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A. Based on observation, testing, and interview, the provider failed to maintain the integrity, safety, and/or cleanliness for the following:
- The walls in laundry area, the dirty side of central sterilization (CS), the women's bathroom by laundry, materials management, the kitchen, the housekeeping closet by the nursery, both the hydro tub rooms, behind the west leaf of the cross-corridor doors in the north hub of the patient floor, around the scrub sink of the operating suite, and across from the scrub area of the operating suite.
- The inside of the door of the old dryer.
- The ceiling ventilation grates in the laundry area and in the kitchen.
- The metal cart for the dirty side of CS.
- Four ceiling tiles in the materials management area.
- One of two wheelchairs at the front entrance to physical therapy (PT).
Findings include:

1. Observation on 6/28/11 from 8:30 a.m. to 11:45 a.m. and from 1:30 p.m. to 5:00 p.m., and again on 6/29/11 from 10:45 a.m. to 11:45 a.m. revealed:
a. The wall behind the 125 pound washer was deteriorated and eroded (photo 1). Interview with the materials management and laundry supervisor at the time of the observation confirmed that finding. She stated that wall had been in that condition for about two years.
b. The wall above the rolling cart on the dirty side of CS and laundry had a large hole approximately five inches by ten inches with wires protruding from that hole (photo 18). Interview with the CS nurse at 11:30 a.m. on 6/29/11 confirmed that finding. She stated that hole was from a clock that had hung on the wall. The clock had fallen and broken this spring and was never fixed or replaced.
c. The painted gypsum wall adjacent to the handsink on the clean side of laundry was gouged, chipped, and pitted (photo 3). Interview with the materials management and laundry supervisor at the time of the observation confirmed that finding. She said the carts would bang into and damage that wall.
d. The gypsum board wall beneath the paper towel dispenser in the women's bathroom next to laundry had chipped and pitted plaster that exposed the chalk beneath the surface (photo 10). Interview with the materials management and laundry supervisor at the time of the observation confirmed that finding. She stated she had put in a work order for that wall a few months ago but had not seen any results.
e. The north and east walls in materials management had small streams of rusty water that ran from the ceiling to the floor (photos 4 and 5). That stream of rusty water could be smeared with the fingers (photo 6) and was wet to the touch. The streams of rusty water left pools of water on the floor. Interview with the materials management and laundry supervisor at the time of the observation confirmed that finding. She stated the wall would seep every time it rained, and she tried to keep clean supplies away from those walls. She stated maintenance was aware of the problem but was unsure how to fix the walls.
f. The painted block wall beneath the chemical fill station in the kitchen was peeling, chipped, and scratched. Interview with the certified dietary manager at the time of the observation confirmed that finding. She stated the chemicals, mop buckets, and mops had damaged the wall.
g. The wall behind the floor sink in the housekeeping closet by the nursery had a bulge the size of a football and had deteriorated (photo 12). The bulge could be depressed with the fingers and the deteriorations could be scraped off the wall with fingernails. Interview with the plant manager at the time of the observation confirmed that finding. He stated he was not aware of the condition of that wall.
h. Both hydro tub rooms on the patient floor had separated seams in the corner walls of the paneling (photos 13 and 15). Interview with the plant manager at the time of the observation confirmed that finding. He stated he was not aware of the condition of those walls.
i. The door stop behind the west leaf of the cross-corridor doors on the north hub of the patient floor was depressed into the wall creating a hole in the wall (photo 14). Interview with the plant manager at the time of the observation confirmed that finding. He stated he was not aware of the condition of that wall.
j. The bead of caulk around the scrub sink in the operating suite had become separated from the wall and created an open area behind the sink. The painted gypsum board wall across from the scrub area was gouged, scraped, and had small dents. Interview with the operating room manager at the time of the observations confirmed those findings. She stated she had not submitted work orders to maintenance for repairs but agreed it needed to be repaired to be cleanable.

2. Observation at 8:50 a.m. on 6/28/11 revealed the inside of the door of the large dryer had chipped and pitted paint (photo 2). The area around the edges of the chipped and pitted paint had a build-up of residue that could be scraped with a fingernail. Interview with the materials management and laundry supervisor at the time of the observation confirmed that finding. She stated she was aware of the condition of the door but had not pursued any options to repaint the door.

3. Observation at 4:30 p.m. on 6/27/11 and at 8:45 a.m. on 6/28/11 revealed the small perforated ceiling ventilation grates in the kitchen and laundry area were clogged with lint and debris. Interview with the dietary manger and materials management and laundry supervisor at the times of the above observations respectively confirmed those findings. They revealed they were not aware those grates were that dirty.

4. Observation at 8:50 a.m. on 6/28/11 revealed the metal rolling cart on the dirty side of CS and laundry had large areas of pitted and chipped paint the size of quarters and dimes on the legs and bottom shelf (photos 16, 17, and 19). Interview with the CS nurse at 11:30 a.m. on 6/29/11 confirmed that finding. She stated she had tried to get a countertop and cabinet in that area for storage but had to use that metal cart.

5. Observation at 9:45 a.m. on 6/28/11 revealed four perforated ceiling tiles in materials management were soiled and/or moldy (photos 7, 8, and 9). Interview with the materials management and laundry supervisor at the time of the observation confirmed that finding. She stated she had made requests to have the tiles changed several times, but she had not seen any results. She stated she had been told the tiles would just become soiled and wet again, as the pipes above the ceiling would sweat and the condensation would drip on the panels.

6. Observation at 10:40 a.m. on 6/28/11 revealed a wheelchair at the front entrance to PT had the arm rests taped with clear packing tape (photo 11). That tape had been placed over athletic tape. Interview with the PT secretary at the time of the observation confirmed that finding. She stated the vinyl on the arms had begun to rip and tear, and she had covered the arms with athletic tape and clean packing tape.


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B. Based on observation and interview, the provider failed to ensure:
*Medical supplies in four of five pods (patient room areas) were secured to ensure quality and safety.
*Expired supplies in labor and delivery room (LDR) one in the obstetrics patient area were removed.
Findings include:

1. Observation on 6/27/11 at 4:00 p.m. and again at 5:10 p.m. revealed:
*Four pods had cabinets that were not secured.
*The doors to those cabinets had locks on them, but they would not latch and lock.
*The doors to those cabinets were open approximately 3 inches.
*Three of those four unsecured cabinets had no staff present at the time of the observations, and visitors were noted in the hall adjacent to the pod areas.
*The cabinets contained various sizes and types of syringes and intravenous (IV) tubing.

Interview on 6/27/11 at 4:30 p.m. with the medical/surgical nurse manager revealed:*The locks did not always work.
*The doors had to be closed or slammed at times for the latches to engage.
*The cabinets held IV solutions, syringes, and IV tubing.
*She attempted to close and lock one of the pod cabinets and was unsuccessful in locking the cabinet.

Interview on 6/27/11 at 5:10 p.m. with registered nurse A revealed:*The cabinet doors did not always lock.
*He believed maintenance had been notified of the problem but was not aware of when.

Interview on 6/29/11 at 9:55 a.m. with the director of nursing revealed:
*He was aware the pod cabinet doors did not always remain locked.
*It had been an ongoing problem.
*He agreed the items in the cabinets could be accessed by unauthorized persons.
*No formal plan had been put into place to correct the security of the items stored in the cabinets.



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2. Observation on 6/28/11 from 8:20 a.m. through 9:00 a.m. of LDR one in the obstetrics patient area revealed the following expired supplies in the neonatal cabinet:
*Two intrauterine pressure catheters (IUPC) with expiration dates of May 2011 and July 2010.
*One package of attach electrodes for the IUPCs with an expiration date of October 2010.
*Two Neovac meconium suction devices with a expiration dates of March 2011.

Interview at that time with the obstetrical nurse manager confirmed those obstetrical supplies were outdated. She further stated:
*She was responsible for checking the two LDRs for outdated supplies.
*She must have missed the above supplies.
*Expiration dates of supplies in the obstetrical patient area were always checked before use.

Based on observation and interview, the provider failed to:
*Ensure intravenous (IV) solutions in four of five pods (patient room areas) were secured to ensure quality and safety.
*Remove expired medications from labor and delivery room (LDR) one and the medication storage room in the obstetrical patient area.
Findings include:

1. Observation on 6/27/11 at 4:00 p.m. and again at 5:10 p.m. revealed:
*Four pods had cabinets that were not secured.
*The doors to those cabinets had locks on them, but they would not latch and lock.
*The doors to those cabinets were open approximately 3 inches.
*Three of those four unsecured cabinets had no staff present at the time of observation, and visitors were noted in the hall adjacent to the pod areas.
*The cabinets contained IV solutions.

Interview on 6/27/11 at 4:30 p.m. with the medical/surgical nurse manager revealed:*The locks did not always work.
*The doors had to be closed or slammed at times for the latches to engage.
*The cabinets held IV solutions.
*She attempted to close and lock one of the pod cabinets and was unsuccessful in locking the cabinet.

Interview on 6/27/11 at 5:10 p.m. with registered nurse A revealed:*The cabinet doors did not always lock.
*He believed maintenance had been notified of the problem but was not aware of when.

Interview on 6/29/11 at 9:55 a.m. with the director of nursing revealed:
*He was aware the pod cabinet doors did not always remain locked.
*It had been an ongoing problem.
*He agreed the items in the cabinets could be accessed by unauthorized persons.
*No formal plan had been put into place to correct the security of the items stored in the cabinets.




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2. Observation on 6/28/11 from 8:20 a.m. through 9:00 a.m. in the obstetrical patient area revealed the following expired items:

*LDR one medication cabinet:
- One 30 milliliter (ml) vial of Polocaine expired in November 2010.
- One 1-ml vial of oxytocin expired in April 2011.
*Medication storage room: One 250 ml bag of 5 percent dextrose intravenous (IV) solution expired in June 2010.

Interview at that time with the obstetrical nurse manager confirmed those medications and the IV solution had expired. She further stated:
*She and the pharmacist were responsible for checking the medications in the two LDRs for outdated medications. *She must have missed those medications in the medication cabinet of LDR one.
*The central supply staff were responsible for ensuring the IV solutions in the medication storage room were not expired.
*Expiration dates of medications in the obstetrical patient area were always checked before use.

Based on record review, observation, and interview, the provider failed to ensure the therapy and dietary departments were aware of the procedures to disinfect items used by one of one patient (32) with Clostridium Difficile (C-diff). Findings include:

1. Review of patient 32's medical record revealed she had a diagnosis of C-diff.

Observation from 6/27/11 through 6/29/11 revealed patient 32 had cautionary signage on the door to her room for contact isolation to be maintained. Those precautions included wearing protective gowns and gloves and for strict handwashing to be used.

Observation on 6/28/11 at 8:25 a.m. revealed registered nurse (RN) C removed patient 32's breakfast tray from her room and placed the tray on a cart. RN B then pushed that cart down the hall and placed the breakfast tray into a closed dietary food cart.

Interview on 6/28/11 at 2:00 p.m. with the registered dietician and certified dietary manager revealed:
*They were not aware patient 32 had C-diff.
*A quaternary or bleach solution was used on the enclosed patient tray cart by staff.
*Different staff used different disinfectants on the cart per their preference.
*They agreed the dietary staff were not aware patient 32 had C-diff.
*They agreed there could be cross-contamination during the handling of the dishes, utensils, and tray from patient 32.

2. Observation on 6/28/11 from 9:20 a.m. through 9:30 a.m. revealed physical therapist (PT) E and a PT student:
*Entered patient 32's room after donning protective gowns and gloves.
*Assisted patient 32 to don her robe and a gait belt after she had used the bathroom.
*Exited patient 32's room and removed the protective gowns and gloves.
*Neither PT E or the PT student washed their hands but applied new gloves.
*Walked with patient 32 to the elevator to go to the physical therapy department located on the first floor.

Interview on 6/28/11 at 10:55 a.m. with the director of therapy and the PT secretary regarding patient 32 revealed:
*The patient had been in the therapy department.
*The patient had worked with PT E and the PT student on climbing and descending steps.
*There was a set of wooden steps with hand railings located in the therapy department.
*A Sani-Wipe that contained a quaternary solution would have been used to disinfect the hand railings and other surfaces that had been touched by patient 32.
*They were not aware the Sani-Wipes were not effective in killing the C-diff organism.

Based on observation, testing, label review, policy review, and interview, the provider failed to comply with proper food handling practices and instill appropriate food safety guidance and hygienic practices to food service workers. Findings include:

1. Observation on 6/27/11 from 4:15 p.m. to 5:10 p.m. and again on 6/29/11 from 10:00 a.m. to 10:30 a.m. revealed the following in the kitchen and in the cafeteria:
a. Two heads of lettuce were laid in the bottom of the left side of the two compartment sink. Continued observation revealed the left side of the two compartment sink was not equipped with an air break. The right side of the sink was equipped with an air break. On the second day of observation two heads of lettuce and two honey dew melons laid in the bottom of the left side of that same sink. Interview at 10:05 a.m. on 6/29/11 with the certified dietary manager (CDM) confirmed that finding. She stated she was aware the left side of the sink did not have a physical air break. She stated staff liked to use that side where the garbage disposal was located.
b. Baking pans (cake and bread pans) and salad bar containers were found stored right side up on the stainless steel shelf next to the walk-in cooler door. Interview at 10:05 a.m. on 6/29/11 with the CDM confirmed that finding. She stated she was aware all pans, bowls, and other vessels must be stored inverted on open shelves to protect from contamination.
c. Slices of pumpkin pie were stored at room temperature on the serving line in the cafeteria. Interview at 10:10 a.m. on 6/29/11 with the CDM confirmed that finding. She stated the commercially frozen pies were baked in the kitchen. She said she had not seen a label on the box to ensure the pies were pasteurized and could be stored at room temperature. The CDM revealed she was not aware the eggs and milk in the pumpkin pie made the food potentially hazardous and must be kept refrigerated.
d. Four containers of sanitizing solution were located throughout the kitchen on both days of observation. Testing of those containers revealed both bleach and quaternary ammonia (quat) were used as a sanitizers. None of the containers were found within the correct parts per million (ppm) concentration. The ppm ranged from 10 ppm to 400 ppm for the bleach and 0 ppm to 100 ppm for the quat. Interview with the CDM at 10:15 a.m. on 6/29/11 revealed some cooks used the quat and others used bleach. She stated neither she, the cooks, or aides tested the sanitizers to ensure they were dispensed and/or made at the proper concentrations. She stated the staff did not test the containers throughout the day to ensure the quat and bleach were kept at the proper ppm. The CDM was not aware what the ppm should have been for the quat until she and the surveyor read the label together. The label revealed the solution for food contact surfaces must be kept at 200 ppm. The CDM was aware the proper ppm concentration for the bleach solution was 100 ppm.
e. Dietary aide (D) was observed wearing a cloth lace-up wrist brace throughout food service and preparation on both days of observation. Dietary aide D wore latex gloves, but those gloves did not completely cover the wrist brace. The uncovered wrist brace allowed the cloth to possibly become a method of cross-contamination when handling ready-to-eat foods and handling clean and dirty dishes. Interview at 10:25 a.m. on 6/29/11 with the CDM confirmed that finding. She stated the aide had broken her wrist and had to wear the brace. She agreed the gloves did not provide any protection from the partially uncovered wrist brace.

Review of the dietary policies revealed there were no policies to cover and give direction to the above concerns.

Based on record review, interview, and policy review, the provider failed to ensure accurate and complete nursing assessments were documented at the time of death for two of four patients' (20 and 25) death records reviewed. Findings include:

1. Review of patient 20's 4/17/11 nursing notes revealed:
*At 1:02 a.m. "All breath sounds were diminished."
*At 7:30 a.m. "All breath sounds remained diminished. The patient was lethargic. His skin was warm and dry."
*At 7:59 a.m. "Patient was pronounced dead. Patient's family in room at time of death."
*At 8:18 a.m. "Attending physician was notified of patient's death."

Review of the provider's December 2010 responsibilities in the notification, documentation, care, and removal of the body policy revealed:
*Upon the death of a patient, the observed absence of cardiac, respiratory, and neurologic function would have been documented.
*In expected deaths where the physician was not present, the registered nurse would have documented the signs and symptoms of death and notified the physician.

Interview at 10:55 a.m. on 6/29/11 with the health information manager confirmed no documentation was found for an assessment at the time of death for patient 20. She stated she was aware nurses were not able to pronounce death for a patient.

Interview at 11:30 a.m. on 6/29/11 with the director of nursing (DON) revealed he was unable to find any documentation related to an assessment at the time of patient 20's death. He confirmed an assessment according to the above policy should have been documented within the nursing notes at the time of death.



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2. Review of patient 25's nurse's notes on 2/23/11 at 7:36 a.m. revealed "Pt. (patient) passed away at 7:01 a.m. Family present at bedside."

Interview at 11:30 a.m. on 6/29/11 with the DON revealed he was unable to find any documentation related to an assessment at the time of patient 25's death. He confirmed an assessment should have been documented within the nursing notes at the time of death.