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Based on observation, interview, record review and policy review, the facility failed to ensure that staff:
-Maintained sterile technique (free from germs) in operating room (OR) #3 during the pre-surgical instrument set up for one patient (#9) of three patients observed.
-Maintained a clean environment in the processing and decontamination room (a dedicated area where reusable equipment, instruments and supplies are cleaned and decontaminated by means of manual or mechanical cleaning processes and chemical disinfection), which processed instruments used in all four OR suites.
-Maintained aseptic technique when placing medical tape on one of two patients' (#17) bedside table (contaminated inanimate object) and then placing the tape directly on one patient's peripheral intravenous (IV,a short, plastic tube inserted into a small vein for the purpose of the administration of medications, fluids and/or blood products) site.
-Utilized proper hand hygiene technique during wound care dressing change for one patient (#19) of two wound care dressing changes observed.
- Utilized proper hand hygiene technique during medication administration for one patient (#13) of five patient medication administrations observed.
- Properly dated IV tubing with a "change tubing" date for one IV tubing observed on patient (#1) of one IV tubing currently utilized on the Geriatric (patients older than 55 years of age) Psychiatric Unit.
- Maintained the floor on the Geriatric Psychiatric Unit in a clean manner or condition that would facilitate a cleanable surface. The Geriatric Psychiatric Unit census was 26.
- Cleaned one of one dirty pill crusher.
- Replaced soiled/stained ceiling tiles in three of three areas (sterile processing room, Emergency Department and Wound Care Clinic.)
- Disposed of outdated food.
-Properly transported clean linens.
These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The facility census was 96.

The severity and cumulative effect of these systemic failures resulted in the facility being out of compliance with 42 CFR 482.42 Condition of Participation: Infection Control.

Please see citation A 0749 for details.

Based on observation, interview, record review and policy review, the facility failed to ensure that staff:
-Maintained sterile technique (free from germs) in operating room (OR) #3 during the pre-surgical instrument set up for one patient (#9) of three patients observed.
-Maintained a clean environment in the processing and decontamination room (a dedicated area where reusable equipment, instruments and supplies are cleaned and decontaminated by means of manual or mechanical cleaning processes and chemical disinfection), which processed instruments used in all four OR suites.
-Maintained aseptic technique when placing medical tape on one of two patients' (#17) bedside table (contaminated inanimate object) and then placing the tape directly on one patient's peripheral intravenous (IV,a short, plastic tube inserted into a small vein for the purpose of the administration of medications, fluids and/or blood products) site.
-Utilized proper hand hygiene technique during wound care dressing change for one patient (#19) of two wound care dressing changes observed.
- Utilized proper hand hygiene technique during medication administration for one patient (#13) of five patient medication administrations observed.
- Properly dated IV tubing with a "change tubing" date for one IV tubing observed on patient (#1) of one IV tubing currently utilized on the Geriatric (patients older than 55 years of age) Psychiatric Unit.
- Maintained the floor on the Geriatric Psychiatric Unit in a clean manner or condition that would facilitate a cleanable surface. The Geriatric Psychiatric Unit census was 26.
- Cleaned one of one dirty pill crusher.
- Replaced soiled/stained ceiling tiles in three of three areas (sterile processing room, Emergency Department and Wound Care Clinic.)
- Disposed of outdated food.
-Properly transported clean linens.
These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The facility census was 96.

Findings included:

1. Record review of the facility's policy titled, "Operating Room Sanitation," dated 06/2016, showed that OR personnel must establish and maintain a clean environment to reduce the possibility of cross infection among surgical patients.

2. Observation and concurrent interview on 08/09/16 at 11:00 AM in OR #3, showed staff transported two instrument bins through a hallway into the surgical suite. Staff J then removed the lids from both bins, and placed the lids top side down on the surgical bed. Staff J stated that she knew that nothing should be placed on the patient's bed, but she was nervous.

When staff transported the instrument bins through the hallway, the outside of the lids were exposed to the environment. Staff J contaminated the surgical bed when she placed the non-sterile lid tops onto the bed.

During an interview on 08/09/16 at 1:30 PM, Staff I, Manager of the OR, stated that laying lids on the patient's bed is not their proper process. She expected the nurses to maintain a sterile environment.

During an interview on 08/10/16 at 10:00 AM, Staff D, Infection Control Coordinator, stated that he did not approve of staff 's practice to lay the top of an instrument tray on the operating room bed prior to the patient being brought to the room. He stated, " I can't defend that."

3. Record review of the facility's policy titled, "Packaging and Storage of Sterile Instruments and Supplies," dated 06/2016, showed that all items packaged for sterilization must be processed in an aseptic environment (used to reduce the chance of contamination from disease producing germs.)

4. Observation on 08/10/16 at 12:50 PM in the processing room across from the surgical suites showed that instruments were being processed and packaged in a contaminated environment. The room was cluttered and unclean and included:
-Rust on a ceiling tile;
-A quarter size hole in the ceiling;
-Bottom shelf of metal cart used to store instruments was dirty and rusted;
-Counter was cluttered;
-Inside ledge of cabinet was dirty with a dried spill; and
-Multiple reference books above processing work space.

During an interview on 08/10/16 at 12:55 PM, Staff Z, Instrument Technician, stated that
he wiped counters down daily and that housekeeping did a terminal (disinfecting all surfaces that can be touched) clean daily.

During an interview on 08/10/16 at 3:25 PM, Staff O, Director of Environmental Services, stated that the processing room was terminally cleaned daily. He stated this included all equipment, lights and anything that can be touched.

During an interview on 08/10/16 at 3:40 PM, Staff AA, Housekeeper, stated that she does not terminally clean the processing room. She stated that she took out the trash, mopped and wiped the counters.

5. Observation on 08/10/16 at 10:50 AM in the decontamination room across from the surgical suites' showed:
-Ultrasonic washer (a device used to clean surgical instruments) had residue inside and on lid;
-Ultrasonic washer had rust on the lid hinges; and
-Two cabinet doors were rusted.

Record review of the maintenance record for the Ultrasonic washer showed that the last maintenance was on 05/03/16 which did not include cleaning of the device.

During an interview on 08/10/16 at 2:40 PM, Staff I, OR Manager, stated that the Ultrasonic washer was cleaned weekly and she was unaware of the rust on the cabinet doors in the decontamination room. She also stated that she expected the processing room to be terminally cleaned daily.

6. Record review of the facility's policy titled, "Intravenous Therapy: Peripheral Vascular Access," dated 05/2012 showed that the nursing guidelines for placement of peripheral IV's is to maintain aseptic technique through the procedure.

7. Observation on 08/10/16 at 9:34 AM, in the preoperative area, showed Staff Y, RN placed six pieces of medical tape on a contaminated bedside table, prepared Patient #17's IV site with alcohol, inserted the IV, then retrieved the medical tape from the contaminated bedside table and placed the tape on the patient's IV site.

During an interview on 08/10/16 at 9:47 AM, Staff Y stated that it is a normal process for her to place the tape on the patient's bedside table.

During an interview on 08/10/16 at 2:42 PM, Staff I, OR Manager stated that she expected RN's to tear individual pieces of tape instead of placing them on the bedside table.

8. Record review of facility policy titled, "Infection Control," dated 08/2016 showed the directive for staff to perform hand hygiene:
- After removing gloves;
- After contact with body fluids, excretions and wound dressings; and
- After contact with inanimate objects.

Record review of the facility policy titled, "Medication Administration," dated 07/2014, showed the directive for staff to gather all equipment and perform hand washing prior to medication administration.

9. Observation in the Wound Care Clinic, on 08/11/16 at 9:15 AM showed Staff FF, RN, in Patient #19's treatment room to change a wound dressing. Staff FF cleansed her hands, put on gloves, removed old dressing from coccyx area (tailbone, just above rectum), cleansed the wound then cleaned a large amount of soft stool from the rectal area. Staff FF then removed the soiled gloves, put on new gloves and placed a new dressing on the wound. Staff FF failed to perform hand hygiene after she removed soiled gloves and before she put on clean gloves.

During an interview on 08/11/16 at 9:25 AM, Staff FF stated, "I always clean my hands when I change gloves and I change gloves often, but, I must have forgotten because I was intent on getting that new dressing on."

During an interview on 08/11/16 at 9:35 AM, Staff E, Chief Nursing Officer (CNO), stated that Staff FF told him that she realized she hadn't cleaned her hands the minute she put the new gloves on.

10. Observation on the Fourth Floor Psychiatric Unit Nurses Station, on 08/10/16 at 9:35 AM showed Staff P, RN, prepared to administer medications to Patient #13. Staff P typed on the keyboard to display the patient's medications. Staff P scanned (hand held electronic device used to read bar codes) the patient's identification band and each one of the six individually packaged medications that were about to be administered. Staff P again typed on the keyboard to indicate that the medications were administered. Staff P opened the packages and placed the pills in a medication cup; three of the pills had to be removed from the package with Staff P's bare fingers. Staff P failed to clean his hands after he touched inanimate objects (keyboard, scanner), and before he touched medications.

During an interview on 08/10/16 at 9:45 AM, Staff P stated that he knew he should have clean his hands before he touched the medications. Staff P stated, "I guess I wasn't paying attention."

During an interview on 08/10/16 at 10:45 AM, Staff B, RN, Psychiatric Unit Nurse Manager, stated that she also saw Staff P touch the pills with his bare fingers, without his hands being cleaned. Staff B stated, "That's not the way we teach them (nurses)."

11. Record review of facility policy titled, "Intravenous Therapy: Peripheral Vascular (catheters typically placed in the hand/arm to provide a direct route into the vein) Access," dated 05/2012, showed directive for staff to:
- Change tubing every 96 hours;
- Label the tubing with a sticker to notify when tubing is due to be changed; and
- Place the nurses' initials on the sticker.

12. Observation in the Geriatric Psychiatric Unit Day Room on 08/09/16 at 10:15 AM showed Patient #1 seated in a wheelchair with 0.45% Normal Saline (a fluid containing minerals) being infused. The tubing that takes the fluid to the IV catheter (device that allows the fluid to enter the vein) was not labeled with a sticker to identify when the tubing should be changed. While the surveyor stood there, Staff A, RN, went to the tubing and put a piece of tape with the date of 08/08/16 and a time of 2:00 PM around the tubing. No nurse initials were present on the tape.
Failure to change the IV tubing could place the patient at risk for a blood or skin infection.

During an interview on 08/09/16 at 10:30 AM Staff A stated that she remembered that she had changed that tubing yesterday at 2:00 PM and forgot to label the tubing. When asked if it should be labeled with the date the tubing should be discontinued, Staff A stated that the RN's put the date that the tubing was being changed on the label and she forgot to put her initials on the tape.

During an interview on 08/09/16 at 10:45 AM Staff B, RN, Psychiatric Unit Nurse Manager, stated that she saw the RN place the tape on the tubing while we stood there. Staff B stated that she wasn't sure if the start or discontinue date should be on the label. Staff B stated, "I would have to check, we don't use IV's very often on this unit."

13. Observation in the Geriatric Psychiatric Unit Day Room on 08/09/16 at 10:15 AM showed a large room (about 20 feet by 30 feet) with six tables and many chairs. The floor in this area looked dirty. Upon closer inspection, the floor had at least twelve areas where there were circular black marks about one inch by one inch. The marks could not be removed by hand and appeared to be ground into the tile or the top surface of the tile had been worn away to a black underlayment (the bottom part of a tile). There was a one inch by three inch area where the tile had been crushed about a half inch down, which caused the integrity of the tile to be destroyed (not a continuous surface). The floor had at least 12 black scuff marks, each at least ten inches long. There was also a three by four inch black area where the tile had worn away and the sub floor showed.
These failures rendered the floor to be unable to be cleaned properly.

During an interview on 08/09/16 at 10:45 AM Staff B stated that the floor had a lot of wear. Staff B stated that some patients spend most of their time in this area. It was where groups were held, where the patients received their medications, where they got their meals, and where they socialized. Staff B stated that the floor was cleaned regularly but the floor gets so much use it did get messy.

During an interview on 08/09/16 at 1:30 PM Staff O, Environmental Service (EVS- Housekeeping) Director, stated that the floor in this area was mopped every day and deep cleaned/scrubbed twice a week (Wednesday and Sunday). Staff O stated that some areas of the floor were unable to be cleaned properly because of the damage. Staff O stated that the floor was difficult to keep clean because of the amount of time the patients spend in the area.

14. Observation in the Geriatric Psychiatric Unit Medication Room on 08/09/16 at 9:55 AM showed the pill crusher to be visibly soiled. The hinged area of the crusher (about four inches away from where the pills would be placed to be crushed) had a black, dusty substance built up around the hinge.

During an interview on 08/09/16 at 10:00 AM, Staff B stated that the pill crusher did look dirty. Staff B stated that that there was no schedule for it to be cleaned; someone would clean it when it looked dirty.

Even though requested, the facility failed to provide a policy related to cleaning pill crushers.

15. Observation on 08/09/16 at 2:00 PM in the Emergency Department (ED) clean storage room showed a two feet by four feet ceiling tile that was approximately 20% soiled with a dried, rust colored stain. The room contained a wide variety of sterile supplies.

During an interview on 08/09/16 at 2:30 PM Staff W, RN, ED Manager, stated, "I'm not sure what caused that or how long it has been there."

16. Observation on 08/11/16 at 9:45 AM in the Wound Care Clinic hallway, near the nurses station, showed a two feet by four feet ceiling tile soiled with a circular wet spot about one foot wide.

Even though requested, the facility failed to provide a policy related to surveillance/replacement of ceiling tiles.

17. Record review of the "United States Department of Health and Human Services Food Code," dated 08/2015, stated that a food shall be discarded if the food is not consumed before the expiration date.

Record review of the facility's policy titled, "Food Supply and Storage Procedures," revised 08/2014, directed staff to discard unused portions of food not utilized within 48 hours.

18. Observation on 08/10/16 at 1:30 PM in the facility kitchen cooler showed a tray of roast beef dated 08/06/16 and a tray of pork dated 08/06/16.

During an interview on 08/10/16 at 1:30 PM, Staff CC, Dietary Manager, stated that the roast beef and pork found in the cooler was a violation of their policy and should have been removed.

19. Record review of the facility's policy titled,"Isolation Room Cleaning," revised 2016, directed staff that the expectation is for the housekeeper to keep clean linen at a safe distance (from body/uniform) so as not to come in contact with it.

20. Observation on 08/10/16 at 12:50 PM on the Medical-Surgical Unit showed Staff BB, EVS, on two separate occasions brought linen to a room that had recently been cleaned and carried the linen against her chest/uniform.

During an interview on 08/10/16 at 12:55 PM, Staff BB, stated that she realized she had placed the linens up to her chest next to her uniform and said,"I normally wouldn't do that."

During an interview on 08/10/16 at 1:00 PM, Staff O, EVS Director, stated that he agreed that clean linen placed against the uniform was not the expectation for staff.










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