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Based on observation, review of record, and interview, the Governing body failed to ensure a sanitary environment in 12 out 12 areas surveyed (Kitchen 1, Kitchen 2, Laundry Room, Rehab Gymnasium, Terminally Cleaned Patient Room and Bathroom, Activity of Daily Living [ADL] Room, Emergency Treatment Room, Nursing Medication Room, Storage Room, Hallway Alcove, and Clean Central Supply Room #1 and #2).

Refer to Tag A0747

Based on observation, review of record, and interview, the infection control officer failed to develop an effective program that ensured a sanitary environment in 12 of 12 areas surveyed (Kitchen 1, Kitchen 2, Laundry Room, Rehab Gymnasium, Terminally Cleaned Patient Room and Bathroom, Activity of Daily Living [ADL] Room, Emergency Treatment Room, Nursing Medication Room, Storage Room, Hallway Alcove, and Clean Central Supply Room #1 and #2).


During the tour of the facility on 10-3-2018 with Staff #1, #4, and #5, the following unsanitary conditions were identified:


Kitchen #1

A refrigerator was found to have patient food in containers and family's food inside. Staff #1 reported, the families and patients get take-out food and it is placed in this refrigerator. The refrigerator was heavily soiled with spilled liquids, food particles, and unidentifiable substances.

Lower cabinets were found to be holding dishes, cooking utensils, and dishwashing soap. The cabinets were heavily soiled with spilled liquids, dust, and dried food particles.

The microwave oven was heavily soiled with dried food particles, spilled liquids and was rusted in the corners.

Inside a drawer was cooking utensils and an oven mitt. The mitt was burned with holes in it and heavily soiled with food particles and spillage.

A cabinet under the bar area was found to have heavy dried liquid spillage down the inside doors.

The fish tank in the dining area was heavily coated with scum on the glass and plants. Staff #4 reported that the fish tank was cleaned every couple of weeks. Staff #4 was unable to show us a cleaning schedule or an exact time and date when it was to be cleaned again.


Laundry Room

In a room labeled washer/dryer, a cart with linen was found uncovered and exposed to the dust and dirt in the room.

The washer was soiled with spilled liquids on the top and sides. Next to the washer and dryer was a linen cart and a commode chair. The commode chair had linen sheets sitting on top. A dresser was found to have patient supplies in the drawers.


Terminally Cleaned Patient Room and Bathroom

Patient Bathroom

In a terminally cleaned patient room, the bathroom was found to have poor lighting.

The bathroom was found to have a wheel chair and commode chair in the shower. Staff #1 reported that the equipment is put in the room for the next patient to use. Staff #1 reported that most patients need this equipment. Staff #1 reported, the equipment was clean and ready to be used.

The wheel chair and commode chair was removed from the shower. The wheel chair was found rusted and dirty.

The commode chair was found to be soiled underneath. The legs were soiled and rusted. The commode bucket was found to have fecal matter on the sides. Staff #1 reported that she could see the rust and fecal matter. Staff #1 shook her head and stated, "Yes, I see it."

A wooden bench was found folded up against the wall in the shower. The bench was exposed wood. The wood was rough and splintered. The hardware was rusted.

The shower was heavily soiled with soap scum, rusted soap dish, and towel holder.

The shower and bathroom floor was heavily soiled with dust and dirt collected in the corners. Behind the toilet the floor was soiled with dust and dirt.


Patient Room

In a terminally cleaned patient room, the walls in the patient room was scuffed and holes were in the sheet rock.

The blinds were raised in the patient room. The window sill was soiled with dust and hair. A plastic cap, trash, and purple paper was found.

The bed was found to have linen that had holes. The mattress was found to have holes and torn open on the seam.

The wall mounted blood pressure machine had a curled cord. The cord was heavily soiled with dust and lint.

The metal bed frame was found to have multiple areas of rust.


Rehab Gymnasium

In the gym, a wooden staircase was found. The staircase was used for training patients to climb stairs. It had six steps up to a platform and stairs going down. Each set of stairs had wooden hand railing. The staircase had exposed wood that was not sealed. The steps were against a wall when entering the gym. The steps had black strips on the steps to keep patients from slipping. The strips on the staircase was peeling off in multiple places with dirt, dust, and hair stuck to them. The dust and the dirt on the stairs was so thick the surveyor was able to write her initials in it. Staff #4 was asked what she saw wrong with the staircase. Staff #4 was unable to find any issues. Staff #4, Infection Control Coordinator, was made aware of the excessive dirt and dust on the stairs. Staff #4 took her foot and pushed the dirt up into a ball and pushed it off the sides. She stated, "yeah, I guess it's a little dirty." Staff #4 was shown the heavily soiled floor between the wall and the staircase. Staff #4 stated, "I see it."

The hand sanitizer dispenser was found to be heavily soiled with dirt, dust, and hair.

The parallel bars were found to sit on a metal base. The base was missing paint. The slip strips had peeled off and was rolled up on the sides. The base and strips were heavily soiled with dirt, dust, and hair.

A 6 ft wooden mirror, on a wooden base, was found at the end of the parallel bars. The mirror was heavily coated in dust, dirt and hair.

3 of 3 rolling stools were found to be heavily soiled with dirt and dust. All three stools were torn.

A roll of medical tape was found sitting on a window sill. The window sill was coated in dust and dirt. The tape was coated on the sides with dust, dirt, and hair. The tape was confirmed by staff #5 as supplies used for patient care.

On a desk area, an open plastic container was found. Inside the container was 4 rolls of soiled medical tape, Wound dressing packages, a roll of Coban dressing, and 4x4 gauze. Mixed in with the patient supplies was wrapped drinking straws, ketchup packages, toothpicks, equal packages, and pamphlets. Staff #5 stated that she was not sure why the dressings were in the container. Staff #5 reported that physical therapy does use the dressing for patient care.

The blinds in the gym window were raised. Dust, dirt and hair covered the blinds and window sills.

A dark blue wedge pillow was found sitting on top of an exercise table. The pillow was heavily soiled with black marks and dust. The pillow was torn on the ends.

A light blue wedge pillow was found sitting on top of an exercise table. The pillow was heavily soiled with black marks and dust.

A plastic yellow ball was found sitting on top of an exercise table. The ball was lying on an exercise table, in a pile of other patient equipment. The ball was soiled and dirty.

On top of the exercise table, a patient knee brace was found. The brace was heavily soiled in dust, dirt and hair.

On top of the exercise table, a patient massager was found. The massager was soiled and dirty. The massager had old tape and tape residue on the top and sides.

A box fan was found on the floor. The fan was rusted and covered in a heavy dust dirt and hair. The handle was broken off.

The exercise table in the gym was covered in dust and patient equipment was sitting on the end by the window. The metal legs of the table had spilled dried liquids flowing downward. The floor underneath the table was coated in a heavy dust, dirt, and hair. Staff #1 and #5 was shown the floor under the table. Staff #1 stated, "Oh I just didn't know it looked like that."

A large bottle of biofreeze (Topical Analgesic), was found open with no dates. The bottle was covered in dust. Staff #1 confirmed it was used on the patients.

A broken and exposed linen cart was found. The linen on the cart was packed on the shelves with cups, card board boxes, gloves, and paper towels. The cart had old tape holding it together.


STORAGE ROOM

The storage room held oxygen containers and had equipment. The floor in the storage room was soiled with dust, dirt, and hair.


ADL BATHROOM

In the ADL bathroom, 2 of 3 light fixtures were not working.

A Hydrocollator was found. (Hydrocollator is a containment system that holds moist heat packs in a water bath.) The top of the machine was heavily soiled with dried liquids, dust and dirt. The water inside the Hydrocollator was milky looking. Rust and mildew was found inside the lid and rim. The Hydrocollator was found sitting in the same room with a working toilet and a bathtub. The bathtub was heavily soiled with dirt, dust and hair. Inside the bathtub was a commode chair and bath bench that were soiled. This exposed the Hydrocollator and its contents to bathroom bacteria.

Staff #5 was asked for the cleaning logs. Staff #5 later confirmed that there was no cleaning log and the last cleaning date could not be confirmed.


Review of Policy No. 160.01, Care and Cleaning of Equipment was as follows:

D. Procedure, 1. Hydrocollator Pack, a. Maintenance, (4) The unit should be cleaned every month or more frequently if utilization warrants it.
Review of Manufacturer's Instructions for Use showed that the manufacturer recommends:

"Cleaning Tips
1. The interior of the unit should be cleaned, at least every two weeks, using a low abrasive bathroom cleaner and a soft cloth or green, blue, or white Scotch-Brite type scouring pad."



HALLWAY ALCOVE

At the end of the hallway was a small alcove with floor to ceiling windows. A 4ft metal fence structure covered the windows. There was exercise equipment found in the area; including rubber work out bands tied to the fence structure. The bands were lying on the soiled floor covered in dirt and dust.

A 4 tier metal cart was found with games and patient equipment. The shelves were dusty and dirty. Under the cart, on the floor, dirt, dust, hair, and m&m's were found.


EMERGENCY TREATMENT ROOM

2 crash carts were found in the emergency treatment room. The carts were covered in old tape and stickers that were collecting dust and hair. The top of the carts and equipment were dusty. The base of the carts was heavily soiled in dirt and dust.

File cabinets were found next to the patient supplies and crash cart. The facility was using this room for storage of office supplies.

There was trash in the biohazard trash can. Staff #1 confirmed the room was clean and ready for a patient if an emergency occurred.


KITCHEN #2

In kitchen #2, a housekeeping closet was found. The closet floor sink was heavily soiled with dirt. The trash can was full.

The commercial ice machine used for patients was found to be dirty on the outside. The surveyor took a clean white paper towel and wiped the inside of the lid. A greenish/blackish mildew was found on the paper towel and shown to staff #4 and #1. Staff #4 stated the ice machine had just been cleaned and reported she was surprised to see the mildew. There was no cleaning schedule provided.

The shelves holding patient food supplies was found to be heavily coated in molasses spillage and soiled with dirt and dust.

The metal cart used to transport patient snacks was found to be rusted.

The large stainless refrigerator was found to have a sign allowing outside food to be brought in and stored in the patient food preparation area. The inside of the refrigerator was soiled with spilled liquids and food particle.

The sink floor drain was rusted and heavily coated in unknown substances. In the bottom of the drain was a white mucous looking substance. There was no cleaning schedule or process for the floor drain.

In kitchen #2, there was 2 large opened canisters of corn starch. Both containers had expired in 8/2017.


NURSES MEDICATION ROOM

In the nurse's medication room, the pill crusher was found. The crusher was heavily soiled in a greasy black substance. The crusher was heavily spoiled with a buildup of pill residue and dirt.

The lower cabinets had medical supplies, cleaning products, and card board shipping boxes mixed together.

Inside the medication room refrigerator, an opened bottle of Humilin R insulin, was found opened with no open date.


CENTRAL SUPPLY ROOM #2

In the central supply room, a pair of dirty surgical scissors was found sitting on the clean patient medical supplies cart.

A metal shelving unit was found next to patient medical supplies. The unit contained old computers that were out of service. The shelves were heavily coated with dust and hair.

Patient medical supplies were sitting in bins coated with dust.

In the central supply room was carpet. The carpet was coated in a heavy dust and rolled up lint balls all under the patient supplies.


An interview with staff #4 on 10-3-18 revealed there was no documentation of enviromental rounding. Staff #4 was asked how infection control was involved in the cleanliness of the facility. Staff # 4 reported that she does daily rounding to see if things were clean. Staff #4 reported there was no enviromental log or documentation of rounds.

Staff #4 provided the 2nd Quarter Quality Assurance Performance Improvement (QAPI) and Utilization Review (UR) council minutes dated 7/27/18. In the meeting minutes under Eviromental Safety, " Monitor Patient room cleanliness daily and terminally cleaning at discharge. Terminal cleaning will be followed by QAPI committee and reported to Housekeeping. Follow up: Ongoing." There was no evidence that housekeeping was followed or attended QAPI meetings. Staff #4 confirmed there was no PI processes for infection control or enviromental. There was no evidence of an ongoing dialog with housekeeping and thier responses. Staff #4 was unable to provide any written goals or time frames for the "ongoing" monitoring of cleanliness of the facility or monitoring patient rooms and terminal cleans.


36827

A tour of the facility was taken on 10-3-2018 with Staff #1, #4, and #5. The following unsanitary conditions were identified:


Kitchen 2

Kitchen 2 was observed to have a white refrigerator/freezer for patient food storage. The interior of the refrigerator was visibly soiled with dried spills. The seals for the refrigerator and freezer doors were observed to have dirt, debris, and mildew in the folds of the seals. The tray washing station and serving carts stored under the station were observed to have dried spills and food particles, along with dust and dirt, build up on them.


Rehabilitation Gym

A metal shelf was observed along the outside wall next to windows. The shelf contained crates with patient use items and supplies in them. The shelf was observed to be visibly dirty with black flecks, dust, and debris. The crate surfaces were visibly dusty and dirty. The contents were covered in dust and lint. The contents contained a mixture of items to be placed on the patient's body such as braces, supports, and assistive devices. Also in the crate were equipment items that had been used and were dirty, such as a tennis ball that had been placed on the leg of a walker and was visibly soiled, along with small pieces of soiled exercise stretch bands.

A wooden exercise incline board was observed. This was used to assist with rehabilitation of the upper extremities. The finish was observed to be deteriorated in places and visibly dirty. The hand grips were covered in a foam material. The foam material was deteriorated and could not be properly sanitized. The incline board was resting on a wooden table. The finish on the table was scratched up and deteriorated in areas. The table was visibly soiled with dirt ground into the scratches in the finish.

Equipment and supplies were observed to be stored on a dirty window sill. The window sill had dust and mildew on it.


Terminally Cleaned Patient Room

Staff #1 was asked to select a room that was terminally cleaned (ready for a patient). A sharps container (a container that is used to collect used needles and other sharp objects for safe destruction) was observed to be filled above the capacity line. When overly filled, the potential exists for staff to be stuck with a contaminated sharp while trying to place objects into the container.

Strands of black hair were observed on the wall behind the night stand and on the clean patient pillow on the bed.

The wall was observed to have a hole in it beside the head of the bed. This would allow rodents and other pests access into the patient room.

The recliner was observed to food particles, dirt, and debris under the chair base and in the crease of the foot rest when extended. The floor between the recliner and wall was littered with trash and dust.



Clean Supply Room #1

The Clean Supply Room was observed to be cluttered. Patient use items such as various sized of Tumble Forms and wedge pillows were observed to be stored on the floor. The floor was observed to be visibly dirty with trash and debris. The fabric sleeves that cover the warm-moist packs, when applied to patients, were observed to be tossed on the top shelf. They were on top of boxes containing heel and elbow pads, and on top of braces to support the foot. They were not covered or protected from dust, dirt, or contamination.

Based on observation and interview, the Quality Director failed to monitor the effectiveness and safety of services, quality of care in infection control, and housekeeping services. The Quality Director failed to recognize and develop an effective program that monitored a sanitary environment in 12 out 12 areas surveyed (Kitchen 1, Kitchen 2, Laundry Room, Rehab Gymnasium, Terminally Cleaned Patient Room and Bathroom, Activity of Daily Living [ADL] Room, Emergency Treatment Room, Nursing Medication Room, Storage Room, Hallway Alcove, and Clean Central Supply Room #1 and #2).


During a tour of the facility on 10-3-2018 with Staff #1, #4, and #5, the following unsanitary conditions were identified:


Kitchen #1

A refrigerator was found to have patient food in containers and family's food inside. Staff #1 reported the families and patients get take-out food and placed it in this refrigerator. The refrigerator was heavily soiled with spilled liquids, food particles and unidentifiable substances.

Lower cabinets were found to be holding dishes, cooking utensils, and dishwashing soap. The cabinets were heavily soiled with spilled liquids, dust, and dried food particles.

The microwave was heavily soiled with dried food particles, spilled liquids and was rusted in the corners.

Inside a drawer was cooking utensils and an oven mitt. The mitt was burned with holes in it and heavily soiled with food particles and spillage.

A cabinet under the bar area was found to have dried liquid spillage down the inside doors.

The fish tank in the dining area was heavily coated with scum on the glass and plants. Staff #4 reported that the fish tank was cleaned every couple of weeks. Staff #4 was unable to show us a cleaning schedule or an exact time and date when it was to be cleaned again.


Laundry Room

In a room labeled washer/dryer, a cart with linen was found uncovered and exposed to the dust and dirt in the room.

The washer was soiled with spilled liquids on the top and sides. Next to the washer and dryer was a linen cart and a commode chair.

Next to the washer and dryer was a linen cart and a commode chair. The commode chair had linen sheets sitting on top. A dresser was found to have patient supplies in them.


Terminally Cleaned Patient Room and Bathroom

Patient Bathroom

In a terminally cleaned patient room the bathroom was found to have poor lighting.

The bathroom was found to have a wheel chair and commode chair in the shower. Staff #1 reported that the equipment is put in the room for the next patient to use. Staff #1 reported that most patients need this equipment. Staff #1 reported the equipment was clean and ready to be used.

The wheel chair and commode chair was removed from the shower. The wheel chair was found rusted and dirty.

The commode chair was found to be soiled underneath. The legs were soiled and rusted. The commode bucket was found to have fecal matter on the sides. Staff #1 reported that she could see the rust and fecal matter. Staff #1 shook her head and stated, "Yes, I see it."

A wooden bench was found folded up against the wall in the shower. The bench was exposed wood. The wood was rough and splintered. The hardware was rusted.

The shower was heavily soiled with soap scum, rusted soap dish, and towel holder.

The shower and bathroom floor was heavily soiled with dust and dirt collected in the corners. Behind the toilet the floor was soiled with dust and dirt.


Patient Room

In a terminally cleaned patient room the walls in the patient room was scuffed and holes were in the sheet rock.

The blinds were raised in the patient room. The window sill was soiled with dust and hair. A plastic cap, trash, and purple paper was found.

The bed was found to have linen that had holes. The mattress was found to have holes and torn open on the seam.

The wall mounted blood pressure machine had a curled cord. The cord was heavily soiled with dust and lint.

The metal bed frame was found to have multiple areas of rust.


Rehab Gymnasium

In the gym a wooden staircase was found. The staircase was used for training patients to climb stairs. It had six steps up to a platform and stairs going down. Each set of stairs had wooden hand railing. The staircase had exposed wood that was not sealed. The steps were against a wall when entering the gym. The steps had black strips on the steps to keep patients from slipping. The strips on the staircase were peeling off in multiple places with dirt, dust, and hair stuck to them. The dust and the dirt on the stairs was so thick the surveyor was able to write her initials in it. Staff #4 was asked what she saw wrong with the staircase. Staff #4 was unable to find any issues. Staff #4, Infection Control Coordinator, was made aware of the excessive dirt and dust on the stairs. Staff #4 took her foot and pushed the dirt up into a ball and pushed it off the sides. She stated, "yeah, I guess it's a little dirty." Staff #4 was shown the heavily soiled floor between the wall and the staircase. Staff #4 stated, "I see it."

The hand sanitizer was found to be heavily soiled with dirt, dust, and hair.

The parallel bars were found to sit on a metal base. The base was missing paint. The slip strips had peeled off and was rolled up on the sides. The base and strips were heavily soiled with dirt, dust, and hair.

A 6 ft wooden mirror, on a wooden base, was found at the end of the parallel bars. The mirror was heavily coated in dust, dirt and hair.

3 out of 3 rolling stools were found to be heavily soiled with dirt and dust. All three stools were torn.

A roll of medical tape was found sitting on a window sill. The window sill was coated in dust and dirt. The tape was coated on the sides with dust, dirt, and hair. The tape was confirmed by staff #5 as supplies used for patient care.

On a desk area, an open plastic container was found. Inside the container was 4 rolls of soiled medical tape. Wound dressing packages, a roll of Coban dressing, and 4x4 gauze. Mixed in with the patient supplies was wrapped drinking straws, ketchup packages, toothpicks, equal packages, and pamphlets. Staff #5 stated that she was not sure why the dressings were in the container. Staff #5 reported that physical therapy does use the dressing for patient care.

The blinds in the gym window were raised. Dust, dirt and hair covered the blinds and window sills.

A dark blue wedge pillow was found sitting on top of an exercise table. The pillow was heavily soiled with black marks and dust. The pillow was torn on the ends.

A light blue wedge pillow was found sitting on top of an exercise table. The pillow was heavily soiled with black marks and dust.

A plastic yellow ball was found sitting on top of an exercise table. The ball was lying on an exercise table, in a pile of other patient equipment. The ball was soiled and dirty.

On top of the exercise table a patient knee brace was found. The brace was heavily soiled in dust, dirt and hair.

On top of the exercise table a patient massager was found. The massager was soiled and dirty. The massager had old tape and tape residue on the top and sides.

A box fan was found on the floor. The fan was rusted, and covered in a heavy dust dirt and hair. The handle was broken off.

The exercise table in the gym was covered in dust and patient equipment was sitting on the end by the window. The metal legs of the table had spilled dried liquids flowing downward. The floor underneath the table was coated in a heavy dust, dirt, and hair. Staff #1 and #5 was shown the floor under the table. Staff #1 stated, "Oh I just didn't know it looked like that."

A large bottle of biofreeze (Topical Analgesic), was found open with no dates. The bottle was covered in dust. Staff #1 confirmed it was used on the patients.

A broken and exposed linen cart was found. The linen on the cart was packed on the shelves with cups, card board boxes, gloves, and paper towels. The cart had old tape holding it together.


STORAGE ROOM

The storage room held O2 containers and had equipment. The floor in the storage room was soiled with dust, dirt, and hair.


ADL BATHROOM

In the ADL bathroom, 2 out of 3 light fixtures were not working.

A Hydrocollator was found. (Hydrocollator is a containment system that holds moist heat packs in a water bath.) The top of the machine was heavily soiled with dried liquids, dust and dirt. The water inside the Hydrocollator was milky looking. Rust and mildew was found inside the lid and rim. The Hydrocollator was found sitting in the same room with a working toilet and a bathtub. The bathtub was heavily soiled with dirt, dust and hair. Inside the bathtub was a commode chair and bath bench that were soiled. This exposed the Hydrocollator and its contents to bathroom bacteria.

Staff #5 was asked for the cleaning logs. Staff #5 later confirmed that there was no cleaning log and the last cleaning date could not be confirmed.


Review of Policy No. 160.01, Care and Cleaning of Equipment was as follows:

D. Procedure, 1. Hydrocollator Pack, a. Maintenance, (4) The unit should be cleaned every month or more frequently if utilization warrants it.
Review of Manufacturer's Instructions for Use showed that the manufacturer recommends:

"Cleaning Tips
1. The interior of the unit should be cleaned, at least every two weeks, using a low abrasive bathroom cleaner and a soft cloth or green, blue, or white Scotch-Brite type scouring pad."


HALLWAY ALCOVE

At the end of the hallway was a small alcove with floor to ceiling windows. A 4ft metal fence structure covered the windows. There was exercise equipment found in the area; including rubber work out bands tied to the fence structure. The bands were lying on the soiled floor covered in dirt and dust.

A 4 tier metal cart was found with games and patient equipment. The shelves were dusty and dirty. Under the cart on the floor, dirt, dust, hair, and m&m's were found.


EMERGENCY TREATMENT ROOM

Two (2) crash carts were found in the emergency treatment room. The carts were covered in old tape and stickers that were collecting dust and hair. The top of the carts and equipment were dusty. The base of the carts was heavily soiled in dirt and dust.

File cabinets were found next to the patient supplies and crash cart. The facility was using this room for storage of office supplies.

There was trash in the biohazard trash can. Staff #1 confirmed the room was clean and ready for a patient if an emergency occurred.


KITCHEN #2

In kitchen #2, a housekeeping closet was found. The closet floor sink was heavily soiled with dirt. The trash can was full.

The commercial ice machine used for patients was found to be dirty on the outside. The surveyor took a clean white paper towel and wiped the inside of the lid. A greenish/blackish mildew was found on the paper towel and shown to staff #4 and #1. Staff #4 stated the ice machine had just been cleaned and reported she was surprised to see the mildew. There was no cleaning schedule provided.

The shelves holding patient food supplies was found to be heavily coated in molasses spillage and soiled with dirt and dust.

The metal cart used to transport patient snacks was found to be rusted.

The large stainless refrigerator was found to have a sign allowing outside food to be brought in and stored in the patient food preparation area. The inside of the refrigerator was soiled with spilled liquids and food particle.

The sink floor drain was rusted and heavily coated in unknown substances. In the bottom of the drain was a white mucous looking substance. There was no cleaning schedule or process for the floor drain.

In kitchen #2, there was 2 large opened canisters of corn starch. Both containers had expired in 8/2017.


NURSES MEDICATION ROOM

In the nurse's medication room, the pill crusher was found. The crusher was heavily soiled in a greasy black substance. The crusher was heavily spoiled with a buildup of pill residue and dirt.

The lower cabinets had medical supplies, cleaning products, and card board shipping boxes mixed together.

Inside the medication room refrigerator, an opened bottle of Humilin R insulin, was found opened with no open date.


CENTRAL SUPPLY ROOM #2

In the central supply room, a pair of dirty surgical scissors was found sitting on the clean patient medical supplies cart.

A metal shelving unit was found next to patient medical supplies. The unit contained old computers that were out of service. The shelves were heavily coated with dust and hair.

Patient medical supplies were sitting in bins coated with dust.

The central supply room was carpeted. The carpet was coated in a heavy dust and rolled up lint balls all under the patient supplies.


An interview with staff #4 on 10-3-18 revealed there was no documentation of enviromental rounding. Staff #4 was asked how infection control was involved in the cleanliness of the facility. Staff # 4 reported that she does daily rounding to see if things were clean. Staff #4 reported there was no enviromental log or documentation of rounds.

Staff #4 provided the 2nd Quarter Quality Assurance Performance Improvement (QAPI) and Utilization Review (UR) council minutes dated 7/27/18. In the meeting minutes under Eviromental Safety, " Monitor Patient room cleanliness daily and terminally cleaning at discharge. Terminal cleaning will be followed by QAPI committee and reported to Housekeeping. Follow up: Ongoing." There was no evidence that housekeeping was followed or attended QAPI meetings. Staff #4 confirmed there was no PI processes for infection control or enviromental. There was no evidence of an ongoing dialog with housekeeping and thier responses. Staff #4 was unable to provide any written goals or time frames for the "ongoing" monitoring of cleanliness of the facility or monitoring patient rooms and terminal cleans.


36827


A tour of the facility was taken on 10-3-2018 with Staff #1, #4, and #5. The following unsanitary conditions were identified:


Kitchen 2

Kitchen 2 was observed to have a white refrigerator/freezer for patient food storage. The interior of the refrigerator was visibly soiled with dried spills. The seals for the refrigerator and freezer doors were observed to have dirt, debris, and mildew in the folds of the seals. The tray washing station and serving carts stored under the station were observed to have dried spills and food particles, along with dust and dirt build up on them.


Rehabilitation Gym

A metal shelf was observed along the outside wall next to windows. The shelf contained crates with patient use items and supplies in them. The shelf was observed to be visibly dirty with black flecks, dust, and debris. The crate surfaces were visibly dusty and dirty. The contents were covered in dust and lint. The contents contained a mixture of items to be placed on the patient's body such as braces, supports, and assistive devices. Also in the crate were equipment items that had been used and were dirty, such as a tennis ball that had been placed on the leg of a walker and was visibly soiled, along with small pieces of soiled exercise stretch bands.

A wooden exercise incline board was observed. This was used to assist with rehabilitation of the upper extremities. The finish was observed to be deteriorated in places and visibly dirty. The hand grips were covered in a foam material. The foam material was deteriorated and could not be properly sanitized. The incline board was resting on a wooden table. The finish on the table was scratched up and deteriorated in areas. The table was visibly soiled with dirt ground into the scratches in the finish.

Equipment and supplies were observed to be stored on a dirty window sill. The window sill had dust and mildew on it.


Terminally Cleaned Patient Room

Staff #1 was asked to select a room that was terminally cleaned (ready for a patient). A sharps container (a container that is used to collect used needles and other sharp objects for safe destruction) was observed to be filled above the capacity line. When overly filled, the potential exists for staff to be stuck with a contaminated sharp while trying to place objects into the container.

Strands of black hair were observed on the wall behind the night stand and on the clean patient pillow on the bed.

The wall was observed to have a hole in it beside the head of the bed. This would allow rodents and other pests access into the patient room.

The recliner was observed to have food particles, dirt, and debris under the chair base and in the crease of the foot rest when extended. The floor between the recliner and wall was littered with trash and dust.



Clean Supply Room #1

The Clean Supply Room was observed to be cluttered. Patient use items such as various sizes of Tumble Forms and wedge pillows were observed to be stored on the floor. The floor was observed to be visibly dirty with trash and debris. The fabric sleeves that cover the warm-moist packs, when applied to patients, were observed to be tossed on the top shelf. They were on top of boxes containing heel and elbow pads, and on top of braces to support the foot. They were not covered or protected from dust, dirt, or contamination.

Based on review and interview, the facility failed to have a Director of Nurses (DON).


An interview was conducted with Staff #1 and #2 on 10-3-18. Staff #1 stated, they did not have a DON at this time. Staff #1 reported that the facility was looking and had interviewed potential candidates. Staff #1 confirmed it had been 2 months since the DON resigned. Staff #1 was asked who was doing the staff schedule and assisting with personnel problems. Staff #1 stated, "I try to help and fill in when needed. I work on the schedule and if there is a personnel problem we all get together and take it to our administrator." Staff #1 confirmed the administrator was out of town for the week at a convention. Staff #1 was asked if she was the DON interim. Staff #1 stated, "no. I don't think I am."


Review of staff #1's employee file revealed there was no job description for staff #1 as the Interim DON.

An interview with staff # 2 revealed there was no job description signed and in the chart for staff #1 as a DON. Staff #2 stated, "I didn't know she needed to have a job description for filling in as the DON."

Based on observation and interview, the facility failed to remove expired drugs from use in two of two drug storage areas observed (Emergency Treatment Room and Nursing Medication Supply Room).

A tour of the facility was conducted on the afternoon of 10-3-2018 with Staff #1, Staff #4, and Staff #8. During the tour of the facility, the following medications were observed to be available for patient use and past the expiration date.


Emergency Treatment Room

Inside of the Crash Cart (a cart used to store supplies and medications for use during a patient emergency such as cardiac arrest), the following medications had expired:

2 of 2 vials of Promethazine HCL Injection had expired 8/2018

2 of 2 ampules of Epinephrine had expired 1 Sep 2018

1 - 500 milliliter bag of premixed Lidocaine intravenous (IV) fluid had expired 08/18


Nursing Medication Supply Room

5 of 5 bags (1000 milliliters each) premixed Potassium Chloride IV fluid had expired 1 Sep 2018.


During an interview with the pharmacist, the pharmacist explained that she had been hired within the past 6 months and had not implemented a process for tracking medications that were about to expire. The pharmacist stated she had been relying on nursing staff to check stock for expiring medications in storage areas outside of the pharmacy.

Base on observation and interview, the facility failed to store supplies and equipment in a manner that ensured they were safe, clean, and within their expiration date in 8 (Kitchen 2, Laundry Room, Rehab Gymnasium, Terminally Cleaned Patient Room, Activity of Daily Living [ADL] Room, Emergency Treatment Room, Nursing Medication Room, and Clean Supply Room) of 9 areas surveyed.


A tour of the facility was conducted on the afternoon of 10-3-2018 with Staff #1, Staff #4, and Staff #5 present. The facility was observed to have no comprehensive plan for storage of supplies and equipment. Equipment and supplies that should be clean and protected for patient use were found to be stored either with dirty items, in a manner that did not protect them from becoming soiled, protect them from damage, or were expired.


Findings included:

Kitchen #2 had serving carts stored under the tray washing table in a manner that allowed for spilled food, spilled liquids, and dust to build up on them.

The Laundry Room was observed to have functional washing machine and an inoperable dryer in it. Contaminated items were brought into the Laundry Room, washed, and hung up to dry. Clean patient linens were stored in the same room which exposed them to the contaminated items being brought into the room to be washed.

The Rehab Gymnasium was observed to have equipment and supplies stored on dirty window sills, on patient exercise beds, on the floor, and in crates on a shelf. Patient use items were stored in the same crates as dirty and used supplies.

A Terminally Cleaned Room (room ready for a patient) was found to have soiled equipment stored in the shower of the patient bathroom.

The ADL Room was observed to have a functioning shower, toilet, and sink in it. It was also being used to store patient equipment and the Tropic Heater brand hydrocollator (a piece of equipment full of warm water to store warm-moist packs to be placed on the patient's body for therapy) exposing the packs to bathroom bacteria. The warm-moist packs were required by manufacturer to be completely submerged in the water to prevent damage to the packs. Two packs were observed to be stored partially submerged instead of fully submerged.

The Emergency Treatment Room was found to have 2 needles inside of the crash cart to be used in an emergency to draw up medication from a vial that had expiration dates of 2018-04 and 2017-12.

The Nursing Medication Room was found to have a soiled vacuum gauge that controls suction (for example: suctioning patient airways, wound vacuums) on a shelf with clean patient supplies. Also on the shelf was a zippered pouch that contained a Bayer Contour Glucometer (commercially sold device for checking blood sugar levels). The back was off of the device with the batteries exposed. The control solution for this device was found to have expired 2015-05. A plastic case for storing a glucometer and supplies was observed on top of the medication dispense machine. The control solution in the case was observed to have a use-by-date of 8-6-2018.

The Clean Supply Storage Room was observed to be cluttered with supplies and equipment. The fabric sleeves that cover the warm-moist packs, when applied to patients, were observed to tossed on the top shelf. They were on top of boxes containing heel and elbow pads, and on top of braces to support the foot. They were not covered or protected from dust, dirt, or contamination. Various sizes of Tumble Forms used for rehabilitation exercises were observed. The covering for these forms have anti-microbial protection built in. These forms had plastic bins full of equipment items stored directly on top of them. This could damage the equipment coating. These forms, along with pillow wedges were stored directly on the floor.

Staff #1, Staff #4, and Staff #5 were asked about the storage of supplies and equipment. All expressed that there was a lack of adequate storage area in the hospital so staff just put things where they can.