HospitalInspections.org

36293


Based on observation, interview the CAH's infection prevention and control program failed to ensure a clean and sanitary environment that avoided potential transmission of infection was maintained.
Findings:

On 01/18/2022 at 11:50 a.m., observation of the medical surgical ward's number two hallway's clean utility room revealed and ice chest with the ice scoop stored inside the chest.

In an interview at this time, S2CNO who accompanied the surveyor during the observation, acknowledged the finding and state the scoop was not to be stored inside the ice chest.

On 01/18/2022 at 1:45 p.m., observation of the food storage areas in the kitchen revealed 5 storage bins containing sugar, bread crumbs, flour, fish fry mix and graham cracker crumbs were located in the pantry. The scoops inside each container were laying directly on top of the food product in the bins.
Observation of the refrigerator revealed a green melon that had been cut in half and covered with clear plastic wrap - it was not labeled with identification or date.
Observation of the freezer revealed a pan of rolls and a pan of leftover sheet cake which was covered with clear plastic wrap - they were not labeled with identification or date.

In an interview at this time, S8DM confirmed that the scoops should have been placed in the plastic holders inside the storage containers and that the food in the refrigerators and freezers should have been labeled prior to storage.

On 01/20/2022 at 8:15 a.m., observation of operating room one following a terminal cleaning revealed hair grime and debris on the visible surfaces of the ventilator, anesthesia drug cart, the computer tower and the framework of the bed located in the operating room. Further observation revealed tears/cracks in the vinyl covering of the bed's mattress which prevents proper sanitizing of the mattress.

In an interview at this time, S6SM who accompanied the surveyor during the observation, acknowledged the findings and stated the room was not properly cleaned.

On 01/20/2022 at 8:30 a.m., observation of the recovery room revealed a mattress in bay one with rips/tears to the vinyl covering which prevents proper sanitizing of the mattress

In an interview at this time, S6SM acknowledged the findings.

Based on observation and interview, the hospital failed to ensure signage (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; was posted conspicuously, in the emergency department and places likely to be noticed by all individuals entering the emergency department. This deficient practice was evidenced by failure to post EMTALA (Emergency Medical Treatment and Labor Act) signage outside of the emergency department's entrance, inside the registration area and triage room, or in the treatment areas for rooms 1, 2 and 3 of the emergency department.
Findings:

On 01/18/2022 at 1:30 p.m., an observation was conducted of the hospital's emergency department accompanied by S3EDManager. Further observation revealed there was no EMTALA signage outside of the emergency department's entrance, inside the registration area and triage room, or in the treatment areas for rooms 1, 2 and 3 of the emergency department.

During an interview at this time, S3EDManager acknowledged the findings.