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Based on review of National Fire and Protection Association (NFPA) and observation, it was determined the facility failed to ensure an acceptable level of safety and quality in that nine of nine empty oxygen tanks were not labeled as empty or full. The failed practice did not assure a nurse would immediately know if the tank was full or empty in the event of an emergency. The failed practice had the potential to affect all patients during an emergency event. Findings follow:

A. Review of NFPA 99 section 11.6.5.3 stated that empty cylinders shall be marked as empty to avoid confusion and delay if a full tank is needed in a rapid manner.
B. Observation of the supply room on 2/10/20 at 9:33 AM showed 9 oxygen tanks were not properly labeled as empty or full.
C. The above finding was verified with the Facility Manager on 02/10/20 at 9:55 AM

Based on observation, policy review, and interview, it was determined the Infection Control Officer failed to prevent and control infections in that the patient nourishment refrigerator had 9 of 21 chocolate milk cartons expired and were available for patient use. The failed practice had the likelihood for patients to experience a foodborne illness due to receiving expired milk. The failed practice had the likelihood to affect any patient receiving the chocolate milk. Findings follow.

A. Observation of the patient nourishment area on 02/10/2020 at 9:30 AM showed:
1) Chocolate 1% milk-8 cartons expired 02/09/2020.
2) Chocolate 1% milk-1 carton expired 02/05/2020.
B. During an interview at the time of the tour, the Chief Nursing Officer confirmed the expired milk.


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Based on review of policy and procedure manuals and interview, it was determined the Infection Control Officer did not prevent and control infections in that there was a policy for active surveillance or evidence active surveillance of hospital staff was performed to assure compliance with all policies, protocols, and other infection control program requirements. The failed practice did not assure that the hospital staff were being monitored for infection control safety practices in order to prevent further spread of any infections or diseases. The failed practice had to the potential to effect all employees and patients in the facility. Findings Follow:

A. Review of policies and procedures on 02/11/20 at 10:00 AM showed no policy concerning active surveillance of the hospital staff's infection control practices.
B. During interview with Infection Control Nurse on 02/11/20 at 10:15 AM, she stated that there had not been any active surveillance performed.
C. During interview on 02/11/20 at 10:20 AM, the Infection Control Nurse verified the finding in A.


Based on review of SAGE Comfort Warmer #1's logs, review of manufacturer's guidelines for Medline Ready Prep CHG 2% Chlorhexidine Gluconate Cloths, observation, and interview, the Infection Control Nurse failed to develop a system to identify and control infections of patients in that 64 of 64 Medline Ready Prep CHG 2% Chlorhexidine Gluconate Cloth packages were stored in excess of 104 degrees Fahrenheit (F). Failure to keep the Medline Ready Prep CHG 2% Chlorhexidine Gluconate Cloths within the recommended temperature did not ensure the antimicrobial effects had not been compromised. This failed practice had the potential to affect all patients in which the Medline Ready Prep CHG 2% Chlorhexidine Gluconate Cloths were used. Findings follow:

A. Review of manufacturer's guidelines for the Medline Ready Prep CHG 2% Chlorhexidine Gluconate Cloths showed the cloths were to be stored at 68-77 degrees F and to avoid excessive temperatures of above 104 degrees F.
B. Review on 02/10/20 at 9:30 AM of SAGE Comfort Warmer #1's logs showed the daily temperature was maintained at 125 degrees F for 3 of 3 (November 2019, December 2019, January 2020) months.
C. Observation of Patient Supply Room #1 on 02/10/20 at 9:30 AM showed:
1) The temperature reading for SAGE Comfort Warmer #1 was 125 degrees F.
2) In the SAGE Comfort Warmer #1, there were 64 packages of Medline Ready Prep CHG 2% Chlorhexidine Gluconate Cloths.
D. The above findings in A, B, and C were verified by interview with the Chief Nursing Officer on 02/10/20 at 10:00 AM.