Sistersville General Hospital

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 38282 Based on observation, document review, and staff interview, the facility failed to ensure that medical supplies and expired food items were removed from use; and that gloves were changed according to policy during food preparation. This failure has the potential to adversely affect all patients receiving treatments and meals at the facility. (Refer to 485.640(a)(3)) Findings are as follows: The policy, titled “Environmental Surveillance/Rounding Program” date revised 06/01/22, was reviewed and stated in part, “a. Rounding Team: All departments of the hospital are inspected by a team ... c. Inspection Items/Tool: The environmental rounding checklist will be approved by the Infection Control Committee and Safety Committee. Inspection items address concerns related to compliance with infection control ... The checklist may be reviewed and revised as needed to include additional items for tracking and trending of compliance ...” The “Daily ED Charge Nurse Checklist;” from 01/01/24 through 05/01/24 were reviewed and included under, “Nightshift Charge Nurse, 1st of month check exp [expiration] dates supply cart and sutures.” All months were checked off. A training document titled, “Preventing Contamination from Hands and Gloves;” last update 04/18; was reviewed, and stated in part, “... Rules for Wearing Gloves: ... Use gloves for only one task. Change your gloves between tasks. For example, change gloves (and wash hands) after handling produce for tossed salad, before cutting and plating desserts ...” A policy, titled “Nutritional Services - Disposable Glove Use;” dated revised: 07/30/19; was reviewed. and stated in part, “... Disposable gloves must be changed, and hands washed when the gloves are dirty or ripped and when moving from one task to another ...” A policy, titled “Food and Supply Storage;” date revised: 01/24; was reviewed and stated in part, “Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption ... Procedures: ... Complete all sections on a Morrison Orange label or use the Medvantage/Fresh date labeling systems ... Discard food past the use-by or expiration date ... Refer to the Food Storage Chart in this policy to determine discard dates for food items.” The policy further stated, “... Dry Storage ... Refrigerated Storage ... Sorts produce daily to remove spoiled pieces ... Frozen Storage ... Wrap food rightly to prevent cross contamination ...” The policy, titled “Nursing Unit Stock and Nutritional Services” date revised 05/21/20, was reviewed and stated in part, “... Discarding of expired items is the responsibility of Nutritional Services and is done according to established guidelines.” An observation was conducted on 05/13/24 at 11:30 a.m. of the ED, accompanied by Employee #1 and Employee #2. The ED had three (3) regular beds and three (3) overflow beds; and was staffed by two (2) RN’s and a physician around the clock. While observing the ED stock room, it was noted that eight (8) Vicryl VCP 422 4.0 suture kits and two (2) J 504 4.0 suture kits expired on 01/31/24; and four (4) Vicryl J 503 5.0 suture kits expired on 02/29/24. An observation was conducted on 05/14/24 starting at 11:47 a.m. of the kitchen area during patient meal preparation. Employee #3 was observed cleaning their hands and donning gloves. Employee #3 proceeded to flip through the patients’ meal menu, handle dishes and utensils, and place various food items on each patient’s tray, all without washing hands and changing the gloves before and after each task according to policy. An observation was conducted on 05/14/2024 at 12:45 p.m. of the kitchen storage area, accompanied by Employee #5. There were expired food items available for use that included but was not limited to: yogurt that expired on 05/13/2024, blue cheese that expired on 05/13/2024, a loaf of bread that expired on 05/13/2024, a bag of muffins that was moist inside the packaging, and turkey sausages that was not tightly wrapped in the freezer. In addition, a container of blueberries was noted with the opened date as 05/04/2024, and the expiration date of 05/07/2024; and a fresh melon did not have any receive or expiration date. An observation was conducted on 05/15/24 at 9:24 a.m. of the Medical/Surgical floor, accompanied by Employee #4. The floor had six (6) semi-private rooms, and the census was three (3); and staffed by an RN, LPN, and Patient Care Tech (PCT). The refrigerator containing patient food was noted to have a container of Ensure with an expiration date of 05/01/24, that was promptly discarded by Employee #4, who confirmed that the dietary staff were responsible for checking the food for outdates. An observation was conducted on 05/15/24 at 9:58 a.m. of the kitchen food storage area, accompanied by Employee #4 and Employee #5. The dry goods area was noted to have an open bag of partially used bagels with no date of opening. The refrigerator was noted to have issues with fresh produce that was labeled as expired, that included, but was not limited to: A labeled expiration date of 05/07/24: Two and one half (2 ½) tubs of cherry tomatoes, iceberg lettuce, green onions, cauliflower, basil, fresh mint, blueberries, peppers, lemons, limes, bananas, and Brussel sprouts. Employee #5 stated that the fresh food items were potentially mislabeled for the expiration date; then promptly discarded the expired food items. An interview was conducted on 05/13/24 at 11:38 a.m. with Employee #2, who confirmed that fourteen (14) suture kits were expired, but not removed from use, and stated, “The staff are responsible for checking supply outdates every month.” An interview was conducted on 05/14/24 at 11:10 a.m. with Employee #1 regarding checking supplies for outdates. Employee #1 stated, “Each department has a check sheet they go by for checking outdates. The ED has daily checks by the charge nurse.” Documentation provided. An interview was conducted on 05/14/24 at 11:55 a.m. with Employee #3 regarding the patients’ meal preparation. Employee #3 concurred that the changing of gloves was not done appropriately according to the training. An interview was conducted on 05/14/24 at 12:55 p.m. with Employee #5 regarding the expired food items. Employee #5 confirmed that the food items were expired, and the bag of muffins were not safe for human consumption. Employee #5 also confirmed that the turkey sausages were not properly stored in the freezer and had to be stored in a vacuum sealed bag. Employee #5 stated, “I don’t think the blueberries have to be thrown out after three days. But I don’t have a chart telling me how long blueberries can be stored” then concurred that the receipt date was noted as 05/04/2024 and the expiration date was 05/07/2024 for the blueberries. Employee #5 also verified that the melon had no dates of receipt or expiration. An interview was conducted on 05/15/24 at 10:10 a.m. with Employee #4 regarding the expired fresh food in the refrigerator. Employee #4 stated, “We have to follow what the label says in regards to an expiration date, even if we think it is ‘labeled wrong’ we must discard it.””

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 37956 Based on document review and staff interview, it was determined the facility failed to conduct fire drills at unexpected times under varying conditions in accordance with NFPA (National Fire Protection Association). This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3. Findings include: a) During the facility document review conducted on 05/13/24 between the hours of 10:30 a.m. and 5:00 p.m., revealed that fire drill conducted from May of 2023 to May of 2024 did not have a sign in sheet to verify that staff participated in the fire drills. b) During the facility document review conducted on 05/13/24 between the hours of 10:30 a.m. and 5:00 p.m., revealed on the midnight shift fire drill conducted on 4/26/24 at 6:00 a.m. and the fire drill conducted on 5/3/23 at 6:00 a.m. and the fire drill conducted on 6/30/23 at 6:00 a.m. is not at unexpected times under varying conditions. c) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/14/24 at approximately 4:00 p.m. at the time of exit.”