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Based on review of records, interviews and observations, the hospital failed to maintain sanitary conditions in 6 out of 6 areas surveyed (5th floor inpatient room, 4th floor inpatient room, 3rd floor inpatient rehabilitation unit, 3rd floor patient nutrition room, 3rd floor nurses station, and 2nd floor intensive care unit clean utility room).

On 7-12-2017, a tour of the hospital was conducted with Staff #2 and Staff #8. The tour was started on the 5th floor and concluded on the 2nd floor. Six different areas were selected for sample of hospital cleanliness as related to potential infections.

A 5th floor inpatient room (room 521) was identified as clean and ready to receive a patient. The following unsanitary findings were observed:

A shower chair was covered in plastic after cleaned and was located inside the bathroom shower. It was removed from the shower and turned over. It was found to have hair on the bottom of the chair and was visibly soiled on the bottom with what had the appearance of mildew.

The bathroom floor had a buildup of dirt and debris in the corners, behind the toilet and next to the shower. Caulking between flooring material and the door frame was separating from the wall and trapped dirt.

The shower door tracks had a buildup of material on and in the tracks.

Inside the shower, underneath the built-in seat, black matter was built up on the caulk and tile.

When the toilet seat was raised, visible debris was located by the seat hinge.

The room sink had mounting tape for equipment that was no longer in use stuck to the back-splash with visible debris stuck to it. A clean patient gown was on the counter, in contact with the mounting tape residue.

The sharps container (for disposing of used needles and other sharp disposable items) was visibly soiled with a reddish dried spill and dark red-brown matter.

A 4th floor inpatient room (room 402) was identified as clean and ready to receive a patient. The following unsanitary findings were observed:

Trash and a large wad of hair were observed on the floor.

Dirt and debris was built up in the corner of the window and the ledge by the window.

Two round rings of what appeared to be a dried liquid spill were found on the ledge by the window and next to the patient's chair.

The 3rd floor inpatient rehabilitation unit, clean equipment room was toured. Hot moist packs were stored in a tank (Hydrocollator) of hot water. The equipment check sheet showed that the tank had been cleaned last on 6-22-2017 (3 weeks prior to survey). Prior to that cleaning, it was last cleaned on 5-2-2017 (7 weeks between cleanings). An interview with Staff #16 was conducted at the time of survey. Staff #16 stated their process was to clean the tank once a month. Staff #16 stated that was the hospital policy and provided a copy of policies being used.

Review of Policy Number 13:04, Section 13 - KHRS ARU P&P Manual, page 1 of 1, titled "Environmental Cleaning" did not specifically address the frequency of cleaning the tank for the Hydrocollator. A form was attached to the policy and was identified as "Temperature and Cleaning Log", Section 7 - KHRS OP P&P Manual, page 1 of 2. The cleaning schedule at the top of the page indicates the "Hot Packs" are to be cleaned monthly (more often as needed).

Staff #16 provided a copy of the manufactures recommendations for cleaning. On page 17, Maintenance Hydrocollator Mobile Heating Units, Care and Cleaning stated, "The tank should also be drained and cleaned systematically, at minimum intervals of every two weeks." Under the section, "To avoid potential for rusting:", item 6, it stated, "Regularly cleaned and drain the tank (every two weeks)."

Staff #16 stated she was not aware of the manufacturer cleaning requirements.

The 3rd floor Patient Nutrition Room was observed to have the following unsanitary conditions:

The inside of the patient refrigerator had dried spills on the door, door seal, inside shelves, food trays, and storage boxes.

A frozen ice cream drink was found in the freezer. It was not dated and did not have a patient identification on it. The sides of the cup contained refrozen drips of the ice cream drink. The lid did not fit the cup and was just resting on the top. What appeared to be frozen condensation was collecting on the bottom of the cup.

Caulking was found to be deteriorated around edging of the counter, allowing dirt and liquids to become trapped between the counter, backsplash, and wall.

A storage caddy for drink lids had dried spills on, behind, and under it.

The tray under the patient coffee maker had dried spills on it.

The storage caddy for condiments had trash, debris, and food particles in the bottoms of them.

A storage cabinet drawer was opened to reveal soup, cereal, and crackers in bins that had trash, debris and food particles in the bottom of them. The drawer front had dried matter on it. What appeared to be coffee grounds was stored in two zip lock plastic bags. The content was not identified or dated.

The 3rd floor Nursing Station was found to have two wall mounted fans that were heavily soiled with dust.

The 2nd floor Intensive Care Unit (ICU) clean equipment room was observed.

Three pumps for administering medications intravenously (IV - into a vein) were soiled with dried matter.

Two poles were found to have dried matter in a tray and at the height adjustment connection.

IV fluid was found to be stored on a shelf, on top of dried matter.

Bins with respiratory supplies were found to have dust and debris in the bottom of them.


Interviews were conducted with Staff #5 and Staff #6. Staff #6 stated she had found these problems before during rounding. Staff #6 provided copies of a rounding sheet from 6/29/2017 with some of the findings on them. She stated she had taken it to the floor supervisors and housekeeping supervisors on multiple occasions but keeps finding the same items. When asked if she had taken it to the Quality Control and Process Improvement Committee to develop a formal process improvement plan for sustainable corrective action, she stated she had not. Staff #5 confirmed that the problems with an unsanitary environment had not been brought up in quality meetings.