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Based on observation, interview and record review the Governing Body failed to ensure contracted services (Dietary and Housekeeping) were provided in a safe manner. 1) The Dietary department was not maintained in a sanitary condition. 2) The Housekeeping department failed to ensure hospital equipment was clean. This practice placed patients at risk for developing and/or acquiring infections while residing in the hospital.

Findings included:

1) On 01/03/12 from 11:15 AM to 12:00 PM a tour of the dietary department was conducted with Personnel #1. The following observations were made:

The walk-in refrigerator shelves and floor was soiled with debris and grime.

The flour, corn meal and sugar bins on wheels were soiled and dirty on the exterior surface. The flour bin had red stains on top of the clear plastic cover. The floor behind the bins was dirty with dust and debris collected on the floor.

The butcher block counter was soiled/stained with debris and food residue. The stand mixer sitting next to the butcher block counter had white food debris dried on the connector which attached the mixing paddle. Personnel #13 informed the surveyor he made a cake earlier in the morning. Personnel #13 said he must of forgotten to clean the connector.

Nine plastic bins labeled for various condiments had a collection of grime and debris buildup on the interior and exterior surface.

Clean metal pans were stacked on a shelf ready for food preparation. Four of eight holding pans for the steam table were stacked on top of each other wet.

The top and bottom of the metal counters in the kitchen were dirty and dusty with grime buildup.

The refrigerator in the cafe area of the kitchen had an empty bowl of food with a label which indicated the food item expired 12/20/11.

The holding oven had a collection of food/debris buildup.

Personnel #1 verified the above findings during the tour.

On 01/03/12 at 3:15 PM Personnel #29 was interviewed. Personnel #29 stated she was the interim director. Personnel #29 stated the kitchen staff know their responsibilities in the kitchen. Personnel #29 verified the kitchen had not been cleaned appropriately.

The policy and procedure entitled, "Required Cleaning and Sanitization" with a revised date of 11/09 reflected, "To prevent cross-contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of operations during which time contamination may have occurred...the food surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil...nonfood contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris.

The daily task list provided on 01/04/12 by Personnel # 29 reflected, "Daily Task List...label/date all opened product...daily cleaning...clean all shelving in chef area, wipe down tops/bottoms of all counter spaces...sweep mop/floors.."

2) On 01/03/12 at approximately 9:45 AM a tour of the clean linen room located on the first floor was conducted with Personnel #6. The clean utility room had a dust pan and a vacuum cleaner attachment sitting next to the door. A black winter jacket was lying on the counter. Personnel #6 identified the jacket as belonging to one of the facility housekeepers and verified the dust pan and vacuum cleaner attachment were not to be stored in the clean linen room.

On 01/05/12 at 10:08 AM observation rounds of the second floor patient care area was conducted with Personnel #1. A patient room was designated by Personnel #1 as a storage area for clean equipment to be used for patient care. The following patient equipment was inspected:

One machine covered with plastic available for use. The bottom of the unit was dusty and the top of the unit soiled with debris.

Two wheelchairs were covered with plastic bags available for use. The base and wheels of the chairs were soiled. The metal frame where the foot rest locked into place was soiled and debris had collected on the metal frame.

The blood pressure machine was soiled and the top of the equipment was dusty and had pieces of left over tape.

On 01/05/12 at 10:12 AM Personnel #6 was interviewed. Personnel #6 stated housekeeping personnel were supposed to be thoroughly cleaning all the equipment.

Based on observation, interview and record review, the hospital failed to ensure the RN's (Registered Nurses) assigned to provide care for 1 of 1 patient (Patient #2) evaluated and/or obtained physician orders for wound treatment for Patient #2's right elbow. Patient #2 was admitted the evening of 12/29/11 and wound treatment orders were not written until the morning of 01/03/12.

Findings Included:

Patient #2's (current) hospital face sheet reflected, Patient #2 was admitted 12/29/11 at 19:00 PM.

Patient #2's History and Physical dated 12/30/11 reflected, "The patient...suffered a fall back in November 2011...sustained a right humerus as well as olecranon fracture...underwent open reduction internal fixation of the fracture and elbow...was placed in a long posterior splint and placed on nonweightbearing to her right upper extremity...patient was admitted to ...Rehabilitation Hospital to address functional impairments related to fracture and nonweightbearing status...the patient was there for about two weeks or so...was discharged to assisted living on 12/10/11...since that time she still has difficulty with performing self care needs and with her mobility...being admitted to...Rehabilitation Hospital...remarkable for a dressing to the right elbow..."

The Interdisciplinary Admission Assessment dated 12/29/11 timed at 22:00 PM reflected under the section entitled, "Skin Risk" the nurse "checked no problems noted...indicate any abrasions, wounds, skin tears, scars or pressure areas on the diagram..." No documentation was found which indicated Patient #2 had a right elbow wound.

The blank, non-dated treatment record found in Patient #2's medical record reflected no documentation which indicated wound treatment and/or orders were initiated upon admission.

The 12/31/11 timed at 19:06 PM physician progress note reflected, "Right arm clean and dry..."

The 01/03/12 physician progress note timed at 08:25 AM reflected, "Right elbow dressing not changed yesterday...wound care to right upper extremity...at 09:30 AM...right elbow non-healing surgical wound...right elbow with edema positive open wound with good granulation..."

The admission physician orders dated 12/29/11 timed at 22:00 PM reflected no orders for wound care.

The physician orders dated 01/03/12 reflected, "Please make sure wound care nurse checks right elbow today (patient states dressing not changed yesterday)...at 09:30 AM the physician ordered Bactroban ointment, Silver foam R (right) elbow daily..."

The 12/30/11 nursing note timed at 19:15 PM reflected, "Reinforced dressing to R (right) elbow..."

The 01/01/12 Rehab (Rehabilitation) 24 hr (hour) Flow Sheet reflected, "Skin within normal limits..." The wound assessment section reflected, no documentation which indicated Patient #2 had a wound to the right elbow.

On 01/03/12 at 10:15 AM, Personnel #11 was observed changing Patient #2's right elbow dressing. Personnel #11 removed the soiled dressing and discarded the dressing in the trash. Personnel #11 cut a piece of polymen silver and applied to Patient #2's right elbow and then covered with gauze. No measurements were completed by Personnel #11. Personnel #11 stated he did not have the Bactroban yet from the pharmacy and would return later to apply to the wound. Personnel #11 stated today was the first day he saw Patient #2's wound and/or was even aware of it. He stated the physician informed him this morning he needed to look at it. Personnel #11 verified no treatment orders were obtained for wound care when Patient #2 was admitted and none of the nursing staff notified him regarding Patient #2's wound.

The policy entitled, "Wound/Skin Photography" with an effective date of 09/09/11 reflected, "The documentation and maintenance of patient skin integrity is of high importance in the care of hospitalized patients...wound pictures shall be taken by an RN (Registered Nurse) or designated clinician within 24 hours of admission or at which time a wound of any kind is identified during the patient's stay. Wounds are considered any areas of altered skin, including, but not limited to incisions, skin tears, pressure ulcers..."

The policy entitled, "Wound Care Dressing Change" with a revision date of 09/09/11 reflected, "Place personal protective equipment on as required...remove old dressing and note any drainage on dressing (type, amount, odor if any)...remove and discard gloves, rewash hands and place on new gloves...cleanse the area with normal saline, wound cleaner, or other physician ordered cleaner. Clean in one direction using one 4 x 4 or item at a time and drop. Use a clean 4 x 4 or item with each swipe until area is cleansed...remove and replace gloves, apply new dressing as ordered, and date/time dressing...document dressing change, along with assessment of the wound on the treatment sheet..."

Based on interview and record review, the hospital failed to enforce its policy and procedure for hospital contract staff orientation and skills competency assessments for 2 of 6 non-employee licensed nurses [contract/agency shared employees] (Personnel #19 and #28) who provided direct patient care on 10/20/11, 11/03/11, 11/04/11, 11/10/11, 11/23/11, 11/28/11, 11/29/11, 12/02/11, 12/03/11, and/or 01/03/12.

Findings included:

1) Record review of Personnel #19's file reflected a hospital orientation not signed or witnessed by hospital staff.

During an interview on 01/03/12 at approximately 11:30 AM Personnel #3 stated "four to six shifts per week" were filled with temporary staff. Personnel #3 stated Personnel #19, a contract agency nurse, was assigned to work the day of survey, 01/03/12.

During an interview on 01/03/12 at 3:10 PM Personnel #3 agreed that "the house supervisor should have signed it [Personnel #19's orientation]."

2) Record review of Personnel #28's file reflected no hospital orientation or agency competency assessment. Review of a list of agency nursing hours provided by Personnel #3 on 01/03/12 at or around 3 PM reflected Personnel #28 worked three day shift assignments on 10/20/11, 11/03/11, 11/04/11, and six night shift assignments on 11/10/11, 11/ 23/11, 11/28/11, 11/29/11, 12/02/11, and 12/03/11.

During an interview on 01/03/12 at 3:10 PM Personnel #3 stated documentation of Personnel #28's orientation was "not in the file."

Review of the hospital's policy on competency assessment for agency staff, revised 02/25/10, reflected requirements for all staff members providing care to "demonstrate clinical,cultural, and age specific competencies" and included "current license verification, educational preparation, and clinical competency." The policy reflected the hospital requirement to provide "contract/agency staff " with a mentor assisted orientation and competency assessment.

Based on observation, interview and record review the hospital failed to ensure the Dietary Director managed the dietary department in a responsible manner. The Dietary department was not maintained in a sanitary condition. This practice placed patients at risk for developing and/or acquiring infections while residing in the hospital.

Findings included:

On 01/03/12 from 11:15 AM to 12:00 PM a tour of the dietary department was conducted with Personnel #1. The following observations were made:

The walk-in refrigerator shelves and floor was soiled with debris and grime.

The flour, corn meal and sugar bins on wheels were soiled and dirty on the exterior surface. The flour bin had red stains on top of the clear plastic cover. The floor behind the bins was dirty with dust and debris collected on the floor.

The butcher block counter was soiled/stained with debris and food residue. The stand mixer sitting next to the butcher block counter had white food debris dried on the connector which attached the mixing paddle. Personnel #13 informed the surveyor he made a cake earlier in the morning. Personnel #13 said he must of forgotten to clean the connector.

Nine plastic bins labeled for various condiments had a collection of grime and debris buildup on the interior and exterior surface.

Clean metal pans were stacked on a shelf ready for food preparation. Four of the eight holding pans for the steam table were stacked on top of each other wet.

The top and bottom of the metal counters in the kitchen were dirty and dusty with grime buildup.

The refrigerator in the cafe area of the kitchen had an empty bowl of food with a label which indicated the food item expired 12/20/11.

The holding oven had a collection of food/debris buildup.

Personnel #1 verified the above findings during the tour.

On 01/03/12 at 3:15 PM Personnel #29 was interviewed. Personnel #29 stated she was the interim director. Personnel #29 stated the kitchen staff know their responsibilities in the kitchen. Personnel #29 verified the kitchen had not been cleaned appropriately.

The policy and procedure entitled, "Required Cleaning and Sanitization" with a revised date of 11/09 reflected, "To prevent cross-contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of operations during which time contamination may have occurred...the food surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil...nonfood contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris.

The daily task list provided on 01/04/12 by Personnel #29 reflected, "Daily Task List...label/date all opened product...daily cleaning...clean all shelving in chef area, wipe down tops/bottoms of all counter spaces...sweep mop/floors.."

Based on observation, interview and record review the facility failed to ensure the hospital's Infection Control Officer developed a system for identifying, investigating,controlling and preventing practices which placed patients and/or hospital personnel at risk for acquiring infections. 1) The Dietary department was not maintained in a sanitary condition. 2) The Housekeeping department failed to ensure hospital equipment was clean, and soiled equipment was not stored in the clean linen room located on the first floor. 3) Patient wound care supplies were left opened available for use for 3 of 3 patients (Patient #2, #23 and #24). 4) The Infection Control Officer was unaware 1 of 1 patient (Patient #1) had a pseudomonas infection.

Findings included:

1) On 01/03/12 from 11:15 AM to 12:00 PM a tour of the dietary department was conducted with Personnel #1. The following observations were made:

The walk-in refrigerator shelves and floor was soiled with debris and grime.

The flour, corn meal and sugar bins on wheels were soiled and dirty on the exterior surface. The flour bin had red stains on top of the clear plastic cover. The floor behind the bins was dirty with dust and debris collected on the floor.

The butcher block counter was soiled/stained with debris and food residue. The stand mixer sitting next to the butcher block counter had white food debris dried on the connector which attached the mixing paddle. Personnel #13 informed the surveyor he made a cake earlier in the morning. Personnel #13 said he must of forgotten to clean the connector.

Nine plastic bins labeled for various condiments had a collection of grime and debris buildup on the interior and exterior surface.

Clean metal pans were stacked on a shelf ready for food preparation. Four of the eight holding pans for the steam table were stacked on top of each other wet.

The top and bottom of the metal counters in the kitchen were dirty and dusty with grime buildup.

The refrigerator in the cafe area of the kitchen had an empty bowl of food with a label which indicated the food item expired 12/20/11.

The holding oven had a collection of food/debris buildup.

Personnel #1 verified the above findings during the tour.

On 01/03/12 at 3:15 PM Personnel #29 was interviewed. Personnel #29 stated she was the interim director. Personnel #29 stated the kitchen staff know their responsibilities in the kitchen. Personnel #29 verified the kitchen had not been cleaned appropriately.

The policy and procedure entitled, "Required Cleaning and Sanitization" with a revised date of 11/09 reflected, "To prevent cross-contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of operations during which time contamination may have occurred...the food surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil...nonfood contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris.

The daily task list provided on 01/04/12 by Personnel # 29 reflected, "Daily Task List...label/date all opened product...daily cleaning...clean all shelving in chef area, wipe down tops/bottoms of all counter spaces...sweep mop/floors.."

2) On 01/03/12 at approximately 9:45 AM a tour of the clean linen room located on the first floor was conducted with Personnel #6. The clean utility room had a dust pan and a vacuum cleaner attachment sitting next to the door. A black winter jacket was lying on the counter. Personnel #6 identified the jacket as belonging to one of the facility housekeepers and verified the dust pan and vacuum cleaner attachment were not to be stored in the clean linen room.

On 01/05/12 at 10:08 AM observation rounds of the second floor patient care area was conducted with Personnel #1. A patient room was designated by Personnel #1 as a storage area for clean equipment to be used for patient care. The following patient equipment was inspected:

One machine covered with plastic was available for use. The bottom of the unit was dusty and the top of the unit soiled with debris.

Two wheelchairs were covered with plastic bags available for use. The base and wheels of the chairs were soiled. The metal frame where the foot rest locked into place was soiled. Debris had collected on the metal frame.

The blood pressure machine was soiled and the top of the equipment was dusty and had pieces of left over tape.

On 01/05/12 at 10:12 AM Personnel #6 was interviewed. Personnel #6 stated housekeeping personnel were supposed to be thoroughly cleaning all the equipment.

3) On 01/03/12 at 10:15 AM Patient #2 was observed in her room. Personnel #11 was providing wound care for Patient #2's right elbow. The surveyor observed a pink bin with treatment supplies inside. Two plastic containers with opened 4 x 4 gauze sponges were observed. The 4 x 4's were hanging out the top of the lid and available for use. The inside of the bin was dusty along with multiple care items.

On 01/03/12 at 10:30 AM Patient #23's room was inspected. A pink bin was observed on the nightstand with a container of opened 4 x 4 gauze sponges, some of the sponges were lying loose in the bin. A medication cup with a light tan colored cream was sitting inside the bin. Personnel #1 stated he thought the cream was a moisture barrier. He stated the moisture barrier should not be in a medication cup.

On 01/03/12 at 10:35 AM Patient #24's room was inspected. A pink bin with treatment supplies was observed. An open container of 4 x 4's was sitting in the bin. The bin had other care items on top of the 4 x 4's.

4) Patient #1's "Admission Information" reflected an admission date of 12/27/11 with an admitting diagnoses to include Paraplegia and Spina Bifida. The "preadmission assessment" document reflected, diagnoses including Hypertension, Anemia, Status Post Acute Respiratory Failure with Trach (eotomy), UTI (Urinary Tract Infection), and Sacral Buttock Ulcer Stage II.

The physician progress note dated 12/27/11 reflected, Patient #1's urine pseudomonas culture was identified on 12/18/11 and Zosyn was started on 12/21/11.

Review of the Medication Reconciliation Order Form dated 12/27/11 reflected the continued use of Zosyn.

Patient #1's medical management consultation note dated 12/28/11 reflected, "Infectious Disease has been consulted" due to a "history of multi-drug resistant Pseudomonal urinary tract infection."

Review of Patient #1's infectious disease progress note dated 01/04/12 reflected, Patient #1 to have "penile discharge." Review of Patient #1's urine sample lab report collected 01/03/12 reflected a final result of "pseudomonas aeruginosa" on 01/05/12.

On 01/04/12 at 3:30 PM Personnel #11 was interviewed. Personnel #11 stated he did not receive any orientation to infection control when taking the position; he stated the previous infection control staff told him to "just fill in the paper." Personnel #11 stated the nursing personnel on the nursing unit did not communicate pertinent infection control information he needed.

On 01/05/12 at 11:05 AM Personnel #11 was interviewed. Personnel #11 stated he was unaware of Patient #1's pseudomonas infection.

The policy entitled, "Infection Control Function" with an effective date of 10/01/08 reflected, "The goal of the program...to reduce the risks of transmission of infectious agents among and between patients and healthcare personnel...to reduce risks of infections developing in patients related to the use of devices and procedures required in healthcare...to use effective processes to reduce the above risk effectively which include, but are not limited to...active surveillance , concurrent analysis of data...implement infection control and prevention measures...to define criteria for identifying major types of infection, either Healthcare Associated and/or Community Acquired...implement method of monitoring...develop and maintain a system for reporting and reviewing infections in patients and personnel...the scope of surveillance, prevention, and control of Infection is organizational wide...Review food handling, environmental practices, sources of infections...review lab reports...cleaning procedures, agents, and schedules and recommend any changes in cleaning products...monitor patient activities that relate to infection control..."