HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital's Governing Body failed to:
- Ensure a clean environment in the dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) treatment room;
- Date opened control solutions (a solution used to calibrate) and test strips (a strip of material containing chemicals that react to certain substances) for four of four glucometers (used to measure the amount of glucose [sugar] in your blood) on two of five patient care units;
- Remove expired supplies on two of five patient care units;
- Date food items in two of five patient nutrition room refrigerator or freezers;
- Date three of three open liquids in Patient #23's room;
- Clean the workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) for three of eight machines observed;
- Clean the surfaces of the crash cart (mobile cart which contains emergency medical supplies and medication) on two of five patient care units;
- Clean vital sign (VS, measurements of the body's most basic functions) machines on two of five patient care units;
- Date food items in the front food service kitchen area;
- Clean the air vents in 24 of 35 patient rooms and the back area of the kitchen;
- Clean the nurses' station floors on two of five patient care units;
- Clean the hallway bumper guards on two of five patient care units;
- Clean the storage room on one of five patient care units;
- Clean the portable air conditioners in the kitchen;
- Clean all surfaces in the front service area and back area of the kitchen;
- Laminate or otherwise cover loose paper in the back area of the kitchen;
- Label, date, and store cleaning solutions (mixture of two or more substances) in the front service area of the kitchen;
- Remove personal items from the front service area of the kitchen;
- Clean four of four patient therapy gymnasium closets;
- Replace damaged particle board under a leaking pipe on one of five patient care units; and
- Follow their Infection Prevention Plan to maintain a sanitary environment.

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The severity and cumulative effect of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.12 Condition of Participation: Governing Body.

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure a clean environment in the dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) treatment room; (A-0749)
- Date opened control solutions (a solution used to calibrate) and test strips (a strip of material containing chemicals that react to certain substances) for four of four glucometers (used to measure the amount of glucose [sugar] in your blood) on two of five patient care units; (A-0749)
- Remove expired supplies on two of five patient care units; (A-0749)
- Date food items in two of five patient nutrition room refrigerator or freezers; (A-0749)
- Date three of three open liquids in Patient #23's room; (A-0749)
- Clean the workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) for three of eight machines observed; (A-0749)
- Clean the surfaces of the crash cart (mobile cart which contains emergency medical supplies and medication) on two of five patient care units; (A-0749)
- Clean vital sign (VS, measurements of the body's most basic functions) machines on two of five patient care units; (A-0749)
- Date food items in the front food service kitchen area; (A-0749)
- Clean the air vents in 24 of 35 patient rooms and the back area of the kitchen; (A-0750)
- Clean the nurses' station floors on two of five patient care units; (A-0750)
- Clean the hallway bumper guards on two of five patient care units; (A-0750)
- Clean the storage room on one of five patient care units; (A-0750)
- Clean the portable air conditioners in the kitchen; (A-0750)
- Clean all surfaces in the front service area and back area of the kitchen; (A-0750)
- Laminate or otherwise cover loose paper in the back area of the kitchen; (A-0750)
- Label, date, and store cleaning solutions (mixture of two or more substances) in the front service area of the kitchen; (A-0750)
- Remove personal items from the front service area of the kitchen; (A-0750)
- Clean four of four patient therapy gymnasium closets; (A-0750)
- Replace damaged particle board under a leaking pipe on one of five patient care units; (A-0750) and
- Follow their Infection Prevention Plan to maintain a sanitary environment. (A-0749 and A-0750)

The severity and cumulative effects of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs and resulted in the hospital's failure to ensure quality health care and safety.

Based on interview and record review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs. These failures had the potential to affect the quality of care and safety of all patients.

Findings included:

Review of the hospital's document titled, "Medical Staff Bylaws," dated 12/15/23, showed the CEO was responsible for the overall management of the hospital.

Review of the hospital's document titled, "Organizational Chart," dated 03/11/24, showed all administrative leaders reported to Staff X, CEO.

During an interview on 05/22/24 at 3:10 PM, Staff X, CEO, stated that he was responsible for the hospital and the staff.

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure a clean environment in the dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) treatment room;
- Date opened control solutions (a solution used to calibrate) and test strips (a strip of material containing chemicals that react to certain substances) for four of four glucometers (used to measure the amount of glucose [sugar] in your blood) on two of five patient care units;
- Remove expired supplies on two of five patient care units;
- Date food items in two of five patient nutrition room refrigerators or freezers;
- Date three of three open liquids in Patient #23's room;
- Clean the workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) for three of eight machines observed;
- Clean the surfaces of the crash cart (mobile cart which contains emergency medical supplies and medication) on two of five patient care units;
- Clean vital sign (VS, measurements of the body's most basic functions) machines on two of five patient care units;
- Date food items in the front food service kitchen area; and
- Follow their Infection Prevention Plan to maintain a sanitary environment.

Findings included:

Review of the contract titled, "DaVita Facility, Hospital Services Agreement," dated 08/10/20, showed the hospital was responsible for janitorial and environmental services in the dialysis treatment room.

Review of the hospital's undated document titled, "Environmental Staff Services Orientation," showed staff were to dust the air vents and pictures weekly and to wet mop the floors daily.

Observation of the dialysis treatment room on 05/21/24 at 9:50 AM, showed:
- A dusty air vent;
- An exam light with dust accumulation;
- A suction cannister with dust accumulation on the top of the lid;
- A dialysis chair with stains and a tear in the seating material and the arm rest;
- A brown stain on the arm rest of the dialysis chair; and
- A dusty picture hung on the wall.

Observation of the dialysis storage room on 05/21/24 at 9:50 AM, showed:
- A sink labeled "dirty sink";
- A storage rack that contained sterile and clean supplies with 31 supply bins that were dusty and had adhesive residue on the exterior portion of the supply bins; and
- A plastic curtain between the "dirty sink" and the storage rack.

During an interview on 05/21/24 at 9:52 AM, Staff Q, Nurse Manager, stated that the cracked area in the chair would be hard to clean and she would expect a smooth surface.

During an interview on 05/21/24 at 10:00 AM, Staff A, Chief Nursing Officer (CNO), stated that the vents should not be dusty.

During an interview on 05/21/24 at 1:24 PM, Staff F, Infection Preventionist, stated that she had not been in the dialysis treatment room in the last five months and the vents should be cleaned routinely.

During an interview on 05/21/24 at 1:50 PM, Staff S, Support Services Manager, stated that environmental services cleaned the floors, removed the trash, and wiped down the dialysis treatment room every day.

During an interview on 05/21/24 at 2:50 PM, Staff V, Registered Nurse (RN), Dialysis Nurse, stated that environmental services cleaned the dialysis treatment room. She was responsible for cleaning the dialysis machines and chairs. She stated that the "dirty sink" was used to discard used liquids and the plastic curtain should be pulled to prevent splashing onto the supply cart.

Review of the hospital's policy titled, "Blood Glucose Monitoring," dated 03/06/24, showed control solutions and strips are dated when opened, per manufacturer's guidelines. Control solutions are stable for 90 days and the bottles must be dated in the space provided with an updated expiration date. Strips are stable for 180 days and the container must be dated in the space provided with an open date and an expiration date.

Observation on 05/20/24 at 2:10 PM, on the Comprehensive Unit, showed five open control solutions and one open test strip bottle with no opened and no expiration dates.

Observation on 05/20/24 at 2:28 PM, on the Annex Unit, showed two open control solutions with no opened and no expiration dates.

During an interview on 05/20/24 at 2:10 PM, Staff E, Evening House Supervisor, stated that all control solutions and test strips should be dated.

During an interview on 05/20/24 at 2:25 PM, Staff I, RN, stated that control solutions should be dated when they were opened and were good for three months.

During an interview on 05/20/24 at 2:30 PM, Staff J, RN, stated that control solutions and test strips should be dated.

During an interview on 05/22/24 at 2:30 PM, Staff A, CNO, stated that control solutions and test strips should be dated when opened.

Although requested no policy related to expired supplies was provided.

Review of the hospital's policy titled, "Emergency Cart Maintenance - Security and Accountability," dated 03/06/24, showed:
- Licensed nursing staff were responsible for checking the integrity of the emergency cart and its supplies daily.
- Nursing staff document that the cart remained properly locked to ensure that all appropriate contents were present, intact, and not expired.
- Nursing was responsible for assuring the contents and expiration dates for supply items remained current.

Observation on 05/20/24 at 12:40 PM, on the Spinal Cord Injury Unit nurses' station crash cart, showed one pink lab tube, one grey lab tube, and 33 green lab tubes had expired on 03/02/24, and one red tube had expired on 05/09/24.

Observation on 05/20/24 at 12:40 PM, on the second-floor nurses' station crash cart, showed one suction (used to remove thick mucus and secretions from the airway, that a person is not able to clear by coughing) catheter kit had expired 05/01/24.

During an interview on 05/20/24 at 12:40 PM and 05/22/24 at 2:45 PM, Staff A, CNO, stated that nursing staff should have discarded the expired lab tubes. She stated that nursing was responsible for checking for outdated materials on the crash cart.

During an interview on 05/22/24 at 1:48 PM, Staff Y, Purchasing Materials Manager, stated that she and her staff were responsible for ensuring lab tubes were not out of date. She stated that there should not be expired lab tubes in the nurses' station crash cart and nursing staff should also assist to ensure expired supplies were removed. Nurses were responsible for ensuring supplies on crash carts were not expired.

During an interview on 05/20/24 at 12:40 PM, Staff L, Physical Therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) Director, stated that she was unsure that the date on the suction catheter kit package reflected outdate. Staff L stated on 05/21/24 at 12:30 PM, that the date on the package showed that the package was expired and no longer usable.

Review of the hospital's policy titled, "Food Brought in to Patients From Outside," dated 03/06/24, showed food brought to patients from outside of the hospital could not be stored in the patients' room or in the refrigerators in the unit nourishment rooms.

Observation on 05/20/24 at 12:40 PM, on the Spinal Cord Injury Unit, showed a clear cup with a pink liquid labeled "G-52" in the nutrition room refrigerator.

Observation on 05/20/24 at 1:55 PM, on the first floor, showed one unlabeled chocolate shake in the nourishment room freezer.

During an interview on 05/20/24 at 1:55 PM, Staff E, Evening House Supervisor, stated that the shake should have a patient label and an expiration date.

During an interview on 05/20/24 at 12:40 PM, Staff A, CNO, stated that staff should have placed a label with the patient information, date, and time on patient food placed in nutrition room refrigerators.

During an interview on 05/20/24 at 12:45 PM, Staff B, RN, stated that patient food placed in the refrigerator should be labeled and discarded within 24-48 hours.

Although requested, no policy related to the labeling of open liquids was provided.

Observation on 05/21/24 at 9:00 AM, in Patient #23's room, showed one open bottle of sterile water with no opened date and no expiration date and two open containers of liquid iodine solution with no opened date and no expiration date.

During an interview on 05/21/24 at 9:00 AM, Staff I, RN, stated that she would have expected to see a date on all three liquids.

During an interview on 05/21/24 at 9:03 AM, Staff Q, Nurse Manager, stated that all three liquids should have been dated.

Although requested, no policy related to cleaning of the WOW was provided.

Observation on 05/20/24 at 2:20 PM, on the Comprehensive Unit, showed three WOW's that had adhesive on top, dirty keyboards, dusty and dirty bases, and dirty wheels.

During an interview on 05/20/24 at 2:25 PM, Staff I, RN, stated that each nurse was responsible for cleaning the WOW at the beginning of their shift.

During an interview on 05/20/24 at 2:30 PM, Staff J, RN, stated that she wiped down the WOW as often as she could and when she left a patient's room.

During an interview on 05/20/24 at 2:20 PM, Staff E, Evening House Supervisor, stated that the WOW should not be dusty and dirty.

During an interview on 05/22/24 at 2:30 PM, Staff A, CNO, stated that each WOW should be wiped down between shifts.

Review of the hospital's policy titled, "Emergency Cart Maintenance - Security and Accountability," dated 03/06/24, showed nursing staff were responsible for checking the integrity of the emergency cart daily.

Observation on 05/20/24 at 12:40 PM, on the second-floor nurses' station, showed visible dust and dried residue on the crash cart.

Observation on 05/21/24 at 8:35 AM, on the Comprehensive Unit, showed dust accumulation on the top of the crash cart.

During an interview on 05/21/24 at 9:30 AM, Staff Q, Nurse Manager, stated that nursing was responsible for cleaning the crash cart.

During an interview on 05/22/24 at 2:45 PM, Staff A, CNO, stated that nursing staff was responsible for cleaning the crash cart.

During an interview on 05/21/24 at 1:50 PM, Staff S, Support Services Manager, stated that nursing staff was responsible for cleaning the crash carts.

Although requested, no policy related to cleaning of the VS machine was provided.

Observation on 05/21/24 at 8:55 AM, showed a VS machine with dust accumulation and brown particles on the base of the machine.

Observation on 05/21/24 at 9:12 AM, showed a VS machine with dust accumulation and small pieces of white trash on the base of the machine.

During an interview on 05/21/24 at 9:30 AM, Staff Q, Nurse Manager, stated that the VS machines should not be dirty and the nursing staff were responsible for cleaning the VS machines.

Review of the hospital's policy titled, "Food Storage and Expiration Codes," dated 03/06/24, showed all perishable products used to prepare and/or were packaged for patient's meals, stock, cafeteria, and vending must be labeled with an expiration date.

Review of the hospital's policy titled, "Infection Control-Nutritional Services Overview," date 03/06/24, showed food was to be stored in a labeled clean wrapper or container.

Review of the hospital's untitled and undated document, showed all condiments were to be discarded and restocked on the last Friday of every month.

Observation on 05/21/24 at 10:20 AM, on the front food service kitchen area, showed:
- All condiments were placed in unlabeled and undated bins with no expiration dates.
- Two bins of individual cereal containers in a cabinet were unlabeled and undated with no expiration date.
- A bin of individual cream cheese packets in a cabinet were unlabeled and undated with no expiration date.

During an interview on 05/21/24 at 12:40 PM, Staff S, Support Services Manager, stated that condiments were put in unlabeled bins and discarded on the last Friday of every month to ensure they were not expired. He was unsure why the cereal boxes in bins were not labeled with the expiration date.

Review of the hospital's document titled, "Infection Prevention Plan 2024," dated 03/06/24, showed:
- The purpose of the plan was to maintain a sanitary environment to avoid sources of, and transmission of, infections and communicable diseases; and to minimize the risk of transmitting infections with the use of procedures during the use of medical equipment and devices.
- The risk assessment was to address the transmission of infection related to medical equipment and medical devices related to appropriate storage, cleaning, and disinfection.
- The maintenance of a sanitary physical environment had specific policies, procedures, and other systematic work processes that addressed ventilation; techniques for safe food storage, preparation, and handling; and techniques for safe cleaning and disinfection of environmental surfaces.
- The Infection Prevention and Control Committee was a multi-disciplinary body composed of representatives from the Infection Control Program, medical staff, nursing, and other direct and indirect care staff. The committee meets on a quarterly basis. Composition of the committee assures, through either membership or invitee, that administration, building maintenance, food service, housekeeping, laboratory, pharmacy, and others are represented as applicable and necessary.
- The functions of the Infection Prevention and Control Committee included monitoring compliance with all policies, procedures, protocols and other infection control program requirements.
- The organization had developed specific policies, procedures, or other systematic work processes that addressed methods for monitoring and evaluating practices of asepsis (process that is intended to minimize contamination from pathogens).

Review of the hospital's undated document titled, "Environment of Care Rounds, 2024 Schedule," showed the following:
- The rounding team was documented as Staff Y, Purchasing Material Manager; Staff T, Quality Management Director; Staff S, Support Services Manager; Staff W, Support Services Supervisor; Staff F, Infection Preventionist; and Staff H, Plant Operations Director.
- On 01/17/24, the Traumatic Brain Injury and Ground Level rounding had been completed by Staff H and Staff Y.
- On 02/13/24, the second-floor nursing area rounding had been completed by Staff H, Staff Y, and Staff S.
- On 03/20/24, the Annex and Spinal Nursing floors rounding had been completed by Staff H and Staff S.
- On 04/14/24, the first-floor exterior rounding had been completed by Staff H and Staff Y.
- On 05/16/24, the receiving area rounding had been completed by Staff H and Staff Y.
- The following areas were scheduled to be completed on a monthly basis for the remainder of the year and included first-floor Comprehensive Unit, first and second floor physical therapy gyms, the kitchen, the cafe, the dock, second-floor exterior safety rounds, administration, physician offices, business offices, and the second-floor patient care unit.

During an interview on 05/21/24, Staff F, Infection Preventionist, stated that:
- Maintenance, environmental services, and the quality department held their own monthly meetings;
- The infection control committee met monthly and she only presented data related to patient care concerns;
- She was not responsible for touring the kitchen or monitoring that area; and
- She reported monthly to Staff A, CNO.

During an interview on 05/22/24 at 1:04 PM, Staff H, Plant Operation Director, stated that:
- He participated in monthly environment of care rounding along with Staff S, Support Services Manager; Staff Y, Purchasing Materials Manager; and Staff F, Infection Preventionist.
- There was a schedule made at the beginning of the year for rounding and the team consisted of Staff S, Staff Y, and Staff F.
- He had not been to the kitchen since last year.
- Staff S and Staff F were responsible for infection prevention.
- The environment of care rounding addressed overall patient safety and there had been a gap when there was not a dedicated infection prevention person.

During an interview on 05/21/24 at 1:50 PM, Staff S, Support Services Manager, stated that he participated in environment of care rounding on a monthly basis along with other staff, depending on who was available. He also stated that he was responsible for both environmental staff employees and kitchen employees.

During an interview on 05/22/24 at 1:48 PM, Staff Y, Purchasing Material Manager, stated that she was a member of the environment of care rounding team and it had been several months since she had been to the kitchen.



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Based on observation, interview, record review and policy review, the hospital failed to:
- Clean the air vents in 24 of 35 patient rooms and the back area of the kitchen;
- Clean the nurses' station floors on two of five patient care units;
- Clean the hallway bumper guards on two of five patient care units;
- Clean the storage room on one of five patient care units;
- Clean the portable air conditioners in the kitchen;
- Clean all surfaces in the front service area and back area of the kitchen;
- Laminate or otherwise cover loose paper in the back area of the kitchen;
- Label, date, and store cleaning solutions (mixture of two or more substances) in the front service area of the kitchen;
- Remove personal items from the front service area of the kitchen;
- Clean four of four patient therapy gymnasium closets;
- Replace damaged particle board under a leaking pipe on one of five patient care units; and
- Follow their Infection Prevention Plan to maintain a sanitary environment.

Findings included:

Review of the hospital's undated policy titled, "Environmental Services Chemical and General Use," showed staff were to dust air vents in patient rooms weekly and all discharged patient rooms and bathrooms.

Review of the hospital's policy titled, "Patient Room, Terminal," dated 03/06/24, showed environmental staff were to clean patient room supply and return diffusers in discharged rooms only.

Review of the hospital's undated document titled, "Environmental Staff Services Orientation," showed staff were to dust vents in the discharged patient rooms.

Review of the hospital's document titled, "Environment of Care (EOC) Rounds," dated 03/20/24, for the Annex Unit did not document that room vents were inspected for dust accumulation.

Observation on 05/20/24 at 12:40 PM, in Patient #7's room on the Annex Unit, showed an accumulation of dust on the ceiling vent.

Observation on 05/20/24 at 12:45 PM, in Patient #8's room on the Annex Unit, showed an accumulation of dust on the ceiling vent.

Observation on 05/20/24 at 2:30 PM, on the Annex Unit at the nurses' station, showed an accumulation of dust on two ceiling vents.

Observation on 05/21/24 at 9:40 AM, on the Annex Unit, showed an accumulation of dust on the ceiling vents in all patient rooms; both occupied which included Patient's #34, #35, and #36, and one unoccupied room.

Observation on 05/21/24 at 8:37 AM, in Patient #22's room on the Comprehensive Unit, showed an accumulation of dust on the ceiling vent.

Observation on 05/21/24 at 8:55 AM, in Patient #23's room on the Comprehensive Unit, showed an accumulation of dust on the ceiling vent.

Observation on 05/21/24 at 9:13 AM, in Patient #24's room on the Comprehensive Unit, showed an accumulation of dust on the ceiling vent.

Observation on 05/21/24 at 9:15 AM, in Patient #25's room on the Comprehensive Unit, showed an accumulation of dust on the ceiling vent.

Observation on 05/21/24 at 9:30 AM, on the Comprehensive Unit, showed an accumulation of dust on the ceiling vents in all patient rooms; both occupied which included Patient's #19, #26, #27, #28, #29, #30, #31, #32, #33, and #38, and six unoccupied rooms.

Observation on 05/21/24 at 10:05 AM, in the dry storage area of the kitchen, showed an accumulation of dust on the ceiling vent.

During an interview on 05/21/24 at 1:50 PM, Staff S, Support Services Manager, stated that environmental services staff were to dust the ceiling vents in the patient rooms and in the kitchen area.

During an interview on 05/21/24 at 9:30 AM, Staff Q, Nurse Manager, stated that she would not expect to see dusty air vents in patient rooms.

During an interview on 05/21/24 at 9:40 AM, Staff R, Environmental Services Technician, stated that the ceiling vents were to be cleaned with a duster after a patient was discharged.

During an interview on 05/21/24 at 10:00 AM, Staff A, Chief Nursing Officer (CNO), stated that ceiling vents should not be dusty.

During an interview on 05/21/24 at 1:24 PM, Staff F, Infection Preventionist, stated that ceiling vents should be routinely cleaned and should not have an accumulation of dust.

Review of the hospital's policy titled, "Nurse Stations," dated 03/06/24, showed direction for environmental services staff to wet mop the floor with germicidal (preventing infection by inhibiting the growth of microorganisms) detergent daily.

Observation on 05/20/24 at 2:13 PM, on the Comprehensive Unit, showed copious amounts of dust on the floor and in the corners at the nurses' station.

Observation on 05/20/24 at 2:28 PM, on the Annex Unit, showed the nurses' station floor was dirty, dusty, and had small pieces of paper in the corners.

During an interview on 05/20/24 at 2:13 PM, Staff E, Evening House Supervisor, stated that housekeeping was responsible for cleaning the floors at the nurses' stations.

During an interview on 05/20/24 at 2:25 PM, Staff I, Registered Nurse (RN), stated that environmental services cleaned the floors at the nurses' stations.

During an interview on 05/20/24 at 2:30 PM, Staff J, RN, stated that environmental services cleaned at least once a day in the nurses' station.

During an interview on 05/21/24 at 1:50 PM, Staff S, Support Services Manager, stated that environmental services cleaned the floors daily.

During an interview on 05/22/24 at 2:30 PM, Staff A, CNO, stated that the nurses' station floors should be clean and free of dust.

Review of the hospital's policy titled, "Cleaning Hallways," dated 03/06/24, directed staff to damp wipe bumper guards daily.

Observation on 05/20/24 at 2:20 PM, on the Comprehensive Unit, showed hallway bumper guards with an accumulation of dust.

Observation on 05/20/24 at 2:28 PM, on the Annex Unit, showed hallway bumper guards with an accumulation of dust.

During an interview on 05/20/24 at 2:13 PM, Staff E, Evening House Supervisor, stated that environmental services were responsible to dust the hallway bumper guards.

During an interview on 05/20/24 at 2:25 PM, Staff I, RN, stated that environmental services cleaned the hallway bumper guards.

During an interview on 05/20/24 at 2:30 PM, Staff J, RN, stated that environmental services cleaned the hallways daily.

During an interview on 05/21/24 at 1:50 PM, Staff S, Support Services Manager, stated that environmental services cleaned the hallways daily.

During an interview on 05/22/24 at 2:30 PM, Staff A, CNO, stated that environmental services staff were responsible to clean the bumper guards in the hallways.

Review of the hospital's policy titled, "Storage Areas and Equipment Closets," dated 03/06/24, showed all storage areas will be cleaned at least weekly, or as needed.

Observation on 05/21/24 at 10:05 AM, in the clean supply room on the Comprehensive Unit, showed:
- Seven storage racks with dusty bottom shelves;
- Five three drawer storage bins with dust and debris inside the drawers;
- 23 blue bins on the respiratory cart with dust accumulation inside the bins;
- 25 blue bins throughout the room with dust accumulation inside the bins; and
- Four stationary linen carts with dust accumulation and miscellaneous debris on the floor under the carts.

During an interview on 05/21/24 at 10:10 AM, Staff T, Quality Management Director, stated that environmental services staff and central supply staff together should clean the room and shelves as necessary.

During an interview on 05/21/24 at 1:50 PM, Staff S, Support Services Manager, stated that central supply should clean the supply room.

During an interview on 05/22/24 at 1:48 PM, Staff Y, Purchasing Materials Manager, stated that her employees would clean the bins when they noticed they appeared dirty and would tag team with environmental services staff to keep those clean. She stated that environmental services staff were responsible to clean the floors in the clean supply rooms.

Although requested, no policy or manufacturer's recommendation for cleaning and maintenance of the portable air conditioner and fan in the kitchen were provided.

Observation on 05/21/24 at 10:30 AM, in the back area of the kitchen, showed:
- An air conditioner had dust and grime accumulated on all surfaces;
- The air filter on the front panel of the air conditioner unit had noticeable dust accumulation;
- A portable fan had dust and grime accumulated on all surfaces; and
- The air filter on the side of the portable fan had noticeable dust accumulation.

During an interview on 05/21/24 at 12:40 PM and 1:48 PM, Staff S, Support Services Manager, stated that housekeeping should clean the air conditioner and fan units as needed and that they should be cleaned currently.

During an interview on 05/22/24 at 1:04 PM, Staff H, Plant Operations Director, stated that the two portable air conditioner units in the kitchen area were owned by the hospital and were to be routinely cleaned by kitchen or environmental services staff.

Review of the hospital's policy titled, "Infection Control - Nutritional Services Overview," dated 03/06/24, showed all food contact surfaces would be washed and sanitized either mechanically or chemically.

Review of the hospital's undated document titled, "Degreasing and Cleaning of Kitchen Equipment Schedule," showed:
- All table legs, sinks, refrigerators, and freezers were cleaned monthly;
- All vents in the kitchen and dish room were cleaned every six months; and
- Invoices for completed kitchen degreasing dated 05/01/24, 04/01/24, and 03/01/24 were sent by a floor and carpet cleaning service.

Review of the hospital's document titled, "EOC Rounds," dated 04/21/23, showed an inspection was completed in the kitchen. The section that required a check for grease behind grills and fryers received a not applicable (N/A) in the "pass" field with a comment that stated "time to power wash grease."

Observation on 05/21/24 at 10:20 AM, in the front service area of the kitchen, showed:
- A cabinet under a sink was covered in a brown, non-flaking residue on all walls, top, and bottom surfaces and was reported to have a leak.
- Two of two refrigerators with sliding doors had grime on the bottom door glides.
- The food warmer and cooler had accumulated dust on the top surfaces causing a finger to appear black after swiping the surface.

Observation on 05/21/24 at 10:30 AM, in the back area of the kitchen, showed:
- A telephone on the wall had grime and dust accumulation on all surfaces and cords connected to the wall;
- A temperature gauge on the wall had dust and grime accumulation on all surfaces;
- Three of three sinks and paper towel dispensers had grime and dust accumulation on all surfaces;
- One of three paper towel dispensers had dried food on the side of the dispenser;
- Three of three trash cans had food splattered at various stages of drying;
- A utensil drawer had dust and food particles accumulated on the bottom surface; and
- A refrigerator with a sliding door had grime on the bottom door glides as well as a brown residue on the bottom surface.

During an interview on 05/21/24 at 12:40 PM and 1:48 PM, Staff S, Support Services Manager, stated that every surface in the front service area and back kitchen were cleaned every couple of days and that a contracted cleaning service provided a deep cleaning once a month. He expected the hired cleaning service to clean all accumulated dust and grime. He stated that the kitchen crew should regularly clean cabinets and drawers as needed. He conducted EOC rounding and clean sweeps monthly. Rounds were completed more often when he believed there would be an inspection completed soon. There was no schedule for cleaning in the kitchen.

During an interview on 05/21/24 at 1:19 PM, Staff F, Infection Preventionist, stated that she did not tour the kitchen, her role did not involve the oversight of kitchen or environmental staff, and she had not seen the kitchen in four to five months.

During an interview on 05/22/24 at 1:05 PM, Staff H, Plant Operations Director, stated that he had no formal infection prevention training but does lead the EOC meetings and participated in rounds throughout the hospital with Staff F, Infection Preventionist, and Staff S, Support Services Manager. The cleanliness of the hospital was Staff S's responsibility. The last EOC rounds in the kitchen were completed in 04/2023.

During an interview on 05/22/24 at 2:31 PM, Staff A, CNO, stated that Staff S, Support Services Manager, was responsible for the nutrition and environmental care areas.

During an interview on 05/22/24 at 3:10 PM, Staff X, Chief Executive Officer (CEO), stated that Staff S, Support Services Manager, oversees the environment and had no specific training or certification in infection prevention. He was in the kitchen every day and stated that he did not see anything concerning. His expectation for staff and any contracted cleaning company was to follow policy.

Although requested no policy related to exposed paper was provided.

Observation on 05/21/24 at 10:30 AM, in the back area of the kitchen, showed exposed paper with no coverings were found throughout the back kitchen area taped to walls, refrigerators, and freezers.

During an interview on 05/21/24 at 12:40 PM, Staff S, Support Services Manager, stated that paper should be covered in all areas of the kitchen.

Review of the hospital's policy titled, "Identification and Labeling of Cleaning Agents Mercy Rehab Hospital St. Louis (MRHSL)," dated 03/06/24, showed labels will be placed on all cleaning agents and stored indicating the product name, dilution ratio, and the appropriate caution sign.

Review of the hospital's policy titled, "Housekeeping Supplies," dated 03/06/24, showed spray bottles should be stored on the utility cart used to clean each assigned area. Spray bottles should be labeled before use.

Observation on 05/21/24 at 10:20 AM, in the front service area of the kitchen, showed one bleach spray bottle, one sticky container of stainless-steel wipes covered in grime, two odor counteractant spray bottles, one multi-purpose floor cleaner spray bottle, one de-lime spray bottle, and one container of disinfectant wipes were stored under the sink.

Observation on 05/21/24 at 10:20 AM, in the front food service area of the kitchen, showed two spray bottles with a blue substance located under the sink that were unlabeled and undated.

During an interview on 05/21/24 at 12:40 PM, Staff S, Support Services Manager, stated that housekeeping mixed cleaning solutions and he was unsure why it was not labeled or dated.

During an interview on 05/21/24 at 12:40 PM, Staff W, Support Services Supervisor, stated that the mixed cleaning solutions used the date of the solution they were mixed from and were not dated on the individual bottle.

Although requested no policy related to personal belonging storage in the kitchen area was provided.

Observation on 05/21/24 at 10:20 AM, in the front service area of the kitchen, showed a personal bag in a cabinet next to four boxes of coffee. A container with a pair of glasses were left on the counter near the serving coolers.

During an interview on 05/21/24 at 12:40 PM and 1:48 PM, Staff S, Support Services Manager, stated that no personal belongings should be in food service areas.

Review of the hospital's policy titled, "Storage Areas and Equipment Closets," dated 03/06/24, showed all storage areas and equipment closets will be cleaned at least weekly, or as needed.

Review of the hospital's document titled, "EOC Rounds," dated 09/08/23, showed an inspection of the second floor Physical Therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) gymnasium was completed. The section for cleanliness of PT gymnasium areas, dust collecting behind doors and around equipment was marked for failed inspection. A note was added at the bottom of the report and stated dust bunnies with hair were found behind doors.

Review of the hospital's policy titled, "EOC Rounds," dated 09/08/23, showed an inspection of the ground level PT gymnasium was completed. The section for cleanliness of PT gymnasium areas, dust collecting behind doors and around equipment was not evaluated with either a pass or fail.

Observations on 05/22/24 from 11:05 AM to 11:30 AM of four gymnasium storage areas showed visible dust, dirt and dust balls on and under the stored patient equipment marked as clean in all four storage rooms.

During an interview on 05/22/24 at 11:35 AM, Staff L, PT Director, stated that rooms should be clean and concurred that the rooms were not clean and that dust was present.

Although requested, no policy related to exposed particle board was provided.

Observation on 05/20/24 at 1:55 PM, in the Nourishment Room on the first floor, showed exposed particle board in the cabinet under the ice machine.

During an interview on 05/20/24 at 1:58 PM, Staff G, Plant Coordinator, stated that the leak under the ice machine had been repaired.

During an interview on 05/20/24 at 2:05 PM, Staff H, Plant Operations Director, stated that the leak in the drain line under the ice machine had been repaired more than 30 days prior. He stated that he would not expect to see exposed particle board and it should have been replaced.

Review of the hospital's document titled, "Infection Prevention Plan 2024," dated 03/06/24, showed:
- The purpose of the plan was to maintain a sanitary environment to avoid sources of, and transmission of, infections and communicable diseases; and to minimize the risk of transmitting infections with the use of procedures during the use of medical equipment and devices.
- The risk assessment was to address the transmission of infection related to medical equipment and medical devices related to appropriate storage, cleaning, and disinfection.
- The maintenance of a sanitary physical environment had specific policies, procedures, and other systematic work processes that addressed ventilation; techniques for safe food storage, preparation, and handling; and techniques for safe cleaning and disinfection of environmental surfaces.
- The Infection Prevention and Control Committee was a multi-disciplinary body composed of representatives from the Infection Control Program, medical staff, nursing, and other direct and indirect care staff. The committee meets on a quarterly basis. Composition of the committee assures, through either membership or invitee, that administration, building maintenance, food service, housekeeping, laboratory, pharmacy, and others are represented as applicable and necessary.
- The functions of the Infection Prevention and Control Committee included monitoring compliance with all policies, procedures, protocols and other infection control program requirements.
- The organization had developed specific policies, procedures, or other systematic work processes that addressed methods for monitoring and evaluating practices of asepsis (process that is intended to minimize contamination from pathogens).

Review of the hospital's undated document titled, "EOC Rounds, 2024 Schedule," showed the following:
- The rounding team was documented as Staff Y, Purchasing Material Manager; Staff T, Quality Management Director; Staff S, Support Services Manager; Staff W, Support Services Supervisor; Staff F, Infection Preventionist; and Staff H, Plant Operations Director.
- On 01/17/24, the Traumatic Brain Injury (TBI, an injury in how the brain works) Unit and Ground Level rounding had been completed by Staff H and Staff Y.
- On 02/13/24, the second-floor nursing area rounding had been completed by Staff H, Staff Y, and Staff S.
- On 03/20/24, the Annex and Spinal Nursing floors rounding had been completed by Staff H and Staff S .
- On 04/14.24, the first-floor exterior rounding had been completed by Staff H and Staff Y.
- On 05/16/24, the receiving area rounding had been completed by Staff H and Staff Y.
- The following areas were scheduled to be completed on a monthly basis for the remainder of the year and included first-floor Comprehensive Unit, first and second floor PT gyms, the kitchen, the cafe, the dock, second-floor exterior safety rounds, administration, physician offices, business offices, and the second-floor patient care unit.

During an interview on 05/21/24, Staff F, Infection Preventionist, stated that:
- Maintenance, environmental services, and the quality department held their own monthly meetings;
- The infection control committee met monthly, and she only presented data related to patient care concerns;
- She was not responsible for touring the kitchen or monitoring that area; and
- She reported off monthly to Staff A, CNO.

During an interview on 05/22/24 at 1:04 PM, Staff H, Plant Operation Director, stated that:
- He participated in monthly EOC rounding along with Staff S, Support Services Manager; Staff Y, Purchasing Materials Manager; and Staff F, Infection Preventionist.
- There was a schedule made at the beginning of the year for rounding and the team consisted of Staff S, Staff Y, and Staff F.
- He had not been to the kitchen since last year.
- Staff S and Staff F were responsible for infection prevention.
- The EOC rounding addressed overall patient safety and there had been a gap when there was not a dedicated infection prevention person.

During an interview on 05/21/24 at 1:50 PM, Staff S, Support Services Manager, stated that he participated in EOC rounding on a monthly basis along with other staff, depending on who was available. He also stated that he was responsible for both environmental staff employees and kitchen employees.

During an interview on 05/22/24 at 1:48 PM, Staff Y, Purchasing Material Manager, stated that she was a member of the EOC rounding team and it had been several months since she had been to the kitchen.

During an interview on 05/22/24 at 2:31 PM, Staff A, CNO, stated that Staff S, Support Services Manager, was responsible for the nutrition and environmental care in all areas of the hospital. Staff S did not participate in the infection prevention committee meetings, but she did consider his role to be a part of the infection prevention plan.



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