HospitalInspections.org

Based on observation, interview, and document review, the hospital failed to have an effective governing body legally responsible for the conduct of the hospital when the hospital-wide quality assessment and performance improvement (QAPI) efforts did not correct infection control findings related to sanitary conditions in the hospital kitchen from previous surveys dated 5/31/24 and 9/17/24.

These failures resulted in continued infection control risks in the kitchen, which date back to 5/31/24. (refer to A0309 and A0750.)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner for patients, staff and visitors who eat food prepared in the hospital kitchen.

Based on observation, interview and administrative document review, the hospital failed to maintain an effective, comprehensive, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program when the program did not effectively identify, collect data, track data, develop, or implement performance improvement activities consistent with their own Plans of Correction dated 5/31/24 and 9/17/24 when infection control deficiencies were not corrected or monitored for ongoing compliance (cross reference A-309)

The cumulative effect of these systemic problems resulted in the facilities inability to comply with statutory requirements for Quality Assessment and Performance Improvement and placed all patients at risk of not receiving care in a safe setting.

Based on observation, interview, and record review, the hospital failed to meet the regulatory requirements for the Condition of Participation: §482.42 Infection Prevention and Control and Antibiotic Stewardship Programs and did not have an active Infection Prevention and Control program which adhered to nationally recognized infection prevention and control guidelines for the surveillance, prevention, and control of HAIs (hospital acquired infections- infection one gets while receiving treatment in a healthcare facility) and other infectious diseases, when:

1. The wheels on the bottom of a food preparation table in the kitchen were covered with dried brown and black debris (Refer to A-0750 Finding 1).

2. Labeling stickers, pieces of plastic and paper, corn kernels, crumbs, and various debris were observed on the floors and shelving of the kitchen's walk-in refrigerators and freezers (Refer to A-0750 Finding 2).

3. Three of six cooling fans' grilles contained dust inside the kitchen's walk-in produce refrigerators (Refer to A-0750 Finding 3).

4. Six of six convection ovens in the kitchen had black, brown, and red grime on the racks, walls, and base of the ovens (Refer to A-0750 Finding 4).

5. The barbeque-type grill in the kitchen was covered with dried black and brown grime and yellow stains on the ledges (Refer to A-0750 Finding 5).

6. Registered Nurse (RN) 5 entered Patient (Pt) 23's contact/enteric isolation (a set of precautions healthcare workers and visitors take to prevent the spread of intestinal germs from a patient to others by wearing an isolation gown and gloves) room in the Emergency Department (ED)without donning (putting on) an isolation gown and gloves to protect the spread of infection (Refer to A-0750 Finding 6).

7. No gowns or gloves were readily available for use to enter an isolation room in the ED (Refer to A-0750 Finding 7).

8. Pt 2 and Pt 34's Intravenous (IV-method of administering medications and fluids directly into the vein) infusion sets (device connecting bags of medications and fluids into the patient's IV access); Pt 32 and Pt 35's tube feeding (administration of nutrition through a tube inserted directly into the gastrointestinal tract) solution sets; and Pt 2's disposable patient circuit (a device used to deliver medical gas or oxygen to a patient's lungs) were not labeled with the date and time of initiation (Refer to A-0750 Finding 8).

9. RN 2 did not perform hand hygiene after a wound dressing change for PT 8 and Pt 8's dressing was not labeled with the date and time of initiation (Refer to A-0750 finding 9).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality patient care in a safe and sanitary environment.

Based on observation, interview and record review, the hospital's governing body did not ensure the hospital-wide quality assessment and performance improvement (QAPI) efforts addressed priorities for improved quality of care and patient safety and that all improvement actions are evaluated when issues identified in the previous surveys dated 5/31/24 and 9/17/24 related to Infection Control were not corrected, tracked, and monitored for compliance.

These failures placed all patients, visitors, and staff at continued risk for hospital acquired infections and illnesses from contaminated kitchen surfaces.

Findings:

During an interview on 1/10/25 at 9:15 a.m. with two members of the Governing Body (GB,) Governing Board Member (GBM) 1 stated she was aware that the Centers of Medicare and Medicaid Services sets out specific responsibilities for the GB to oversee Quality Assurance and Performance Improvement (QAPI) program in the hospital. GBM 1 stated the GB has responsibility for ensuring that patients receive care in a safe setting. GBM 1 stated the GB was given a copy of the Plan of Correction dated 5/31/24 and 9/17/24 and they were aware that there have been problems with sanitation in the kitchen. GBM 1 stated she was "not really aware" that the same or similar issues had been ongoing since the California Department of Public Health (CDPH) survey dated 5/31/24. GBM 1 stated, "when there are so many opportunities for improvement in a hospital, sometimes we lose track of the details, and we trust that the Directors of the departments are on top of those details." GBM 2 stated he will be more involved with observations in the kitchen and will ask more questions about the quality improvement projects in the kitchen in the future. GBM 2 stated, "Now that I know the extent of the problem and how long it has been going on, I will make sure there are changes, so thank you for bring this to our attention."

During an interview on 1/7/25 at 3:50 pm with the Chief Operating Officer (COO) regarding continued issues with infection control concerns in the kitchen, the COO stated the Food and Nutrition staff report to him, and he was responsible for ensuring the kitchen is safe and sanitary. The COO stated he has done tours in the kitchen himself and was aware that it needed to be cleaned more often.

During a review of the hospital document titled, "Plan of Correction" submitted by hospital leadership and approved by the California Department of Public Health on 12/9/24 indicated, " ...On September 10, 2024, FANS (Food and Nutrition Services) staff cleaned all items identified during the survey including: 1. Drawers - ensuring drawers do not contain crumbs and personal items. 2. The floor under fixed equipment - ensuring that food, grease and black grime are removed. 3. The floor drain under refrigerators - ensuring there is no food or other debris in the floor drain. 4. Shelves in reach-in refrigerators -The metal was immediately removed and replaced with plastic trays to prevent chards. 5. The plate warmer - ensuring the warmer does not contain crumbs or other debris. 6. The food warmer and the convection oven - ensuring there is no black and red grime or other findings. The Facilities Services Department assisted the Food and Nutrition (FANS) department with adjusting deep cleaning process from every 60 days to every 30 days. This deep cleaning includes under certain equipment, all drains, and ovens and hood. The contacted company, [vendor name] is scheduled next on October 14, 2024, and October 15, 2024, to deep clean the hoods in the kitchen, and on October 21, 2024, to deep clean under the equipment and drains. [Vendor] will continue to be utilized for deep cleaning every month. A Daily end of shift rounding was implemented on 9/25/2024 to ensure the kitchen cleanliness is maintained. This form is signed by FANS leadership to ensure that FANS standards are maintained. The FANS department attends and reports their QAPI initiatives, action plans, and findings at the QAPI committee meeting ..."

During an observation on 1/7/25 at 10:50 a.m. in the hospital kitchen, the wheels on the bottom of a food preparation table were covered with dried brown and black debris.

During a concurrent interview and record review on 1/10/25 at 8:48 a.m. with the Infection Control Director (ICD), "Food Preparation Table Image (FPTI, photograph of the wheels taken by the surveyor)", dated 1/7/25 at 10:50 a.m., was reviewed. The ICD identified the debris as rust on the food preparation table wheels and stated the rust had to have happened over time.

During a concurrent observation and interview on 1/7/25 at 10:53 a.m. in the kitchen's walk-in freezer and with the Food & Nutrition Director (FND), labeling stickers, pieces of plastic and paper, corn kernels, crumbs and various debris were on the floors and shelving. The FND stated the floors are swept every time stock is received. The FND stated stock is received approximately 4 times per week.

During a concurrent interview and record review on 1/10/25 at 8:49 a.m. with the ICD, "Freezer and Refrigerator Images (FRI, photographs of the floor and shelving in the freezer and refrigerator taken by the surveyor)", dated 1/7/25, were reviewed. The ICD stated he would expect the floor to be swept at the end of each day.

During a review of a professional reference from the "United States Food & Drug Administration (FDA) Food Code", dated 2017, the "FDA" indicated, " ... The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests ...".

During a concurrent observation and interview on 1/7/25 at 10:55 a.m. in the kitchen's walk-in produce refrigerator 1 with the Food & Nutrition Director (FND), two of three cooling fans had dust on the grilles. The FND stated the fans are cleaned by the maintenance department once a month and as needed.

During a concurrent observation and interview on 1/7/25 at 10:56 a.m. in the kitchen's walk-in produce refrigerator 2 with the Food & Nutrition Director (FND), one of three cooling fans had dust on the grilles.

During a concurrent interview and record review on 1/10/25 at 8:50 a.m. with the ICD, "Fan Images (FI, photographs of the fans in the food storage areas taken by the surveyor)", dated 1/7/25 were reviewed. The ICD stated the fans had dust on them.

During a review of a professional reference from the "United States Food & Drug Administration (FDA) Food Code", dated 2017, the "FDA" indicated, " ... Walls and Ceilings, Attachments ... attachments to walls and ceilings such as light fixtures, mechanical room ventilation system components, vent covers, wall mounted fans ...shall be easily cleanable ...".

During a concurrent observation and interview in the kitchen on 1/7/25 at 10:57 a.m. with the FND, six of six convection ovens contained black, brown, and red grime on the racks, walls, and base of the ovens. The FND stated the ovens were deep cleaned weekly.

During an interview on 1/9/25 at 2:55 p.m. with the FND, the FND stated when she began employment at the hospital in 5/2024, the kitchen equipment was damaged from lack of cleaning. The FND stated some current employees in the kitchen were "... not on board with change ...".

During a concurrent interview and record review on 1/10/25 at 8:52 a.m. with the ICD, "Oven Images (OI, photographs of the convection ovens taken by the surveyor)", dated 1/7/25, were reviewed. The ICD stated the oven buildup of grime happened over time and can affect "... food condition ...". The ICD stated he expected the kitchen cleaning at minimum to follow the manufacturer's Instructions for Use (IFU).

During a review of "Gas Convection Oven Owner's Manual (OOM)", dated 11/2023, the "OOM" indicated, " ... Cleaning ... oven interior is finished with porcelain enamel coating. 'Spillovers' should be cleaned from the interior bottom surface as soon as possible to prevent carbonizing and burnt-on condition. Grease or any residue should be cleaned from interior surfaces as soon as it accumulates ... Daily Cleaning and Maintenance .... Remove interior rack and rack slide frames ... wash the racks and rack slides in a sink with mild detergent and warm water. Dry them thoroughly with a clean cloth ... wash interior surfaces with mild detergent and warm water ... For stubborn accumulation of grease and carbon build up, use a commercial Non-Caustic oven and Grill Cleaner ...".

During a concurrent observation and interview on 1/7/25 at 11:00 a.m. in the kitchen with the FND, a barbeque-type grill in the kitchen was covered with dried black and brown grime and yellow stains on the ledges. The FND stated the grill was cleaned once a week.

During a concurrent interview and record review on 1/7/25 at 3:50 p.m. with the Chief Operating Officer (COO), "Oven & Grill Images (OGI, photographs of the convection ovens and grill taken by the surveyor)", dated 1/7/25, were reviewed. The COO stated the kitchen equipment might have been overlooked in the cleaning process due to new equipment slated to arrive soon.

During a concurrent interview and record review on 1/10/25 at 8:52 a.m. with the ICD, "Grill Image (GI, photographs of the grill taken by the surveyor)", dated 1/7/25, was reviewed. The ICD stated the buildup of grime had to have happened over days and he would expect cleaning to follow the manufacturer's Instructions for Use (IFU) or more frequently. The ICD stated if debris was not going away, the cleaning needs to be more frequent.

During a review of "Operational Manual Gas Charbroiler (OMGC)" (undated), the "OMGC" indicated, " ... Cleaning ... Scrape top grates during broiling with a wire brush to keep the grates clean. Do not allow debris to accumulate on the grates ... Top grates may be immersed in strong commercial cleaning compound overnight. In the morning rinse with hot water ... Daily, when cool, remove top grates and radiants to clean where fat, grease, or food can accumulate

Based on interview and record review, the hospital failed to ensure Licensed Nurses (LNs) followed policies and procedures (P&Ps) in developing, maintaining current, and patient specific nursing care plans (NCP- a process through which the nurse identifies, documents, and keeps track of a patient's state or condition, needs, and risks) for two of fourteen (14) sampled patients (Pt 27 and Pt 3) when:

1. Pt 27's NCP had not been updated or changed to reflect Pt 27's medically complex problems, needs, and risks after Pt 27 experienced a change of condition requiring a transfer from a medical surgical unit (lower level of care) to a critical care unit (higher level of care). Once in Critical Care Unit, Pt 27 was intubated with ventilator (a procedure that involves inserting a tube into a patient's airway and connecting it to a ventilator -a machine used to help a patient breathe) support, administered continuous intravenous (IV) vasopressor (an agent that raises blood pressure by constricting (squeezing) blood vessels), and placed on extracorporeal membrane oxygenation (ECMO- a type of artificial life support that can help a person whose lungs and heart aren't functioning correctly) support, none of which were reflected on care plans.

This failure resulted in Pt 27 receiving care in a critical care unit without an assessment and development of a patient specific NCP to guide care and had the potential to result in patient harm if critical care needs were not met.

2. Pt 3 was admitted to the hospital without any wounds (pressure ulcer- a sore or wound in the skin caused by prolonged pressure on an area of the body) and developed pressure ulcers and nurses did not create a new care plan for new wounds.

This failure resulted in Pt 3 developing a wound while admitted to the hospital and worsening of that wound while an inpatient in the hospital.

Findings:

1. During a review of Pt 27's "Face Sheet (FS-a document that contains a summary of a patient's personal information)," dated 1/8/25 and "History and Physical (H&P), dated 1/8/25, the FS indicated Pt 27 was admitted to the hospital on 1/5/25 at 5:23 p.m. The H&P indicated, " ...78-year-old female with history of hypertension (high blood pressure), transferred to hospital from another hospital for concerns of STEMI (ST-segment- The ST Segment represents the interval between ventricular (relating to, or being a ventricle, which is a fluid-filled cavity in the heart or brain) depolarization (the electrical activity that occurs in the heart's ventricles when they are stimulated and contract) and repolarization (the process by which the heart's ventricles regain their ability to depolarize after a contraction) elevation myocardial infarction) a life-threatening type of heart attack that occurs when a coronary artery (major blood vessels, in your body, supplying blood to your heart), is completely blocked. (also known as a massive heart attack or sudden cardiac arrest), chronic (a condition that lasts for a long time and usually cannot be cured, but can be controlled) obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and Coronary artery disease (CAD- a common heart disease that occurs when plaque builds up in the coronary arteries, reducing blood flow to the heart. It's also known as coronary heart disease or ischemic heart disease.)..."

During a concurrent interview and record review on 1/8/25 at 11:36 a.m. with Registered Nurse Quality (RNQ) 1, Pt 27's "Electronic Medical Record (EMR-an electronic record of health-related information on an individual)," 1/5/25 to 1/8/25, and "Interdisciplinary Care Plans (ICP)," dated 1/5/25 to 1/8/25 were reviewed. RNQ1 stated Pt 27's NCPs were not representative of the patient's condition observed during our tour of the Cardiovascular Intensive Care Unit (CVICU) on 1/7/25. RNQ1 stated the NCP identified as active and displayed in the EMR were not patient specific, and did not reflect the change of condition or transfer to a critical care unit for life saving interventions (i.e.: intubated and on a ventilator, multiple vasopressor drips, and on ECMO). RNQ1 stated she would expect new conditions along with nursing interventions to be documented by the primary nurse in Pt 27's medical record. RNQ1 confirmed the three NCPs listed in Pt 27's EMR, "...Heart Failure Care Plan (initiated) 01/05/2025 6:41 p.m. ...Pain Care Plan (Initiated) 01/05/2025 at 6:42 p.m... Discharge Planning Care Plan (Initiated) 01/05/2025 1:42 p.m...."were initiated when the patient was alert and able to participate, probably on admission (1/5/25), were not patient specific, and did not accurately represent Pt 27's current critical medical needs and risks."

2. A review of Pt 3's History and physical (H&P) indicated Pt 3 was admitted to the hospital with diagnosis of obstructive uropathy (a condition in which the flow of urine is blocked).

A review of "Nursing Note" for Pt 3 dated 11/3/24 indicated "Mepilex dressing noted in the coccyx area, no redness or wound noted".

A review of Pt 3's "Wound Care Note" by the Wound Care Nurse (WCN), dated 11/15/24, indicated " ...Coccyx (the last bone at the bottom (base) of your spine) to R&L (Right and Left ) Buttocks (one of two round, fleshy mounds of tissue behind the pelvis) evolving deep tissue injury (unstageable pressure injury)..."

A review of Pt 3's care plan, indicated staff did not create care plan for wounds for Pt 3.

During a concurrent interview and record review on 1/10/25 at 11:00 a.m., with the Registered Nurse Shift Manager (RNSM), RNSM reviewed Pt 3's care plan and stated staff did not create individualized care plan for Pt 3's wounds, and creating care plan for wound is important because staff is doing care and treatment based on what they see on the care plan.

During an interview on 1/10/25 at 11:35 a.m. with the Chief Nursing Officer (CNO) and Quality Director (QD), CNO stated [NCPs] drive the care of the patient. CNO stated the purpose of the CP is to meet the patient needs ensuring all staff are "on the same page" when delivering care to the patient. CNO stated the goal [of the NCP] is to get patients well and in better medical condition "than they came to us in."

During a review of the hospital's P&P titled, "PC.AD.1.08 Documentation Policy," dated 9/28/22, the P&P indicated, "... II. PURPOSE: To outline responsibilities related to documentation of patient care from admission through discharge...III. POLICY: Clinical Documentation is taken to mean a process of recording and communicating a written rationale of intervention, and as such becomes part of the patient medical record. The patient medical record reflects the complete picture of the patient's health status, treatment, and progress from admission to discharge from which other health professionals can take over responsibility for the patient concerned and for the retrieval of data for research and management. It should include a comprehensive assessment; identified problems; expected outcomes; the plan of care and care delivered (or not delivered); teaching given; advice sought in decision making; and the patient's response to treatment; discharge and plans for ongoing care... 11. Assessment and Interventions: a. The EHR system generated tasks for fall, Braden, reflect Columbia Suicide Risk Assessment, and Interdisciplinary Education will be completed. All applicable sections will be documented and updated throughout the course of the patients' hospitalization... c. ... Each patient (including short stay observation) will have a Plan of Care [NCP] developed. Identified care problems and care goals shall be developed and documented by the RN and ancillary departments as indicated. Identified patient needs that are not pertinent to hospitalization will not be addressed in the plan of care. i. Care plan will be updated every shift and with changes in patient status/condition. Upon discharge note whether the problem is "ongoing at discharge", or "met." The patients' problem list is initiated within 8 hours of admission. Nursing care is administered with attention to the problems identified. ..."

During a review of a professional reference titled, "Nursing Process," dated 4/10/23, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499937/, the Nursing Process indicated, " ...Planning ...The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP (Evidence-based Practice- recommendations for nursing care that are based on scientific evidence) guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. Goals should be: 1. Specific; 2. Measurable or Meaningful; 3. Attainable or Action-Oriented; 4. Realistic or Results-Oriented; 5. Timely or Time-Oriented ..."

Based on observation, interview, and record review, the hospital failed to maintain a clean and sanitary environment to avoid sources and transmission of infection in accordance with infection control standards and hospital policy and procedure when:

1. The wheels on the bottom of a food preparation table in the kitchen were covered with dried brown and black debris.

2. Labeling stickers, pieces of plastic and paper, corn kernels, crumbs, and various debris were observed on the floors and shelving of the kitchen's walk-in refrigerators and freezers.

3. Three of six cooling fans' grilles contained dust inside the kitchen's walk-in produce refrigerators.

4. Six of six convection ovens in the kitchen had black, brown, and red grime on the racks, walls, and base of the ovens.

5. The barbeque-type grill in the kitchen was covered with dried black and brown grime and yellow stains on the ledges.

6. Registered Nurse (RN) 5 entered Patient (Pt) 23's contact/enteric isolation (a set of precautions healthcare workers and visitors take to prevent the spread of intestinal germs from a patient to others by wearing an isolation gown and gloves) room in the Emergency Department (ED) without donning (putting on) an isolation gown and gloves, and did not wash hands with soap and water after touching door handle in isolation room.

7. No gowns or gloves were readily available for use to enter an isolation room in the ED.

8. Pt 2 and Pt 34's Intravenous (IV-method of administering medications and fluids directly into the vein) infusion sets (device connecting bags of medications and fluids into the patient's IV access); Pt 32 and Pt 35's tube feeding (administration of nutrition through a tube inserted directly into the gastrointestinal tract) solution sets; and Pt 2's disposable patient circuit (a device used to deliver medical gas or oxygen to a patient's lungs) were not labeled with the date and time of initiation.

9. RN 2 did not perform hand hygiene after a wound dressing change for PT 8 and Pt 8's dressing was not labeled with the date and time of initiation.

These failures had the potential to place patients at risk for cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect), organism growth, and the spread of infection.

Findings:

1. During an observation on 1/7/25 at 10:50 a.m. in the hospital kitchen, the wheels on the bottom of a food preparation table were covered with dried brown and black debris.

During a concurrent interview and record review on 1/10/25 at 8:48 a.m. with the Infection Control Director (ICD), "Food Preparation Table Image (FPTI, photograph of the wheels taken by the surveyor)", dated 1/7/25 at 10:50 a.m., was reviewed. The ICD identified the debris as rust on the food preparation table wheels and stated the rust had to have happened over time.

2. During a concurrent observation and interview on 1/7/25 at 10:53 a.m. in the kitchen's walk-in freezer and with the Food & Nutrition Director (FND), labeling stickers, pieces of plastic and paper, corn kernels, crumbs and various debris were on the floors and shelving. The FND stated the floors are swept every time stock is received. The FND stated stock is received approximately 4 times per week.

During a concurrent observation and interview on 1/7/25 at 10:54 a.m. in the kitchen's walk-in produce refrigerator 1 with the Food & Nutrition Director (FND), labeling stickers, pieces of plastic, and black grime were on the floors. The FND stated the floors are swept every time stock is received. The FND stated stock is received approximately 4 times per week.

During a concurrent interview and record review on 1/10/25 at 8:49 a.m. with the ICD, "Freezer and Refrigerator Images (FRI, photographs of the floor and shelving in the freezer and refrigerator taken by the surveyor)", dated 1/7/25, were reviewed. The ICD stated he would expect the floor to be swept at the end of each day.

During a review of a professional reference from the "United States Food & Drug Administration (FDA) Food Code", dated 2017, the "FDA" indicated, " ... The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests ...".

3. During a concurrent observation and interview on 1/7/25 at 10:55 a.m. in the kitchen's walk-in produce refrigerator 1 with the Food & Nutrition Director (FND), two of three cooling fans had dust on the grilles. The FND stated the fans are cleaned by the maintenance department once a month and as needed.

During a concurrent observation and interview on 1/7/25 at 10:56 a.m. in the kitchen's walk-in produce refrigerator 2 with the Food & Nutrition Director (FND), one of three cooling fans had dust on the grilles.

During a concurrent interview and record review on 1/10/25 at 8:50 a.m. with the ICD, "Fan Images (FI, photographs of the fans in the food storage areas taken by the surveyor)", dated 1/7/25 were reviewed. The ICD stated the fans had dust on them.

During a review of a professional reference from the "United States Food & Drug Administration (FDA) Food Code", dated 2017, the "FDA" indicated, " ... Walls and Ceilings, Attachments ... attachments to walls and ceilings such as light fixtures, mechanical room ventilation system components, vent covers, wall mounted fans ...shall be easily cleanable ...".

4. During a concurrent observation and interview in the kitchen on 1/7/25 at 10:57 a.m. with the FND, six of six convection ovens contained black, brown, and red grime on the racks, walls, and base of the ovens. The FND stated the ovens were deep cleaned weekly.

During an interview on 1/9/25 at 2:55 p.m. with the FND, the FND stated when she began employment at the hospital in 5/2024, the kitchen equipment was damaged from lack of cleaning. The FND stated some current employees in the kitchen were " ... not on board with change ...".

During a concurrent interview and record review on 1/10/25 at 8:52 a.m. with the ICD, "Oven Images (OI, photographs of the convection ovens taken by the surveyor)", dated 1/7/25, were reviewed. The ICD stated the oven buildup of grime happened over time and can affect " ... food condition ...". The ICD stated he expected the kitchen cleaning at minimum to follow the manufacturer's Instructions for Use (IFU).

During a review of "Gas Convection Oven Owner's Manual (OOM)", dated 11/2023, the "OOM" indicated, " ... Cleaning ... oven interior is finished with porcelain enamel coating. 'Spillovers' should be cleaned from the interior bottom surface as soon as possible to prevent carbonizing and burnt-on condition. Grease or any residue should be cleaned from interior surfaces as soon as it accumulates ... Daily Cleaning and Maintenance .... Remove interior rack and rack slide frames ... wash the racks and rack slides in a sink with mild detergent and warm water. Dry them thoroughly with a clean cloth ... wash interior surfaces with mild detergent and warm water ... For stubborn accumulation of grease and carbon build up, use a commercial Non-Caustic oven and Grill Cleaner ...".

5. During a concurrent observation and interview on 1/7/25 at 11:00 a.m. in the kitchen with the FND, a barbeque-type grill in the kitchen was covered with dried black and brown grime and yellow stains on the ledges. The FND stated the grill was cleaned once a week.

During a concurrent interview and record review on 1/7/25 at 3:50 p.m. with the Chief Operating Officer (COO), "Oven & Grill Images (OGI, photographs of the convection ovens and grill taken by the surveyor)", dated 1/7/25, were reviewed. The COO stated the kitchen equipment might have been overlooked in the cleaning process due to new equipment slated to arrive soon.

During a concurrent interview and record review on 1/10/25 at 8:52 a.m. with the ICD, "Grill Image (GI, photographs of the grill taken by the surveyor)", dated 1/7/25, was reviewed. The ICD stated the buildup of grime had to have happened over days and he would expect cleaning to follow the manufacturer's Instructions for Use (IFU) or more frequently. The ICD stated if debris was not going away, the cleaning needs to be more frequent.

During a review of "Operational Manual Gas Charbroiler (OMGC)" (undated), the "OMGC" indicated, " ... Cleaning ... Scrape top grates during broiling with a wire brush to keep the grates clean. Do not allow debris to accumulate on the grates ... Top grates may be immersed in strong commercial cleaning compound overnight. In the morning rinse with hot water ... Daily, when cool, remove top grates and radiants to clean where fat, grease, or food can accumulate ...".

6. During a review of Patient (Pt) 23's "ED Note (EDN)", dated 1/7/25, the "EDN" indicated Pt 23 came to the ED on 1/7/25 with abdominal discomfort, was being treated for C-difficile (C-Diff, a potential life-threatening, enteric [affecting the intestines] bacterial infection that causes diarrhea and inflammation of the colon) and was awaiting admission.

During a concurrent observation and interview on 1/7/25 at 2:10 p.m. in Pt 23's room with RN 5, RN 5 donned a gown and gloves while inside the isolation room. RN 5 then provided care to Pt 23. When she was finished with patient care, RN 5 removed her gown and gloves and washed her hands with soap and water in the room. RN 5 grasped the door handle to open the door, exited the room and used hand sanitizer located outside the room. RN 5 stated she now needed to find a sink to wash her hands with soap and water again because Pt 23 had C-Diff, which hand sanitizer does not kill.

During an interview on 1/7/25 at 2:20 p.m. with EDM and EDD, the EDM stated Pt 23 was placed in the room without an anteroom because it was the only private room in the section for patients who were waiting to be admitted. The EDD stated the ED " ... should have a better set up ..." for isolation purposes.

During a review of "Transmission Based Precautions (TBP)", dated 5/22/24, "TBP" indicated, " ... Policy ... Use of universal (standard) precautions for contact with blood/body fluids, mucous membranes, and non-intact skin ... will prevent the transmission of most microorganisms and most infectious diseases ... However, additional precautions may be needed for patients suspected or confirmed to be infected or colonized with pathogens [organisms that cause disease collect] which are highly transmissible ... Contact/Enteric isolation- For organisms/diseases that are gastrointestinal in origin, transmitted via contact or indirect contact ... all hand hygiene to be done with soap and water. (example: C difficile) ... Contact isolation ... Staff must wear gloves and gowns when entering the room ... the employee must don the appropriate PPE before contact occurs ... Enteric Isolation ... Staff must wear gloves and gowns when entering the room. Change gloves after contact with potentially infective material or objects that could be contaminated. Remove gloves and gown and dispose in trash prior to leaving the room and immediately wash hands with soap and water ... *Hand sanitizer containing Alcohol should not be used as it will not remove some of the enteric germs [germs from the intestine] ...".

7. During a concurrent observation and interview on 1/7/25 at 2:10 p.m. in the ED with ED Manager (EDM) and ED Director (EDD), Pt 23 was in a private room with a window, on contact isolation. Other patients were immediately outside the room in the hallway. Pt 23's room did not have an anteroom (an adjacent room to put on and remove gowns and gloves and wash hands). RN 5 was inside Pt 23's room donning a gown and gloves. No gowns or gloves were visibly available outside the room. The EDM stated there used to be a rack on the wall for Personal Protective Equipment (PPE, infection protection equipment such as gowns, masks, and gloves), but it was taken down to paint the walls. The EDM stated the walls were painted a couple of months ago and the racks were not put back on the wall. The EDM and EDD stated they did not have PPE carts (a cart containing PPE, placed outside of a patient's room, so that PPE is available to don prior to entering the room) in the ED.

8. During a concurrent observation and interview on 1/7/25, at 11:02 a.m., with nurse manager (NM 1), Pt 34's IV solution set (tubing) was inspected. The IV solution set included an unlabeled (with the date and time of initiation to indicate how old it was) saline flush (fluid used to ensure all medication was infused into the patient) solution, an empty albumin (medication to restore the body's fluid balance and increase blood pressure) bag attached through secondary tubing to the flush solution line. After inspection of the IV solution set, NM 1 was unable to determine how long the flush bag was in use because it was unlabeled. NM 1 stated staff were expected to affix a label to the IV solution bags to determine the date, time and who had hung the IV solution.

During a record review of Pt 34's medication administration record (MAR) titled, "MAR January 06, 2025 - January 09, 2025," dated 1/9/25, the MAR indicated Pt 34 received five administrations of albumin with the first administration starting at 1/6/25, 6:40 p.m. to the last administration on 1/7/25, 5:53 a.m. Patient 34 also received a saline bolus (a rapid administration of a salt based fluid to increase blood pressure) on 1/7/25, at 4:17 a.m.

During a concurrent observation and interview on 1/7/25, at 11:15 a.m., with NM 1, an enteral (administration of nutrition through a tube inserted directly into the gastrointestinal tract) feeding solution set infusing a bottle of tube feeding solution into Pt 35 was inspected. After inspection, NM 1 stated the enteral feeding solution set was not labeled appropriately and NM 1 was unable to determine how long the tube feeding set was in use. NM 1 stated staff were expected to change the feed set every 24 hours and label the feed set and bottle with a date and time of setup.

During a concurrent observation and interview on 1/7/25, at 2:05 p.m., with nurse supervisor (NS 1), an enteral feeding solution set infusing a bottle of tube feeding solution into Pt 32 was inspected. After inspection, NS 1 stated the enteral feeding bottle was not labeled appropriately. NS 1 stated staff were expected to label the feed set or bottle with a date and time of setup and ensure it was replaced every 24 hours.

During an interview on 1/10/25, at 8:50 a.m., with the Infection Control Director (ICD), the ICD stated changing IV and tube feeding solution sets were expected to be done according to hospital policy to prevent growth of pathogenic organisms in the equipment.

During an interview on 1/10/25, at 11:30 a.m., with Chief Nursing Officer (CNO), the CNO stated primary nursing staff were responsible to ensure IV and tube feeding solutions and lines were labeled with the date, time and nurse who started the solution.

During a review of hospital policy and procedure (P&P) titled "Venous Access Device, Prevention, Insertion and Maintenance Policy, Procedure and Protocol," dated 5/22/24, the P&P indicated "the policy establishes guidelines ... to reduce the incidence of ... complications related to vascular access [providing access to the patient's veins] devices ... label all IV infusions with hang date, time, nurse initials, patient name and solution.".

During a review of hospital P&P titled, "Enteral Feedings," dated 5/22/19, the P&P indicated for "use of manufacturer prepared tube feedings ... these preparations will be labeled with the product name, strength, patient name, room number and date prepared ... tube feeding hang times are appropriate: Ready to Hang bottles/bags - 24 hours hang time ... feeding tube maintenance will be the responsibility of nursing.".

During a record review of Pt 2's H&P, indicated Pt 2 was admitted to the hospital with the diagnosis of Acute respiratory failure with hypoxia (a condition where the lungs cannot supply enough oxygen to the body).

During a concurrent observation and interview on 1/7/25 at 1:40 p.m., in Pt 2's room with the Registered Nurse (RN) 1, Pt 2 was receiving Intravenous (IV) medication with no label that identified patient's name and no date the tubing was hung. Pt 2 also had an IV access on the right hand and one on the left hand with no date and time. RN 1 stated all the IVs, including bags and supplies, should be labeled with the date and name of the patient.

During a concurrent observation and interview on 1/7/25 at 2:00 p.m., in Pt 2 's room with the Respiratory Therapist (RT) 1, Pt 2 was using Vapotherm machine (a medical device that delivers oxygen through a tube) and the tube connected to the machine did not have a date and time label to indicate when it was initiated. RT 1 stated RTs usually do not label the tube connected to Vapotherm machine. RT 1 stated he did not know how often to change the tube and stated it was changed whenever tube is not clean.

During an interview on 1/9/25 at 10:20 a.m., with the Respiratory Therapist Manager (RTM), RTM stated the RTs should change the Vapotherm's tube every 30 days and label the tube with the date and time of initiation. RTM stated the RTs were not labeling or documenting the changing of the tubes.

During a record review of the facility's policy and procedure "Venous Access Device [VAD]: Prevention, Insertion and Maintenance Policy, Procedure, and Protocol "dated 5/22/24, indicated " ...d. Label all IV infusions with hang date, time, nurse initials, patient name, and solution. e. Label all IV tubing near the VAD connection with name of medication and label device type when applicable ...".

During a record review of the facility's policy and procedure "Vapotherm High Velocity Therapy (HVNI) Protocol" dated 9/24/24, indicated " ...Disposable Patient Circuit [tubing] is Valid for 30-day continuous single patient use [ used for one patient only] ...".

9. During a record review of Pt 8's History and Physical (H&P) the record indicated Pt 8 was admitted to the hospital with the diagnosis of abdominal abscess (An enclosed collection of pus in tissues, organs, or confined spaces in the body. An abscess is a sign of infection and is usually swollen and inflamed).

During a concurrent observation and interview on 1/7/25 at 2:15 p.m., in Pt 8's room with RN 2 and RN 3, RN 2 finished the wound dressing change, removed gloves, and without sanitizing hands, touched the wound vac machine (a suction device that helps the wound heal) and programmed the machine. After RN 2 and RN 3 finished the dressing change, they left the room without writing date and time or any other information on the dressing. RN 2 stated, the nurses should write on the dressing, the date, time, type of the dressing and how many pieces of dressing they used for the dressing change. RN 2 stated she should have sanitized hands after removing the gloves and before touching the wound vac machine, but she did not do that.

During a record review of the facility's policy and procedure titled "PC.AD.1.12 Hand Hygiene Policy" dated 10/26/22, indicated " ...Decontaminate hands after removing gloves. NOTE: Gloves are not a substitute for hand hygiene ...".

During a record review of the facility using 3M guideline for V.A.C (vacuum assisted closure) therapy "A reference source for clinicians" dated 2021, indicated " ...Always count the total number of pieces of foam used in the wound. Document the foam quantity and dressing change date on the foam quantity label if available, and in the patient chart ...".