The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

WESLEY MEDICAL CENTER 550 N HILLSIDE STREET WICHITA, KS 67214 Aug. 22, 2018
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, interviews, current and discharged record reviews, and document reviews the hospital failed to provide a sanitary dietary service area and patient care areas to include 2 of 2 kitchens with trash/dirt and food debris on floor,1 of 2 kitchens with broken floor tiles, moldy food, lime build up to dishwasher and a cockroach on the floor, 5 of 8 patient tower units (tower 3, 7, 8, 9, and 10) with mobile patient equipment with dirt build up on the bottom, 2 of 8 patient tower units (tower 7 and 8) had soiled utility rooms with dirty floors and unflushed flushable basins, 1 of 8 patient towers (tower 3) had clean utility rooms with uncovered linen carts, 2 of 8 patient towers (tower 3 and 8) had clean supply rooms with boxes on the floor, 1 of 1 dietary hostess in and out of patient rooms without cleaning computer equipment, 1 of 4 ICU's (SICU) had unflushed flushable basins, and 1 of 4 ICU's (SICU) with dust coated equipment cart with items for repair. The hospital's systemic failure to ensure a sanitary environment has the potential for serious negative impact on patient health, increases the patient risk for hospital acquired infection and the spread of communicable disease to patient, staff and visitors.

Findings include:

Document review of the hospital's policy titled "Infection prevention and Control Plan revised 07/2018 showed the Infection Prevention and Control program is to protect patients, visitors and healthcare professionals from harm due to infectious agents and promote safety, quality and value in the healthcare services delivered.

Document review of the hospital's policy titled, "Patient Care Equipment and Cleaning," revised on 02/2017 showed staff must clean and disinfect all reusable patient equipment within the facility after each patient use.

Document review of the hospital policy titled "Prevention of bed bug, cockroach and other pest" revised 03/2018, showed that plant operations is responsible to coordinate with environmental services and exterminator if base cover or wall coverings need to be removed for further inspection or extermination.

1. Observation on 08/20/18 between 9:15 AM and 10:15 AM and 08/21/18 of the main kitchen between revealed the following:
a. one live cockroach on the kitchen floor by the food prep sink.
b. dishwasher with lime deposit on side of machine
c. dishwasher parts laying on the floor coated with lime deposits
d. multiple missing and broken floor tiles
e. food splashes dried on multiple walls
f. food crumbs under dry goods shelving and kitchen equipment
g. dry goods shelving located near employee timeclock with food dried and stuck to it
h. floor drain with trash and food built up near the kitchen manager entrance
i. line of refrigerators with dried food spills on the surface
j. kitchen fan with dirt buildup on the fan cage
k. kitchen floors with dirt, small trash, and food items
l. produce cooler showed a putrefied cucumber with liquefied moldy growth and three hamburger buns with greenish moldy growth.
m. Food Cooler located in the public service area showed three peanut butter and jelly sandwiches with a use by date of 08/20/18.

During an interview on 08/22/18 at 11:15 PM in the conference room, Staff W, Food and Nutrition Services (FNS) Director, stated that the staff are responsible for cleaning the area they work in. Staff W stated that the chef is responsible for ensuring that staff complete all cleaning as well as checking the coolers and refrigerators for outdates and removing foods as needed. Staff D stated that he performs random spot checks in the kitchen but realizes now that he must increase his efforts.

During an interview on 08/20/18 at 9:30 AM in the kitchen, Staff D, Executive Chef, stated that kitchen staff clean their kitchen instead of environmental services (EVS). Staff D stated that he is responsible for providing oversight and making sure things are clean. Staff D stated that staff should have cleaned all the items identified and does not know why they had not been and failed to answer why he had not reported cleaning failures to the department manager.

During an interview on 08/20/18 at 9:45 AM in the kitchen managers office, Staff G, Kitchen Retail Manager, stated that she put in work orders for the broken tiles, but EVS denied them. She stated that plant operations staff told her to put in a small project request. Staff G stated that she needed to do that today.

During an interview on 08/22/18 at 11:45 AM via telephone, Staff W, FNS Director, stated that kitchen staff reported the broken and missing floor tiles to EVS on 01/01/18 but EVS told them they were going to be fix it as a big project. Staff W stated that kitchen staff have not done anything to reduce infection risks that broken floor tiles cause.

During an interview on 08/22/18 at 1:30 PM in the conference room, Staff X, Plant Operations Director, stated that he has two million square feet, so he must rely on the department managers to tell him if the need for repairs are necessary and need immediate attention. Staff X stated that of we put a repair request on hold the manager should notify us if there is an immediate necessity for us to complete the repair.

During an interview on 08/22/18 at 12:00 PM in the conference room, Staff W, FNS Director, stated that he does not receive reports from the contracted pest control company and was not aware of any repairs they may have recommended.

Review of contracted pest control company's records on 08/22/18 at 2:00 PM showed customer service report findings from the service date of 08/03/18 were that "cockroaches were noted during service; cockroaches noted at bread wall, wall void in main kitchen. A hole/gap noted Steele plate on bread wall is loose and there are gaps on the other side of wall under the sink in main kitchen. Please seal to help prevent pest activity."

Review of the kitchens pest sighting/evidence log from 01/01/18 through 08/20/18 showed the following entries:
a. 03/13/18 Bugs; cooks hot line
b. 05/30/18 roach; behind food line
c. 06/20/18 three roaches; under warmer on caf
d. 07/27/18 roach; main kitchen around small ice machine
e. 08/13/18 roach; main kitchen, cold prep by cooler holding patient fruit and liquids

During an interview on 08/22/18 at 1:00 PM in the conference room Staff Y, EVS Director, stated typically he would put in a work request based off their pest control contractors report and communicate with the necessary parties. Staff Y stated he does not recall ever getting that report or the contractor communicating with anyone about the needed repairs. Staff Y stated that either he or the kitchen manager should have put in the work order

2. Observation on 08/20/18 at 10:00 AM of the "Four Corners Caf" showed an island containing soda and condiments with food and trash underneath.
During an interview on 08/20/18 at 9:45 AM Staff D, Executive Chef, stated that staff can not the island, but they should still be sweeping and mopping underneath it.

3. Observation on 08/20/18 at 11:30 AM of the 10-Tower Stroke Unit showed the following:
a. clean supply room with two mobile vital sign monitoring machines with dirt buildup on the base.

4. Observation on 08/20/18 at 11:45 AM of the 9-Tower Orthopedic/Neurological Unit showed the following:
a. two rolling patient equipment stands with a white powdery substance on the base of the stand and one with a thick layer of dust on the base of the stand.

5. Observation on 08/20/18 at 12:00 PM of the 8-Tower Oncology Unit showed the following:
a. soiled utility room with dirty floors and a white powder (Absolute Solidifier used in suction containers that contain bodily fluids to make the fluid gel like) spilled all over the counter
b. unknown fluids in the unflushed basin
c. one clean supply room with four boxes containing patient supplies laying directly on the floor
d. four rolling patient equipment stands with dust and build of dirt on the base of the stands in several locations throughout the unit.

During an interview on 8/20/2018 at 12:15 PM in the clean supply room staff B Registered Nurse (RN) Director of Quality and staff N RN stated that staff must not store boxes of supplies on the floor. Staff B explained the staff from purchasing unload the supplies in the loading dock area and bring them up to the units.

6. Observation on 08/20/18 at 2:45 PM of the 7-Tower Medical/Trauma Unit showed the following:
a. soiled utility room with dirt and a dried spill on the floor
b. In the alcove where they store clean equipment showed two rolling patient equipment stands with dust and dried spills on the base of the stand
c. unknown fluids in the unflushed basin

7. Observation on 08/20/18 at 3:05 PM of the 5-Tower Pediatric Unit showed the following:
a. glove on the floor near room 517
b. trash on floor near the clean utility room

8. Observation on 08/20/18 at 3:25 PM of the 3-Tower Cardiac Step-Down Unit showed the following:
a. South side clean utility room with open door to the linen cart
b. full bag of trash leaking onto the floor outside of room 4-310. No unit staff members were nearby with knowledge of the trash bag on the floor
c. North side clean utility room with three boxes stored directly on the floor and a three-tiered utility cart in the clean utility room with uncovered laundry on it.
d. in the nourishment kitchen showed a microwave oven with food spills inside of it
e. a soiled utility room with a sticky substance on the floor
f. Point of use room contained two WOWs (work station on wheels) with dirt and dried spills on the base and five rolling patient equipment stands with dust and dried spills on the base of the stands.

During an interview on 08/20/18 at 3:25 PM near the clean supply room, Staff Z, an unidentified Registered Nurse (RN), stated she put in a work order for the broken door. Staff Z failed to place a cover over the clean linen cart until EVS could repair the door leaving them exposed to dust and dirt buildup.

During an interview on 08/20/18 at 3:30 PM near room 4-310, Staff B, Director of Quality, stated that staff should never leave trash unattended and on the hallway floor.

9. Observation on 08/20/18 at 3:55 PM of the 2-Tower Endoscopy/Pediatric Sedation Unit showed the following:
a. missing ceiling tile in the clean supply room
b. sharps container secured to a workstation on wheels (WOW) with a zip tie

During an interview on 08/20/18 at 4:00 PM near a hallway charting station, Staff AA, RN, stated that she knew staff should not have attached it to the WOW like that and said she had never seen anything like that before. Staff AA stated she didn't know who to call to get it removed. Staff B directed Staff AA to cut the zip tie with a pair of scissors to remove the sharps container from the WOW.

10. Observation on 08/21/18 at 9:20 AM in the Medical Intensive Care Unit (MICU) showed staff K, dietary hostess, typing on a small computer that she placed on the patient's overbed table in patient room #4. Staff K exited the patient's room performed and entered another patient's room without disinfecting the small computer's surface.

During an interview on 8/21/18 at 9:25 AM at the nurse's desk Staff K stated that they go to each patient's room to review the days menu with the patient and enter what the patient wants to eat for that day.

During an interview on 8/21/18 at 9:25 AM at the nurse's station Staff A, Infection Control Officer, confirmed they observed Staff K going from one patient's room to another patient's room without disinfecting the surface of the computer.

11. Observation on 08/21/18 at 9:50 AM in the Surgical Intensive Care Unit (SICU) showed a soiled utility room with dirty water in the flushable basin. A utility cart on the unit with a gray bin containing the following items for repair; patient call lights and castor wheels for a chair. The bin had a heavy buildup of dust in the bottom of the bin.

During an interview on 08/21/18 at 9:55 AM with Staff M, Registered Nurse (RN), observed and confirmed the dust build up in the bin that held items for repair.

During an interview on 08/21/18 at 9:50 AM in the soiled utility room with Staff L, Director of Critical Care, stated that it probably was housekeeping staff because they dump the dirty water from the floor cleaning machine in the flushable basin.

12. Observation on 08/21/18 from 10:20 AM to 10:40 AM in the Emergency Department (ED) showed in the "Ready Care" area one rolling patient equipment stand with dust and dirt build up on the base and one trash can with a blood droplet on the outside surface, in the "Triage" area one rolling patient equipment stand with dust and dirt build up on the base, and in the "Trauma Room" area four rolling patient equipment stands with dust and dirt build up, one metal stand with dust and dirt build up, eight wood "documentation stations" on wheels with chips and gouges in the surfaces of the wood exposing the bare wood, rendering them uncleanable.

During an interview on 8/21/18 at 10:40 AM, Staff A, Infection Control Officer, stated that the "documentation stations" have uncleanable surfaces because of the exposed bare wood.