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Based on observation interview and document review the facility failed to ensure a sanitary environment in 2 of 7 Hospital departments reviewed. (Surgery, Dietary, Housekeeping, Laundry, Radiology, Laboratory, Respiratory services)

On 8/13/2015 at 11:30 a.m. a tour of the Dietary department, with staff #25, revealed the following observations:
1. Entry into the dietary department at the dishwashing station. Five, (5) missing wall tiles near the floor were observed. Four, (4) severely cracked floor tiles were observed where the wall joined the floor.
2. Observed in the refrigerator one (1), quart pot with a handle was observed to be covered with foil. The foil was over the top of the pot and a basting brush was sticking out of the pot. The content of the pot was an unidentified clear liquid. There was no date on the foil and the foil was not secure on the pot.
3. The surface of all the pots and pans which were suspended from the overhead rack were observed to be pitted and all were coated with a visible yellow sticky substance.
4. All the graduated metal mixing bowls were observed stored right side up on a lower level stainless steel shelf.
5. Nine, (9) baking sheets were observed with heavy carbon build up. These 9 baking sheets were stacked on each other and resting on a metal baker's rack that was coated with a sticky substance. The frame and shelves of the stainless steel baker's rack was covered in lint that had stuck to the rack resembling short gray hair.
6. External shipping boxes TNTC, (to numerous to count) were observed in the dry food storage stock room.
7. The red floor tiles were observed to have a black nonskid barrier applied. All the barrier surfaces were peeled up presenting a safety risk as well as sanitation risk.
8. Lower lever stainless steel shelving was observed with light oil and particulate matter visible.
9. Pans used for frying and baking were observed with heavy black carbon build up on the bottom of the pans.
10. The Commercial mixer was free from visible oils and was covered with a plastic cover; however, the base and arms of the mixer had visible paint chips in the surface making sanitation unlikely.
11. The deep well fryer was observed filled with oil. The lid and back of the fryer was observed to have a layer of a thick yellow sticky substance. The cook staff #14 was asked how often the deep fryer was used. She replied 1-2 times a week. Staff #14 was asked, when was the oil changed last? She replied " We changed it in May " . Staff #14 was asked if they scheduled the oil to be changed once a quarter and she replied "yes". Staff #25 was asked if she understood the cook to indicate the fryer oil had not been changed in three (3) months.
All of the above was witness and confirmed by Staff #25.
On 8/14/2015 in the conference room an interview with the Infection Control officer (ICO) revealed she made environmental rounds in the kitchen. She was asked what exactly was she looking for when she made rounds. What the Infection Control officer described was general safety precautions. She indicated she checked for extension cords in use or observed on the floor. She checked to ensure fire extinguishers were present and charged. Her observations did not include potential infection control risks in the dietary department. The dietary department submitted department specific information to the Quality Assessment Process Improvement but the ICO failed to recognize risks within the department that went unnoticed buy the department staff.

Based on document review and interview the facility failed to:
A. follow the manufacture's instruction for the use of an enzymatic/detergent product used to pre-soak endoscopic scopes. The manufacture's instruction for the product used to clean surgical instruments was not followed by the facility.
A review of the product label for the enzymatic/detergent used to pre-soak endoscopic scopes revealed add 1 oz. (1pump) of concentrate to one gallon of warm water (68F-104F) ....
A review of the product label for the detergent used to clean surgical instruments revealed add one half ounce (1/2 oz.) (measuring spoon enclosed) of cleaner to one gallon of warm water ....
An interview with staff #10 on 8/11/2015 at approximately 1:00PM revealed I add enough water to cover the scope and I put about three pumps of this product in the water. When asked how many gallons of water are used the response was" I just guessed." During an interview with staff #10 in dirty area of the instrument cleaning area staff #10 revealed I use enough water to cover the instruments and add a couple scoops of this powder. When asked how many scoops are used to a gallon of water the response "I just guess".
B. follow the AORN recommended practices and implementing AORN recommended practices for surgical attire.
On 08/11/2015 at approximately 11:45AM Dr. #28 was observed wearing a skull cap in the surgical area.
A review of the document titled AORN Recommended Practices, Implementing AORN Recommended Practices for Surgical Attire revealed Recommendation IV: All personnel should cover their head and facial hair when in the semirestricted and restricted areas.1(p62) Hair coverings should cover facial hair, sideburns, and the nape of the neck. Perioperative nurses can help minimize the risk of surgical site infections by covering head and facial hair, which prevents skin squames and hair shed from the scalp from falling onto the sterile field.17,18 Skull caps are not recommended because they do not completely cover the wearer's hair and skin; they fail to cover the side hair above and in front of the ears and the hair at the nape of the neck (Figure 8). Perioperative nurses can talk with their department managers and materials management department personnel to eliminate the availability of skull caps .....
An interview on 8/11/2015 with staff #8 confirmed that Dr. #28 was wearing a skull cap during a surgical procedure. Staff #8 confirmed the facility had not followed the AORN's recommendation and had not eliminated skull caps.

Based on document review and interview the facility failed to provide Registered Nurse supervision of the postanesthesia patients during their Phase II recovery.

Staff #11 (LVN) was observed as being the only nurse in the PACU (Post-anesthesia Care Unit)

A review of the Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings revealed during the Postanesthesia Phase I Level of care the RN roles in this phase is to focus on providing postanesthesia nursing care to the patient in the immediate postanesthesia period, and transitioning them to Phase II level of care.

Two RNs, one of whom is an RN competent in Phase I postanesthesia nursing, are in the same room/unit where the patient is receiving Phase I level of care.

Phase II level of care the nursing role during this phase focus on preparing the patient/family/significant other for care in the home or Extended Care level of care.

Two competent personnel, one of whom is an RN competent in Phase II postanesthesia nursing, are in the same room/unit where the patient is receiving Phase II level of care. An RN must be in the Phase II PACU at all times while a patient is present.

An interview with staff #11 (LVN) confirmed the RN was pulled to the operating room to circulate a case. Staff #11 confirmed being the only nurse in the PACU unit.