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Based on observation, interview and record review, the hospital failed to provide care in a safe environment as evidenced by 1) hand hygiene practices noncompliant with acceptable standards of practice and 2) failure to ensure clean linen was handled, transported and stored by methods to ensure its cleanliness. This failure could place seven patients identified as census on 12/12/12 at risk for cross contamination of microorganisms and hospital acquired illnesses.

Findings included:

1) On 12/13/12 at 11:30 AM Hospital Personnel #24 was observed taking off his gloves after emptying Patient #2's urinal. Without washing his hands, Personnel #24 donned a new pair of gloves and performed blood glucose testing on Patient #2. After the test, Personnel #24 removed the gloves. Without washing his hands, Personnel #24 went to the medication room, prepared the insulin syringe, returned to Patient #2's room for assistance with Patient #2's self administered insulin administration, then entered Patient #1's room. While speaking with Patient #1, Hospital Personnel #24 touched Patient #1"s walker and the bedside overhead table with his hands.

During an interview on 12/13/12 at 8:45 AM Hospital Personnel #23 stated no data were collected for hand washing compliance.

Record review of the hospital's "Infection Control Nurse Job Description" dated 02/01/98 reflected as "essential duties and responsibilities" to determine "compliance with infection control policies and procedures."

The Centers for Disease Control (2012) recommended that "healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings)" (http://www.cdc.gov/handhygiene/Basics.html)

2) On 12/12/12 at 1:55 PM and 12/13/12 at 8:40 AM, observations in the hospital's laundry facility across the parking lot from the main hospital revealed clean linen without a protective sheet stacked on built in wall shelves. A polyvinyl gray blanket touching the clean linen was identified by Hospital Personnel #18 as cover for clean linen transport across the parking lot. The clean linen room in the main hospital had built in shelves and linen without cover. The room was unlocked and accessible to personnel and visitors.
During an interview on 12/12/12 at 1:55 PM Hospital Personnel #18 agreed that clean linen was not covered.
Record review of the laundry supervisor job description dated 02/01/98 reflected as essential duties and responsibilities to assure "the maintenance of cleanliness and sanitary conditions in Laundry operations."
The Centers for Disease Control (2011) recommended "clean linen should be handled, transported, and stored by methods that will ensure its cleanliness" (http://www.cdc.gov/HAI/prevent/laundry.html).

Based on observation, interview and record review the hospital failed to ensure that dietetic services organization requirements were met as evidenced by undated and/or outdated and unlabeled food items in the kitchen

Findings included:
Observation in the hospital kitchen's walk in refrigerator on 12/12/12 at 8:45 AM revealed two containers labeled cottage cheese with an expiration date of 10/12/12. A one gallon bottle of Cocktail Sauce was dated 10/23/12 and a bottle with Tartar Sauce was dated 10/11/12. A one gallon bottle of Buttermilk dressing had a hand written "11/12" date on the cap without an expiration date. Three flats with 48 donuts each were undated. Personnel #16 stated, "Someone took them out of the big box and didn't date them." Four 16-ounce containers of chicken broth were undated. In the kitchen's dry goods storage area, an undated Ziploc bag labeled "cream soup base" without a date and three bags of marshmallows dated 9/19/12 were observed on 12/12/12 at 9:05 AM. On 12/12/12 at 1:10 PM a plastic bag with unidentified brown patties was observed unlabelled and undated; a second bag identified by Personnel #16 as "French Fries" was undated and unlabelled.

Hospital Personnel #23 was interviewed on 12/13/12 at 8:15 AM and stated that environmental safety rounds conducted at the hospital "did not address the kitchen."

Record review of the director of food service job description dated 02/01/98 reflected as essential duties and responsibilities to monitor the "sanitary conditions in food handling and preparation and compliance with infection control procedures."

Based on record review, and interview, the Surgical Services had not maintained a roster that included the current delineation of surgical privileges for all physicians performing surgery in the hospital for 3 of 4 surgeons (Personnel #29, #30 and #31).

Findings included:

During a tour of the Surgical Services at 10:00 AM on 12/13/12 with the Director of the Operating Room (Personnel #26), she was asked for the physician roster that specified the surgical privileges of each physician who performed surgery in the hospital. She provided the surveyor with the credentialing files containing the delineated privileges for each of the four surgeons who perform surgeries in the hospital. Review of these files noted the following:

Personnel #29 - The most recent delineation of surgical privileges, found in the Surgical department, was located in this physician's re-credentialing letter from the hospital's Governing Board dated 04/18/07.

Personnel #30 - The most recent delineation of surgical privileges, found in the Surgical department, was located in this physician's re-credentialing letter from the hospital's Governing Board dated 06/19/07.

Personnel #31 - The most recent delineation of surgical privileges, found in the Surgical department, was located in this physician's re-credentialing letter from the hospital's Governing Board dated 05/19/09.

In an interview at 10:15 AM on 12/13/12 with the Director of the Operating Room (Personnel #26), she confirmed that she had not been aware that when physicians are re-credentialed, the process included a renewal of the delineation of their surgical privileges.

Based on record review, and interview, the operating room register was not complete and up-to-date, in that it did not contain the times when anesthesia began and ended, which staff members were performing "scrub" or "circulating" duties during each surgery, the disposition of specimens, or if there were any unusual occurrences, for the last year reviewed from December 2011 to December 2012.

Findings included:

Review of the Operating Room Register from December 2011 through December 2012, revealed the hospital had not documented the time anesthesia began and ended, which staff members were performing "scrub" or "circulating" duties during each surgery, the disposition of specimens, or if there were any unusual occurrences, during that period.

In an interview at 10:30 AM on 12/13/12 with the Director of the Operating Room (Personnel #26), she confirmed they had not documented the time anesthesia began and ended, which staff members were performing "scrub" or "circulating" duties during each surgery, the disposition of specimens, or if there were any unusual occurrences, in the hospital's operating room register from December 2011 to December 2012.