HospitalInspections.org

Based on observation, review of documents and staff interview it was determined the hospital failed to maintain the scope of the Environmental Tours to inspect all patient care areas and failed to use the data collected to monitor the effectiveness and safety of environmental services and quality of care. This failure has the potential to adversely impact the condition of all patients by increasing infection risks. Findings include:

1. A tour and observation of all eleven (11) nursing units was conducted between 9:15 am and 11:15 am on 9/29/14. At least one (1) room which had been cleaned and was ready to admit a new patient in each area was observed. The surveyors were accompanied on the tour by both the Joint Commission Coordinator and Interim Chief Nursing Officer. Examination of multiple patient rooms revealed dust was noted on overhead ceiling tiles, sprinkler heads, tops of cabinets and wall hangings. Discolored areas were noted on both toilet bowls and bathroom floors which were labeled as clean and ready for patient admission. Patient items (non reusable) were noted to be left in room which had been cleaned. The following are examples of the multiple observations made during this tour include:

a. Room 317: heavy dust noted on tops of patients' communication boards. Air flow vent in ceiling heavily dusty.

b. Cardiovascular Unit (CVU) 18: bottom of bed dusty, chunks of dust noted dangling from ceiling tiles and sprinkler head dusty.

CVU 2 and 8: Light covers in hallway across from these rooms filled with large amount of dark substance and dust noted on ceiling tiles around light covers.

c. Intensive Care Unit (ICU) 6: dusty window sill, dust on top of cabinets over sink, multiple holes in wall noted in wall at head of bed, two (2) rolls of tape noted in room on shelf.

d. Room 234: toilet bowl soiled, dust above head of patient's bed and television, soap stains on bathroom floor.

e. Room 218: heavy dust on top of cabinet.

f. Room 153: hair on toilet bowl, soap stains on floor in bathroom, dust on sprinkler head.

g. Room 118: contact precautions sign and intake and output record date 9/27/14 for previous patient still hanging in room.

Dust, soiled areas and patient items left in cleaned' rooms poses an infection risk to patients placed in these rooms.

These observations were discussed with the Interim Chief Nursing Officer during the course of the tour and she agreed with these findings.

2. The Safety Management Plan, effective 2/17/14, was provided for review. The Objectives for this Plan includes: "Maintain the scope of the Environmental Tours to ensure all patient care areas are inspected twice annually..."Under Organization and Responsibility the plan notes in part: "The Patient and Environmental Safety Committee meet at least bimonthly to receive reports and conduct a timely review of safety issues."

The 2013-2014 Environmental Tour Checklist was provided as the tool utilized for this purpose. The 2013-2014 schedule of Environmental Tours was also provided for review.

An interview was conducted with both the Joint Commission Coordinator and Director of Risk Management/Patient Safety at 3:30 pm on 9/30/14. During this interview a sampling of Environmental Audits for the past year were reviewed. It was determined the 1 East Nursing Unit has not had an Environmental Tour completed since 8/27/13. The Risk Manager stated the results of the Environmental Tours are reported at the Patient and Environmental Safety Committee. The Risk Manager provided a current list of eleven (11) Environmental Tour Reports with Open Problems. One of the open problems was based on a tour on 9/12/13. He acknowledged that currently there is no ongoing oversight process or monitoring of the open problems for completion.

Minutes for the bi-monthly Patient and Environmental Safety Committee meetings were reviewed from August 2013 through June 2014. Review of the minutes revealed two (2) references to the Environmental Tours. Review of 2/24/14 Patient and Safety Committee meeting minutes revealed the following: "...presented the Safety Report for October 1 - December 31, 2013. He noted that during the environmental tour inspections a total of 72 problems were noted with 54 problems still open for a completion percentage of deficiencies identified during tours for this reporting period of 25%." Review of 4/24/14 Patient and Environmental Safety Committee meeting minutes revealed the following:..."...presented the Safety Report for January 1 - March 31, 2014. He noted that during environmental tour inspections a total of 60 problems were noted with 46 problems still open for a 23.33% completion rate.

The above information was discussed and reviewed with the Risk Manager. He acknowledged the hospital had not maintained the required frequency for documentation of the Environmental Tours in patient areas. He also acknowledged that currently the hospital was not using the data collected to monitor effectiveness of services. He provided an email indicating that the following will be added to the next Environment of Care-Patient Safety Committee Meeting agenda: Tour completion compliance, number of outstanding issues, identified trends and recommended actions based upon trends.

Based on observation, review of policy and staff interview it was determined the infection control officer failed to ensure patient rooms were maintained in a clean manner per hospital policy and processes. This failure was noted in six (6) of eleven (11) patient units toured and creates the potential for all the care and condition of all patients to be adversely impacted. Findings include:

1. A tour and observation of all eleven (11) nursing units was conducted between 9:15 am and 11:15 am on 9/29/14. At least one (1) room which had been cleaned and was ready to admit a new patient in each area was observed. The surveyors were accompanied on the tour by both the Joint Commission Coordinator and Interim Chief Nursing Officer. Examination of multiple patient rooms revealed dust was noted on overhead ceiling tiles, sprinkler heads, tops of cabinets and wall hangings. Discolored areas were noted on both toilet bowls and bathroom floors which were labeled as clean and ready for patient admission. Patient items (non reusable) were noted to be left in room which had been cleaned. The following are examples of the multiple observations made during this tour.

a. Room 317: heavy dust noted on tops of patients' communication boards. Air flow vent in ceiling heavily dusty.

b. Cardiovascular Unit (CVU) 18: bottom of bed dusty, chunks of dust noted dangling from ceiling tiles and sprinkler head dusty.

CVU 2 and 8: Light covers in hallway across from these rooms filled with large amount of dark substance and dust noted on ceiling tiles around light covers.

c. Intensive Care Unit (ICU) 6: dusty window sill, dust on top of cabinets over sink, multiple holes in wall noted in wall at head of bed, two rolls of tape noted in room on shelf.

d. Room 234: toilet bowl soiled, dust above head of patient's bed and television, soap stains on bathroom floor.

e. Room 218: heavy dust on top of cabinet.

f. Room 153: hair on toilet bowl, soap stains on floor in bathroom, dust on sprinkler head.

g. Room 118: contact precautions sign and intake and output record date 9/27/14 for previous patient still hanging in room.

Dust, soiled areas and patient items left in 'cleaned' rooms poses an infection risk to patients placed in these rooms.

These observations were discussed with the Interim Chief Nursing Officer during the course of the tour and she agreed with these findings.

2. The current (undated) Steps of Regular Discharge Room Cleaning were provided for review. The process includes, perform high dusting (shoulder high or higher) and clean ledges, sills and windows, clean room furnishings (thoroughly clean the bed) clean restroom, dust mop and wet mop the floor and inspect area (check that room is picture perfect).

Interview was conducted with the Environmental Services Director at 11:40 am on 9/30/14. The tour and observation findings on the patient units were reviewed and discussed. He stated he felt the Environmental staff generally do a good job but acknowledged the surveyors' observations revealed room cleaning was not being consistently performed as expected.

3. The Safety Management Plan, effective 2/17/14, was provided for review. The Objectives for this Plan includes: "Maintain the scope of the Environmental Tours to ensure all patient care areas are inspected twice annually..."Under Organization and Responsibility the plan notes in part: "The Patient and Environmental Safety Committee meet at least bimonthly to receive reports and conduct a timely review of safety issues."

Minutes for the bi-monthly Patient and Environmental Safety Committee were reviewed from August 2013 through June 2014. Review of the minutes revealed two references to the Environmental Tours. Review of 2/24/14 Patient and Safety Committee meeting minutes revealed the following: "...presented the Safety Report for October 1 - December 31, 2013. He noted that during the environmental tour inspections a total of 72 problems were noted with 54 problems still open for a completion percentage of deficiencies identified during tours for this reporting period of 25%." Review of 4/24/14 Patient and Environmental Safety Committee meeting minutes revealed the following:..."...presented the Safety Report for January 1 - March 31, 2014. He noted that during environmental tour inspections a total of 60 problems were noted with 46 problems still open for a 23.33% completion rate.

4. The Infection Prevention and Control Plan, effective date 5/29/14, was provided for review. The Plan states in part: "The purpose of this plan is to provide a program of surveillance, prevention and control of infection...Surveillance, prevention and control of infection cover a broad range of processes and activities...The Infection Control Staff, in consultation with the Infection Control Chairperson, institute appropriate action for the management of identified patterns and trends and facilitates ongoing monitoring and problem solving in order to sustain improvements in the Infection Control Program, and assess the overall failure or success of key processes for preventing and controlling infections."

On 9/30/14 at 2:50 pm an interview was conducted with the Infection Control Officer. She confirmed she is a member of the Patient and Environmental Safety Committee. The above findings were reviewed with her. She confirmed that only the number of problems which are identified on the Environmental Tours are being reported. She also acknowledged there is not enough information being reported related to the Environmental Tours to identify, track and trend infection control problems.