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Based on record review, observation, and interview, the hospital failed to ensure the hospital-wide QAPI program set priorities aimed at performance improvement activities that focused on high risk, high volume, or problem prone areas that affected health outcomes, patient safety, and quality of care. This deficient practice was evidenced by failure of the hospital's QAPI program to identify infection control breaches in laundering of the patients' linens and infection control issues in the hospital environment. Findings:

Reveiw the hospital's Performance Improvement Plan revealed in part, provide for a hospital-wide program that assures the facility designs processes well and systematically measures, assesses and improves performance by analyzing collected data and tracking quality indicators; including adverse patient events, processes of care, patient health outcomes in a collaborative, cross-departmental, interdisciplinary approach.

Reveiw of the hospital's quality indicators for November 2019, December 2019 and January 2020 for the environmental rounds quality indicators, patient rooms quality indicators, dryer room monitoring and weekly laundry services review failed to identify the numerous infection control breaches with the laundering of the hospital's linens and environmental infection control issues.

An interview was conducted with S6Quality on 02/19/2020 at 12:30 p.m. S6Quality confirmed she was the infection control nurse and was over the hospital's QAPI program. She further reported she was unaware of the infection control breaches in the laundering of the patients' linens and the environmental infection control issues identified by the surveyors while conducting the survey. She further reported these infection control issues should have been identified by the hospital-wide QAPI program and a plan implemented to correct the hospital's infection control practices.

Based on policy review, observation and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area and locked to prevent unmonitored access by unauthorized individuals. This deficient practice was evidenced by failure to ensure the medication room door was locked, at all times, when not in use.

Findings:

Review of the hospital policy titled "Medication Management", Document Number II.D.1.0, revised 05/13 revealed in part: The medication room door will be locked at all times.

Observation on 02/17/2020 at 11:10 a.m. of the medication room revealed the door propped open with a large brown cardboard box. There was a 4-shelf rack containing over the counter medicines, a medicine-dispensing unit, and a small refrigerator.

Interview on 02/17/2020 at 11:15 a.m. with the S2DON stated that the door should never be propped open and must remain closed at all times.

Based on record review and interview, the hospital failed to ensure a system for controlling infections and communicable diseases of patients and personnel were established. This deficient practice was evidenced by the hospital's:

1) failure to maintain clean environment during the laundering process,
2) failure to have hospital laundry cleaned and processed as per their policy and procedure, and by CDC standards,
3) failure to maintain laundry staff wearing appropriate PPE when laundering and maintaining patient's linens,
4) failure to ensufre the food was stored, prepared and served under sanitary conditions,
5) failure to maintain a sanitary enviroment, and
6) failure to prevent expired supplies to be readily available for patient use and to have expired nutritional supplement available for patient consumption. This deficient practice had the potenital to affect 10 out of 10 (Patient #1-10) patients currently in the facility.

Findings:

1) failure to maintain clean environment during the laundering process

Review of the hospital policy titled "Soiled and Clean Linen Distribution", Policy Number III.D.46.0, revised 3/17 revealed in part: Linen will be processed according to CDC guidelines. Clean and dirty linen will be separately processed. 1) Employee's who have contact with contaminated linen shall wear gloves and other appropriate personal protective equipment. 2) All contaminated linen should be placed in laundry hampers lined with large plastic bags in designated areas. 3) Clean and soiled linen should be handled separately. 4) Laundry shall only be processed one load at a time. 5) Clean linen will be removed from the washing machine area completely before processing soiled linens. 7) Following the handling of dirty linen, handwashing will be completed according to hand hygiene policy and procedure. 8) Clean linen are folded and placed in clean, decontaminated laundry cabinet for storage until use.

Review of the CDC Guidelines for Environmental Infection Control in Health-Care Facilities (2003) revealed the following, in part:

A laundry facility is usually partitioned into two separate areas - a "dirty" area for receiving and handling the soiled laundry and a "clean" area for processing the washed items. To minimize the potential for decontaminating cleaned laundry with aerosolized contaminated lint, areas receiving contaminated textiles should be at negative air pressure relative to the clean areas. Laundry areas should have handwashing facilities readily available to workers. Laundry workers should wear appropriate personal protective equipment (e.g., gloves and protective garments) while sorting soiled fabrics and textiles.

Observation of the linen area during initial tour on 02/17/2020 at 10:50 a.m. revealed door labeled soiled linen the room contained two industrial washing machines and a sink that was dirty and covered in dark brown stains. There were two large white plastic barrels on casters next to carts labeled soiled linens. The floor was filthy and covered with stains and foreign matter. The drainpipe located behind the washing machines where the chemicals were stored was covered in brown foreign matter and stains. The floor behind the washing machines was dirty and contaminated with foreign matter. The outer surface of the washing machines had dry white crystal formations covering the top and sides and front of the machines. Across the hall, a door marked clean linen contained two large industrial dryers a cart for storage of clean folded linens, a small folding table and a handwashing sink.

Interview on 02/17/2020 at 10:55 a.m. with S4Laundry confirmed the white plastic barrels were clean stored in the soiled linen room and she used them to transport clean washed linen across the hall to the clean linen area where the dryers were located. S4Laundry further stated that the area where the clean barrels were stored was considered the dirty area.

2) failure to have hospital laundry cleaned and processed as per their policy and procedure, and by CDC standards

Observation on 02/18/2020 at 9:30 a.m. of the soiled linen area revealed two clear plastic bags containing pillows, and one plastic bag containing folded hospital gowns lying on top of a cart in the soiled linen area.

Interview on 02/18/2020 at 9:35 a.m. with S4Laundry confirmed the plastic bags contained clean pillows and hospital gowns. S4Laundry stated that she did not know why the bags were stored in the soiled linen area.

3) failure to maintain laundry staff wearing appropriate PPE when laundering and maintaining patient's linens

Review of the hospital policy titled "Guidelines for Transmission Base Precautions", Policy Number III.A.10.0, revised 12/19 revealed in part: Use of Personal Protective Equipment (PPE). 2. Gowns; wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient.

Observation on 02/17/2020 at 1:35 p.m. revealed S4Laundry in the soiled linen area that contained a cart labeled soiled linens that contained dirty soiled linens, a plastic bag opened lying on the floor in front of the washing machines that had soiled linens hanging out of the bag on the floor. S4Laundry was observed to not be wearing any type of PPE during the process of removing linens from the washing machine. S4Laundry was observed to touch the door in the dirty soiled linen area and other surfaces pushing the white barrel across the hall into the clean linen area, and not perform any type of hand hygiene. The two dryers where in the process of drying linens. S4Laundry was asked if she had any type of PPE and stated that she used only gloves when handling soiled linens.


4) Failure to ensure the food was stored, prepared and served under sanitary conditions

On 02/18/2020 at 8:07 a.m. a tour of the kitchen with S3Dietician revealed the following unsanitary conditions:
1) Walk in freezer with black substance on the floor, with pieces of food;
2) Reach in freezer door gasket with black substance, which was able to be wiped off by S3Dietician;
3) Ice machine with white substance on the outside and black substance over the control panel;
4) Steamtable guard with a black substance on the underside of the top of the guard over the food tray areas.

In an interview on 02/18/2020 at 8:20 a.m. S3Dietician verified all the above.



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5. Failure to maintain a sanitary environment

On 02/17/2020 at 10:45 a.m. an observation was conducted with S2DON of the main patient hallway. The hallway floor had numerous light to dark gray liquid spots and marks on the flooring. The hand railing in the main hallway had a space in the railing which contained debris and dust. An interview was conducted with S2DON on 02/17/2020 at 10:45 a.m. S2DON confirmed the floors were dirty and needed to be cleaned and the hand railing had dirt and debris in the railing.

An observation was made on 02/17/2020 at 10:50 a.m. of a hallway inset with missing paint which protruded in the main hallway as a shelving ledge. The missing paint allowed for exposure of a foam material that is unable to be disinfected. S2DON confirmed the finding.

An observation was conducted on 02/17/2010 at 10:55 a.m. of a countertop behind the nursing station that had missing formica which allowed for exposure of the bare wood, which is unable to be disinfected. S2DON confirmed the findings.

An observation was conducted on 02/17/2020 at 11:00 a.m. of the AED behind the nursing station with a black sticky substance on the outside of the equipment. S2DON confirmed the findings.

Further observations were conducted with S2DON on 02/17/2020 at 11:10 a.m. which revealed a functioning staff bathroom behind the nurses' station. In the bathroom, stored on a shelf approximately 3 feet from the toilet, were 4 boxes of vacucontainers and a small refrigerator that was utilized for storage of the patients' specimens.

An interview was conducted with S2DON on 02/17/2020 at 11:00 a.m. He confirmed the bathroom was utilized by the staff and clean supplies and a specimen refrigerator were being stored in the bathroom due to the hospital's limited space.

An observation was conducted with S2DON on 02/17/2020 at 11:15 a.m. of a small sink directly behind the nurse's station. The sink had rust spots in bottom of the sink, which made it unable to be disinfected and pieces of paper were observed in the bottom of the drain.

An observation 02/17/2020 at 11:20 a.m. was conducted of a medicine cart with multiply liquid drips and crusted material on the side of the medicine cart. S2DON confirmed the observation on 02/17/2020 at 11:20 a.m.

6. Failure to prevent expired supplies to be readily available for patient use and to have expired nutritional supplement available for patient consumption.

An observation of a small supply closet was conducted on 02/10/2020 at 10:35 a.m. In the supply closet was the following expired supplies- 14 packages of Curad wound dressings with an expiration date of January 2020.

Further observations of the supply closet revealed 14 containers of expired Jevity 1.2 with an expiration date of January 2020. These findings were confirmed by S2DON.









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