HospitalInspections.org

Based on document review, observation, and interviews, the facility failed to maintain a clean and sanitary environment by not ensuring patient rooms on 6-south were cleaned daily in 2 of 12 days reviewed (02/21/2025 & 02/24/2025); and failed to ensure soap was replaced in accordance with policy in 7 of 12 days reviewed (02/17/2025, 02/18/2025, 02/212025, 02/22/2025, 02/23/2025, 02/24/2025, and 02/27/2025).

Findings include:

1. Policy/procedure titled, "ES Environmental Cleaning," Publication date 01/09/2025; indicated under V. Policy Statements: G. Occupied inpatient rooms should be cleaned on a daily basis.

2. Policy/procedure titled, "ES Environmental Cleaning," Publication date 01/09/2025; indicated under VI. Procedures: E. Hospital additional locations: b. Public areas such as lobbies, waiting rooms, chapel and public restrooms. 2. Follow the general cleaning principles. A. Cleaning Principles: 4. Assess the room: a. determine what needs to be replaced such as paper towels, toilet paper, soap, alcohol hand rub, and sharps containers fill level.

3. Review of the environmental service daily cleaning logs for 6-south, lacked documentation of a cleaning log for all patient rooms on 6-south as follows:
a. No documentation of cleaning on 02/212025 and 02/24/2025.

4. Review of the environmental service daily cleaning logs, lacked documentation of a cleaning log for the public restrooms on 6-south as follows:
a. No documentation on 02/17/2025, 02/18/2025, 02/212025, 02/22/2025, 02/23/2025, 02/24/2025, and 02/27/2025.

5. On 03/18/25 at approximately 3:00 p.m. this surveyor, accompanied by A1 and A2, was given a tour of 6-south. While interviewing P12, this surveyor observed the floor was dirty.