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Based on observation, interview, and document review, the facility failed to maintain accurate records of expired scheduled/controlled drugs (e.g. narcotic, anxiety medications), resulting in the potential for improper use and/or abuse of these drugs for all patients served by the facility. Findings include:

Observation of the Pharmacy Controlled Medication Room, on 7/22/19 at approximately 1530, revealed that the expired scheduled/controlled drugs (e.g. narcotics, anxiety) were stored in a separate locked area in the room. A request to review and count one or two categories of expired controlled drugs revealed that it could not be done until XYZ disposal company came to pick them up. Interview with Pharmacist WW, on 7/22/19 at approximately 1600 revealed that pharmacy staff reconciled any discrepancies of the count with XYZ disposal company monthly. A request for the last two "Drugs Surrendered for Disposal Logs," revealed the following:

On 5/1/19 Fentanyl in an intravenous (IV) drip of five percent dextrose in water (D5W), 1000 micrograms (mcg) /100 milliliters (ml) count was to be two (2), but only one (1) was surrendered. There was no notation of what happened to the other bag.
The count for Fentanyl-Bupivacaine 5 mcg/0.075% 1250 mcg/ 250 ml epidural bag was to be three (3), but only one (1) was surrendered. A note that there were two Dilaudid 5 mg IV drips that must have made up the count was documented.

On 4/3/19 Lorazapam (Ativan) /D5W IV drip 25 mg/250 ml intravenous count was to be one (1), but the surrendered count was two (2). No documentation was noted for the discrepancy.

Further interview with the Pharmacy Director VV, on 7/24/19 at approximately 1100, revealed that a perpetual updated count had not been maintained. On 7/24/19 at approximately 1115, review of the facility policy and procedure titled "Medication Distribution of Controlled Substances, MM-6F, dated 2/2018" documented, "An expired Schedule II Controlled Substance Log or electronic equivalent must be used to document the presence of expired or otherwise unusable Schedule II medications in the pharmacy prior to their disposition." This same language also applied to Schedule III-V controlled substances.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated July 24, 2019.
K-0223
K-0321
K-0353
K-0363

Based upon observation and interview, the facility failed to maintain the physical environment to provide occupants a safe and functional environment resulting in the potential for less than optimal outcomes for all patients
Findings include:

On July/22/2019 between the hours of 1030 and 1630 the following observations were made:

1. The bio med room located on the 2nd floor of the Central Tower where machines are serviced and disinfected is not equipped with the required eyewash station. The typical eyewash station shall be a hands-free type, provided with tepid water, and must be readily accessible for use and to comply with applicable code. Areas subjected to handling of blood and cleaning and handling of bleach and other corrosive materials where used to conduct daily services at this facility must have a fully compliant eyewash station(s) per OSHA/ANSI (Occupational Safety and Health Administration/American National Standards Institute) requirements ANSI Z358.1 - 2014.

2. The central shower room serving the 4th floor of the Central Tower have the required nurse call system placed outside of the shower wall preventing the proper use of the call system should the need to use the call arises.

3. Medication room located on the 4th floor of the Central tower is not equipped with the required handwash sink. The room was noted to have a work desk and the illumination level is dim. Minimum of 50 foot-candle (fc) lighting is required. No work desk and/or staff belonging is permitted in medication room.

Above findings were confirmed by staff AA and unit managers on 7/23/19 at the time of the observation

This citation has mulitple deficient practice statements.

Deficient practice statement #1:

Based on observation and interview the facility failed to ensure sanitary conditions at various locations including but not limited to typical patient floors (South and Central Towers), Pharmacy, Radiology, Surgery, Lab, and Emergency Departments resulting in the increased potential for cross contamination and infectious disease and/or agents to all patients and working staff. Findings include:

On 7/22/19 and 7/23/19 during the tour of the South and Central Towers between 10:30 AM and 16:30 PM, the following observations and interviews were made:

1. The typical nourishment room refrigerator serving the typical patient floors have ice cubes bins with a scoop inserted into the ice and inside the freezer promoting a cross contamination as multiple hands will come in contact with the ice and the inserted scoop. This finding was typical on all patient floors at both towers.

2. The drain hose for the Ice machine serving the 9th floor of the South Tower nourishment room is tucked inside the drain inlet without the required air-gap of at least 1" or twice the diameter of the drain pipe or hose allowing for the potential for cross contamination should the ice machine goes into reverse mode.

3. The typical clinical sink serving the typical patient floor's soiled utility at both Central and South Towers is not equipped with the proper back splash shielding promoting the potential for cross contamination to working staff clothing.

4. Multiple unused live water lines were discovered at various locations including but not limited to exam/treatment room across from patient room 1219 on the 12th floor of the South Tower, unused/abandoned showers on 4th and 6th floors Central Tower, and Patient rooms 651, 652, 667, 668, 669, and 670 on the 6th floor of the Central Tower have a typical live water lines dialysis box. The typical dialysis box does not get exercised and is creating the dead leg concept as confirmed by the unit managers. All unexercised live water lines can promote bacteria growth.

5. High dusting is a typical issue at the Lab, Pharmacy, Emergency, and Radiology Departments. Dust was visible on the mast arm of the task light at operating rooms #5 of the Surgery, Wall cabinets surfaces in Lab and Pharmacy, also, on the floors of the Lab, Emergency, and Radiology Departments.

6. Floor fans were in use in each of the Blood, Histology, General chemistry, Hematology, and Micro Biology of the Lab Department. Working fans are not permitted as the can be a source for potential of spreading of infectious agents from one location to the other. This finding confirmed by the Lab Manager.

Above items confirmed by accompanying staff AA, R, and QQ at the date and time of the survey.


15195

Deficient Practice Statement #2

Based on observation, interview, and record review, the facility failed to maintain infection control precautions for one (#24) of three patients observed in isolation, resulting in the potential of cross infection for 18 patients on the intensive care unit. Findings include:

During observational tour of the of the 5 South Intensive Care Unit, on 7/22/19 at 1140, room 511 (patient 24) was observed with staff (except Staff Z) in the room gowned and gloved. A sign just outside the door was posted, "Contact Precautions." Interview with the Unit Director, on 7/22/19 at 1141, revealed "he (Staff Z) should have a gown and gloves on." The Director handed Staff Z a gown to put on.

Review of patient 24's electronic medical record with Staff Y, on 7/22/19 at approximately 1200, revealed that the patient had a tracheostomy and was in contact precaution isolation for multi-drug resistant organisms (MDRO) and Methicillin resistant staph aureus (MRSA) in the sputum. On 7/23/19 at approximately 1200, review of the facility policy titled, "Isolation Precautions, IC-407, dated 5/10/19" documented, "Contact... Patient placement in private room (if possible)... Wear gloves when entering the patient's room...Wear a gown when entering the room..."




27408

Deficient Practice Statement #3

Based on observation, interview and policy review, the facility failed to ensure the policy for proper surgical attire was followed which could result in the potential for infection for the 41 patients being treated in the 14 operating rooms and the 4 patients being treated in the Vascular Lab ("Hybrid Room") on the observation date of 07/23/19, as well as all patients being treated in the 14 operating room suites. Findings include:

On 07/23/19 at 1400, during tour of the Vascular Lab ("Hybrid Room") with Staff JJ, three male staff members (Staff KK, Staff LL and Staff NN) were observed standing at the bedside wearing skull caps only. At this time, 1400, Staff JJ was asked if the three males work at the facility and if they work in the restricted areas. Staff JJ stated, "yes they all work here in the lab". Staff JJ was further queried regarding if skull caps were regularly worn by staff in the restricted areas and what their policy was. Staff JJ stated, "yes most of the guys wear only the skull caps. I know our policy reflects it (the covering of the skull cap with the bouffant cap). We will just need to reinforce it."

On 07/23/19 at 1420, during tour of the Surgical Services/Operating Room (OR) area, it was noted in OR #3, that Staff MM (Resident), was in the OR completing a surgical procedure wearing a skull cap with no required bouffant cap, in the restricted area. During an interview with Staff JJ (Director of Surgical Services) at 1420, Staff JJ was asked if the three males work at the facility and if they work in the restricted areas. Staff JJ stated, "yes they all work here, two of them are doctors and the other is a registered nurse. " Staff JJ was further queried regarding surgical attire and if skull caps were regularly worn. Staff JJ stated, "yes many of our male employees wear skull caps, I did know that, and our policy reflects it. We will enforce that (the covering of the skull cap with a bouffant cap."

On 07/23/19 at 1600, during review of the policy titled "Protocol For Proper Operating Room /PACU (Post Anesthesia Care Unit) (Central Processing Department) /Endo Attire" dated "June 2015" stated under provision # "12. Because the hair can harbor bacteria, skullcaps that fail to cover side hair and hair above the ears and hair in the nape of the neck, are unacceptable; a disposable bouffant cap must be worn."


32000

Deficient Practice Statement #4

Based on observation and interview the facility failed to ensure sanitary conditions in the kitchen resulting in the increased potential for cross contamination of food, foodborne illness and transmission of infectious agents to 317 patients receiving oral foods. Findings include:

On 7/22/19 during a dietary tour of the kitchen between 11:16 AM and 1:53 PM, the following observations and interviews took place:

1. An accumulation of dust and debris was observed on multiple exhaust and supply ventilation grates in the dishwashing, pots and pans storage, main food preparation, baking closet, and dry storage areas of the kitchen. On 7/22/19 at 11:28 AM, upon interview with the dietary manager, staff AA, on who is responsible for the cleaning of the exhaust and supply ventilation grates they stated, "I'd have to talk to maintenance for information about the filters, but we would clean around the outside".

2. On 7/22/19 at 11:40 AM, 22 dead flies were observed on the bottom interior of the reach-in "jello" cooler. Upon observation the surveyor inquired with staff AA if the facility was aware of the current state of the cooler to which they stated, "no, we will get someone on this right now." At this time the surveyor inquired with staff AA if the facility handles their own pest control on site or if a third party assists them with this task, to which they replied, "we have a pest control company that comes out every month, but my cooks are supposed to clean the interior of these units every Monday".

3. On 7/22/19 at 11:50 AM, an air gap of at least 1" and twice the diameter of the receiving drain was not observed present on the three-compartment sink's rinse and sanitizing compartment drain lines. At this time upon interview with staff AA the surveyor inquired if there had been any recent changes to the plumbing system to which they replied, "I don't think so".

4. Multiple food contact surfaces were observed soiled with dried food debris on their surfaces such as slotted spoons, spatulas, serving plates, knives, and one of the #10 can openers. Between 11:16 AM and 1:53 PM, staff AA acknowledged each observation and was observed removing each of the items from their storage locations and placing them in the dish room for cleaning, or providing the items to staff members and instructing them to take the items back to the dish room for cleaning. On 7/22/19 at 12:38 PM, upon interview with Staff AA regarding the current state of the ready for use items they stated, "it happens, but we should have caught them".

5. Two bags of ice, two dozen individually portioned containers of pureed chicken, and two medium sized boxes of individually portioned cups of ice cream were observed stored on the floor in the vegetable and meat walk-in freezers. On 7/22/19 at 1:18 PM, upon interview with Staff AA regarding the practice of food being stored on the floor of these areas they stated, "we don't allow it. We get deliveries Monday, Wednesday, and Friday, but I don't know if the truck came today or not".