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Based on observation, document review and interview, the facility failed to ensure that a medication room was kept clean, and used patient equipment was appropriately stored in accordance with its infection control policies and procedures.

Findings include:

During a tour of the facility's 3 West unit on 6/8/21, the following was observed:

At 2:44 PM, during tour of the medication room, the following was noted: Hand washing sink blocked by large garbage bin directly placed in front of the sink, preventing access to the sink. On the floor beside the garbage bin to the right was a rolling vein finder. The base had dust balls and other debris in it. Resting immediately beside the sink on the right side was a large, opened plastic storage container with 9 bags of IV fluids of 0.9NS (normal saline) for irrigation (250cc bags); A small plastic bag with 10 intravenous syringe flushes and 5 insulin syringes. The floor of the medication room was visibly dirty with heavy dust, and with very dark or black stains in front of the handwashing sink and behind the door below the hinges.

Staff A, Nurse Manager who was present during the tour acknowledged findings.

At 2:55 PM, two (2) clear blue plastic bags were seen on the floor in front of the beds of two patients in room 318. The bags contained used patient equipment. Staff A who was present during the finding called an RN to remove the bags from the room and place them on the hallway floor by the patient's door. Staff A explained to surveyor that the usual practice is to place the bags outside the door of the room (which is in the hallway). The staff makes a call for pickup of the items.

Review of the facility's policy titled: "Cleaning and Disinfecting of Mobile and Other Medical Equipment," last reviewed 09/2020 states: "Mobile Medical Equipment (MME) that has been used in the patient care environment may be temporarily relocated to a soiled utility/storage room while awaiting disinfection and subsequent storage in a clean utility/storage."

During interview on 6/9/21 at approximately 1:00 PM, Staff F, Director of Infection Prevention stated: "Dirty equipment should be taken to Central Sterile. It gets bagged and picked up by Material Management and taken to Central Sterile. It is placed in a blue or green bag."