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Based on observations, interviews and document review, the facility staff failed to ensure: that the kitchen area of the dietary department was integrated in the Quality Assurance Performance Improvement Program and the Infection Control Program; they followed acceptable guidelines for kitchen sanitation by ensuring the dishwasher functioned properly, the ventilation was clean, pots and pans were not stacked/nested wet for storage, that refrigeration, freezer temperatures were accurate for food storage, and that pest control was properly assessed; the staff and staff documentation were monitored for accuracy, provided training if documentation was not accurate, and to be alerted for problems.


See Tag 0619 for details related to this condition.

Based on observations and interview, the facility staff failed to ensure the physical condition of the facility was maintained in a manner that was safe for patients, visitors and staff as evidenced by: torn carpets in hallways, broken tiles in hallways and kitchen area, broken hand rail in ICU, exposed porous wood furniture in the mother baby rooms and ICU patient rooms. There were discolored tiles under the handwashing sinks, broken tiles in the nursery, and a missing transition from one room to the other in the nursery leaving a trip hazard. Jagged hand rails in the mother baby hallway, chipped trim around the doorways, monitor carts with chipped and missing Formica trim.

See tag 0701 for details related to this condition.

Based on observations, interviews and document review, the facility staff failed to ensure a sanitary environment by failing to: integrate the dietary department (including the kitchen area) in the Quality Assurance Performance Improvement Program and the Infection Control Program; follow acceptable guidelines for kitchen sanitation by ensuring the dishwasher functioned properly, the ventilation was clean, pots and pans were not stacked wet for storage and refrigeration and freezer temperatures were accurate for food storage. They also failed to ensure the staff temperature documentation was monitored for accuracy, training if documentation was not accurate and to be alerted for problems. The facility staff also failed to ensure carpets and furniture were clean and that furniture with exposed wood surfaces (porous surface) was either removed from service or repaired. The facility failed to ensure staff wore Personal Protective Devices appropriately and changed them per the facility policies, cleaned point of care devices appropriately after use and performed hand hygiene, and they failed to follow their policy related to cleaning items in radiology.



See Tag 0749 for specific details related to this condition.

Based on interview, observations, and document review, the facility staff failed to ensure the hospital kitchen was assessed in the data collection for performance improvement. The kitchen is an area that can affect the health of patients (who are provided food from the kitchen), staff and visitors who access the food produced or provided by the kitchen.

The findings include:

On 7/11/19 at approximately 4:30 P.M., the facility's Performance Improvement Program (PIP) was reviewed with Staff Member #28. Staff Member #28 stated, "We have identified three (3) areas of focus; HAIs (Hospital Acquired Infections), decrease the use of opiods for pain management and blood utilization. We did not identify the environment and/or the kitchen as a focus area for improvement but we do look at each area of the hospital."

During the initial tour of the hospital kitchen on 7/9/19 at approximately 1:30 P.M., the following observations and interviews occurred:
The dishwashing area had water on the floor around two (2) sides of the dishwasher where staff walk. A mop and mop bucket were present and a rubber mat had been placed over the area with the most water. Staff Member #19 stated, "The dishwasher has been leaking for about four (4) weeks. They came to repair it a couple of weeks ago and was able to replace one part but brought the second part was the wrong part and had to be ordered. We are waiting for it to be installed."

Dishes were coming out of the dishwasher and being placed in a stack on top of each other. Staff Member #19 explained, "When the pots and pans and dishes come out they are stacked on this cart to dry (Staff Member #19 pointed to a large metal cart to the right of the dishwashing area)." On the left side of the dishwasher exit site was a second large metal rack with slots to hold items in an upright position. The second large rack was empty. Staff Member #19 stated, "The rack (pointed to second rack) is too small for the large pans. After the pans are dried, we put them on the other side of the kitchen for use." The pans were assessed on the first rack and found to be stacked wet. The pans were assessed in the area on the other side of the kitchen and were found stacked wet and the bottom pans were dirty.

Staff Member #19 stated, "We have budgeted for a new dishwasher for the past two (2) years, but it has been pushed back."

The three (3) compartment sink was observed with each compartment full of water. The sinks labeled rinse and sanitation contained food debris. Staff Member #27 stated, "I have not had time to change the water from breakfast." Staff Member #27 was observed adding hot water the first sink (wash sink).

To the left of the three compartment sink was an area with two (2) rat traps, a type of small animal feces, a sticky strip (later explained to catch fruit flies), and flying fruit flies or gnats. Staff Member #19 stated, "We had the pest control people out last week and they caught a rat in this area and one in the dry storage area. They also put up the sticky hanging strips to catch the fruit flies. We have them come every week."

Over the dishwashing area, a vent in the ceiling that blows out air was observed to be dirty with a black residue and grease. Staff Member #19 stated, "We have put in a work order to have the vents cleaned." The vent was reassessed on 7/11/19 and appeared to have been cleaned. The remaining vents, some over the food preparation area, were assessed on 7/11/19 at approximately 9:00 A.M. Two (2) of the vents over the food preparation area were soiled with dirt and grease. Staff Member #19 was asked why the other vents were not cleaned and stated, "I don't really know."

In the middle of the kitchen, there was an area where a steamer had been. There were two (2) roadside type orange cones on each corner with yellow caution tape tied around the area. Staff Member #19 stated, "The steamer went down about 2-3 months ago." Observed in the area was a hole in the floor, dried shriveled potato, grease and dirt. Adjacent to this space was another steamer, which was soiled on the top and had gaskets around the inside that felt sticky

The PIP data reviewed on 7/11/19 with Staff Member #28 did not include any information related to the needs of the kitchen. The kitchen is a high risk area that could affect patients, visitors and staff members that are served by or access food produced in the kitchen if food is not stored or served properly and if dishes are not cleaned and stored properly.

Based on document review and interview, it was determined that the facility staff failed to follow the nursing plan of care related to pain by not reassessing the pain level after administration of pain medication for one (1) of thirty (30) patients (Patient # 4).

The findings include:

On July 11, 2019 at 10:30 a.m., a review of the clinical record for Patient # 4 revealed the following:
On July 9, 2019 at 11:56 a.m. nursing documentation reads, "Patient # 4's pain at a "9" based on a numeric pain scale of 0 - 10 (10 being most pain ever experienced). Dilaudid 1 mg IV (intravenous) was given. Patient stated pain goal "4"."
At 2:29 p.m. nursing documentation reads, "Patient # 4's pain at a "9" based on the numeric pain scale.", two (2) hours and thirty three (33) minutes after the administration of IV pain medication.

Patient # 4's plan of care for pain failed to follow the facility policy and procedure to "reassess the patient's pain within one hour after administration of a medication given to relieve pain."

An interview with Staff Member # 7 on July 11, 2019 at 11:45 a.m. revealed "the nurse should reassess the patient's pain within an hour after the administration of pain medication."

The facility policy titled "Pain Management Policy" provided by Staff Member # 7 on July 11, 2019 at 12:30 a.m. read in part "Reassessment of the patient's pain will be performed within an hour after administration of a medication given to relieve pain, as appropriate to the route of the medication, to determine the effectiveness of the medication. Route: IV Suggested time frame for pain reassessment: between 15 and 30 minutes."

Based on observations, interviews and document review, the facility staff failed to ensure: that the kitchen area of the dietary department was integrated in the Quality Assurance Performance Improvement Program and the Infection Control Program; they followed acceptable guidelines for kitchen sanitation by ensuring the dishwasher functioned properly, the ventilation was clean, pots and pans were not stacked/nested wet for storage, that refrigeration, freezer temperatures were accurate for food storage and that pest control was properly assessed; that the staff and staff documentation were monitored for accuracy, provided training if documentation was not accurate, and to be alerted for problems.

The findings include:

During the initial tour of the hospital kitchen on 7/9/19 at approximately 1:30 P.M. the following observations and interviews occurred:
The dishwashing area had water on the floor around two (2) sides of the dishwasher where staff walk. A mop and mop bucket were present and a rubber mat had been placed over the area with the most water. Staff Member #19 stated, "The dishwasher has been leaking for about four (4) weeks. They came to repair it a couple of weeks ago and was able to replace one part but brought the second part was the wrong part and had to be ordered. We are waiting for it to be installed."

Dishes coming out of the dishwasher were being placed in a stack on top of each other. Staff Member #19 explained, "When the pots and pans and dishes come out they are stacked on this cart to dry (Staff Member #19 pointed to a large metal cart to the right of the dishwashing area)." On the left side of the dishwasher exit site was a second large metal rack with slots to hold items in an upright position. The second large rack was empty. Staff Member #19 stated, "The rack (pointed to second rack) is too small for the large pans. After the pans are dried we put them on the other side of the kitchen for use." The pans were assessed on the first rack and found to be stacked wet. The pans were assessed in the area on the other side of the kitchen and were found stacked wet and the bottom pans were dirty.

Staff Member #19 stated, "We have budgeted for a new dishwasher for the past two (2) years, but it has been pushed back."

The three (3) compartment sink was observed with each compartment full of water. The sinks labeled rinse and sanitation contained food debris. Staff Member #27 stated, "I have not had time to change the water from breakfast." Staff Member #27 was observed adding hot water the first sink (wash sink).

To the left of the three compartment sink was an area with two (2) rat traps, a type of small animal feces, a sticky strip (later explained to catch fruit flies), and flying fruit flies or gnats. Staff Member #19 stated, "We had the pest control people out last week and they caught a rat in this area and one in the dry storage area. They also put up the sticky hanging strips to catch the fruit flies. We have them come every week."

Over the dishwashing area, a vent in the ceiling that blows out air was observed to be dirty with a black residue and grease. Staff Member #19 stated, "We have put in a work order to have the vents cleaned." The vent was reassessed on 7/11/19 and appeared to have been cleaned. The remaining vents, some over the food preparation area, were assessed on 7/11/19 at approximately 9:00 A.M. Two (2) of the vents over the food preparation area were soiled with dirt and grease. Staff Member #19 was asked why the other vents were not cleaned and stated, "I don't really know."

In the middle of the kitchen, there was an area where a steamer had been. There were two (2) roadside type orange cones on each corner with yellow caution tape tied around the area. Staff Member #19 stated, "The steamer went down about 2-3 months ago." Observed in the area was a hole in the floor, dried shriveled potato, grease and dirt. Adjacent to this space was another steamer, which was soiled on the top and had gaskets around the inside that felt sticky.

Per the facility Policy #F019: Dishwasher temperatures for the final rinse should be 180° to 194° Fahrenheit (F).

A review of the temperature logs from April 2019 through July 2019 for the dishwasher, refrigerators and freezers revealed the following:
Each log, for every device included a section for documentation of Corrective Action and Manager Weekly Review.
There was no indication on any refrigeration log identifying the item as a cooler or milk box cooler.
At the bottom of each refrigeration log, there was the following directive comment:
"Standard: Cooler Min temp: 34° Fahrenheit Max temp: 41° Fahrenheit.
Milk Box Cooler: Min temp: 36° Fahrenheit and Max temp 41° Fahrenheit".

In April 2019, the following final rinse temperatures (dates and meals not recorded below were within acceptable range) were documented:
Breakfast: April 7, 12, 21 through 27 and 30, 2019 as 168-178 ° Fahrenheit.

Lunch: April 2, 4, 6 through 10, 12 through 13, 15 through 23, 25 through 27, and 29 through 30 as 166 through 179 ° Fahrenheit.

Dinner: April 1 there were no temperatures taken. April 3, 6, 11 and 16 through 19 as 167° to 179 ° Fahrenheit. On April 20, comment stated, "Alerted supervisor CDG -Work order placed". April 22, 23 and 25 comment stated, "Parts ordered, work order placed." There was no comment for April 24. Temperatures for April 20, 21 and 25 were 167° Fahrenheit.

April 27 and 28 comments stated, "Using Quat Sanit (three compartment sink)".
One manager review was documented in April and was dated 4/20/19.

According to an interview on 7/11/19 with Staff member #19 and review of the April 2019 temperature log, the facility began using a Dishwasher Temperature Test Strip on or about April 19, 2019. here were three (3) strips attached to the dishwasher log for dates on or about April 19 to 23, 2019 (12 days) when there should have been thirty-six (36). There were no other dates checked. The directions on the strip read, "Blue-Black turns bright orange when temp is above 160° Fahrenheit." All three (3) strips in the April log were observed to be black.


Per the facility's Refrigerated Storage Temperature Record, the lowest acceptable refrigerator temperature was 34° Fahrenheit and the highest acceptable temperature was 41° Fahrenheit. The maximum acceptable temperature for a freezer was 0° Fahrenheit; there was no lowest acceptable temperature.

April 2019 Temperature logs review revealed the following for
Refrigerator #4:
at 4:30 A.M. on 4/1, 4/2 and 4/3/19 were between 52 and 55° Fahrenheit;
at 5:00 P.M. on 4/1/19 was 56° Fahrenheit with a comment "Door left open.";
at 6:00 A.M. on 4/6/19 was 42° Fahrenheit with no corrective action comment and no manager documentation;
April 17, there were no temperatures recorded. Comment reads, "Box unplugged" with no manager comment;
April 18, there were no temperatures recorded for the evening shift.

Refrigerator #6:
April 1, 3, 6 and 7 refrigerator was documented as "off" in the evening but an acceptable day temperature recorded on 4/3/19;
April 19th, the refrigerator was "off for defrosting";
April 23rd, the refrigerator "cut off during the night";
April 26th "not working";
April 27 and 28 temps were not recorded.

Refrigerator #7:
April 15th, the refrigerator was off and comment stated, "No longer in service."
April 17th and 18th, the comment read, "Back in service" but during the P.M. temperatures, documentation read, "Off". There was no documentation in the manager review.

Refrigerator #8 and #9 logs for April 2019 lacked manager weekly reviews.

Freezer #10:
4/4/19 temperature was documented as +2° at 4:30 A.M. and +3° at 5:00 P.M.
There were no manager weekly reviews.

Refrigerator #11:
4/1/19 4:30 A.M. temperature was minus 38° Fahrenheit and at 5:00 P.M. minus 6° Fahrenheit. No manager weekly review documented.

Freezer #12:
4/1 through 4/23 and 4/25 through 4/30 at 4:30 A.M., 6:00 A.M., 7:00 A.M. and 4:49 A.M. temperatures were documented as +2° to +19°.
4/1 through 3, 8, 10, 11, 12, 17, 21 and 25 did not indicate if the temp was positive or negative,
4/4, 6, 79, 15, 16, 20 and 29 the 4:30 P.M. and 5:00 P.M. temperatures ranged from +6° to +16° Fahrenheit.
4/23 the comment stated the freezer door was left open but still within range.
There were no weekly manager notes.

Freezer #13 and #23 lacked weekly manger notes.
Refrigerators #14 - #22 lacked weekly manger notes.

May 2019 Dishwasher, Refrigerator and Freezer logs reviewed on July 12, 2019 revealed the following:
Dishwasher final rinse:
Breakfast for May 1 through 7, 10, 14, 15, 18, 19, 20 through 24, 28, 29 and 31 temperatures ranged from 165° to 178° Fahrenheit.
Lunch for May 1, 2, 4, 6 through 9, 14 through 17, 20, 21, and 27 through 31 temperatures ranged from 168° to 179° Fahrenheit.
Dinner for May 2, 3, 4, 6, 7, 9 through 21 and 30 temperatures ranged from 162° to 174°Fahrenheit. There were no weekly manager review notes in May.

Dishwasher Temperature Test strips for May revealed;
thirteen (13) strips did not turn bright orange.
On May 20, 2019, the dishwasher did not reach the required temperature; maintenance was called.
The May 2019 Dishwasher Temperature Test Strip Log contained 27 strips. (If a strip was ran at each meal there should be ninety-three (93) strips for the month of May.)

May Refrigerator and Freezer Logs revealed the following:
Refrigerators #1, #2, #3, #4, #5 and #6 lacked weekly manager review notes.
Refrigerator #6 had the following notes:
6:00 A.M. on May 4 and 5, "Off for the weekend".
4:30 A.M. on May 13, "Off for defrosting".
6:00 A.M. May 18 and 19, "Off for weekend".
5:00 A.M. May 25 and 26, "Off for weekend".
5:00 A.M. on May 26, "Off for weekend".
4:30 A.M. on May 27 "off" at 5:00 P.M. "37 (° Fahrenheit)".

Refrigerators #7, #8, #9, #10, #11, #14 through #22 and Freezer #12, #13 and #23 had no weekly manger review notes for May 2019.

Freezer #12:
May 1 through 24 and 27 through 31 the 4:30 A.M., 5:00 A.M., 6:00 A.M. temperatures were documented as +1° to +20° Fahrenheit. May 1, 2, 4, 5, 13, 18 and 19 the 4:30 P.M. and 5:00 P.M. temperatures were above 0° Fahrenheit and ranged from +12° to +18° F.

June 2019 Dishwasher, Refrigerator and Freezer logs review, done on July 12, 2019, revealed the following:
Dishwasher final rinse:
Breakfast: June 1 through 5, 9, 19, 20 and 30 temperatures ranged from 168° to 178° Fahrenheit. There were no weekly manager review notes.
Lunch: June 1 through 8 and 30 temperature ranged from 168° to 179° Fahrenheit.
Dinner: June 9, 10, 11, 13, 14, 19 through 21, 24 through 28 and 30 temperatures ranged from 168° to 178° Fahrenheit.

Dishwasher Temperature Test strips for June revealed eleven (11) test strips for breakfast, ten (10) test strips for lunch and five (5) test strips for dinner. There should have been thirty (30) test strips for each meal in June. Ten (10) of the strips retained failed to turn bright orange.

June Refrigerator and Freezer Logs revealed the following:
Refrigerators #1, #2, #3, #4, #5, #7, #9, #11 and #14 through #22 and Freezer #10, #12, #13 and #23 lacked weekly manager review notes.
Refrigerator #6 had the following notes: 6:00 A.M. on June 1 and 2, "Off for the weekend"; June 15, 16, 29 and 30, "Off for the weekend".
Refrigerator #8: June 26 and 27 at 4:30 A.M. "Off", at 5:00 P.M. "Deicing the box";
June 28 (no time) "Back on";
June 30 at 6:00 A.M. 48° Fahrenheit and at 4:30 P.M., "Out of service".

Freezer #12 temps for June 2019 were as follows:
June 1 through 30 the morning (4:30 A.M. or 6:00 A.M.) temperatures were documented as +1 to +24° Fahrenheit. June 1, 2, 3, 7, 11, 13 through 17, 24, 25, 29 and 30 evening (4:30 P.M. or 5:00 P.M.) temperatures were documented as positive and ranged from +12 to +21° Fahrenheit. There were no weekly manager review notes.

July 2019 Dishwasher, Refrigerator and Freezer logs review, done on July 12, 2019, revealed the following:
Dishwasher final rinse:
Dinner: July 2, 3 and 9 temperatures ranged from 176° to 179° Fahrenheit. On July 10 the dishwasher was placed "Out of Service for lunch and dinner".
Staff Member #35 stated on July 12, 2019 at approximately 10:45 A.M., "We were using the long term care facilities' dishwasher for lunch and dinner yesterday. They repaired the dishwasher and we are using ours now."

Dishwasher Temperature Test strips for July 1 through 11 revealed; ten (10) test strips for breakfast, and no test strips for lunch or dinner. There should have been twenty-six (26) test strips for each meal for July at the time of the survey. Six (6) strips failed to turn bright orange.

July Refrigerator and Freezer Logs revealed the following:
Refrigerators #1, #3, #4, #5, #6, #7, #9, #11, #14 through #22 and Freezer #2, #10, #12, #13 and #23 lacked weekly manager review notes.

Refrigerator #8 had the following notes:
July 1 at 4:30 A.M. "Out of Service";
July 2 "Temp to low still (Temp 30° Fahrenheit) being serviced",
July 3 at 4:30 A.M. temperature 30° Fahrenheit but there were no indication it was not being used.
July 6 at 6:00 A.M. temperature 52° Fahrenheit note read, "Called Best Tech 7:00 A.M.".
July 9 at 4:30 A.M. temperature 42° Fahrenheit, but there were no indication the refrigerator was, "Out of service".
July 10 at 4:30 A.M. temperature 50° Fahrenheit, no indication the refrigerator placed, "Out of service".
July 11 at 4:30 A.M., "Off" and note read, "Out of Service called Best Tech."

Freezer #12: July 8 through 11 at 4:30 A.M. and 5:00 P.M., the temperatures read +16° through +26°. Staff Member #19 stated, "The person recording the temperatures is reading the outside thermometer, which is broken, and should be reading the inside thermometer."

Refrigerator #19: July 4 at 4:30 A.M. temperature was 32° Fahrenheit.


On 7/11/19 at approximately 4:30 P.M., the Performance Improvement Program (PIP) was reviewed with Staff Member #28. Staff Member #28 stated, "We have identified three (3) areas of focus; HAIs (Hospital Acquired Infections), decrease the use of opiods for pain management and blood utilization. We did not identify the environment and/or the kitchen as a focus area for improvement but we do look at each area of the hospital."

The 2019 PIP data reviewed with Staff Member #28 did not include information related to the needs of the kitchen. The kitchen is a high risk area that could affect patients, visitors and staff members that are served by or access food produced in the kitchen if food is not stored or served properly and if dishes are not cleaned and stored properly.

A review of the facility's Infection Prevention and Control Program (IPCP) 2019 with Staff Member #31 and #32 was conducted on 7/11/19 and revealed the following:
Part I was a description of the program. The Scope read as follows, "The plan covers all components of the organization, the main hospital facility, surrounding buildings, ambulatory areas, as well as on and offsite affiliated physician practices and services. The plan covers all employees, medical staff members, licensed independent practitioners, students/trainees, contract workers, patients and their families, visitors and volunteers."

Part II, Section C: Risk Assessment and Prioritization of Goals, read, "...A risk assessment will be conducted at least annually or whenever significant changes occur. Consideration will be given to those issues, which are high risk, high volume, related to emerging or reemerging trends and problem prone..."

Part IV, Section B: Epidemiological principles read, "...Surveillance; Related Activities: ...Regularly conducting tours of the physical attributes of the facilities to ensure that risks for the transmission of disease or occupation hazards are minimized and a sanitary hospital environment is maintained.
Monitoring compliance with all policies, procedures, protocols and other infection control program requirements."

Evaluation for the 2018 program read as follows:
"Event:
Improper cleaning/disinfection of environment:
Strategies:
...Implement ATP (Adenosine triphosphate) monitoring system to evaluate cleanliness of environment.."

Interview with Staff Member #19 on 7/11/19 revealed no evidence of the detection of temperature documentation error or corrective action to include staff education.

Document review revealed work orders were entered in January, February and July 2019 to clean the ceiling vents and repair a leak over the dishwasher.

An on-site and off-site review of the kitchen's Health Department Inspection Reports from November 2018 to June 2019 was conducted. The November 2018 and January 2019 reports indicated the dishwasher was not functioning properly but was corrected by the February 2019 return inspection. The June 12, 2019 inspection noted the damaged floor around the steamer area.

Based on observations and interview, the facility staff failed to ensure the physical condition of the facility was maintained in a manner that was safe for patients, visitors and staff as evidenced by: torn carpets in hallways, broken tiles in hallways and kitchen area, broken hand rail in Intensive Care Unit (ICU), exposed porous wood furniture in the mother baby rooms and ICU patient rooms. There were discolored tiles under the handwashing sinks, broken tiles in the nursery, and a missing transition from one room to the other in the nursery leaving a trip hazard. Jagged hand rails in the mother baby hallway, chipped trim around the doorways, monitor carts with chipped and missing Formica trim. The Out Patient Laboratory waiting area had four (4) of twenty-four (24) chairs with the arm rest finish chipped or worn away leaving exposed porous wood (some splintery), one (1) chair with a torn seat, and a table with a broken leg. A patient chair in the phlebotomy area had torn vinyl-like arms. The defibrillator in the Computed tomography (CT) area was not checked for two (2) days to assess functionality.

The findings include:

Beginning on 7/9/19 at approximately 10:55 A.M. various parts of the hospital were observed.
The Out Patient Laboratory waiting area had twenty-four (24) chairs in the waiting area. Four (4) of the chairs had the finish worn away leaving exposed porous wood, some of which was splintery, and one (1) had a torn seat. Also in this area, a table was observed with a table leg laying on top of the table leaving only three (3) attached legs.

In the phlebotomy area of the lab was a chair described by Staff Member #4 as, "Used by patients if they are dizzy or feel like they are going to be sick." The chair had a vinyl like covering which had torn arms leaving exposed padding.

In the CT area of Radiology, the defibrillator had not been checked on 7/8/19 or 7/9/19 for functionality. Staff Member #5 stated, "They are to be checked first thing in the morning."

The floors in the Radiology area had tile that was broken and or buckling making a trip hazard for staff and patients.

At approximately 12:15 P.M. on 7/9/19, the Emergency Department was observed. In the hallway, a stretcher had rusted areas unable to be cleaned between patient uses.

On 7/9/19 at approximately 1:30 P.M., the kitchen was observed. In the kitchen area, by the dishwasher, the floor was covered in water. A rubber mat had been placed on the floor to allow staff to pass from one area to another. A hole was in the floor where a steamer had been. Staff member #19 stated, "The steamer went down about 2-3 months ago."

The Telemetry area was observed on 7/10/19 at approximately 1:00 P.M. The carpets in the hallway where torn making trip hazards for patients, staff and visitors. Staff Member #38 stated, "It has been about 10 or 11 years since this unit was refurbished. We are an old facility."

In patient room 3037 (no patient present), the mattress was torn.

On 7/11/19 at approximately 3:30 P.M., the Center for Birth was observed. There were broken tiles under the handwashing sinks, some with black edges indicating water had gotten under the tiles.

A doorway leading to the medication area had broken tile and was missing a transition piece causing a trip hazard. There was a special nursery area accessed by going through the main nursery through the medication room to the special nursery. There was one baby in the special nursery area. If the baby was removed and taken to a rocking chair in the main nursery, the nurse carrying the baby could be exposed to the trip hazard.

Handrails in the mother baby area had some areas that were jagged and splintery.

The mother baby area consisted of twenty-three (23) rooms. Five (5) of the rooms had sofa/beds with worn wooden arm rest leaving a porous exposed surface that could not be cleaned and disinfected. A monitor cart (being used as a night stand) had Formica trim that was chipped and missing.


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2. On July 9, 2019 at 11:00 a.m., during a tour of the Laboratory Department with Staff Member # 1, countertops were observed to have chips, cracks and were being held together with tape. Staff Member # 1 asked lab personnel to have the tape removed from the counter due to "infection control issue."

On July 10, 2019 at 9:00 a.m., a tour of an offsite Physical Therapy Center with Staff Member # 8, revealed eleven (11) of eleven (11) chairs observed in the waiting area to have wooden arms with exposed bare wood. There were planks of exposed wood with nicks and dent in Vestibular Rooms 1 & 2. A table used for physical therapy patients had tears in the mat. The steps used for physical therapy patients had wooden rails with exposed bare wood. There was a wooden cabinet in the patient bathroom that had dents and scratches.

On July 10, 2019 at 10:20 a.m., a tour of the Operative Department (OR) with Staff Member # 1 revealed the doorways to OR rooms and the Sterile Processing Department (SPD) had cracked and chipped paint.

Based on observations, interviews and document review, the facility staff failed to ensure their Infection Prevention and Control Plan was followed by Staff Members by following acceptable guidelines for kitchen sanitation. Staff failed to ensure the temperature documentation was monitored for accuracy, training provided if documentation was not accurate and to be alerted for problems. The facility staff failed to ensure carpets and furniture were clean and that furniture with exposed wood surfaces (porous surface) was either removed from service or repaired. Failed to ensure staff appropriately wore Personal Protective Devices and changed them per the facility policies, cleaned point of care devices appropriately after use, performed hand hygiene, and failed to follow their policy related to cleaning items used in radiology

The findings include:

1. During the initial tour of the hospital kitchen on 7/9/19 at approximately 1:30 P.M. the following observations and interviews occurred:
The dishwashing area had water around two (2) sides of the dishwasher both of which were in the staff walking area. A mop and mop bucket were present and a rubber mat had been placed over the area with the most water. Staff Member #19 stated, "The dishwasher has been leaking for about four (4) weeks. They came to repair it a couple of weeks ago and was able to replace one part but brought the second part was the wrong part and had to be ordered. We are waiting for it to be installed."

Dishes coming out of the dishwasher were being placed in a stack on top of each other. Staff Member #19 explained, "When the pots and pans and dishes come out they are stacked on this cart to dry (Staff Member #19 pointed to a large metal cart to the right of the dishwashing area)." On the left side, of the dishwasher exit site was a second large metal rack with slots to hold items in an upright position. The second large rack was empty. Staff Member #19 stated, "The rack (pointed to second rack) is too small for the large pans. After the pans are dried we put them on the other side of the kitchen for use." The pans were assessed on the first rack were found to be stacked wet. The pans were assessed in the area on the other side of the kitchen and were found stacked wet and the bottom pans were dirty.

Staff Member #19 stated, "We have budgeted for a new dishwasher for the past two (2) years, but it has been pushed back."

The three (3)-compartment sink was observed with each compartment full of water. The sinks labeled "rinse" and "sanitation" contained food debris. Staff Member #27 stated, "I have not had time to change the water from breakfast." Staff Member #27 was observed adding hot water the first sink (wash sink).

To the left of the three compartment sink was an area with two (2) rat traps, a type of small animal feces, a sticky strip (later explained to catch fruit flies), and flying fruit flies or gnats. Staff Member #19 stated, "We had the pest control people out last week and they caught a rat in this area and one in the dry storage area. They also put up the sticky hanging strips to catch the fruit flies. We have them come every week."

Over the dishwashing area, a vent in the ceiling that blows out air was observed to be dirty with a black residue and grease. Staff Member #19 stated, "We have put in a work order to have the vents cleaned." The vent was reassessed on 7/11/19 and it appeared to have been cleaned. The remaining vents, some over the food preparation area, were assessed on 7/11/19 at approximately 9:00 A.M. Two (2) of the vents over the food preparation area were soiled with dirt and grease. Staff Member #19 was asked why the other vents were not cleaned and stated, "I don't really know."

In the middle of the kitchen area was an area where a steamer had been. There were two (2) roadside type orange cones on the corner of the area with yellow caution tape tied around the area. Staff Member #19 stated, "The steamer went down about 2-3 months ago." Observed in the area was a hole in the floor, dried shriveled potato, grease and dirt. Adjacent to this space was another steamer which was soiled and had gaskets around the inside that felt sticky.

Per the facility Policy #F019: Dishwasher temperatures for the final rinse should be 180° to 194° Fahrenheit (F).

A review of the temperature logs from April 2019 through July 2019 for the dishwasher, refrigerators and freezers revealed the following:
Each log for every device included a section for documentation of Corrective Action and Manager Weekly Review.
There was no indication on any refrigeration log identifying the item as a cooler or milk box cooler.
At the bottom of each refrigeration log there was the following directive comment:
"Standard: Cooler Min temp: 34° Fahrenheit Max temp: 41° Fahrenheit.
Milk Box Cooler: Min temp: 36° Fahrenheit and Max temp 41° Fahrenheit."

In April 2019, the following final rinse temperatures (dates and meals not recorded below were within acceptable range) were documented:
Breakfast: April 7, 12, 21 through 27 and 30, 2019 as 168°-178° Fahrenheit.

Lunch: April 2, 4, 6 through 10, 12 through 13, 15 through 23, 25 through 27, and 29 through 30 as 166° through 179 ° Fahrenheit.

Dinner: April 1 there were no temperatures taken. April 3, 6, 11 and 16 through 19 as 167° to 179 ° Fahrenheit. On April 20, comment stated "Alerted supervisor CDG -Work order placed". April 22, 23 and 25 comment stated, "Parts ordered, work order placed." There was no comment for April 24. Temperatures for April 20, 21 and 25 were 167° Fahrenheit.

April 27 and 28 comments stated, "Using Quat Sanit (three compartment sink)."
One manager review was documented in April and was dated 4/20/19.

According to an interview on 7/11/19 with Staff member #19 and review of the April 2019 temperature log, the facility began using a Dishwasher Temperature Test Strip on or about April 19, 2019. There were three (3) strips attached to the dishwasher log for dates on or about April 19 to 23, 2019 (12 days) when there should have been thirty-six (36) strips. There were no other dates checked. The directions on the strip read, "Blue-Black turns bright orange when temp is above 160° Fahrenheit." All three (3) strips in the April log were black.

Per the facility's Storage Temperature Records, the lowest acceptable refrigerator temperature was 34° Fahrenheit and the highest acceptable temperature was 41° Fahrenheit. The maximum acceptable temperature for a freezer was 0° Fahrenheit; there was no acceptable lowest temperature.

April 2019 Temperature log review revealed the following for
Refrigerator #4:
at 4:30 A.M. on 4/1, 4/2 and 4/3/19 were between 52° and 55° Fahrenheit;
at 5:00 P.M. on 4/1/19 was 56° Fahrenheit with a comment "Door left open.";
at 6:00 A.M. on 4/6/19 was 42° Fahrenheit with no corrective action comment and no manager documentation;
April 17, there were no temperatures recorded. Comment reads, "Box unplugged" with no manager comment;
April 18, there were no temperatures recorded for the evening shift.

Refrigerator #6:
April 1, 3, 6 and 7 refrigerator was documented as "off" in the evening but an acceptable day temperature recorded on 4/3/19;
April 19th, the refrigerator was "off for defrosting";
April 23rd, the refrigerator "cut off during the night";
April 26th "not working";
April 27 and 28 temps were not recorded.

Refrigerator #7:
April 15th, the refrigerator was off and comment stated, "No longer in service";
April 17th and 18th, the comment reads, "Back in service" but during the P.M. temperatures, documentation reads, "Off". There was no documentation in the manager review.

Refrigerator #8 and #9 logs for April 2019 lacked manager weekly reviews.

Freezer #10:
4/4/19 temperature was documented as +2° at 4:30 A.M. and +3° at 5:00 P.M.
There were no manager weekly reviews.

Refrigerator #11:
4/1/19 4:30 A.M. temperature was minus 38° Fahrenheit and at 5:00 P.M. minus 6° Fahrenheit. No manager weekly review documented.

Freezer #12:
4/1 through 4/23 and 4/25 through 4/30 at 4:30 A.M., 6:00 A.M., 7:00 A.M. and 4:49 A.M. temperatures were documented as +2° to +19°;
4/1 through 3, 8, 10, 11, 12, 17, 21 and 25 did not indicate if the temperature was positive or negative;
4/4, 6, 79, 15, 16, 20 and 29 the 4:30 P.M. and 5:00 P.M. documented temperatures ranged from +6° to +16° Fahrenheit;
4/23 the comment stated the freezer door was left open but still within range;
There were no weekly manager notes.

Freezer #13 and #23 lacked weekly manger notes.
Refrigerators #14 - #22 lacked weekly manger notes.

May 2019 Dishwasher, Refrigerator and Freezer logs reviewed on July 12, 2019 revealed the following:
The following final rinse temperatures (dates and meals not recorded below were within acceptable range) were documented:
Dishwasher:
Breakfast for May 1 through 7, 10, 14, 15, 18, 19, 20 through 24, 28, 29 and 31 temperatures ranged from 165° to 178° Fahrenheit;
Lunch for May 1, 2, 4, 6 through 9, 14 through 17, 20, 21, and 27 through 31 temperatures ranged from 168° to 179° Fahrenheit;
Dinner for May 2, 3, 4, 6, 7, 9 through 21 and 30 temperatures ranged from 162° to 174°Fahrenheit;
There were no weekly manager review notes in May.

Dishwasher Temperature Test strips for May revealed;
thirteen (13) strips did not turn bright orange.
On May 20, 2019, the dishwasher did not reach the required temperature; maintenance was called.
The May log contained 27 strips. (If a strip was ran at each meal there should be ninety-three (93) strips for the month of May.)

May Refrigerator and Freezer Logs revealed the following:
Refrigerators #1, #2, #3, #4, #5 and #6 lacked weekly manager review notes.
Refrigerator #6 had the following notes:
6:00 A.M. on May 4 and 5, "Off for the weekend";
4:30 A.M. on May 13, "Off for defrosting";
6:00 A.M. May 18 and 19, "Off for weekend";
5:00 A.M. May 25 and 26, "Off for weekend";
5:00 A.M. on May 26, "Off for weekend";
4:30 A.M. on May 27 "off", at 5:00 P.M. "37 (° Fahrenheit)".

Refrigerators #7, #8, #9, #10, #11, #14 through #22 and Freezer #12, #13 and #23 had no weekly manger review notes for May 2019.

Freezer #12:
May 1 through 24 and 27 through 31 the 4:30 A.M., 5:00 A.M., 6:00 A.M. temperatures were documented as +1° to +20° Fahrenheit. May 1, 2, 4, 5, 13, 18 and 19 the 4:30 P.M. and 5:00 P.M. temperatures were above 0° Fahrenheit and ranged from +12° to +18° F.

June 2019 Dishwasher, Refrigerator and Freezer logs review, done on July 12, 2019, revealed the following:
Dishwasher final rinse:
Breakfast: June 1 through 5, 9, 19, 20 and 30 temperatures ranged from 168° to 178° Fahrenheit. There were no weekly manager review notes.
Lunch: June 1 through 8 and 30 temperatures ranged from 168° to 179° Fahrenheit.
Dinner: June 9, 10, 11, 13, 14, 19 through 21, 24 through 28 and 30 temperatures ranged from 168° to 178° Fahrenheit.

Dishwasher Temperature Test strips for June revealed eleven (11) test strips for breakfast, ten (10) test strips for lunch and five (5) test strips for dinner. There should have been thirty (30) test strips for each meal in June. Ten (10) of the strips retained failed to turn bright orange.

June Refrigerator and Freezer Logs revealed the following:
Refrigerators #1, #2, #3, #4, #5, #7, #9, #11 and #14 through #22 and Freezer #10, #12, #13 and #23 lacked weekly manager review notes.
Refrigerator #6 had the following notes: 6:00 A.M. on June 1 and 2, "Off for the weekend"; June 15, 16, 29 and 30, "Off for the weekend".
Refrigerator #8: June 26 and 27 at 4:30 A.M. Comment "Off", at 5:00 P.M. "Deicing the box";
June 28 (no time) "Back on".
June 30 at 6:00 A.M. 48° Fahrenheit and at 4:30 P.M., "Out of service".

Freezer #12 temps for June 2019 were as follows:
June 1 through 30 the 4:30 A.M. or 6:00 A.M. temperatures were documented as +1° to +24° Fahrenheit. June 1, 2, 3, 7, 11, 13 through 17, 24, 25, 29 and 30 the 4:30 P.M. or 5:00 P.M. temperatures were positive and ranged from +12° to +21° Fahrenheit. There were no weekly manager review notes.

July 2019 Dishwasher, Refrigerator and Freezer logs review done on July 12, 2019 revealed the following:
Dishwasher final rinse:
Dinner: July 2, 3 and 9 temperatures ranged from 176° to 179° Fahrenheit. On July 10 the dishwasher was placed "Out of Service for lunch and dinner".
Staff Member #35 stated on July 12, 2019 at approximately 10:45 A.M., "We were using the long term care facilities' dishwasher for lunch and dinner yesterday. They repaired the dishwasher and we are using ours now."

Dishwasher Temperature Test strips for July 1 through 11 revealed; ten (10) test strips for breakfast, and no test strips for lunch or dinner. There should have been twenty-six (26) test strips for each meal for July at the time of the survey. Six (6) strips failed to turn bright orange.

July Refrigerator and Freezer Logs revealed the following:
Refrigerators #1, #3, #4, #5, #6, #7, #9, #11, #14 through #22 and Freezer #2, #10, #12, #13 and #23 lacked weekly manager review notes.

Refrigerator #8 had the following notes:
July 1 at 4:30 A.M. "Out of Service";
July 2 "Temp to low still (Temp 30° Fahrenheit) being serviced",
July 3 at 4:30 A.M. temperature 30° Fahrenheit but there were no indication it was not being used.
July 6 at 6:00 A.M. temperature 52° Fahrenheit note read, "Called Best Tech 7:00 A.M.".
July 9 at 4:30 A.M. temperature 42° Fahrenheit, but there were no indication the refrigerator was, "Out of service".
July 10 at 4:30 A.M. temperature 50° Fahrenheit, no indication the refrigerator placed, "Out of service".
July 11 at 4:30 A.M., "Off" and note reads, "Out of Service called Best Tech."

Freezer #12: July 8 through 11 at 4:30 A.M. and 5:00 P.M., the temperatures read +16° through +26°. Staff Member #19 stated, "The person recording the temperatures is reading the outside thermometer, which is broken, and should be reading the inside thermometer."

Refrigerator #19: July 4 at 4:30 A.M. temperature was 32° Fahrenheit.

Interview with Staff Member #19 on 7/11/19 revealed no evidence of the detection of temperature documentation error or corrective action to include staff education.


On 7/11/19 at approximately 4:30 P.M. the Performance Improvement Program (PIP) was reviewed with Staff Member #28. Staff Member #28 stated, "We have identified three (3) areas of focus; HAIs (Hospital Acquired Infections), decrease the use of opiods for pain management and blood utilization. We did not identify the environment and/or the kitchen as a focus area for improvement but we do look at each area of the hospital."

The 2019 PIP data reviewed with Staff Member #28 did not include information related to the needs of the kitchen. The kitchen is a high risk area that could affect patients, visitors and staff members that are served by or access food produced in the kitchen if food is not stored or served properly and if dishes are not cleaned and stored properly.


A review of the facility's 2019 Infection Prevention and Control Program (IPCP) with Staff Member #31 and #32 was conducted on 7/11/19 and revealed the following:
Part I was a description of the program. The Scope read as follows, "The plan covers all components of the organization, the main hospital facility, surrounding buildings, ambulatory areas, as well as on and offsite affiliated physician practices and services. The plan covers all employees, medical staff members, licensed independent practitioners, students/trainees, contract workers, patients and their families, visitors and volunteers."

Part II, Section C: Risk Assessment and Prioritization of Goals, read, "...A risk assessment will be conducted at least annually or whenever significant changes occur. Consideration will be given to those issues, which are high risk, high volume, related to emerging or reemerging trends and problem prone..."

Part IV, Section B: Epidemiological principles read, "...Surveillance; Related Activities: ...Regularly conducting tours of the physical attributes of the facilities to ensure that risks for the transmission of disease or occupation hazards are minimized and a sanitary hospital environment is maintained.
Monitoring compliance with all policies, procedures, protocols and other infection control program requirements."

Evaluation for the 2018 program reads as follows:
"Event:
Improper cleaning/disinfection of environment:
Strategies:
...Implement ATP monitoring system to evaluate cleanliness of environment..."

Infection Control Today, December 7, 2010 describe ATP as:
"Adenosine triphosphate (ATP) is an enzyme that is present in all living cells, and an ATP monitoring system can detect the amount of organic matter that remains after cleaning an environmental surface, a medical device or a surgical instrument. Hospitals are using ATP-based sanitation monitoring systems to detect and measure ATP on surfaces as a method of ensuring the effectiveness of their facilities sanitation efforts. The amount of ATP detected, and where this ATP was detected, indicates areas and items in the healthcare setting that may need to be re-cleaned, and the possible need for improvement in a healthcare facilities cleaning protocols."

Infection Control Today, Cintas Shares Top Tips for Keeping Foodservice Areas Clean, November 10, 2012:
"...3. Keep the Kitchen Clean. Two ways to prevent this (food poisoning) are ensuring hand washing supplies are in stock and properly cleaning and sanitizing equipment and surfaces between tasks. Using properly diluted sanitizers and disinfectants will assist in keeping food preparation surfaces clean and free of foodborne bacteria such as salmonella.

Like many cooking surfaces, kitchen drains can also harbor harmful bacteria such as Listeria monocytogenes. To limit opportunities for bacteria growth, establish a regular drain line maintenance program to keep drains free of debris and odors. Further, a maintenance program will help to prevent buildup that can cause drain backups and provide breeding grounds for drain flies..."

Hospitals Can Be A Hotbed Of Cross Contamination Opportunities, January 1, 2003
"...When inservicing kitchen workers about cross contamination, infection control practitioners (ICPs) may want to consider addressing the potential hazard of "wet-nesting" of foodservice dishware..."


2. On 7/9/19, the radiology department was observed. In the CT room, there were pillows and wedges observed lying on a cabinet behind the CT machine. Staff Member #5 stated, "Those should be covered because they are clean. We did not follow our own policy."

Policy #IC-10, updated 03/2019, was reviewed and documented on page 2, Procedure 1. D reads, "A device that is not covered with a clear plastic bag will be considered contaminated and must be cleaned prior to use."

On July 9, 2019 the Intensive Care Unit (ICU) was observed with Staff Member #17, Director of Intensive Care Unit, and the following noted:
The ICU had sixteen (16) rooms equipped with a wooden bedside tables. Three (3) of the rooms were observed with Staff Member #17. The bedside tables had worn surfaces leaving exposed porous wood that could not properly be cleaned and disinfected. Staff Member #17 was asked if all the rooms' bedside tables were wooden and in the same condition, Staff Member #17 stated, "Yes".

On 7/10/19 at approximately 10:00 A.M. the Cancer Institute, located across the street from the hospital, was observed with Staff Member #15, Manager of Cancer Institute. Staff Member #15 was asked if they had access to the anesthesia cart and stated, "No that is anesthesia." Staff Member #15 was asked if someone from anesthesia could be available to access the cart for inspection. The Director of Anesthesia, Staff Member #37, arrived and assisted in the inspection of the anesthesia cart. At approximately 3:00 P.M., Staff Member #37 was asked if the scrubs worn to the Cancer Institute had been changed after re-entering the main hospital. Staff Member #37 stated, "No, had a scrub coat on."

Statement on Operating Room Attire:
The Board of Regents of the American College of Surgeons (ACS) approved this statement in July 2016.
"...In addition, in so far as clean and properly worn attire may decrease the incidence of health care-associated infections, it also speaks to a desire and drive for excellence in clinical outcomes and a commitment to patient safety."

The ACS guidelines for appropriate attire (based the available evidence) are as follows:
· Soiled scrubs and/or hats should be changed as soon as feasible and certainly prior to speaking with family members after a surgical procedure.
· Scrubs and hats worn during dirty or contaminated cases should be changed prior to subsequent cases even if not visibly soiled.
· Masks should not be worn dangling at any time.
· Operating room (OR) scrubs should not be worn in the hospital facility outside of the OR area without a clean lab coat or appropriate cover up over them.
· OR scrubs should not be worn at any time outside of the hospital perimeter.
· OR scrubs should be changed at least daily.


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3. On July 10, 2019 at 10:30 a.m., Staff Member # 23 was observed with a mustache and goatee not wearing a beard cover or mask while in the Sterile Processing Department (SPD). Staff Member # 26 asked Staff Member # 23 for a beard cover. Staff Member # 23 stated, "There are none in SPD." Staff Member # 26 went and got beard covers and donned the beard cover. Staff Member # 23 did not don a beard cover or mask.

On July 10, 2019 at 12:30 p.m. three (3) employees wearing navy scrubs were observed in the hallway wearing disposable hats and masks carrying "to go containers" from the cafeteria.

On July 11, 2019 at 8:45 a.m., an employee wearing navy scrubs was observed walking in the hallway wearing a non-disposable hat and a disposable mask hanging around the neck. Staff Member # 7 was observed talking with the employee. The employee removed the mask.

On July 10, 2019 at 11:45 a.m. Staff Member # 24 was observed performing point of care testing (POCT) for a blood glucose reading for Patient # 5. Staff Member # 24 placed the carrying case with point of care device on the computer on wheels at the patient's bedside. Staff Member # 24 was observed removing dirty gloves twice during the procedure and donning clean gloves without performing hand hygiene. Staff Member # 24 placed dirty alcohol pad and dirty gauze on the computer on wheels where the carrying case for the device with sitting. Staff Member # 24 sanitized the point of care device after the procedure, placed in the carry case, took the carrying case back to the nurse's station and placed on counter. Staff Member # 24 failed to clean the computer on wheels before and after the procedure and failed to clean the carrying case before returning it to the nurse's station. Staff Member # 24 did use hand sanitizer when exiting the patient's room.

On July 9, 2019 at 11:30 a.m., an interview with Staff Member # 7 revealed "the hospital uses color coded scrubs, in the OR (operating room) staff wear navy scrubs."
On July 10, 2019, an interview with Staff Member # 26 revealed there were now beard covers stocked in SPD.
On July 10, 2019 at 12:15 p.m., an interview with Staff Member # 7 revealed, "the carrying case for POCT should be cleaned if soiled otherwise daily."

The facility policy titled "Attire in Semi-Restricted and Restricted Areas" provided by Staff Member # 7 on July 10, 2019 at 2:00 p.m. read in part, "Disposal hoods or beard covers should contain and cover all facial hair including side burns and neckline. Facility provided attire worn in restricted and semi-restricted areas must be removed prior to leaving the facility, including head and shoe covers. Masks are to be changed between every case or whenever they become moist. Masks may not be dangled around the neck or placed in the pocket."

The facility policy titled "Hand Hygiene" provided by Staff Member # 7 on July 10, 2019 at 2:00 p.m. read in part "Indications for hand hygiene: after body fluid exposure risk - clean your hands immediately after an exposure risk to body fluids (and after glove removal)."

The facility policy titled "Point of Care Testing" provided by Staff Member # 7 on July 10, 2019 at 2:00 p.m. read in part, "POCT is always proactive in the safe testing of our patients and testing personnel in helping reduce the HAI (hospital acquired infections). Meters are to be wiped down after each patient use."