HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.

Based on observations, staff interviews and review of hospital documentation of environmental safety rounds, the hospital failed to ensure that the in-patient psychiatric unit was free from ligature risks and/or that an activity room on the unit known to have ligature points and/or unsafe items remained locked.

Please see A144

Based on clinical record review, hospital policy and staff interview for 2 of 3 sampled patients reviewed for suicidal ideation (Patient # 52 and #53) the hospital failed to ensure the patients were on continuous observation per policy and/or that the patient rooms were secure and free of harmful items.

Please see A144

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of three sampled patients (Patient #11) reviewed for patient rights, the facility failed to ensure the patients were protected after an allegation of abuse and/or failed to have a policy or procedure to prevent and investigate patient abuse by an employee. The findings include:

Please see A145

Based on clinical record review, hospital documentation and staff interview for 4 of 7 sampled patients reviewed for restraints, (Patients #54, #55, #71 and #72) the facility failed to discontinue the use of the restraints at the earliest possible time.

Please see A174


On 8/7/19 the hospital provided an action plan that included the initiation of environmental safety rounds every fifteen minutes to enclude visualization of all wall sconces and ensuring that all doors identified as needing to be locked remained locked.

1. Based on observations, staff interviews and review of hospital documentation of environmental safety rounds, the hospital failed to ensure that the in-patient psychiatric unit was free from ligature risks and/or that an activity room on the unit known to have ligature points and/or unsafe items remained locked. The findings include:

a. A tour of the in-patient psychiatric unit was conducted on 8/7/19 at 10:00 AM with the Nursing Manager. Observations identified that the unit consisted of three hallways, two of which had no direct visualization from the nursing desk or main hallway. All three unit hallways contained wall mounted lighting with loopable surfaces that posed a ligature risk. According to the Nursing Manager, the hallways had been continuously monitored by video but that was discontinued more than one year ago. Currently, all patients are monitored every 15 minutes but the monitoring did not include visualization of the sconces and the surrounding areas. The Nurse Manager identified that he had previously identified (7/18/19) that the sconces posed a ligature risk and needed to be removed. However, as of 8/7/19 the sconces remained in the environment and no additional environmental safety monitoring was initiated.


b. Tour of the in-patient psychiatric unit was conducted on 8/7/19 with the Nursing Manager. At 10:45 AM it was observed that an activity room in an unmonitored hallway was unlocked providing access to patients. A sign posted on the activity room door identified "this room needs to be locked at all times". The activity room contained cabinet and drawer hardware that was loopable and posed a ligature risk. In addition, the room contained paint and arts and craft items that a patient could use to harm self or others. The Nurse Manager identified that the activity room was not a safe room and should be locked.

On 8/7/19 the hospital provided an action plan that included the initiation of environmental safety rounds every fifteen minutes to include visualization of all wall sconces and ensuring that all doors identified as needing to be locked remained locked.





2. Based on clinical record review, hospital policy and staff interview for 2 of 3 sampled patients reviewed for suicidal ideation (Patient # 52 and #53) the hospital failed to ensure the patients were on continuous observation per policy and/or that the patient rooms were secure and free of harmful items. The findings include:

a. Patient # 52 was admitted to the Emergency Department (ED) on 3/17/19 on a Police Emergency Evaluation Request (PEER) after verbalizing suicidality. The triage note identified the patient reported to the police that he/she was suicidal and was going to slit his/her wrists or take pills. Review of the History and Physical (H&P) dated 3/17/19 identified the patient was discharged from another hospital earlier that day with the same complaints of suicide ideation. The note identified the patient reported to the police that he/she was still having Suicidal Ideation's (SI) and thoughts of hurting self and was upset and yelling upon arrival. Review of the Emergency Psychiatric Services evaluation dated 3/17/19 at 5:04 PM identified the patient has had 25-30 suicide attempts in the past and numerous psychiatric admissions.

Review of the Suicide Risk Assessment dated 3/17/19 at 1:00 PM identified the patient as a medium risk, has considered suicide in the past. The assessment noted the patient's belongings were removed and hourly checks were initiated.

Interview and review of the clinical record with the ED Manager on 8/12/19 at 10:50 AM failed to identify the patient was on continuous observation. The ED Manager stated that the patient should have been on continuous observation, not hourly checks according to the policy in effect at that time.



b. Patient # 53 was admitted on 10/29/18 after an intentional overdose with a diagnosis of depressive disorder. The triage note dated 10/29/18 identified the patient ingested 30 tablets of Ativan 0.5 mg. The H&P dated 10/29/18 identified the patient presented after an overdose of 15 mg of Ativan and drinking 4 large glasses of wine. The note further identified the patient was trying to harm self.

Review of the Suicide Risk Assessment dated 10/29/18 at 6:40 AM identified the patient as a medium risk, has considered suicide in the past, the patient depends on alcohol or drugs for stress relief, feelings of sadness/hopelessness and serious loss of significant support person. The assessment noted the patient's belongings were removed and hourly checks were initiated.

Interview and review of the clinical record with the ED Manager on 8/9/19 at 1:30 PM failed to identify the patient was on continuous observation per policy and/or that the patient's room was secure. The ED Manager stated that they do not have a ligature free room for suicidal patients so when they are admitted they are to remove any potentially harmful items. The ED manager further stated that the patient was to be on continuous observation not hourly checks.

Review of the Suicidal Risk Assessment and Precautions policy in effect in October 2018 identified the policy as a guideline for the care of patients who present to the ED who may be dangerous to themselves. The policy identified if the patient is assessed to be a suicidal risk, the ED provider will be notified and a treatment plan instituted. The plan will be based on the patient's acuity and appropriate level of observation will be initiated. The policy indicated for patients who are at medium risk, the patient will undress and remove belongings, including electronic devices, wanded by security, monitor changes in behaviors and to be on continuous observation provided by video surveillance or staff and to document hourly.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of three sampled patients (Patient #11) reviewed for patient rights, the facility failed to ensure the patients were protected after an allegation of abuse and/or failed to have a policy or procedure to prevent and investigate patient abuse by an employee. The finding includes:

Patient #11 was admitted on 5/17/18 with diagnosis that included anorexia and mood disorder. The patient's care plan dated 7/14/18 identified the patient needed to stay in common areas until bedtime. If unable to do so, notify MD, as patient would require 1:1 level of observation , 1:1 staff not to socialize with patient, it should only be for safety monitoring.

Interview and review of facility documentation with RN Manager #2 on 8/12/19 at 10:00 AM identified on 7/22/19 the hospital was notified by another treatment facility that Psychiatric (Psych) Tech #1 had an inappropriate relationship with Patient #11 while a patient in the hospital that continued after discharge with the exchange of text messages and messages on social media. Manager #2 identified that although an investigation was immediately initiated, the Psych Tech was allowed to work on 7/30/19 and 7/31/19 and was not placed on administrative leave until 8/1/19. RN Manager #2 was unable to provide an explanation for how the hospital was protecting patients from potential abuse from Psych Tech #1 while the investigation was pending from 7/22/19 -8/1/19.

Interview with the Senior Human Resource (HR) Partner on 8/12/19 identified although it is best practice to put an employee on administrative leave, the hospital does not have a process or policy that requires the employee to be placed on administrative leave, but it is done on a case by case basis. He further identified after a thorough investigation by the manager and human resources, the allegation was not substantiated and the employee was cleared to return to work on 8/9/19.

Interview with Quality Improvement Manager #2, and the Administrator on 8/12/19 at 2:00 PM identified all patient concerns are investigated as a grievance utilizing the employee accountability policy. They identified the hospital does not have a specific hospital policy or procedure to prevent, protect, and/or investigate an allegation of abuse.

The employee accountability policy identified employees have an obligation and duty including moral and ethical obligations to prevent unjustified emotional, physical, or fiscal risk or harm to patients.

Multiple attempts to contact Psych Tech #1 were unsuccessful.

Based on clinical record review, hospital documentation and staff interview for 4 of 7 sampled patients reviewed for restraints, (Patients #54, #55, #71 and #72) the facility failed to discontinue the use of the restraints at the earliest possible time. The findings include:

a. Pt # 54 was admitted to the ED on 8/5/19 with suicidal thoughts. The H&P identified the patient was agitated, yelling and appears intoxicated. Review of the Behavioral Restraint assessment dated 8/5/19 at 8:15 PM noted the patient to be threatening, physical violence, danger to self, aggressive posturing with concern for physical harm, danger to others and was placed in 4 point locking restraints. The Licensed Independent Practitioner (LIP) assessment/order dated 8/5/19 at 8:31 PM directed the use of 4 point locking restraints related to aggressive posturing with concern for physical harm. The order further directed to discontinue the use of restraints as soon as the patient exhibited calm behaviors and verbalized the desire to cooperate. Further review of the patient's behavior identified from 8:45 PM through 9:30 PM the patient was quiet and/or sleeping but the restraints remained on and not discontinued until 9:30 PM. Interview with the ED Clinical Manager on 8/7/19 at 10:45 AM stated that when a patient stops exhibiting the behaviors that lead to the use of restraints, the restraints should be discontinued. Review of the clinical record at that time with the ED Clinical Nurse Manager identified the patient's restraints should have been discontinued at 8:45 PM when the patient was quiet. Further review noted that the patient remained in locking restraints for 1/2 hour more while the patient was sleeping.



b. Patient # 55 was admitted to the ED on 8/6/19 for crisis evaluation. The triage admission note identified the patient was confused, found walking in and out of traffic, intoxicated and reporting that he/she wants to jump off a bridge. Review of the behavioral restraint assessment dated 8/6/19 at 8:40 PM identified the patient as a danger to self, aggressive posturing with concern for physical harm and a danger to others and was placed in 4 point locking restraints. The LIP order/assessment dated 8/6/19 at 8:50 PM directed the use of 4 point locking restraints related to aggressive posturing with concern for physical harm. The order further directed to discontinue the use as soon as patient exhibited calm behaviors and verbalized the desire to cooperate. The assessment lacked documentation of the behavior warranting the use of the restraints and/or lacked documentation of interventions determined to be ineffective prior to the implementation of restraints. Additionally, the safety checks were either blank or documented as "unable due to safety reason." Further review noted the patients behaviors at 9:30 PM and 9:45 PM were identified as cursing and "other", see progress notes. Review of progress notes dated 8/6/19 at 9:30 PM identified behavior continues as previously documented, patient unable and unwilling to contract for safety and will continue to reassess. At 9:45 PM the nurse's notes identified the patient was more calm, less belligerent, continues to pull on restraints but agrees to safety, 2 restraints released. Interview with the ED Clinical Nurse Manager on 8/7/19 at 10:55 AM stated that when the patient's behaviors decreased and was no longer a danger, the restraints should have been discontinued. The ED Clinical Nurse Manager further stated that the behavioral restraint assessment needs to be completed while the patient is in restraints to identify the behaviors for which the patient is in the restraints, the interventions implemented and that identified safety checks were done.



c. Patient #71 was admitted to the Walden Eating Disorder unit on 5/3/19. Review of a restraint order dated 5/11/19 at 1:30 PM identified the patient was violent, a danger to self and others and aggressive and was placed in 4-point restraints. Criteria for discontinuation was left blank. Review of the restraint flow sheet between 1:30 PM and 2:45 PM identified that on 3 separate 15 minute safety checks (2:15 PM, 2:30 PM and 2:45 PM) the patient was assessed as lying down, talking to staff and quiet. In this timeframe, the hospital failed to justify the continued use of 4 point restraints. Additionally, a restraint order dated 5/11/19 at 4:15 PM identified the patient was violent, a danger to self and others and aggressive and was placed in 4-point restraints. Criteria for discontinuation included calm and verbalizes desire to cooperate. Review of the restraint flow sheet between 4:45 PM and 7:00 PM (10 consecutive 15 minute safety checks) identified the patient was lying down, quiet and/or sleeping and remained in 4 point restraints. In this timeframe the hospital failed to justify the continued use of the 4 point restraint.

Interview with the Nurse Manager on 8/12/19 at 11:50 PM identified that if a patient was assessed as calm, they should be released from restraints.


d. Patient #72 was admitted to the Walden Eating Disorder unit on 5/17/19. Review of a restraint order dated 6/8/19 at 7:00 PM identified the patient was a danger to self due to pulling out the nasogastric tube line and was placed in 4-point restraints. Criteria for discontinuation was left blank. Review of the restraint flow sheet between 9:15 PM and 11:30 PM (10 consecutive 15 minute safety checks) identified the patient was lying down, quiet talking to staff and/or calm/asleep but agitated when awakened and remained in 4 point restraints. In this timeframe the hospital failed to justify the continued use of the 4 point restraint.

Interview with the Nurse Manager on 8/12/19 at 11:50 PM identified that if a patient was assessed as calm, they should be released from restraints.


Review of the Hospital policy for the Restraints for Violent or Self Destructive Behaviors identified the patient must be monitored every 15 minutes while in restraints and that they are to be assessed for the discontinuation every fifteen minutes.

Based on clinical record review, hospital policy and staff interview for 1 of 3 sampled patients reviewed for pain (Patient # 51) the hospital failed to assess a patient who exhibited symptoms of pain. The finding includes:

Patient # 51 was admitted to the ED after a fall on 9/12/18. Review of the triage report dated 9/12/18 noted the patient had an unwitnessed fall and had complaints of rib, lower back and nose pain. Nurse's notes dated 9/12/18 at 11:13 AM identified the patient presents after falling with injuries to the face, forehead and nose. The note identified the patient symptoms included pain, abrasions, bruising and swelling. Review of the pain/comfort assessment dated 9/12/18 at 11:27 AM noted the patient had pain to the face, lower back and bilateral ribs. The assessment and clinical record lacked documentation of the nonverbal indicators of pain, the intensity of the pain, the quality, and duration, and any intervention used to alleviate pain. In addition, review of the clinical record failed to identify the patient was medicated for pain. Review of the clinical record identified the patient sustained a moderately depressed and angulated right nasal bone fracture. Interview with RN #1 on 8/9/19 at 9:50 AM stated that she should have completed the pain assessment.

Review of the Pain Assessment and Management policy for the ED identified all patients will be screened for the presence or absence of pain upon arrival and throughout the ED visit as conditions warrant. The pain description should include assessment parameters such as location, onset, duration, pain scale, quality, radiation and interventions and response to interventions.

Based on a review of the medical record, review of facility policies, and interviews for one of four patients reviewed for intravenous (IV) insertion (P #56) the facility failed to ensure that proper procedures were followed and/or that the patient was assessed following an alteration in skin integrity. The finding includes:

Patient (P) #56 had a history of, in part, traumatic brain injury and was admitted to the facility on 7/6/19 for suspicion of aspiration pneumonia.

Nursing documentation by Registered Nurse (RN) #3 dated 7/7/19 noted that the right foot IV was discontinued at 6:30 PM and restarted on 7/8/19 at 6:40 AM in the right hand by RN#2. A nurses note dated 7/8/19 by RN #4 identified that at 10:00 AM a tourniquet was found on P #56's upper right arm. The patient's right arm was elevated and warm packs were applied. The medical record lacked an assessment by RN#4.

A Medical Doctor (MD) progress note dated 7/8/19 indicated a tourniquet has been left in place on P#56's right arm with associated edema and deep tissue injury. A subsequent MD progress note dated 7/9/19 identified there was no indication for imaging at that time and continue to monitor the area.

A Transfer Summary dated 7/11/19 indicated the patients right upper extremity had some mild blistering and eschar however the arm had good pulses and no significant swelling. No treatment was identified.

Interview with the Laboratory Director on 8/9/19 at 8:35 AM identified that although P #56 had blood drawn the morning of 7/8/19, lab personnel used a blue tourniquet and an orange tourniquet was found on P #56's right arm.

Interview with RN #3 on 8/9/19 at 10:45 AM noted that P #56's right foot IV fell out during a seizure at the beginning of the 3:00 PM to 11:00 PM shift on 7/7/19. She further identified that after P #56's seizure a complete change of bed and clothing was provided and the tourniquet was not in place on the right arm at that time. RN #3 indicated that she only tried to restart P #56's IV in the right foot and did not attempt to insert an IV in the right arm.

Interview with RN #2 on 8/9/19 at 9:17 AM noted that although she inserted P #56's IV in the right hand on 7/8/19, she placed the tourniquet on P #56's lower right arm, not upper right arm.

Interview with RN #4 on 8/8/19 at 2:25 PM indicated that on the morning of 7/8/19 she removed the orange tourniquet from the patient's right arm. Although she did not document an assessment she stated P#56's right arm was firm, swollen and the skin all around the arm, where the tourniquet had been, was slightly red with tiny blisters.

The facility failed to ensure a tourniquet was removed after an IV insertion and/or failed to ensure a nursing assessment of the resulting injury was documented at the time the tourniquet was discovered.

The facility policy for IV insertion identified to slightly advance the IV catheter and needle to assure full entry into the vein lumen and then release the tourniquet.

The facility policy for wound assessment identified that all wounds are documented by a licensed nurse on admission and every time a wound is visualized. The policy further noted that wounds are assessed, in part, for location, type and appearance.

Based on clinical record review, interview, and review of facility policy for one of three patients reviewed for medication reconciliation (Patient #17) the facility failed to ensure the patient's medical record accurately identified the patient's current, active medications taken at home. The finding included:

Patient (P) #17 arrived at the Emergency Department (ED) on 9/14/18 at 7:31 PM for a chief complaint of decubitus ulcers. Diagnoses included Parkinson's disease, Diabetes Mellitus and hypertension.

Review of the ED record identified the patient's allergies included Aspirin and Azelex. P#17's current home medications, as reconciled, included carbidopa- levodapa, duloxetine, hydrocodone, ibuprofen, potassium gluconate, sulfamethoxazole, trihexyphenidyl, and vitamin E.

A provider note dated 9/14/18 at 9:47 PM identified the patient was informed that his/her physician would like P#17 to be admitted to the facility under observation for continued services.

Review of a history and physical (H&P) dated 9/14/18 at 9:59 PM identified the patient's allergies included aspirin however the H&P failed to identify that the patient had an allergy to Azelex. In addition, the H&P identified the patient's home medications included, Baclofen, carbidopa- levodapa, Vitamin D3, duloxetine, hydrocodon, ibuprofen, trihexyphenidyl, and Bactrim DS, however Baclofen was not included in P#17's current home medications reconciled in the ED on 9/14/18.

A review of P#17's medication list from a previous hospitalization indicated P#17 was on Baclofen.

Review of the patient's medication administration record (MAR) identified, in part, that Baclofen 10 mg was ordered and administered to the patient on 9/14/18 at 11:54 PM and 9/15/18 at 11:02 PM.

Review of the patient's discharge summary and/or discharge instructions dated 9/15/18 at 12:16 PM identified P#17 would be discharged home and his/her discharge medications included, in part, Baclofen 10 mg twice daily.

An ED record identified that P#17 arrived in the ED on 9/16/18 at 9:00 AM with a chief complaint of hallucinations. The ED record indicated that P#17 and his/her family felt that the hallucinations were secondary to P#17 receiving Baclofen. The record identified that the patient's family reported an extensive history identifying that Baclofen caused the patient to hallucinate therefore the patient no longer took Baclofen,

Subsequently Baclofen was added to P#17's ED allergy list.

Interview with MD #2 identified that when Patient #17 was admitted on 9/14/18, MD#2 ordered for P#17 to receive Baclofen based on a review of P#17's electronic medical record (EMR) from a previous hospitalization. MD#2 indicated s/he did not question that Baclofen was not included in P#17's current ED medication reconciliation prior to ordering the Baclofen.

The facility failed to ensure that the patient's medical record contained accurate updated medication information to promote continuity of care.

Review of facility's admission policy identified that the patient's medication history is completed by the practitioner and the nurse must review the home medication list with the patient and complete the allergy information of the medication section.

Based on a tour of the facility, review of facility policies, observations and interviews the facility failed to ensure that radiation safety standards were followed in the operative suites. The finding includes:

During a tour of the surgical department with the Quality Manager and Surgical Technician (ST) #1 on 8/7/19 at 10:07 AM, observation identified the use of one mini c-arm (fluoroscopy/radiation equipment) located in the surgical department.

Interview with ST #1 on 8/7/19 at 10:07 AM indicated that, at times, a radiology technician may bring in a large c- arm for use in the operating room (OR). ST #1 further indicated that cautionary signs (x-ray in use/radiation) are not posted on OR entry doors during fluoroscopy cases.

Interview with the Medical Imaging Manager on 8/9/19 at 12:10 PM noted that cautionary signs are posted on doors in the radiology department when x-ray/fluoroscopy equipment is used and was unaware of the need to place signage on the doors in the OR when c-arms are in use.

The facility policies did not address the posting of x-ray signage in the surgical department.

According to RCSA Sec. 19-24-8(C) Each area or room in which sources of ionizing radiation other than radioactive materials are used shall be conspicuously posted with a sign or signs bearing the radiation caution symbol and appropriate wording to designate the nature of the source or sources of ionizing radiation

Based on clinical record review and staff interview for 1 of 3 patients (Patient #53) who were in the ED for greater than 8 hours, the hospital failed to provide the patient with a nutritious meal. The findings include:

Patient # 53 was admitted to the hospital on 10/29/18 at 6:32 AM after ingesting 30 tablets of 0.5 mg of Ativan. Review of the clinical record identified the patient was transferred to another facility at 9:02 PM, 14.5 hours after the patient was admitted to the ED.

Review of the clinical record with the ED Manager on 8/12/19 at 9:50 AM identified the only nourishment provided to the patient and documented on was at 11:35 AM when fluids and crackers were given to the patient. The ED Manager stated that there are 2 areas (nourishment and procedure areas) in the clinical record where staff can document if a patient receives a meal. Review of the procedure section and nourishment documentation with the ED Manager failed to identify the patient received a meal.

Interview with Manager of Quality Improvement # 2 on 8/8/19 at 11:35 AM stated that there is no policy regarding serving meals to patients while in the ED. The Manager stated that if a patient requests a meal the staff can call down to dietary to have a meal brought up. The Manager further stated that it would depend on why the patient in the ED if they could have something to eat.

The Condition of Participation for Physical Environment has not been met.

Based on observations, staff interviews and review of hospital documentation of environmental safety rounds, the hospital failed to ensure that the in-patient psychiatric unit was free from ligature risks and/or that an activity room on the unit known to have ligature points and/or unsafe items remained locked. The findings include:

Please see A701

Based on observations, staff interviews and review of hospital documentation of environmental safety rounds, the hospital failed to ensure that the in-patient psychiatric unit was free from ligature risks and/or that an activity room on the unit known to have ligature points and/or unsafe items remained locked. The findings include:

a. A tour of the in-patient psychiatric unit was conducted on 8/7/19 at 10:00 AM with the Nursing Manager. Observations identified that the unit consisted of three hallways, two of which had no direct visualization from the nursing desk or main hallway. All three unit hallways contained wall mounted lighting with loopable surfaces that posed a ligature risk. According to the Nursing Manager, the hallways had been continuously monitored by video but that was discontinued more than one year ago. Currently, all patients are monitored every 15 minutes but the monitoring did not include visualization of the sconces and the surrounding areas. The Nurse Manager identified that he had previously identified (7/18/19) that the sconces posed a ligature risk and needed to be removed. However, as of 8/7/19 the sconces remained in the environment and no additional environmental safety monitoring was initiated.


b. Tour of the in-patient psychiatric unit was conducted on 8/7/19 with the Nursing Manager. At 10:45 AM it was observed that an activity room in an unmonitored hallway was unlocked providing access to patients. A sign posted on the activity room door identified "this room needs to be locked at all times". The activity room contained cabinet and drawer hardware that was loopable and posed a ligature risk. In addition, the room contained paint and arts and craft items that a patient could use to harm self or others. The Nurse Manager identified that the activity room was not a safe room and should be locked.

On 8/7/19 the hospital provided an action plan that included the initiation of environmental safety rounds every fifteen minutes to include visualization of all wall sconces and ensuring that all doors identified as needing to be locked remained locked.

Based on a tour of the facility, review of facility policies, observations and interviews the facility failed to ensure that a sanitary environment was maintained in the surgical department. The finding includes:

A tour of the surgical department was conducted with the Quality Manager and Surgical Technician (ST) #1 on 8/7/19. Observations beginning at 9:52 AM identified rust and/or peeling paint on intravenous (IV) poles, castors and soiled linen bins. The observations further identified breaches in and/or build-up of tape and tape remnants on the vinyl of Operating Room (OR) tables/attachments. The rust, peeling paint/breaches and tape rendered the equipment unable to be properly sanitized.

Interview with the Quality Manager on 8/7/19 at 9:43 AM indicated that the ORs and equipment are cleaned, in part, with germicidal wipes between cases by OR staff and at the end of the surgical day by housekeeping staff. The facility policy for perioperative services/OR sanitation identified that cleaning and disinfection is done prior to the first case and after each procedure using a hospital-approved registered disinfectant.

The policy further noted that Environmental Services will clean areas daily on the evening shift.