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Based on observation and interview, the facility failed to ensure medications stored on mobile nurse carts were locked when not attended in 1 out of 1 mobile cart observed.

Findings included:

On 4-23-2018 a tour of the first floor was made with Staff #1. An unattended nursing cart was observed in the hallway with syringes of normal saline for flushing medications through intravenous (IV) lines. Approximately fifteen (15) IV flushes were stored openly on the cart where they could be accessed and/or tampered with by unauthorized individuals.

Interview was conducted with Staff #1. Staff #1 confirmed that the cart was unattended and that this was the normal nursing practice.

Based on observation, review of records, and interview, the infection control officer failed to ensure that effective processes were in place for maintaining a sanitary environment in 8 areas on the first floor (physical therapy storage room, unserviceable equipment storage room, hallway, patient/visitor seating area, nursing station, medication room, patient nutrition room and central supply) out of 11 (physical therapy storage room, unserviceable equipment storage room, hallway, patient/visitor seating area, nursing station, medication room, patient nutrition room, central supply, therapy treatment room, visitor bathrooms, and patient room) areas toured.

Findings included:

A tour of the physical therapy storage room was made with Staff #1 and Staff #5 on 4-23-2018. The storage room was for clean Physical Therapy equipment, and was located across from Physical Therapy treatment room on the first floor. A partially consumed bottle of water and an empty bottle of water was found with the clean equipment. The floor was visibly dirty with a dead bug, dust and dirt.

The bathroom in the storage room was being used to store clean equipment. Cushions were stacked on top of an open toilet seat (no lid). Equipment was placed next to the toilet. Boxes with cushions for patient use were stored on the bathroom floor. The bathroom floor had dust, dirt, and debris in the corners of the bathroom and shower stall. Gaps in the flooring material, where the flooring did not meet up with the wall, allowed dirt and debris to build up. The bathroom sink had the appearance of being used by staff. A partially used tube of toothpaste and a bottle of barrier film used to protect intact skin from chaffing were found on the sink back.

The shower stall was being used to store clean equipment. Also found in the shower stall was a used patient boot. The boot was for treating foot drop, a condition in which the forefoot drops due to weakness or paralysis. Staff #5 confirmed that the boot had been used at some point in time, but was not able to identify the patient it had been used on. Staff #5 stated that "Someone just probably didn't know what to do with it. So, they put it in here." Since that patient it was used on could not be identified, it could not be determined if the patient had any conditions that involved infectious disease processes or multi-drug resistant organisms.

The tour of the first floor was continued with Staff #1. Another decommissioned patient room was located next to the physical therapy storage room. This was a storage room for unserviceable equipment, per Staff #1. The room cluttered and packed to the point that entrance into the room could not be made without moving equipment out. This provided a condition that could be harboring rodents and pests without the knowledge of staff since it could not be adequately inspected for cleanliness. The bathroom of this room was also being used for storage of unserviceable mobile workstations that were awaiting repair or replacement. Staff #1 was not able to provide a date or time frame that this was to take place. The wall of the room had drops of what initially appeared to be dried blood. After wiping with a sanitizing cloth, it was evident that the drops were red marker. There was mounting tape for a white board that had been removed when the room was decommissioned and the wall had not been cleaned since that time.

The hallway on the first floor had fold-down chart stations on the walls outside patient rooms. A chart station was opened. Inside the chart station was trash. The desk surface created when opening the chart station was visibly soiled. There was a bed with an extra mattress in the hallway. When asked about the status of the bed, Staff #1 stated that it was unserviceable. When asked how anyone would know it was unserviceable, Staff #1 stated because it did not have a plastic bag tied to the rail indicating it was clean. When asked if it was dirty, Staff #1 stated, "No, it's clean." Staff #1 was not able to explain how a staff member was to know the bed was clean, or how a staff member was to know not put the bed back in service since it had no tags or signs that indicated it was not to be used.

The patient and visitor sitting area on the first floor contained 3 blue vinyl couches and a brown storage cabinet. The vinyl couches had visible crumbs along the meeting point of the seat cushion and backrest cushion. When pressure was applied to the seat cushion and the area between the seat cushion and seat back cushion was exposed, it was found to be full of dirt, dust, and debris. The cushions had visible dried spills on them. One couch had trash behind it when pulled away from the wall. Another had wall hangings stored on the floor behind it. The brown cabinet had an opened can of Thicken in it. Thicken is a substance used for patients to thicken liquids when the patient has difficulty swallowing thin liquids. Staff #1 stated she did not know why that would be there. On another shelf in the cabinet was a foam cup with a room temperature brown liquid in it and a straw. There was a plastic bag with an unopened beverage in it. Staff #1 stated the cabinet was for staff use and used to have a lock on it. She did not know why it was not locked or why those items were in there.

The first floor nurse's station was observed to have a heavily soiled floor. Under the cabinet was equipment to include a tool box that battery operated lights for emergency. The top of the box was heavy with dust and particles. On the floor under the handwashing sink was a heavily soiled cardboard box that was labeled as parts for the copy machine. This allowed water from regular hand washing to drop onto the top of the box. The box was up against a trash can that was heavily soiled on the outside of the can. The box had bits of trash on top of it.

The medication room bins were found with dried spills. The bin for medications that were discontinued was found to have an open package of gauze pads like those used when checking blood sugar levels. The pads were out of the package and just lying open to contaminants in the bin. The cabinet under the sink was heavily soiled and had dried spilled matter on it along with cardboard trash. The patient medication refrigerator had trash on the bottom shelf. There were dried spills on the floor in front of the refrigerator. Kool-Aid Gels for patient consumption were located in the bottom crisper drawer. Individual containers did not have stamped use-by dates on them. Once separated from the original package, the use-by date could not be determined. Several gel containers were found to be in a liquid state, not gel. No product use-by marking system had been implemented to ensure safety of the food items.

The patient nutrition room floor was also heavily soiled. Two cases of water for patients (one opened, one unopened) were sitting directly on the floor. Patient liquid nutrition for tube feedings and oral supplements for patients needing extra nutrition were stored on trays on open shelves. The trays were rusted, dirty, and had trash on them. The ice dispense nozzle and water dispense nozzle were visibly soiled. The inside of the refrigerator and freezer were soiled with dirt, hair, food particles and dried spills. The exterior the refrigerator had a buildup of dust and dirt on top and in the door seals for the freezer and refrigerator doors.

The cabinet under the ice and water dispenser was opened. The back of the cabinet was missing and opened to a large hole in the wall. The hole in the wall opened to a dead space between walls. This allowed easy access for rodents and pests into the patient nutrition room. A dirty cloth rag and foam cup could be seen behind the cabinet. The cabinet contained liquid patient nutrition for tube feeding in bottles and cans. The can tops were visibly soiled and rusted. A dirty metal tray was also stored under the cabinet.

A drawer in the patient nutrition room contained individual packages of crackers. A large, sharp knife was stored in the drawer also. The cracker wrappers could be potentially compromised by the knife, exposing crackers to contaminates. Drawers, shelves, storage bins and countertops were found to be heavily soiled. One bin had a torn and soiled paper label with "EXP: 07/19/14" on it, indicating the paper label had been in place for approximately four years.

Upon entering room number 1180 to speak with a patient, it was noted that the room number sign on the wall outside of the room was visibly dirty.

Central supply storage room floor was noted to be heavily soiled in places. Supplies were found to have fallen on the floor and were pushed up under shelves.

Interview was conducted with Staff #6. Staff #6 stated that the housekeeping staff was responsible for wiping down exterior surfaces in the patient nutrition room. Staff #6 confirmed the surfaces were soiled.

Interview was conducted with Staff #1. Staff #1 stated that there had been on-going problems with the contracted company that provided housekeeping services. Staff #1 stated that she made monthly environmental rounds.

Review of the Infection Control Plan for 2018 was made. It was identified in the risk assessment that "There has been a noted decrease in cleanliness of the hospital in general. It has been noted in patient surveys that the rooms are not clean. There was marked improvement in Q1 and Q2 for 2017. However for Q3 and Q4 we are beginning to see cleanliness as an issue again." (sic) Under the Evaluation section "CNO, DQM, and manager of SSH area for contracted housekeeping service to meet in February 2018 and set a POA for cleaning. Monthly meetings to be held and reports given to leadership, QAPI and OIC."

Review of meeting minutes found that the February meeting and monthly reporting did not take place.

Review of "Monthly Infection Control Rounds: for 4-4-2018 completed by Staff #1 showed that none of the deficiencies cited had been identified during the Infection Control rounds. No cleanliness issues were identified at all on the 4-4-2018 rounds.