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Based on document review, observation and interview with staff it was determined nursing staff failed to follow infection control policies and procedures for maintaining clean and decontaminated equipment storage in the clean supply room of the Emergency Department (ED). This failure has the potential to provide a source of transmission of infection to all patients who present to the ED for care.

Findings include:

A review of the policy titled "Infection Prevention and Control: Nursing," revised 8/20/13, stated in part: "PURPOSE: The purpose of this policy is to set forth guidelines for use in preventing the spread of infection among patients, hospital personnel and visitors .. III. EQUIPMENT: All patient care equipment must be cleaned and decontaminated between each patient contact using disinfectant wipes or an approved spray disinfectant."

A tour of the ED was conducted on 2/14/22 at 10:00 a.m. with the Director of the Intensive Care Unit (ICU)/Cardiac Care Unit (CCU) and the Office Manager. A tour of the clean supply room in the ED revealed equipment stored in the clean supply room that was not marked as cleaned. When the ICU/CCU Director was asked what is the process for ensuring equipment is cleaned, he/she stated all cleaned bedside commodes (BSC) should have a paper around the toilet seat and all other equipment should be covered with a plastic garbage bag to be marked as cleaned. Located in the clean supply room were six (6) BSC not marked as cleaned, two (2) seizure pads not marked as cleaned, one (1) fluid warmer not marked as cleaned, two (2) heat lamps not marked as cleaned, one (1) bladder scanner not marked as cleaned, and one (1) walker not marked as cleaned. Cleaned equipment, which was bagged and marked as clean, had their electrical plugs laying on the floor of the clean supply room. The clean supply room had garbage laying on the floor.

During the tour on 2/14/22 at 10:00 a.m., the Director of ICU/CCU stated, "I can't argue with the findings of the ED."

Based on observation, document review and interview with staff it was determined the facility failed to provide infection control surveillance, and provide a clean and sanitary environment to avoid sources and transmission of infection, in the Emergency Department (See Tag A 750).

Based on document review, observation and interview with staff it was determined the facility failed to provide infection control surveillance and prevention, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, in the Emergency Department (ED). This failure was identified in two (2) of two (2) observations of the ED and has the potential to adversely affect all patients presenting to the ED for care.

Findings include:

A review of the policy titled "Cleaning Patient/Discharge/Transfer," revised 12/02/18, stated in part: "POLICY: All patient rooms will be cleaned when a patient has been discharged, transferred and/or the room is an isolation ... Patient Discharge/Transfer/Isolation Procedure: ... Dust mop floor as per procedure (depending on floor covering) ... Damp mop floor with an EPA approved cleaner/germicidal solution."

A review of the policy titled "Infection Prevention and Control: Nursing," revised 8/20/13, stated in part: "PURPOSE: The purpose of this policy is to set forth guidelines for use in preventing the spread of infection among patients, hospital personnel and visitors ... III. EQUIPMENT: All patient care equipment must be cleaned and decontaminated between each patient contact using disinfectant wipes or an approved spray disinfectant."

A review of the policy titled "Infection Prevention and Control Plan," revised 10/29/21, stated in part: "Goals: The goals of the Infection Prevention and Control Program are: To provide a safe, clean environment for team members, patients and visitors, and to institute measures to prevent acquisition of infection ... 5. Infection Control Surveillance ... g. Surveillance Activities 1 c) To conduct environmental rounds ... e) To assist with infection prevention and control related problems and serve as a resource for infection prevention control needs."

A tour of the ED conducted on 2/14/22 at 10:00 a.m. with the Director of the Intensive Care Unit (ICU)/Cardiac Care Unit (CCU) and the Office Manager. The surveyors were informed Trauma Room #3 (TR 3) and ED Rooms #5, 16 and 19 were cleaned and ready for patient use. Observation of these rooms revealed the following:

Located behind the large garbage can in TR 3, trash was laying on the floor. The trash included a wad of tissues, alcohol pad packages, electrodes, and needle caps. Located behind the biohazard container were needle caps. The floor of TR 3 was dirty. The surveyor took a wipe and wiped two (2) spots on the floor of TR 3. The wipe was soiled and appeared black in color after wiping two (2) small areas on the ED floor. The Office Manager concurred with the findings of TR 3.

ED Room 19 had blood on the floor beside of the ED cot. When ED staff were asked if Room 19 was ready for patients, the surveyor was informed Room 19 was cleaned and ready for the next patient. The Office Manager asked two (2) separate ED staff what rooms were cleaned and was informed Room 19 was ready for the next patient. During the tour of Room 19, the ICU/CCU Director was asked what the expectations of cleaning would be between patients. The Director stated, "The staff should clean the IV (intravenous) pump, all chairs, bedside table, the phone, the sink, receptacles, and handles should be cleaned between patients routinely." When asked about mopping of the ED, the Director stated they do not mop between every patient.

ED Room 16 (behavioral health room) had a dirty floor. When staff was asked if patients had been in Room 16 prior to the surveyors arriving, the ED staff stated no patients had been in the room today and concurred the room was cleaned.

The ED clean supply room revealed equipment stored in the clean supply room that was not marked as clean. When the ICU/CCU Director was asked what the process is for ensuring equipment is cleaned, the Director stated all cleaned bedside commodes (BSC) should have a paper around the toilet seat and all other equipment should be covered with a plastic garbage bag to be marked as cleaned. Located in the clean supply room were six (6) BSC not marked as cleaned, two (2) seizure pads not marked as cleaned, one (1) fluid warmer not marked as cleaned, two (2) heat lamps not marked as cleaned, one (1) bladder scanner not marked as cleaned, and one (1) walker not marked as cleaned. Cleaned equipment, which was bagged and marked as clean, had their electrical plugs laying on the floor of the clean supply room. The clean supply room had garbage laying on the floor. The Director stated, "I can't argue with the findings of the ED."

A tour of ED Room 20 and TR 1 was conducted on 2/15/22 at 9:15 a.m. with the ED Director. The ED Director verified with nursing staff Room 20 had been cleaned and was ready for patient use. Located behind the nightstand of Room 20 was a used IV cathlon, and an orange pull tab was located beside the nightstand. TR 1 revealed trash laying on the floor behind the large garbage can. The ED Director concurred these rooms were not properly cleaned.

An interview was conducted with the Environmental Services (EVS) Supervisor on 2/14/22 at 12:32 p.m. When asked if audits are completed in the ED, the EVS Supervisor stated, "I go through the ED four (4) to five (5) times a day." When asked what the expectation would be for the housekeepers (EVS staff) to mop the ED department, the EVS Supervisor stated, "Mopping should be completed between every patient." When asked who cleans the ED when the housekeeper is taken to another floor, the EVS Supervisor stated, "Nursing should assist with ensuring rooms are cleaned between patients seen in the ED." When asked if he/she was informed about the complaint received regarding the condition of the ED, the EVS Supervisor stated, "I don't get complaints, if I did get complaints I would go to the room and talk to the patient. Currently, I am trying to get two (2) staff per shift in the ED. EVS staff does not get much help from the nurses or the ED techs when cleaning the rooms."

An interview was conducted with RN #1 on 2/14/22 at 1:51 p.m. When asked about EVS staff, RN #1 stated, "Housekeeping is very understaffed, and I know the rooms were terrible today. Housekeeping never mops between patients, the rooms are wiped down, but they are never mopped." RN #1 stated, "I can count on one (1) hand how many times the ED floors have been mopped in two (2) weeks, twice." When asked about mopping at nights, RN #1 stated, "The floors look identical from one (1) shift to the other, no mopping occurs at night." RN #1 stated, "The floors in the ED looked dirty, it looks bad." When asked about patient #1, RN #1 stated, "There was a used IV catheter or a J tube on the floor when patient #1 was in the ED."

An interview was conducted with Vice President (VP) of Operations on 2/14/22 at 3:08 p.m. When asked about the condition of the ED, the VP stated, "This is on us. Nursing has expressed concerns about the ED. Recently there was a lot of changes in EVS. The Director of EVS resigned. The facility has restructured the Department of EVS."

An interview was conducted with the ED Director on 2/15/22 at 10:35 a.m. When asked about the condition of the ED, the ED Director stated, "This is on us. I brought this up when I first came here about the floors of the ED." When asked how long he/she had been the ED Director at this facility, he/she stated they came in October 2021. The ED Director stated, "The floors are not mopped between every patient." When asked who is responsible for the cleaning of patient rooms if housekeeping is not available, the ED Director stated, "Nursing would be responsible to ensure all rooms were cleaned. Nursing has said that they need a mop and broom in the ED to clean up after patients." When informed of the blood spill in Room 19 during the tour on 2/14/22, and staff were reporting the room was cleaned and ready for patient use, the ED Director stated, "Nursing staff should have wiped up the blood off the floor prior to making the room available for patients use." The ED Director stated, "I watched staff clean the rooms of the ED last night, the rooms were clean but obviously there is still soiled floors in the ED."

An interview was conducted with Vice President (VP) of Operations on 2/15/22 at 2:02 p.m. When discussing the tour that was conducted on 2/15/22 at 9:15 a.m., the VP concurred the rooms were not cleaned appropriately when an IV cathlon was located behind the nightstand and garbage was located behind the large garbage can. The VP stated, "All nursing staff knows where the cleaning cart is located, if nursing has to clean patient rooms when EVS staff are not available."

An interview was conducted with the Interim Infection Preventionist (IP) on 2/16/22 at 10:23 a.m. When asked if audits are conducted in the ED, the Interim IP stated, "No audits have been done in the ED since starting at the facility. I have been here since 1/3/22. I go to the ED, look at hand washing, sink situation and supplies. Now it will be a priority for the Infection Preventionist to do more audits due to this survey. An Infection Preventionist was hired and is starting on Monday. It will be important to get the Director of the ED and staff to participate in these rounds." When asked about the policy for cleaning of the ED after patient discharge, the Interim IP stated, "The ED follows the hospital policy." When informed staff stated the floors are not mopped routinely between patients the Interim IP concurred as per policy, when a patient leaves the ED, the floor should be mopped. The Interim IP stated the Infection Preventionist must meet with the Director of EVS and do some training.

During an interview with the ED Director on 2/15/22 at 10:35 a.m., and an interview with the VP of Operations on 2/16/22 at 10:23 a.m., both concurred the ED was not cleaned properly.