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Based on observation, interview and policy review, the hospital failed to:
- Prepare a clean work surface prior to performing patient care for two current patients (#5 and #16) of 13 patients observed;
- Cleanse the intravenous (IV, in the vein) tubing port prior to IV medication administration for one current Operating Room (OR) patient (#16) of one OR patient observed;
- Perform hand hygiene (wash hands with soap and water or hand sanitizer) and glove changes during patient care for one current OR patient (#16) of one OR patient observed;
- Perform hand hygiene and glove changes for one dietary staff member of four staff members observed;
- Clean OR equipment prior to providing care for one current OR patient (#16) of one OR patient observed;
- Follow their internal policy for skin preparation for one current OR patient (#16) of one OR patient observed;
- Discard a previously opened single-use sterile (completely clean and free from germs) gauze package, and used the gauze bandage for one OR patient (#16) of one OR patient observed;
- Ensure staff members removed OR masks between OR procedures;
- Ensure hair and jewelry were covered by hospital attire and/or hair coverings within the OR and Sterile Processing Department (SPD);
- Remove dirty urinals from overbed tables for two current patients (#6 and #9) of two patients observed;
- Perform daily and weekly kitchen cleaning;
- Ensure open dates were marked on open frozen food items;
- Discard an apple retrieved from a hospital unit that was placed in the kitchen sugar bin;
- Discard expired (past the date of safe use) food items in the patient nutrition room for one patient care unit of seven patient care units observed;
- Discard an open single-use package of a dried food item in the patient nutrition room for one patient care unit of seven patient care units observed; and
- Ensure expiration dates were written on food items in the patient nutrition room for one patient care unit of seven patient care units observed.

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 Antibiotic Stewardship Programs and resulted in the hospital's failure to ensure quality health care and safety.

Please refer to A-0749 for details.

48359




50496

Based on observation, interview and policy review, the hospital failed to:
- Prepare a clean work surface prior to performing patient care for two current patients (#5 and #16) of 13 patients observed;
- Cleanse the Intravenous (IV, in the vein) tubing port prior to IV medication administration for one current Operating Room (OR) patient (#16) of one OR patient observed;
- Perform hand hygiene (wash hands with soap and water or hand sanitizer) and glove changes during patient care for one current OR patient (#16) of one OR patient observed;
- Perform hand hygiene and glove changes for one dietary staff member of four staff members observed;
- Clean OR equipment prior to providing care for one current OR patient (#16) of one OR patient observed;
- Follow their internal policy for skin preparation for one current OR patient (#16) of one OR patient observed;
- Discard a previously opened single use-sterile (completely clean and free from germs) gauze package, and used the gauze bandage for one OR patient (#16) of one OR patient observed;
- Ensure staff members removed OR masks between OR procedures;
- Ensure hair and jewelry were covered by hospital attire and/or hair coverings;
- Remove dirty urinals from overbed tables for two current patients (#6 and #9) of two patients observed;
- Perform daily and weekly kitchen cleaning;
- Ensure open dates were marked on open frozen food items;
- Discard an apple retrieved from a hospital unit that was placed in the kitchen sugar bin;
- Discard expired (past date of safe use) food items in the patient nutrition room for one patient care unit of seven patient care units observed;
- Discard an open single-use package of a dried food item in the patient nutrition room for one patient care unit of seven patient care units observed; and
- Ensure expiration dates were written on food items in the patient nutrition room for one patient care unit of seven patient care units observed.

Review of hospital's policy titled "Standard Precautions (also known as universal precautions, avoiding contact with patients' bodily fluids by means of wearing gloves, goggles and face shields)," revised 03/2021, showed:
- All staff are to wash their hands immediately after gloves are removed and when otherwise indicated to avoid transfer of microorganisms (organisms, such as bacteria, too small for the naked eye) to the environment.
- Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.
- Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and wash hands immediately to avoid transfer of microorganisms to the environment.
- Procedures for the routine care, cleaning and disinfection of environment surfaces should always be followed.
- Scrub the port of invasive lines with alcohol using friction before injecting an IV medication.

Review of hospital's policy titled "Cleaning of ORs at the End of Day," revised 02/2009, showed staff will wipe down all equipment with disinfectant. During the OR Suite Terminal Cleaning (a thorough, deep cleaning of a room to include the ceiling, walls and floors) a cleaning agent will be used to clean the stem and base of the OR table.

Review of the hospital's policy titled, "Skin Preparation," revised 06/2012, showed when using a betadine (a solution that kills germs on the skin) preparation kit, use one sponge over the area to be prepared, discard the sponge and repeat the process using a fresh sponge.

Concurrent observations on 05/29/24 at 9:30 AM in the OR showed:
- Staff GG, Certified Registered Nurse Anesthetist (CRNA, registered nurses [RNs] who have obtained graduate-level education and board certification in anesthesia), failed to place a barrier prior to inserting an intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) and placed sterile IV supplies on Patient #16's blanket.
- Staff HH, CRNA, failed to cleanse the IV tubing port prior to administering IV medication to Patient #16.
- Staff CC, Surgical Services Director; Staff FF, Physician; Staff GG, CRNA; and Staff HH, CRNA; failed to perform hand hygiene prior to putting on gloves when providing care to Patient #16.
- Staff CC, Staff GG and Staff HH failed to change gloves and perform hand hygiene when he/she touched Patient #16, touched inanimate objects and continued to provide care to Patient #16.
- Staff CC picked trash off the OR floor and continued to provide care to Patient #16 without performing hand hygiene or changing her gloves.
- Staff CC placed a gauze bandage found in a previously open single-use package on Patient #16's new IVC site.
- Staff EE, Registered Nurse (RN), failed to perform the second surgical site skin preparation with a fresh betadine sponge for Patient #16.
- Two OR computer monitors had brown, dried drips of an unknown substance on the front of each screen. The OR table base had drops of a brown substance.

Observation on 05/28/24 at 2:15 PM, in the Oncology Unit, showed Staff Q, Licensed Practical Nurse (LPN), placed Patient #5's IV supplies on her overbed table prior to the removal of the IV and failed to clean the dirty surface or place a barrier down.

Observation on 05/28/24 at 3:25 PM showed Staff T, Dietary Aide, mixed fruit and yogurt with gloved hands, wiped his nose with a gloved hand and failed to perform hand hygiene and a glove change before returning to mixing the yogurt and fruit.

Observation on 05/28/24 at 2:23 PM, in the Oncology Unit, showed a dirty urinal on the overbed table next to Patient #6's water cup.

Observation on 05/28/24 at 2:32 PM, in the Oncology Unit, showed a dirty urinal on the overbed table next to Patient #9's water cup.

During an interview on 05/28/24 at 2:20 PM, Staff Q, LPN, stated that she kept the supplies on the opened package and did not think they touched the surface of the table. She stated that it was not normal practice to clean a surface before it was used for patient care.

During an interview on 05/28/24 at 3:25 PM, Staff T, Dietary Aide, stated that the normal process was to change gloves and wash hands after he touched his face.

During an interview on 05/28/24 at 2:36 PM, Staff R, RN, stated that it was a problem for a dirty urinal to have been set next to a patient's water cup. She stated that it should have been on the patient's bed siderail.

Review of the hospital's policy titled, "Attire in Surgery," revised 12/2013, showed:
- The head/hair cover must cover all exposed head and facial hair.
- Masks are not to be left dangling around the neck.
- Jewelry including earrings and necklaces that cannot be contained or confined within the surgical attire should not be worn in the semi-restricted and/or restricted areas of the surgery department.

Observation on 05/29/24 at 9:25 AM showed Staff JJ, RN, walked into the OR staff breakroom with a mask dangling around his neck.

Concurrent observations on 05/29/24 at 10:15 AM showed Staff KK, Sterile Processing Department (SPD, area designated to clean, prepare, sterilize [process that eliminates viruses and bacterial], store and track reusable medical and surgical instruments or equipment) Lead Technician, had hoop earrings visible outside of her hair covering; and Staff LL, SPD Technician, had gauge earrings, a necklace and hair visible outside of her attire and hair covering.

Although requested, the hospital failed to provide a policy that directed staff on when and how to clean the kitchen.

Observation on 05/28/24 at 3:23 PM showed the kitchen grill hood had a thick buildup of grease and debris.

Review of the hospital documents titled, "Diet Office, Checker Station, Nourishment Station Checklist," dated 04/01/24 through 05/20/24, showed the daily cleaning of the desktops, counter surfaces and front cabinets was not done on 05/13/24, 05/14/24, 05/15/24, 05/16/24 and 05/17/24.

Review of the hospital documents titled, "Catering Cleaning Checklist," dated 04/01/24 through 05/20/24, showed the daily cleaning of the buffet dishes, silverware bins, carts, cover plates, bowls and the right side of the refrigerator and door was not done on 04/06/24, 04/07/24, 04/13/24, 04/14/24, 04/20/24, 04/21/24, 05/04/24, 05/05/24, 05/13/24, 05/18/24, 05/19/24, 05/25/24 and 05/26/24.

Review of the hospital documents titled, "Six AM Starter Cleaning List," dated 04/01/24 through 05/20/24, showed the daily cleaning of the work area counters, top and bottom, plate dispenser and base table were not cleaned on 04/01/24 and 04/03/24. The pots and pans sink was not cleaned on 04/01/24, 04/03/24 and 04/17/24.

Review of the hospital document titled, "Carts Cleaning Checklist," dated 04/01/24 through 05/20/24, showed the daily sweeping and mopping of the coolers and freezer was not done on 05/18/24.

Review of the hospital documents titled, "Dish room/Beverage Cleaning Checklist," dated 04/01/24 through 05/20/24, showed:
- The daily sanitizing of the outside and door seal of the ice machine was not done on 04/01/24, 04/03/24, 04/11/24, 04/12/24, 04/14/24, 04/18/24, 04/29/24, 04/30/24, 05/01/24, 05/03/24 and 05/19/24.
- The daily cleaning of the carts and the wiping of the inside and outside of the dish machine was not done on 04/14/24, 04/18/24 and 05/19/24.
- The daily cleaning of the under roller and end table was not done on 04/14/24, 04/18/24, 05/04/24, 05/05/24 and 05/19/24.
- The daily wiping in the beverage station, conveyor belt and beverage cooler was not done on 04/18/24.
- The weekly cleaning of the dish room, beverage cooler and change trays was not done the week of 04/29/24.
- The weekly cleaning of the dish room walls was not done the week of 05/13/24.
- The weekly cleaning of the dish room ceiling vents and tiles was not done the week of 05/20/24.

Review of the hospital documents titled, "Seven AM Grill Cleaning List," dated 04/01/24 through 05/20/24, showed the daily wiping of counters, filling of the condiments and cleaning of the cart, sneeze guards, shelf above the sneeze guards and nacho cheese machine was not done on 04/06/24, 04/07/24, 04/13/24, 04/14/24, 04/20/24, 04/21/24, 05/04/24, 05/05/24, 05/18/24, 05/19/24, 05/25/24 and 05/26/24.

Review of the hospital documents titled, "Nine AM Grill Cleaning List," dated 04/01/24 through 05/20/24, showed the daily cleaning of the ice cream catch tray, warmer, counter tops, cart, blender, microwave, microwave stand, plate station and table next to the ice cream machine was not done on 04/20/24.

Review of the hospital documents titled, "Hot Food Production Cleaning Checklist," dated 04/01/24 through 05/20/24, showed:
- The daily cleaning of the outsides and tops of the ovens was not done on 04/05/24.
- The daily cleaning of the plate heater outside and lids was not done on 04/12/24.
- The daily wiping of the inside of the ovens was not done on 04/10/24, 04/11/24, 05/02/24, 05/20/24, 05/22/24 and 05/23/24.
- The daily cleaning of the fryers and fryer baskets was not done on 04/10/24, 04/11/24, 05/02/24, 05/04/24, 05/05/24, 05/13/24, 05/20/24, and 05/23/24.
- The daily cleaning of the stove burn plates was not done on 05/22/24.
- The daily changing of the trays in the pass-through hotbox was not done on 05/21/24 and 05/22/24.
- The weekly cleaning of the inside of the plate cleaner was not done the week of 04/29/24.
- The weekly cleaning of the delime steamers was not done the week of 05/13/24.
- The weekly cleaning of the reach in freezer was not done the week of 05/20/24.

Review of the hospital documents titled, "Café' Daily and Weekly Cleaning List," dated 04/01/24 through 05/20/24 showed:
- The daily cleaning of dining room tables and floors was not done on 04/04/24, 04/05/24, 04/14/24, 04/17/24, 04/18/24, 04/19/24, 05/15/24, 05/20/24, 05/21/24, 05/23/24, 05/25/24 and 05/26/24.
- The daily cleaning of the cappuccino machine and nozzles was not done on 04/04/24, 04/05/24, 04/08/24, 04/09/24, 04/11/24, 04/12/24, 04/14/24, 04/15/24, 04/16/24, 04/17/24, 04/18/24, 04/19/24, 04/20/24, 04/21/24, 04/29/24, 04/30/24, 05/01/24, 05/02/24, 05/03/24, 05/04/24, 05/05/24, 05/15/24, 05/25/24 and 05/26/24.
- The weekly cleaning of the inside of the wrap cooler was not done the week of 04/15/24.
- The daily cleaning of the donut case and toaster was not done on 04/02/24, 04/04/24, 04/05/24, 04/06/24, 04/07/24, 04/13/24, 04/14/24, 05/25/24 and 05/26/24.
- The daily cleaning of the front of the ice and water machine, water and ice spouts, coffee and tea drains and coffee and tea pots was not done on 04/08/24, 05/25/24 and 05/26/24.
- The weekly cleaning of the cup and lid dispenser's baskets was not done the weeks of 04/08/24 and 04/15/24.
- The weekly cleaning of the coffee filter baskets was not done the weeks of 04/08/24, 04/15/24 and 04/29/24.
- The daily cleaning of the back counter and front cabinets, glass in serving area, and dessert cart glass was not done on 04/13/24, 04/14/24, 05/14/24, 05/25/24 and 05/26/24.

Review of the hospital documents titled, "Delbert Day Cancer Institute (DDCI) Cleaning Checklist," dated 04/01/24 through 05/20/24 showed:
- The weekly cleaning of the clean storage area was not done the weeks of 04/29/24, and 05/20/24.
- The weekly cleaning of the syrup caddy was not done the weeks of 04/01/24, 04/29/24, and 05/20/24.
- The weekly cleaning of the cup and lid holder was not done the week of 04/29/24.
- The weekly cleaning of the condiment caddy was not done the weeks of 04/01/24 and 04/29/24.
- The weekly cleaning of the top of the ice maker was not done the weeks of 04/01/24, 04/08/24 and 04/29/24.
- The weekly cleaning of the sleeve holder was not done the week of 04/08/24.
- The weekly cleaning of the clean storage area was not done the weeks of 04/08/24, 04/29/24, and 05/20/24.
- The weekly cleaning of the under counter refrigerator was not done the week of 04/08/24.
- The weekly wiping of the walls was not done the weeks of 04/01/24, 04/08/24, 04/15/24.
- The daily cleaning of the microwave, cooler doors, cookie oven, clean trap, top of the brewer, trashcan and sanitizer/soap dispensers was not done the week of 04/29/24.

Although requested, the hospital failed to provide a policy that directed staff on how to date food items in the kitchen.

Observation on 05/28/24 at 3:35 PM showed one expired milkshake and six boxes of opened frozen food without dates opened marked on the boxes in the walk-in freezer.

Observation on 05/28/24 at 3:15 PM showed an apple wrapped in a paper towel was found in a sugar bin in the kitchen.

Review of hospital's policy titled "Floor Stock," revised 01/2006, showed stocked items will have an expiration date placed by the Food Service personnel who stocked the floor.

Observation on 05/28/24 at 2:00 PM in the Labor and Delivery patient nutrition room showed:
- An expired multiuse bottle of coffee creamer on the countertop.
- An opened, single-use package of coffee grounds in a drawer.
- Packets of broth, sweetener, sugar and tea bags in a tray without written expiration dates.
- Fourteen single wrapped cheese packets in the refrigerator drawer without written expiration dates.

During an interview on 05/30/24 at 10:00 AM, Staff NN, Chief Nursing Officer (CNO), stated that staff were to follow the five moments of hand hygiene as written in the hospital's policy. The hospital needed to provide unit and staff specific training in all areas. She expected a clean surface for medication administration and patient care supplies. In the OR, she expected a surgical table or drape was used to create a clean surface. She expected the IV port was scrubbed with alcohol before all IV medication administrations. She stated the scrubbing of the port was a "standard practice." She expected the policy for OR skin preparation was followed. A betadine preparation included two sponges. A previously opened gauze container was contaminated and she expected staff to discard the bandage, not use the bandage for patient care. She expected the OR tables and monitors were clean. It was the OR staff members responsibility to ensure the room was clean prior to bringing the patient into the OR. Environmental Services staff perform the OR cleaning. OR staff were to ensure the environment was safe and clean. She stated that staff were to remove used urinals from the patient's overbed table to keep the urinal away from food, water, medications and supplies. Staff were to clean the surface when a urinal was removed from the overbed table. Urinals were stored on the bedside rail. Kitchen staff were to follow the five moments of hand hygiene. She expected items in dated bags in the patient nutrition area to remain in the dated bags. All expired food and supply items were discarded. She expected the kitchen was cleaned daily. She expected the Nutrition Services Director to observe and ensure the completion of the kitchen cleaning. She expected the kitchen cleaning logs were 100 percent completed. Freezer items were labeled with an open date and items without open dates in the freezer were discarded.

During an interview on 05/29/24 at 2:45 PM, Staff SS, Quality and Infection Prevention Executive Director, stated that she expected hand hygiene was performed before touching a patient, after touching a patient, after touching equipment and before providing patient care. She expected glove changes when moving between clean and dirty items/areas. Hand hygiene and glove changes were performed after an item was picked off the floor. She expected hand hygiene and glove changes when a staff member touched their face/nose. She expected staff to clean an area or place a barrier before setting down IV supplies. She expected the IV port was scrubbed with an alcohol wipe with every IV medication administration. A betadine skin preparation should follow the hospital policy and use two sponges. She expected opened, unused single-use supply package items were discarded and a previously opened single-use item was not used for patient care. Dirty monitors and the dirty OR table base did not meet her expectations for a clean OR. Visible hair and jewelry in the OR and SPD did not meet her expectations. She expected dirty urinals were placed on the patient's bed siderail. Expired food was discarded. All items in the patient nutrition rooms required dates of expiration. Items in the dated bags remained in the bags for patient use. Open single-use food packages were discarded, not stored in the patient nutrition room drawer or refrigerator. She expected written expiration dates on frozen food items.

During an interview on 05/29/24 at 10:20 AM, Staff CC, Surgical Director, stated that she expected staff members to wash their hands with glove changes. She expected glove changes and hand hygiene when moving between clean and dirty objects. She expected the port of IV tubing was cleansed with an alcohol wipe before IV medication administration. Clean items for patient care should not be placed on the patients blanket or bedside table. A clean barrier was to be prepared before items were placed on a surface. A previously opened package of sterile gauze was discarded, not used for patient care. She expected unused, single-use package items were discarded. Masks were not worn dangling from a staff member's neck. Masks were removed between patient procedures. She did not know what the substance was on the OR monitors. The dirty monitors and the dirty OR table base did not meet her expectations for a clean OR. There should not be any visible jewelry or hair in the OR or SPD. Hospital attire and hair covers were to completely cover jewelry and hair.

During an interview on 05/28/24 at 3:15 PM and 05/29/24 at 3:20 PM, Staff J, Nutrition Services Director, stated that if a staff member "touched themselves," they were to remove their gloves, perform hand hygiene and re-glove. The hood vent was cleaned by the cooks every week. She performed rounds to observe for kitchen cleanliness. Her rounds were not documented. Opened single-use food items were discarded, not stored in a drawer or the refrigerator. The unit staff were responsible to discard expired multi-use creamer bottles. The apple wrapped in a paper towel found in the sugar bin was "probably picked up from a hospital unit and the kitchen staff member did not yet discard the apple." The apple did not belong in the sugar bin. The current process was to date the box when a frozen food item was opened. The frozen item was good for one month after the date opened. There was no policy to show how to date frozen items for expiration when opened.