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Based on observation and interview the facility failed to maintain a safe environment, in particular, with respect to providing electrical isolated power for operating room wet locations (C-0912), failed to ensure that the eyewash safety equipment in the acute care wing was properly maintained (C-0914), failed to keep a clean environment for storage of supplies (C-0924), failed to ensure proper ventilation including temperature, humidity,and direction of air flow from the decontamination room and the two operating rooms (C-0926), and failed to provide and maintain adequate physical facilities for Safety from Fire (C-0930). The cumulative effects of these systemic deficiencies result in the potential for an unsafe physical environment for all patients and employees of the facility.

Based upon record review and interview the facility failed to maintain a safe environment in particular with respect to providing electrical isolated power for operating room wet locations and/or routinely evaluating the two operating rooms to determine whether or not they would be considered wet locations per National Fire Protection Association (NFPA)99. The lack of an adequate isolated power system in a wet location could result in significant harm to those patients undergoing invasive surgical procedures should an electrical fault occur and continue undetected.

Findings include:

On 05/18/22 at 1356, during the tour of the operating room suite, observed that the electrical outlets in both OR 1 & 2 had a combination of Groud-Fault Circuit Interrupter (GFCI) outlets and hospital grade grounded outlets. Isolated power was not provided and when we asked Staff C, the VP of nursing, he confirmed that the facility had not conducted a risk assessment to determine whether or not the OR's would be considered wet locations. There was no documentation available for review regarding isolated power or wet locations.

Staff V, Director of Environment of Care, confirmed these findings during interview and at the time of record review.

Based on observation, interview and document review, the facility failed to ensure that the eyewash safety equipment in the acute care wing was properly maintained, resulting in the potential for permanent eye injury for staff exposed to injurious or corrosive chemicals not having access to fully functional emergency eyewash station.

Findings include:

1. On 05/18/22 at 1120, observed that eyewash station in the soiled utility room on the acute care patient floor was not working properly. The water flow was too low for proper flushing. Also, there was no eyewash sign. Reviewed the eyewash testing log provided by Staff X and she explained that they test the eyewash once per month or perhaps every 2 months. The standard OSHA requirement is to test emergency eyewash facilities weekly. Staff X also explained that she takes the dust caps off before testing the eyewash. Since the eyewash must be activated within 1 second, the ANSI Z 358.1 eyewash standard explains that the dust caps must pop off on their own. Observed that, when activated, only one of the duct caps came off on it's own. Staff Q, W and X were present to confirm this finding.

Based on observation and interview, Kalkaska Memorial Hospital failed to keep a clean environment for storage of supplies and maintaining a safe environment, potentially exposing patients and staff to infectious agents or physical injury.

Findings include:

1. On 05/18/22 at 1006, observed an unsecured Type E oxygen cylinder in the mobile MRI parking garage. Staff Q confirmed the findings at the time of observation.

2. On 05/18/22 at 1107, observed a syringe, an opened package of briefs, tape and other trash and debris under two storage racks in the supply room in acute care, across from patient room 3. During interview with Staff W they stated they did not clean under the racks as to not disturb the organization of the racks in the room. Staff W and Staff Q confirmed the findings at the time of the survey.

Based upon observation and interview, the facility failed to ensure proper ventilation including temperature, humidity,and direction of air flow from the decontamination room and the two operating rooms, resulting in an increased risk for spark ignited fires, infections and other adverse health effects affecting the well being of all surgical patients.

Findings include:

1. On 05/18/22 at approximately 1400, observed that there were no instruments in OR 1 or OR 2 to provide a visible indication to occupants of the current room temperature and humidity. Staff Q explained that maintenance tracks temperature and humidity through their Stanley computer tracking system. Staff R, in Sterile Processing, mentioned the same thing but also had her own temperature/humidity gauge in Sterile processing. During document review with Staff V, Director of Environment of Care, they were able to display temperature and humidity reading for the operating rooms taken at 15 minute intervals for the month of May but could not bring up records from mid February 2022 when we requested to see historic records. Staff V provided an electronic record of temperature and humidity at 15 min intervals for the OR 1 from 04/19/22 to 05/23/22. The report printed in red when humidity readings dropped below 30 % RH and above 60 % RH. There were no readings below 20% RH; however, there were approximately 20 readings above 60 % RH during the days 05/14/22 - 05/16/22. Staff V explained that the system did not retain earlier records.

2. At approximately 1310, during tour of the operating room suite, observed that the decontamination room in central sterile processing had a positive air pressure relationship to the corridor, as shown by performing a tissue flutter strip test at the undercut of the corridor door. Staff J, Q, and R confirmed this finding at the time of observation.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 485.62(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated May 18, 2022.
K-0100
K-0211
K-0353
K-0372
K-0511
K-0781
K-0923

Based on observation, interview, and policy review the facility failed to ensure staff adherence for their infection control policy/procedure during the treatment for one (#2) patient that was COVID-19 positive, resulting in the potential for the transmission of infections for all 9 patient's that were being served in the Emergency Department at the time of the observations.
(See tag C-1208)

Based on observation, interview, and policy review the facility failed to ensure staff adherence for their infection control policy/procedure, during treatment for one patient (#2), that was COVID-19 positive, resulting in the potential for the transmission of infections for all 9 patients that were being served in the Emergency Department (ED) at the time of the observations.

Findings include:

On 5/17/2022 at 1430 a tour of the Emergency Department was conducted with the ED Nurse Manager Staff H and the following was revealed:

A sign was observed posted at the entry of room #3 for, "Airborne/Contact Precautions" with instructions that included: mask, gloves, isolation gown upon entering. A visitor was also observed through the glass sliding door seated in a chair. The visitor's mask was observed beneath her chin. The visitor's nose and mouth were exposed. The visitor was not observed wearing an isolation gown.

On 5/17/2022 at 1435, Staff I was observed as she entered the room #3 wearing a yellow mask and gloves. Staff I was not wearing an isolation gown

On 5/17/2022 at 1440, Staff H was queried regarding the need for Airborne/Contact precautions for patient #2. She replied, "Oh he is not on contact precautions, we don't need to wear gowns in the room." She explained, he has COVID. We are just waiting to transfer him to a (name of local hospital) for placement and treatment for COVID. A review of the patient's medical record revealed the patient was an 84-year-old male who presented to the ED on 5/17/2022 at 0739, due to fall this am and for falling twice the day before. Medical decision making included: "The treating paramedic reported the patient's room air oxygen saturation was 90% and improved into the mid 90's with nasal oxygen. The patient's COVID test is positive today and he presents with an acute infection as he had a negative test 6 days ago. At this time, we are waiting on a bed assignment to (name of a local hospital) and the patient's care will be turned over to (name of accepting medical doctor)." Further record review revealed the patient (#2) tested positive for COVID on 5/17/2022 at 0839.

On 5/17/2022 at 1445, Staff H was asked if visitors were required to wear mask while in patients room who were positive for COVID infection. Staff H said yes, they are. Staff H was asked to explain why the visitor was not wearing a mask properly and she replied, "they both have dementia." At that time, Staff H was overheard and she prompted the visitor for patient #2 to pull her mask up.

On 5/17/2022 at 1450, Staff I was observed as she came out of the patient's room wearing a yellow mask, wearing gloves and holding a device. Staff I was observed as she proceeded with cleaning the device at the nurse's station.

On 5/17/2022 at 1500, Staff H was asked to explain the role of Staff I and she replied, she's a basic Emergency Medical Tech. Staff H was asked if it was okay for staff to wear simple face mask when providing care/treatment for patients that tested positive for COVID. She replied, no it's not. Staff H was asked if it was okay for staff to exit patient's room with gloves and clean device at the nurse's station for patient's that tested positive for COVID. She replied, no it's not. At that time, Staff H was overheard as she asked Staff I why she did not have on her respirator and why she did not remove her gloves prior to exiting the patient's room. Staff I was overheard as she replied, my respirator is outside and there is no garbage can in the patient's room.

Staff I was queried about patient #2's COVID-19 infection and the mask she was wearing during an interview on 5/17/2022 at 1505. She confirmed the patient had COVID. She confirmed she was wearing a simple mask. She confirmed she should have been wearing an N-95 mask. She said, my respirator is outside.

On 5/17/2022 at 1540 an interview was conducted with the Infection Control Staff M. When asked to explain transmission precautions for patients who test positive for COVID-19 she explained, the precautions should be "Airborne with eye protection, PAPR/CAPR or N95 with eye protection". She said gowns or gloves are not required.

Review of the facility's "Standard and Transmission Based Isolation Precautions" policy, dated 3/28/2022 documented the following:
Policy:
A. Standard Precautions are used for all patient care. Standard precautions are designed to reduce the risk of exposure to blood and other potentially infectious material (OPIM). Additional precautionary measures are instituted in specific conditions or when patients are identified with certain pathogens.
Standard Precautions:
A. The care of all patients is based on the assumption that blood and OPIM may contain infectious agents. Healthcare personnel should use appropriate personal protective equipment (PPE) to prevent contact with patient bodily fluids.
B. Hand hygiene is require after touching blood and OPIM, regardless of whether gloves are worn. Hand hygiene must be performed before gloves are worn and after gloves are removed, as well as before and after patient contact.
C. "...Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and perform hand hygiene immediately after removal.

Transmission/Pathogen/Condition-Base Precautions:
F. Special Pathogen COVID-19 requires Airborne with eye protection.
1. Airborne with Eye Protection Precautins are required.
a. Mask- Wear a PAPR/CAPR or N95 with eye protection.
However, that was not done.