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Based on observation, interview, and record review, the facility failed to make sure the oversight of removing expired food (used for medical purposes) in the clean utility room (area used to store medical supplies) which affects all patients is consistent. This failed practice is likely to cause harm from food borne illness (disease caused by consuming contaminated food or drink.)

The findings are:

A. On 07/08/2021 at 9:00 am during tour of the Floor 7 ICU (Intensive Care Unit) clean utility room, the following was observed:
1. On a bottom shelf, four Glucerna (brand name, high protein nutritional drink) containers with manufacturer expiration date of May 1, 2021 and one can of TWOCAL HN (brand name, protein nutritional drink) with manufacturer expiration date of June 1, 2021.

B. On 07/08/2021 at 9:05 am during interview, Staff (S)#6 (Nurse Manager) confirmed the expired nutritional protein drinks on the shelf and confirmed dietary staff should check the clean utility room daily to remove expired items.

C. Record review of [name of facility] Title: Dietary- Food Expiration, Approved Date: 09/09/2020, Document Number P-DS-1044.1, page 1 of 2, under Policy section, revealed, "Food in the kitchen will be dated for expiration and disposed of on or before the date of expiration to ensure freshness." Under section Procedure/Guideline: item 2, revealed, "Upon receiving food, the store room clerk will verify all items have an expiration date on the product package from the manufacturer."

Based on observation and interview the facility failed to remove expired medications and medical supplies used for patient care from the medical supply room. This deficient practice can result in patients not receiving needed medical care because of the facility not having enough medical supplies that are within the recommended date of use before needing to dispose.

The findings are:

A. On 07/08/2021 at 10:00 am during observation of the Floor 9 Neuro Unit (an intensive care unit devoted to the care of patients with immediately life-threatening neurological problems), the following was observed in the medical supply room:
1. A box of (44) red cap Vacuette blood collection tubes (clear glass tubes used to collect blood), expired as of 03/11/2021.

2. Three bottles of BD BACTEC Lytic/10 Anaerobic/F Culture Vials (chemical sensor which can detect increases in CO2 produced by the growth of microorganisms.), expired as of 06/30/2021.

3. One bag of Covidien Stryker DL Disposable Cable & Wire System 5 Lead Ref 33135T (a wiring system that is connect to a patient to record the electrical signal from the heart to check for different heart conditions.), expired as of 02/23/2021.

B. On 07/08/2021 at 10:05 am during interview, Staff (S)#6 (Nurse Manager of ICU) confirmed the box of (44) red cap Vacuette blood collection tubes, expired as of 03/11/2021, three bottles of BD BACTEC Lytic/10 Anaerobic/F Culture Vials, expired as of 06/30/2021, and one bag of Covidien Stryker DL Disposable Cable & Wire System 5 Lead Ref 33135T, expired as of 02/23/2021.

Based on observation and interview, the facility failed to maintain a safe physical environment by identifying and managing the integrity (condition) of patient rooms to minimize the spreading of infections or communicable diseases. This failed practice is likely to expose patients to infectious diseases.

The findings are:

A. On 07/07/2021 at 11:00 am during tour of Floor 7 ICU (Intensive Care Unit) the following was observed:
1. Patient room 7128, the toilet seat was broken and the screw to hold the toilet seat cover was exposed. Both cabinet storage unit doors and the door handles on the cabinet storage unit were loose.
2. Patient room 7129, both door handles on the cabinet storage unit were loose, and one of the handles was broken and half of the handle was missing. An electric outlet by where the head of the bed is placed was loose and leaning forward.
3. Patient room 7130, the door handle on the cabinet storage unit was loose and one other door to the cabinet did not have a handle. In a storage bin near the entrance, the laminate (material used for countertop coating made of natural materials that are much more susceptible to damage from water and cleaning products) was cracked and in some areas the laminate was missing.
4. Patient room 7132, both door handles on the cabinet storage unit were loose. In a storage bin near the entrance, the laminate was cracked and in some areas the laminate was missing.

B. On 07/08/2021 at 9:00 am during tour of Floor 9 Neuro Unit (an intensive care unit devoted to the care of patients with immediately life-threatening neurological problems), the following was observed:
1. In several patient rooms, the laminate edges on the sink countertops, were missing, loose, or taped down with clear tape on both sides of the countertop.

C. On 07/07/2021 at 11:20 am during interview, Staff (S)#3 (Director of Medical ICU) confirmed the broken toilet seat, cabinet storage loose doors and loose or missing door handles, laminate cracked or missing, and the loose and leaning forward electric outlet.

D. On 07/08/2021 at 9:20 am during interview, Staff (S)#6 (Nurse Manager of ICU) confirmed that the edges on the sink countertop, the laminate was either missing, loose, or taped down with clear tape on both side of the countertop.

Based on observation and interview the facility failed to maintain the integrity or replace the equipment which would prevent the spreading of infections or communicable diseases. Provide and monitor a sanitary (clean and free from dirt, bacteria, or etc.) environment to minimize the transmission of communicable disease within the unit by ensuring proper housekeeping processes are done correctly. This failed practice can place patients at risk for exposure to infectious diseases while receiving treatment.

The findings are:

A. On 07/07/2021 at 11:00 am during tour of Floor 7 ICU (Intensive Care Unit) the following was observed:

1. Patient room 7123, the lining on the area where the patients back would be on the mattress was faded (due to the disinfectant solution used to clean), and there was a tear (approximately 1 inch in diameter.)

2. Patient room 7129, the lining on the mattress had several dark spots (unable to determine if blood or from a medical solution to treat wounds.)

B. On 07/07/2021 at 11:05 am during interview, Staff (S)#3 (Director of Medical ICU) confirmed the faded area and tear on the mattress lining, and the several dark spots on the mattress lining (unable to determine if blood or from a medical solution to treat wounds.)

Based on observation, interview and record review, the facility failed to provide and monitor a sanitary (clean and free from dirt, bacteria, or etc.) environment to minimize the transmission of communicable disease within the unit by ensuring proper housekeeping processes are being done daily and correctly and ensure adequate infection control measures are in place by not throwing all sharps (needles) in the sharps receptacle (a puncture-resistant and leak-proof container). This failed practice can place patients at risk for infections and could lead to accidental injury with potentially contaminated needles while receiving medical treatment.

The findings are:

A. On 07/07/2021 at 11:05 am during a tour of Floor 7 ICU (Intensive Care Unit) the following was observed:
1. Room 7123, the floor was dirty (covered or marked with an unclean substance) and appeared to not have been swept or mopped.
2. Room 7129, the floor was dirty (covered or marked with an unclean substance) and appeared to not have been swept or mopped. The entrance glass door had markings that appeared to be from when the glass was wiped but not dried. A medical drip IV stand (device that keep intravenous (administered into, a vein or veins) bags full of medicine or fluid in place. The bags are hung from the hooks at the top of the pole.) had a yellow sticky substance on the monitor platform and on the bottom base where the wheels are. Underneath the sink and at the base of the toilet there was dirt and white debris (scattered pieces of waste or remains.)

B. On July 7, 2021 at 1:30 pm, a flash tour of the 7th floor ICU was conducted and observation revealed blood sugar lancets (finger stick needles) being disposed of in the regular trash. Any instruments used to pierce skin are now considered contaminated, as they have come in direct contact with potentially infected blood. These instruments need to be thrown away in a sharps container (hard plastic container specifically made to prevent contact with needle tip after it is inside the container).

C. On 07/08/2021 at 9:25 am during observation of room 7129 to confirm complete cleaning and disinfecting process the following was revealed:
1. The dirt and white debris under the sink and at the base of the toilet had not been cleaned from the previous day.

D. On 07/07/2021 at 11:10 am during interview, Staff (S)#3 (Director of Medical of ICU) confirmed the spots on the floor and it was noticeable the floor was not swept or mopped in room 7123 and 7129, and the dirt and white debris under the sink and at the base of the toilet.

E. On 07/07/2021 at 10:15 am during interview, S#3 confirmed when a patient is discharged, nursing staff and EVS (Environmental Services) are notified through the facilities (EPIC) computer system to clean and disinfect the room.

F. On 07/07/2021 at 10:20 am during interview, S#3 confirmed nursing staff is responsible to remove the linens (bed sheets), throw the trash, wipe down monitor cables, and wipe down pumps (used for patient care to push air through) and EVS (Environmental Services) staff is responsible to clean the floors, cabinets, chairs, and the toilets.

G. On 07/07/2021 at 10:30 am during interview, S#3 confirmed room 7129 was marked as cleaned and ready for patient use by a nursing and EVS staff.

H. On 07/07/2021 at 2:35 pm during interview, S#7 (Environmental Service Director (EVS) confirmed EVS staff is responsible to clean under sinks, around the base and the top of the toilets, clean the floors, cabinet countertops, and chairs. S#7 confirmed the dirt and white debris under the sink and at the base of the toilet. S#7 will have S#8 (EVS Tech) clean under the sink and near the base of the toilet. S#7 confirmed room 7129 was marked as cleaned and ready for patient use by an EVS staff.

I. On 07/08/2021 at 10:30 am during interview, S#4 (Process Improvement Engineer) confirmed the dirt and white debris from the previous day under the sink and at the base of the toilet in room 7129.

J. Record review of [name of facility] Title: Environmental Services- Cleaning Patient Rooms, Effective Date: 02/03/2015, Reference# 2996 Version: 3, page 1 of 4, under Procedure: Occupied Patient Rooms: Non-Isolation section, revealed, "Empty all waste containers. Dust all fixtures, ledges and surfaces in the and bathroom. Damp dust over bed tables, bedside tables, telephone, chairs, stools, ledges, light switches, lamps and spots on walls or cabinets with a hospital-approved germicidal solution (a cleansing solution to disinfectant or sanitize hard surfaces.) Dust mop floor as per procedure (depending on floor covering). Place wet floor signs at the door to the room. "

Based on record review and interview, the governing body (administration) failed to ensure the safety of patients by not maintaining an oversight of removal of expired food, a safe physical environment by identifying and managing the integrity (condition) of patient rooms, providing and monitoring a sanitary (clean and free from dirt, bacteria, or etc.) environment to minimize the transmission of communicable disease within the unit. This failed practice has the potential to increase the risk of harm from food borne illness (disease caused by consuming contaminated food or drink), exposure to infectious diseases while receiving medical treatment.

The findings are:

A. Record review of [name of facility] Title: EC (name of form) Ongoing Environmental Tours, Approved Date: 04/19/2021, Document Number P-PE-1007.5, page 1 of 2, under Policy section, Item b) revealed, "Environmental tours of all patient care areas of the facility will be performed on a minimum of every six months basis." Under Item d) revealed, "The Hospital Environmental tours team consist of representatives from: i) Safety, ii) Security, iii) Physical Plant, iv) Infection Control (1) Not all are required to conduct tours." Under Item e) revealed, "The Safety Officer is responsible for notifying responsible department Manager/Director of any deficiencies." Under Item h) revealed, "All hazards will be communicated to the appropriate department(i.e., work orders issued) to repair as soon as possible depending on the hazard with necessary precaution taken to preclude all injuries. Any condition is found which poses an imminent risk to patients, visitors or staff will receive immediate mitigation.

B. Record review of work orders dated between 01/24/2021- 05/23/2021 submitted on the new computer software Wizard (name of software) for the 7th floor ICU unit revealed:
1. None of the work orders submitted included requesting repairs for the loose cabinet doors
2. Loose door handles on the cabinet storages
3. The loose broken in half door handle
4. The missing cabinet door handle
5. The cracked and missing laminate (material used for countertop coating made of natural materials that are much more susceptible to damage from water and cleaning products) on storage bin near the entrance of the patient rooms.

C. Record review of work orders dated between 02/10/2021- 03/15/2021 submitted on the new computer software Wizard (name of software) for the 9th floor unit revealed:
1. None of the work orders submitted included requesting to repair the edges on the sink countertop, the missing laminate or taped down laminate with clear tape on both side of the countertop.

D. On 07/07/2021 at 10:45 am during interview, Staff (S)#3 (Director of Medical ICU) confirmed if there is anything in any of the patient's rooms that needs to be fixed, repaired or removed a work order will be submitted on the facilities computer system. S#3 confirmed staff that sees an area of concern can submit the work order request or call the Facility Director or Environmental Services Director.