HospitalInspections.org

Based on observation, staff interview, and document review, it was determined that the facility failed to ensure that manufacturer's instructions for use (IFUs) are followed for cleaning and disinfecting environmental surfaces in patient care areas during the Coronavirus Disease (COVID-19) pandemic.

Findings include:

Reference #1: CDC [Centers for Disease Control and Prevention] Guidelines for Environmental Infection Control in Health-Care Facilities, 2003 page 147 states, "E. Recommendations-Environmental Services
E.I. Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas ...A. Select EPA-registered disinfectants, if available, and use them in accordance with the manufacturer's instructions."

Reference #2: Clorox Germicidal Bleach Concentrated instructions for use states, "For Hospital Use Instructions ... let stand for 3 minutes."

1. During an observation in the Emergency Department on 7/23/2020 at 12:20 PM, a container labeled, "Sodium Hypochlorite Solution 1 part bleach and 9 parts water; General Disinfection Solution" was found on top of the environmental service cart.

2. Upon interview, Staff #20 stated that the environmental service department prepared the disinfectant wipes using Sodium Hypochlorite solution which is the active ingredient of Clorox Germicidal Bleach concentrate using 1 part bleach and 9 parts water.

a. Upon interview, Staff #20 stated that facility practice is to use the disinfectant wipes to clean the patient room during a room turnover.

b. Upon interview, Staff #20 was questioned about the required contact time for the disinfectant wipes he/she was using. Staff #20 did not know what the contact time for the Clorox disinfectant wipes were. Staff #20 also stated that the room turnover was a very quick process.

3. The above finding was confirmed by Staff #1 and Staff #2.