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Based on observation, interview and policy review, the hospital failed to ensure that staff:
- Performed hand hygiene during the care of 10 patients (#1, #2, #3, #7, #8, #9, #10, #14, #15 and #29) of 15 patients observed;
- Identified and removed expired food in the kitchen;
- Identified and removed outdated supplies;
- Labeled Intravenous (IV, in the vein) tubing with an expiration date for two patients (#2 and #9) of six patients observed;
- Labeled respiratory equipment with an expiration date for two patients (#1 and #7) of three patients observed; and
- Identify that patient nourishment room was dirty, which included the ice machine, cabinet doors and countertops.
These failures increased the risk of cross-contamination and infection for all patients admitted to the hospital.

The hospital census was 17. These failures increased the risk of cross-contamination and infection for all patients admitted to the hospital.

The cumulative effects of these systemic failures resulted in the facility's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Control, and resulted in the facility's failure to ensure safe infection control practices to prevent infections and communicable diseases.

Please refer to A-0749.

Based on observation, interview and policy review, the hospital failed to ensure that staff:
- Performed hand hygiene during the care of 10 patients (#1, #2, #3, #7, #8, #9, #10, #14, #15 and #29) of 15 patients observed;
- Identified and removed expired food in the kitchen;
- Identified and removed outdated supplies;
- Labeled Intravenous (IV, in the vein) tubing with an expiration date for two patients (#2 and #9) of six patients observed;
- Labeled respiratory equipment with an expiration date for two patients (#1 and #7) of three patients observed; and
- Identify that patient nourishment room was dirty, which included the ice machine, cabinet doors and countertops.
These failures increased the risk of cross-contamination and infection for all patients admitted to the hospital. The hospital census was 17.

Findings included:

1. Review of the hospital policy titled, "Hand Hygiene," dated 06/2018, directed staff to perform hand hygiene:
- Before and after contact with all patients;
- After contact with body fluids, mucous membranes, non-intact skin, and inanimate objects (not alive, for example computer keyboard, medical equipment, medical bed, etc.) that were likely to be contaminated;
- After removing gloves; and
- Before performing invasive procedures.

Observation on 01/27/20 at 3:30 PM, showed Staff F, Registered Nurse (RN) failed to perform hand hygiene before she put on her gloves during medication administration for Patient #1.

Observation on 01/29/20 at 10:00 AM, showed Staff CC, Patient Care Technician (PCT), performed a fingerstick for a blood glucose test (a test that shows the amount of sugar that circulates in the blood) for Patient #1, which showed Staff CC:
- Failed to perform hand hygiene before she put on her gloves.
- Touched the patient, then exited the room, and then touched a computer keyboard.
- Returned to the room, did not change her gloves, and performed the fingerstick on the patient.

Observation on 01/27/20 at 3:52 PM, showed Staff F, RN. failed to perform hand hygiene after she removed her gloves during blood administration for Patient #2.

During an interview on 01/29/20 at 2:47 PM, Staff F stated that hand hygiene should be performed before you put on gloves, and after you remove gloves, and between glove changes.

Observation on 01/27/20 at 4:20 PM, showed Staff G, RN, failed to perform hand hygiene after she removed her gloves during blood administration for Patient #2.

Observation on 01/28/20 at 8:50 AM, showed Staff G, RN, failed to perform hand hygiene before she put on her gloves during medication administration for Patient #8.

Observation on 01/28/20 at 9:35 AM, showed Staff E, Licensed Practical Nurse (LPN), failed to perform hand hygiene before she put on gloves during medication administration for Patient #9.

Observation on 01/28/20 at 10:00 AM, showed Staff N, Respiratory Therapist (RT), touched Patient #3's tracheostomy (an opening in the neck to place a tube in a person's windpipe that allows air to enter into the lungs) and removed the tracheostomy dressing with gloved hands, then touched cabinet drawers, the patient's hospital bed, ventilator (a machine that helps someone breathe), nebulizer (a device that turns liquid medication into a mist for inhalation into the lungs), and oxygen machine, then cleaned the tracheostomy wound. Staff N then removed her gloves, failed to perform hand hygiene before she put on new gloves, then suctioned the patient, cleaned the patient's mouth and washed his face.

During an interview on 01/28/20 at 10:30 AM, Staff N, RT stated that she was not aware that she should perform hand hygiene in between procedures.

Observation on 01/28/20 at 12:02 PM, showed Staff Q, Nursing Manager; Staff AA, RT; and Staff Z, Nurse Practitioner (NP), failed to perform hand hygiene upon entrance and exit of Patient #14's room.

During an interview on 01/29/20 at 2:52 PM, Staff Z, NP, stated that hand hygiene should be performed before you enter a patient's room, when you exit a patient's room, and in between "doing stuff" in the patient's room.

Observation on 01/28/20 at 4:50 PM, showed Staff L, PCT, failed to perform hand hygiene before he put on his gloves while he cared for Patient #15.

During an interview on 01/28/20 at 4:50 PM, Staff L stated that he should perform hand hygiene before he put on his gloves.

Observation on 01/30/20 at 9:45 AM, showed Staff LL, LPN, removed Patient #15's soiled wound dressing, failed to remove her gloves and perform hand hygiene, then proceeded to open new dressing supplies and redress the wound.

During an interview on 01/30/20 at 10:00 AM. Staff LL stated that if there was an infection she would have removed gloves and performed hand hygiene during the procedure.

Observation on 01/29/20 at 9:15 AM, showed Staff GG, RN, failed to perform hand hygiene after she removed a medication patch from Patient #10.

Observation on 01/29/20 at 10:10 AM, showed Staff GG, RN, failed to perform hand hygiene after she removed her gloves during medication administration for Patient #10.

During an interview on 01/29/20 at 3:04 PM, Staff GG stated that hand hygiene should be performed before contact with a patient, when you move from dirty duties to clean, and in between glove changes.

Observation on 01/30/20 at 9:00 AM, showed Staff LL, LPN, failed to perform hand hygiene before she put on her gloves while she cared for Patient #29.

During an interview on 01/30/20 at 9:33 AM, Staff LL stated that she should have performed hand hygiene before putting on her gloves.

Observation on 01/30/20 at 9:00 AM, showed Staff P, PCT, failed to perform hand hygiene before he put on his gloves while he cared for Patient #29.

Observation on 01/30/20 at 9:00 AM, showed Staff MM, NP, failed to perform hand hygiene before she put on her gloves while she cared for Patient #29.

During an interview on 01/30/20 at 10:13 AM, Staff PP, Medical Director stated that hand hygiene should be performed before entering a patient's room, before putting on gloves, after removing gloves, and when leaving a patient's room.

During an interview on 01/30/20 at 10:48 AM, Staff B, Chief Clinical Officer (CCO) stated that hand hygiene should be performed before putting on gloves, after removing gloves, and between glove changes.

2. Review of the hospital policy titled, "Code Dating of Food", effective 06/15/18 directed staff to rotate stock following the first in, first out method, to ensure there were no outdated products.

Observation on 01/28/20 at 9:48 AM, in the kitchen showed:
- Three single serve salad dressings with an expiration date of 12/16/19;
- 13 single serve salad dressings with an expiration date of 01/20/20;
- One bag of frozen blueberries with a use by date of 01/10/20;
- One bag of frozen french fries with a use by date of 01/19/20;
- One carton of liquid eggs with a use by date of 01/21/20; and
- One carton of heavy cream with a use by date of 01/21/20.

During an interview on 01/28/20 at 9:48 AM, Staff T, Kitchen Manager, stated that all food items should be rotated and no food items should be expired.

During an interview on 01/30/20 at 10:13 AM, Staff PP, Medical Director stated that expired food should not be available for use in the kitchen.

3. Although requested, the hospital failed to provide a policy that addressed outdated supplies.

Observation on 01/27/20 at 3:00 PM, showed one box of safety needles in the medication room with an expiration date of 12/2018.

Observation on 01/27/20 at 3:00 PM, in the medication room showed:
- One bacteria swab kit with an expiration date of 12/21/19;
- Two lesion swab kits with an expiration date of 12/31/19;
- One Nasopharyngeal (upper part of the throat behind the nose) swab kit, with an expiration date of 12/31/19.

Observation on 01/27/20 at 3:20 PM, of the Medical Surgical Unit crash cart, showed one primary IV tubing with an expiration date of 10/01/19, and one defibrillator (a device that activates a shock to the heart when indicated) pad with an expiration date of 07/28/19.

During an interview on 01/30/20 at 10:48 AM, Staff B, Chief Clinical Officer (CCO) stated that expired supplies should not be in the medication room.

During an interview on 01/30/20 at 10:13 AM, Staff PP, Medical Director stated that expired supplies should not be in the medication room.

During an interview on 01/30/20 at 10:34 AM, Staff A, Chief Executive Officer, (CEO), stated that expired supplies should not be in the medication room.

4. Review of the hospital policy titled, "IV Therapy, Basic Principles," dated 11/2018 directed staff to change IV tubing every 72 hours.

Observation on 01/27/20 at 3:48 PM, showed a sticker on the IV tubing that read change Wednesday with no date or time for Patient #2.

Observation on 01/28/20 at 9:35 AM, showed a sticker on the IV tubing that read change Wednesday with no date or time for Patient #9.

During an interview on 01/29/20 at 2:47 PM, Staff F, RN stated that IV tubings were changed on Wednesday and Sunday and the sticker should have a date and time.

During an interview on 01/29/20 at 3:04 PM, Staff GG, RN stated that IV tubings were changed on Sunday and Wednesday and the sticker should have a date and time.

During an interview on 01/30/20 at 10:13 AM, Staff PP, Medical Director stated that IV tubing should have a date and time on the sticker.

During an interview on 01/30/20 at 10:48 AM, Staff B, CCO stated that IV tubing should have a date and time on the sticker.

5. Review of the hospital policy titled, "Respiratory Therapy, Changing Equipment," dated 06/2018 directed staff to label the equipment with the date and person's initials.

Observation on 01/27/20 at 3:48 PM, showed a bottle of sterile (without bacteria) water connected to an oxygen flowmeter (regulates the flow of oxygen delivery) labeled 01/19 with no initials, and one bag of saline labeled 01/23 with no initials for Patient #1.

Observation on 01/28/20 at 4:20 PM, showed a bottle of sterile saline (salt water solution) connected to the oxygen flowmeter, with no date or initials for Patient #1.

Observation on 01/29/20 at 3:10 PM, showed a bottle of sterile water connected to the oxygen flowmeter, with no date or initials for Patient #7.

During an interview on 01/28/20 at 4:20 PM, Staff U, Respiratory Therapy Manager, stated that all tubings and solutions were changed out on Sunday or whenever they were empty, and that there should be a date and initials on all of the solutions.

During an interview on 01/30/20 at 10:13 AM, Staff PP, Medical Director stated that respiratory equipment should have a date and initials present.

During an interview on 01/30/20 at 10:48 AM, Staff B, CCO stated that respiratory equipment should have a date and initials present.

6. Review of the facility's policy titled, "Infection Prevention and Control Committee," dated 09/2015, showed direction for infection prevention was to facilitate services and equipment that allowed staff to maintain efficacy in infection prevention and control.

Review of the facility's policy titled, "Ice Machines, Ice and Infection Control," dated 07/15/17, showed direction for staff to prevent the growth of microorganisms during the handling and storage of ice on the unit, used for patient consumption.

Observation on 01/27/20 at 3:45 PM, in the patient nourishment room, showed the following:
- The ice machine was dirty with hard-water deposits.
- The cabinet doors were dirty, with unknown liquid drip marks down the front.
- The countertops were visibly dirty.

During an interview on 01/29/20 at 10:30 AM, Staff FF, Plant Operations Director, stated that:
- The housekeeping staff had cleaned the counters and cabinet doors but found the drips were not food or liquid that could be cleaned.
- The counters and cabinets were scheduled to be replaced since they were in such poor condition.
- The staff had been unable to clean the hard-water deposits from the ice machine.

During an interview on 01/29/20 at 10:30 AM, Staff EE, Environment of Care Corporate Director, stated that he did not know when the countertops and cabinets would be replaced, but knew of a hospital approved chemical that would take the hard-water deposits off of the ice machine.







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