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Based on random observation, testing, and interview, the provider failed to ensure the following areas and items were maintained cleanable, in good repair, and in a safe condition:
*Two of two housekeeping closet shelves (basement and first floor) were not cleanable.
*Twenty-three of twenty-three Christmas stockings were tied to the handrails on second floor.
*One of three floor mop sinks (second floor) was dirty and uncleanable.
*One of two shower chairs (main shower) had starburst cracks around the two bolts in the seat of the plastic chair.
*Five of five Rejuvnal disinfectant spray bottles were stored intermingled with patient hygiene products in the main shower.
Findings include:

1. Observation on 12/9/14 from 1:15 p.m. to 4:15 p.m. revealed:
a. The particle board shelf in the basement housekeeping closet was deteriorated, warped, and splintered. The plywood shelf in the first floor housekeeping closet was unsealed, splintered, and stained. Interview with the director of plant operations at the time of the above observations confirmed those findings.
b. Twenty-three Christmas stockings were tied around the handrails on both sides, the entire length of the hall, on the patient floor. By gliding a hand along the handrails it was found those stockings and tied ribbons were an entanglement for those patients who would use the handrails. Interview with the director of plant operations at the time of the above observations and testing confirmed those findings.
c. The second floor mop sink in the housekeeping closet was made from formed concrete. The concrete had become almost black from stains and imbedded dirt. White paint that had once covered the concrete had chipped away and only remained on approximately one third of the surface. Interview with the director of plant operations at the time of the above observation confirmed that finding.
d. The tan shower chair in the main shower had starburst cracks the size of quarters. When finger pressure was applied to those cracks they would open and close. Interview with the director of plant operations at the time of the above observation and testing confirmed that finding.
e. Five Rejuvnal disinfectant spray bottles were stored intermingled with bathing and hygiene products in the main shower on the patient floor. Those items included shampoo, hair conditioner, lotion, body wash, soap, and barrier cream soap. Interview with the director of plant operations at the time of the above observations confirmed those findings.

Continued interview with the director of plant operations revealed he was also over environmental services. He stated he did not have a preventive maintenance for environmental concerns or small repairs. He stated he relied on other staff to fill out a work order for his department. He had asked the different departments to compile a quarterly report of environmental concerns and repairs needed for their department. He stated he thought the last reports for each department had been in March 2013. He had asked for the reports to be discontinued as he did not have time to log the work orders needed for each department into the system.

Review of a quarterly inspection for plant operations completed on 3/6/13 by the operating suite revealed forty-nine items were listed on that report. The director of plant operations could not confirm if all those items had been corrected or repaired. He stated neither he nor the department kept track of each work order that had or had not been completed. He did not reply back to the departments if the work order had been completed.

He also stated the director of nursing would have been responsible for the Christmas stockings and the main shower room. He would let her know about the concerns.

20031

A. Based on random observation, testing, label review, and interview, the provider failed to ensure the following areas/items were maintained, cleanable, and/or in good repair:
*One of one shower cap and the three of three packages of shower caps were dirty.
*Two of three commodes in the soiled utility were visibly soiled.
*Three of three housekeeping carts had soiled and stained carpet on top of the carts.
Findings include:

1. Observation on 12/8/14 from 2:00 p.m. to 4:45 p.m. revealed:
a. A small plastic caddy sat on the window ledge in the main shower room. That caddy was layered with dust, sticky debris, and unidentified stains. The three packages of shower caps inside that caddy were also soiled and sticky. Interview with the director of plant operations at the time of the above observations confirmed those findings.

Interview on 12/10/14 at 2:25 p.m. with the director of nursing (DON) revealed she was not aware the staff were not keeping the main shower room clean.

b. Three commodes were stored in the soiled utility room on the patient floor. Two of those commodes were still visibly soiled with what appeared to be fecal matter and urine drops. Interview with the director of plant operations at the time of the above observations confirmed those findings.

Interview on 12/10/14 at 2:25 p.m. with the DON revealed her staff were responsible to clean the commodes after each use. She stated it was then housekeeping's responsibility to thoroughly clean the commodes before they were placed in storage.

c. A housekeeping cart was stored in the housekeeping closet on the patient floor. Closer observation of that cart revealed carpet had been glued onto the top of the cart. That carpet was dirty, soiled, and had embedded debris in it. Interview with the director of plant operations at the time of the observation confirmed that finding. He stated all three carts had glued carpet on the top. They were also very dirty and stained. He agreed the carpet was not a cleanable surface.

B. Based on observation, interview, document review, and label review, the provider failed to ensure the disinfectant used throughout the facility was used in according to manufacturer's recommendations. Findings include:

1. Observation on 12/9/14 at 2:55 p.m. revealed there was directional signage posted in the cardiac rehabilitation therapy room for disinfection of the equipment. The signage was for use of PDI disinfection wipes. A spray bottle labeled as Rejuvnal (a disinfectant) sat on a ledge in the room next to a pile of dry blue rags. On another shelf a bucket labeled as Rejuvnal had wet blue rags in it. Interview with the director of plant operations at the time of the above observations confirmed those findings. He stated he thought the therapy staff educated the patients on use of the Rejuvnal spray to disinfect the equipment before and after use. He was not aware there were directional signs for another disinfection product.

Observation on that same day at 3:10 p.m. revealed several other spray bottles of Rejuvnal throughout the physical therapy (PT) suite. In conjunction with those spray bottles were piles of dry blue rags, buckets labeled with Rejuvnal and wet blue rags inside those buckets.

Interview with PT aide B at the time of the observation confirmed the above findings. She stated they offered instructions to the patients on how to use the spray bottles for disinfection of the equipment. She revealed the spray was offensive to most of the patients, so she told them to spray the rags with disinfectant and then wipe it on the equipment. She was not aware of the required amount of time the surface must remain wet to meet the manufacture's required contact time for disinfection.

Continued interview with the director of plant operations at that time revealed he was also over environmental services. Rejuvnal was used throughout the hospital as a disinfectant. He stated he was also unaware of the required amount of contact time required by the manufacturer for that chemical. He stated they were in the process of changing out suppliers as there were a lot of different disinfectants used throughout the hospital.

Surveyor 26632:
Interview on 12/10/14 at 1:00 p.m. with the infection control officers revealed:
*They had just taken over the infection control duties in October 2014.
*They had a meeting set-up with the new environmental supervisor to review products and procedures for cleaning and sanitation.
*They were aware there were different products used by different departments.
*They agreed not all staff were aware of the contact time for all the different sanitizing products.

Review of the manufacturer's guidelines and recommendations revealed the product must remain wet for up to ten minutes.

Review of the cleaning solutions policy dated February 2010 revealed:
-All cleaning supplies and chemicals will be used according to manufacturer and department guidelines.

Review of an undated provider chemical list for environmental services revealed:
*"Disinfectants:
--3M 25-quaternary (quat).
--Rejuvnal-quat.
--Dispatch-(C.diff) Bleach based.
--Clorox Germicidal Bleach wipes (C.diff).
--PDI wipes-quat."

Review of infection prevention committee meeting minutes dated 5/5/14 revealed:
*"Topic: Steriplex wipes. Findings/Conclusions:
-New; coverage included spores.
-Recommendations/Actions: Use for all surface cleaning. Responsible party: no one was listed.
-Follow-up: no date or person was listed."

C. Based on observation, testing, and interview, the provider failed to ensure the following areas/items were maintained, cleanable, and not recontaminated:
*One of one towel used to line the bottom of the endoscope cabinet in the procedure room.
*Two of two sponges used to cover the tips of the endoscopes in the endoscope cabinet in the procedure room.
*Four of four drying rack shelves for the sterilized instruments in central sterilization.
*Various plastic (frosting and whip cream containers, bowls, and cubbies) and cardboard (boxes) single-use items in two of two operating rooms.
Findings include:

1. Observation on 12/9/14 from 9:15 a.m. to 10:35 a.m. of the surgical and procedural suite revealed:
*A towel was used to line the bottom of the endoscope cabinet. Interview at the time of the observation with the director of the operating room (OR)confirmed that finding. She stated they lined that cabinet to catch possible drips. She stated they never changed the towel or had a timeframe to change out the towel. Continued interview with the surgical technician (tech) at that same time confirmed that finding. The surgical tech stated they used the 2014 Association of periOperative Registered Nurses (AORN) standards and recommended practices and guidelines for reference in the OR area.
-Review of the 2014 AORN guideline for storage cabinets revealed they should be cleaned and disinfected when visibly soiled and on a weekly or monthly schedule.
*Two blue cleaning sponges were used to cover the tips of two scopes that hung inside the cabinet. Interview at the time of the observation with the director of the OR confirmed that finding. They had used the sponges to cover the tips of the scopes to ensure the fiber optics were not damaged. She stated those sponges were reused for covers and kept in the cabinet to keep clean. She had not considered the fact that those two sponges had been treated and injected with an enzymatic cleaner that might have contaminated the ends of the scopes.
*A metal rack with four wooden doweled shelves was stored by the sterilizer. Those dowels were worn to the touch. The original clear coating had been worn off those dowels from continual use. Interview at the time of the observation with the director of the OR and surgical tech confirmed that finding. They stated they used those racks for additional dry time from the sterilizer. They had not realized the wooden rack was no longer a cleanable surface.
*Various plastic frosting and whip cream containers and other pre-used plastic containers were used for storage throughout the OR and procedural suite. In addition cardboard boxes were re-used for storage in OR one and two. Interview at the time of the observations with the director of the OR and surgical tech confirmed those findings. They stated they had thought they could re-use those plastic items as there were cleanable. They were not aware the plastic and cardboard items were single-use items and only were intended for the storage of the original contents.

Interview on 12/10/14 at 11:30 a.m. with the director of the OR revealed she had no specific policies for the endoscope storage cabinet. She stated she had used the manufacturer's guidelines for training purposes.

D. Based on interview, observation, and document review, the provider failed to use a disinfection process for co-mingled hospital laundry. Findings include:

1. Interview on 12/9/14 at 1:30 p.m. with the director of plant operations revealed he was in charge of the laundry personnel. He stated the facility laundered housekeeping mops and rags with bleach. He stated they would also launder individual personal clothing for swing bed patients. If an employee's clothes became grossly soiled while at work, they would also launder those items separately. He stated all other items were laundered by the contract laundry service.

Observation on that same day at 3:30 p.m. revealed an undated note pinned to the patient floor soiled linen bag. That bag held scrubs, towels, and gait belts. The note gave the following directions:
"Please use this linen bag for any items we launder here; 'Pink' scrubs, green scrub pants (or any other odd color with elastic waists), gait belts, white towels, 4X or 5X scrubs top/bottoms (these are difficult to get from RC). Anything sent to RC will not come back!! Thank You, Environmental Svc (Services)."

Review of the soiled linen handling policy dated April 2010 revealed:
*Soiled linen should have been removed to the soiled linen room daily and then picked up by the contract laundry service.
*Soiled linen was removed from all areas of the hospital and placed into a hamper bag in each area.

Review of an undated provider chemical list for environmental services revealed:
*"Laundry:
-Betco Simplicity Detergent - laundry soap.
-Clorox Ultra Bleach concentrate - 1/2 cup/wash load.
-Hydrogen Peroxide - laundry per-wash for blood/protein stains.
-Purex Color Safe Bleach."


E. Based on observation, interview, and policy review, the provider failed to comply with proper hygiene and food handling practices in one of one main kitchen as evidenced by the following:
*Re-use of single-use items.
*Storage and dispensing of ready-to-eat (RTE) foods.
*Improper handwashing and glove application.
Findings include:

1. Observation on 12/8/14 from 2:30 p.m. to 4:00 p.m. and on 12/9/14 from 11:15 a.m. to 11:45 a.m. revealed:
a. The kitchen and cafeteria had reused the following single-use items:
-Large one gallon plastic mayonnaise jugs were used to make ice tea.
-Cardboard had been cut to use for dividers in the condiment packages and coffee additives trays.
-Interview with the certified dietary manager (CDM) at the time of the observations confirmed those findings. She stated she did not realize single-use items could not be used again.
b. The cafeteria line and laboratory waiting area had the following RTE items displayed incorrectly:
-Apples were unwrapped.
-Bagels, English muffins, whole wheat bread, and cookies were left inside the original packages and not repackaged for individual selection. The inside of the bags could become contaminated.
-Interview with the CDM at the time of the observations confirmed those findings. She stated she had not realized the possibility of contamination by the public.
c. Handwashing observation of cook A revealed she had removed her gloves and a glove still remained on her left hand. She stated she had cut her hand early that morning and had bandaged the cut and then applied a glove. She then double-gloved when gloves were needed in the kitchen. But when handwashing was required she would leave the original glove on her hand to protect her wound.
-Interview on 12/9/14 at 11:45 with the CDM revealed she was not aware cook A had washed her gloved on her bandaged hand. She stated gloves were not to be reused and definitely not washed.

Review of the handwashing policy dated December 2011 revealed:
-B. Hand Care. 1.c. Covering all cuts and sores with Band-Aids and plastic gloves.
-C. Gloves. 2.a. Wash hands before putting on gloves and when changing into a fresh pair of gloves.

No policy was provided for re-use of single-use items or packaging and display of RTE foods.

Based on record review and interview, the provider failed to follow the utilization review plan to ensure the services provided an efficient use of resources. Findings include:

1. Review of the provider's revised 11/20/14 Utilization Review Plan and signed by the hief of taff and the chief executive officer (CEO) on 12/2/14 revealed:*The medical staff would conduct peer review of medical care.
*The approved screening criteria included re-admissions, observation stays, one day stays, and admissions not meeting Centers for Medicare/Medicaid Services (CMS) approved medical necessity criteria.
*The medical staff should review and approve criteria for the necessity of admission and continued stay.
*The utilization review (UR) medical doctor and the UR reviewer might recommend strategies or actions designed to improve the efficient use of hospital resources.
*All recommendations would be submitted to the performance improvement committee.
*Medical care evaluation would be completed by the medical staff.
*A summary of the number and types of cases reviewed and ongoing evaluation for length of stays for medical specialties would be part of the peer review.

Review of the provider's Physician Peer Review documents from January 2013 through September 2014 revealed:
*January 2013 through March 2013 five physician peer reviews and one mortality review had been completed.
*April 2013 through June 2013 seven physician peer reviews and four mortality reviews had been completed.
*July 2013 through September 2013 four physician peer reviews and three mortality reviews had been completed.
*October 2013 through December 2013 one physician peer review and three mortality reviews had been completed.
*January 2014 through March 2014 five physician peer reviews and four mortality reviews had been completed.
*April 2014 through June 2014 one physician peer review and three mortality reviews had been completed.
*July 2014 through September 2014 one physician peer review and one mortality review had been completed.
*Those above reviews included leaving against medical advice from the emergency department, dissatisfaction of care, re-admissions, and deaths.

Review of the provider's Medical Staff Meeting minutes from January 2014 through October 2014 revealed no review of the physician peer or mortality reviews.

Review of the provider's Quality Assurance Performance Improvement minutes from January 2014 through October 2014 revealed no review of the physician peer or mortality reviews.

Interview on 12/9/14 at 9:00 a.m. with the CEO revealed she:
*Agreed parts of the UR plan had not been followed.
*Was not aware the UR had not been discussed at the medical staff meetings.
*Agreed there was room for improvement with the UR.