HospitalInspections.org

Based on observation and interview the facility failed to provide a clean and sanitary environment resulting in the potential for transmission of infectious agents among patients, visitors and healthcare workers. Findings include:

On 7/23/2013 starting at approximately 1025 until 1100, during a tour of H3 intensive care unit found the following areas:

Soiled utility room
a.) a bio-hazard receptacle open with the lid placed underneath the bin leaving all contents of the bio-hazard bin exposed
b.) gloves left on the counter top available for use not stored in the box provided and not discarded
c.) soiled mop head located in back corner of soiled utility room

Common Corridor to Patient Rooms
d.) High dusting on picture frames and on computers at nursing documentation stations

On 7/23/2013 at approximately 1035 an interview with Staff B was conducted. When queried about the open biohazard bins of whether it was acceptable practice to store the lids beneath the bins leaving the biohazard bin completely exposed she stated " no, this is not acceptable practice and I have never seen the lids to the bins stored this way before. "

On 7/23/2013 at approximately 1045 an interview with Staff B was conducted. When queried about the common corridor accumulation of dust and was dusting a part of a regular cleaning schedule it was stated "yes, housekeeping should have the common areas on a regular check list." Staff W, staff X, and staff Z were asked if general areas such as the corridors and soiled utility rooms were on a regular cleaning schedule and all three staff members stated yes the areas were supposed to be cleaned but a work check list was not available to ensure what areas were to be cleaned. On 7/23/2013 at approximately 1500 a work list was provided for general cleaning of common areas but the staff were not aware of the work list for the general common areas. Staff B stated there was an interim person filling the position of director of environmental services.

On 7/23/2013 starting at approximately 1105 until 1145, during a tour of H2 intensive care unit found the following areas:

Soiled utility room
h.) a bio-hazard receptacle open with the lid placed underneath the bin leaving all contents of the bio-hazard bin exposed

Common Corridor to Patient Rooms
i.) High dusting on picture frames and on computers at nursing documentation stations

Pantry
j.) Ice machine that with an accumulation of a large amount of dust located on the top surface and white residue located on the dispensing area
k.) food refrigerator with dust and debris collected on the seal of the door
l.) drawers with an accumulation of crumbs and debris

Medication Room
m.) single red storage bin with intravenous medication was found to have and accumulation of dust and debris

On 7/23/2013 at approximately 1120 an interview with Staff B was conducted. When queried about the open biohazard bins of whether it was acceptable practice to store the lids beneath the bins leaving the biohazard bin completely exposed she stated " no, this is not acceptable practice and I have never seen the lids to the bins stored this way before. It must be related to the person replacing the biohazard bins once they are full."

On 7/23/2013 at approximately 1140 an interview with staff B and staff T was conducted. When asked if the ice machine should have an accumulation of white colored mineral deposit on the front of the machine both staff B and staff T responded that the ice machines had been brought to their attention for maintenance. When asked about the dust accumulation on the top of the machine it was stated by staff T "it needs to be dusted." The accumulation of debris and dust located on the seal of the refrigerator was found on July 23, 2013 at approximately 1142. When asked if this was acceptable practice staff B stated "no. Dietary should be checking the cleanliness of the seals and inside of patient food drawers on a regular basis."

On 7/23/2013 at approximately 1145 an interview with staff T was conducted. When asked who was responsible for keeping the bins clean it was unable to be determined if it was the responsibility of nursing or pharmacy or both. The staff T stated she was unsure if the responsibility was delegated to a specific department. It was then asked if this was an acceptable practice to store medications in a dirty container and she stated " no it is not acceptable. "