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Based on observation and interview, the facility's contracted inpatient dialysis services failed to ensure ongoing security of the water treatment room in the hospital. This deficient practice had the potential to affect 2 inpatients currently receiving treatments in the hospital and any potential inpatients that received dialysis treatments in the hospital.

Findings include:

On 9/27/16, at 8:40 a.m. a tour of the dialysis treatment area was conducted with dialysis manager (DM)-A present. The treatment room, which was located on the 4th floor of the facility, had four stations for inpatients to be brought in for dialysis treatments. In addition, two large portable reverse osmosis (RO) tanks on wheels were observed against the outside wall, near the nurses station of the treatment room.

DM-A indicated patients admitted to the facility who required dialysis treatments received treatments in this area. She stated for inpatients who were admitted to intensive care (ICU) area in the facility, a portable RO unit and dialysis machine was moved to ICU to serve as the patient's room for treatment.

On 9/27/16, at approximately 8:45 a.m. a tour of the water room was conducted with DM-A and clinical manager (CM)-A present. The dialysis water room was located on the 3rd floor unit, with the water room door accessible from the hallway and adjacent to the patient rooms in the hallway of the unit. The water room door had a metal keypad affixed to the door and a sign on the front of the door which indicated the room was the water room.

The 3rd floor nursing unit had patients in individual rooms, with several personnel present in various locations within the nursing station and unit. The various personnel included replacement nursing staff, physicians, dietary staff and unidentified personnel. CM-A walked up to the door, reached out and immediately opened the door and entered the water room, without entering a security code into the keypad. The water room contained equipment for production of reverse osmosis water used for the treatment of dialysis patients.

At 8:55 a.m. CM-A indicated she was not an authorized dialysis staff and confirmed the water room door had not been locked when she opened the door. She stated she completed daily inspections of the unit and had entered the water room door approximately "1/2 hour ago" to look for any concerns with cleanliness. CMA-A said she was unaware of who else in the facility was aware of the security code for the room, and again stated the door had likely not shut properly following her inspection for cleanliness.

At 10:04 a.m. contracted biomedical technician (CBT)-A stated the water room door was to "always be locked." CBT-A stated the water room door had a keypad entry, was to be locked at all times and "just dialysis staff" were to have access to the water room. He stated he expected the water room to be secured at all times to eliminate the potential of tampering with the water system and stated it was not acceptable for the door not to be locked.

At 11:01 a.m. DM-A stated the hospital did not have a policy for security of the dialysis water room.

At 11:04 a.m. CBT-A stated the contracted dialysis company did not have a policy related to security of the water room, however, stated it was "a given" that the water room be secured at all times.

Bases on observation, interview and document review, the hospital failed to maintain sanitation of the food preparation areas in the kitchen. This had the potential to affect all patients, visitors and employees who received food provided from the kitchen.

The findings include:

A kitchen tour was conducted on 9/27/16, at 8:30 a.m. with the food service director (FSD), patient services manager, nutrition services director and the executive chef. During the tour, a blue garbage bin was observed at the loading dock area off the adjacent kitchen. The bin was full of food waste. The FSD explained the bin had been taken from the kitchen and placed at the dock area for pick-up by a farmer to use for pig feed. The bin had dark soiling down the sides and a soiled and cracked lid. The FSD explained the farmer would take the full bins away and leave empty bins for use in the kitchen. The FSD verified she did not know the process for sanitizing the bins between uses as they were the property of the pig farmer.

The hospital's nutrition services department policy Food Safety and Sanitation, dated August, 2016 included: "It is the policy of the Nutrition Services Department to develop and maintain safe, accurate and sanitary preparation of food as well as non-food products. This includes the environment they are received, stored, prepared and served in".

Based on observation, interview, and record review, the hospital was found to be out of compliance with Life Safety Code requirements. These findings had the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code inspection tags: K-56 and K-62.