HospitalInspections.org

Based on review of facility documents, personnel files (PF) and staff interview (EMP), it was determined one of fifteen personnel files did not include all required documents per the job description. (PF1)

Findings include:

Review on November 20, 2024, of the facility policy "BLS Training," last reviewed on October 24, 2024, revealed: "Purpose To provide a mechanism to systematically monitor, evaluate and ensure Basic Life Support (BLS) training is current for employees as required by credentialing organizations or as required by department. Policy Employees ... must successfully complete BLS training consistent with Geisinger standards, at the time intervals designated below. Section 1 Employees - Clinical Care Licensed & Clinical Care Unlicensed ... New employees that have not completed BLS training and/or do not possess an American Heart Association BLS Provider eCard, have 60 days of the start date, or as required by department/credentialing organizations to obtain. ... "

Review on November 20, 2024, of Radiology Facilitator job description labeled "Geisinger overview" revealed "... Qualifications/Certifications required: Yes Basic Life Support Certification."

Review on November 20, 2024, of PF1 revealed a Radiology Facilitator job description, date of last change October 18, 2024. PF1 did not contain the required BLS (Basic Life Support) certification documentation.

Interview with EMP5 on November 20, 2024, at approximately 1330 confirmed PF1 began the position of Radiology Facilitator on June 30, 2024.

Interview with EMP5 on November 20, 2024, at approximately 1330 confirmed the above findings.

Based on observation, review of facility documents and staff interview (EMP), it was determined 1) the facility failed to ensure equipment and areas within the dietary department were cleaned per established cleaning schedules for ten of ten months reviewed (January 1, 2024 - October 31, 2024), and 2) the facility failed to ensure the medical/surgical unit flooring was maintained at an acceptable level of cleanliness and quality.

Findings include:

Review on November 20, 2024 of facility policy, "Cleaning and Sanitizing, Foodservice," last reviewed January 29, 2024, revealed "Purpose To ensure food contact and non-food contact surfaces area cleaned and sanitized using Foodservice-approved cleaning agents, sanitizer, and methods. ... Policy The Foodservice department at each site is to have an effective cleaning program & schedule in place to ensure proper cleaning and sanitizing. This plan utilized the correct chemicals and procedures to keep food contact and non-food contact surfaces clean and sanitized. ..."

Review on November 20, 2024, of the "Cooks Daily Cleaning Log," revealed the inside ovens are to be cleaned every weekend. Review of this cleaning log for January 2024 revealed the inside ovens were not cleaned on January 13, 14, 27 or 28. Review of this cleaning log for February 2024 revealed the inside ovens were not cleaned on February 10, 11, 24 or 25. Review of this cleaning log for March 2024 revealed the inside ovens were not cleaned on March 9, or 10. Review of this cleaning log for May 2024 revealed the inside ovens were not cleaned on May 11 or 12. Review of this cleaning log for June 2024 revealed the inside ovens were not cleaned on June 15, 16, 29 or 30. Review of this cleaning log for August 2024 revealed the inside ovens were not cleaned on August 10 or 11. Review of this cleaning log for September 2024 revealed the inside ovens were not cleaned on September 7, 8, 21, or 22.

Review on November 20, 2024, of the "Lead Daily Cleaning Log," revealed the storeroom is to be cleaned every weekend. Review of this cleaning log for January 2024 revealed the storeroom was not cleaned on January 6, 7, 13 or 14. Review of this cleaning log for February 2024 revealed the storeroom was not cleaned on February 24 or 25. Review of this cleaning log for March 2024 revealed the storeroom was not cleaned on March 9, 10, 23 or 24. Review of this cleaning log for May 2024 revealed the storeroom was not cleaned on May 4, 5, 11,12, 18 or 19. Review of this cleaning log for June 2024 revealed the storeroom was not cleaned on June 1, 2, 8, 9, 15, 16, 29 or 30. Review of this cleaning log for July 2024 revealed the storeroom was not cleaned on July 6, 7, 13, 14, 20, 21, 27, or 28. Review of this cleaning log for August 2024, revealed the storeroom was not cleaned on August 10, 11, 17 or 18. Review of this cleaning log for September 2024 revealed the storeroom was not cleaned on September 7, 8, 14, 15, 21, 22, 28 or 29.

Review on November 20, 2024, of the "Dishroom Daily Cleaning Log," revealed the garbage cans, fridges on floors, and drains are to be cleaned every weekend. Review of this cleaning log for January 2024 revealed the garbage cans, fridges on floors, and drains were not cleaned on January 6, or 7. Review of this cleaning log for April 2024 revealed the garbage cans, fridges on floors, and drains were not cleaned on April 27 or 28. Review of this cleaning log for May 2024 revealed the garbage cans, fridges on floors, and drains were not cleaned on May 4, 5, 11, 12, 18 or 19. Review of this cleaning log for June 2024 revealed the garbage cans, fridges on floors, and drains were not cleaned on June 8, 9, 15, 16, 29 or 30. Review of this cleaning log for July revealed the garbage cans, fridges on floors, and drains were not cleaned on July 6, 7, 13, 14, 20, 21, 27 or 28. Review of this cleaning log for August 2024 revealed the garbage cans, fridges on floors, and drains were not cleaned on August 3, 4, 10, 11, 17, 18, 24 or 25. Review of this cleaning log for September 2024 revealed the garbage cans, fridges on floors, and drains were not cleaned on September 7, 8, 14, 15, 21, 22, 28 or 29.

Review on November 20, 2024, of the "Cafe Daily Cleaning Log," revealed the salad bar is to be cleaned every weekend. Review of this cleaning log for January 2024 revealed the salad bar was not cleaned on January 6, 7, 13, 14, 20, 21, 27 or 28. Review of this cleaning log for February 2024 revealed the salad bar was not cleaned on February 3, 4, 10, 11, 17, 18, 24 or 25. Review of this cleaning log for April 2024 reveal the salad bar was not cleaned on April 6, 7, 13, 14, 20, 21, 27 or 28. Review of this cleaning log for May 2024 revealed the salad bar was not cleaned on May 4, 5, 11, 12, 18, 19, 25 or 26. Review of this cleaning log for June 2024 revealed the salad bar was not cleaned on June 1, 2, 8, 9, 15, 16, 22, 23, 29 or 30. Review of this cleaning log for July 2024 revealed the salad bar was not cleaned on 6, 7, 13, 14, 20, 21, 27 or 28. Review of this cleaning log for August 2024 revealed the salad bar was not cleaned on August 3, 4, 10, 11, 17, 18, 24, 25, or 31. Review of this cleaning log for September 2024 revealed the salad bar was not cleaned on September 1, 7, 8, 14, 15, 21, 22, 28 or 29. Review of this cleaning log for October 2024 revealed the salad bar was not cleaned on October 12, 13, 19, 20, 26 or 27. Continued review of the "Cafe Daily Cleaning Log," revealed 22 additional areas which are to be cleaned daily. Review of the 2024 log revealed there was no documentation these areas were cleaned on January 1, 6, 7, 13, 14, 20, 21, 27 and 28, February 3, 4, 10, 11, 17, 18, 24, and 25. March 2, 3, 9, 10, 16, 17, 23, 24, 30 and 31. April 6, 7, 13, 14, 20, 21, 27, and 28. May 4, 5, 12, 18, 19, 25, and 26. June 1, 2, 8, 9, 15, 16, 22, 23, 29 and 30. July 4, 6, 7, 13, 14, 20, 21, 27 and 28. August 3, 4, 10, 11, 17, 18, 24, 25, and 31. September 1, 2, 7, 8, 14, 15, 21, 22, 28, and 29. October 5, 6, 12, 13, 19, 20, 26 and 27.

Interview with EMP4 on November 20, 2024, at 1030, confirmed the findings noted above for the Cooks Daily Cleaning Log, Lead Daily Cleaning Log, Dishroom Daily Cleaning Log, and the Cafe Daily Cleaning Log. EMP4 confirmed the weekend cleaning may be completed over two days, as it may take two days to complete the items listed, i.e. the two ovens.

Interview with EMP8 on November 20, 2024, at 1445, confirmed the findings noted above for the Cooks Daily Cleaning Log, Lead Daily Cleaning Log, Dishroom Daily Cleaning Log, and the Cafe Daily Cleaning Log.

2) Tour and observation of the 3rd floor medical/surgical unit conducted with EMP2 and EMP3 on November 19, 2024, at 1425 revealed multiple grayish-black spots covering the flooring throughout the unit hallways. The laminate flooring was noted to be cracked and chipped away at the adjoining seams on the medical/surgical unit.

Interview with EMP3 on November 19, 2024, at 1430 confirmed the above findings. EMP3 stated they suspect the hand sanitizer is causing the spots.

Review of the "Infection Prevention and Control Plan, Surveillance, Risk Assessment and Goals" policy, last reviewed on July 31, 2024, revealed "... Cleaning and Disinfection for ... Environmental Surfaces GBH" [Geisinger- Bloomsburg Hospital] "staff, manager and designers select ... fixture surfaces that are made of nonabsorbable, non-porous materials that can be cleaned and disinfected following environmental cleaning and disinfection policies & guidelines. The practices and procedures promote and maintain a clean and sanitary environment that decreases environmental infection risk... EVS" [Environmental Services] "specific cleaning policies are in the Environmental Services manual located in Policy Manager, providing frequency, responsibilities, audit processes and procedures..."

Review of "Environmental Services Scope of Services" policy, last reviewed on October 8, 2024, revealed "Purpose The purpose of the Environmental Services Department is to provide best in class and sustainable environmental services to our Patients, our Geisinger Family, and our community. ... The Environmental Services Department is a service-oriented department within Geisinger. Our mission is enhancing the quality of the healthcare environment ... Objectives: ... Utilize green cleaning chemicals and practices, when possible, without compromising cleanliness or infection control standards ... Services provided by the Environmental Services department include, but are not limited to: Provide routine cleaning services to all on campus buildings and peripheral areas (where applicable). In-Patient room cleaning & disinfection-occupied patient rooms-daily; discharge patient rooms as rooms are vacated. ... Floor care, to include stripping, waxing, buffing, and carpet extraction - scheduled and as needed. ..."

A request was made on November 19, 2024 at 1440, to EMP2 for the 3rd floor medical/surgical unit scheduled floor cleaning.

Review on November 20, 2024, at 0910, of the floor cleaning schedule from July - November 2024, provided by EMP6, revealed documentation of weekly cleaning/scrubbing of the 3rd floor medical/surgical unit flooring.

Interview with EMP7 on November 20, 2024, at 1450 indicated leadership was aware of the condition of the floor. The flooring was unable to be replaced due to budget constraints.