, something that can be improved on."

Based on observation, record review and interview, the facility failed to follow policies and procedures to prevent potential transmission of Covid infections by failing to follow their isolation precautions in 1 of 1 Covid patient observation (Patient #2) in a department census of 27 Emergency Department patients during the survey.

Findings include:

Record review of policy "Standard and Transmission-based Precautions and Isolation" number 63564, revision date 10/12/2023, under types of isolation precautions #6 revealed "Combination Precautions... 1) Contact/Droplet "(N95)/ Eye Protection is used for SARS CoV" (Covid). Under Signage revealed "When a patient is placed in isolation precautions, use the sign appropriate to the isolation order."

Patient #2's medical record revealed Patient #2 presented to the Emergency Department 8/22/2023 at 9:51 AM after a fall. Patient #2 had a history of cough, a Covid test was ordered, and "Contact, droplet with N95 isolation" was ordered 8/22/2023 at 10:13 AM. Covid test came back positive at 11:05 AM. Physician note 8/22/2023 at 10:08 AM revealed patient "has had symptoms [Covid] for a week now, and so will not qualify for Paxlovid use." Patient #2 was given an albuterol treatment and discharged home 8/22/2023 at 2:33 PM.

On 8/22/2023 at 1:17 PM observed a cart with personal protective equipment (PPE) two rooms to the left of Patient #2's room (Room # 17). Patient #2's door was opened approximately 7 inches with a sign to the left of the door "Droplet & Contact Precautions," no N95 respirator noted. Patient #2's wife was sitting outside of Patient #2's door with mask on, and called for help stating Patient #2 was climbing out of bed. Registered Nurse (RN) Y went past the cart with PPE inside, into the nursing station and came back with a surgical mask on her face and entered Patient #2's room leaving the door open approximately an inch.

On 8/22/2023 at 1:22 PM during interview with ED manager B, when asked if Patient #2 had Covid, ED Manager B stated "yes." When asked if his/her door should have been kept closed to prevent transmission of Covid and if the RN should have worn a N95 mask and gown, Manager B stated s/he "was in a hurry."

On 8/22/2023 at 3:48 PM during interview with Infection Preventionist F, when asked what type of precautions are required for patients with Covid in the Emergency Department, Infection Preventionist F confirmed the patient's "door is kept closed," and airborne and contact precautions should be initiated "a N95" and a sign, identifying which type of isolation required, should be placed on the door.

Based on observation, record review and interview, facility staff failed to maintain a clean and sanitary environment free from potential sources of contamination in 24 of 27 Emergency Department (ED) rooms (ED waiting room rest room, ED waiting room, triage room 1, ED medication room, ED radiology procedure room, ED room #1, #2, #3, #4, #5, #6, #8, #11, #12, #13, #14, sink area outside room #14, #18, #19, #7, #9, #10, #15 and #20) and 1 of 1 Ultrasound Procedure Room, and failed to provide a blood spill kit for decontamination of surfaces potentially contaminated with blood in 1 of 2 departments (Emergency Department) in a total of 2 departments observed.

Findings include:

Review of Facility Policy #6842, last reviewed 09/11/2020, titled, "(System) Cleaning Inpatient Rooms and Adjoining Public Areas," revealed, "To prevent transition of communicable disease or the spread of Multidrug Resistant Organisms and pathogens by providing direction for cleaning and disinfecting areas in clinical departments and patient rooms.....8. Notification of appropriate department problems... should be documented on a daily duty sheet, reported to an EVS [Environmental Services] Supervisor or Manager, and/or a work ticket is to be submitted... #18 Upon completion of room cleaning, perform a final inspection;... d) Are any soiled areas missed?"

Review of policy "7 Step Cleaning Procedure" effective date 8/02/2022, under Damp Wiping revealed "the process... to remove visible soil and perform surface disinfection." Under Procedure, H, revealed "1. Report any area in the room that is damaged or in need of repair."

Review of checklist "Environmental Services Duty Sheet Emergency" revised date 6/09/2021, under Emergency Rooms revealed "Wipe all beds, Remove all trash, Wet mop all floors." Under Common side duties revealed "vents, spot clean walls, tables, chairs, chairs legs." Under Support Area Cleaning revealed "High/low dust, Vacume or Wet mop floor, wipe down flat surfaces, Spot clean walls if needed." Under Restroom Cleaning revealed Empty trash, clean all Fixtures, Spot clean walls as needed."

Emergency Department

Per observations on 8/22/2023 from 11:04 AM to 12:45 PM in the Emergency Department, verified by Emergency Department (ED) Manager B and Environmental Services (EVS) Supervisor, the following infection control breaches were observed:

Emergency Department rest room trash can full of paper towels, large, thick white smudges on trash can flap.

ED waiting area glass enclosing the reception area was spotted and smeared with finger prints and a cloudy residue.

Triage Room 1 with tape residue on the cardiac monitor and computer desk and visible dirt on the walls and ceiling vents.

Medication room floor with brown dirt on floor, dust and debris at floor boards.

ED radiology procedure room with visible dirt on the baseboards. Paper towel holder on sink with white thick soap residual behind holder with white scale. Anti-static cleaner wipes and peroxide cleaner with no expiration dates. Glass window in front of the technician station was smeared. A thyroid cover, used to protect a patient during a radiology test, was laying on the floor behind the linen hamper, covered in visible dust.

Emergency Department (ED) Room 1 with tape residue on the cardiac monitor and bottom of bedstand with dirt and dust, and dirt and dust noted on foot pedal to linen hamper. .

ED Room 2 with multiple areas of tape residue present on the computer desk, cardiac monitor and cupboard area.

ED Room 3 with tape residue on the cardiac monitor.

ED Room 4 with multiple areas of tape residue present on the cardiac monitor, computer desk and visible dirt present on the bottom of the bedside table..

ED Room 5 with multiple areas of tape residue present on the cardiac monitor, computer desk, cupboards and drawers and dirt and dust noted on foot pedal to linen hamper.

ED Room 6 with 2" X 5" plastic wrap on floor and tape residue on the cardiac monitor.

ED Room 8 with tape residual on the cardiac monitor, cupboards and computer desk and a white, raised residual around the sink area.

ED Room 11 with peeling tape on the cupboards, laptop desk, and cardiac monitor and visible dirt on the ceiling vents and ceiling.

ED Room 12 with multiple areas of tape residue on the computer desk and cardiac monitor.

ED Room 13 with tape residue on the monitors, computer table, and intravenous (IV) pump and visible dust on the ceiling and ceiling vent.

ED Room 14 with tape residue on computer cart and cardiac monitor.

The sink and cupboard area located by Room 14 in hallway with tape residue, peeling pieces of labels on the cupboards and drawers, and visible raised hard water stains around the sink faucet.

ED Room 18 with tape residue on the cardiac monitor and counter by sink and dried dark red flecks on edge of hanging plastic drape.

ED Room 19 with dust and dirt on bottom of stand and wheels of the blood pressure machine.



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Per observations on 08/22/2023 at 3:00 PM in the Emergency Department (ED) room, verified with ED Manager B during observation, noted the following:

ED Room 7 with white residue around the sink, tape residue and peeling tape on the cupboards, computer desk and cardiac monitor,

ED Room 9 with white, rough, removable residue present on the sink faucet, peeling tape on the cupboards, door handles, computer desk, and cardiac monitor, dust on the ceiling and ceiling vents, and visible dust on the intravenous (IV) pump pole and computer base.

ED Room 10 with tape residue on the cupboard, computer desk and cardiac monitor. Visible dirt was present on the wall behind the sink.

ED Room 15 with tape residue on the cardiac monitor, computer desk, and the sink counter.

ED Room 20 with tape residue on the cardiac monitor and computer cart. Three pieces of paper were taped on inside door window with one edge hanging down.

During an interview on 8/22/2023 at 10:23 AM with ED Manager B, when asked if the tape residue should be removed with cleaning, Manager B stated, "I don't know how they [housekeeping] clean, I can't answer that."

During an interview on 8/22/2023 at 10:46 AM with EVS Supervisor E, when asked if housekeeping removes tape residue during room cleaning, Supervisor E stated, "if they get a work order."

On 08/22/2023 at 12:00 PM in an interview with Infection Preventionist F when asked what nationally recognized infection control standards are followed, F stated, "We follow the CDC (Centers for Disease Control)."

During an interview with EVS Staff M on 8/22/2023 at 3:00 PM during observation of room cleaning, Staff M stated, "I try to do a base clean every time, surface clean the equipment, it's hard to keep up. Once a patient is discharged, I'm in the room cleaning. " When asked who removes the tape residue, or fixes repairs that are needed, M stated, "It's not my primary focus to remove the adhesive, I do it if I come across it, anyone can put in a ticket for maintenance."

Radiology Department

On 8/22/2023 at 12:30 PM during tour of Ultrasound procedure room with Ultrasound Technician (US tech) X, observed container of disinfection wipes with no expiration date.

On 8/22/2023 at 12:30 PM during interview with US tech X, X stated they are responsible to clean between patients and to check expiration dates of their cleaning supplies. X stated they had just had a mock drill where missing expiration dates were noted and stated "I'm not sure why they didn't write the expiration date on the container", they told us "the wipes use date had not expired."

Blood Spill Kit

On 08/22/2023 at 3:30 PM in an interview with ED Manager B when asked where the blood spill kit was located in the department, Manager B stated, "There is no blood spill kit in the department." When asked what would happen if there was a blood spill, how would you know what to do, B stated, "I would need to look at the policy."

On 08/22/2023 at 3:42 PM during interview with Director of Quality D, Director D confirmed they "have no" blood spill policy.

On 8/23/2023 at 12:15 PM during interview with System Director of Facilities Q, during review of safety rounding summaries, when asked who is responsible for doing the rounding inspections and ensuring a sanitary environment in the ED and Radiology Departments, Director Q stated the department leaders involved with environmental rounding are essentially responsible and stated it's "something we certainly, something that can be improved on."

Based on record review and interview, the facility failed to provide competency-based training, orientation and education on the practical applications of infection prevention and control guidelines in cleaning the emergency department rooms or cleaning blood spills in 6 (Staff A, I, J, K, W and X) out of 7 personnel training records reviewed.

Findings include:

Review of facility policy #69620, last reviewed 05/03/2023, titled, "(System) Competency Assessment.," revealed, "I. Purpose: To provide a measurable process for the assessment of a teammate's knowledge (critical thinking), skills (technical), abilities and behaviors (interpersonal) necessary to fulfill their role....Policy: A. Initial Competency 1. Initial Competency is verified and documented before a teammate completes orientation and practices independently..V. Procedure:...1. The direct supervisor is accountable for ensuring completion of initial and ongoing competencies for each role within their span of control.. B. Orientation/Onboarding: 1. Each teammate completes an Initial....Skills Checklist for skill validation prior to independently performing skills. 2. Initial Competence: a) at a minimum, at the end of the new teammate orientation period......the new teammate will have completed: (1) Initial competency verification related to their role and responsibilities...C.Ongoing Competence...2. A competency documentation tool is to be created for each competency, clearly identifying the purpose, methods, performance expectations, and critical behaviors necessary."

During an interview on 08/22/2023 at 12:30 PM with ED RN J, when asked if there were times that EVS wasn't available, J stated, "Yes, there are some times where nursing staff needs to clean the rooms." When J was asked if they had received training in how to clean patient rooms, J stated, "No."

During an interview with ED Tech I on 08/22/2023 at 12:45 PM when asked who is reponsible for cleaning ED patient rooms, ED Tech I stated, "It depends, most of the time it is housekeeping, if they are on break then it will be the RN's and Tech's." When asked how Tech I was trained to clean rooms, Tech I stated, "I was shown by other staff, there was no specific training."

On 08/22/2023 at 3:30 PM in an interview with ED Manager B when asked where the blood spill kit was located in the department, Manager B stated, "There is no blood spill kit in the department." When asked what would happen if there was a blood spill, how would you know what to do, B stated, "I would need to look at the policy."

On 08/22/2023 at 3:35 PM in an interview with ED RN O when asked what would you do if there was a blood spill, O stated, "I don't know."

On 08/22/2023 at 3:42 PM during interview with Director of Quality D, Director D confirmed they "have no" blood spill policy or competency.

On 08/23/2023 at 08:20 AM during review of personnel files with Human Resource (HR Director H, there was no evidence of orientation provided to staff in how to clean patient rooms following infection control standards for Ultrasound Tech A, ED Tech I, ED Registered Nurse J, Radiology Tech K, Registered Nurse W and Ultrasound Tech X. These findings were confirmed by HR Director H.

In an interview on 08/23/2023 at 9:30 AM with EVS Supervisor E, when asked who does the training on how to clean ED patient rooms, E stated, "EVS doesn't do the training for nursing for cleaning rooms."

In an interview with Director of Imaging Services T on 08/23/2023 at 9:40 AM, T stated during orientation staff receive a general orientation to each room and are educated on universal precautions. EVS doesn't touch the room between patients, it is up to the tech to ensure that surfaces are clean and this is taught by the preceptor."

In an interview on 08/23/2023 at 10:00 AM with HR Director H, when asked to confirm that there was no documentation or orientation completed for cleaning patient rooms, H stated, "That is my understanding."

In an interview on 08/23/2023 at 11:30 AM with Regulatory Coordinator C, stated, "We do not have a policy on EVS orientation of room cleaning." Nurses and technicians do not have an orientation or specific training on cleaning patient rooms, "for room cleaning they would follow the policy, we don't do a competency on it, they see one, do one, teach one, there isn't a competency sign off."

In an interview on 08/23/2023 at 12:05 PM with Infection Preventionist F, F stated, "We follow APIC (Association for Professionals in Infection Control) and CDC (Centers for Disease Control) standards, Training on how to disinfect rooms, is not my role, that is EVS. We do rounding on these rooms, but it is a snapshot in time. If staff are not trained in cleaning a room, they shouldn't be cleaning a room. It's a collaborative effort between the ED and EVS Manager."

In an interview on 08/23/2023 at 1:15 PM with Regulatory Coordinator C, during review of the annual safety education provided to staff, when asked to show where the education on the environment of care and infection control was, C stated, "There is nothing there on the environment of care in the yearly education for staff."