HospitalInspections.org

Based on review of facility policy, observations, and interviews, the facility failed to maintain a sanitary environment for 10 (Cardiovascular Intensive Care, 3rd Floor, Surgical Intensive Care Unit, Emergency Department, Dietary Department, 6th Floor, Nursery, 7th Floor, Obstetrics Department, and the Rehabilitation Unit) departments of 34 departments observed, resulting in the facility not discarding expired supplies and medication, not ensuring medication dispensing equipment and dietary equipment was clean, storing dietary food and equipment improperly, and storing clean and dirty patient care items together.

The findings include:

Review of the facility policy titled, "Patient Equipment Cleaning," dated 12/2015, showed "...In order to provide a clean and safe environment for patients and staff, equipment must be cleaned and disinfected to minimize the risk of transmission of infection...Cleaning is the physical removal of organic material or soil from objects..."

Review of the facility policy titled, "MANAGEMENT OF EXPIRING INVENTORY," dated 6/23/2016, showed "...Items that are expiring in the current month should be removed..."

Review of the facility policy titled, "Nursing Unit Inspections," dated 8/2016, showed "...The Department of Pharmacy Services conducts monthly inspections of all areas within the hospital where drugs and pharmaceuticals are stocked...Medication drawers and pockets are clean...There are no expired meds [medications]..."

Review of the facility policy titled, "Food Supply and Storage Procedures," dated 12/2017, showed "...all products contain an expiration date...cover, label and date unused portions and open packages...product is protected from the possibility of dust...through the use of a solid barrier such as a sheet of plastic...remove from storage any items for which the expiration date has expired...use plastic bags...approved for food storage...food that are stored on...racks must be fully covered to prevent contamination from airborne contaminants as well as from dripping condensation...Frozen storage...wrap food tightly to prevent cross contamination..."

Review of the facility policy titled, "Inventory Control-Expired and Unusable Medications," dated 7/2019, showed "...Medications are removed from the medication areas if they are...Expired..."

Review of the facility policy titled, "Storage of Pots, Dishes, Flatware, Utensils" dated 11/2019, showed"...dish handlers, tray line area associates...air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet..."

Observation and interview in the Cardiovascular Intensive Care Unit (CVICU) medication area on 2/3/2020 at 8:57 AM, with the CVICU Director of Nursing (DON), showed the following:
*1 container of bleach wipes with an expiration date of 4/2018
*1 container of bleach wipes with an expiration date of 8/2018
*1 container of bleach wipes with an expiration date of 3/2019
*1 container of bleach wipes with an expiration date of 8/2019
*59 green top laboratory tubes with an expiration date of 11/30/2019
During an interview, the CVICU DON stated the supplies were expired and were available for patient use.

Observation and interview on the 3 South Nursing Station on 2/3/2020 at 9:15 AM, with the 3 South DON, showed the following:
*2 D sized batteries with a use by date of 3/2009
*2 D sized batteries with a use by date of 3/2014.
During an interview, the 3 South DON stated the batteries were expired and were available for patient use.

Observation and interview of the medication dispensing system in the Surgical Intensive Care Unit (SICU) on 2/3/2020 at 10:03 AM, with the SICU Director, showed 2 vials of Atropine (medication used to treat a low heart rate) 0.4 milligrams/milliliter with an expiration date of 11/2019. During an interview, the SICU Director stated the medications were expired and were available for patient use.

Observation and interview of the medication dispensing system in the Emergency Department (ED) on 2/3/2020 at 10:28 AM, with the ED Director, showed a large amount of dust, lint, dirt, and debris inside each drawer of the dispenser. During an interview, the ED Director stated the medication dispenser was dirty.

Observation and interview of a supply area in the ED on 2/3/2020 at 10:45 AM, with the ED Director, showed the following:
*1 package of size 5.0 sutures with expiration date of 7/2019
*1 package of size 6.0 sutures with expiration date of 1/2018.
During an interview, the ED Director stated the sutures were expired and were available for patient use.

Observation and interview in the kitchen on 2/3/2020 at 1:10 PM, with the Dietary Manager, the Regional Dietary Manager, and the Executive Chef, showed a dishwasher operator removed 14 wet baking sheets from the dishwasher and stacked them on a metal stand while wet. During an interview, the Dietary Manager and the Executive Chef stated the baking sheets should be allowed to air dry prior to storage on the metal stand.

Observation and interview of the food prep walk-in cooler in the kitchen on 2/3/2020 at 1:15 PM, with the Dietary Manager, the Regional Dietary Manager, and Executive Chef, showed 2 cooling fans with a buildup of dust. A metal bowl with uncovered broccoli pieces and a bowl of uncovered mixed lettuce were stored on a shelf across from the cooling fans. During an interview, the Dietary Manager and Executive Chef stated the 2 cooling were covered with dust and the food items should have been covered.

Observation and interview of the produce walk-in cooler in the kitchen on 2/3/2020 at 1:20 PM, with the Dietary Manager, the Regional Dietary Manager, and the Executive Chef showed the following:
*1 opened five pound box of matchstick carrots
*8 opened cups of mandarin orange slices
*22 opened cups of orange jello
During an interview, the Dietary Manager and Executive Chef stated the box of carrots, the mandarin orange slices, and the jello should have been covered.

Observation and interview of the double convection ovens in the kitchen on 2/3/2020 at 2:07 PM, with the Dietary Manager, the Regional Dietary Manager, and the Executive Chef, showed both ovens had a heavy accumulation of grime inside and outside the ovens and a buildup of blackened debris on the floor around the ovens. During an interview, the Dietary Manager and Executive Chef stated both ovens had an accumulation of grime and there was a buildup of debris on the floor.

Observation and interview of a freezer in the kitchen on 2/3/2020 at 2:10 PM, with the Dietary Manager, the Regional Dietary Manager, and the Executive Chef showed the following:
*3 unpackaged veggie burgers
*1 bag of chicken fingers opened to air and undated
*1 bag of french fries opened to air and undated
During an interview, the Dietary Manager and the Executive Chef stated the veggie burgers should have been covered and the bag of chicken fingers and the french fries should have been dated and covered.

Observation and interview of the medication dispensing system on the 6th floor Nursing Unit on 2/3/2020 at 2:14 PM, with the 6th Floor Manager showed the medication dispensing system had a build-up of lint, dust, and debris on the shelves and in the drawers. During an interview, the 6th Floor Nurse Manager stated the medication dispensing system was dirty.

Observation and interview in the Nursery on 2/3/2020 at 2:58 PM, with the Nursery Director and the Nursery Manager, showed the following:
1 Premature Infant Nipple and Ring with a use by date of 8/1/2016
1 Premature Infant Nipple and Ring with a use by date of 12/1/2016
2 Premature Infant Nipple and Ring with a use by date of 8/1/2018
1 Premature Infant Nipple and Ring with a use by date of 7/1/2019
6 Premature Infant Nipple and Ring with a use by date of 9/1/2019
6 bottles of infant milk containing 2 fluid ounces with a use by date of 11/1/2019
During the interview, the Nursery Director and the Nursery Manager stated the items were expired and were available for patient use.

Observation and interview of the 7th Floor Clean Linen Storage room on 2/4/20202 at 8:16 AM, with the 7th Floor Director and the Assistant Nurse Manager showed 2 bedside commodes stored in the clean linen room without a "clean" label attached.
During an interview, the 7th Floor Director stated dirty items were stored in the clean linen room.

Observation and interview in the Obstetric (OB) Operating Room (OR) #4 on 2/4/2020 at 8:29 AM, with the OB Director, showed two 60 millimeter syringes with an expiration date of 8/2019. During an interview, the OB Director stated the syringes were expired and were available for patient use.

Observation and interview on the 7th Floor Nursing Station on 2/4/2020 at 8:31 AM, with the 7th Floor Director showed the following:
2 D sized batteries with a use by date of 6/2011
1 D sized battery with a use by date of 3/2012
5 green top laboratory tubes with an expiration date of 11/30/2019
1 green top laboratory tube with an expiration date of 12/31/2019
During an interview, the 7th Floor Director stated the supplies were expired and were available for patient use.

Observation and interview in OB OR #3 on 2/4/2020 at 8:36 AM, with the OB Director showed 1 oxygen tubing for an infant with an expiration date of 8/2019. During an interview, the OB Director stated the oxygen tubing was expired and was available for patient use.

Observation and interview in the 6th Floor Storage room on 2/4/2020 at 9:48 AM, with Assistant Nurse Manager #4 showed 1 bedside commode stored with a "clean" label attached and 2 bedside commodes stored with no "clean" label attached.
During an interview, the Assistant Nurse Manager stated clean and dirty items were stored together.

Observation and interview of the refrigerator/freezer in the kitchen on the Acute Care Rehabilitation Unit on 2/5/2020 at 9:05 AM, with the Rehabilitation Unit Manager and the Quality Manager showed the following:
*1/3 loaf of whole wheat bread located in the freezer and expired 11/22/2019
*5 sausage patties stored in the freezer and opened to air and undated
*a 16 ounce package of chopped spinach stored in the freezer and open to air and undated
*1 package of bacon stored in the refrigerator open to air and undated
*1/2 pound of yellow cheese slices stored in the refrigerator open to air and undated
*a 12 ounce package of sausage links expired 1/2020
During an interview, the Quality Manager confirmed the sausage links and the wheat bread were expired and food items should be stored covered and dated.

Observation and interview of the food storage cabinet on the Acute Care Rehabilitation Unit on 2/5/2020 at 9:30 AM, with the Unit Manager and the Quality Manager showed the following:
*1 opened and undated 16 ounce bag of self-rising flour
*1 opened and undated 16 ounce bag of all-purpose flour.
During an interview, the Quality Manager confirmed the flour should not be storeed open and should be dated.