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.

MONUMENT HEALTH RAPID CITY HOSPITAL 353 FAIRMONT BLVD POST OFFICE BOX 6000 RAPID CITY, SD 57701 June 24, 2021
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, interview, and policy review, the provider failed to ensure accurate measurement of a liquid medication (med) was done for one of four patient medication administration observation (9) to prevent under or over medication. Findings include:

1. Observation on 6/23/21 at 8:50 a.m. of registered nurse (RN) Q administering meds to patient 9 revealed she:
*Had prepared to administer the patient 1250 milligrams (mg) of liquid Calcium Carbonate.
-The med had been dispensed into a unit dose container of 500 mg/5 milliters (ml).
-The patient's orders required him to have 12.5 ml of the med daily.
-That dose had required her to pour the med and measure it into a 30 ml med cup.
*Opened two containers of the med and emptied them into the med cup to make a total of 10 ml.
*Opened a third container of the med, held the med cup up to eye level, and poured more of the med into it.
*Stated the final measurement was between the 10 ml and 15 ml mark on the med cup.
*Asked the surveyor if that was what she saw?
*This surveyor stated "No, it was difficult to read."
*Administered patient 9 the Calcium Carbonate.
*Had not been observed placing the med cup on a level surface to ensure the patient was administered the correct dose.

Interview on 6/23/21 immediately after the above observation with RN Q confirmed:
*The method of administration for calcium carbonate was her normal process of administering that med.
*She needed to add 2.5 ml of calcium carbonate to the 10 ml already in the med cup for a final dosage of 12.5 ml.
*The final amount of calcium carbonate in the med cup was not accurate as she had estimated the last 2.5 ml added.
*The best practice would have been to measure out 2.5 ml in a separate med cup or syringe and then add it to the rest of the medication.
-That process would have supported a more accurate measurement of the med.

Interview on 6/23/21 at 3:42 p.m. with nurse managers M and P revealed:
*Medication administration should be as accurate as possible.
*A third medication cup should have been placed on a level surface and then pour the correct amount to provide an accurate measurement.
*If not using that method that could have been considered a med error for either underdosing or overdosing the patient.
*Appropriate medication administration was part of the nurse's scope of practice.
*Education on medication administration was provided during orientation and on different types of medication administration practices.

Review of the provider's September 2020 Medication Administration and Documentation policy revealed:
*One of the five rights of medication administration was the "Right Dose."
*Education for medication administration was provided on orientation, for new or revised processes and procedures, and on an as needed basis.
VIOLATION: INFECTION CONTROL Tag No: A0747
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







A. Based on observation, interview, record review, policy review, and job description review, the provider failed to ensure:
*Cleanliness was maintained in three of three observed patient care areas (main hospital operating suite, pre-operative anesthesia care unit (PreOp), and post-anesthesia care unit (PACU).
*Two of five surgical staff (C and D) had worn the required personal protective equipment (PPE) while assisting one of one surgical patient (1) who had an infectious disease.
*The infectious disease for one of one sampled patient (1) was reviewed during the time-out session prior to his surgical procedure by one of one registered nurse (RN) (C).
*Staff performed hand hygiene as required during two of two surgical procedures when care was provided for two of two sampled patients (1 and 2).
*Personal belongings for both the staff and patients were not taken into the operating room (OR) 3 during two of two observed surgical procedures.
*Linens for the patients were stored in a sanitary manner in the PreOp and PACU.
*Equipment and supplies were stored in a sanitary manner in one of one PreOp area (clean utility room and stretcher storage room).
*Biohazardous wastes of soiled linens and garbage had been properly stored in a designated soiled utility area (Dirty/Elevator area).
Findings include:

1. Interview and review of patient 1's medical record on 6/22/21 at 9:30 a.m. with RN B revealed:
*He:
-Had a left foot chronic diabetic ulcer (wound).
-Was scheduled to have a procedure done on that ulcer at approximately 10:00 a.m.
--A skin graft substitute was scheduled to be applied to the wound with wound vacuum (vac) assisted closure (type of wound treatment).
*His chart showed a yellow highlighted area with the words "bleach isolation" typed inside of it.
*RN B stated:
-"That's a warning and means he has some type of infectious disease."
-"The room should be cleaned with a bleach solution."
-"Yes, PPE of gown, gloves, and a mask have to be worn when taking care of him even during his procedure."
-"It looks like he has [DIAGNOSES REDACTED] [clostridium difficile colitis]."
*She confirmed [DIAGNOSES REDACTED] was a highly infectious communicable disease.
*He was scheduled to have the procedure in OR 3 that morning.

Observation on 6/22/21 at 9:35 a.m. of the entrance door for OR 3 revealed:
*On the door there was a sign taped to it. The following information was on the sign:
-"Bleach isolation" and the sign had directed the staff to wear "gloves, gown, mask, and clean with bleach."

Observation on 6/22/21 from 9:40 a.m. through 10:50 a.m. in OR 3 with patient 1 and the surgical team revealed:
*The patient was awake and laying on the surgical cot.
*The staff had been preparing the room and patient for the procedure.
*There were two biohazard sharps containers inside of the room.
-One of the containers had personal clothing laying on top of it.
*The patient had required the use of a wound vac for the treatment of the wound on his left foot.
-His wound vac was sitting on the OR floor along with the used collection fluid container still attached to it and the tubing laying on the floor.
-The end of the tubing was not covered with a protective cap.
-The collection container was 1/2 full of a serous sanguineous colored fluid that had come from his wound.
*The surgical team consisted of the circulating nurse, certified registered nurse anesthetist (CRNA), scrub technician (tech), and surgeon.
*All of the staff had been dressed in the appropriate PPE for a patient on bleach isolation except for the surgeon.
*Surgeon D had:
-Gone in and out of the surgical room four times prior to the procedure.
-Not been observed sanitizing his hands each time he left or entered the OR.
-Applied a clean pair of gloves each time he entered the room to check the status of the patient without sanitizing his hands first.
-Not worn a gown when he checked on the patient.
-Assisted the staff with positioning the patient the fourth time he entered the room. He was not wearing a gown as directed by the sign on the OR door and his scrubs touched the patient's legs and cot while positioning him.
-Placed his personal cell phone in the back pocket of his scrub pants and left it there during the procedure.
*The surgeon left the room and completed his three minute hand scrub after the patient was positioned.
*With her gloves on RN C had completed multiple tasks prior to removing them. Those tasks had been:
-Assisting the CRNA with supplies while an airway was established for the patient.
-Assisted the surgeon and CRNA with patient positioning for his procedure.
*With those soiled gloves on RN C had:
-Opened a sterile package that had been laying on a metal cart. Inside of the package was a betadine preparation (prep) kit.
-Used the betadine prep to clean the patient's surgical site (left leg and foot).
*RN C removed the gloves and without sanitizing her hands put on a clean pair of gloves.

Continued observation on 6/22/21 with patient 1 and the surgical team revealed:
*The surgeon requested a time-out to review the patient's status and confirm the procedure that was to be completed.
*RN C verbally conducted the time-out review with the surgical team.
-During the review she had not mentioned he was on bleach isolation for [DIAGNOSES REDACTED].
*During the procedure:
-RN C left the OR multiple times to get supplies for the surgeon.
-Each time she left the room she removed her gloves but had not sanitized her hands prior to leaving.
-After she removed the soiled gloves and prior to leaving the room she was not observed sanitizing her hands.
*Shortly after the procedure was started the surgeon requested another blanket to better position the patient's leg and foot.
*RN C had:
-Removed her gown, gloves, and left the room without sanitizing her hands.
-Returned with a clean blanket and without sanitizing her hands put on a clean pair of gloves.
-Not put on another gown to protect her clothing during the rest of the procedure as directed by the bleach isolation sign.
-Placed the blanket where the surgeon requested. That process required touching the patient's leg to move it.
-Worked in the room and around the patient during the procedure.
*Towards the end of the procedure RN C had:
-Changed her gloves without sanitizing her hands in-between.
-Picked up the wound vac and removed the fluid filled collection container with its tubing and put it in the garbage.
-Not changed her gloves after handling the soiled equipment used for the patient's wound.
-Taken a package containing a new collection bag and tubing.
-Opened the package and applied the clean collection container and tubing with her soiled gloves to the wound vac.
-Proceeded to attach the tubing to the patient's clean dressing which covered his left foot.

Interview on 6/22/21 at 11:05 a.m. with surgeon D after the procedure for patient 1 revealed he:
*Was not sure of the process or requirements for hand hygiene when changing gloves.
*Would have expected:
-The circulating nurse to update the staff on patients with an infectious disease and isolation precautions during the time-out session. That process would have ensured all the surgical staff had on the appropriate PPE.
*Was aware what PPE had been required when providing care for a patient on bleach isolation.
*Stated:
-"We put on gowns before we do the procedure so my scrubs are covered then."
-"We are supposed to change our scrubs between the procedures."
*No comment was offered regarding the observations of him not wearing the proper PPE when he had assisted with positioning the patient.

2. Observation on 6/22/21 from 1:40 p.m. through 2:40 p.m. of RN C revealed:
*At 1:40 p.m. her and the CRNA had arrived in the PreOp area to transport patient 2 to OR 3 for her procedure.
*She had sanitized her hands and put on a clean pair of gloves and gown.
*With those gloves on she had:
-Moved the patient to OR 3 by pushing the headboard of the cot.
-To exit the PreOp area and enter the OR area she had to push the handicap door opener on the wall to open the doors.
-Positioned the bed in OR 3 for the surgical procedure.
*With those dirty gloves on RN C had:
-Assisted the CRNA with packaged equipment to help establish an airway for the patient.
-Opened a sterile package that had been laying on a metal cart. Inside of the package was a betadine prep kit.
-Used the betadine to clean the patient's surgical site.
*RN C removed the gloves and without sanitizing her hands had put on a clean pair.
*Throughout the procedure she was observed:
-Leaving and re-entering the room multiple times to get supplies.
-Not sanitizing her hands when going in and out of the room or changing her gloves.

Observation on 6/22/21 from 1:45 p.m. through 2:40 p.m. of certified scrub technician (CST) F in OR 3 revealed he had:
*Left and re-entered the room multiple times to get supplies.
*Not sanitized his hands when going in and out of the room.
*Changed his gloves several times without sanitizing his hands.
*Assisted the staff with positioning the patient on the stretcher.
-He changed his gloves after that task.
-He had not sanitized his hands prior to putting on a clean pair.
*A personal cell phone in his scrub pocket.
-The phone remained in his pocket the entire time he was in the OR.

Interview on 6/23/21 at 2:40 p.m. with CST F regarding the observations above revealed:
*He was:
-A traveling CST and had worked at the facility for five weeks.
-Not aware of a specific policy for sanitization of hands when he left the OR or upon returning.
*He stated:
-"There's nothing specific and I wasn't told anything."
-"We really only need to change our gloves if we touch the patient or the bed. The room's clean."
-"I've not been told about sanitizing when we change gloves."
-"I think everyone is good about changing their gloves a lot."
*He confirmed a gown should have been worn in the OR at all times when a patient was on isolation.
*He stated:
-"We really should have a runner then."
-"Personally, I would change my scrubs after an isolation case. But otherwise, it's a personal choice to change between cases."
*He was not aware of a policy regarding cell phones and personal items in the OR.
*He stated:
-"Typically the doctors leave theirs with the nurse so she can answer it for them."
-"They field calls for them."
-"We all have things in our pockets like pens, paper, I don't see the big deal."
*They would have been educated on any changes first thing in the morning and later at shift change.

Interview on 6/23/21 at 3:10 p.m. with RN C regarding the above observations revealed:
*It was a normal process for her to go and get supplies for the surgeon during a procedure.
*Each surgeon had a reference card to follow on preferences of supplies or equipment for their procedures.
*She was not quite sure on the updating process for those cards.
*She stated:
-"They get changed every now and then, I know that."
-"When someone is on isolation you can't bring extra things in the room."
-"Sometimes we have a runner, and we really should with an isolation case."
-"We don't have one a lot so then the nurses have to do it."
*Staff should have sanitized their hands when entering and exiting the core surgical supply area.
-She agreed she had not followed that process and should have.
*Gowns should have been worn when transporting a patient to and from OR and during patient care.
-There was no requirement on wearing a gown at any other time during a procedure.
*She stated "Except if they are on isolation then we have to wear a gown during patient care."
*Gloves should not have been worn when reaching into the cabinets, warmer, and core area.
*Hand sanitization should have occurred between glove change or when removed.
-She agreed she had not followed that process and should have.
*The surgical prep for the patients was not a sterile procedure.
-Hands should have been sanitized and clean gloves applied prior to completing the prep.
*She was not aware that she:
-Had completed several tasks with the same gloves on before changing them.
-Had not changed her gloves and sanitized her hands prior to completing the surgical prep.
-Was observed not sanitizing her hands between glove change.
-Assisted with the patient in bleach isolation without wearing a gown.
*She confirmed:
-There should not have been personal belongings in the OR room and that it was unsanitary.
-The surgeon's and some staff brought their phones into the OR.
-The patients should not have worn their personal clothes into the OR.
*She stated:
-"A lot of times the physician's will leave their phones with the circulating nurse and have us answer it for them."
-"Those were the patient's pants you saw. He had worn them without us knowing it into the OR."
-"That happens a lot where the patient's will leave their pants, shoes, or other clothing on without us knowing it until they are in the OR."
*There had been:
-Recent inservices and training for cleaning of the OR.
-Ongoing changes to that process and staff.
--Staff are assigned a letter (A, B, or C) and specific cleaning duties were assigned to those letters.
-Random testing of the surfaces after they had been cleaned.
-Changes made based on the results from those tests.
*She stated: "The wipes [PDI disinfectant wipes] were changed to Oxifer and then changed back to what we were using because we were failing the tests."

B. Based on observation, interview, and policy review, the provider failed to ensure a preventative maintenance program was in place for one of three surgical suites (main hospital) to ensure the integrity and cleanliness of the patient use area and equipment was maintained. Findings include:

1a. Observation on 6/22/21 at 9:37 a.m. and again at 1:50 p.m. of OR 3 revealed:
*The door had several areas of missing paint giving it a polka dot look.
*A smaller door was attached to the right side of it.
*There was a long strip of rubber to seal the doors together when shut.
*The rubber seal had started to detach from the doors from the bottom up.
-This had created an approximate one inch gap between the doors and was approximately four inches long.
*The gap had created the potential for:
-Exterior contaminated particles to enter the room.
-The room temperature, humidity, and pressure to not be at the required surgical levels.
*The closure of the door was slow.
-Three times it remained open after the staff had entered or left the room during both of the surgical procedures above.
*Several times:
-The staff allowed the door to remain open for two to three minutes or longer while talking to the staff in the hallway.
-The door had to be manually pushed shut.
*The walls in the OR had several areas of missing or peeling paint that had created an uncleanable surface.
*There was a soiled linen bag attached to a metal cart on wheels.
-The metal area above the wheels was dusty and had rusted areas on them.
*The rubber footboard around the walls was detached in scattered areas.

Interview on 6/23/21 at 3:10 p.m. with RN C regarding the environmental concerns observed in OR 3 revealed:
*She was aware:
-Of the issues and environmental concerns identified in the OR.
-The entrance door into OR 3 was not working properly.
*She stated:
-"That's not the only door not working right, there are others that do the same."
-"I don't know if anyone reported it or not."
-"It's really crammed around here [regarding the halls and rooms full of patient use equipment]."

b. Observation on 6/22/21 at 11:52 a.m. of the PACU revealed:
*A large room with fourteen bay areas of patients to be monitored and taken care of after their surgical procedure.
*The floor had:
-Two baseball sized indentations located in front of the nurse's station and blanket and the fluid warmer.
--The surface of those areas had been cracked in multiple areas and created an uncleanable surfaces where high flow traffic occurred.
*There was a PACU block cart (type of pain management) by the nurse's station.
-The top of the cart had a plastic pump bottle labeled Avagard hand antiseptic.
--Underneath of the Avagard bottle was a layer of fine gray dust. When the surveyor attempted to pick-up the bottle to check the expiration date it could not be moved. It was stuck to the cart and the dust under it was to.
*The clean supply room had a large metal cart with several shelves.
-Clean linens had been stored on those shelves and were covered with sheets.
-Those sheets were not impermeable and would not have protected the clean linens from contaminants.

Surveyor:
2. Observation on 6/23/21 at 10:25 a.m. in the PACU of RN Y performing care and assessments of patient 12 revealed he:
*Performed hand hygiene with alcohol and applied clean gloves.
*Picked up patient 12's urinary catheter bag and attached it to the bed.
*With those same gloved hands he:
-Wrote some notes on a piece of paper.
-Checked the resident's blood pressure.
*Removed his gloves.
*Without performing hand hygiene he:
-Picked up a thermometer and checked the patient's temperature.
-Put on a stethoscope and listened to the patient's lungs.
*At that time he performed hand hygiene and put on clean gloves.

Interview on 6/24/21 at 9:05 a.m. with RN charge nurse W who was working on 6/23/21 in PACU regarding RN Y's hand hygiene confirmed he had missed opportunities of hand hygiene:
*After handling the catheter bag.
*After removing soiled gloves.

3. Observation on 6/23/21 at 10:50 a.m. of the preoperative (PreOp) unit revealed:
*The soiled utility room floor had:
-Several large stained areas.
-Areas between stored items against the walls had build-up of grime and large dust bunnies.
*The clean utility room contained:
-Two oxygen stands.
-Three oxygen E tanks on wheeled carts.
-Three intravenous (IV) poles.
-A large rocking chair holding Christmas greenery and decorations.
-An office chair.
-Seasonal decorations lining the wall on shelves adjacent to the sink.
-A two-tiered rolling cart containing approximately fifteen large wall hangings in front of the sink.
-Approximately ten seasonal wall decorations had been placed directly on the floor.

This writer was unable to get to the sink because of the non-medical items [DIAGNOSES REDACTED] the room.

Continued observation on 6/23/21 of the PreOp patient rooms revealed:
*Room 4 had been set up for patient use.
-The floor in room 4's toilet room had areas of dark, dried on fluid in front of the toilet.
*Room 5 had been set up for use.
-The floor in room 5's toilet room had dried fluid on the floor in front of the toilet.
*Room 9:
-Did not have a bed.
-Had a large dark, dried-on stain approximately twelve by thirty-six inches on the floor.
--That dried-on stain was slightly raised and crystallized to the touch.
-An approximately three-inch piece of tape had been partially attached to the floor.
-Areas of unattached particles remained on the floor.

Interview on 6/23/21 at 11:20 a.m. with RN X revealed:
*Room 9 for had not been used for patient care that day.
*He:
-Was not sure exactly who was responsible to keep the floors clean.
-Thought it could have been the personal care champions (PCC) that might have cleaned some of the floors.
-Stated "Maybe the environmental services (EVS) could do it because they removed garbage during the night."
*The PCCs were responsible for cleaning the floor if there were patients on contact precautions.

Interview on 6/23/21 at 11:30 a.m. with PCC V regarding cleaning floors revealed:
*EVS were supposed to clean the floors every night, but it was not being done.
*EVS had stated the responsibility of the floor cleaning was to have been the responsibility of the nursing department.
*There was a mop in PreOp and the PCCs were doing it for a while, but they had the responsibility of patient care.

Interview on 6/23/21 at 12:05 p.m. with RN/PreOp nurse manager G confirmed:
*The floors were not being cleaned daily.
*EVS services had changed with the transition of owners.
*She had made:
-Several attempts to resolve the lack of environmental services for floor cleaning but was not getting results.
-A schedule for her PCC staff to do the daily floor cleaning for a while, but the PCCs were busy doing patient care.
*There was no policy for floor cleaning and disinfection.
*The clean utility room was full of non-medical supplies.
-Those supplies made the hand sink unreachable.
-The non-medical supplies should have been placed in other storage areas.

Surveyor:
4. Observation on 6/22/21 from 9:15 a.m. through 12:00 noon and again at 3:15 p.m. of the surgical suite area revealed:
*There had been 14 ORs with individualized scrub areas outside of their entrance area.
*The OR 3 scrub area had two large scrub sinks with four total areas for the staff to scrub prior to the procedures.
-The staff had to push their knee into a metal plate attached to the front of the sink to turn on the faucets. Each faucet had one for water and one for soap.
-One out of four faucets worked. When surgeon D attempted to activate one of them with his knee the faucet would not turn on for him to scrub.
*There was an area designated in back of the sinks for putting on clean PPE for surgical procedures.
-In OR 3 scrub area there had been several items stored there. Those items had been:
--A cardiopulmonary resuscitate (CPR) board.
--A large scope for imaging purposes during a procedure.
--Three oxygen tanks.
*All the walls had been damaged in several areas and uncleanable surfaces were created. Such as:
-Long scrapes down the hallways from moving beds, cots, or equipment.
-Several areas of missing or chipped paint exposing the wallboard or gypsum underneath of it.
-Laminate siding attached to some of the walls had been detaching from the walls along the edges.
-The baseboard along the bottom of the walls had been detaching in in multiple areas. Some of the corners were chipped and/or had been missing large pieces to expose uncleanable surfaces.
-The entrance door for OR 5 had the same appearance as OR 3. The paint had been chipped and missing in several areas. It gave a polka dot appearance.
*The handrail located by OR 6 had an approximate 6 inch by 6 inch missing section of the protective covering exposing the metal surfaces underneath of it.
*A clean patient stretcher had been stored inside of OR 8's scrub sink area.

Continued observation on 6/22/21 at 3:25 p.m. of the surgical suite area by OR 3, 4, 5, and 6 revealed:
*Multiple medical, surgical, and patient equipment and supplies stored up and down both sides of the hallway.
*Across from OR 4:
-Was a casting medical supply cart.
-On top of the casting cart was a large bin containing opened and exposed gauze Kerlex rolls for wrapping the required area. Multiple staff were observed in the area and walking up and down the hallway by those exposed supplies.
-Were several carts stored right next to each other with no space in between them. Those carts had been:
--An anesthesia cart stored right next to an opened 30 gallon garbage bin with various garbage items in it.
--On the other side of the garbage bin was the soiled linen cart containing soiled linens.
--On the other side of the soiled linen cart was a cart containing exposed clean linens.
*Across from OR 6:
-Was a metal stand covered with dust next to another clean linen cart.
--On top of the cart was an opened box of gloves.
--The covering on the clean linen cart was in poor repair. It had cracked and jagged areas that exposed uncleanable surfaces.
-Had 2 stands with multiple protective radiology imaging supplies and coverings.
-An IV pole with the edges of the base covered with a white and tan colored dust type substance.
-The urology medical supply cart was stored in the hallway.
*The flooring:
-Underneath of all the carts and equipment was covered with dust.
-In some areas the dust had collected and was formed into balls.
-Along all the edging behind the carts, supplies, and equipment was dust and dirt.

Observation on 6/22/21 at 3:35 p.m. across from the control room and surgical procedure board revealed:
*A small alcove type area with a sign on the wall with the words "Dirty/Elevator" on it.
*There had been double doors leading into that area.
-They had remained in the open position.
*Inside of that area was:
-A small hand washing sink with no available handsoap.
-An elevator.
-Two large open bins with several clear and red colored bags inside of them.
--The bins had been used for storage and transport of soiled linens and garbage through the elevator.
-Four large biohazard waste containers sitting on the floor.
--Those containers had used medication vials, syringes, and various types of IV catheter type tubing inside of them.
*The area had a foul odor to it.
*Several staff had been observed:
-Going up and down the hallway past the area with their clean scrubs on.
-Hauling several bags of garbage and soiled linens down the hall to the room and deposited them in the bins.

Interview on 6/22/21 at the time of the above observation with CRN E revealed:
*He confirmed:
-The elevator was used to transport the laundry and garbage to a contaminated area in central supply.
-The doors to that area remained open at all times.
*He stated:
-"It's not up to me if those doors should be open or closed."
-"Like the sign says, it's a dirty room and a dirty elevator."
-"And this is considered a dirty hall."

5. Observation, interview, and tour of the surgical suite on 6/23/21 at 8:40 a.m. with the RN A and RN BB revealed:
*RN G joined us at 8:50 a.m. to review the PreOp area:
*There had been 12 bays for patients to receive care and prep prior to their procedures.
*The bays each had:
-A cupboard and cabinet area that contained multiple patient use supplies and equipment.
-The countertop on two of the observed cabinets had been covered with a laminate surface. Several areas of that laminate was detaching from the pressed board and had been taped back into place.
-Several areas of molding along the walls that was cracked, detaching, or missing. Those exposed areas were not cleanable.
*There was a room labeled stretcher area. Inside of the room was:
-Three large carts covered with sheets. The edges of the sheets had been hanging open to expose the clean linens in two of those carts.
-The sheets were not impermeable and could not have protected the linens from contaminants.
-Along one of the walls had been three large areas that were scraped down to the gypsum. That surface was not cleanable.
-There was a black cart that contained equipment and supplies used for patients with pacemakers. The cart was dirty with dust on all three shelves. The surveyor was able to draw in the dust with her finger.
*They:
-Agreed the observations and areas above had not been either clean or cleanable and should have been.
-Had not been aware of all the concerns identified above.
*RN A stated:
-"When people see these issues they should be putting in work orders."
-"I'm not sure how our Plant Ops [plant operations] team handles the work orders or what their process is for fixing things."
-"We have a team of us that walk through the areas monthly and will check for things that need fixing."
-"Then at the monthly meeting we look at several things for cleanup and fixing."
-"Plant Ops is there for the walk-thru and meeting."

Continued observation, interview, and tour of the surgical suite on 6/23/21 at 9:30 a.m. with RN A and RN BB revealed:
*RN A:
-Was not aware of all the concerns identified above in the OR area.
-Was not sure where the environmental team was at in the process of fixing the doors.
*The carts should not have been stored in the hallway.
-The casting cart should have been out only during a procedure that had required use of those items.
*She agreed:
-The unwrapped and exposed Kerlex wrap was not stored in a sanitary manner.
-All the observations above supported an unsanitary environment.
-The surgical suite should have been kept clean and sanitary as possible.
*She:
-Confirmed the area across from the control room was considered a soiled area.
*Stated:
-"But this whole hall is considered a dirty area and we don't even have to wear scrubs down here."
-"This area has always been like this."
-"You know it would really be hard to get those bins and stuff in and out with the doors shut."
-"They really did not allow for expansion or changes with technology when they built this."
-"There is no place to store all of this stuff."
-"There is a shortage of space."
-"We are slated to have an OR remodel done in October."
*No comment was made to support all the observed areas of concern during that tour had been identified on their monthly walk-thru rounds.

Interview on 6/23/21 at 11:00 a.m. with RN A revealed she:
*Agreed:
-The staff had not maintained a sanitary process or environment during the two observed procedures for patients 1 and 2 and should have.
-The staff should have:
--Sanitized their hands between glove change and when entering or exiting the OR.
--Changed their gloves after patient care and when soiled from completing a task.
-The process the circulating nurse used to clean both of the patient's procedure sites was unsanitary and placed the patients at risk for a surgical site infection.
*Was aware that staff had been taking their phones into the surgical suite.
*Stated:
-"I have a hard time with the doctors with that and the staff know they take them into the OR."
-"The rule is they are not to use them in patient care areas."
-"Nurses are to wipe them off."
*Was not aware there was a concern with patients wearing their personal clothing into the OR.
*Stated "That should be taken care of in PreOp or when they come down from the floor."
*Had not required the staff to wear a gown at all times in the OR with an isolation case.
-They had been required to wear a gown during patient cares only.
*Stated:
-"That process is in the works. I am supposed to write a policy on isolation and PPE for surgical staff."
-"It's different when you are in a patient room versus an OR and unless they are doing patient care they really shouldn't need one."
-"I'm hoping they will let me just make an addendum to the current policy."
*Confirmed there should have been another staff member in the OR as a runner when able.
-That was dependent on staff availability and case load.
*Stated "The travelers don't always know all the ins and outs of things. Like where stuff is, ect. It takes time to learn that."
*Would have expected the staff to change their scrubs after an isolation case.

Continued interview on 6/23/21 at 11:20 a.m. with RN A revealed:
*She stated:
-"We do have a quality and surgery improvement team and are working on the turn-around cleaning process."
-"The staff are responsible for cleaning the equipment. When the infection control [IC] team came and watched them in the OR it was not good."
-"They cleaned some things and not others."
-"Housekeeping checks their cleaning after their terminal cleaning. They use the ATP [Adenosine Triphosphate] process."
-"So we started to do that too."
-"There's a range for the ATP testing of 10 to 30."
-"Housekeeping uses 10 and we use 30."
-"Anything over 10 or 30 has to be re-done or cleaned again."
-"We have a turn-around crew and they are assigned either an A, B, or C letter."
-"Certain cleaning assignments are a part of each letter."
-"Every week the team will take a day and follow behind every caseload and do ATP testing."
-"The top three problem surface areas were identified and are now done with every case. One of them is the mayo table that the surg [surgical] techs use."
*The testing:
-Was not completed at random times and was done weekly from 7:00 a.m. through 7:00 p.m.
-And the cleaning process was to be repeated with any initial results greater than 30.
*There were no policies in place for zone cleaning and ATP testing.

6. Review of the ATP testing results from 4/14/21 through 6/23/21 revealed:
*The testing was completed weekly on the same three surfaces after every procedure that day.
-Those surfaces had been the mayo table, bed control, and the back table.
*The documentation supported:
-The date the testing had been completed.
-What OR the test was completed in and the surgical specialty.
-The surfaces cleaned and the test results.
-What action was completed if the test results had been greater than 30.
*From April through June the surfaces had required recleaning 28 times.
-Not all the second cleaning test results had been documented to support if the recleaning was effective or not.
*On 4/23/21 the back table test results had been 504 after it was cleaned with bleach.
-The patient was on isolation f