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Based on review of documents, interview, and review of the facility's policy and procedure, the facility failed to ensure emergency equipment was checked daily to determine it was available for immediate use. This failure could result in a delay of staff response during an emergency, placing all emergency and inpatients at risk of negative outcomes.

Findings Include:

Review of the facility's policy titled, "Code Blue," last revised 10/01/15, revealed, Code Cart Checks: Each code cart is checked daily, in areas that operate seven days per week.

On 02/18/19 at 10:50 AM, review of the February "Emergency Equipment Check Logs" for both the adult and pediatric crash carts located in the Emergency Department revealed the carts had not been checked on 02/07/19 and 02/18/19.

During an interview, Staff D, the Clinical Resource Nurse/Infection Preventionist, reviewed the ED crash cart checks logs and stated that the Emergency Department operated seven days a week and the crash cart checks had been missed on the two dates noted above.

On 02/18/19 at 11:50 AM, review of the January and February 2019 "Emergency Equipment Check Logs" for the "Med Surg" (Medical Surgical/Inpatient/Swing Bed) Unit revealed the carts had not been checked on 01/02/19, 01/03/19, 01/12/19, 01/13/19, 01/15/19, 01/16/19, 01/30/19, 01/31/19, 02/10/19, and 02/17/19.

During an interview, Staff C, the Nurse Manager of the Inpatient/Swing Bed Unit, reviewed the Med Surg crash cart logs and stated that the Inpatient/Swing Bed units operated seven days a week and the crash cart checks had been missed on the dates noted above.

Based on observation, interview and document review, the facility failed to ensure staff followed appropriate infection control procedures. This included failure to perform hand hygiene, (washing the hands with soap and water or with alcohol-based hand rub), during one of one observation of patient care. This failure can lead to cross contamination from pathogens (bacteria and viruses) when failing to perform hand hygiene before and after patient care. The facility also failed to monitor the temperature of a refrigerator containing patient food items putting patients at risk of food-borne illnesses and infections.

Findings Include:

Review of the facility's policy titled, "Hand Hygiene," last revised 11/01/16, revealed, All employees will perform hand hygiene: Before and after direct contact with patients or their environment...and before handling medications.

1. An observation of patient care conducted on 02/19/19 on the Inpatient/Swing Bed Unit from 8:00 AM to 9:10 AM. At 8:05 AM, Staff E, Registered Nurse (RN) entered the medication room at the nurse's station and, without performing hand hygiene, removed medications from the Omnicell (computerized medication system). Staff E then entered patient room 112 to administer medications. Staff E stated one of the pills needed to be split in half and picked up the pill with bare hands to place in the pill splitter device, then placed the pill with bare hands in the patient's medication cup and administered the medication.

At 8:25 AM on 02/19/19, Staff E returned to the medication room, used a tissue from Staff E's pocket to wipe nasal secretions, replaced the tissue and, without performing hand hygiene, reached for items on the medication room shelf.

At 8:30 AM on 02/19/19, Staff E entered patient room 109 and, without performing hand hygiene, donned gloves to administer patient medications. At 8:40 AM, Staff E entered the medication room and, without performing hand hygiene, removed medications from the Omnicell. At 9:00 AM, Staff E entered patient room 104 and, without performing hand hygiene, conducted a physical assessment of the patient using a stethoscope and bare hands, then, without performing hand hygiene, entered data on the computer keyboard in the room and administered the medication.

During an interview, Staff D, the Clinical Resource Nurse/Infection Preventionist, became aware of the observations of Staff E. Staff D agreed hand hygiene should have been performed upon entry to the medication room, after wiping nasal secretions and before and after direct care of the patients.


2. Review of the facility's policy titled, "Nutrition Services Equipment Temperatures," effective date 01/17/19, revealed, Refrigerator and freezer temperatures will be taken at least once daily and documented by a nutrition services employee.

A review of the Refrigerator/Freezer Temperature Logs on the Inpatient/Swing Bed unit on 02/19/19 at 11:50 AM revealed the refrigerator and freezer containing patient food items had not been checked on 02/02/19, 02/05/19, 02/07/19, and 02/16/19.

During an interview, Staff C, the Nurse Manager of the Inpatient/Swing Bed Unit, verified the patient refrigerator and freezer temperatures had not been checked on the dates noted above.