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Based on observation, and interview the facility failed to ensure the physical environment was clean and secure. Eleven (11) supply carts out of 18 were inspected (C1, C3, C5, C7, C9, C10, B6, A1, A3, A9, B9, B6) were inspected and found to be unlocked in the individual patient rooms in the emergency department; leaving the access of sterile supplies and needles to both patients and others.

Findings:

Based on observation, and interview the facility failed to ensure the physical environment was clean and secure. Eleven (11) supply carts out of 18 (C1, C3, C5, C7, C9, C10, B6, A1, A3, A9, B9, B6) were inspected and found to be unlocked in the individual patient rooms in the emergency department. Each cart had intravenous needles and other sterile supplies accessible to patients and visitors.

Interview with 10/03/2024 at 1030, staff (ID#8) and others who were present during the tour "stated the carts should be locked" and proceeded to lock the carts during the tour.

Based on observation and interview on 10/03/2024 at 1130, the blue equipment room was noted to be a clean utility room, but had dirty equipment in the room, i.e. a cart with visible brown stain fluid was noted, the Steris light had blood splatter on the light and broken equipment, ie intravenous pump, and a used bear hugger were also noted in the room.

Interview with 10/03/2024 at 1130, staff (ID#8) who stated the room is a clean utility and the items should not be in the room.