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Based on observation, review of documentation and interview, it was determined that the facility governing body was not responsible for the conduct of the hospital.


Cross refer to:


A0057


In an interview with administrative staff member # 7 on 7/16/14, the above deficits were confirmed.

Based on a tour of the dietary and kitchen areas of the hospital, review of facility policies and procedures, and observation and staff interviews, the facility failed to provide a sanitary environment in the dietary department (food storage and preparation areas), which created a potential for cross-contamination due to poor general sanitation practices, unsanitary cooking implement storage, unsanitary food service items (pans and utensils) and not following policies and procedures related to temperature requirements. It was determined that these deficient practices presented a risk to all patients, staff, and visitors consuming food prepared in the dietary department.

Findings included:

During a tour of the hospital kitchen the morning of 7/18/14 accompanied by Administrative Staff #3 and Dietary Staff #1, Food Service Manager, the following was observed:
? There was a red sanitizing bucket approximately 2/3 full of a clear liquid and a white rag available for use in disinfecting food preparation surfaces. When the surveyor asked Staff #1 to test the disinfectant solution with a test strip to determine the concentration of the solution, Staff #1 obtained a test strip from another area of the kitchen and dipped it into the solution. There was no color change registered on the strip to indicate any concentration of the disinfectant in the liquid, or less than 50 PPM. The surveyor asked to see the test strips and observed that there were no labels on the test strip container to indicate the acceptable range and there was no expiration date on the test strips. Staff #1 was unable to find any other test strips to test the solution. Two more red sanitizing buckets, available for use, were tested with no change registered on the test strips. Staff #1 then stated he was using the wrong strips, however he was unable to produce any other test strips to test the solution. Pathogenic microorganisms can survive and contaminate food products if food-contact surfaces are not properly cleaned and sanitized with a sanitizing agent maintained at the proper level. When the surveyor asked Staff #1 if the sanitizing solution in the red buckets was being tested, Staff #1 stated, "I'd have to say no." When asked, Staff #1 stated that a log was not maintained to demonstrate sanitizer solution testing; there was no documented evidence provided to the surveyor to indicate that sanitizing solutions were being tested. The above was confirmed in an interview with Staff #1 and Administrative Staff #3.

During a continued tour of the hospital kitchen the morning of 7/18/14 accompanied by Administrative Staff #3 and Dietary Staff #1, Food Service Manager, the following was observed:
? There was condensation on the outer walls of the walk-in freezer, creating an 18 by 12 inch puddle of water on the floor in the kitchen food prep area, which was a high traffic area in the kitchen. There was no "wet floor" or other safety sign, creating an unsafe environment and risk for falls.
? The door handle to the walk-in freezer was observed to be broken and incapable of fully latching and securely closing the freezer door.
? There was an ice accumulation, approximately one inch in height on the threshold of the freezer door, which prevented the freezer door from closing. After observation of the ice accumulation by the surveyor, a food service worker, at the request of the food service manager, used a mop handle to forcefully break and remove the ice to allow the freezer door to be pushed closed; however, as the latch was broken, the door would not stay closed tightly.
? There were ice stalactites visible hanging from two fans and from the ceiling in the freezer. The presence of stalactites indicates a potential issue with maintaining temperatures in the freezer.
? Review of the temperature log for the Walk-In Freezer revealed the acceptable temperature of less than or equal to zero (0) degrees Fahrenheit. Per the log, the morning temperatures were with-in the range for the month of July from 7/1/14 through 7/15/14. However, the PM temperatures were noted to be above zero (0) degrees Fahrenheit eleven (11) days from 7/1/14 through 7/14/14. There was no documentation in the column marked "Action Taken" for any of the eleven (11) days the temperature was out of range. The temperatures were taken between 5:00 pm and 6:30 pm and were documented as follows:

DatePM Temp1 -7.82 9.53 8.54 4.75 -13.16 -2.37 8.68 4.29 19.610 8.711 0.412 4.613 8.714 10.1
? In an interview the morning of 7/15/14 with Administrative Staff #3 and Dietary Staff #1, they confirmed the above out of range findings. Administrative Staff #3 stated that when the temperatures are out of range, there should be action taken and the action taken should be documented on the form.

Also during the tour of the hospital kitchen the morning of 7/15/14 accompanied by Administrative Staff #3 and Dietary Staff #1, Food Service Manager, the following was observed:
? In the Dishwashing machine room, there was a sign posted which stated, "Tape the Breakfast T-stick (used for checking temperature) to the paper and put the lunch and dinner T-stick in the container. Thank you" Review of the posted "Dishmachine Temperature Check Log" dated "July 2014", there were T-sticks taped to the log for July 1 - 10, however there was no T-Stick taped to the log for July 11, 12, 13, 14, and 15 as required per posting and per policy. The log stated, "(Tape the breakfast T-strip to this form on the left)."
? There was a layer of greasy dust on the top of the tea brewing machine.
? The rear-tray-line area cabinets were in need of cleaning and maintenance as there were rusted areas in the drawers, drips down the front of the cabinet and in the drawers, and areas sticky to the surveyor's touch. There were paper placemats used on patient trays, towels, and serving bowls stored in the cabinet, available for use in patient meal preparation.
? The floor underneath the reach-in refrigerator #1 and reach-in refrigerator #2 was in need of cleaning as there was dust and debris and what appeared to be an old grape on the floor.
? A large food tray transport cart in the kitchen was being used for storage of plastic gallon jugs; however the cart was in need of cleaning, as there was black and clear tape adhered on the inside that was dirty.
? There was a thick layer of greasy dust and debris on top of the ovens.

On a wire storage rack the following was observed on the dishware available for patient food prep.:
? There was a visibly wet metal colander with a brown substance adhered to the inside. When the surveyor lifted the colander from the rack, water dripped off the colander. There was a large muffin tin that was in need of cleaning due to carbon build-up and a brown substance which appeared to be food adhered to the inside of the muffin cups. There was a second muffin tin that was stacked on top of the dirty muffin tin that also had food substance adhered.
? There were 2 large sheet trays which were in need of cleaning with a greasy layer and dried food adhered.
? There were 3 large pans with a greasy layer adhered to the interior of the pan.
? There were 4 wet pans and 2 wet trays on the wire storage rack. The wet stacked trays and pans create a risk for bacterial growth in the moist environment.
? There was a white grainy substance on a pan.

Further findings in the kitchen included:
? The plate/pellet warmer in the tray line area was in need of cleaning, as the hinges for the top were dirty with a greasy substance and there was a greasy substance inside the food warmer where clean plates/pellets were stored, available for patient use, creating a risk for cross contamination.
? The condiment cart was in need of cleaning as the cart handles had a sticky, black, greasy substance adhered to it. This was confirmed by the surveyor and Administrative Staff #3 who both touched the handle and confirmed the sticky substance.
? The large rolling rice bin had a broken lid and only half of the bin was covered with a lid. When asked, the kitchen manager was unable to find a cover for the rice bin. There was an old blueberry in the rice bin. The rice bin had 2 strips of dirty tape approximately 6 inches x 2 inches adhered to the rice bin. This creates a risk for cross contamination.
? There were approximately 18 long drips down the inside of the large rolling sugar bin.
? In the metal storage cabinet used to store catering equipment, there was a first aid kit containing the following items: Eye wash, expiration date 5/08, Eye wash, expiration date 11/07, Acetaminophen 500 mg packet expired 12/07, Calcium carbonate 2 tabs expired 1/08. There were also two tubes of chlorine test strips which expired 7/11. There was a dirty corrugated box on the top of the catering cabinet, which was next to the dessert food prep area.
? The top of the knife storage rack had a dirty, greasy film. Three knives, available for use in food prep were dirty, with dried food adhered and there was a thick, black, sticky substance on all three knives where the blade shank was attached to the knife handle (the bolster).
? Two knives had chips in the metal blades. This presents a risk for cross contamination and a risk for metal shavings to be introduced into food products.
? There was a black substance adhered to the upper surface inside the ice storage area of the ice machine above the ice.
? A large manual can opener mounted on a prep table was rusted and dirty with a dried black substance.
? There was a large, industrial-size mixer which was in need of cleaning as there were multiple dried, crusty whitish substances on the base, and top of the mixer; there were whitish drips down the sides of the mixer and the base. The mixer parts were stored on a shelf above the mixer; the shelf was coated with a greasy, dusty film.
? The floors under the ovens were in need of cleaning, as there was dirt and what appeared to be food debris on the floors;

On the blue wire rack, the following was observed, available for use in food preparation:
? There was one pan with approximately 30 small pitted holes in the pan, which could not be properly cleaned, due to the pitting.
? There was a pan with white food adhered inside and outside of the pan.
? There were greater than 20 pans on the bottom shelf which were all covered in a greasy, blackish raised layer of dust.
? The plastic lining on the bottom shelf was in need of cleaning as there was a layer of greasy blackish raised layer of dust and food debris.

In the food prep table drawers, the following was observed, available for use in food preparation:
? Three cracked rubber spatulas, which could not be fully cleaned due to the cracks.
? One rubber spatula with a seed on it, which was the size and appearance of a cantaloupe seed.
? One food cleaning brush with a quarter-inch piece of black substance adhered.
? Three food cleaning brushes with price labels still adhered but were black with a sticky residue.
? There was a food-like substance observed in the bottom of the spatula drawer.
? There was a food-like substance adhered to two ice cream scoops.
? There were 8 large spoons which were in the drawer stored spoon up; there was a dry whitish substance in the bowl of the spoon, indicating the spoons were probably put into the drawer while wet.
? There was a metal meat mallet with a broken wooden handle, which created a risk for injury or broken pieces of wood to be introduced into food products.
? There was a rolling pin with the dirty, sticky price label adhered.
? There was a knife in the drawer which had been inserted back into the original plastic packaging; the plastic packaging was dirty and was touching other knives and food prep ware in the drawer.
? There were two tongs which had dried particles adhered to the surface and a dirty, sticky price label adhered.
? There were three ladles with dried food particles adhered.

In the Dry Food Storage Room, the following was observed:
? The automatic door closer was broken and not fully attached to the door to the dry food storage room.
? There were seven holes in the ceiling around the pipes and tubing for the soda pop; there was a hole in one of the ceiling tiles approximately 2 inches.
? There was dust and food on the floor underneath the shelving units.
? There was a three foot by 6 inch area of the wall in need of painting.
? There was a wet box of lemonade which appeared to be damaged and leaking on the food shelving unit, next to spices, cornbread mix and other food items.

The above findings were confirmed during the tour the morning of 7/15/14 with Administrative Staff #3 and Dietary Staff #1, Food Service Manager.

During a tour of the hospital kitchen the afternoon of 7/15/14 accompanied by Administration Staff #1, the surveyor observed the contract vendor conducting a training session with dietary/kitchen employees on how to prepare and check sanitizing solutions for use in sanitizing food prep and service areas in the kitchen.

During a tour of the hospital kitchen the morning of 7/16/14 accompanied by Administrative Staff #3 and Dietary Staff #1, Food Service Manager, the following was observed:
? Review of the walk-in freezer temperature log, described previously, revealed an entry made for the PM temperature after the surveyor tour on 7/15/14. The temperature log revealed an entry timed 5:20 in the "PM Time" column and a temperature of 6.0, which was above the acceptable temperature of less than or equal to zero degrees Fahrenheit. There was again no documentation in the "Action Taken" column, despite the out of range temperature.
? There were three pans on the blue wire shelving unit which had water dripping off the pans onto the floor. Upon closer observation, there were greater than 8 pans which were stacked and nested together and were wet. The dripping water and wet pans provided a medium for bacterial growth.
The above was confirmed during the tour at the time of the observation by Administrative Staff #3 and Dietary Staff #1, Food Service Manager.

During a tour of the hospital kitchen the afternoon of 7/16/14 accompanied by Administration Staff #1, Chief Executive Officer, the surveyor observed the dietary staff in another training session on the sanitizing solutions and products; the session was led by the contract vendor. The sanitizing solutions were observed to be within the range of 150-400 PPM of sanitizer in the solution.

In an interview the afternoon of 7/16/14 at 1:40 pm with Administrative Staff #3 in the conference room, when asked for policies or procedure for setting up the sanitizer solution buckets, instructions for using the proper sanitizer, and using the right strips to test the sanitizer strength, Staff #3 stated there was no policy referencing requirements. There was no documented evidence of any policy or procedure provided to the surveyor.

Review of a "Kitchen Self-Inspection Checklist & Follow Up Audit Form completed by Staff #8, Facilities Director dated 3/31/2014, revealed similar findings identified during this survey, including the following:
"Any temperatures not meeting standard are addressed, corrected and the resolution documented on the log." An "x" was placed in the column headed "Does Not Meet Standard."
"Ice machine is clean. Ice machine cleaning log is posted and cleaning is up to date." An "x" was placed in the column headed "Does Not Meet Standard."
"Towels are stored in red sanitizer bucket with quat sanitizer maintained at 150-400 PPM." An "x" was placed in the column headed "Does Not Meet Standard."

Review of Food and Nutrition Services Policies and Procedures provided to the surveyors revealed the following:
Hospital policy, "HACCP and Food Safety policy" Policy # C3, last revised 2/1/2014, stated, in part,
"Kitchen staff will be well trained on food safety policies and procedures. Supervisors will monitor staff and correct any problems or concerns at the time they occur ...
8. The leading cause of FBI [food borne illness] is improperly cooled foods, followed by:...
Cross contamination...equipment not properly cleaned/sanitized..."

Hospital policy, "General HACCP Guidelines for Food Safety" Policy # C8 last revised 2/1/2014 stated, in part, "9. Refrigerator/Freezer Temperatures Internal temperatures of each unit in kitchen are taken 2 times each day...
If temperatures are poor (<40 [degrees] F for refrigerators or > 0 [degrees] F for freezers), call Plant Operations immediately for repair. Assess safety of foods in the unit, and discard any questionable foods."

Hospital policy, "Food Storage", Policy # C10, Last revised 2/1/2014, stated, in part, "Food is stored in an area that is clean, dry and free from contaminants...
Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour sugar, dried vegetables, and broken lots of bulk foods."

Hospital policy, "General Food Preparation and Handling" Policy # C12, Last revised 2/1/2014, stated, in part, "Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and free of injurious organisms and substances.
Procedure:
1. The kitchen is kept neat and orderly.
a. the kitchen and equipment are clean...
3. Food Preparation...
h. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. Any utensil or serving dish must be thoroughly cleaned and sanitized prior to use...
j. Wash all tops of canned foods before opening; wash and sanitize can opener daily...
5. Equipment:
a. All food service equipment should be cleaned, sanitized, dried, and reassembled after each use.
b. Plastic-ware or dishware that has lost its glaze or is chipped or cracked must be disposed."

Hospital policy, "Food Safety - Food Service Supervisors Responsibility" Policy # D2, Last revised 2/1/2014, stated, in part, "The food service supervisor is responsible for providing safe foods to all individuals.
Procedure:
The food service supervisor assures all of the following:
1. Good sanitary food handling practices.
2. Sanitary conditions are maintained in the storage, preparation and serving areas....
7. All personnel follow proper cleaning and sanitizing instruction for all kitchen equipment."

Hospital policy, "Cleaning Dishes/Dish Machine" Policy # D9, Last revised 2/1/2014, stated, in part, "Procedure:
1. Prior to use, run the machine for a few minutes, then, use a 160 {degree] T-strip for verification of proper temperature...Place the breakfast T-stick on the dish machine temperature log...
9. Allow the dishes to air dry on the dish racks. Do not dry with towels.10. Remove the dishes, inspect for cleanliness and dryness, and put them away if clean."

Hospital policy, "Dish Machine Temperature Log" Policy # D10, Last revised 2/1/2014, stated, in part,
"Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes.
Procedure:
1. The food service supervisor will provide the dishwashing staff with a log to be posted near the dish machine...
3. Staff will record dish machine temperatures at each meal.
? The disposable temperature sensor will be run through the dish machine prior to washing dishes at each meal.
? The breakfast sensor will be taped to the temperature log...
4. The food service manager will spot check this log to assure temperatures are appropriate and staff is actually monitoring dish machine temperatures."

Hospital policy, "Handling Clean Equipment and Utensils" Policy # D14, Last revised 2/1/2014, stated, in part,
"Clean equipment and utensils will be handled to prevent contamination.
Procedure:...
2. Clean equipment and utensils will be stored in a clean, dry location in a way that protects them from contamination by splashes and dust. Stationary equipment will also be protected from contamination.
3. Glasses and cups will be stored in an inverted position.
4. Other stored utensils should be covered or inverted wherever possible."

Hospital policy, "Dry Storage Areas" Policy #D15, Last revised 2/1/2014, stated, in part,
"Dry storage areas will be kept in a condition which protects stored foods from infestation.
Procedure:
6. Floors must be swept and clean at all times and mopped at least weekly.
7. Leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other foods...
11. Containers with tight-fitting covers should be used for storing cereal, grain products, dried vegetables and broken lots of bulk food."

Hospital policy, "Care of Storeroom" Policy # D16, Last revised 2/1/2014, stated, in part,
"The staff will maintain care of the storeroom according to the following guidelines.
Procedure:
1. The floors, walls, shelves and equipment in the storeroom are clean...
3. Leaking cans and spoiled foods will be removed and disposed of promptly."

Hospital policy, "Ice Machine Cleaning and Maintenance" Policy # D17, Last revised 2/1/2014,
"Ice will be produced, stored and dispensed in a manner to avoid contamination.
Procedure:
1. The ice machine is cleaned and sanitized at least monthly, and/or as needed. Inside and outside of machine are cleaned..."

Hospital policy, "Kitchen Cloths" Policy # D19, Last revised 2/1/2014, stated, in part,
"Kitchen cloths will be clean and available as needed.
Procedure:
5. Kitchen towels are not used to dry dishes, cups, glasses, utensils or cooking equipment. All of these items must be washed, sanitized, rinsed and allowed to air dry."

Hospital policy, "Cleaning Instructions: Can Opener" Policy # E10, Last revised 2/1/2014, stated, in part,
"The can opener will be cleaned after each use."

Hospital policy, "Cleaning Instructions: Counter Space" Policy # E13, Last revised 2/1/2014, stated, in part,
"Counter space will be wiped and sanitized prior to and following food preparation and meal service, and as needed.
Procedure:
2. To sanitize:...
? Spray the counter with sanitizing solution and wipe with clean cloth or us a bucket of Qwat sanitizer."

Hospital policy, "Floor Safety" Policy # F9, Last revised 2/1/2014, stated, in part,
"Floors will be maintained in a safe manner...
1. Floors will be kept clean and dry.
2. When cleaning floors, one area should be mopped at a time. Use "wet floor" signs to caution others to be careful...
6. Any spills should be cleaned immediately."

The above findings were confirmed in an interview with Administrative Staff #1 the afternoon of 7/16/14 in the facility conference room and in the kitchen area.

Based on observation, review of documentation and interview, it was determined that the facility was not maintained to ensure the safety of staff and patients.


Cross refer to:

A0726
A0749
A0701

In an interview with the Infection Control Officer on 7/16/14, the above deficits were confirmed.

Based on a review of facility policies, staff interviews and tours of the facility, the facility failed to maintain an infection control program which actively ensured the prevention and control of infections and communicable diseases.

Findings were:

A review of facility policies, procedures, and documents, tours of the facility, and staff interviews, revealed the facility failed to ensure an effective infection control program. There were multiple risks for cross contamination, infection, and spread of communicable disease in the provision of hospital services, including the following:

? torn pillows, mattresses and foot stirrups which could not be disinfected

? dirty flooring throughout the facility

? dust on high horizontal surfaces

? gouges in walls and chipped paint throughout the facility

? blood and/or betadine on the flooring, light fixtures, a crash cart and a wound VAC machine

? a wet bed frame

? expired medications

? water stains on the ceiling tiles

? open entry areas around pipes

? spilled food in the patient nourishment station

? open patient supplies on the floor

? used supplies and broken equipment on a cart next to a patient blanket warmer

? missing temperature logs on a blanket warmer

? external shipping boxes above patient supplies

? molding pulling away from the walls

? a torn padded toilet seat in a patient room

? staff wearing soiled shoes who traveled among instrument sterile reprocessing, ORs and common areas of the hospital

? dusty vents and dirty air conditioning filters (including in the Sterile Supply Room)

? peeling laminate and paint, as well as cracked floor tiles throughout the facility

? rusty equipment

? dusty vents, dirty air conditioning and dehumidifier filters (including in the Sterile Supply Room)

? a non-functional humidity detector in the OR

? tape throughout all areas of the hospital

? a dangling electrical socket in an X-Ray room

? a water-stained upholstered chair

? dirty absorbent pads taped to a cabinet

? a heavily soiled lead apron lying partially on a lead storage box and the floor

? dirty mops and brooms stored with clean patient linen

? lack of evidence of sterilization equipment being maintained per manufacturer's instructions

? an inaccurate and outdated policy regarding state notifiable conditions


Cross refer CFR 482.42(a)(1)

Based on observation, document review, and interview, it was determined that the facility failed to provide surgical services that were organized and provided in accordance with acceptable standards.

Findings were:

Tour of the facility on 7/14, 7/15 and 7/16/14 revealed the following:

? In the surgical area, the flooring was heavily gouged and chipped, particularly in the hallways. The surgical suites had numerous gouges in the floor, rendering disinfection impossible.
? Also in the surgical suites, the walls had numerous gouges.
? 3 of 5 surgical suites used portable dehumidifiers. These dehumidifiers were not maintained according to manufacturer's recommendations.
? Termites were discovered in OR room #5 on 7/3/14 and then again on 7/5/14. Termites were also found in the OR woman's dressing room.
? The Sterile Reprocessing Technician who gave the survey team a tour of the surgical area on 7/15/14 had on a pair of soiled sneakers. He wore these shoes inside the operating rooms and the sterile reprocessing areas. He then wore the shoes out into the common areas of the hospital. He stated, "I normally only wear these shoes in the sterile reprocessing area but my mind is spinning today."
? In the sterilization area, above the Steris (sterilization) machine, a dusty vent was noted. The ceiling tiles did not fit tightly around the 2 pipes that fed into the ceiling. These openings around the pipes could allow access of vectors into the area.
? Laminate was observed peeling from the cabinets in the dirty processing room and floor tiles were cracked and molding was observed pulling away from the wall rendering thorough cleaning of the area impossible.
? 2 portable air conditioning units were found in the sterile supply room. These units had been in this room since December of 2013. These units blew air onto the trays of "sterile" equipment. Even with these portable air conditioners, this supply room was very warm (89.9 degrees). Surgical staff member # 2 (Sterile Reprocessing Technician) said that the heat and humidity in the room rendered the supplies unusable. When surgical cases were scheduled, the supplies were sterilized before each case. The same staff member was not aware that the filters in the air conditioning units required cleaning.
? In OR room # 1, paint was observed to be peeling from the doorframe and there were tears in the operating table mattress. Rust was noted on the bottom of the operating table and on the linen and trash cart. The wheels on the cauterization cart and the wheels on the suction machine were also rusted. These factors render cleaning impossible and cross contamination likely. It appeared as if dirt is sealed within the wax on the floor, indicating the floor was not cleaned before waxing. The humidity detector was not functioning which made it impossible to monitor the moisture in the OR suite. (High levels of moisture increase the risk of bacteria proliferation.) A dehumidifier with a dirty filter was found in the room and the condensation container was found to be overflowing onto the floor, creating a slip hazard. The staff did not proactively check the status of the water container but waited until the machine stopped before emptying the full container. Additionally, the staff was unaware that this water container should be cleaned after emptying the water.
? In OR room # 3, a dehumidifier was found. The filter on this machine was dust covered. The same issues were present concerning the water condensation container. Betadine and tape was found on the floor and the wheels on the cauterization cart were rusted. It appeared as if dirt is sealed within the wax on the floor, indicating the floor was not cleaned before waxing. On the floor outside of OR room # 3, the flooring is missing and cracked. According to staff member # 1 (Surgery Staff), the floor has been in its current condition for over 2 years.
? OR room # 4 was used for storage and was not maintained.
? In OR room # 5, the x-ray viewer had broken glass. Many small gouges were found on the floor and it appeared as if dirt is sealed within the wax on the floor, indicating the floor was not cleaned before waxing.
? A sign on the door of the Cysto room said that the room had been "Terminally Cleaned." Trash was noted on the floor and the bottom of the fluoroscopy machine was rusted. There were tears in the foot stirrups on the procedure table. A stool that the surgeon sits on (per Director of OR), was covered with tape that concealed tears in the fabric. These issues made cleaning impossible and cross contamination likely.
? OR room # 1's humidity detector was not functioning. This made it impossible to monitor the moisture in the OR suite. 2 portable dehumidifiers were located in Operating Rooms # 1 and 3. Use of these portable dehumidifiers indicated the facility's internal dehumidifying system was not functioning properly.
In OR 2, the following was observed:
? There was no solid barrier on the bottom shelf of a wire shelving unit with cardboard boxes of patient supplies, creating a risk for cross contamination.
? There was a layer of raised dust on the ceiling vent in the pharmacy.
? There was rust on the wheels of the black pain management cart; rust cannot be disinfected, creating a risk for cross contamination.
? There was tape and sticky, dirty tape residue on the OR bed.
? There was rust and tape on the red cart containing patient supplies, such as airways, needles, and syringes.
? There was tape and sticky, dirty tape residue on the automatic tourniquet machine.
? There were 12 holes in the sheetrock on the back wall, preventing effective disinfection.
? There was black dust on the wall vent in the back of the room.
? There was a layer of dust on the horizontal surfaces of a plastic bin unit containing patient supplies such as med cups, surgery instruments, Kerlix and other supplies, available for patient use.
? There was a tear noted in the operating table mattress. There was also tape residue on the mattress. The wheels on the cauterization cart were rusted. These issues render cleaning impossible and cross contamination likely.
? Betadine spots were observed on the floor. It appeared as if dirt is sealed within the wax on the floor, indicating the floor was not cleaned before waxing.
In the Pre-Op area, the following was observed:
? Under the sink, there was a 2 by 1.5 inch hole in the back wall. There were 2 pipes coming through the back wall which were not sealed. The wall underneath the sink was stained. There was a dead spider hanging from a spider web.
? In the Post-Op area, the following was observed:
? There was a water damaged ceiling tile, approximately 6 inches in diameter.
? There was light visible from the outside on the left lower corner of an external door, which could allow the entry of dust and insects into the patient area.
In the "Cidex Room," the following was observed:
? Under the sink there were open holes surrounding water pipes. In addition, the cabinet under the sink contained black particulate matter identified as "dirt" by Surgery Center Staff #5 during the tour. She added, "Something must have gotten in here."

In an interview with the Sterile Reprocessing Technician and the OR Director on 7/15/14, the humidity and temperature concerns were acknowledged.

Based on a tour of the facility and a review of documentation, the facility failed to appoint a Chief Executive Officer who was responsible for managing the hospital.

Findings were:

Facility policy PC.02.01.11 EP 2 titled "Crash Carts" states, in part, "II Procedure: A. Adult Emergency Carts (crash carts) on the nursing units will be checked daily for integrity using a documentation checklist available on a clipboard or binder on the outside of the cart. Emergency carts in areas that close weekends will be checked daily Monday through Friday.

Facility document titled "CRASH CART-DAILY CHECKLIST" located in the radiology department states, in part, "DAILY: 4. Verify lock number: All lock numbers must be documented."

During a tour of the radiology department on 7-16-14, a review of the Crash Cart checklist located on the radiology department crash cart revealed that the lock number had not been documented for 5 of 16 days of the current month. The above information was confirmed in an interview with Administrative staff #7 during a tour of the radiology unit.

Based on review of documentation and interview the facility failed to ensure that medical records were accurate and complete for restrained patients.

Findings were:

Review of the medical records for 2 restrained patients, revealed incomplete documentation of monitoring for 2 of the 2 patients at the intervals identified in the facility based policy.

Facility based policy entitled, "Restraint and Seclusion", (in effect until 06/2013) stated in part,
"Monitoring Restraints for Acute Medical and Surgical Care
....Patients who are restrained according to the acute medical/surgical standard will be monitored at a minimum of once per hour with documentation of assessment and interventions on the restraint flowsheet and in the daily care record."

The Restraint Flowsheets for Restraint Patient # 1 revealed the following incomplete documentation.
? On 04/22/2014 the areas on the top of the RESTRAINT FLOWSHEET including sections I. Assessment of Patient at High Risk for Injury: (including Mental Status, Potential for Falls, Injury and Behavior) and sections II. Actions, Alternatives to restraints (including General Measures, Diversional Measures and Environmental Measures) was totally incomplete.
? On 04/22/2014 there was no documentation on the flowsheet for section III: Exercise or ROM, nor Reposition for the time: 21:00.
? On 04/25/2014 and 04/23/2014 (two different dates were documented on one sheet) there was no documentation on the flowsheet for section I, except two x's indicating that patient #1 had on both a right and left wrist restraint. Section II was totally blank and section III was missing documentation for Exercise and Reposition for the hours of 01:00 and 03:00.
? On 04/25/2014 there was no documentation on the flowsheet for section I, except two x's indicating that patient #1 had on both a right and left wrist restraint. Section II was totally blank and section III was missing documentation for Exercise and Reposition for the hours of 24:00, 01:00, 02:00, 03:00, 04:00, 05:00, 06:00, 07:00, 08:00, 09:00, 10:00, 11:00, 12:00 and 13:00 hours.

The Restraint Flowsheet for Restraint Patient # 2 revealed the following incomplete documentation.
? On 06/19/14 there was no documentation on the flowsheet for the following periods of time: 0700, 0900, 1100, 1300, 1500, and 1700.
? On 06/20/14 there was no documentation on the flowsheet for the following periods of time: 0700, 0900, 1100, 1300, 1500, 1700, 1900, 2100, and 2300.
? On 06/21/14 there was no documentation on the flowsheet for the following periods of time: 0100, 0300, 0500, 2100, and 2300.
? On 06/22/14 there was no documentation on the flowsheet for the following periods of time: 0100, 0300, and 0500.
? On 06/23/14 there was no documentation on the flowsheet for the following periods of time: 0100, 0300, 0500, and/or 1500-1800.
? On 6/25/14 there was no documentation of range of motion (ROM) every 2 hours, per the form, from 2400-0600.

In an interview on 7/16/14, nursing staff member #6 confirmed that they had been the director of Intensive Care Unit until February 2014. Nursing staff member #6 stated that, "We need to sharpen up documentation across the hospital." This staff member stated that the documentation of the above restraint patient was incomplete. They stated, "Everything that needs to be documented is on the form, things like circulation, range of motion. The flow sheets tell us what we need to be documenting."

The above incomplete documentation on the Restraint Flowsheets was confirmed in an interview on 7/16/14 with nursing staff member # 6 and administrative staff member # 6.

Based on a review of hospital documentation and staff interviews, the hospital failed to conduct performance improvement projects.

In an interview with the Director of Quality and Risk and the Quality Assurance Officer on the afternoon of 7/16/14 in the office of the Quality Assurance Officer, the Quality Assurance Officer stated they were following a number of quality indicators for the hospital. When asked how the indicators had been chosen, she said, "They were handed down to us from Houston [site of the corporate office of the hospital], but they pretty much work for us too." The Director of Quality and Risk stated, "It's part of my plan to go through those indicators and decide which of them are pertinent to what we do." When asked how the indicator data was being collected, the Quality Assurance Officer said that this was left up to the unit managers. "They [the unit managers] then come up with a correction plan to address any problems."

The Quality Assurance Officer also stated the only hospital-wide performance improvement project they were conducting was "a project handed down by corporate to improve HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems] scores," again referring to the discussion in the paragraph above regarding quality indicators and unit specific correction plans. No documented evidence could be provided that the hospital is currently conducting performance improvement projects. Upon further discussion, both individuals stated the facility did not currently conduct such projects. The Director of Quality and Risk stated, "Those are part of the plan for the future."

A review of the University General Hospital Governing Board Meeting Minutes from December 2013 through May 2014 revealed discussion related to quality indicators and unit correction plans, but no discussion of current performance improvement projects conducted by the hospital.

Based on review of documentation and interview, the facility failed to ensure that mislabeled or otherwise unusable drugs were not made available for patient use.

Findings were:

United States Pharmacopeia General Chapter 797 recommends the following for multi dose vials of sterile pharmaceuticals: "If a multi dose has been opened or accessed (e.g. needle punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. If a multi dose vial has not been opened or accessed, it should be discarded according to the manufacturer's expiration date. The manufacturer's expiration date refers to the date after which an unopened multi dose vial should not be used. The beyond use date refers to the date after which an opened multi dose vial should not be used. The beyond use date should never exceed the manufacturer's original expiration date."

Facility policy entitled "Multiple and Single Use Sterile Drugs" stated in part,
" ...4. Length of Use of Multiple-Use Sterile Drugs
After the initial entry, multiple-use sterile drugs may be used, if there exists no restriction on use, for up to 28 days unless otherwise specified in the manufacturer's product information (if it specifies a shorter date for opened containers)."

Tour of the second floor medication room on 07/14/2014 revealed the following:
? In the refrigerator in the second floor medication room, 7 punctured mult-dose vials of Humulin Reg Insulin were found to have no notation indicating date opened nor initials of who opened the vials.
? In this same refrigerator, 2 Humalog punctured multi-dose vial were found to have no notation indicating date opened or initials of who opened the vials.
? On the counter in this medication room, an open multi-dose vial of Famotidine Injection had no notation indicating date opened nor initials of who opened the vial.
? Due to the missing date opened and initials, it is unknown if the 28 day length of use period had passed for these medications.

Interview with staff member #6 in the medication room on 7/14/2017 it was determined that policy had not been followed as indicated above.

Based on observation and interview, it was determined that the facility was not maintained to assure the safety of staff and patients.

Findings were:

"OSHA/Bloodborne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

Tour of the facility on 7/14, 7/15 and 7/16/14 revealed the following:

? Molding was observed to be pulling away from the walls throughout the building.
? In many of the patient rooms, floor tiles appeared to be slightly swollen and water damaged around toilets and shower stalls.
? Also in every patient room, the sheet rock walls were gouged and damaged. Laminate cabinet surfaces were chipped and peeling.
? In elevator # 2, the floor was bubbled and uneven, creating a trip hazard for both patients and staff.
? In the radiology department, laminate flooring was noted to be peeling up, again creating a fall hazard for both patients and staff.
? In the surgical area, the flooring was heavily gouged and chipped, particularly in the hallways. The surgical suites had numerous gouges in the floor, rendering disinfection impossible.
? Also in the surgical suites, the walls had numerous gouges.
? 3 of 5 surgical suites used portable dehumidifiers. These dehumidifiers were not maintained according to manufacturer's recommendations.
? Termites were discovered in OR room #5 on 7/3/14 and then again on 7/5/14. Termites were also found in the OR woman's dressing room.
? 2 portable air conditioning units were found in the sterile supply room. These units had been in this room since December of 2013. Even with these portable air conditioners, this supply room was very warm (89.9 degrees). Surgical staff member # 2 (Sterile Reprocessing Technician) said that the heat and humidity in the room rendered the supplies unusable. When surgical cases were scheduled, the supplies were sterilized before each case.
? In the CT room in the Radiology Department, a chair that was upholstered in fabric was situated under a vent in this room. The chair was water stained. The Radiology Technologist told the survey team that when it rained, water dripped from the vent onto the chair, creating the stain.

In an interview with the OR Director and the Director of Clinical Services on 7/14 and 7/15/14, the above deficits were confirmed. The Coordinator of Medical Imaging and the Radiology Technologist acknowledged the above physical plant issues on 7/16/14.



28043

During a tour of the laboratory the afternoon of 7/14/14 accompanied by Laboratory Staff # 1, Lab Manager, the following was observed:
? The bottom end of the emergency call light in the patient bathroom for urine specimen collection was approximately 2.5 feet from the floor, rendering it out of reach of a patient who had fallen on the floor. When the surveyor pulled the emergency call light cord, there was a one-time "ding" sound and the external light lit. However, when the nearest lab staff member, a phlebotomist, was asked if she heard or was aware that the call light had been pulled, she stated that she did not hear anything. There was no response to the emergency call light. When the Lab Manager was asked if the call light alarmed any other place, the Lab Manager stated he did not know. When the emergency call light was pulled a second time, again, there was again no response after approximately 5 minutes. The lack of staff response to the emergency call light presents a risk for injury or lack of response for any patient needing emergency or other assistance in the phlebotomy area patient bathroom. The above findings were confirmed in an interview with the lab manager during the tour the afternoon of 7/14/14.
? In the phlebotomy office area in the phlebotomy trays, there were five (5) EDTA blood collection tubes which had expired 6/2014.
? In the phlebotomy drawing station room, there were thirty-eight (38) red top microtainer blood collection tubes which had expired 6/2014.
? In the lab storage room, on the wire shelving units, there were 2 dirty, corrugated shipping boxes on the top shelf, stored over items associated with patient care, including urine collection containers, culturette tubes, and plastic glucometer cases. This presents a risk for cross-contamination of patient care items, which were available for use.

The above findings were confirmed in an interview with Laboratory Staff #1 during the tour the afternoon of 7/14/14.



30250

During a tour of the Emergency Department on 07/15/14, the following physical plant issues were identified:
? The back entrance to the Emergency Department there was a missing section of floor tile, approximately 1 X 12 inches in size. The flooring was visibly cracked along the seam of the back entryway.
? In the hallway by the entry to the Emergency Department, a 2 x 4 inch hole in the dry wall was observed.
? In the staff bathroom which contained the patient ice machine, cracked floor tiles were observed near a drain in the floor with a black substance surrounding the drain.
? In the nurse's station 4 office chairs were observed with 6 inch tears in the covering, exposing foam underneath.
? In the storage room, one tank of oxygen was observed unsecured.
? In Room 101 (identified as clean), a sticky substance, gum like in appearance, was observed on the floor. Chips in the paint were observed on the wall of this room. A crack in the wall was observed approximately 3 inches in size, was observed beside the red outlet. The dividing wall in the room had a 2 mm gap at the bottom.
? In Room 104 (identified as clean), the call light cord in the restroom, was observed wrapped around the hand rail, if a patient fell in the bathroom the call light would be inoperable. A shelve was observed with visible dust and 2 needle caps present.
? In Room 105, (identified as clean), a shelf was observed with visible dust present, 1 phlebotomy tube, 1 roll of tape, 4 various needle caps, 3 otoscope covers, and 1 tourniquet were present on the dusty shelf. Debris, including, toilet paper was visible on the floor of the restroom room. Remnants of toilet paper were observed in the toilet. A radiology apron was observed under the sink in this room. Water damage 3 X 3 inches in circumference was observed to a ceiling tile. Paint on the wall of this room was observed to be chipped. A 2 X 3 inch portion of the laminate to the door was missing. One sprinkler was observed to be missing the housing unit around the ceiling tile, leaving a gap between the sprinkler and the tile.
? In Room 108 (identified as clean), an overhead lamp was observed with tape and tape residue present in a 4 X 4 inch area. Paint chips were observed on the wall throughout the room. The trash can was observed to be full of debris and not emptied. Debris was observed on the floor, including pieces of plastic. The call light cord in the restroom was observed to be caught behind the toilet paper dispenser, rendering it inoperable.

In an interview with the Emergency Department Director on 7/15/14, the above deficits were confirmed.




32870

Tour of the Primary Linen Storage area on 7/16/14 revealed the following:

? Two ceiling tiles with large brown circular stains in the primary linen storage. One stain was approximately 10" in diameter and the other was 12" in diameter. The stains appeared to be the result of water damage.
? Areas of chipped paint on the walls approximately 10" x 2" and 3" x 2" along with many smaller chipped areas.
? there was also a chipped floor tile approximately 3" x2".

The above issues were identified during the tour of the area with Environmental Staff #1 and Administration Staff #8 on the afternoon of 7/15/14. In a simultaneous interview, these two individuals agreed that these physical plant maintenance issues needed to be addressed by the facility.

Tour of the outpatient Waxahachie Surgery Center on the morning of 7/16/14 revealed the following environmental issues:

? Under the sink in the "Cidex Room," (Cidex is a solution used for disinfection) there were open holes surrounding water pipes. In addition, the cabinet under the sink contained black particulate matter identified as "dirt" by Surgery Center Staff #5 during the tour. She added, "Something must have gotten in here."
? The cabinet under the sink in the PACU contained a large brown stain that was approximately 12" x 6". Open holes were noted around the pipes allowing for entry of rodents or insects.

In an interview with Surgery Staff #5 and Administration Staff #8 on the morning of 7/16/14 during the facility tour, the above physical plant maintenance issues were identified. The two individuals agreed that the issues needed to be addressed by the facility.

Based on review of documentation, tour of the facility and interview, it was determined that the facility failed to control the temperature and humidity in all areas of the hospital.

Findings were:

Tour of the OR and sterilization areas on 7/15/14 revealed the following:

? 2 portable air conditioning units were found in the sterile supply room. These units had been in this room since December of 2013. These units blew air onto the trays of "sterile" equipment. Even with these portable air conditioners, this supply room was very warm (89.9 degrees). Surgical staff member # 2 (Sterile Reprocessing Technician) said that the heat and humidity in the room rendered the supplies unusable. When surgical cases were scheduled, the supplies were sterilized before each case.
? OR room # 1's humidity detector was not functioning. This made it impossible to monitor the moisture in the OR suite. 2 portable dehumidifiers were located in Operating Rooms # 1 and 3. Use of these portable dehumidifiers indicated the facility ' s internal dehumidifying system was not functioning properly.

In an interview with the Sterile Reprocessing Technician and the OR Director on 7/15/14, the humidity and temperature concerns were acknowledged.

Based on observation and interview, it was determined that the facility failed to provide a sanitary environment in all areas of the hospital.

Findings were:

Tour of the ICU on 7/14/14 revealed the following:

? Tears were noted in the vinyl cover on a pillow in ICU room # 1. These tears made cleaning impossible and cross contamination impossible.
? Dust was noted on all high horizontal surfaces in ICU room # 1 and the floors were dirty which indicated improper cleaning of the area.
? Also noted in ICU room # 1 were gouges on the sheetrock walls. These gouges made cleaning of the walls impossible.
? In ICU room # 2, the sheetrock walls were also gouged. A dried drop of blood was noted on the floor. The floor was also dirty with evident streaks of dirt. These deficits indicated improper cleaning of the area.
? Also in ICU room # 2, when the bed was taken apart, the bed frame was wet. This indicated the bed was put together and made without allowing it to dry. This could cause cross contamination.
? The ICU Nourishment Station had sugar spilled in drawers and an open, half eaten Popsicle in the refrigerator. The refrigerator had food particles in the drawers which indicated improper cleaning. The ceiling tile over the refrigerator was stained which indicated a water leak.
? In the Pulmonary Supply Closet in the ICU, a catheter and a mask was observed on the floor.
? A storage cart was noted next to the blanket warmer in ICU. Used supplies and broken equipment were observed in the cart.
? Temperature logs on blanket warmer were missing dates of temperature documentation.
? In a room designated for acute renal dialysis, used patient supplies were observed on the window sill (shampoo, tape). The sink was pulling away from the wall and a dried puddle of soap was noted on the floor under the soap dispenser. Also witnessed in this same room were spurts of body fluids (blood, serosanguinous fluid) on the fluorescent light fixture on the ceiling and on the wound VAC machine. This indicated improper cleaning of the area.

Tour of the Medical/Surgical floor on 7/14/14 revealed the following:

? On the crash cart located in a common hallway, 2 small drops of blood were observed. This indicated improper cleaning of the cart. 2 used patient telemetry strips were left in the electrode storage box which indicated improper handling of private patient (PHI) information.
? In patient room 206, the floor was dirty and molding was observed to be pulling away from the walls. Dust was noted on high horizontal surfaces. Blood or Betadine was on the floor under the sink. This indicated improper cleaning of the area. A 2 foot by 1 foot board was affixed to the wall behind the bed. This board was covered with wall paper that was peeling. This peeling paper made cleaning of the wall surface impossible.
? In patient room 207, a portable, padded, raised toilet seat was observed. The vinyl cover of this toilet seat was torn, which made cleaning the seat impossible and cross contamination likely. This seat was found in a "clean" patient room however the survey staff was unable to determine if and when it had been last cleaned.

Tour of the surgical and equipment serialization areas on 7/14 and 7/15/14 revealed the following:

? The Sterile Reprocessing Technician who gave the survey team a tour of the surgical area on 7/15/14 had on a pair of soiled sneakers. He wore these shoes inside the operating rooms and the sterile reprocessing areas. He then wore the shoes out into the common areas of the hospital. He stated, "I normally only wear these shoes in the sterile reprocessing area but my mind is spinning today."
? In the sterilization area, above the Steris (sterilization) machine, a dusty vent was noted. The ceiling tiles did not fit tightly around the 2 pipes that fed into the ceiling. These openings around the pipes could allow access of vectors into the area.
? Laminate was observed peeling from the cabinets in the dirty processing room and floor tiles were cracked and molding was observed pulling away from the wall rendering thorough cleaning of the area impossible.
? 2 portable air conditioning units were found in the sterile supply room. These units had been in this room since December of 2013. These units blew air onto the trays of "sterile" equipment. Even with these portable air conditioners, this supply room was very warm (89.9 degrees). Surgical staff member # 2 (Sterile Reprocessing Technician) said that the heat and humidity in the room rendered the supplies unusable. When surgical cases were scheduled, the supplies were sterilized before each case. The same staff member was not aware that the filters in the air conditioning units required cleaning.
? In OR room # 1, paint was observed to be peeling from the doorframe and there were tears in the operating table mattress. Rust was noted on the bottom of the operating table and on the linen and trash cart. The wheels on the cauterization cart and the wheels on the suction machine were also rusted. These factors render cleaning impossible and cross contamination likely. It appeared as if dirt is sealed within the wax on the floor, indicating the floor was not cleaned before waxing. The humidity detector was not functioning which made it impossible to monitor the moisture in the OR suite. (High levels of moisture increase the risk of bacteria proliferation.) A dehumidifier with a dirty filter was found in the room and the condensation container was found to be overflowing onto the floor, creating a slip hazard. The staff did not proactively check the status of the water container but waited until the machine stopped before emptying the full container. Additionally, the staff was unaware that this water container should be cleaned after emptying the water.
? In OR room # 2, there was a tear noted in the operating table mattress. There was also tape residue on the mattress. The wheels on the cauterization cart were rusted. These issues render cleaning impossible and cross contamination likely. Betadine spots were observed on the floor. It appeared as if dirt is sealed within the wax on the floor, indicating the floor was not cleaned before waxing.
? In OR room # 3, a dehumidifier was found. The filter on this machine was dust covered. The same issues were present concerning the water condensation container. Betadine and tape was found on the floor and the wheels on the cauterization cart were rusted. It appeared as if dirt is sealed within the wax on the floor, indicating the floor was not cleaned before waxing. On the floor outside of OR room # 3, the flooring is missing and cracked. According to staff member # 1 (Surgery Staff), the floor has been in its current condition for over 2 years.
? OR room # 4 was used for storage and was not maintained.
? In OR room # 5, the x-ray viewer had broken glass. Many small gouges were found on the floor and it appeared as if dirt is sealed within the wax on the floor, indicating the floor was not cleaned before waxing.
? A sign on the door of the Cysto room said that the room had been "Terminally Cleaned." Trash was noted on the floor and the bottom of the fluoroscopy machine was rusted. There were tears in the foot stirrups on the procedure table. A stool that the surgeon sits on (per Director of OR), was covered with tape that concealed tears in the fabric. These issues made cleaning impossible and cross contamination likely.

Tour of the Pharmacy on 7/16/14 revealed the following:

? Dirt was evident on the floor in the area behind the staff refrigerator indicating improper cleaning of the area.
? The laminate covering was peeling off of various shelving units and countertops. The porous surface of the uncovered wood does not allow for appropriate cleaning.

Tour of the Radiology area on 7/16/14 revealed the following:

? Patient supplies and equipment were stored in an unused radiology room. A patient gurney was in the room that had a thick strip of tape on the mattress, thus rendering cleaning of the mattress impossible.
? In X-Ray room # 4, a wall socket was observed dangling from the wall. The walls were chipped and gouged and a lead cape (which is used to cover the patient during procedures) was dirty and torn. The cabinets were chipped.
? The Ultrasound room had a mattress that had a 2 X 1 inch tear which made cleaning impossible and cross contamination likely. Tape was noted on the bedframe and the cabinets in the room were chipped.
? The CT room had a hole in the sheetrock that measured approximately 1 X 1 inch. The vinyl floor was peeling in large sheets, creating a trip hazard for staff. A chair that was upholstered in fabric was situated under a vent in this room. The chair was water stained. The Radiology Technologist told the survey team that when it rained, water dripped from the vent onto the chair, creating the stain.
? In the Nuclear Medicine room, the laminate floor was cracked and peeling. The procedure table padding was torn. Two absorbent pads were noted to be taped to a cabinet. The pads appeared used and dirty. The Nuclear Medicine technician stated "Those pads are pretty clean. I changed them a couple of weeks ago." A heavily soiled lead apron was noted to be positioned on top of a lead storage box. This apron was partially lying on the floor, creating an opportunity for cross contamination.

In an interview with the OR Director and the Director of Clinical Services on 7/14 and 7/15/14, the above infection control issues were confirmed. The Coordinator of Medical Imaging and the Radiology Technologist also acknowledged the above infection control problems on 7/16/14.




32870

Tour of the Primary Linen Storage area on 7/15/14 revealed the following:

? Two ceiling tiles with large brown circular stains in the primary linen storage. One stain was approximately 10" in diameter and the other was 12" in diameter. The stains appeared to be the result of water damage in the ceiling above the area where clean linen was stored and ready for patient use.
? Areas of chipped paint on the walls approximately 10" x 2" and 3" x 2" along with many smaller chipped areas which made cleaning difficult.
? A chipped floor tile approximately 3" x 2" which made cleaning difficult.
? Approximately six dirty dust mops and brooms were stored next to clean linen ready for patient use.

Facility policy #IC 15, entitled Housekeeping Infection Control, approval date May 2013, stated, in part: "The housekeeping supply rooms will be kept in neat and orderly fashion...Rags and mops are to be placed with other dirty linen..."

The above issues were identified during the tour of the area with Environmental Staff #1 and the Facilities Director on the afternoon of 7/15/14. In a simultaneous interview, these two individuals agreed that these infection control issues needed to be addressed by the facility.

Tour of the outpatient Waxahachie Surgery Center on the morning of 7/16/14 accompanied by Staff #5 and the Facilities Director revealed the following environmental issues:

- There was 1 dirty external corrugated FedEx shipping box on wire shelving containing a shelf full (greater than 10) of LR 1000 ml IV fluid, which was available for patient use. This presents a risk of cross contamination as external shipping containers are exposed to dirt and other contaminants during shipping.
- There was no solid barrier on the bottom shelf of a wire shelving unit with cardboard boxes of patient supplies, creating a risk for cross contamination.
- There was a layer of raised dust on the ceiling vent in the pharmacy.

In OR 2, the following was observed:

- There was no solid barrier on the bottom shelf of a wire shelving unit with cardboard boxes of patient supplies, creating a risk for cross contamination.
- There was a layer of raised dust on the ceiling vent in the pharmacy.
- There was rust on the wheels of the black pain management cart; rust cannot be disinfected, creating a risk for cross contamination.
- There was tape and sticky, dirty tape residue on the OR bed.
- There was rust and tape on the red cart containing patient supplies, such as airways, needles, and syringes.
- There was tape and sticky, dirty tape residue on the automatic tourniquet machine.
- There were 12 holes in the sheetrock on the back wall, preventing effective disinfection.
- There was black dust on the wall vent in the back of the room.
- There was a layer of dust on the horizontal surfaces of a plastic bin unit containing patient supplies such as med cups, surgery instruments, Kerlix and other supplies, available for patient use.

In the Pre-Op area, the following was observed:
? Under the sink, there was a 2 by 1.5 inch hole in the back wall. There were 2 pipes coming through the back wall which were not sealed. The wall underneath the sink was stained. There was a dead spider hanging from a spider web.

In the Post-Op area, the following was observed:
? There was a water damaged ceiling tile, approximately 6 inches in diameter.
? There was light visible from the outside on the left lower corner of an external door, which could allow the entry of dust and insects into the patient area.

In the "Cidex Room," the following was observed:
? Under the sink there were open holes surrounding water pipes. In addition, the cabinet under the sink contained black particulate matter identified as "dirt" by Surgery Center Staff #5 during the tour. She added, "Something must have gotten in here."

In the PACU area, the following was observed:
- The cabinet under the sink contained a large brown stain that was approximately 12" x 6". Open holes were noted around the pipes allowing for entry of rodents or insects.
- Sticky tape was found on the patient ice machine and patient fridge in the PACU making cleaning difficult. Tape was also found on the sharps containers throughout the area.
- When Surgery Staff #5 was asked how often the curtains dividing patient beds in the area were cleaned, she stated, "I'm not sure what the rotation of the curtains are." No surgical center staff could provide information on this matter. The facility could provide no policy addressing this issue.

Expired medications included:
? 1 vial of Recoronium Bromide Injection 100 mg/10mL which had handwritten "ex 7/6" on the label.

In an interview with Surgery Staff #5 and the Facilities Director on the morning of 7/16/14 during the facility tour, the above infection control issues were identified. The two individuals agreed that the issues needed to be addressed by the facility.

Environmental Services entitled "Patient and Isolation Room Cleaning and Discharge Cleaning" stated in part "All patient rooms will be treated as if they were in isolation rooms. Rooms are cleaned when a patient has been discharged or transferred. The patient care unit will notify the Environmental Services Department when the patient has left the premises ...
? Strip the bed of linen by rolling toward the center of the bed. Hold linens away from the body. Place linens in the soiled linen container. Using a disinfectant saturated blue towel wipe the bed frame, both sides of the mattress, pillows and bed control with disinfectant germicidal solution and let it air dry for 7-10 minutes. Use clean linens to remake the bed."

Facility policy entitled "High Dusting" stated in part "The purpose of this policy is to establish a procedure for:
? Preventing the accumulation of dust and lint on surfaces.
? Providing and maintaining a clean and micro-biologically safe environment.
Standards:
1. Obtain the necessary equipment and materials. Treated high micro fiber head duster and handle with extended handle up to 54" and counter duster.
2. Using a treated high duster, begin cleaning in a counter clockwise direction around the area. High dust surfaces above shoulder height. Dust the top of the lights, doors, curtain tops, and wall mounted TV sets, partitions, etc."

Facility policy entitled "Patient Care Blood and Body Fluid Spills Cleaning" stated in part "Patient Care Assistant or nursing staff should contain the blood or the body fluid spills as soon as it happens to assure safety; especially, when a room is occupied by a patient; the EVS staff will come in as soon as notified to clean and disinfect the area."

Facility policy entitled "Environmental Guidelines" stated in part "Patient food may be stored in the nourishment refrigerator. Food should be stored in closed containers, labeled with patient name and dated. Food greater than 3 days old will be discarded."

Facility policy entitled "Terminal Cleaning for Surgery, Cath Labs and OR Areas" stated in part:
"Damp wipe, using an approved disinfectant solution and clean cloths, all cabinet exteriors, push plates and handles. Clean all wall surfaces, ledges and baseboards spotted or soiled with blood/body fluid or medication.

Floors will be shower scrubbed and emblazed once every three months or more often if lint and/or soil accumulation is visible. All equipment will be moved to clean the floor as needed.

Disassemble the OR table and remove the pieces of the pieces of the mattress. Clean using an approved disinfectant cleaner, all mattress pieces, table surfaces, arm boards, stirrups and adaption equipment.

Move all equipment to one-half of the room being careful with the electrical cords. Thoroughly dry and wet mop the entire floor with an approved disinfectant solution.

Project Surgery Cleaning:
a) All operating rooms will be wall washed once per month or more frequently with the coordination and the request of the department head if lint and/or soil accumulation require.
b) All operating rooms will be soft scrubbed and buffed once per month or more frequently or per department head request if lint and/or soil accumulation require. All equipment, tables, stands, etc. will be moved to clean the floor as needed."

Facility policy entitled "Environmental Cleaning of the Surgical Practice Setting" stated in part "Floors will be stripped and waxed monthly by the designated OR person and Environmental Services Department."

Facility policy entitled "Vent/Radiator/Grill Cleaning" stated in part "Air Vents/Door Grills-Dust the entire vent with a dust wand or dust cloth. Pay special attention to debris in the crevices and cracks of the vents ...Use a clean cloth dampened with an all-purpose cleaner to wipe the vent area. If you are unable to reach the surface using a safety step ladder, a wall washing tool may be used."

Facility policy entitled "Sterile Processing" stated in part "Central Sterile personnel are required to wear scrub attire. Shoe covers are worn if wearing outside shoes in department."

Operator Manual for Friedrich Dehumidifier gave the following manufacturer's recommendations: "The purpose of the air filter is to filter dust and other materials from the air. If the filter is blocked by dust the electricity usage will be greater than normal. For optimal moisture removal and efficiency, clean the filter every two weeks."

Operator Manual for Honeywell Portable Air Conditioner gave the following manufacturer's recommendation: "The air filter should be cleaned every two weeks."
A review of the User Manual for the Getinge 400HC/500HC Series Steam Sterilizers included daily maintenance to be performed as follows:
"Remove the sediment screens from the chamber drains, and clean thoroughly. They can be removed and replaced without using tools. If the sterilizer has an integral steam boiler without automatic blow-down, manually blow down the boiler..."

In an interview with the Director of the Surgery Center on the morning of 7/16/14 during the facility tour, she stated, "I think we're probably doing that, but I'm not sure. I guess we need to keep a log on that." Thus, the facility could provide no documented evidence that the surgery center sterilizers were maintained according to manufacturer's instructions.

In an interview with the Director of Infection Control on the afternoon of 7/16/14 in the facility conference room, he stated there were many issues with the hospital related to the physical plant. He stated, "This is really all about funding. There just aren't the resources to address some of these issues." He said that he and the Facilities Director either together or separately completed environment of care rounds periodically. A review of Patient Safety/EOC Rounding Tool - Infection Control from January 2014 through July 2014 revealed the completed checklists rarely included findings or issues.

When asked about surveyors' findings related to infection control and whether they'd been noted in the rounds and addressed, he reported on specific issues as follows, "The humidity in the ORs should be fine. A technician came in and fixed some electrical contacts for the humidifiers ...They did some drilling for the termites last night ...The filters were cleaned in the ORs last summer ...A lot of this stuff is environment of care. There just are no resources."

Regarding a serious infection control issue discovered during the survey in the kitchen wherein dishes were being washed only in water without soap, he was asked what had been done to address it. He replied "[The Director of Quality and Risk] mentioned it in our closing discussion about the survey yesterday. She already mentioned that we should probably create a training situation."

When asked how staff was involved in infection control, he stated, "I depend on my staff to notify me if there's a problem. I look at linens. I look to see that people are washing their hands appropriately. If there are questions about organisms, I address those. I have patient instructional information to give out regarding organisms."

A review of Patient Safety/EOC Rounding Tool - Infection Control dated 1/18/14 revealed a handwritten note by the Director of Infection Control, "Issues exist [with] SPD [Sterile Processing Department] Temp & Humidity Levels. Reported to Facility-Maintenance."

A review of facility policy entitled Reportable Diseases Responsibilities to Public Health Department, approval date July 2013, revealed the policy listed Notifiable Conditions in Texas which were not based on the most current Texas Notifiable Conditions requirements. Attached to the policy was a listing of Texas Notifiable Conditions which expired on 1/31/12. In addition, the policy included no mention of, and thus no contact information for the Infectious Disease Surveillance and Epidemiology Branch of the Texas Department of State Health Services.

In the same interview noted above with the Director of Infection Control on the afternoon of 7/16/14 in the facility conference room, he stated he thought he had a current copy of the Texas Notifiable Conditions "somewhere" and agreed that the facility policy was not accurate.

The above findings were confirmed in an interview with Surgery Center Staff #5 the morning of 7/16/14 while observed during the tour of the surgery center.