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Based on observation, interview, and document review the hospital failed to maintain an environment where the safety and well-being of patients are assured by having conditions conducive to the potential attraction, access, and harborage of pests, and the adulteration of food.

The condition of the hospital had the potential for the attraction, access, and harborage of pests that can spread communicable diseases (as infectious diseases, illnesses that result from the infection, presence and growth of pathogenic biologic agents [a microorganism that causes or can cause diseases] from an individual human or other animal host) carried and or transmitted by waste products and contaminated surfaces.

Findings:

1. Facility A

During a concurrent observation and interview on 02/06/23, at 11:00 a.m. with Facility Manager A of Facility A, it was observed that there was a water- stained carpet and a 3-inch (a unit of measurement) by 10-inch penetration at a wall in the Clinical Analysis office. Facility Manager A stated the water stain was from water intrusion from a boiler room adjacent to the Clinical Analysis office.

During a concurrent observation and interview on 2/6/23, at 11:03 a.m., in the boiler room, there was an open-ended vertical pipe leaking water into a bucket. Facility Manager A stated that the vertical pipe was detached from one of two water heaters that serve the HVAC system (Heating Ventilation and Air Conditioning system-system used for moving air between indoor and outdoor areas) because the water heater's heater exchange was under repair. It was also observed that there was a continuous water leak from an overhead water copper pipe. Facility Manager A stated the pipe was the water feed to the boiler room that was discovered that morning to have a pinhole leak and that the plumber had been called to repair the leak.

During a concurrent observation and interview on 2/6/23, at 11:03 a.m., with Facility manager A, there was a 4-foot by 4-foot section of wall missing, exposing wood framing and insulation in the wall cavity of the wall that separates the boiler room from the Clinical Analysis Office. Facility Manager A stated they were waiting for the insulation to dry in order to repair the wall.

In addition, there was a 2-foot by 4-foot and a 2-foot by 1-foot penetration at the ceiling of boiler room exposing the wood framing and cavity in the ceiling. Facility Manager A stated the penetrations in the ceiling were caused by the last rain about a week ago. There was also an accumulation of stagnant water on the ground of boiler room. The stagnant water was a potential source of water for pests and mosquito breeding.

During a concurrent observation and interview on 2/6/23, At 11:34 a.m., with Facility A cook, in the kitchen, there was an accumulation of a dark gray substance in the floor sink next to the ice machine and at the open end of a copper drainpipe above the floor sink. Facility A Cook stated he (Facility A cook) usually cleans the floor sink once a week but had not done it today (02/06/2023-date of observation and interview).

During an interview on 2/6/23, at 11:58 a.m., with the Engineering Staff, Engineering Staff stated the accumulation of a dark gray substance in the kitchen floor sink is from staff pouring coffee in the cafeteria ice machine's drain tray that drains to the kitchen's floor sink, and that the drain pipes' run is too long so that when water is poured down the drain tray, the water is unable to flush the accumulation of the dark gray substance out and away from the drain pipe.

A review of the hospital's Nutrition Services Daily Responsibilities indicated the Cook was the person responsible to clear drains of food particles, and to initial the log when completed. The document was dated from Wednesday 02/01/2023 to Sunday 02/12/2023. There were no initials on the document for completion of clearing drains of food particles.

During a concurrent observation and interview on 2/6/23, at 11:58 a.m.,in the Cafeteria, with the Engineering staff, there was an accumulation of gray slime matter in the secondary overflow drain within the cafeteria ice machine. The Engineering Staff stated the secondary overflow drain is cleaned every quarter and that it was last cleaned in December of 2022.

A review of a work order dated 12/13/2022, indicated preventive maintenance was performed on the cafeteria ice machine.

During a concurrent observation and interview on 2/6/23, at 12:48 p.m., at Nurses Station One, water was continuously running from the hand wash sink faucet. Facility Manager A stated that they tried to fix the faucet by adjusting the pedals, but it did not work and is leaking again, and that the faucet is going to be replaced with an automatic faucet.

A review of a work order dated 12/21/2022, indicated "Disassembled, removed debris and lubricated. Sink is operating normally."

During a concurrent observation and interview on 2/6/23, at 12:55 p.m., with Facility Manager A, Patient Room 606's bathroom door was jammed against the door frame and would not fully close. Facility Manager A stated the door would have to be shaved so it closes in its door frame.


During a concurrent observation and interview on 2/7/23, at 11:49 a.m., with Facility Manager A, in Room 212, there was a 3-inch tear at upper left side of window screen at the openable window.The combination of the torn screen and openable window created a condition conducive to the potential access of flying and climbing insects. Facility Manager A acknowledged the torn screen and openable window. Earlier at 11:35 a.m., the Facility Manager had stated that the last time a portion of the hospital's window screens were replaced was two to three years ago.

During a concurrent observation and interview on 2/7/23, at 11:55 a.m., with Facility Manager A, in the Employee Lounge, there was a one-inch gap between the window screen frame and a window frame that was accessible from two openable windows. The combination of a window screen that was not tight fitting in the window frame and an openable window created a condition conducive to the potential access of flying and climbing insects.
Facility Manager A acknowledged the gap between the screen and openable window.

In addition, there was an uncovered slice of cake sitting on the Employee Lounge table. Uncovered food sitting out potentially attracts pests. Also, there was an accumulation of debris where the floor meets the corner wall behind a refrigerator in the Employee Lounge. Facility Manager A acknowledged the debris behind the refrigerator.

During a concurrent observation and interview on 2/7/23, at 12:05 p.m., with Facility Manager A, in the Occupational Therapy Room, there was a one-quarter-inch hole in the window screen of an openable window, and the window screen was missing at the second openable window. The combination of a missing window screen and an openable window created a condition conducive to the potential access of flying and climbing insects.
Facility Manager A acknowledged the hole in the screen, missing screen, and openable windows.

During an interview on 2/7/23, at 2:10 p.m., the Facility Manager stated that there are no routine inspection rounds on the placement and condition of window screens at the hospital. Facility Manager A said that there ae inspection rounds to ensure windows are not openable and that the last inspection rounds were done in December of 2022, but that he has no documented evidence of the inspection rounds.

Facility Manager A also stated environmental assessment of the hospital was done by the hospital because of an incident of maggots in August of 2022. Facility manager A said openable windows and the condition of screens was included in the assessment but does not recall. Furthermore, the reason the windows in the employee lounge and the occupational therapy room were openable was because there was a communication problem because the maintenance department was told to ensure the windows in all patient rooms and offices were not openable, and that the windows in the employee lounge and the occupational therapy room were not included in the e-mail.

At 2:20 p.m., the evaluator requested the hospital's Pest Control Policy and Procedure from Facility Manager A. The Pest Control Policy and Procedure was not provided.

A review of a document titled Huddle Topic dated 08/09/2022 - 08/19/2022 the document indicated under infection control to not open patients room windows, that some window screens were broken. The document did not indicate to not open any other windows in the hospital.

A review of the hospital's Environment of Care Safety Survey/Compliance log dated 02/08/2023 does not indicate that inspection rounds were done for windows and window screens.


2. Facility B and Facility C

During a concurrent observation and record review on 2/8/23, at 10:45 a.m., with facility Manager B, there was a three- foot by 2- foot pool of stagnant gray water on the ground soil next to kitchen exterior door. The stagnant water was a potential source of water for pests and mosquito breeding. Facility Manager B acknowledged the stagnant water and stated that he did not know the source of the water.

During a concurrent observation and interview on 2/8/23, between 10:48 a.m. and 11:30 a.m., with faacility manager B, at the center patio, there were overgrown weeds, accumulation of dry vegetation near a patient room window and on the ground below a tree. The branches of a tree were touching the roof edge and growing over the roof. The overgrown weeds and accumulation of dry vegetation is conducive to the hiding/harborage of pests. The tree touching and growing over the roof is conducive to creating an access point on to the roof for pests. Facility Manager B acknowledged the overgrown weeds, accumulation of dry vegetation, and the tree touching and growing over the roof, and stated that the gardener was hit and miss with removing the overgrown weeds.

A review of pest control records dated 06/21/2022, 07/28/2022, 08/25/2022, 09/29/2022, 10/26/2022, 11/23/2022, 12/21/2022, and 01/26/2023 continuously indicated conditions observed of accumulated debris around building - too much accumulated debris all around the exterior of building that could provide harborage to pest. Trees and landscaping overgrown next to structure.

The pest control record had continuous action recommendations to clear accumulated debris (dead leaves) all around the building, and to cut back trees/landscape close to building.

During a concurrent observation and interview on 2/8/23, at 11:10 a.m., with Facility Manager B, in the Kitchen, there was peeling paint at ceiling above steam table/tray line and above a food preparation sink/counter.
The peeling paint over the steam table/tray line and food preparation sink/counter had the potential for patient food adulteration. Facility Manager B stated the peeling paint was caused by the last rain.

On 2/8/23, between 11:30 a.m., and 12:00 p.m., the evaluator requested the hospital's Pest Control Policy and Procedure from Facility Manager B and the Senior Facility Manager. During a concurrent interview, the Senior Facility Manager stated that the hospital's pest control contract was the hospital's Pest Control Policy and Procedure. The Policy and Procedure was not provided.

A review of the hospital's Administrative Environment of Care Rounding Tool did not indicate that inspection rounds were done for exterior areas.

On 02/09/2023, during a continued complaint validation survey of Facility C, at 11:30 a.m. the evaluator requested the hospital's Pest Control Policy and Procedure from Facility Manager A and the Senior Facility Manager. Facility Manager A and the Senior Facility Manager stated that the hospital did not have a Pest Control Policy and Procedure.

Based on observation, interview, and record review, Facility A failed to ensure their cleaning and disinfecting supplies, and personal protective equipment (PPE) gowns (used to protect the wearer from the spread of disease-causing microbials if the wearer comes in contact with potentially infectious liquid or solid material) were stored properly according to the facility's policy and procedure (P&P) in the patient care areas for 30 of 30 sampled patients.

This deficient practice had the potential to result in the spread of infection from microorganisms (bacteria or viruses that cause illness) on or within corrugated boxes and other patient care supplies, which are not properly stored.

Findings:

1. During an observation and concurrent interview, on 2/6/2023, at 11:05 a.m., in the Station 1 nursing unit's cleaning closet with Housekeeper (EVS) 1, twelve (12) disinfectant wipes containers were observed on the floor under the sink. EVS 1 stated the disinfectant wipes containers are placed inside the patient rooms to disinfect the surfaces.

During an interview on 2/9/2023, at 10:35a.m., with Housekeeper (EVS) 1, EVS 1 stated they (EVS staff) did not know why supplies cannot be stored on the floor.

During an observation on 2/6/2023, at 11:15 a.m., in the Station 3 nursing unit's cleaning closet with Chief Clinical Officer (CCO) 1, one box of personal protective equipment (PPE) gowns (used to protect the wearer from the spread of disease-causing microbials if the wearer comes in contact with potentially infectious liquid or solid material) was found on the floor under the sink.

During an observation on 2/6/2023, at 11:20 a.m., in the Station 3 nursing unit's bathtub room with CCO 1, twelve corrugated boxes of cleaning supplies were found inside the bathtub room.

During an observation on 2/9/2023, at 12:32 p.m., in the facility's main hallway, EVS 1 was observed moving two corrugated boxes on a cart into the patient care area (Station 1).

During an interview on 2/7/2023, at 2:56 p.m., with Infection Preventionist (IP), IP stated corrugated boxes (cardboard material with ridges and grooves) cannot be in the patient areas because these corrugated boxes are susceptible to pathogens (organism that can produce disease) and cross contaminate with patients. IP also stated supplies shoud not be stored directly on the floor due to possible pathogens on the floor that could cross contaminate with patients.

A review of the facility's policy and procedure (P&P) titled, "CORE: Maintaining Utility Storage Areas," dated 6/2022, indicated items should not be stored on the floor and in cardboard boxes which are not allowed in the patient care areas or storage rooms.

A review of the facility's orientation manual titled, "Safety Orientation," dated 6/2022, did not indicate supplies cannot be stored on the floor to prevent cross contamination.